Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment

Topical polidocanol application in combination with static stretching in tendinopathies: a prospective pilot study

BACKGROUND

Highly operator-based injection therapy with vasosclerosing and anesthetic polidocanol is used for tendinopathies. This pilot-study evaluates the topical application of polidocanol gel.

METHODS

Prospective case series. 39 patients with tendinopathies (14 Achilles, 14 patella, 11 wrist extensors) with a symptom duration > 6 months were included. Polidocanol and static stretching were the therapy in the first 2 weeks, while static stretching was continuously performed for 6 months. Clinical outcome was evaluated with VISA-A, VISA-P and DASH Scores and sonographically with B-Mode (B-Mode), Power Doppler (PD) and Shearwave Elastography (SWE).

RESULTS

22 patients clinically improved (>+10 score points), 11 patients were without improvement (<+ 10) and 1 patient worsened during 6 months. The VISA-A Score increased in average 19 points from 56 to 75 (p< 0.01), VISA-P Score increased 13 points from 59 to 72 (p< 0,01) and the DASH-Score decreased 20 points from 40 to 20 (p< 0,01). SWE correlates better than B-Mode or PD with symptom improvement.

CONCLUSION

The combination of static training and topical polidocanol application seems to be successful in the treatment of tendinopathies. Further RCT studies need to evaluate the efficiency of topical polidocanol application. SWE is a more sensitive tool to describe symptom development than PD or B-Mode.

LEVEL OF EVIDENCE

IV.

Tendon vascularity in overhead athletes with subacromial pain syndrome and its correlation with the resting subacromial space

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.

Acute effect of running exercise on physiological Achilles tendon blood flow

Sonographically detectable intratendinous blood flow (IBF) is found in 50%-88% of Achilles tendinopathy patients as well as in up to 35% of asymptomatic Achilles tendons (AT). Although IBF is frequently associated with tendon pathology, it may also represent a physiological regulation, for example, due to increased blood flow in response to exercise. Therefore, this study aimed to investigate the acute effects of a standardized running exercise protocol on IBF assessed with Doppler ultrasound (DU) "Advanced dynamic flow" in healthy ATs. 10 recreationally active adults (5 f, 5 m; 29±3 years, 1.72±0.12 m, 68±16 kg, physical activity 206±145 minute/wk) with no history of AT pain and inconspicious tendon structure performed 3 treadmill running tasks on separate days (M1-3) with DU examinations directly before and 5, 30, 60, and 120 minutes after exercise. At M1, an incremental exercise test was used to determine the individual anaerobic threshold (IAT). At M2 and M3, participants performed 30- minute submaximal constant load tests (CL₁ /CL₂ ) with an intensity 5% below IAT. IBF in each tendon was quantified by counting the number of vessels. IBF increased in five ATs from no vessels at baseline to one to four vessels solely detectable 5 minutes after CL₁ or CL₂ . One AT had persisting IBF (three vessels) throughout all examinations. Fourteen ATs revealed no IBF at all. Prolonged running led to a physiological, temporary appearance of IBF in 25% of asymptomatic ATs. To avoid exercise-induced IBF in clinical practice, DU examinations should be performed after 30 minutes of rest.

Nonsurgical Management of Midsubstance Achilles Tendinopathy

Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery.

Noninsertional Achilles Tendinopathy Pathologic Background and Clinical Examination

The term tendinopathy includes a series of pathologies, all of which have a combination of pain, swelling, and impaired performance. The terms tendinosis, tendinitis and peritendinitis are all within the main heading of tendinopathy; this terminology provides a more accurate understanding of the condition and highlights the uniformity of clinical findings while distinguishing the individual histopathological findings of each condition. Understanding the clinical features and the underlying histopathology leads to a more accurate clinical diagnosis and subsequent treatment selection. Misuse of the term tendinitis can lead to the underestimation of chronic degenerative nature of many tendinopathies, affecting the treatment selection.

Ex vivo evaluation of the effect of various surgical procedures on blood delivery to the patellar tendon of dogs

