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Molina-Payá FJ, Ríos-Díaz J, Carrasco-Martínez F, Martínez-Payá JJ. Reliability of a New Semi-automatic Image Analysis Method for Evaluating the Doppler Signal and Intratendinous Vascular Resistance in Patellar Tendinopathy. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3491-3500. [PMID: 34538534 DOI: 10.1016/j.ultrasmedbio.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/09/2021] [Accepted: 08/14/2021] [Indexed: 06/13/2023]
Abstract
The aim of this study was to determine the intra- and inter-rater reliability of a new semi-automatic image analysis method for quantification of the shape of the Doppler signal and the intratendinous vascular resistance in patellar tendinopathy. Thirty athletes (27.4 y, standard deviation = 8.57 y) with patellar intratendinous vascularity were included in a cross-sectional study (42 tendons analyzed). The intratendinous blood flow was assessed with power Doppler and ImageJ (Version 1.50b, National Institutes of Health, Bethesda, MD, USA) quantification software over a manually selected region of interest. Two blinded observers performed the analysis of the Doppler signal (vascular resistance) and shape descriptors (number of signals, pixel intensity, area, perimeter, major diameter, minor diameter, circularity and solidity). The intraclass correlation coefficient (ICC) was calculated, and the Bland-Altman mean of differences (MoD) and 95% limits of agreement (LoA) were determined. Also, small real differences (SRDs) and the standard error of measurement (SEM) were calculated. Intra-rater reliability was at a maximum for area (ICC = 0.999, 95% confidence interval [CI] = 0.998-0.999) and at a minimum for solidity (ICC = 0.782, 95% CI: 0.682-0.853). The MoD and 95% LoA were very low, and the relative SRD and SEM were below 5.3% and 2%, respectively. The inter-rater reliability was the maximum for area (ICC = 0.993, 95% CI = 0.989-0.996) and the minimum for circularity (ICC = 0.73; 95% CI=0.611-0.817). The MoD and 95% LoA were low, with the SRD and SEM below 6% and 2.2%. The proposed quantitative method for studying the intratendinous Doppler signal in the patellar tendon is reliable and reproducible.
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Affiliation(s)
| | - José Ríos-Díaz
- Fundación San Juan de Dios. Centro de Ciencias de la Salud San Rafael, Universidad Nebrija, Madrid, Spain.
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Merkel MFR, Hellsten Y, Magnusson SP, Kjaer M. Tendon blood flow, angiogenesis, and tendinopathy pathogenesis. TRANSLATIONAL SPORTS MEDICINE 2021. [DOI: 10.1002/tsm2.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Max Flemming Ravn Merkel
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Stig Peter Magnusson
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Center for Healthy Aging Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Center for Healthy Aging Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Equine flexor tendon imaging part 1: Recent developments in ultrasonography, with focus on the superficial digital flexor tendon. Vet J 2021; 278:105764. [PMID: 34678500 DOI: 10.1016/j.tvjl.2021.105764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 09/14/2021] [Accepted: 10/15/2021] [Indexed: 12/15/2022]
Abstract
Flexor tendon injuries are a major cause of lameness in performance horses and have considerable impact on equine welfare and the wider horse industry. Ageing and repetitive strain frequently cause varying degrees of tendon micro-damage prior to the recognition of clinical tendinopathy. Whilst B-mode ultrasonography is most commonly utilised for detection and monitoring of tendon lesions at the metacarpal/metatarsal level, the emphasis of recent research has focused on the identification of subclinical tendon damage in order to prevent further tendon injury and improve outcomes. The introduction of elastography, acoustoelastography and ultrasound tissue characterisation in the field of equine orthopaedics shows promising results and might find wider use in equine practice as clinical development continues. Based on the substantial number of research studies on tendon imaging published over the past decade this literature review aims to examine the currently used ultrasonographic imaging techniques and their limitations, and to introduce and critically appraise new modalities that could potentially change the clinical approach to equine flexor tendon imaging.
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Zhou H, Chen C, Zhang Y, Ugbolue UC. Ultrasound Color Doppler Measures Neovascularization in Achilles Tendinopathy: Review. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2021. [DOI: 10.1166/jmihi.2021.3573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose: Color Doppler ultrasonography (CD) has been used to employ in Achilles tendinopathy, there is a need to measure neovascularization in Achilles tendinopathy to reach a consensus for CD application. The object of this systematic retrospect is to summarize
the literature regarding whether is a relationship between the neovascularization and Achilles tendinopathy by CD detecting. Method: The databases search of PubMed, Scopus, and Embase extracted 543 articles for title and abstract review. After deleting duplicate papers and evaluating
which one meets the inclusion criteria, a total of 8 articles were selected. Results and conclusion: Differentiate a physiological and pathological color Doppler flow in Achilles tendon is important to further clinically diagnose, since neovascularization in tissue structure can be
influenced by variation reasons. The standardized tenoangiography protocol be supposed to develop when assessment asymptomatic or symptomatic tendons.
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Affiliation(s)
- Huiyu Zhou
- Faculty of Sports Science, Ningbo University, Ningbo, 315211, China
| | - Chaoyi Chen
- School of Health and Life Sciences, University of the West of Scotland, Scotland, G72 0LH, UK
| | - Yan Zhang
- Faculty of Sports Science, Ningbo University, Ningbo, 315211, China
| | - Ukadike Chris Ugbolue
- School of Health and Life Sciences, University of the West of Scotland, Scotland, G72 0LH, UK
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Risch L, Stoll J, Schomöller A, Engel T, Mayer F, Cassel M. Intraindividual Doppler Flow Response to Exercise Differs Between Symptomatic and Asymptomatic Achilles Tendons. Front Physiol 2021; 12:617497. [PMID: 34295255 PMCID: PMC8290144 DOI: 10.3389/fphys.2021.617497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
Objective This study investigated intraindividual differences of intratendinous blood flow (IBF) in response to running exercise in participants with Achilles tendinopathy. Design This is a cross-sectional study. Setting The study was conducted at the University Outpatient Clinic. Participants Sonographic detectable intratendinous blood flow was examined in symptomatic and contralateral asymptomatic Achilles tendons of 19 participants (42 ± 13 years, 178 ± 10 cm, 76 ± 12 kg, VISA-A 75 ± 16) with clinically diagnosed unilateral Achilles tendinopathy and sonographic evident tendinosis. Intervention IBF was assessed using Doppler ultrasound “Advanced Dynamic Flow” before (Upre) and 5, 30, 60, and 120 min (U5–U120) after a standardized submaximal constant load run. Main Outcome Measure IBF was quantified by counting the number (n) of vessels in each tendon. Results At Upre, IBF was higher in symptomatic compared with asymptomatic tendons [mean 6.3 (95% CI: 2.8–9.9) and 1.7 (0.4–2.9), p < 0.01]. Overall, 63% of symptomatic and 47% of asymptomatic Achilles tendons responded to exercise, whereas 16 and 11% showed persisting IBF and 21 and 42% remained avascular throughout the investigation. At U5, IBF increased in both symptomatic and asymptomatic tendons [difference to baseline: 2.4 (0.3–4.5) and 0.9 (0.5–1.4), p = 0.05]. At U30 to U120, IBF was still increased in symptomatic but not in asymptomatic tendons [mean difference to baseline: 1.9 (0.8–2.9) and 0.1 (-0.9 to 1.2), p < 0.01]. Conclusion Irrespective of pathology, 47–63% of Achilles tendons responded to exercise with an immediate acute physiological IBF increase by an average of one to two vessels (“responders”). A higher amount of baseline IBF (approximately five vessels) and a prolonged exercise-induced IBF response found in symptomatic ATs indicate a pain-associated altered intratendinous “neovascularization.”
