Types and epidemiology of tendinopathy

Diagnostic imaging guideline for musculoskeletal complaints in adults-an evidence-based approach-part 2: upper extremity disorders

PURPOSE

To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for upper extremity disorders.

METHODS

A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. Dissemination and implementation strategies are discussed.

RESULTS

Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided, supported by over 126 primary and secondary citations. The overall quality of available literature is low, however. On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommendations. Peer review by specialists reflected high levels of agreement and perceived ease of use of guidelines and implementation feasibility.

CONCLUSIONS

The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional Achilles tendinopathy

BACKGROUND

High-energy extracorporeal shock wave therapy has been shown to be an effective treatment for chronic insertional Achilles tendinopathy. The results of high-energy shock wave therapy for chronic noninsertional Achilles tendinopathy have not been determined.

HYPOTHESIS

Shock wave therapy is an effective treatment for noninsertional Achilles tendinopathy.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated with a single dose of high-energy shock wave therapy (shock wave therapy group; 3000 shocks; 0.21 mJ/mm(2); total energy flux density, 604 mJ/mm(2)). Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated not with shock wave therapy but with additional forms of nonoperative therapy (control group). All shock wave therapy procedures were performed using regional anesthesia. Evaluation was by change in visual analog score and by Roles and Maudsley score.

RESULTS

One month, 3 months, and 12 months after treatment, the mean visual analog scores for the control and shock wave therapy groups were 8.4 and 4.4 (P < .001), 6.5 and 2.9 (P < .001), and 5.6 and 2.2 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 12 and 0 (P < .001), 17 and 9 (P < .001), 5 and 17 (P < .001), and 0 and 8 (P < .001), respectively. A chi(2) analysis revealed that the percentage of patients with excellent ("1") or good ("2") Roles and Maudsley scores, that is, successful results, 12 months after treatment was statistically greater in the shock wave therapy group than in the control group (P < .001).

CONCLUSION

Shock wave therapy is an effective treatment for chronic noninsertional Achilles tendinopathy.

Management of insertional tendinopathy of the Achilles tendon

Posterior heel pain is common and disabling. Most cases respond to nonoperative treatment. The literature is confusing about the treatment rationale because many papers treat a variety of pathologies in the same way on an empirical basis. The authors critically review the literature with special reference to surgical treatment. The key to successful management of posterior heel pain is a proper understanding of the anatomy and pathological processes. Only then can appropriate treatment be recommended and proper advice about recovery times be offered to patients.

Light microscopic histology of supraspinatus tendon ruptures

We analysed the morphological features of the human surgical specimens of supraspinatus tendon from patients with rotator cuff tears. Tendon samples were harvested from 31 subjects (21 men and 10 women; mean age 51 years, range 38-64) who underwent arthroscopic repair of a rotator cuff tear, and from five male patients who died of cardiovascular events (mean age, 69.6 years). Histological examination was performed using Haematoxylin and Eosin, Masson's Trichrome and Van Gieson's connective tissue stain. The specimens were examined twice by the same examiner under white light and polarized light microscopy. Particular effort was made to assess any evidence of the changes associated with tendinopathy. Within each specific category of tendon abnormalities, the chi-square test showed significant differences between the control and ruptured tendons (P < 0.05). Using the kappa statistics, the agreement between the two readings ranged from 0.57 to 0.84. We found thinning and disorientation of collagen fibres and chondroid metaplasia to be more pronounced on the articular side of the specimens from patients with rotator cuff tear (P < 0.05). The present study provides a description of the histological architecture of human surgical specimens of normal supraspinatus tendon from patients with rotator cuff tears and demonstrates more frequent tendon changes on the articular side of the rotator cuff.

The value of power Doppler ultrasonography in Achilles tendinopathy: a prospective study

BACKGROUND

Neovascularization, detected with power Doppler ultrasonography (PDU), is thought by some to play a central role in pathogenesis of Achilles tendinopathy.

HYPOTHESIS

Power Doppler ultrasonography neovascularization score is correlated with clinical severity at baseline and after conservative treatment.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

Seventy tendons from 58 patients with chronic midportion Achilles tendinopathy were included, and 63 symptomatic tendons were analyzed. All patients were prescribed a 12-week heavy-load eccentric training program and evaluated with PDU at baseline and 12 weeks. Patient satisfaction, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, and mean visual analog scale (VAS) score were correlated with degree of neovascularization (5-grade scale).

