Asymptomatic Achilles, patellar, and quadriceps tendinopathy: a longitudinal clinical and ultrasonographic study in elite fencers

Sonoelastography of the Achilles Tendon: Prevalence and Prognostic Value Among Asymptomatic Elite Australian Rules Football Players

OBJECTIVE

To investigate the prevalence of sonographic abnormalities at the mid-Achilles tendon among a cohort of asymptomatic professional football players and to determine whether these sonographic abnormalities predict midportion Achilles tendon symptoms.

DESIGN

Longitudinal study.

SETTING

A single competitive season in the Australian Rules Football League.

PARTICIPANTS

Forty-two elite Australian Rules football players.

MAIN OUTCOME MEASURES

Using ultrasound and sonoelastography, 42 players were examined at baseline and again 9 months later (postseason) for the existence of intratendinous hypoechogenicity, delamination, softening, and neovascularization. The anterio-posterior (AP) thickness and cross-sectional area (CSA) were measured. Players reporting Achilles tendon pain or with Victorian Institute of Sports Assessment-Achilles scores below 80 at the end of the season were classified as symptomatic.

RESULTS

At preseason, ultrasound and/or sonoelastographic abnormalities were found in 22 (22/42, 52.4%) asymptomatic players. Baseline AP thickness and CSA were significantly greater in symptomatic players at the end season than those in asymptomatic players (0.57 ± 0.05 cm vs 0.50 ± 0.03 cm; P < 0.001 and 0.67 ± 0.07 cm vs 0.57 ± 0.06 cm; P < 0.001, respectively). The presence of intratendinous softening and delaminations at baseline was associated with pain onset during the season (P = 0.046; P = 0.048, respectively).

CONCLUSIONS

Ultrasound and sonoelastography-detected abnormalities were relatively common among the asymptomatic footballers. Greater AP thickness and CSA and also the presence of intratendinous softening and delaminations were associated with the increased risk of developing symptoms.

CLINICAL RELEVANCE

Conventional ultrasound supplement with sonoelastography may be able to identify elite athletes at risk of Achilles tendon injury, which may, in turn, impact therapeutic decisions.

Evaluation of Achilles and patellar tendinopathy with greyscale ultrasound and colour Doppler: using a four-grade scale

PURPOSE

In tendon research, using ultrasound (US), studies often refer to tendon thickness, structural abnormalities and neovascularisation. The reliability concerning these measurements and evaluations is seldom reported. The aim of this study was to assess the intra- and inter-observer reliability for quantitative measures (thickness) and qualitative evaluations (structure and neovascularisation) of symptomatic and asymptomatic Achilles and patellar tendons with US and colour Doppler using a modified Öhberg score.

METHODS

Twenty-eight consecutive patients with symptomatic and asymptomatic Achilles (n = 27) and patellar tendons (n = 26) were included. Tendon anteroposterior thickness was measured. Tendon structure and neovascularisation were evaluated using a modified Öhberg score. US-images were evaluated twice by four independent observers.

RESULTS

Mean thickness for Achilles and patellar tendons was 8.4 mm (±2.0) and 5.5 mm (±1.7), respectively. The reliability for measures of distance was high all over (ICC = 0.963-0.999). A moderate-strong correlation was found between observers concerning evaluation of neovascularisation (r = 0.767-0.992) and poor-moderate correlation concerning evaluation of structural changes (r = 0.379-0.837). Intra-observer reliability was moderate strong for evaluations of both tendon structure (k = 0.537-0.873) and neovascularisation (k = 0.639-0.864).

CONCLUSIONS

With a strict method for how to measure tendon thickness and set criteria for evaluating structural changes and amount and distribution of neovascularisation, US and colour Doppler is a reliable method for evaluating Achilles and patellar tendons. The modified, 4-graded, Öhberg score was found to be a reproducible instrument for assessment of tendon structure and neovascularisation.

Different distributions of operative diagnoses for Achilles tendon overuse injuries in Italian and Finnish athletes

BACKGROUND

the origin of chronic Achilles tendinopathy (AT) is currently unclear and epidemiological factors, such as ethnicity, may be associated.

METHODS

intraoperative findings from the treatment of 865 Finnish and 156 Italian athletic patients with chronic Achilles tendon related pain were evaluated, retrospectively. The mean age was 34 years (range, 18 to 65 years) in the Finnish and 29 years (range, 17-63 years) in the Italian patients. In total, 786 patients were males and 226 females of which 84 and 87% Finnish, respectively. Data were collected, retrospectively from patient records. The differences in the frequencies of operative findings were assessed for statistical significance.

RESULTS

retrocalcaneal bursitis, partial tear and chronic paratenonitis were the most prevalent findings in patients with chronic AT undergoing surgery. Tendinosis and chronic paratenonitis were significantly (p=0.011) more common in Finnish athletes. Italian patients exhibited significantly (p<0.001) more insertional calcific tendinopathy (heel spurs) and prominent posterosuperior calcaneal corners (Haglund's heel).

CONCLUSION

ethnicity appears to be associated with specific characteristics of overuse-related Achilles tendon pathology. This is an issue that should be considered in the planning of genetic research on AT.

Sonoelastography of the distal third of the Achilles tendon in asymptomatic volunteers: correlation with anthropometric data, ultrasound findings and reproducibility of the method

OBJECTIVE

Evaluating prospectively elastosonographyc (EUS) findings of distal third of Achilles tendon in asymptomatic volunteers and correlating with subject characteristics and ultrasound (US) findings and, subsequently, calculating reproducibility of method.

MATERIALS AND METHODS

70 consecutives Achilles tendons were examined with US and EUS in 35 asymptomatic volunteers. Mean age 42.3 years (±7.6), 22 were female (mean age 41 ± 8.7) and 13 were male (mean age 42.5 ± 11.4). Information about population was collected (anthropometric data, sport activity, taken therapy and associated conditions/pathologies).