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Affiliation(s)
- Lucie Risch
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany
| | - Josefine Stoll
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany
| | - Anne Schomöller
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany
| | - Tilman Engel
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany
| | - Frank Mayer
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany.,Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
| | - Michael Cassel
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany.,Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
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Lacitignola L, Rossella S, Pasquale DL, Crovace A. Power Doppler to investigate superficial digital flexor tendinopathy in the horse. Open Vet J 2019; 9:317-321. [PMID: 32042652 PMCID: PMC6971361 DOI: 10.4314/ovj.v9i4.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 10/15/2019] [Indexed: 12/02/2022] Open
Abstract
Background: Recent advances in tendinopathy research have focused on tendon vascularization detected with Color Doppler (CD) ultrasound. The use of CD has also been described in horses in a study on chronic lesions of superficial digital flexor tendon and suspensory ligament. Aim: The aim of this study was to investigate the occurrence and distribution of power Doppler (PD) signal in horses with superficial digital flexor tendinopathy. Methods: Twenty-five horses with tendinopathy were included and 10 healthy horses with no lameness and no ultrasonographic abnormalities were used for comparison. Results: In all horses with tendinopathy, the PD signal was visible while normal tendons with no abnormalities in B-mode were PD signal-free. Conclusion: We can speculate that PD could provide essential information about the healing process than the grayscale ultrasound.
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Affiliation(s)
- Luca Lacitignola
- Dipartimento dell'Emergenza e dei Trapianti di Organi (D.E.T.O.), Sezione di Cliniche Veterinarie e P.A, Università degli Studi di Bari "Aldo Moro", s.p. per Casamassima Km 3, 70010 Valenzano, Italy
| | - Santovito Rossella
- Dipartimento dell'Emergenza e dei Trapianti di Organi (D.E.T.O.), Sezione di Cliniche Veterinarie e P.A, Università degli Studi di Bari "Aldo Moro", s.p. per Casamassima Km 3, 70010 Valenzano, Italy
| | - De Luca Pasquale
- Dipartimento dell'Emergenza e dei Trapianti di Organi (D.E.T.O.), Sezione di Cliniche Veterinarie e P.A, Università degli Studi di Bari "Aldo Moro", s.p. per Casamassima Km 3, 70010 Valenzano, Italy
| | - Antonio Crovace
- Dipartimento dell'Emergenza e dei Trapianti di Organi (D.E.T.O.), Sezione di Cliniche Veterinarie e P.A, Università degli Studi di Bari "Aldo Moro", s.p. per Casamassima Km 3, 70010 Valenzano, Italy
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Roesch HJ, Milanese S, Osborne B, Spurrier DJ, Thoirs KA. The acute effects of exercise on tendon dimensions and vascularity. An exploratory study using diagnostic ultrasound of the male Achilles tendon. J Sci Med Sport 2018; 21:982-987. [DOI: 10.1016/j.jsams.2017.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 11/06/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
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In Achilles tendinopathy, the neovascularization, detected by contrast-enhanced ultrasound (CEUS), is abundant but not related to symptoms. Knee Surg Sports Traumatol Arthrosc 2018; 26:2051-2058. [PMID: 29079961 DOI: 10.1007/s00167-017-4710-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE AND HYPOTHESIS Mid-portion Achilles tendinopathy is characterized by a proliferation of small vessels, called neovascularization, which can be demonstrated by power Doppler sonography (PD). Neovascularization can be correlated with diagnosis and consequent therapies focused on vascular supply. Published data regarding the relationship between neovascularisation and symptoms, such as pain and disability, are contradictory. The hypothesis that contrast-enhanced ultrasound (CEUS) could detect with more sensibility than PD the new vessel ingrowth in human degenerated Achilles tendons and therefore the correlation of neovascularization with pain and disability, was evaluated. METHODS Thirty consecutive patients of recalcitrant Achilles tendinopathy were studied with ultrasound greyscale (US), PD, CEUS and magnetic resonance imaging. Neovascularization was recorded as percentage on the whole extension of examined area. The vascularization time was recorded as venous and arterial type. Imaging data were classified both concurrently with the examination and in a secondary blinded assessment; any difference in the subjective assessment was discussed and a consensus view formed. Pain and disability were assessed by Western Ontario McMaster Universities Arthritis Index (WOMAC) and EuroQuality of life 5-dimension-5-level questionnaire and visual analogue scale (EQ-VAS). All results were analysed with suitable statistical methods. RESULTS 76.7% of cases were degenerated; 23.3% had also partial discontinuity of the fibres. PD detected vascularization in 54% of cases, whereas CEUS in 83% of cases: in 13 cases, PD did not detect vascularization. The vascularization time was rapid (< 20 s, arterial type) in 60% of cases. WOMAC pain mean value is 6.4 and SD 3.4; WOMAC total score mean value is 21.6 and SD 12.8. EQ-VAS mean value is 56 and SD 18.3. No statistically significant correlation emerged between vascularization and pain/disability. CONCLUSIONS CEUS showed a greater ability to detect neovessels than PD in chronic Achilles tendinopathies. Nevertheless in 30 consecutive tendinopathies, no correlation between pain/disability and neovascularization was found: the role of multiple neovessels continue to be unclear. The possibility to discriminate arterial from venous vessels ('vascularization time') could be useful to understand the pathophysiology of tendinopathies and its healing process. STUDY TYPE Diagnostic study. LEVEL OF EVIDENCE II.
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Risch L, Wochatz M, Messerschmidt J, Engel T, Mayer F, Cassel M. Reliability of Evaluating Achilles Tendon Vascularization Assessed With Doppler Ultrasound Advanced Dynamic Flow. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:737-744. [PMID: 28960372 DOI: 10.1002/jum.14414] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The reliability of quantifying intratendinous vascularization by high-sensitivity Doppler ultrasound advanced dynamic flow has not been examined yet. Therefore, this study aimed to investigate the intraobserver and interobserver reliability of evaluating Achilles tendon vascularization by advanced dynamic flow using established scoring systems. METHODS Three investigators evaluated vascularization in 67 recordings in a test-retest design, applying the Ohberg score, a modified Ohberg score, and a counting score. Intraobserver and interobserver agreement for the Ohberg score and modified Ohberg score was analyzed by the Cohen κ and Fleiss κ coefficients (absolute), Kendall τ b coefficient, and Kendall coefficient of concordance (W; relative). The reliability of the counting score was analyzed by intraclass correlation coefficients (ICC) 2.1 and 3.1, the standard error of measurement (SEM), and Bland-Altman analysis (bias and limits of agreement [LoA]). RESULTS Intraobserver and interobserver agreement (absolute/relative) ranged from 0.61 to 0.87/0.87 to 0.95 and 0.11 to 0.66/0.76 to 0.89 for the Ohberg score and from 0.81 to 0.87/0.92 to 0.95 and 0.64 to 0.80/0.88 to 0.93 for the modified Ohberg score, respectively. The counting score revealed an intraobserver ICC of 0.94 to 0.97 (SEM, 1.0-1.5; bias, -1; and LoA, 3-4 vessels). The interobserver ICC for the counting score ranged from 0.91 to 0.98 (SEM, 1.0-1.9; bias, 0; and LoA, 3-5 vessels). CONCLUSIONS The modified Ohberg score and counting score showed excellent reliability and seem convenient for research and clinical practice. The Ohberg score revealed decent intraobserver but unexpected low interobserver reliability and therefore cannot be recommended.
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Affiliation(s)
- Lucie Risch
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Monique Wochatz
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Janin Messerschmidt
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Tilman Engel
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Frank Mayer
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Michael Cassel
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
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Tsui SSM, Leong HT, Leung VYF, Ying M, Fu SN. Tendon vascularity in overhead athletes with subacromial pain syndrome and its correlation with the resting subacromial space. J Shoulder Elbow Surg 2017; 26:774-780. [PMID: 28081996 DOI: 10.1016/j.jse.2016.09.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/08/2016] [Accepted: 09/27/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Supraspinatus tendinopathy is one of the common causes of subacromial pain syndrome (SAPS) in overhead athletes. Changes in tendon vascularity have been reported in painful tendons; however, the prevalence and distribution have not been investigated in young overhead athletes. METHODS We conducted a cross-sectional study of 47 overhead athletes (male, 31; female, 16) aged 18 to 36 years with SAPS for >3 months. A sonographer graded the severity of the tendinopathy and area of vascularization. Ultrasound imaging was used to measure supraspinatus tendon thickness, vascularity, and resting subacromial space. A self-written program was used to semiquantify the intensity of vascularity, expressed as the vascular index. RESULTS The majority (87.2%) of the participants had signs of tendinopathy in the supraspinatus tendon, and 40 (85.1%) of the tendinopathic tendons had vascularity. The majority (66.0%) of the vascularized subjects presented with minimal increase in vascularity, and 19.1% had moderate to severe vascularization. Most (79.2%) of the vascularization was observed in the pericortical region. The vascular index was negatively correlated with the resting subacromial space in male athletes with a reduced subacromial space (ρ = -0.63; P = .038). CONCLUSION Of overhead athletes with SAPS, 87.2% had supraspinatus tendinopathy with minimal to moderate vascularization, with the majority of vascularization occurring in the pericortical region. In male athletes with a reduced subacromial space, greater vascularity in the supraspinatus tendon was associated with a smaller resting subacromial space.
