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Hutchison AM, Evans R, Bodger O, Pallister I, Topliss C, Williams P, Vannet N, Morris V, Beard D. What is the best clinical test for Achilles tendinopathy? Foot Ankle Surg 2013; 19:112-7. [PMID: 23548453 DOI: 10.1016/j.fas.2012.12.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 11/20/2012] [Accepted: 12/14/2012] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Anne-Marie Hutchison
- Department of Physiotherapy, Trauma and Orthopaedics, Morriston Hospital, Abertawe Bro Morgannwg University Health Board and College of Medicine, Swansea University, Wales, United Kingdom.
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Abstract
The incidence of AT rupture has increased in recent decades. AT ruptures frequently occur in the third or fourth decade of life in sedentary individuals who play sport occasionally. Ruptures also occur in elite athletes. Clinical examination must be followed by imaging. Conservative management and early mobilization can achieve excellent results, but the rerupture rate is not acceptable for the management of young, active, or athletic individuals. Open surgery is the most common option for AT ruptures, but there are risks of superficial skin breakdown and wound problems. These problems can be prevented with percutaneous repair.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, Trigoria, Rome 00128, Italy.
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Fernández-Sarmiento JA, Domínguez JM, Granados MM, Morgaz J, Navarrete R, Carrillo JM, Gómez-Villamandos RJ, Muñoz-Rascón P, Martín de Las Mulas J, Millán Y, García-Balletbó M, Cugat R. Histological study of the influence of plasma rich in growth factors (PRGF) on the healing of divided Achilles tendons in sheep. J Bone Joint Surg Am 2013; 95:246-55. [PMID: 23389788 DOI: 10.2106/jbjs.k.01659] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The use of plasma rich in growth factors (PRGF) has been proposed to improve the healing of Achilles tendon injuries, but there is debate about the effectiveness of this therapy. The objective of the present study was to evaluate the histological effects of PRGF, which is a type of leukocyte-poor platelet-rich plasma, on tendon healing. METHODS The Achilles tendons of twenty-eight sheep were divided surgically. The animals were randomly divided into four groups of seven animals each. The repaired tendons in two groups received an infiltration of PRGF intraoperatively and every week for the following three weeks under ultrasound guidance. The tendons in the other two groups received injections with saline solution. The animals in one PRGF group and one saline solution group were killed at four weeks, and the animals in the remaining two groups were killed at eight weeks. The Achilles tendons were examined histologically, and the morphometry of fibroblast nuclei was calculated. RESULTS The fibroblast nuclei of the PRGF-treated tendons were more elongated and more parallel to the tendon axis than the fibroblast nuclei of the tendons in the saline solution group at eight weeks. PRGF-treated tendons showed more packed and better oriented collagen bundles at both four and eight weeks. In addition to increased maturation of the collagen structure, fibroblast density was significantly lower in PRGF-infiltrated tendons. PRGF-treated tendons exhibited faster vascular regression than tendons in the control groups, as demonstrated by a lower vascular density at eight weeks. CONCLUSIONS PRGF was associated with histological changes consistent with an accelerated early healing process in repaired Achilles tendons in sheep after experimental surgical disruption. PRGF-treated tendons showed improvements in the morphometric features of fibroblast nuclei, suggesting a more advanced stage of healing. At eight weeks, histological examination revealed more mature organization of collagen bundles, lower vascular densities, and decreased fibroblast densities in PRGF-treated tendons than in tendons infiltrated with saline solution. These findings were consistent with a more advanced stage of the healing process. CLINICAL IMPLICATIONS Based on the findings in this animal model, PRGF infiltration may improve the early healing process of surgically repaired Achilles tendons.
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Affiliation(s)
- J Andrés Fernández-Sarmiento
- Department of Animal Medicine and Surgery, University of Córdoba, Campus de Rabanales, Ctra. Madrid - Km 396, 14014, Córdoba, Spain.
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154
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Millar NL, Murrell GAC, McInnes IB. Alarmins in tendinopathy: unravelling new mechanisms in a common disease. Rheumatology (Oxford) 2013; 52:769-79. [DOI: 10.1093/rheumatology/kes409] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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155
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BARDAŞ CIPRIAN, BENEA HOREA, MARTIN ARTUR, TOMOAIA GHEORGHE. The traumatic rupture of the Achilles' tendon - an analysis of the modern methods of evaluation and treatment. CLUJUL MEDICAL (1957) 2013; 86:128-32. [PMID: 26527933 PMCID: PMC4462436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 04/07/2013] [Accepted: 04/08/2013] [Indexed: 11/17/2022]
Abstract
AIMS The main aim of this article is an analysis of both advantages and disadvantages of the modern solutions of treatment - percutaneous surgery, in comparison with the classic methods of treatments described in the surgery of Achilles' tendon. PATIENTS AND METHOD The study was conducted on 23 patients admitted to the Orthopedics and Traumatology Clinic of Cluj-Napoca between January 2011-June 2012. Nineteen (19) patients were diagnosed with a complete rupture of the Achilles tendon and 4 patients with a partial rupture. The diagnosis of traumatic Achilles tendon ruptures was usually clinical, the Ultrasound (common or 3D) and the MRI confirmed the lesion and determined its location and extension. We analyzed the diagnostic methods, the elapsed time before surgery, the treatment options depending on lesion's location, technical difficulties, costs, postoperative care, the average healing time, complications. RESULTS The Ultrasound was performed in 65.2% of the patients (15 patients) for confirming the extension of the lesion and it served for pre-operative planning. In most of the cases, the classical methods of Achilles tendon reconstruction were used (18 cases). The complications rate was about 8%. We diagnosed an iterative Achilles tendon rupture (the patient was initially treated using the percutaneous methods) and a delay in cicatrisation. CONCLUSIONS The percutaneous surgical techniques are a viable alternative for the acute ruptures of Achilles tendon, the classic intervention has clear indications in lesions diagnosed late, in the recurrent tendon ruptures.
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156
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Spaas JH, Guest DJ, Van de Walle GR. Tendon Regeneration in Human and Equine Athletes. Sports Med 2012; 42:871-90. [DOI: 10.1007/bf03262300] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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157
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Acupuncture for chronic achilles tendnopathy: A randomized controlled study. Chin J Integr Med 2012; 19:900-4. [DOI: 10.1007/s11655-012-1218-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Indexed: 10/27/2022]
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158
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Heat shock proteins in tendinopathy: novel molecular regulators. Mediators Inflamm 2012; 2012:436203. [PMID: 23258952 PMCID: PMC3507314 DOI: 10.1155/2012/436203] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 09/25/2012] [Indexed: 11/26/2022] Open
Abstract
Tendon disorders—tendinopathies—are the primary reason for musculoskeletal consultation in primary care and account for up to 30% of rheumatological consultations. Whilst the molecular pathophysiology of tendinopathy remains difficult to interpret the disease process involving repetitive stress, and cellular load provides important mechanistic insight into the area of heat shock proteins which spans many disease processes in the autoimmune community. Heat shock proteins, also called damage-associated molecular patterns (DAMPs), are rapidly released following nonprogrammed cell death, are key effectors of the innate immune system, and critically restore homeostasis by promoting the reconstruction of the effected tissue. Our investigations have highlighted a key role for HSPs in tendion disease which may ultimately affect tissue rescue mechanisms in tendon pathology. This paper aims to provide an overview of the biology of heat shock proteins in soft tissue and how these mediators may be important regulators of inflammatory mediators and matrix regulation in tendinopathy.