RESULTS

Of the 63 symptomatic tendons, baseline neovascularization scores were 23 grade 0 (37% no neovessels), 18 grade 1, 8 grade 2, 8 grade 3, and 6 grade 4 (63% neovascularization grades 1-4). At baseline, neovascularization was not significantly correlated with the mean VAS score (r=.19, P=.131) and VISA-A score (r=-.23, P=.074). At 12-week follow-up, the neovascularization score significantly correlated with the mean VAS score (r=.43, P<.001) and VISA-A score (r=-.46, P<.001). No significant differences were found in improvement of VISA-A score after treatment between patients with neovessels (grades 1-4) or without neovessels (grade 0) at baseline.

CONCLUSION

Sixty-three percent of the symptomatic tendons were found to have neovessels at baseline. There was no significant correlation between neovascularization score and clinical severity at baseline, but at follow-up, there was a significant correlation. Neovascularization at baseline did not predict clinical outcome after conservative treatment.

Effect of repetition rate on the formation of microtears in tendon in an in vivo cyclical loading model

We reported previously the formation of microtears in an in vivo loaded Flexor Digitorum Profundus (FDP) rabbit tendon with a repetition rate of 60 repetitions per minute and a peak force of 15% of maximum peak tetanic force for 80 cumulative hours. Tear area as a percent of tendon area, tear density (tears/mm(2)), and mean tear size (microm(2)) were higher in tendons from the loaded limb compared to the unloaded control limb. The purpose of the present study was to compare those results to results obtained with a repetition rate of 10 while maintaining the same peak force and force-time integral (n = 8). Due to a strain gradient between the inner and outer sides of the FDP tendon, microtears were quantified in four regions, two regions each along the inner and outer sides of the tendon. The tear area as a percent of total tendon area and the mean tear size were significantly greater in the loaded limb compared to the unloaded limb (p < 0.03). However, the effects were less than those observed at 60 repetitions/min. The higher repetition loading pattern resulted in an increase in tear measures in all four regions, while the lower rate produced changes only in the outer regions of the tendon. This finding may establish where the initial sites of damage occur in tendons that insert into bone in a similar arrangement as the FDP. The results suggest that repetition rate or number of loading cycles is associated with increased tendon microtears or fragility in a dose-response pattern.

Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment

Lateral epicondylitis (tennis elbow) is the most frequent type of myotendinosis and can be responsible for substantial pain and loss of function of the affected limb. Tennis biomechanics, player characteristics and equipment are important in preventing the condition. This article presents an overview of the current knowledge on lateral epicondylitis, and focuses on treatment strategies. Conservative and surgical treatment options are discussed, and recent techniques are outlined.

The role of stretching in tendon injuries

The function of tendons can be classified into two categories: tensile force transmission, and storage and release of elastic energy during locomotion. The action of tendons in storing and releasing energy is mainly seen in sports activities with stretch-shortening cycles (SSCs). The more intense the SSC movements are (jumping-like activities), the more frequently tendon problems are observed. High SSC movements impose high loads on tendons. Consequently, tendons that frequently deal with high SSC motion require a high energy-absorbing capacity to store and release this large amount of elastic energy. As the elasticity of tendon structures is a leading factor in the amount of stored energy, prevention and rehabilitation programmes for tendon injuries should focus on increasing this tendon elasticity in athletes performing high SSC movements. Recently, it has been shown that ballistic stretching can significantly increase tendon elasticity. These findings have important clinical implications for treatment and prevention of tendon injuries.

The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial

AIM

To assess whether the use of a night splint is of added benefit on functional outcome in treating chronic midportion Achilles tendinopathy.

METHODS

This was a single-blind, prospective, single centre, randomised controlled trial set in the Sports Medical Department, The Hague Medical Centre, The Netherlands. Inclusion criteria were: age 18-70 years, active participation in sports, and tendon pain localised at 2-7 cm from distal insertion. Exclusion criteria were: insertional disorders, partial or complete ruptures, or systemic illness. 70 tendons were included and randomised into one of two treatment groups: eccentric exercises with a night splint (night splint group, n = 36) or eccentric exercises only (eccentric group, n = 34).