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Affiliation(s)
- Sammi Sin Mei Tsui
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong (SAR), China
| | - Hio Teng Leong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong (SAR), China
| | - Vivian Yee Fong Leung
- Department of Radiology and Imaging, Prince of Wales Hospital, Shatin, Hong Kong (SAR), China
| | - Michael Ying
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong (SAR), China
| | - Siu Ngor Fu
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong (SAR), China.
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Karzis K, Kalogeris M, Mandalidis D, Geladas N, Karteroliotis K, Athanasopoulos S. The effect of foot overpronation on Achilles tendon blood supply in healthy male subjects. Scand J Med Sci Sports 2016; 27:1114-1121. [DOI: 10.1111/sms.12722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 11/30/2022]
Affiliation(s)
- K. Karzis
- Department of Physiotherapy; Asklipieio General Hospital of Voula; Athens Greece
| | - M. Kalogeris
- Department of Medical Imaging; Medical Centre Palaiou Falirou; Athens Greece
| | - D. Mandalidis
- School of Physical Education and Sport Science; Department of Sport Medicine and Biology of Exercise; National and Kapodistrian University of Athens; Athens Greece
| | - N. Geladas
- School of Physical Education and Sport Science; Department of Sport Medicine and Biology of Exercise; National and Kapodistrian University of Athens; Athens Greece
| | - K. Karteroliotis
- School of Physical Education and Sport Science; Department of Sport Medicine and Biology of Exercise; National and Kapodistrian University of Athens; Athens Greece
| | - S. Athanasopoulos
- School of Physical Education and Sport Science; Department of Sport Medicine and Biology of Exercise; National and Kapodistrian University of Athens; Athens Greece
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Risch L, Cassel M, Messerschmidt J, Intziegianni K, Fröhlich K, Kopinski S, Mayer F. Is Sonographic Assessment of Intratendinous Blood Flow in Achilles Tendinopathy Patients Reliable?: Consistency of Doppler Ultrasound Modes and Intra- and Inter-observer Reliability. Ultrasound Int Open 2016; 2:E13-8. [PMID: 27689161 PMCID: PMC5023215 DOI: 10.1055/s-0035-1569286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 11/08/2015] [Indexed: 10/22/2022] Open
Abstract
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.
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Affiliation(s)
- L. Risch
- University Outpatient Clinic, Sports Medicine and Sports Orthopaedics, University of Potsdam, Potsdam, Germany
| | - M. Cassel
- University Outpatient Clinic, Sports Medicine and Sports Orthopaedics, University of Potsdam, Potsdam, Germany
| | - J. Messerschmidt
- University Outpatient Clinic, Sports Medicine and Sports Orthopaedics, University of Potsdam, Potsdam, Germany
| | - K. Intziegianni
- University Outpatient Clinic, Sports Medicine and Sports Orthopaedics, University of Potsdam, Potsdam, Germany
| | - K. Fröhlich
- University Outpatient Clinic, Sports Medicine and Sports Orthopaedics, University of Potsdam, Potsdam, Germany
| | - S. Kopinski
- University Outpatient Clinic, Sports Medicine and Sports Orthopaedics, University of Potsdam, Potsdam, Germany
| | - F. Mayer
- University Outpatient Clinic, Sports Medicine and Sports Orthopaedics, University of Potsdam, Potsdam, Germany
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Abstract
OBJECTIVE To assess the effectiveness of high-volume image-guided injection in the middle term in patients with recalcitrant patellar tendinopathy. DESIGN Case series study; Level of evidence, 4. SETTING All tertiary referrals, public, and private healthcare. PATIENTS Forty-four patients (41 men and 3 women) with diagnosis of recalcitrant patellar tendinopathy were included. INTERVENTION Tendon injection of a mixture of 10 mL of 0.5% bupivacaine hydrochloride, 62 500 international units of aprotinin, and 40 mL of normal saline solution. MAIN OUTCOME MEASURES The Victorian Institute of Sport Assessment-patellar tendon (VISA-P), visual analogue scale, and Roles and Maudsley were assessed at baseline and at the last follow-up. RESULTS The baseline VISA-P score of 46 ± 18.2 (range, 28-75) improved to 75.3 ± 19.2 (range, 68-100) by 15 months (P = 0.003). The mean pain visual analogue scale changed from 91 mm (range, 66-92 mm) before the injection to 28 mm (2-52 mm) (P = 0.01). Of 32 physically active patients, 23 (72%) had returned to sport at the same level practiced before the onset of symptoms. Thirty-five of the 44 patients (80%) rated their condition as good or excellent. CONCLUSIONS High-volume injection at the interface between the deep surface of the patellar tendon and Hoffa body improves in the short-term symptoms and function of the knee. CLINICAL RELEVANCE This procedure is minimally invasive, safe, and effective in the short term in athletes.
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Conze P, van Schie HTM, van Weeren R, Staszyk C, Conrad S, Skutella T, Hopster K, Rohn K, Stadler P, Geburek F. Effect of autologous adipose tissue-derived mesenchymal stem cells on neovascularization of artificial equine tendon lesions. Regen Med 2015; 9:743-57. [PMID: 25431911 DOI: 10.2217/rme.14.55] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIMS To investigate whether autologous adipose tissue-derived mesenchymal stem cells (AT-MSCs) treatment of tendon lesions increases neovascularization during tendon healing. MATERIALS & METHODS A standardized surgical model was used to create lesions in both front limb superficial digital flexor tendons (SDFTs) of nine horses. Either AT-MSCs or control substance was injected intralesionally 2 weeks post-surgery. Color Doppler ultrasonography of SDFTs was performed at regular intervals. Horses were euthanized 22 weeks post-treatment and SDFTs were harvested for histology. RESULTS The color Doppler ultrasonography signal was significantly more extensive at 2 weeks post-treatment and the number of vessels counted on histologic slides was significantly higher at 22 weeks post-treatment in AT-MSC-treated SDFTs. CONCLUSION Our findings indicate that AT-MSC treatment has a beneficial effect on neovascularization of healing tendons.
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Affiliation(s)
- Philipp Conze
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Hannover, Bünteweg 9, 30559 Hannover, Germany
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15
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Ooi CC, Richards PJ, Maffulli N, Ede D, Schneider ME, Connell D, Morrissey D, Malliaras P. A soft patellar tendon on ultrasound elastography is associated with pain and functional deficit in volleyball players. J Sci Med Sport 2015; 19:373-8. [PMID: 26095373 DOI: 10.1016/j.jsams.2015.06.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 05/18/2015] [Accepted: 06/01/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the diagnostic performance of grey scale Ultrasound (US), power Doppler (PD) and US elastography for diagnosing painful patellar tendinopathy, and to establish their relationship with Victorian Institute of Sport Assessment-Patella (VISA-P) scores in a group of volleyball players with and without symptoms of patellar tendinopathy. DESIGN Cross-sectional study. METHODS Thirty-five volleyball players (70 patellar tendons) were recruited during a national university volleyball competition. Players were imaged with conventional US followed by elastography. The clinical findings of painful patellar tendons were used as the reference standard for diagnosing patellar tendinopathy. In addition, all participants completed the VISA-P questionnaires. RESULTS Of the 70 patellar tendons, 40 (57.1%) were clinically painful. The diagnostic accuracy of grey scale US, PD and elastography were 60%, 50%, 62.9%, respectively, with sensitivity/specificity of 72.5%/43.3%, 12.5%/100%, and 70%/53.3%, respectively. Combined US elastography and grey scale imaging achieved 82.5% sensitivity, 33.3% specificity and 61.4% accuracy while routine combination technique of PD and grey scale imaging revealed 72.5% sensitivity, 43.3% specificity and 60.0% accuracy. Tendons in players categorized as soft on elastography had statistically significantly greater AP thickness (p<0.001) and lower VISA-P scores (p=0.004) than those categorized as hard. There was no significant association between grey scale US abnormalities (hypoechogenicities and/or fusiform swelling) and VISA-P scores (p=0.098). CONCLUSIONS Soft tendon properties depicted by US elastography may be more related to patellar tendon symptoms compared to grey scale US abnormalities. The supplementation of US elastography to conventional US may enhance the sensitivity for diagnosing patellar tendinopathy in routine clinical practice.