OBJECTIVE To determine the effect of arthrotomy alone or in combination with osteotomy of the proximal portion of the tibia on blood delivery to the patellar tendon of dogs. SAMPLE 24 canine cadavers. PROCEDURES One hind limb from each cadaver was assigned to 1 of 4 treatment groups: medial arthrotomy (MA; MA group), lateral arthrotomy (LA; LA group), MA and LA with tibial tuberosity transposition (MALA group), and MA with tibial plateau leveling osteotomy (TPLO; TPLO group). The contralateral hind limb served as the control sample. Contrast solution (barium [33%], India ink [17%], and saline [0.9% NaCl] solution [50%]) was injected through an 8F catheter inserted in the caudal portion of the abdominal aorta. Limbs were radiographed to allow examination of vascular filling. The patella, patellar tendon, and tibial crest were harvested, radiographed to allow examination of tissue vascular filling, and fixed in 4% paraformaldehyde. Vessels perfused with contrast solution were counted in sections obtained from the proximal, middle, and distal regions of each patellar tendon. RESULTS Vessel counts did not differ significantly among the 3 tendon regions. Compared with results for the control group, delivery of contrast solution to the patellar tendon was significantly decreased in the MALA and TPLO groups but was not changed in the MA or LA groups. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that surgical procedures used to treat cranial cruciate injuries (ie, TPLO) and patellar luxation decreased blood delivery to the patellar tendon of canine cadavers, at least acutely.

Utility of Ultrasonography in Assessing the Effectiveness of Extracorporeal Shock Wave Therapy in Insertional Achilles Tendinopathy

Introduction. The aim of this study was to investigate the utility of ultrasonography (US) for predicting and assessing the effectiveness of extracorporeal shock wave therapy (ESWT) in insertional Achilles tendinopathy (IAT). Methods. A total of 42 patients with an established diagnosis of chronic IAT were examined by US before ESWT and at 4 weeks and 12 weeks after ESWT. The thickness and cross-sectional area (CSA) of the Achilles tendon, size of calcific plaques, tendon structure score, and neovascularization score were measured at each time point. Results. After therapy, Victorian Institute of Sport Assessment-Achilles (VISA-A) scores increased significantly, and the size of calcific plaques decreased (P < 0.05). Neovascularization scores increased at the 4th week and then decreased at the 12th week (P < 0.05). The thickness, CSA, and structure of the Achilles tendon did not change. Variables observed by US at baseline were not associated with changes in VISA-A scores at follow-up. However, the changes in calcific plaque size and neovascularization scores were related to the improvement of VISA-A scores between pre- and posttherapy (P < 0.01). Conclusion. Ultrasonography can reveal some changes in the insertion of the Achilles tendon after ESWT, but the outcome of ESWT in IAT cannot be predicted by the variables observed by US.

Shear Wave Elastography (SWE) for the Evaluation of Patients with Tendinopathies

RATIONALE AND OBJECTIVES

Shear wave elastography (SWE) has been shown to be a powerful tool to estimate tissue stiffness. The aim of this study was to compare the diagnostic accuracy of SWE to that of standard ultrasound (US) (combined use of B-mode US and power Doppler [PD] US) for diagnosing tendinopathies.

MATERIALS AND METHODS

This is a prospective institutional review board-approved study on 112 participants (mean age 42 ± 13.4 years) with chronic (>6 months) tendon pain in Achilles, patellar, or epicondylar tendons. Participants were systematically examined with US, PD, and SWE using a high-resolution linear 15 MHz probe (SuperSonic Imagine). A semiquantitative analysis of SWE color charts and a quantitative region of interest-based analysis of tendon elasticity were performed. SWE values of symptomatic and healthy tendons were compared by using Student t test. Clinical symptom scores served as the standard of reference. US findings were compared to clinical symptom scores by using Spearman correlation.

RESULTS

At semiquantitative analysis of SWE color charts, symptomatic tendons were rated as "soft" in 80/140 (57.1%), as "intermediate" in 54/140 (38.6%), and as "rigid" in 6/140 (4.3%). Healthy tendons were rated as "soft" in 8/84 (10%), as "intermediate" in 31/84 (37%), and as "rigid" in 45/84 (53%). At quantitative analysis, symptomatic tendons exhibited significantly lower mean SWE values (60.3 kPa/4.48 m/s; range 15.3-201.4 kPa/2.26-14.18 m/s) than healthy tendons (185 kPa/7.85 m/s; range 56-265 kPa/4.32-9.23 m/s) (P = 0.0004). SWE values correlated closely with patients' clinical symptoms obtained by clinical scores (r = 0.81). Overall sensitivity of conventional US and PD in detecting tendinopathies could be enhanced from 67.1% (94/140) to 94.3% (132/140) when combined with SWE.

CONCLUSIONS

SWE is a simple way to estimate tissue stiffness and, by reduced tissue rigidity, to identify tendon pathology. SWE significantly increases the diagnostic accuracy of tendon sonography and may prove to be a sensitive tool to early detect or monitor tendinopathy.

Treatment of midportion Achilles tendinopathy: an evidence-based overview

In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made.

LEVEL OF EVIDENCE

IV.