INTERVENTIONS

Both groups completed a 12-week heavy-load eccentric training programme. One group received a night splint in addition to eccentric exercises. At baseline and follow-up at 12 weeks, patient satisfaction, Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) score and reported compliance were recorded by a single-blind trained researcher who was blinded to the treatment.

RESULTS

After 12 weeks, patient satisfaction in the eccentric group was 63% compared with 48% in the night splint group. The VISA-A score significantly improved in both groups; in the eccentric group from 50.1 to 68.8 (p = 0.001) and in the night splint group from 49.4 to 67.0 (p<0.001). There was no significant difference between the two groups in VISA-A score (p = 0.815) and patient satisfaction (p = 0.261).

CONCLUSION

A night splint is not beneficial in addition to eccentric exercises in the treatment of chronic midportion Achilles tendinopathy.

Evaluation of lower leg function in patients with Achilles tendinopathy

Achilles tendinopathy is considered to be one of the most common overuse injuries in elite and recreational athletes. However, the effect that the Achilles tendinopathy has on patients' physical performance is still unclear. The purpose of this study was to evaluate if Achilles tendinopathy caused functional deficits on the injured side compared with the non-injured side in patients. A test battery comprised of tests for different aspects of muscle-tendon function of the gastrocnemius, soleus and Achilles tendon complex was developed to evaluate lower leg function. The test battery's test-retest reliability and sensitivity (the percent probability that the tests would demonstrate abnormal lower limb symmetry index in patients) were also evaluated. The test battery consisted of three jump tests, a counter movements jump (CMJ), a drop counter movement jump (drop CMJ) and hopping, and two strength tests, concentric toe-raises, eccentric-concentric toe-raises and toe-raises for endurance. The reliability was evaluated through a test-retest design on 15 healthy subjects. The test battery's sensitivity and possible functional deficits in patients with Achilles tendinopathy were evaluated on 42 patients (19 women and 23 men). An excellent reliability was found between test days 1-2 and 2-3 for all tests (ICC = 0.76-0.94) except for concentric toe-raise, test 2-3, which had fair reliability (ICC = 0.73). The methodological error ranged from 8 to 17%. There were significant differences (P = 0.001-0.049) between the non-injured (or least symptomatic) side and injured (most symptomatic) side for hopping, drop CMJ, concentric and eccentric-concentric toe-raises, and significant differences (P = 0.000-0.012) in the level of pain during CMJ, hopping, and drop CMJ. The sensitivity of the test battery at a 90% capacity was 88. Achilles tendinopathy causes not only pain and symptoms in patients but also apparent impairments in various aspects of lower leg muscle-tendon function as measured with the test battery. This test battery is reliable and able to detect differences in lower leg function between the injured or "most symptomatic" and non-injured or "least symptomatic" side in patients with Achilles tendinopathy. The test battery has higher demand on patients' function compared with each individual test.

Chronic tendinopathy: effectiveness of eccentric exercise

OBJECTIVES

To determine the effectiveness of eccentric exercise (EE) programmes in the treatment of common tendinopathies.

DATA SOURCES

Relevant randomised controlled trials (RCTs) were sourced using the OVID website databases: MEDLINE (1966-Jan 2006), CINAHL (1982-Jan 2006), AMED (1985-Jan 2006), EMBASE (1988-Jan 2006), and all EBM reviews--Cochrane DSR, ACP Journal Club, DARE, and CCTR (Jan 2006). The Physiotherapy Evidence Database (PEDro) was also searched using the keyword: eccentric.

REVIEW METHODS

The PEDro and van Tulder scales were employed to assess methodological quality. Levels of evidence were then obtained according to predefined thresholds: Strong--consistent findings among multiple high-quality RCTs. Moderate--consistent findings among multiple low-quality RCTs and/or clinically controlled trials (CCTs) and/or one high-quality RCT. Limited--one low-quality RCT and/or CCT. Conflicting--inconsistent findings among multiple trials (RCTs and/or CCTs). No evidence-no RCTs or CCTs.