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159
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Abstract
OBJECTIVE Overuse and traumatic injuries of the elbow are common, occurring in both athletes and nonathletes. This article will discuss the commonly encountered soft-tissue and osseous pathologic abnormalities around the elbow and their imaging appearance on MRI and ultrasound. CONCLUSION The current treatment of tendon disease of the elbow is reviewed, with a focus on platelet-rich plasma injection.
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160
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Gallo RA, Plakke M, Silvis ML. Common leg injuries of long-distance runners: anatomical and biomechanical approach. Sports Health 2012; 4:485-95. [PMID: 24179587 PMCID: PMC3497945 DOI: 10.1177/1941738112445871] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
CONTEXT Long-distance running (greater than 3000 m) is often recommended to maintain a healthy lifestyle. Running injury rates increase significantly when weekly mileage extends beyond 40 miles cumulatively. With the development of running analysis and other diagnostic tests, injuries to the leg secondary to bone, musculotendinous, and vascular causes can be diagnosed and successfully managed. EVIDENCE ACQUISITION Searches used the terms running, injuries, lower extremity, leg, medial tibial stress syndrome, compartment syndrome, stress fractures, popliteal artery entrapment, gastrocnemius soleus tears, and Achilles tendinopathy. Sources included Medline, Google Scholar, and Ovid from 1970 through January 2012. RESULTS Tibial stress fractures and medial tibial stress syndrome can sometimes be prevented and/or treated by correcting biomechanical abnormalities. Exertional compartment syndrome and popliteal artery entrapment syndrome are caused by anatomic abnormalities and are difficult to treat without surgical correction. CONCLUSION Leg pain due to bone, musculotendinous, and vascular causes is common among long-distance runners. Knowledge of the underlying biomechanical and/or anatomic abnormality is necessary to successfully treat these conditions.
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Affiliation(s)
- Robert A. Gallo
- Department of Orthopedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Michael Plakke
- Department of Orthopedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Matthew L. Silvis
- Department of Orthopedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
- Department of Family and Community Medicine, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
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161
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Ultrasound-guided injection of platelet-rich plasma in chronic Achilles and patellar tendinopathy. J Ultrasound 2012; 15:260-6. [PMID: 23730392 DOI: 10.1016/j.jus.2012.09.006] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The efficacy of platelet-rich plasma (PRP) in the treatment and healing of chronic tendinopathy through stimulation of cell proliferation and total collagen production has been demonstrated by both in vitro and in vivo studies. The aim of this study is to evaluate the effectiveness of ultrasound (US)-guided autologous PRP injections in patellar and Achilles tendinopathy. MATERIALS AND METHODS Autologous PRP was injected under US-guidance into the Achilles and patellar tendons (30 Achilles tendons, 28 patellar tendons) in 48 prospectively selected patients (30 males, 18 females, mean age 38 ± 16 years, range 20-61 years). All patients were previously evaluated according to the Victoria Institute of Sport Assessment (VISA) scale, which assessed pain and activity level, and they all underwent US of the tendon before treatment and at follow-up after 20 days and 6 months. Statistical analysis was performed with Chi-square and Wilcoxon tests. RESULTS 20 days after PRP injection the patients presented a non-significant improvement of clinical symptoms. At the 6-month follow-up VISA score increased from a mean value of 57-75.5 (p < .01). US evaluation revealed a reduction of hypoechoic areas in 26 tendons (p < .01) associated with a widespread improvement of fibrillar echotexture of the tendon and reduced hypervascularity at power Doppler. CONCLUSION PRP injection in patellar and Achilles tendinopathy results in a significant and lasting improvement of clinical symptoms and leads to recovery of the tendon matrix potentially helping to prevent degenerative lesions. US-guidance allows PRP injection into the tendon with great accuracy.
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163
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Neovascularization in Achilles tendinopathy: have we been chasing a red herring? Knee Surg Sports Traumatol Arthrosc 2012; 20:1891-4. [PMID: 22890896 DOI: 10.1007/s00167-012-2172-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 07/28/2012] [Indexed: 01/08/2023]
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164
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Tardioli A, Malliaras P, Maffulli N. Immediate and short-term effects of exercise on tendon structure: biochemical, biomechanical and imaging responses. Br Med Bull 2012; 103:169-202. [PMID: 22279080 DOI: 10.1093/bmb/ldr052] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Introduction Tendons are metabolically active structures, and their biochemical, biomechanical and structural properties adapt to chronic exercise. However, abnormal adaptations may lead to the development of tendinopathy and pain. Acute and subacute adaptations might contribute to tendon pathology. Sources of data A systematic search of peer-reviewed articles was performed using a wide range of electronic databases. A total of 61 publications were selected. Areas of agreement Exercise induces acute responses in collagen turnover, blood flow, glucose, lactate and other inflammatory products (e.g. prostaglandins and interleukins). Mechanical properties are influenced by activity duration and intensity. Acute bouts of exercise affect tendon structure, with some of the changes resembling those reported in pathological tendons. Areas of controversy Given the variation in study designs, measured parameters and outcomes, it remains debatable how acute exercise influences overall tendon properties. There is discrepancy regarding which investigation modality and settings provide optimal assessment of each parameter. Growing points There is a need for greater homogeneity between study designs, including subject consortium and age, exercise protocols and time frames for parameter assessing. Areas timely for developing research Innovative methods, measuring each parameter simultaneously, would allow a greater understanding of how and when changes occur. This methodology is key to revealing pathological processes and pathways that alter tendon properties according to various activities. Optimal tendon properties differ between activities: more compliant tendons are beneficial for slow stretch shortening cycle (SSC) activities such as countermovement jumps, whereas stiffer tendons are considered beneficial for fast SSC movements such as sprinting.
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Affiliation(s)
- Alex Tardioli
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry,Mile End Hospital, London, UK
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165
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Guner S, Buyukbebeci O. Analyzing the effects of platelet gel on knee osteoarthritis in the rat model. Clin Appl Thromb Hemost 2012; 19:494-8. [PMID: 22790657 DOI: 10.1177/1076029612452117] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Platelet gel (PG) includes concentrated dose of growth factors which plays role in physiological processes of healing. The goal of this study is to evaluate repairing effects of intra-articular injection of PG use in a rat model of knee osteoarthritis (OA). A total of 20 rats were randomly distributed into a PG group and a control group. Both the groups were induced OA in knee joints with intra-articular formaline injection. The rats in the PG group and the control group were injected in the knee joint with PG and 0.9% NaCl solution, respectively. Two weeks after last injections, all rats were sacrificed by ether asphyxiation. Tissue samples were obtained from the knee joints and were examined histopathologically. No statistically significant differences were found between the groups regarding cartilage healing (P > .05). We were unable to determine any beneficial or harmful effects of PG on joint cartilage healing in OA.