Lower limb tendinopathy in athletes

Tendinopathy is a common and debilitating problem especially affecting athletes. Understanding of the disease has increased over the past two decades with the most notable change being in the perception that the pathology of tendinopathy is of a noninflammatory origin. The most prevalent aetiological factors implicated in the development of tendinopathy in athletes are overuse and training errors. The commonest lower limb tendinopathy affects the achilles tendon closely followed by patella tendinosis. Achilles tendinopathy is usually seen in running sports whereas patella tendinopathy is commoner in sports that involve jumping. The diagnosis can be confirmed by taking a good history and clinical examination and supported by appropriate radiological imaging. The investigations of choice are ultrasonography and magnetic resonance imaging with each of the investigations having some benefit over the other depending on the questions needing to be answered for the clinician. Treatment of lower limb tendinopathy is mainly conservative and includes activity modification, correction of training errors and eccentric exercises. To date, there have not been any conclusive studies to prove the benefits of nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids which are currently used to help in the management of pain. Surgical treatment has a variable success rate (45—100%) and is normally reserved as the last option if conservative modalities fail. Novel therapies like infection of sclerosing agent, Traumeel®, platelet-derived growth factors (PDGF) or autologous blood injections into diseased tendons are showing promising results but need more multicentre clinical trials to evaluate their efficacy.

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.

Ultrasound assessment for grading structural tendon changes in supraspinatus tendinopathy: an inter-rater reliability study

AIM

To evaluate the inter-rater reliability of measuring structural changes in the tendon of patients, clinically diagnosed with supraspinatus tendinopathy (cases) and healthy participants (controls), on ultrasound (US) images captured by standardised procedures.

METHODS

A total of 40 participants (24 patients) were included for assessing inter-rater reliability of measurements of fibrillar disruption, neovascularity, as well as the number and total length of calcifications and tendon thickness. Linear weighted κ, intraclass correlation (ICC), SEM, limits of agreement (LOA) and minimal detectable change (MDC) were used to evaluate reliability.

RESULTS

'Moderate-almost perfect' κ was found for grading fibrillar disruption, neovascularity and number of calcifications (k 0.60-0.96). For total length of calcifications and tendon thickness, ICC was 'excellent' (0.85-0.90), with SEM(Agreement) ranging from 0.63 to 2.94 mm and MDC(group) ranging from 0.28 to 1.29 mm. In general, SEM, LOA and MDC showed larger variation for calcifications than for tendon thickness.

CONCLUSIONS

Inter-rater reliability was moderate to almost perfect when a standardised procedure was applied for measuring structural changes on captured US images and movie sequences of relevance for patients with supraspinatus tendinopathy. Future studies should test intra-rater and inter-rater reliability of the method in vivo for use in clinical practice, in addition to validation against a gold standard, such as MRI.

TRIAL REGISTRATION NUMBER

NCT01984203; Pre-results.

Plantaris Excision and Ventral Paratendinous Scraping for Achilles Tendinopathy in an Athletic Population

BACKGROUND

Achilles tendinopathy is a frequent problem in high-level athletes. Recent research has proposed a combined etiologic role for the plantaris tendon and neovascularization. Both pathologies can be observed on ultrasound imaging.(1,13) However, little is known about the change in structure of the Achilles tendon following the surgical treatment of these issues. The purpose of the study was to assess if excising the plantaris and performing ventral paratendinous "scraping" of the neovascularization improved symptoms of Achilles tendinopathy and whether there was a change in the fibrillar structure of the tendon with ultrasound tissue characterization (UTC) following this operation.

METHODS

This prospective consecutive case series included 15 professional/semiprofessional athletes (17 Achilles tendons) who underwent plantaris excision and paratendinous scraping to treat noninsertional Achilles tendinopathy. The plantaris tendon was excised if adherent to the Achilles tendon, and the area of neovascularization for scraping was demarcated on preoperative imaging. Preoperative and postoperative Victorian Institute of Sports Assessment-Achilles (VISA-A) scores were taken. UTC was performed on 11 of 17 tendons preoperatively and postoperatively. The mean follow-up was for 25 months.

RESULTS

Fourteen of 15 patients had a successful outcome after the surgery. The mean VISA-A improved from 51 to 95 (p=.0001). There was a statistically significant (p=.04) improvement in the aligned fibrillar structure of the tendon confirmed with UTC scanning following surgery from 90% (±8) to 96% (±5).

CONCLUSION

This group of high-level athletes derived an excellent clinical result from this operation. Furthermore, UTC scanning offered an objective method to evaluate the healing of Achilles tendons.

LEVEL OF EVIDENCE

Level IV, case series.

Is Sonographic Assessment of Intratendinous Blood Flow in Achilles Tendinopathy Patients Reliable?: Consistency of Doppler Ultrasound Modes and Intra- and Inter-observer Reliability

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.