RESULTS

Twenty relevant studies were sourced, 11 of which met the inclusion criteria. These included studies of Achilles tendinopathy (AT), patella tendinopathy (PT) and tendinopathy of the common wrist extensor tendon of the lateral elbow (LET). Limited levels of evidence exist to suggest that EE has a positive effect on clinical outcomes such as pain, function and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound. Levels of evidence were found to be variable across the tendinopathies investigated.

CONCLUSIONS

This review demonstrates the dearth of high-quality research in support of the clinical effectiveness of EE over other treatments in the management of tendinopathies. Further adequately powered studies that include appropriate randomisation procedures, standardised outcome measures and long-term follow-up are required.

Common tendinopathies in the upper and lower extremities

Overuse tendon injuries (tendinopathies) present a challenge to sports medicine patients and clinicians. Despite the high prevalence of tendinopathy in recreational and competitive athletes, treatment is often hampered by contradictory definitions and descriptions of the underlying pathology, with a limited repertoire of evidence-based treatments. This review provides the clinician with a basic overview of tendon structure and pathophysiology, and highlights the most common tendinopathies affecting the upper and lower extremities, including an update on recent advances in conservative management.

Golf injuries: a review of the literature

Golf is one of a few activities that people of all ages and skill level can play. Injury as with all sports can occur. The low back is the most common injury sustained whilst playing golf, and the dynamic action of the golf swing is a major contributing factor to injury. The golf swing is a complex movement that utilises the whole body in a coordinated fashion and when repeated frequently can result in injury. Injury can be overuse or traumatic in nature. Overuse injuries predominate in the professional golfer, and amateur golfer injury tends to occur secondary to an incorrect golf swing. Upper limb injuries are also common due to their role in linking the fast moving golf club with the power-generating torso. Fortunately, injury from a club or ball strike is rare. More common are the overuse injuries associated with the back, neck and shoulder. Most golf injury data have been collected retrospectively and further epidemiological study of a prospective nature is required to determine injury incidence and factor relating to the onset of injury.

Complete rupture of the distal biceps tendon in a woman: case report

Complete ruptures of the distal biceps tendon are rare in women. The pathogenesis and gender bias of distal biceps ruptures remain poorly understood. We report a case of a woman with a complete distal biceps rupture who had a successful 1-incision repair with bone anchors.

High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy

BACKGROUND

Results of high-energy extracorporeal shock wave therapy for the treatment of insertional Achilles tendinopathy are not determined. It is unclear how local anesthesia alters the outcome of this procedure.

HYPOTHESIS

Extracorporeal shock wave therapy is an effective treatment for insertional Achilles tendinopathy. Local anesthesia field block adversely affects outcome.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Thirty-five patients with chronic insertional Achilles tendinopathy were treated with 1 dose of high-energy extracorporeal shock wave therapy (ESWT group; 3000 shocks; 0.21 mJ/mm2; total energy flux density, 604 mJ/mm2), and 33 were treated with nonoperative therapy (control group). All extracorporeal shock wave therapy procedures were performed using a local anesthesia field block (LA subgroup, 12 patients) or a nonlocal anesthesia (NLA subgroup, 23 patients). Evaluation was by visual analog score and by Roles and Maudsley score.

RESULTS

One month, 3 months, and 12 months after treatment, the mean visual analog score for the control and ESWT groups were 8.2 and 4.2 (P < .001), 7.2 and 2.9 (P < .001), and 7.0 and 2.8 (P < .001), respectively. Twelve months after treatment, the number of patients with successful Roles and Maudsley scores was statistically greater in the ESWT group compared with the control group (P > .0002), with 83% of ESWT group patients having a successful result, and the mean improvement in visual analog score for the LA subgroup was significantly less than that in the NLA subgroup (F = 16.77 vs F = 53.95, P < .001). The percentage of patients with successful Roles and Maudsley scores did not differ among the LA and NLA subgroups.

CONCLUSION

Extracorporeal shock wave therapy is an effective treatment for chronic insertional Achilles tendinopathy. Local field block anesthesia may decrease the effectiveness of this procedure.