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Affiliation(s)
- Savas Guner
- 1Department of Trauma and Orthopedic Surgery, Medical School of Yuzuncu Yil University, Van, Turkey
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166
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Tinsley BA, Ferreira JV, Dukas AG, Mazzocca AD. Platelet-Rich Plasma Nonoperative Injection Therapy—A Review of Indications and Evidence. OPER TECHN SPORT MED 2012. [DOI: 10.1053/j.otsm.2012.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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167
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Chuter VH, Janse de Jonge XAK. Proximal and distal contributions to lower extremity injury: a review of the literature. Gait Posture 2012; 36:7-15. [PMID: 22440758 DOI: 10.1016/j.gaitpost.2012.02.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 01/10/2012] [Accepted: 02/03/2012] [Indexed: 02/02/2023]
Abstract
Excessive or prolonged foot pronation has been linked to the development of numerous overuse injuries affecting the lower limb. The originally proposed pathomechanical model suggests foot motion affects more proximal structures through disruption of distal to proximal coupling between the foot, tibia, femur, and hip. Research evidence supports the presence of a dynamic coupling mechanism between lower limb segments, however, the direction of the coupling is inconclusive. Recent prospective investigations of the role of the lumbo-pelvic hip complex have identified a strong association between proximal dysfunction and increased risk of lower limb injuries. Strength of muscles of the lumbo-pelvic hip complex (core muscles) is suggested to be essential to controlling hip abduction, subsequent internal rotation of the femur and potentially more distal movement. Proximal muscle weakness and altered motor control have also been implicated in the development of numerous lower limb injuries, many of which have previously been attributed to excessive foot pronation. This review discusses the theoretical basis for the role of proximal and distal structures in biomechanical dysfunction of the lower limb and the development of lower limb overuse injury. Current prospective evidence relating to the contributions of excessive foot pronation and core muscle function to the development of lower extremity injury is evaluated.
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168
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Perry M, Tillett E, Mitchell S, Maffulli N, Morrissey D. The morphology and symptom history of the Achilles tendons of figure skaters: an observational study. Muscles Ligaments Tendons J 2012; 2:108-114. [PMID: 23738283 PMCID: PMC3666509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This cross-sectional study assessed the prevalence of Achilles tendinopathy symptoms and ultrasound (US) abnormalities in male and female ice skaters, and compared this to age-matched controls. The 20 skaters of mean (sd) age 17.3 (7.9) were recruited from British figure skating clubs. The 17 non-skaters of mean age 18.0 (3.7) were recruited from a secondary school and university. Each group had 12 females. All participants completed a questionnaire, and Achilles tendons were ultrasound-scanned for thickening, hypoechoic areas, paratenon blurring and neovascularization. Skaters experienced significantly more lifetime symptoms (p=0.012) than the control group but there were no differences in present symptoms. Mid-tendon longitudinal thickness and the coefficient of variation (CoV) for longitudinal tendon thickness were significantly greater in the skaters (p=0.001 and p=0.017 respectively). No other ultrasound abnormalities were detected in either group. Figure skaters may be at a greater risk of Achilles tendon problems than the general population and have adaptive changes in their tendons.
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Affiliation(s)
- Mark Perry
- National Clinical Guideline Centre, Royal College of Physicians, London, UK
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169
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Yu J, Lee G. Comparison of pathway and center of gravity of the calcaneus on non-involved and involved sides according to eccentric and concentric strengthening in patients with achilles tendinopathy. J Sports Sci Med 2012; 11:136-140. [PMID: 24149129 PMCID: PMC3737847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 01/25/2012] [Indexed: 06/02/2023]
Abstract
This study compares the changes in pathway and center of gravity (COG) on the calcaneus of non-involved and involved sides according to eccentric and concentric strengthening in patients with unilateral Achilles tendinopathy. The goal was to define the biomechanical changes according to eccentric strengthening for the development of clinical guidelines. Eighteen patients with Achilles tendinopathy were recruited at the K Rehabilitation Hospital in Seoul. The subjects were instructed to perform 5 sessions of concentric strengthening. The calcaneal pathway was measured using a three-dimensional (3D) motion analyzer, and COG was measured by a force plate. Subsequently, eccentric strengthening was implemented, and identical variables were measured. Concentric and eccentric strengthening was carried out on both the involved and non-involved sides. There was no significant difference in the calcaneal pathway in patients with Achilles tendinopathy during concentric and eccentric strengthening. However, during eccentric strengthening, the calcaneal pathway significantly increased on the involved side compared to the non-involved side for all variables excluding the z-axis. COG significantly decreased on the involved side when compared to the non-involved side in patients with Achilles tendinopathy during eccentric and concentric strengthening. During concentric strengthening, all variables of the COG significantly increased on the involved side compared to the non-involved side. Compared with eccentric strengthening, concentric strengthening decreased the stability of ankle joints and increased the movement distance of the calcaneus in patients with Achilles tendinopathy. Furthermore, eccentric strengthening was verified to be an effective exercise method for prevention of Achilles tendinopathy through the reduction of forward and backward path length of foot pressure. The regular application of eccentric strengthening was found to be effective in the secondary prevention of Achilles tendinopathy in a clinical setting.
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Affiliation(s)
- Jaeho Yu
- Department of Physical Therapy, Sahmyook University , Seoul, Republic of Korea
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170
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Yoo SD, Choi S, Lee GJ, Chon J, Jeong YS, Park HK, Kim HS. Effects of extracorporeal shockwave therapy on nanostructural and biomechanical responses in the collagenase-induced Achilles tendinitis animal model. Lasers Med Sci 2012; 27:1195-204. [PMID: 22274874 DOI: 10.1007/s10103-011-1049-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Accepted: 12/21/2011] [Indexed: 11/30/2022]
Abstract
The aim of this study was to quantitatively investigate the effects of extracorporeal shockwave therapy (ESWT) on the nanostructure and adhesion force of collagen fibrils in a rat model of collagenase-induced Achilles tendinitis (CIAT) using histology and atomic force microscopy. A total of 45 rats were divided into experimental groups of three rats each: a control group, 27 CIAT rats with nine time points, and 15 ESWT rats with five time points. Progressive changes in nanostructure including the fibrillary diameter and D-periodicity, and biomechanical properties including the fibrillary adhesion forces in each healing phase were investigated over a 5-week period after collagenase injection. On postoperative day 3, CIAT rats showed granulomatous tissue associated with subacute inflammation, and a deterioration in nanostructure and mechanical properties compared to controls. On postoperative day 12, the ESWT group showed increased vascularity, fibroblastic activity, lymphocyte and plasma cell infiltration, dense histocytes, and disorganization of the fibers compared to the CIAT group. The ESWT group showed and improvement in nanostructure and mechanical properties compared to controls, while the CIAT group showed a deterioration in nanostructure and mechanical properties compared to controls. On postoperative day 26, the ESWT group showed 30% inflamed tissue and 70% fibrotic tissue, while the CIAT group showed chronic inflammation. By the end of the experiments, in both groups the changes had reversed and the tissues were similar in appearance to those in the control group. Following ESWT the deformed and irregular collagen network returned to a well-aligned normal collagen network nanostructure. These results suggest that ESWT may promote the healing response in Achilles tendinitis.