Are the Symptoms of Calcific Tendinitis Due to Neoinnervation and/or Neovascularization?

BACKGROUND

Calcific tendinitis can be a substantial cause of pain and dysfunction in the shoulder, and the pathophysiology is unclear. Recent studies have shown a link among nerve ingrowth, neovascularization, and pain in tendinopathy. The aim of this study was to determine whether there is evidence of neoinnervation and/or neovascularization in calcific tendinitis lesions of the shoulder.

METHODS

At arthroscopy, ultrasound was used to identify calcium within the tendon. Samples were taken from the supraspinatus tendon adjacent to the calcific lesion (in the calcific tendinitis group, with ten patients), the torn supraspinatus tendon of patients undergoing rotator cuff repair (the rotator cuff tear group, with ten patients), and the subscapularis tendon of patients undergoing a stabilization surgical procedure (the control group, with ten patients). Biopsied tendon samples were evaluated immunohistochemically by quantifying the presence of macrophages (using CD68 and CD206), T cells (CD3), mast cells (mast cell tryptase), vascular endothelium (CD34), and peripheral nerve markers (PGP 9.5).

RESULTS

There was a twofold to eightfold increase of nerve markers, neovascularization, macrophages, M2 macrophages, and mast cells in the calcific tendinitis group compared with the rotator cuff tear group (p < 0.001) and the control group (p < 0.001). Increased nerve counts positively correlated with more frequent extreme pain (r = 0.5, p < 0.01) and with increased neovascularization (r = 0.7, p < 0.01) and counts of CD68 macrophages (r = 0.8, p < 0.01), M2 macrophages (r = 0.6, p < 0.01), and mast cells (r = 0.7, p < 0.01).

CONCLUSIONS

This is the first study to show a significant increase in neovascularization and neoinnervation in calcific tendinitis lesions of the shoulder along with an eightfold increase in mast cells and macrophages. The findings are consistent with the hypothesis that, in calcific tendinitis, the calcific material is inducing a vigorous inflammatory response within the tendon with formation of new blood vessels and nerves.

CLINICAL RELEVANCE

This study helps to explain why calcific tendinitis is related to substantial pain in the clinical setting.

Ultrasound-guided intervention in the ankle and foot

In this comprehensive review, we discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, Morton's neuromas and Plantar fasciitis as well as techniques for intra-articular and peritendinous injections. We present the different imaging techniques and injectable agents that can be used in clinical practice, trying to help the reader decide the most appropriate way of managing the patient with a problem in the ankle and foot.

Clinical commentary of the evolution of the treatment for chronic painful mid-portion Achilles tendinopathy

The chronic painful Achilles tendon mid-portion was for many years, and still is in many countries, treated with intratendinous revision surgery. However, by coincidence, painful eccentric calf muscle training was tried, and it showed very good clinical results. This finding was unexpected and led to research into the pain mechanisms involved in this condition. Today we know that there are very few nerves inside, but multiple nerves outside, the ventral side of the chronic painful Achilles tendon mid-portion. These research findings have resulted in new treatment methods targeting the regions with nerves outside the tendon, methods that allow for a rapid rehabilitation and fast return to sports.

Perspectives in ultrasound-guided musculoskeletal interventions

Ultrasonography (USG) is a safe, easily available, and cost-effective modality, which has the additional advantage of being real time for imaging and image-guided interventions of the musculoskeletal system. Musculoskeletal interventions are gaining popularity in sports and rehabilitation for rapid healing of muscle and tendon injuries in professional athletes, healing of chronic tendinopathies, aspiration of joint effusions, periarticular bursae and ganglia, and perineural injections in acute and chronic pain syndromes. This article aims to provide an overview of the spectrum of musculoskeletal interventions that can be done under USG guidance both for diagnostic and therapeutic purposes.

WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY?

Achilles Tendinopathy is a complex problem, with the most common conservative treatment being eccentric exercises. Despite multiple studies assessing this treatment regime little is known about the mechanism of effect. This lack of understanding may be hindering therapeutic care and preventing optimal rehabilitation. Of the mechanisms proposed, most relate to tendon adaptation and fail to consider other possibilities. The current consensus is that tendon adaptation does not occur within timeframes associated with clinical improvements, therefore the clinical benefits must occur through another unidentified pathway. This clinical commentary critically reviews each of the proposed theories and highlights that muscle alterations are observed prior to onset of Achilles Tendinopathy and during the disease. Evidence shows that the observed muscle alterations change with treatment and that these adaptations have the ability to reduce tendon load and thereby improve tendon health. The purpose of this clinical commentary is to review previous theories regarding the mechanisms by which eccentric exercise might affect Achilles tendinopathy and offers a novel mechanism by which the plantarflexor muscles may shield the Achilles tendon.