RESULTS

Statistically significant correlation was found between BMI and EUS findings (p = 0.007) and between EUS aspect and US diagnosis (p = 0.039) both to the right tendon. Possible influence of smoking (p = 0.063 to right) and associated conditions (p = 0. 059 to left), has been found. The multivariate analysis showed that EUS results are correlated only with BMI (high BMI corresponds to the best EUS results), independently from smoke and associated conditions on right side. No correlations have emerged for the left tendon. The 22.8 % of the volunteers took on chronic therapies, none statistically significant correlation. In the past, 80 % of subjects played sports (7.4 % agonistic and 92.6 % non-agonistic). The 22.9 % of volunteers played sporadic or no activity. The 60 % of volunteers has played sports that may lead overload of the Achilles tendon. The 61.5 % of subjects with BMI ≥ 25 was active little or nothing; 63.6 % of the subjects with BMI < 25 is playing sports. US examination showed 57.1 % normal tendons and 42.9 % tendinosic. Rate of tendinosic tendons was similar in both left and right (40 and 45.7 %, respectively). Statistically significant correlation was found between EUS aspect and US diagnosis on the right tendon but not on the left Correlation between thickness and EUS aspect was calculated: no correlation was found. Interoperator correlation was excellent (k = 0.89 for left tendon and k = 0.91 for right tendon).

CONCLUSIONS

The EUS is an interesting and useful technique, characterised by a high reproducibility. Its results are related to BMI and US appearance of the tendon, and they are probably influenced by the smoke and associated conditions. However, the flexed ankle position, needed to properly examine the distal third by US, alters the elasticity of the tendon and causes false negative results to EUS. Then, for the EUS study of the distal third, it would be appropriate the relaxed position, with a gel pad to optimise the probe adhesion.

Tendinopathy: Is Imaging Telling Us the Entire Story?

Synopsis Tendinopathy is frequently associated with structural disorganization within the tendon. As such, the clinical use of ultrasound and magnetic resonance imaging for tendinopathy has been the focus of numerous academic studies and clinical discussions. However, similar to other musculoskeletal conditions (osteoarthritis and intervertebral disc degeneration), there is no direct link between tendon structural disorganization and clinical symptoms, with findings on imaging potentially creating a confusing clinical picture. While imaging shows the presence and extent of structural changes within the tendon, the clinical interpretation of the images requires context in regard to the features of pain and the aggravating loads. This review will critically evaluate studies that have investigated the accuracy and sensitivity of imaging in the detection of clinical tendinopathy and the methodological issues associated with these studies (subject selection, lack of a robust gold standard, reliance on subjective measures). The advent of new imaging modalities allowing for the quantification of tendon structure or mechanical properties has allowed new critical insight into tendon pathology. A strength of these novel modalities is the ability to quantify properties of the tendon. Research utilizing ultrasound tissue characterization and sonoelastography will be discussed. This narrative review will also attempt to synthesize current research on whether imaging can predict the onset of pain or clinical outcome, the role of monitoring tendon structure during rehabilitation (ie, does tendon structure need to improve to get a positive clinical outcome?), and future directions for research, and to propose the clinical role of imaging in tendinopathy. J Orthop Sports Phys Ther 2015;45(11):842-852. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5880.

Does the adolescent patellar tendon respond to 5 days of cumulative load during a volleyball tournament?

Patellar tendinopathy (jumper's knee) has a high prevalence in jumping athletes. Excessive load on the patellar tendon through high volumes of training and competition is an important risk factor. Structural changes in the tendon are related to a higher risk of developing patellar tendinopathy. The critical tendon load that affects tendon structure is unknown. The aim of this study was to investigate patellar tendon structure on each day of a 5-day volleyball tournament in an adolescent population (16-18 years). The right patellar tendon of 41 players in the Australian Volleyball Schools Cup was scanned with ultrasound tissue characterization (UTC) on every day of the tournament (Monday to Friday). UTC can quantify structure of a tendon into four echo types based on the stability of the echo pattern. Generalized estimating equations (GEE) were used to test for change of echo type I and II over the tournament days. Participants played between eight and nine matches during the tournament. GEE analysis showed no significant change of echo type percentages of echo type I (Wald chi-square = 4.603, d.f. = 4, P = 0.331) and echo type II (Wald chi-square = 6.070, d.f. = 4, P = 0.194) over time. This study shows that patellar tendon structure of 16-18-year-old volleyball players is not affected during 5 days of cumulative loading during a volleyball tournament.

Light microscopic histology of quadriceps tendon ruptures

PURPOSE

To assess histological changes and possible differences in the quadriceps of patients undergoing open repair of the tendon after spontaneous rupture, and subjects with no history of tendon pathology.

MATERIALS

Biopsies were harvested from the quadriceps tendon of 46 patients (34 men, 12 women) who had reported unilateral atraumatic quadriceps tendon rupture and had undergone surgical repair of the tendon. Samples were also harvested from both the tendons in 11 (N = 11 × 2) patients, nine males and two females, dying from cardiovascular disorders. For each tendon, three slides were randomly selected and examined under light microscopy, and assessed using a semiquantitative grading scale (range 0-21) which considers fibre structure, fibre arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinisation.

RESULTS

The pathological sum-score averaged 19.2 ± 3.7 in ruptured tendons and 5.6 ± 2.0 in controls, and all variables considered were significantly different between the two groups, showing an association between tendon abnormalities and rupture (0.05 < P < 0.001).

CONCLUSION

This study confirms that the presence of histological degenerative changes in torn quadriceps tendons increases the risk of rupture.