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Affiliation(s)
- Seung Don Yoo
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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171
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Juras V, Zbýň Š, Pressl C, Domayer SER, Hofstaetter JG, Mayerhoefer ME, Windhager R, Trattnig S. Sodium MR Imaging of Achilles Tendinopathy at 7 T: Preliminary Results. Radiology 2012; 262:199-205. [DOI: 10.1148/radiol.11110897] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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172
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Gurovich AN. Controlled Re-Injury of a Thigh Muscle Tear in a Soccer Player: a Case Study. J Phys Ther Sci 2012. [DOI: 10.1589/jpts.24.295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alvaro N Gurovich
- School of Kinesiology and Physical Therapy, Pontificia Universiadad Catolica de Valparasio
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173
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Abstract
The pathogenesis of rotator cuff tears is multifactorial. Tendon abnormalities of the rotator cuff include alteration of collagen fiber structure, tenocytes, cellularity, and vascularity. Ruptured tendons show marked collagen degeneration and disordered arrangement of collagen fibers. Fibroblast population decreases as the size of the tear in the rotator cuff increases. The larger fibroblast population seen in the smaller tears is also actively proliferating and is part of an active reparative process. Inflammatory cell infiltrate correlates inversely to rotator cuff tear size in the torn supraspinatus tendon samples, with larger tears showing a marked reduction in all cell types. As tear size increase, there is also a progressive decrease in the number of blood vessels. Whether rotator cuff tear heals spontaneously is an important pathologic and clinical question. Histologic changes indicative of repair and inflammation lead to consider biological options in addition to biomechanical treatment of the rotator cuff tears.
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Miners AL, Bougie TL. Chronic Achilles tendinopathy: a case study of treatment incorporating active and passive tissue warm-up, Graston Technique, ART, eccentric exercise, and cryotherapy. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2011; 55:269-79. [PMID: 22131563 PMCID: PMC3222702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To describe the subjective pain and functional improvements of a patient with chronic Achilles tendinopathy following a treatment plan incorporating active and passive tissue warm-up, followed respectively by soft tissue mobilization utilizing both Graston Technique(®) and Active Release Techniques(®), eccentric exercise, and static stretching in combination with cryotherapy. BACKGROUND The primary characterization of chronic Achilles tendinopathy is gradual onset of pain and dysfunction focused in one or both Achilles tendons arising secondary to a history of repetitive use or excessive overload. INTERVENTION AND OUTCOME Conservative treatment is commonly the initial strategy for patient management. Tissue heating, soft tissue mobilization, eccentric training, and static stretching with cryotherapy were implemented to reduce pain and improve function. SUMMARY A specific protocol of heat, soft tissue mobilization, eccentric exercise, stretching, and cryotherapy appeared to facilitate a rapid and complete recovery from chronic Achilles tendinopathy.
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Affiliation(s)
- Andrew L. Miners
- Assistant professor, Clinical Education, Canadian Memorial Chiropractic College, 6100 Leslie St., Toronto, Ontario M2H 3J1
| | - Tracy L. Bougie
- Sport Sciences Resident, Canadian Memorial Chiropractic College, 6100 Leslie St., Toronto, Ontario, M2H 3J1
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Cho NS, Hwang JH, Lee YT, Chae SW. Tendinosis-like histologic and molecular changes of the Achilles tendon to repetitive stress: a pilot study in rats. Clin Orthop Relat Res 2011; 469:3172-80. [PMID: 21800208 PMCID: PMC3183207 DOI: 10.1007/s11999-011-2000-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 07/13/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tendinopathy (pain and tendon degeneration) is associated with repetitive use and mechanical overload. However, the etiology of tendinopathy remains unclear. Clarification of histologic and molecular changes of tendon to repetitive stress could provide better understanding of Achilles tendon disorders related to repetitive stress. QUESTIONS/PURPOSES We asked whether repetitive stress simulating overuse of the Achilles tendon induced (1) histologic changes in rats similar to tendinosis (increased cellularity of fibrocytes, increased disorganization of collagen fiber, and increased roundness of the nucleus of the fibrocyte), (2) increased collagen Type III occurrence, and (3) increased inducible nitric oxide synthase (iNOS) expression. METHODS We used an exercise protocol simulating repetitive, jerky, eccentric contraction of the triceps surae in 15 rats. We conducted the exercise for 2 hours per day, three times per week using the right rear legs only and the left legs as internal controls. We harvested Achilles tendons after either 2, 4, or 6 weeks of exercise, and evaluated changes in tendon thickness, fibrocyte count, collagen fiber arrangement, collagen fiber type, and occurrence of iNOS. RESULTS Exercised Achilles tendons showed increased cellularity of fibrocytes at 4 and 6 weeks of exercise, and disorganized collagen fiber arrangement at 6 weeks of exercise. There was a trend for Type III collagen occurrence being greater in experimental groups. Expression of iNOS increased after 2 and 4 weeks of exercise when compared with that of the controls, but decreased after 6 weeks. CONCLUSIONS These observations suggest repetitive, synchronized, passive, and jerky exercise induced by electrical stimulation can lead to the tendinosis-like changes in the Achilles tendons in rats with imbalance between synthesis and degeneration after 4 weeks of exercise. CLINICAL RELEVANCE This newly designed exercise protocol may be used to design an animal model of Achilles tendon overuse. With this model, therapeutic interventions of tendinopathy could be analyzed by investigation of tendon biology and response in terms of histologic and molecular changes.
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Affiliation(s)
- Nam Soon Cho
- Department of Physical Medicine and Rehabilitation, Korea University Ansan Hospital, Korea University College of Medicine, Gyeonggi-do, Korea
| | - Ji Hye Hwang
- Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Taek Lee
- Department of Physical Medicine and Rehabilitation, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seoung Wan Chae
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Autologous platelet gel for tissue regeneration in degenerative disorders of the knee. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 10:72-7. [PMID: 22044954 DOI: 10.2450/2011.0026-11] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 07/13/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND The refinement of the use of platelet-derived growth factors that has occurred over the last decade has led to a broadening of the fields of use, in particular for new treatments in orthopaedics aimed at improving tissue regeneration. MATERIALS AND METHODS Twenty-seven patients, aged between 18 and 81 years, with a diagnosis of degenerative joint disease lasting for more than 1 year were treated. The patients were divided into two groups, one with arthritis of the knee, the other with degenerative cartilage disease of the knee. Both groups were treated with a therapeutic protocol consisting of a cycle of three infiltrations of platelet-rich plasma at weekly intervals.The extemporaneous preparation was made from a sample of about 8 mL of venous whole blood collected into a specific Fibrin Polymer 2 test-tube from RegenLab(®) and centrifuged before addition of calcium gluconate.During the initial pre-treatment evaluation, specific questionnaires were administered, the Numerical Rating Scale (NRS) for subjective measurement of pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); these assessments were repeated 7 days after the end of the treatment and at 6 months during the follow-up. RESULTS The parameters evaluated improved in both groups after treatment and there was a further improvement after 6 months of follow-up; furthermore, there was a substantial decrease in pain right after the first infiltration. DISCUSSION The patients were treated on an out-patient basis by a specifically created multidisciplinary team comprising a transfusion specialist, an orthopaedist and a radiologist, who collaborate in a symbiotic manner. The out-patient protocol exploits the regenerative properties of platelet-rich plasma, which is a low cost treatment; in practice, a diagnostic-therapeutic programme of lower intensity, but of high technical and professional quality is created. The strategy also reduces both the number of hospital services and the pharmacological support required, thereby optimising the use of health care resources.