LEVEL OF EVIDENCE

5.

Sclerosing injections and ultrasound-guided arthroscopic shaving for patellar tendinopathy: good clinical results and decreased tendon thickness after surgery-a medium-term follow-up study

PURPOSE

Treatment of patellar tendinopathy/jumper's knee with ultrasound-guided sclerosing injections or ultrasound-guided arthroscopic shaving has shown good clinical short-term results. Former studies indicate that the tendon thickness and structure stays unaffected after successful treatment. The aim of this study was to evaluate the sonographic findings and clinical outcome 3-5 years after treatment of patellar tendinopathy with ultrasound-guided sclerosing injections or arthroscopic shaving.

METHODS

Fifty-seven patellar tendons (43 patients) with chronic patellar tendinopathy were evaluated, with ultrasound, colour Doppler (CD) and visual analogue scale (VAS) for pain and satisfaction with treatment, 3-5 years after treatment. Functional status was evaluated with a single question-"Back in full loading activity?" yes or no.

RESULTS

At endpoint (mean 46 months), there was a significant decrease in anteroposterior thickness of the proximal patellar tendon in patients treated with ultrasound-guided arthroscopic shaving but not after sclerosing injections. Tendon structure had improved, and CD local blood flow had diminished significantly in both groups. There were good clinical results with a significant decrease in VAS for pain after sclerosing injections (VAS 64 ± 18 → 17 ± 23) with 74 % satisfied patients and also after arthroscopic shaving (VAS 77 ± 16 → 13 ± 23) with 80 % satisfied patients. There were no significant differences in VAS between groups. A significant correlation between low local blood flow and high patient satisfaction was found.

CONCLUSIONS

Tendon thickness decreased over time after ultrasound-guided arthroscopic shaving, and tendon structure and local blood flow decreased after both treatments. There were good, and similar, clinical results with both methods.

LEVEL OF EVIDENCE

III.

Effect of autologous adipose tissue-derived mesenchymal stem cells on neovascularization of artificial equine tendon lesions

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.

Healing of donor site in bone-tendon-bone ACL reconstruction accelerated with plasma rich in growth factors: a randomized clinical trial

PURPOSE

To determine whether the use of plasma rich in growth factors accelerates healing of the donor site in bone-tendon-bone anterior cruciate ligament (ACL) reconstruction (patellar graft). The use of the patellar graft presents post-operative problems such as anterior knee pain, which limits its use and leads to preference being taken for alternative grafts.

METHODS

A double-blind, randomized, clinical trial was performed comparing two groups of patients who underwent ACL reconstruction using patellar tendon graft and comparing the use of plasma rich in growth factors at the donor site after graft harvest in terms of local regeneration by ultrasound assessment.

RESULTS

The plasma rich in growth factors group shows earlier donor site regeneration in comparison with the control group (2 months earlier), with significant differences in the first 4 months of the follow-up.

CONCLUSION

The application of plasma rich in growth factors shows accelerated tissue regeneration processes with respect to the control group. This fact, together with the previously published with similar conclusions, can create a knowledge basis in order to set out new recovery guidelines following ACL reconstruction.

LEVEL OF EVIDENCE

Therapeutic study, Level I.

Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes

Achilles (AT) and patellar tendons (PT) are commonly affected by tendinopathy in adult athletes but prevalence of symptoms and morphological changes in adolescents is unclear. The study aimed to determine prevalence of tendinopathy and intratendinous changes in ATs and PTs of adolescent athletes. A total of 760 adolescent athletes (13.0 ± 1.9 years; 160 ± 13 cm; 50 ± 14 kg) were examined. History, local clinical examination, and longitudinal Doppler ultrasound analysis for both ATs and PTs were performed including identification of intratendinous echoic changes and vascularization. Diagnosis of tendinopathy was complied clinically in case of positive history of tendon pain and tendon pain on palpation. Achilles tendinopathy was diagnosed in 1.8% and patellar tendinopathy in 5.8%. Vascularizations were visible in 3.0% of ATs and 11.4% of PTs, hypoechogenicities in 0.7% and 3.2% as well as hyperechogenicities in 0% and 0.3%, respectively. Vascularizations and hypoechogenicities were statistically significantly more often in males than in females (P ≤ 0.02). Subjects with patellar tendinopathy had higher prevalence of structural intratendinous changes than those without PT symptoms (P ≤ 0.001). In adolescent athletes, patellar tendinopathy is three times more frequent compared with Achilles tendinopathy. Longitudinal studies are necessary to investigate physiological or pathological origin of vascularizations and its predictive value in development of tendinopathy.