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Affiliation(s)
- Chin Chin Ooi
- Department of Medical Imaging & Radiation Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton Campus, Australia; Department of Diagnostic Radiology, Singapore General Hospital, Singapore; Imaging at Olympic Park, AAMI Park, Australia
| | - Paula J Richards
- University Hospital of North Staffordshire NHS Trust, X-ray Department, UK
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary, University of London, UK; Department of Musculoskeletal Surgery, University of Salerno School of Medicine and Surgery, Italy
| | - David Ede
- Oxford University Hospitals Trust, UK
| | - Michal E Schneider
- Department of Medical Imaging & Radiation Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton Campus, Australia
| | - David Connell
- Department of Medical Imaging & Radiation Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton Campus, Australia; Imaging at Olympic Park, AAMI Park, Australia
| | - Dylan Morrissey
- NIHR/HEE, Centre for Sports and Exercise Medicine, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, UK; Physiotherapy Department, Bart's Health NHS Trust, UK
| | - Peter Malliaras
- Imaging at Olympic Park, AAMI Park, Australia; Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary, University of London, UK.
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Abate M, Salini V, Antinolfi P, Schiavone C. Ultrasound morphology of the Achilles in asymptomatic patients with and without diabetes. Foot Ankle Int 2014; 35:44-9. [PMID: 24163317 DOI: 10.1177/1071100713510496] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The prevalence of tendinopathies is increased in subjects with diabetes mellitus. However, there are few data on the structural abnormalities of Achilles tendons in asymptomatic diabetic patients. The aim of the study was to assess the morphologic characteristics of the Achilles tendon in subjects with diabetes in comparison with controls without diabetes. METHODS Participants were consecutively recruited from an outpatient population. Ultrasound longitudinal and transverse scans were performed bilaterally along the full length of Achilles tendon from the musculotendinous junction to the insertion. Degenerative features (abnormal fibrillar pattern, hypo-hyperechoic areas), signs of enthesopathy (bony erosion, enthesophytes, and bursitis), and intratendinous neovessel formation were recorded. RESULTS Asymptomatic sonographic abnormalities (ASA) were significantly increased in subjects with diabetes (35/136 [25.7%] vs 32/273 [11.7%], P = .0003). Sixty tendons with ASA were observed in the first group and 45 in the latter because ASA were bilateral in 25 and in 13 subjects, respectively. ASA were more frequently localized at the enthesis (32/60 [53.3%] vs 9/45 [20%], P = .0005) in the diabetes group, whereas, on the contrary, they were more prevalent at the midportion in controls (38/45 [84.4%] vs 36/60 [60%], P < .006). CONCLUSION Diabetes may predispose to Achilles tendinopathy and particularly to Achilles enthesopathy. Longitudinal studies, evaluating the progression of the lesions not only in the midportion of the tendon but also at the insertion are needed to support this conclusion. LEVEL OF EVIDENCE Level III, comparative series.
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Affiliation(s)
- Michele Abate
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Italy
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17
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Abstract
OBJECTIVE 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. DESIGN Single-blind cross-sectional study. SETTING Research laboratory. PARTICIPANTS 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. INTERVENTIONS 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. MAIN OUTCOME MEASURES Images were assessed for neovascularization by 2 trained raters who were blinded to group (rotator cuff tendinopathy or asymptomatic group). RESULTS 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%). CONCLUSIONS 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.
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Yang X, Coleman DP, Pugh ND, Nokes LDM. The volume of the neovascularity and its clinical implications in achilles tendinopathy. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:1887-1895. [PMID: 22975033 DOI: 10.1016/j.ultrasmedbio.2012.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 06/27/2012] [Accepted: 07/03/2012] [Indexed: 06/01/2023]
Abstract
Thirty-seven pathologic Achilles tendons from 27 patients were investigated by a three-dimensional (3-D) power Doppler ultrasound system. Both the volume of the neovascularity (VON) and the volume of Achilles tendon (VOAT) were investigated. VON-VOAT index (VVI), as the normalization of the neovascularization, was accordingly calculated. Patient's clinical indications were assessed using the visual analog scale for pain (VAS) and Victorian Institute of Sport Assessment Achilles (VISA-A). Relationships between VAS and VON, VISA-A and VON, VAS and VOAT, VISA-A and VOAT, VAS and VVI, and VISA-A and VVI, were statistically analyzed. The vascular mapping within and surrounding the symptomatic Achilles tendons was investigated. 97.3% of the Achilles tendons were found to have neovascularization. In 55.6% of these Achilles, the neovascularity was associated with the location of thickening. The VAS was found to be positively correlated with the VON and the VVI, the VON was found to be independent from the VOAT.
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Affiliation(s)
- Xin Yang
- Institute of Medical Engineering and Medical Physics, School of Engineering, Cardiff University, Cardiff, United Kingdom.
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19
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Real-time sonoelastography of the Achilles tendon: pattern description in healthy subjects and patients with surgically repaired complete ruptures. Skeletal Radiol 2012; 41:1067-72. [PMID: 22167230 DOI: 10.1007/s00256-011-1339-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 11/24/2011] [Accepted: 11/24/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of this study is to describe the elastographic appearance of the Achilles tendon in healthy subjects and patients with surgically repaired complete ruptures. MATERIALS AND METHODS Nineteen Achilles tendons of 16 amateur footballers with surgically repaired complete ruptures and their contralateral asymptomatic Achilles tendons were assessed with ultrasound and real-time sonoelastography. Additionally, 40 asymptomatic Achilles tendons of 20 healthy amateur footballers were assessed. The Achilles tendons were divided into the distal, middle, and proximal thirds for elastographic image evaluation. Tendons were classified into three main types according to the elasticity features: type 1, blue (hardest tissue); type 2, blue/green (hard tissue); or type 3, green (intermediate tissue). In addition, three subtypes were determined: homogeneous, relatively homogeneous, and heterogeneous. RESULTS Most of the Achilles tendons of the patients with surgically repaired complete ruptures were detected to have type 2 elasticity (64.9%), and the remaining had type 1 (35.1%). In contrast, most of the healthy tendons had type 2 (64.2%), and the remaining had either a type 3 (20.8%) or a type 1 (15%) elastographic pattern. All of the ruptured tendons had a heterogeneous structure, whereas all of the healthy Achilles tendons had a homogeneous or relatively homogeneous structure. CONCLUSION In sonoelastography, the recognition of normal tendon structure will be useful in assessing pathologies of the Achilles tendon. Additionally, in patients with excellent American Orthopedic Foot and Ankle Society (AOFAS) scores and surgically repaired complete ruptures, a hard and heterogeneous pattern of tendon structure may be a natural consequence of tendon healing.