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Silva RD, Glazebrook MA, Campos VC, Vasconcelos AC. Achilles tendinosis: a morphometrical study in a rat model. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2011; 4:683-691. [PMID: 22076169 PMCID: PMC3209609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Accepted: 10/05/2011] [Indexed: 05/31/2023]
Abstract
This study addresses the morphopathogenesis of Achilles tendinosis, using a rat model and presenting quantitative analysis of time-dependent histological changes. Thirty Wistar rats were used, randomly split in experimental and control groups. Animals of the experimental group were submitted to a treadmill running scheme. Five animals of each group were euthanized at four, eight and sixteen weeks. Achilles tendons were collected and processed routinely for histopath sections. Slides were stained by Hematoxylin-Eosin, Picrosirius Red, Alcian Blue, AgNOR, TUNEL and evaluated morphometrically. Cellular density decreased slightly along the time and was higher in the experimental group than in controls at fourth, eighth and sixteenth weeks. Fiber microtearing, percentual of reticular fibers and glycosaminoglycans content increased along the time and were higher in experimental group than in controls at all-time intervals. AgNOR labeling here interpreted as a marker of transcription activity was higher in the experimental groups than in controls at all-time intervals. Apoptotic cells were more frequent and diffusely distributed in tendinosis samples than in control groups. These results suggest that as mechanical overload is becoming chronic, cellular turnover and matrix deposition increases leading to tendinosis. The combination of staining techniques and morphometry used here to describe the evolution of lesions occurring in a rat model system has proved to be suited for the study of induced Achilles tendinosis.
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Affiliation(s)
- Rafael Duarte Silva
- Departament of General Pathology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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178
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WATTS AE, NIXON AJ, YEAGER AE, MOHAMMED HO. A collagenase gel/physical defect model for controlled induction of superficial digital flexor tendonitis. Equine Vet J 2011; 44:576-86. [DOI: 10.1111/j.2042-3306.2011.00471.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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179
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Massoud EIE. Repair of fresh open tear of Achilles tendon Tension regulation at the suture line. Foot Ankle Surg 2011; 17:131-5. [PMID: 21783072 DOI: 10.1016/j.fas.2010.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 01/28/2010] [Accepted: 03/04/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lack of the timely mechanical loading of the repaired tendon is detrimental for healing progress. The current knowledge knows the appropriate time for the mechanical loading, but need to find out a suitable tool for this purpose. Therefore we present a technique based on using of an absorbable reinforcement device for tension regulation at the suture line. METHODS 24 patients with open tear of Achilles tendon were repaired surgically, the repair was reinforced using an absorbable suture and the outcomes were prospectively assessed at 24 months. RESULTS No tendon lengthening or reruptures were reported; patients returned to pre-injury daily activates by fourth month. One patient reported 1cm atrophy of the calf, scar adhesion Grade 1 and ankle dorsiflexion decreased 5°. CONCLUSION Restoration of the continuity and actual length of repaired tendons support use of the absorbable reinforcement device for regulation of the mechanical environment at the suture line.
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Affiliation(s)
- Elsayed Ibraheem Elsayed Massoud
- Orthopaedic Department, Sohag Teaching Hospital, General Organization for Teaching Hospitals and Institutes, Nile St., Sohag, Egypt.
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180
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Baur H, Müller S, Hirschmüller A, Cassel M, Weber J, Mayer F. Comparison in lower leg neuromuscular activity between runners with unilateral mid-portion Achilles tendinopathy and healthy individuals. J Electromyogr Kinesiol 2011; 21:499-505. [DOI: 10.1016/j.jelekin.2010.11.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 11/04/2010] [Accepted: 11/29/2010] [Indexed: 10/18/2022] Open
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Lundgreen K, Lian OB, Engebretsen L, Scott A. Tenocyte apoptosis in the torn rotator cuff: a primary or secondary pathological event? Br J Sports Med 2011; 45:1035-9. [PMID: 21482545 DOI: 10.1136/bjsm.2010.083188] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Little information exists on the contribution of apoptosis to pathological tendon changes in rotator cuff tendinopathy. The purpose of this study was to quantitate the rate of tenocyte apoptosis in torn supraspinatus tendons and in the matched intact subscapularis and to examine the potential relation between apoptotic index (AI) and tendon pathology. In addition, the authors examined tenocyte density, proliferation rate and p53 gene expression patterns to gain further insight into relevant pathological mechanisms in the torn suprapinatus. 15 torn supraspinatus tendons with matched intact subscapularis tendon samples and 10 reference subscapularis samples were collected. Immunohistochemistry was used to define the AI (F7-26), proliferation rate (Ki67) and presence of p53 (M7001). Tendon degeneration was evaluated according to the Bonar scale. Expression of p53 and relevant genes (n=84) was examined on a subset of samples using microfluidic arrays. The AI was significantly increased in torn supraspinatus tendon and matched subscapularis tendon (R² =0.5742; p=0.0005). Cell density and proliferation rate were also elevated in torn supraspinatus compared with reference subscapularis tendons (p<0.05). A significant increase in p53 occurred specifically in torn supraspinatus tendon (p<0.05), and several genes encoding p53-inhibiting proteins were downregulated in association, including HDAC1 (p<0.05), MDM4 (p<0.001) and PPM1D (p<0.05). Our results suggest that tenocyte apoptosis results from more than one mechanism in the injured rotator cuff, including both intrinsic factors related specifically to the torn supraspinatus tendon, as well as a more generalised effect on the adjacent subscapularis tendon.
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Affiliation(s)
- Kirsten Lundgreen
- Department of Orthopaedic.Surgery, Lovisenberg Deaconal.Hospital, Oslo, Norway.
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182
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Silbernagel KG, Brorsson A, Lundberg M. The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. Am J Sports Med 2011; 39:607-13. [PMID: 21084657 DOI: 10.1177/0363546510384789] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Systematic reviews indicate that exercise has the most evidence of effectiveness in treatment of midportion Achilles tendinopathy. However, there is a lack of long-term follow-ups (>4 years). PURPOSE To evaluate the 5-year outcome of patients treated with exercise alone and to examine if certain characteristics, such as level of kinesiophobia, age, and sex, were related to the effectiveness of the treatment. STUDY DESIGN Case series; Level of evidence, 4. METHODS Thirty-four patients (47% women), 51 ± 8.2 years old, were evaluated 5 years after initiation of treatment. The evaluation consisted of a questionnaire regarding recovery of symptoms and other treatments, the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A) for symptoms, the Tampa Scale for Kinesiophobia, and tests of lower leg function. RESULTS Twenty-seven patients (80%) fully recovered from the initial injury; of these, 22 (65%) had no symptoms, and 5 (15%) had a new occurrence of symptoms. Seven patients (20%) had continued symptoms. Only 2 patients received another treatment (acupuncture and further exercise instruction). When compared with the other groups, the continued-symptoms group had lower VISA-A scores (P = .008 to .021) at the 5-year follow-up and the previous 1-year follow-up but not at any earlier evaluations. There were no significant differences among the groups in regard to sex, age, or physical activity level before injury. There was a significant (P = .005) negative correlation (-0.590) between the level of kinesiophobia and heel-rise work recovery. CONCLUSION The majority of patients with Achilles tendinopathy in this study fully recovered in regard to both symptoms and function when treated with exercise alone. Increased fear of movement might have a negative effect on the effectiveness of exercise treatment; therefore, a pain-monitoring model should be used when patients are treated with exercise.