Differences between the cell populations from the peritenon and the tendon core with regard to their potential implication in tendon repair

The role of intrinsic and extrinsic healing in injured tendons is still debated. In this study, we characterized cell plasticity, proliferative capacity, and migration characteristics as proxy measures of healing potential in cells derived from the peritenon (extrinsic healing) and compared these to cells from the tendon core (intrinsic healing). Both cell populations were extracted from horse superficial digital flexor tendon and characterized for tenogenic and matrix remodeling markers as well as for rates of migration and replication. Furthermore, colony-forming unit assays, multipotency assays, and real-time quantitative polymerase chain reaction analyses of markers of osteogenic and adipogenic differentiation after culture in induction media were performed. Finally, cellular capacity for differentiation towards a myofibroblastic phenotype was assessed. Our results demonstrate that both tendon- and peritenon-derived cell populations are capable of adipogenic and osteogenic differentiation, with higher expression of progenitor cell markers in peritenon cells. Cells from the peritenon also migrated faster, replicate more quickly, and show higher differentiation potential toward a myofibroblastic phenotype when compared to cells from the tendon core. Based on these data, we suggest that cells from the peritenon have substantial potential to influence tendon-healing outcome, warranting further scrutiny of their role.

Current concepts in examination and treatment of elbow tendon injury

Context:

Injuries to the tendons of the elbow occur frequently in the overhead athlete, creating a significant loss of function and dilemma to sports medicine professionals. A detailed review of the anatomy, etiology, and pathophysiology of tendon injury coupled with comprehensive evaluation and treatment information is needed for clinicians to optimally design treatment programs for rehabilitation and prevention.

Evidence Acquisitions:

The PubMed database was searched in January 2012 for English-language articles pertaining to elbow tendon injury.

Results:

Detailed information on tendon pathophysiology was found along with incidence of elbow injury in overhead athletes. Several evidence-based reviews were identified, providing a thorough review of the recommended rehabilitation for elbow tendon injury.

Conclusions:

Humeral epicondylitis is an extra-articular tendon injury that is common in athletes subjected to repetitive upper extremity loading. Research is limited on the identification of treatment modalities that can reduce pain and restore function to the elbow. Eccentric exercise has been studied in several investigations and, when coupled with a complete upper extremity strengthening program, can produce positive results in patients with elbow tendon injury. Further research is needed in high-level study to delineate optimal treatment methods.

Dynamic contrast enhanced magnetic resonance imaging in chronic Achilles tendinosis

Background

Chronic Achilles tendinosis is a common problem. When evaluating and comparing different therapies there is a need for reliable imaging methods. Our aim was to evaluate if chronic Achilles tendinosis affects the dynamic contrast-enhancement in the tendon and its surroundings and if short-term eccentric calf-muscle training normalizes the dynamic contrast-enhancement.

Methods

20 patients with chronic Achilles tendinopathy were included. Median duration of symptoms was 31 months (range 6 to 120 months). Both Achilles tendons were examined with dynamic contrast enhanced MRI before and after a 12- week exercise programme of eccentric calf-muscle training. The dynamic MRI was evaluated in tendon, vessel and in fat ventrally of tendon. Area under the curve (AUC), time to peak of signal, signal increase per second (SI/s) and increase in signal between start and peak as a percentage (SI%) was calculated. Pain and performance were evaluated using a questionnaire.

Results

In the fat ventrally of the tendon, dynamic contrast enhancement was significantly higher in the symptomatic leg compared to the contralateral non-symptomatic leg before but not after treatment. Despite decreased pain and improved performance there was no significant change of dynamic contrast enhancement in symptomatic tendons after treatment.

Conclusion

In Achilles tendinosis there is an increased contrast enhancement in the fat ventrally of the tendon. The lack of correlation with symptoms and the lack of significant changes in tendon contrast enhancement parameters do however indicate that dynamic enhanced MRI is currently not a useful method to evaluate chronic Achilles tendinosis.

Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle?

PURPOSE

The purpose of the study is to explain the cause-effect relationship in three patients who reported combined ruptures of the Achilles tendon and the gastrosoleus complex 6 months after they had received corticosteroids injections for the management of retrocalcaneal bursitis.

METHODS

Three cryopreserved cadavers (three men, three left legs) were examined to assess the anatomic connection between the retrocalcaneal bursa and the Achilles tendon (distal and anterior fibers). Blue triptan medium contrast was injected.

RESULTS

An unexpected connection between the retrocalcaneal bursa and the anterior fibers of the Achilles tendon was found in all instances.