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Yang X, Coleman DP, Pugh ND, Liu W, Nokes L. Quantitative assessment of intra-vascular volume in human Achilles tendinopathy. J Med Eng Technol 2012; 35:172-8. [DOI: 10.3109/03091902.2011.558170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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21
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Boesen AP, Boesen MI, Torp-Pedersen S, Christensen R, Boesen L, Hölmich P, Nielsen MB, Koenig MJ, Hartkopp A, Ellegaard K, Bliddal H, Langberg H. Associations between abnormal ultrasound color Doppler measures and tendon pain symptoms in badminton players during a season: a prospective cohort study. Am J Sports Med 2012; 40:548-55. [PMID: 22328709 DOI: 10.1177/0363546511435478] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Color Doppler ultrasound is widely used to examine intratendinous flow in individuals with overuse tendon problems, but the association between color Doppler and pain is still unclear. HYPOTHESIS Intratendinous flow is present and associated with pain in badminton players, and intratendinous flow and pain increase during a badminton season. STUDY DESIGN Cohort study (prognosis); Level of evidence, 2. METHODS Ninety-five semiprofessional badminton players were included in the study at a tournament at the start of the badminton season. All players were interviewed regarding pain. The anterior knee tendons and Achilles tendons were studied. Each tendon was scored using a quantitative grading system (grades 0-5) and a qualitative scoring system (color fraction) using color Doppler ultrasound. Eight months later, 86 of the players (91%) were retested by the same investigators during an equivalent badminton tournament (including 1032 tendon regions; 86 players with 4 tendons each with 3 regions), thus forming the study group. RESULTS At the start of the season, 24 players (28%) experienced pain in 37 tendons (11%), and at the end of the season, 31 players (36%) experienced pain in 51 tendons (15%), which was a statistically significant increase (P = .0002). Abnormal flow was found in 230 tendon regions in 71 players (83%) at the start of the season compared with 78 tendon regions in 41 players (48%) at the follow-up. The decrease in abnormal flow was statistically significant (P < .0001). Of the 37 painful tendons at the start of the season, 25 had abnormal flow (68%). In contrast, 131 tendons (85%) with abnormal flow at the start of the season were pain free. At the end of the season, 18 of the 51 painful tendons (35%) had abnormal flow. Ninety-six of the 131 pain-free tendons (73%) with abnormal flow at the start of the season were normalized (no pain and normal flow) at the end of the season. CONCLUSION It was not possible to verify any association between intratendinous flow and pain at the start of the season or at the follow-up (end of the season). Intratendinous flow at the start of the season could not predict symptomatic outcome at the end of the season. The decrease in Doppler flow during the season might suggest that intratendinous flow could be part of a physiological adaptive response to loading and that intratendinous flow as previously believed is not always a sign of pathological changes.
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Affiliation(s)
- Anders Ploug Boesen
- Institute of Sports Medicine, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark.
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22
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van der Plas A, de Jonge S, de Vos RJ, van der Heide HJL, Verhaar JAN, Weir A, Tol JL. A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med 2011; 46:214-8. [PMID: 22075719 PMCID: PMC3277725 DOI: 10.1136/bjsports-2011-090035] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results. Aim To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson's heel-drop exercise programme. Study design Part of a 5-year follow-up of a previously conducted randomised controlled trial. Methods 58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded. Results In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051). Conclusion At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson's heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.
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Affiliation(s)
- A van der Plas
- Sports Medicine Department, The Hague Medical Centre Antoniushove, Burgemeester Banninglaan 1, Leidschendam, The Netherlands
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Giombini A, Dragoni S, Di Cesare A, Di Cesare M, Del Buono A, Maffulli N. Asymptomatic Achilles, patellar, and quadriceps tendinopathy: a longitudinal clinical and ultrasonographic study in elite fencers. Scand J Med Sci Sports 2011; 23:311-6. [PMID: 22092963 DOI: 10.1111/j.1600-0838.2011.01400.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2011] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- A Giombini
- Department of Health Sciences, University of Molise, Molise, Italy
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Genovese E, Ronga M, Recaldini C, Fontana F, Callegari L, Maffulli N, Fugazzola C. Analysis of achilles tendon vascularity with second-generation contrast-enhanced ultrasound. JOURNAL OF CLINICAL ULTRASOUND : JCU 2011; 39:141-145. [PMID: 21283996 DOI: 10.1002/jcu.20789] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 10/22/2010] [Indexed: 05/30/2023]
Abstract
PURPOSE To compare morphological, power Doppler, and contrast-enhanced ultrasound (CEUS) features of the Achilles tendon between asymptomatic athletes and athletes who had undergone surgical repair of a previous rupture. METHODS Twenty-four athletes were divided in two groups (A and B). Group A included 14 patients with a median age of 32 years (range 27 to 47 years) who had undergone surgical repair for unilateral Achilles tendon rupture. Group B (control group) included 10 subjects with a median age of 34 years (range 27 to 40 years) with no previous or present history of tendinopathy. All patients were evaluated with ultrasound, power Doppler, and CEUS with second-generation contrast agent. We studied the uninjured Achilles tendon in athletes of group A and either the left or the right Achilles tendon of the athletes in group B. RESULTS CEUS showed a significantly greater ability to detect a greater number of vascular spots within the uninjured tendon of group A compared to group B (<0.05). CONCLUSIONS In athletes who had suffered a tear of an Achilles tendon, CEUS detected small vessels that were not identified by power Doppler ultrasound in the uninjured contralateral Achilles tendon. CEUS is useful to evaluate vascularity not detected by other imaging techniques. Vascularity in the uninjured tendon seems to be increased in patients who had a previous rupture.
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Evidence of accumulated stress in Achilles and anterior knee tendons in elite badminton players. Knee Surg Sports Traumatol Arthrosc 2011; 19:30-7. [PMID: 20652535 DOI: 10.1007/s00167-010-1208-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 06/23/2010] [Indexed: 10/19/2022]
Abstract
Tendon-related injuries are a major problem, but the aetiology of tendinopathies is unknown. In tendinopathies as well as during unaccustomed loading, intra-tendinous flow can be detected indicating that extensive loading can provoke intra-tendinous flow. The aim of present study is to evaluate the vascular response as indicated by colour Doppler (CD) activity in both the Achilles and patella tendon after loading during high-level badminton matches. The Achilles tendon was subdivided into a mid-tendon, pre-insertional, and insertional region and the anterior knee tendons into a quadriceps-, patella- and tuberositas region. Intra-tendinous flow was measured using both a semi-quantitative grading system (CD grading) and a quantitative scoring system (CF) on colour Doppler. Intra-tendinous flow in the Achilles and anterior knee tendons was examined in fourteen single players before tournament and after 1st and 2nd match, respectively on both the dominant and non-dominant side. All players had abnormal intra-tendinous flow (Colour Doppler ≥ grade 2) in at least one tendon in at least one scan during the tournament. At baseline, only two of the 14 players had normal flow in all the tendons examined. After 1st match, tendencies to higher intra-tendinous flow were observed in both the dominant patella tendon and non-dominant quadriceps tendon (P-values n.s.). After 2nd match, intra-tendinous flow was significant increased in the dominant patella tendon (P = 0.009). In all other locations, there was a trend towards a stepwise increase in intra-tendinous flow. The preliminary results indicate that high amount of intra-tendinous flow was found in elite badminton players at baseline and was increased after repetitive loading, especially in the patella tendon (dominant leg). The colour Doppler measurement can be used to determine changes in intra-tendinous flow after repetitive loading.
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Meknas K, Johansen O, Kartus J. Retro-trochanteric sciatica-like pain: current concept. Knee Surg Sports Traumatol Arthrosc 2011; 19:1971-85. [PMID: 21678093 PMCID: PMC3195768 DOI: 10.1007/s00167-011-1573-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Accepted: 05/31/2011] [Indexed: 12/05/2022]
Abstract
The aim of this manuscript is to review the current knowledge in terms of retro-trochanteric pain syndrome, make recommendations for diagnosis and differential diagnosis and offer suggestions for treatment options. The terminology in the literature is confusing and these symptoms can be referred to as 'greater trochanteric pain syndrome', 'trochanteric bursitis' and 'trochanteritis', among other denominations. The authors focus on a special type of sciatica, i.e. retro-trochanteric pain radiating down to the lower extremity. The impact of different radiographic assessments is discussed. The authors recommend excluding pathology in the spine and pelvic area before following their suggested treatment algorithm for sciatica-like retro-trochanteric pain.