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Affiliation(s)
- Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Sciences atSahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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183
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Watts AE, Yeager AE, Kopyov OV, Nixon AJ. Fetal derived embryonic-like stem cells improve healing in a large animal flexor tendonitis model. Stem Cell Res Ther 2011; 2:4. [PMID: 21272343 PMCID: PMC3092144 DOI: 10.1186/scrt45] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 01/27/2011] [Indexed: 12/18/2022] Open
Abstract
Introduction Tendon injury is a common problem in athletes, with poor tissue regeneration and a high rate of re-injury. Stem cell therapy is an attractive treatment modality as it may induce tissue regeneration rather than tissue repair. Currently, there are no reports on the use of pluripotent cells in a large animal tendon model in vivo. We report the use of intra-lesional injection of male, fetal derived embryonic-like stem cells (fdESC) that express Oct-4, Nanog, SSEA4, Tra 1-60, Tra 1-81 and telomerase. Methods Tendon injury was induced using a collagenase gel-physical defect model in the mid-metacarpal region of the superficial digital flexor tendon (SDFT) of eight female adult Thoroughbred or Thoroughbred cross horses. Tendon lesions were treated one week later with intra-lesional injection of male derived fdESCs in media or media alone. Therapy was blinded and randomized. Serial ultrasound examinations were performed and final analysis at eight weeks included magnetic resonance imaging (MRI), biochemical assays (total DNA, glycosaminoglycan, collagen), gene expression (TNC, TNMD, SCX, COL1A1, COL3A1, COMP, DCN, MMP1, MMP3, MMP13, 18S) and histology. Differences between groups were assessed with Wilcoxon's rank sum test. Results Cell survival was demonstrated via the presence of the SRY gene in fdESC treated, but not control treated, female SDFT at the end of the trial. There were no differences in tendon matrix specific gene expression or total proteoglycan, collagen or DNA of tendon lesions between groups. Tissue architecture, tendon size, tendon lesion size, and tendon linear fiber pattern were significantly improved on histologic sections and ultrasound in the fdESC treated tendons. Conclusions Such profound structural effects lend further support to the notion that pluripotent stem cells can effect musculoskeletal regeneration, rather than repair, even without in vitro lineage specific differentiation. Further investigation into the safety of pluripotent cellular therapy as well as the mechanisms by which repair was improved seem warranted.
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Affiliation(s)
- Ashlee E Watts
- Department of Clinical Sciences, Comparative Orthopaedics Laboratory at Cornell University, Ithaca, NY, 14850 USA.
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184
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Maffulli N, Longo UG, Hüfner T, Denaro V. [Surgical treatment for pain syndromes of the Achilles tendon]. Unfallchirurg 2011; 113:721-5. [PMID: 20703442 DOI: 10.1007/s00113-010-1834-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Pain syndromes of the Achilles tendon (AT) include both insertional and non-insertional tendinopathy, two distinct disorders with different underlying pathophysiologies and management options, characterized by pain, impaired performance and swelling in and around the tendon. This article gives an overview of the operative treatment of pain syndromes of the Achilles tendon, including both insertional tendinopathy of the AT and tendinopathy of the main body of the AT. New minimally invasive techniques for the management of this condition, including endoscopy are also reported.
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Affiliation(s)
- N Maffulli
- Centre for Sports and Exercise Medicine, Queen Mary University of London, London, England.
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185
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Abstract
The Achilles tendon is the most injured tendon of athletes in the lower extremities and is the most common tendon to rupture spontaneously. Operative repair provides earlier return to sporting activities and lesser rate of rerupture. The general goal is to attempt anastomosis of the acute ruptured ends; however, delayed ruptures may require more extensive procedures. New surgical approaches, including percutaneous and mini-open techniques, are being introduced to potentially diminish perioperative complications. Advent of early protective range of motion and rehabilitation has shown a potential for earlier return to sporting activities for Achilles ruptures.
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186
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Soomekh DJ. New technology and techniques in the treatment of foot and ankle injuries. Clin Podiatr Med Surg 2011; 28:19-41. [PMID: 21276516 DOI: 10.1016/j.cpm.2010.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The advancement of new technologies in the treatment of foot and ankle injuries seems exponential over the last several years. As surgeons expand their knowledge of the pathology and improve their treatment techniques, they come upon new and different ways to treat the same pathologic conditions. Foot and ankle injuries are commonplace in competitive sports. This article provides an overview of the diagnosis and treatment, including surgical techniques, of common foot and ankle injuries.
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Affiliation(s)
- David J Soomekh
- University Foot and Ankle Institute, 2121 Wilshire Boulevard, Santa Monica, CA 90403, USA.
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187
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Abstract
BACKGROUND The management of Achilles tendon (AT) ruptures in elite athletes can be challenging. We performed a retrospective review of prospectively collected data study to evaluate the results of percutaneous repair of an acute AT rupture in elite athletes. MATERIALS AND METHODS Seventeen elite athletes with prodromal tendinous problems sustained an acute tear of the AT and underwent percutaneous surgical repair. We performed preoperative evaluations the day of surgery, and report the results of postoperative evaluation at a final followup at an average of 72 months from the procedure. Each patient was evaluated for limb dominance, trauma history, duration and type of preoperative symptoms, and postoperative AT Total Rupture Score (ATRS). RESULTS All patients were able to fully weightbear on the operated limb by the end of the 8th postoperative week. The average time to return to full sport participation was 4.8±0.9 months. Two of the 15 elite athletes on whom we have full data suffered from a superficial infection of the surgical wound. CONCLUSION Our study suggests that percutaneous repair of the AT is a good option for elite athletes, allowing a safe and prompt return to sport activities.
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Affiliation(s)
- Nicola Maffulli
- Queen Mary University of London, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, United Kingdom.
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188
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Elengard T, Karlsson J, Silbernagel KG. Aspects of treatment for posterior heel pain in young athletes. Open Access J Sports Med 2010; 1:223-32. [PMID: 24198561 PMCID: PMC3781873 DOI: 10.2147/oajsm.s15413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Posterior heel pain occurs in young athletes involved in running and jumping. Due to the pain, the child often limits his/her physical activity level, with a possible negative effect on health and well-being. Although numerous research studies have examined the cause and treatment of heel and Achilles tendon pain in adults, there are no randomized clinical trials on treatment in children and adolescents. Therefore, there is limited evidence for how to treat young athletes with this type of complaint. The purpose of this review was to analyze critically and summarize the literature in regards to the cause and treatment of posterior heel pain in young athletes. The various diagnoses and clinical presentations relating to posterior heel and Achilles tendon pain are discussed. The theory and mechanism behind various recommended treatment strategies are also reviewed in the context of use in the young athlete. In summary, it is important to perform a thorough evaluation of each young athlete with heel pain to determine the appropriate diagnosis and to treat the deficits found and allow for a gradual progression to training. However, the recommendations at this time are based on clinical experience and a few retrospective studies, so further well designed prospective studies with validated outcome measures are urgently needed for the young athlete.