CONCLUSIONS

Local corticosteroid injection of the retrocalcaneal bursa may help the symptoms of retrocalcanear bursitis, but pose a risk of Achilles tendon rupture. This risk-benefit has to be taken into account when corticosteroid injections are prescribed to professional and high-level athletes.

New objective findings after whiplash injuries: High blood flow in painful cervical soft tissue: An ultrasound pilot study

Background

The presence of high blood flow in the structurally abnormal and painful regions of tendinosis, but not in the normal pain-free tendons, was recently confirmed by colour Doppler (CD) ultrasound (US). Biopsies from the regions with high blood flow demonstrated the presence of sympathetic and sensitive nerve fibres juxtapositioned to neovessels. Grey-scale US and CD are reliable methods used to evaluate structural homogeneity, thickness, and blood flow in the peripheral tendons. The aim of this study was to utilize CD to qualitatively evaluate for the presence of abnormal high blood flow in paravertebral tissues after whiplash injuries in patients with chronic neck pain.

Methods

Twenty patients with chronic neck pain after whiplash-associated disorder (WAD) and 20 pain-free control subjects were included in the study. The same experienced radiologist performed all grey-scale US and CD examinations.

Results

More regions with high blood flow were observed in the patient group than in the control group. At all levels, the high blood flow pattern was detected at the enthesis of the spinous processes and bilaterally juxtapositioned to the facet joints.

Conclusion

All regions identified by the patients as painful and tender corresponded to the positive high blood flow found during the CD examination.

Implications

These findings document increased blood-flow/neovascularisation at insertions of neck muscles which may indicate that there are pathological neovascularisation with accomanying pain-and sympathetic nerves, similar to what has been found in Achilles-tendinosis. These findings promise that similar treatments that now is successful with Achilles tendinosis, may be effective in the WAD-painful muscle insertions of the neck.

The management of bilateral high hamstring tendinopathy with ASTYM® treatment and eccentric exercise: a case report

High hamstring tendinopathy (HHT) is an overuse injury that occurs most commonly in runners. The management of HHT is often challenging and the research supporting many interventions is limited. Eccentric exercise has been proven effective in the treatment of various tendinopathies but has not been thoroughly studied with HHT. Soft tissue mobilization, including ASTYM, is often utilized in the treatment of tendinopathies, though there is limited evidence supporting this approach. The purpose of this paper is to present the case of a patient referred to physical therapy with bilateral HHT. The patient was a 41-year-old recreational runner that had an insidious onset of right buttock pain 12 months prior to initiating therapy and left buttock pain 9 months prior. Her primary complaints included an inability to run, pain with prolonged or brisk walking, and pain with sitting on hard surfaces. The patient was treated in physical therapy two times per week for 16 visits with treatment focused on eccentric hamstring strengthening and ASTYM. By her eighth visit, the patient was able to walk 2·5 miles without pain and by her 12 visit, she was able to jog 1 mile before the onset of pain. After 16 visits, the patient reported that she was approximately 95% improved, was able to run 2·5 miles without pain, and had no pain with sitting on hard surfaces. This case suggests that eccentric exercise combined with ASTYM may be an effective treatment for HHT.

What is the best clinical test for Achilles tendinopathy?

BACKGROUND

Differential diagnosis of Achilles pathology is demanding. This study evaluates the diagnostic accuracy of clinical tests identified for a chronic mid body Achilles tendinopathy. Ultrasound scanning provides the reference standard.

METHODS

Twenty-one participants with, and without, an Achilles tendinopathy, had an ultrasound scan followed immediately by the application of ten clinical tests. The accuracy and reproducibility of each test was determined.

RESULTS

The most valid tests are; pain on palpation of the tendon (sensitivity 84%, specificity 73%, kappa 0.74-0.96) and the subjective reporting of pain 2-6 cm above the insertion into the calcaneum (sensitivity 78%, specificity 77%, kappa 0.75-0.81).

CONCLUSION

Only location of pain and pain on palpation were found to be sufficiently reliable and accurate, to be recommended for use.

Interventional musculoskeletal US: an update on materials and methods

Pain is one of the most common causes of reduced productivity. The annual cost of health-related reductions in productivity has been estimated at approximately 225 billion dollars in the United States alone. Ultrasound-guided locoregional infiltration procedures have frequently been shown to offer economical, effective, lasting relief of pain. In-depth familiarity with the equipment (probes and needles) and techniques used to perform these procedures are fundamental for safe, effective treatment. In fact, depending on the characteristics of the patient and the clinical problem, the approach and technique may have to be modified to simplify the procedure and ensure better results. Up-to-date knowledge of the drugs used for these infiltrations (indications, how they are used) is equally important. Our aim is to provide an update on the techniques and materials used in interventional musculoskeletal ultrasonography based on a review of the most recent literature as well as on our personal experience.