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Affiliation(s)
- Khaled Meknas
- Department of Orthopaedics, University Hospital of North Norway, 9038 Tromsø, Norway.
| | - Oddmund Johansen
- Department of Orthopaedics, University Hospital of North Norway, 9038 Tromsø, Norway ,Institute of Clinical Medicine, Faculty of Medicine, University of Tromsø, Tromsø, Norway
| | - Jüri Kartus
- Department of Orthopaedics, NU-Hospital Organization, Trollhättan, Uddevalla, Sweden
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Yang X, Pugh ND, Coleman DP, Nokes LDM. Are Doppler studies a useful method of assessing neovascularization in human Achilles tendinopathy? A systematic review and suggestions for optimizing machine settings. J Med Eng Technol 2010; 34:365-72. [DOI: 10.3109/03091902.2010.497892] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Malliaras P, Voss C, Garau G, Richards P, Maffulli N. Achilles tendon shape and echogenicity on ultrasound among active badminton players. Scand J Med Sci Sports 2010; 22:149-55. [DOI: 10.1111/j.1600-0838.2010.01156.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Richards PJ, McCall IW, Day C, Belcher J, Maffulli N. Longitudinal microvascularity in Achilles tendinopathy (power Doppler ultrasound, magnetic resonance imaging time-intensity curves and the Victorian Institute of Sport Assessment-Achilles questionnaire): a pilot study. Skeletal Radiol 2010; 39:509-21. [PMID: 19711073 DOI: 10.1007/s00256-009-0772-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 06/17/2009] [Accepted: 07/27/2009] [Indexed: 02/02/2023]
Abstract
AIM To evaluate the imaging of the natural history of Achilles tendinopathy microvascularisation in comparison with symptoms, using a validated disease-specific questionnaire [the Victorian Institute of Sport Assessment-Achilles (VISA-A)]. METHOD A longitudinal prospective pilot study of nine patients with post-contrast magnetic resonance imaging (MRI), time-intensity curve (TIC) enhancement, ultrasound (US) and power Doppler (PD) evaluation of tendinopathy of the mid-Achilles tendon undergoing conservative management (eccentric exercise) over 1 year. RESULTS There were five men and four women [mean age 47 (range 30-62) years]. Six asymptomatic tendons with normal US and MRI appearance showed less enhancement than the tibial metaphysis did and showed a flat, constant, but very low rate of enhancement in the bone and Achilles tendon (9-73 arbitrary TIC units). These normal Achilles tendons on imaging showed a constant size throughout the year (mean 4.9 mm). At baseline the TIC enhancement in those with tendinopathy ranged from 90 arbitrary units to 509 arbitrary units. Over time, 11 abnormal Achilles tendons, whose symptoms settled, were associated with a reduction in MRI enhancement mirrored by a reduction in the number of vessels on power Doppler (8.0 to 2.7), with an improvement in morphology and a reduction in tendon size (mean 15-10.6 mm). One tendon did not change its abnormal imaging features, despite improving symptoms. Two patients developed contralateral symptoms and tendinopathy, and one had more abnormal vascularity on power Doppler and higher MRI TIC peaks in the asymptomatic side. CONCLUSIONS In patient with conservatively managed tendinopathy of the mid-Achilles tendon over 1 year there was a reduction of MRI enhancement and number of vessels on power Doppler, followed by morphological improvements and a reduction in size. Vessels per se related to the abnormal morphology and size of the tendon rather than symptoms. Symptoms improve before the Achilles size reduces and the restoration of normal imaging over time.
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Affiliation(s)
- Paula J Richards
- University Hospital of North Staffordshire NHS Trust (UHNS), Stoke on Trent, Staffordshire, UK.
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30
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Divani K, Chan O, Padhiar N, Twycross-Lewis R, Maffulli N, Crisp T, Morrissey D. Site of maximum neovascularisation correlates with the site of pain in recalcitrant mid-tendon Achilles tendinopathy. ACTA ACUST UNITED AC 2010; 15:463-8. [PMID: 20427222 DOI: 10.1016/j.math.2010.03.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Revised: 03/18/2010] [Accepted: 03/24/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Neovascularisation is associated with pain in Achilles tendinopathy (AT). The anatomical relationship between ultrasound (US)-defined indicators of tendinopathy and clinically determined pain sites has not been investigated. PURPOSE To measure the spatial correlation between the sites of maximum palpated tenderness, site of patient-indicated pain, maximum US-determined neovascularisation and maximum antero-posterior tendon thickness in patients with chronic recalcitrant AT (CRAT). METHODS A custom-designed measuring apparatus and clinical examination were used to measure the sites of maximum tenderness and subjectively defined pain on 29 tendons from patients diagnosed with mid-tendon CRAT. All tendons had been previously non-responsive to eccentric loading. Maximal neovascularisation and tendon thickness were measured by US scanning in conjunction with the measuring device. RESULTS A significant association exists between clinically determined pain and neovascularisation (r = 0.85, p < 0.001), patient reported pain (r = 0.91, p < 0.001), maximal tendon thickness (r = 0.91, p < 0.001), maximal thickness and maximal neovascularisation (r = 0.86, p < 0.001). CONCLUSION Sites of subjectively defined pain, clinically palpated tenderness, tendon thickness and neovascularisation are anatomically associated. Palpation can be reliably used as a clinical guide when planning interventions in patients with CRAT.
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Affiliation(s)
- Kiran Divani
- Centre for Sports and Exercise Medicine, Mile End Hospital, London E14DG, United Kingdom
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Mitchell AWM, Lee JC, Healy JC. The use of ultrasound in the assessment and treatment of Achilles tendinosis. ACTA ACUST UNITED AC 2009; 91:1405-9. [DOI: 10.1302/0301-620x.91b11.23060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of ultrasound in the diagnosis and management of disorders of the tendo Achillis is discussed. Some of the pathological processes which occur in Achilles tendinopathy can be identified by ultrasound, which may also be used to direct local treatment.
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Affiliation(s)
- A. W. M. Mitchell
- Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
| | - J. C. Lee
- Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
| | - J. C. Healy
- Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
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Sengkerij PM, de Vos RJ, Weir A, van Weelde BJG, Tol JL. Interobserver reliability of neovascularization score using power Doppler ultrasonography in midportion achilles tendinopathy. Am J Sports Med 2009; 37:1627-31. [PMID: 19359416 DOI: 10.1177/0363546509332255] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Power Doppler ultrasonography is widely used to examine neovascularization in midportion Achilles tendinopathy. The reliability of the grading of the degree of neovascularization has not been examined previously. HYPOTHESIS Power Doppler ultrasonography can be performed with a high interobserver reliability to determine the neovascularization score in patients with midportion Achilles tendinopathy. STUDY DESIGN Case control study (diagnosis); Level of evidence, 4. METHODS Thirty-three symptomatic and 17 asymptomatic Achilles tendons from 25 consecutive patients were included for ultrasound examination. Victorian Institute of Sport Assessment-Achilles score was used to assess the severity of the Achilles tendinopathy. Each tendon was scored twice by different radiologists using the modified Ohberg score for neovascularization. RESULTS The intraclass correlation coefficient for interobserver reliability was 0.85. Neovascularization was observed in 70% (23/33) of the symptomatic tendons and in 29% (5/17) of the asymptomatic tendons. The Spearman correlation coefficient between the Victorian Institute of Sport Assessment-Achilles score and the degree of neovascularization was - 0.16 (P = .10). CONCLUSION An excellent interobserver reliability was found for determining the degree of neovascularization on power Doppler ultrasonography examination. Neovessels were present in a majority of symptomatic tendons. The severity of symptoms was not correlated with the neovascularization score. CLINICAL RELEVANCE Power Doppler ultrasonography is widely used to evaluate tendinopathy without knowledge of the difference in observations between several testers. Interobserver reliability of the evaluation of the degree of neovascularization in chronic midportion Achilles tendinopathy is excellent.
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Miquel A, Molina V, Phan C, Lesavre A, Menu Y. [Ultrasound of the Achilles tendon after percutaneous repair]. ACTA ACUST UNITED AC 2009; 90:305-9. [PMID: 19421115 DOI: 10.1016/s0221-0363(09)72509-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate clinical and ultrasound (US) results following percutaneous repair of the Achilles tendon. MATERIALS AND METHODS Thirty-four patients underwent percutaneous Achilles tendon repair between 2004 and 2006. Seventeen patients (11 males and 6 females aged 30 to 59 years) underwent clinical and US follow-up at a mean of 15 months. US evaluation included assessment of the bilateral Achilles tendons with recording of maximum tendon diameter, echotexture, and presence of intratendonous neovascularization on power Doppler US. RESULTS On clinical evaluation, all patients were satisfied with the outcome and able to resume their normal level of activity. On US evaluation, there was no tendon discontinuity, and all tendons showed hypoechoic thickening with mean maximal diameter of 13 mm. Focal changes in echotexture were noted in 11 patients, hypoechoic in 5 cases and echogenic in 6 cases. A normal fibrillar echotexture was noted in 5 cases, at more than on eyear after surgery. Intratendonous neovascularization was present in 10 cases, mild in 6 cases, moderate in 2 cases and marked in 2 cases. The degree of neovascularization decreased with increasing postsurgical time. CONCLUSION Postsurgical Achilles tendons were characterized on US by hypoechoic thickening and loss of normal fibrillar echotexture. The presence of intratendonous neovascularization probably corresponds to postsurgical scarring that decreases over time.