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Affiliation(s)
- Thomas Elengard
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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189
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Bojsen-Møller J, Schwartz S, Kalliokoski KK, Finni T, Magnusson SP. Intermuscular force transmission between human plantarflexor muscles in vivo. J Appl Physiol (1985) 2010; 109:1608-18. [PMID: 20884838 DOI: 10.1152/japplphysiol.01381.2009] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The exact mechanical function of synergist muscles within a human limb in vivo is not well described. Recent studies indicate the existence of a mechanical interaction between muscle actuators that may have functional significance and further play a role for injury mechanisms. The purpose of the present study was to investigate if intermuscular force transmission occurs within and between human plantarflexor muscles in vivo. Seven subjects performed four types of either active contractile tasks or passive joint manipulations: passive knee extension, voluntary isometric plantarflexion, voluntary isometric hallux flexion, passive hallux extension, and selective percutaneous stimulation of the gastrocnemius medialis (MG). In each experiment plantar- and hallux flexion force and corresponding EMG activity were sampled. During all tasks ultrasonography was applied at proximal and distal sites to assess task-induced tissue displacement (which is assumed to represent loading) for the plantarflexor muscles [MG, soleus (SOL), and flexor hallucis longus (FHL)]. Selective MG stimulation and passive knee extension resulted in displacement of both the MG and SOL muscles. Minimal displacement of the triceps surae muscles was seen during passive hallux extension. Large interindividual differences with respect to deep plantarflexor activation during voluntary contractions were observed. The present results suggest that force may be transmitted between the triceps surae muscles in vivo, while only limited evidence was provided for the occurrence of force transfer between the triceps surae and the deeper-lying FHL.
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Affiliation(s)
- Jens Bojsen-Møller
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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190
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191
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Wyndow N, Cowan SM, Wrigley TV, Crossley KM. Neuromotor Control of the Lower Limb in Achilles Tendinopathy. Sports Med 2010; 40:715-27. [DOI: 10.2165/11535920-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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192
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Abstract
OBJECTIVE To investigate the effects of footwear on Achilles tendon tension by directly measuring Achilles tendon tension and dorsiflexion range of motion. DESIGN A total of 48 matched pair tests were performed comparing the effects of shoe type (high-top vs low-top) for each shoelace configuration (tied vs untied). These were performed using the Achilles tendons of 4 human cadaver lower extremities that were instrumented with a customized load cell designed to measure tension. The lower extremity was inverted in a custom testing apparatus designed to inertially invoke dorsiflexion of the foot, putting the Achilles tendon in tension. SETTING Research laboratory. PATIENTS Left and right lower extremities of 2 human cadavers. INTERVENTIONS None. Independent variables were shoe type and shoelace configuration. MAIN OUTCOME MEASURES Achilles tendon tension and dorsiflexion range of motion. RESULTS High-top shoes significantly reduced peak Achilles tendon tension by an average of 9.9% when compared with low-top shoes. Tied laces significantly reduced peak tension for low-top (3.7%) and high-top (12.8%) shoes when compared with untied laces. With tied laces, high-top shoes significantly reduced peak dorsiflexion angle by an average of 7.2% when compared with low-top shoes. Tied laces with high-top shoes significantly reduced peak dorsiflexion angle by an average of 4.7% when compared with untied laces. A P value of 0.05 was determined to be significant. CONCLUSIONS This study offers valuable insight that footwear can affect Achilles tendon loading during dorsiflexion.
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Donoghue OA, Harrison AJ, Coffey N, Hayes K. Functional data analysis of running kinematics in chronic Achilles tendon injury. Med Sci Sports Exerc 2010; 40:1323-35. [PMID: 18580414 DOI: 10.1249/mss.0b013e31816c4807] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Chronic Achilles tendon (AT) injuries are common, but kinematic studies confirming the exact mechanisms of injury and how orthoses are effective are lacking. Existing analysis often relies on discrete measures and provides an incomplete analysis because many of the data are discarded. Functional data analysis (FDA) views the entire dataset as a function, thus retaining the main features of the curve. This study uses FDA to examine the mechanisms of chronic AT injury and the functional effects of orthoses. METHODS Twelve subjects with a history of chronic AT injury and 12 controls ran on a treadmill with and without customized orthoses. Three-dimensional kinematic data were obtained using Qualisys motion capture systems operating at 200 Hz. Ankle dorsiflexion (ADF), knee flexion (KF), eversion (EV), calcaneal, and leg abduction angles were calculated across stance. These angle data were represented as functions, and functional principal components were extracted to describe the factors accounting for variation in the data. These components were compared in AT versus control groups and orthoses versus no-orthoses conditions. RESULTS Kinematic differences were observed, with the AT group showing greater EV, ADF, and KF during stance, whereas orthoses reduced ADF but increased EV. Different patterns of frontal plane variation distinguished between groups and conditions. CONCLUSION Results provided additional information about movement patterns compared to traditional approaches and identified the first half of stance as the most relevant period in injury occurrence. The study showed evidence that variability is related to the presence of injury in this clinical population. Further FDA focusing on within-subject variation is recommended to gain greater insight into the role of variability in injury occurrence.
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Affiliation(s)
- Orna A Donoghue
- Department of Physical Education, Sport & Leisure Studies, University of Edinburgh, UNITED KINGDOM.
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194
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Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med 2010; 1:165-74. [PMID: 19468902 PMCID: PMC2682411 DOI: 10.1007/s12178-008-9032-5] [Citation(s) in RCA: 309] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In Europe and the United States, there is an increasing prevalence of the use of autologous blood products to facilitate healing in a variety of applications. Recently, we have learned more about specific growth factors, which play a crucial role in the healing process. With that knowledge there is abundant enthusiasm in the application of concentrated platelets, which release a supra-maximal quantity of these growth factors to stimulate recovery in non-healing injuries. For 20 years, the application of autologous PRP has been safely used and documented in many fields including; orthopedics, sports medicine, dentistry, ENT, neurosurgery, ophthalmology, urology, wound healing, cosmetic, cardiothoracic, and maxillofacial surgery. This article introduces the reader to PRP therapy and reviews the current literature on this emerging treatment modality. In summary, PRP provides a promising alternative to surgery by promoting safe and natural healing. However, there are few controlled trials, and mostly anecdotal or case reports. Additionally the sample sizes are frequently small, limiting the generalization of the findings. Recently, there is emerging literature on the beneficial effects of PRP for chronic non-healing tendon injuries including lateral epicondylitis and plantar fasciitis and cartilage degeneration (Mishra and Pavelko, The American Journal of Sports Medicine 10(10):1–5, 2006; Barrett and Erredge, Podiatry Today 17:37–42, 2004). However, as clinical use increases, more controlled studies are needed to further understand this treatment.
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Affiliation(s)
- Steven Sampson
- The Orthobiologic Institute (TOBI), Santa Monica, CA, USA.