Intense pulsed light treatment of chronic mid-body Achilles tendinopathy

We conducted a randomised controlled trial to determine whether active intense pulsed light (IPL) is an effective treatment for patients with chronic mid-body Achilles tendinopathy. A total of 47 patients were randomly assigned to three weekly therapeutic or placebo IPL treatments. The primary outcome measure was the Victorian Institute of Sport Assessment – Achilles (VISA-A) score. Secondary outcomes were a visual analogue scale for pain (VAS) and the Lower Extremity Functional Scale (LEFS). Outcomes were recorded at baseline, six weeks and 12 weeks following treatment. Ultrasound assessment of the thickness of the tendon and neovascularisation were also recorded before and after treatment.

There was no significant difference between the groups for any of the outcome scores or ultrasound measurements by 12 weeks, showing no measurable benefit from treatment with IPL in patients with Achilles tendinopathy.

Cite this article: Bone Joint J 2013;95-B:504–9.

Reparable rotator cuff tears with concomitant long-head biceps lesions: tenotomy or tenotomy/tenodesis?

PURPOSE

The aim of the study was to determine clinical, functional, and radiological results of two groups of patients affected by rotator cuff tear with concomitant degeneration of the long head of the biceps tendon treated with tenotomy/tenodesis or tenotomy.

METHODS

Sixty-five patients were randomly assigned to group A (35 patients, tenotomy/tenodesis) and group B (30 patients, tenotomy). All patients underwent physical examination and simple shoulder test and Constant score scales. Moreover, they underwent dynamometric tests and power Doppler ultrasonography in order to evaluate the exact location of the long-head biceps and the vascularization of the repaired rotator cuff and of the long-head biceps.

RESULTS

Physical examination and clinical evaluation scales showed satisfactory results in both groups, with no significant differences (n.s.). Popeye sign was detected in 5 patients (17%) of group B and in no one patient of group A. Ultrasound examination showed the LHB within the bicipital groove in 80% of group A and group B. Power Doppler ultrasonography showed signs of vascularization of the LHB in 20% of patients of group A and in 40% of group B and signs of vascularization of the repaired rotator cuff in 28% of group A and 40% of group B.

CONCLUSIONS

Long head of the biceps tenotomy combined with tenodesis does not provide any significant clinical or functional improvement than isolated tenotomy. However, the incidence of the Popeye sign is significantly higher, even though not associated with any functional disfunction.

LEVEL OF EVIDENCE

Therapeutic study, Level II.

The volume of the neovascularity and its clinical implications in achilles tendinopathy

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.

Tendinopathy in sport

CONTEXT

Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited.

EVIDENCE ACQUISITION

The authors conducted a MEDLINE search on tendinopathy, or "tendonitis" or "tendinosis" or "epicondylitis" or "jumpers knee" from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature.

RESULTS

Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies.

CONCLUSIONS

Novel targeted therapies are emerging, but multicenter trials are needed to confirm the results of exercise and mini-invasive treatments.

Treatment of patellar tendinopathy--a systematic review of randomized controlled trials

PURPOSE

Patellar tendinopathy is a common, painful, overuse disorder. Although many different treatment methods have been described, there is no consensus regarding the optimal treatment for this condition. The purpose of this study was to systematically review, summarize, and compare treatments for patellar tendinopathy from published randomized controlled trials.

METHODS

Database searches were performed for randomized prospective controlled trials comparing treatment methods for patellar tendinopathy. The thirteen articles considered relevant were scrutinized according to quality assessment guidelines and levels of evidence.

RESULTS

Strong evidence was found for the use of eccentric training to treat patellar tendinopathy. Moderate evidence was found for conservative treatment (heavy slow resistance training) as an alternative to eccentric training. Moderate evidence suggests that low-intensity pulsed ultrasound treatment did not influence treatment outcomes. Limited evidence was found for surgery, sclerosing injections, and shockwave therapy.

CONCLUSION

Physical training, and particularly eccentric training, appears to be the treatment of choice for patients suffering from patellar tendinopathy. However, type of exercise, frequency, load, and dosage must also be analyzed. Other treatment methods, such as surgical treatment, sclerosing injections, and shockwave therapy, must be investigated further before recommendations can be made regarding their use. Ultrasound can likely be excluded as a treatment for patellar tendinopathy. There is a persistent lack of well-designed studies with sufficiently long-term follow-up and number of patients to draw strong conclusions regarding therapy.

LEVEL OF EVIDENCE

II.