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Affiliation(s)
- A Miquel
- Service de Radiologie, Hôpital Saint-Antoine, Paris, France.
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Crisp T, Khan F, Padhiar N, Morrissey D, King J, Jalan R, Maffulli N, Frcr OC. High volume ultrasound guided injections at the interface between the patellar tendon and Hoffa's body are effective in chronic patellar tendinopathy: A pilot study. Disabil Rehabil 2009; 30:1625-34. [PMID: 18608403 DOI: 10.1080/09638280701830936] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate a novel conservative management modality for patellar tendinopathy. METHODS We recruited nine patients with patellar tendinopathy who had failed conservative management and showed evidence of neovascularisation on power Doppler scanning. A high volume ultrasound guided injection at the interface between the patellar tendon and Hoffa's body. The injection contained 10 ml 0.5% Bupivacaine, 25 mg Hydrocortisone, and between 12 and 40 ml normosaline. 100 mm visual analogue scales (VAS) for pain and for function, and Victorian Institute of Sport Assessment - Patellar tendon (VISA-P) questionnaires at an average of 9 months from the injection. RESULTS All but one patient (whose pain was unchanged) improved (p = 0.028). The mean improvement in function 2 weeks after injection was 58 mm on VAS (interquartile range 27 - 88, p = 0.018). The mean improvement in pain 2 weeks after injection was 56 mm on a VAS scale (interquartile range 32 - 80, p = 0.018). At a mean follow up of 9 months, an improvement of 22 points from a baseline score of 46 on the VISA-P questionnaire (100 being normal) was established. CONCLUSION High volume injections to mechanically disrupt the neovascularisation in patellar tendinopathy are helpful in the management of this condition. Controlled trials would be warranted to investigate in a more conclusive fashion this management modality.
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Affiliation(s)
- Tom Crisp
- Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
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35
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Tan SC, Chan O. Achilles and patellar tendinopathy: current understanding of pathophysiology and management. Disabil Rehabil 2009; 30:1608-15. [PMID: 19005917 DOI: 10.1080/09638280701792268] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Achilles and patellar tendinopathy cause significant morbidity in professional and recreational athletes. Both the Achilles and patellar tendons are weight-bearing tendons that lack a true tendon sheath but are surrounded by paratenon. METHOD A review of the literature to outline the characteristics of tendinopathy in these two tendons, and to discuss current concepts of pathophysiology, use of imaging in the diagnosis and aid to clinical management strategies in tendinopathy. RESULTS Achilles and patellar tendinopathy share common histopathology such as intratendinous failed healing response and neoangiogenesis. CONCLUSION Achilles and patellar tendinopathy cause much morbidity in the athletic and non athletic population attending sports medicine and rheumatology clinics. Tendinopathy is essentially an 'overuse', degenerative condition. Neovascularisation evident on Doppler ultrasound correlates well with pain and poor function. Peritendinous injections and eccentric training decrease neovascularity, relieve pain and improve outcome. Although surgery is the last resort in those patients failing conservative management, it is still unclear how the removal of adhesions and excision of affected tendinopathic areas affects healing and vascularity, or resolves pain.
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Richards PJ, Braid JC, Carmont MR, Maffulli N. Achilles tendon ossification: pathology, imaging and aetiology. Disabil Rehabil 2009; 30:1651-65. [PMID: 18720126 DOI: 10.1080/09638280701785866] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND We report a patient with ossification of the Achilles tendon, presenting plain radiographs, ultrasound, power doppler, computed tomography and magnetic resonance findings. The majority of the tendon was ossified, and there was adjacent soft tissue oedema. The appearance of peritendinous oedema associated with ossification has not, to our knowledge, been reported in the literature, and could account for hindfoot pain in cases of tendon ossification. METHOD A review of 44 articles on aetiology, histology and imaging was performed. RESULTS Trauma, either accidental or from surgery, rather than tendinopathy is the likely aetiological factor. CONCLUSION The Achilles tendon usually responds to an insult with the development of mature bone, not dystrophic calcification, with no evidence of inflammatory or degenerative changes.
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Affiliation(s)
- Paula J Richards
- Department of Radiology, The University Hospital of North Staffordshire, Keele University, Stoke on Trent, UK.
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Chan O, O'Dowd D, Padhiar N, Morrissey D, King J, Jalan R, Maffulli N, Crisp T. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil 2009; 30:1697-708. [PMID: 18608362 DOI: 10.1080/09638280701788225] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To determine the effectiveness of high volume image guided injections (HVIGI) for chronic Achilles tendinopathy. METHODS We included in the study 30 consecutive patients (mean age 37.2 years, range 24 - 58 years) with Achilles tendinopathy for a mean of 35.8 months (range 2 - 276 months) who had failed to improve after a three-month programme of eccentric loading of the gastro-soleus complex. Patients were injected with 10 ml of 0.5% Bupivacaine Hydrochloride, 25 mg Hydrocortisone acetate, and up to 40 ml of injectable normal saline. A study-specific questionnaire and the Victorian Institute of Sport Assessment - Achilles tendon (VISA-A) were retrospectively administered to assess short- and long-term pain and functional improvement. RESULTS Some 21 patients (70%) responded. Patients reported significant short-term improvement at 4 weeks of both pain (mean change 50 mm, [SD 28, p < 0.0001], from a mean of 76 mm [SD 18.2], to a mean of 25 mm [SD 23.3]), and function scores (mean change 51 mm, [SD 31.2, p < 0.0001], from a mean of 78 mm [SD 20.8], to a mean of 27 mm [SD 28.4]). Patients also reported significant long-term improvement in symptoms using the VISA-A questionnaire (mean change 31.2 points, [SD = 28, p < 0.0001], from a mean of 44.8 points [SD 17.7], to a mean of 76.2 points [SD 24.6]) at a mean of 30.3 weeks from the injection. CONCLUSIONS HVIGI significantly reduces pain and improves function in patients with resistant Achilles tendinopathy in the short- and long-term.
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Affiliation(s)
- Otto Chan
- Department of Imaging, The London Independent Hospital, London, UK
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38
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Rompe JD, Furia JP, Maffulli N. Mid-portion Achilles tendinopathy--current options for treatment. Disabil Rehabil 2009; 30:1666-76. [PMID: 18608388 DOI: 10.1080/09638280701785825] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE To report on the present option for management of tendinopathy of the main body of the Achilles tendon. BACKGROUND Tendinopathy of the main body of tendo Achillis affects athletic and sedentary patients. Mechanical loading is thought to be a major causative factor. However, the exact mechanical loading conditions which cause tendinopathy are poorly defined. Repetitive mechanical loading induces a non-inflammatory pathology, and repetitive microtrauma ultimately exceeds the healing response. The management of Achilles tendinopathy is primarily conservative. Although many non-operative options are available, few have been tested under controlled conditions. This review article specifically focuses on eccentric training, and on shock wave therapy. Surgical intervention can be successful in refractory cases. However, surgery does not usually completely eliminate symptoms and complications are not rare. CONCLUSIONS Further studies are needed to discern the optimal non-operative and surgical management of midsubstance Achilles tendinopathy.
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Affiliation(s)
- Jan D Rompe
- OrthoTrauma Evaluation Center, Mainz, Germany
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39
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Smith J, Finnoff JT. Diagnostic and Interventional Musculoskeletal Ultrasound: Part 2. Clinical Applications. PM R 2009; 1:162-77. [DOI: 10.1016/j.pmrj.2008.09.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 09/30/2008] [Indexed: 10/21/2022]
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40
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Malliaras P, Richards PJ, Garau G, Maffulli N. Achilles tendon Doppler flow may be associated with mechanical loading among active athletes. Am J Sports Med 2008; 36:2210-5. [PMID: 18593843 DOI: 10.1177/0363546508319052] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tendon Doppler flow may be associated with tendon pain in symptomatic patients, but the relationship between Doppler flow and pain among athletes who are still competing is unclear. HYPOTHESIS Among active athletes, Doppler flow may partly reflect tendon adaptation to increased mechanical load and/or asymptomatic tendinopathy. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS The Achilles tendons of 61 badminton players (24 elite, 37 recreational) were examined with gray-scale and color Doppler ultrasound. Achilles tendon pain and activity level (badminton training, badminton playing, badminton years) were measured. RESULTS Doppler flow was not associated with current Achilles tendon pain but was associated with an increased anteroposterior tendon diameter (an indicator of tendinopathy) (P = .02). Athletes who had been playing badminton for longer were more likely to have Doppler flow (P < .01), and there was a trend toward an association between a greater number of badminton playing hours per week and Doppler flow (P = .07). CONCLUSION Achilles tendon Doppler flow appears to be a sign of asymptomatic tendinopathy rather than pain among active athletes. The association between weekly badminton hours and badminton years and Doppler flow suggests that Doppler flow may be a response to mechanical load in this cohort.