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Chalmers R, Tare M, Niranjan N. Vascularised Achilles tendon graft reconstruction – By the tendon for the tendon. J Plast Reconstr Aesthet Surg 2010; 63:e273-6. [DOI: 10.1016/j.bjps.2009.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 07/04/2009] [Accepted: 07/08/2009] [Indexed: 10/20/2022]
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196
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Filardo G, Presti ML, Kon E, Marcacci M. Nonoperative biological treatment approach for partial Achilles tendon lesion. Orthopedics 2010; 33:120-3. [PMID: 20192152 DOI: 10.3928/01477447-20100104-31] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Tendon injuries, especially those of the Achilles tendon, are major concerns in sports medicine. The clinical presentation can be acute or chronic and the pathologic findings can range from peritendonitis to full-thickness tendon rupture. Nonsurgical treatment is not always successful; in particular, significant partial ruptures seem to respond poorly to conservative measures and do not improve with time. Surgery is most often considered the favored treatment option for this kind of lesion to obtain pain relief and full functionality with long-standing effects.This article describes a case of a partial tear of the Achilles tendon in a 34-year-old competitive athlete where surgical treatment was avoided in favor of a new biological approach. We applied autologous platelet growth factors through multiple platelet-rich plasma injections; approximately 6.5 billion platelets were injected into the lesion 3 times, 7 days apart. The treatment with platelet-rich plasma and a progressive rehabilitation program allowed the patient to play for 20 minutes in a basketball game 64 days after the trauma and in a full game 75 days after the trauma. To date, 18 months later, he has participated regularly in all the season's games and received no further treatment for his tendon.The fast tissue repair, confirmed by magnetic resonance and ultrasound imaging, allowed a swift return to full functionality and competitive sports activity, suggesting a possible role of platelet growth factors in promoting rapid tendon healing with high-quality tissue. This biological approach may represent a less-invasive therapeutic option even in cases where severe tendon lesions are candidates for surgical treatment.
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Affiliation(s)
- Giuseppe Filardo
- Department of Orthopedic and Sports Trauma, Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy.
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197
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Abstract
BACKGROUND The pathogenesis of chronic tendinopathy is unclear but it does not appear to be an inflammatory process. Apoptosis may lead to degenerate tissue through a nitric oxide-mediated pathway. Increased levels of nitric oxide have been demonstrated in Achilles tendinopathy. HYPOTHESIS Nitric oxide-mediated apoptosis is an important mechanism in the development of Achilles tendinopathy. STUDY DESIGN Controlled laboratory study. METHODS Samples were obtained from the Achilles tendons of 14 patients with noninsertional Achilles tendinopathy. Control samples were taken from macroscopically normal tendon correlating with areas of normal tissue on magnetic resonance imaging. Immunohistochemical techniques identified the expression of inducible and endothelial nitric oxide synthase as markers of nitric oxide production. Apoptotic cells were identified using terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) and the demonstration of caspase-3 activation. RESULTS Significant differences were found between the diseased tendon and the controls for all parameters. The mean caspase-3 cell count for diseased tendon was 51.9 versus 28.3 for the controls (P < .001). The mean TUNEL cell count for diseased tendon was 24.1 compared with 14.8 (P < .001). Inducible nitric oxide synthase (iNOS) densitometry revealed a mean of 26.1 for the diseased tissue versus 15.0 for the controls (P < .001) and the values for endothelial nitric oxide synthase (eNOS) were 48.3 and 23.7, respectively (P = .015). CONCLUSION Apoptosis may play a role in the development of noninsertional Achilles tendinopathy and appears to be related to the presence of raised eNOS and iNOS levels. CLINICAL RELEVANCE A clearer understanding of the tendinopathic process may lead to new treatment strategies aimed at modulating apoptosis.
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Affiliation(s)
- Christopher J Pearce
- Department of Trauma and Orthopaedic Surgery, Basingstoke and North Hampshire Hospitals, NHS Foundation Trust, Basingstoke, United Kingdom.
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198
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Arya S, Kulig K. Tendinopathy alters mechanical and material properties of the Achilles tendon. J Appl Physiol (1985) 2009; 108:670-5. [PMID: 19892931 DOI: 10.1152/japplphysiol.00259.2009] [Citation(s) in RCA: 252] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The purpose of this study was to investigate the in vivo material and mechanical properties of the human Achilles tendon in the presence of tendinopathy. Real-time ultrasound imaging and dynamometry were used to assess Achilles tendon stiffness, Young's modulus, stress, strain, and cross-sectional area (CSA) in 12 individuals with Achilles tendinopathy and 12 age- and gender-matched controls. The results of this study suggest that tendinopathy weakens the mechanical and material properties of the tendon. Tendinopathic tendons had greater CSA, lower tendon stiffness, and lower Young's modulus. These alterations in mechanical characteristics may put the Achilles tendon at a higher risk to sustain further injury and prolong the time to recovery. Results from this study may be used to design treatment strategies that specifically target these deficits, leading to faster and permanent recovery from tendinopathy.
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Affiliation(s)
- Shruti Arya
- Jacqueline Perry Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, USA.
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199
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Fascicles of the adult human Achilles tendon – An anatomical study. Ann Anat 2009; 191:586-93. [DOI: 10.1016/j.aanat.2009.07.006] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Revised: 06/23/2009] [Accepted: 07/31/2009] [Indexed: 11/21/2022]
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Munteanu SE, Landorf KB, Menz HB, Cook JL, Pizzari T, Scott LA. Efficacy of customised foot orthoses in the treatment of Achilles tendinopathy: study protocol for a randomised trial. J Foot Ankle Res 2009; 2:27. [PMID: 19852853 PMCID: PMC2775021 DOI: 10.1186/1757-1146-2-27] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 10/24/2009] [Indexed: 11/10/2022] Open
Abstract
Background Achilles tendinopathy is a common condition that can cause marked pain and disability. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. The exception to this is eccentric calf muscle exercises, which have become a standard non-surgical intervention for Achilles tendinopathy. Foot orthoses have also been advocated as a treatment for Achilles tendinopathy, but the long-term efficacy of foot orthoses for this condition is unknown. This manuscript describes the design of a randomised trial to evaluate the efficacy of customised foot orthoses to reduce pain and improve function in people with Achilles tendinopathy. Methods One hundred and forty community-dwelling men and women aged 18 to 55 years with Achilles tendinopathy (who satisfy inclusion and exclusion criteria) will be recruited. Participants will be randomised, using a computer-generated random number sequence, to either a control group (sham foot orthoses made from compressible ethylene vinyl acetate foam) or an experimental group (customised foot orthoses made from semi-rigid polypropylene). Both groups will be prescribed a calf muscle eccentric exercise program, however, the primary difference between the groups will be that the experimental group receive customised foot orthoses, while the control group receive sham foot orthoses. The participants will be instructed to perform eccentric exercises 2 times per day, 7 days per week, for 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. The secondary outcome measures will be participant perception of treatment effect, comfort of the foot orthoses, use of co-interventions, frequency and severity of adverse events, level of physical activity and health-related quality of life (assessed using the Short-Form-36 questionnaire - Version two). Data will be collected at baseline, then at 1, 3, 6 and 12 months. Data will be analysed using the intention to treat principle. Discussion This study is the first randomised trial to evaluate the long-term efficacy of customised foot orthoses for the treatment of Achilles tendinopathy. The study has been pragmatically designed to ensure that the study findings are generalisable to clinical practice. Trial registration Australian New Zealand Clinical Trials Registry Number: ACTRN12609000829213.
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Affiliation(s)
- Shannon E Munteanu
- Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora 3086, Victoria, Australia.
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