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Affiliation(s)
- Peter Malliaras
- School of Health Science and Social Care, Brunel University, Uxbridge, Middlesex, UK.
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Abstract
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.
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Knobloch K, de Vos RJ, Weir A, Tol JL. The use of a neovascularization score to predict clinical severity in Achilles tendinopathy. Am J Sports Med 2008; 36:395; author reply 395-7. [PMID: 18202299 DOI: 10.1177/0363546507312378] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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44
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Rudzki JR, Adler RS, Warren RF, Kadrmas WR, Verma N, Pearle AD, Lyman S, Fealy S. Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: age- and activity-related changes in the intact asymptomatic rotator cuff. J Shoulder Elbow Surg 2008; 17:96S-100S. [PMID: 18069013 DOI: 10.1016/j.jse.2007.07.004] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 06/18/2007] [Accepted: 07/05/2007] [Indexed: 02/01/2023]
Abstract
The natural history of the blood supply to the rotator cuff and its role in the etiology of rotator cuff disease has not been definitively established. To date, there has not been an in-vivo dynamic assessment of the baseline vascularity of the asymptomatic rotator cuff. This study was designed to test the hypothesis that regional variations in supraspinatus tendon vascularity exist with an age-dependent decrease in asymptomatic individuals with intact rotator cuffs. Lipid microsphere, contrast-enhanced ultrasound shoulder examinations were done in 31 patients with a mean age of 41.5 years (range, 22-65 years). Images were obtained at baseline, after contrast administration at rest, and after contrast administration following exercise to visualize the intratendinous blood flow to the supraspinatus tendon. Qualitative and quantitative analysis was performed by determining 4 regions of interest (bursal medial, articular medial, bursal lateral, and articular lateral) with quantification and analysis software (QLAB Philips, Andover, MA) to examine each region of interest and normalize data for interpretation of the mean intensity per pixel. A statistically significant decrease in blood flow to the supraspinatus tendon with age was observed in a comparative analysis of patients aged younger than 40 and older than 40, (P < .05 for all 4 zones after exercise and for the bursal medial, articular medial, and bursal lateral zones after exercise; P = .07 for the articular lateral zone after exercise). A statistically significant increase in blood flow with exercise was observed in an analysis of all patients (P < .001). The age-related decrease in the vascular supply of the tendon observed in this study is consistent with published reports demonstrating an increasing prevalence of rotator cuff pathology with age and may predispose to the development of rotator cuff tendinopathy and, ultimately, attritional tears.
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Affiliation(s)
- Jonas R Rudzki
- Sports Medicine & Shoulder Service, Hospital for Special Surgery, New York, NY, USA.
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45
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Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. J Bone Joint Surg Am 2008; 90:52-61. [PMID: 18171957 DOI: 10.2106/jbjs.f.01494] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative management of chronic tendinopathy of the Achilles tendon insertion has been poorly studied. With the recently demonstrated effectiveness of eccentric loading and of repetitive low-energy shock wave therapy in patients with midsubstance Achilles tendinopathy, the aim of the present randomized, controlled trial was to verify the effectiveness of both procedures exclusively in patients with insertional Achilles tendinopathy. METHODS Fifty patients with chronic (six months or more) recalcitrant insertional Achilles tendinopathy were enrolled in a randomized, controlled study. All patients had received treatment, including local injections of an anesthetic and/or corticosteroids, a prescription of nonsteroidal anti-inflammatory drugs, and physiotherapy, without success for at least three months. A computerized random-number generator was used to draw up an allocation schedule. Twenty-five patients were allocated to receive eccentric loading (Group 1), and twenty-five patients were allocated to treatment with repetitive low-energy shock wave therapy (Group 2). Analysis was on an intention-to-treat basis. Primary follow-up was at four months, and afterward patients were allowed to cross over. The last follow-up evaluation was at one year after completion of the initial treatment. The patients were assessed for pain, function, and activity with use of a validated questionnaire (the Victorian Institute of Sport Assessment-Achilles [VISA-A] questionnaire). RESULTS At four months from baseline, the mean VISA-A score had increased in both groups, from 53 to 63 points in Group 1 and from 53 to 80 points in Group 2. The mean pain rating decreased from 7 to 5 points in Group 1 and from 7 to 3 points in Group 2. Seven patients (28%) in Group 1 and sixteen patients (64%) in Group 2 reported that they were completely recovered or much improved. For all outcome measures, the group that received shock wave therapy showed significantly more favorable results than the group treated with eccentric loading (p = 0.002 through p = 0.04). At four months, eighteen of the twenty-five patients from Group I had opted to cross over, as did eight of the twenty-five patients from Group 2. The favorable results after shock wave therapy at four months were stable at the one-year follow-up evaluation. CONCLUSIONS Eccentric loading as applied in the present study showed inferior results to low-energy shock wave therapy as applied in patients with chronic recalcitrant tendinopathy of the insertion of the Achilles tendon at four months of follow-up. Further research is warranted to better define the indications for this treatment modality.
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Affiliation(s)
- Jan D Rompe
- OrthoTrauma Evaluation Center, Hans-Zoeller Strasse 83, D-55130 Mainz, Germany.
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Abstract
A number of imaging modalities are available for the assessment of soft tissue complaints. The strengths and advantages of each modality must be seen in the context of any corresponding weakness or disadvantage. The sensitivity and specificity of the imaging technique must also be understood. In this article, each main radiological technique will be considered in turn. Fundamental technical aspects and common variations of the basic imaging theme will be explained and their relative strengths and limitations will be explored. Typical common clinical uses in the context of soft-tissue complaints will be considered.
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Affiliation(s)
- Philip W P Bearcroft
- Department of Radiology, Box 219, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK.
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50
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James SLJ, Ali K, Pocock C, Robertson C, Walter J, Bell J, Connell D. Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. Br J Sports Med 2007; 41:518-21; discussion 522. [PMID: 17387140 PMCID: PMC2465422 DOI: 10.1136/bjsm.2006.034686] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the efficacy of ultrasound guided dry needling and autologous blood injection for the treatment of patellar tendinosis. DESIGN Prospective cohort study. SETTING Hospital/clinic based. PATIENTS 47 knees in 44 patients (40 men, 7 women, mean age 34.5 years, age range 17 to 54 years) with refractory tendinosis underwent sonographic examination of the patellar tendon following referral with a clinical diagnosis of patellar tendinosis (mean symptom duration 12.9 months). INTERVENTIONS Ultrasound guided dry needling and injection of autologous blood into the site of patellar tendinosis was performed on two occasions four weeks apart. MAIN OUTCOME MEASURES Pre- and post-procedure Victorian Institute of Sport Assessment scores (VISA) were collected to assess patient response to treatment. Follow up ultrasound examination was done in 21 patients (22 knees). RESULTS Therapeutic intervention led to a significant improvement in VISA score: mean pre-procedure score = 39.8 (range 8 to 72) v mean post procedure score = 74.3 (range 29 to 100), p<0.001; mean follow up 14.8 months (range 6 to 22 months). Patients were able to return to their sporting interests. Follow up sonographic assessment showed a reduction in overall tendon thickness and in the size of the area of tendinosis (hypoechoic/anechoic areas within the proximal patellar tendon). A reduction was identified in interstitial tears within the tendon substance. Neovascularity did not reduce significantly or even increased. CONCLUSIONS Dry needling and autologous blood injection under ultrasound guidance shows promise as a treatment for patients with patellar tendinosis.
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