Current concepts in the management of tendon disorders

Primary disorders of tendons are common and constitute a high proportion of referrals to rheumatologists. Certain tendons are particularly vulnerable to degenerative pathology; these include the Achilles, patella, elements of the rotator cuff, forearm extensors, biceps brachi and tibialis posterior tendons. Disorders of these tendons are often chronic and can be difficult to manage successfully in the long term. Significant advances have been made in understanding the pathophysiology of these conditions. Histopathological evidence, together with advances in imaging techniques, has made us more appreciative of the degenerative (rather that inflammatory) nature of these conditions. Additionally the presence of neovascularization is now well-recognized in long-standing tendinopathy. We review the mechanical, vascular and developing neural theories that attempt to explain the aetiology of degenerative tendinopathy. We also explore theories of why specific tendons (such as the Achilles and supraspinatus tendons) are particularly prone to degenerative pathology. Traditionally, treatments have placed a heavy emphasis on anti-inflammatory strategies, which are often inappropriate. Recently, however, significant advances in the practical management of tendon disorders have been made. In particular the advent of 'eccentric loading' training programmes has revolutionized the treatment of Achilles tendinopathy in some patients. This concept is currently being extended to include other commonly injured tendons. Other current treatments are reviewed, as are potential future treatments.

Biomechanical basis for tendinopathy

Tendinopathy affects millions of people in athletic and occupational settings and is a nemesis for patients and physicians. Mechanical loading is a major causative factor for tendinopathy; however, the exact mechanical loading conditions (magnitude, frequency, duration, loading history, or some combinations) that cause tendinopathy are poorly defined. Exercise animal model studies indicate that repetitive mechanical loading induces inflammatory and degenerative changes in tendons, but the cellular and molecular mechanisms responsible for such changes are not known. Injection animal model studies show that collagenase and inflammatory agents (inflammatory cytokines and prostaglandin E1 and E2) may be involved in tendon inflammation and degeneration; however, whether these molecules are involved in the development of tendinopathy because of mechanical loading remains to be verified. Finally, despite improved treatment modalities, the clinical outcome of treatment of tendinopathy is unpredictable, as it is not clear whether a specific modality treats the symptoms or the causes. Research is required to better understand the mechanisms of tendinopathy at the tissue, cellular, and molecular levels and to develop new scientifically based modalities to treat tendinopathy more effectively.

Referred pain and hyperalgesia in human tendon and muscle belly tissue

The sensitivity of tendon and tendon-bone junction is not fully described although these tissues have high clinical impacts. This study assessed (1) pain intensity and referred pain caused by hypertonic saline injection to the proximal tendon-bone junction (PTBJ), tendon and muscle belly sites of tibialis anterior muscle and (2) pressure pain sensitivity, pre, during and post hypertonic saline injections. Eighteen subjects (14 males and 4 females) participated. Subjects also had constant mechanical stimulation for 120s at 130% of baseline pressure pain threshold (PPT) during which VAS parameters were recorded. VAS parameters after hypertonic saline for PTBJ (VAS area, VAS peak), and tendon sites (VAS area, duration and time to maximum VAS) were significantly (P < 0.05) higher than muscle belly. During hypertonic saline pain all three sites displayed local and frequently enlarged and referred pain areas. Hypertonic saline pain at the PTBJ and tendon transiently increased pressure sensitivity at these sites (P < 0.05). When referred pain was caused by mechanical stimulation it occurred predominantly at the PTBJ and tendon sites (86% cases). Constant mechanical stimulation caused steadily increasing pain (summation of pain) at all sites. Hypertonic saline pain at the tendon and PTBJ caused significantly higher (P < 0.001) final VAS scores compared to the muscle belly site. The results indicate the PTBJ and tendon sites are more sensitive and susceptible to sensitisation by hypertonic saline than muscle belly. Furthermore, there may be site specific central changes reflected by the differences in the results regarding sensitivity and summation over time.

[Extracorporeal shockwave therapy in the treatment of chronic insertional Achilles tendinopathy]

PURPOSE

The purpose of this study was to determine the efficacy of extracorporeal shock wave therapy (ESWT) for the treatment of adults with chronic insertional Achilles tendinopathy.

METHODS

68 patients with chronic insertional Achilles tendinopathy were enrolled in this study. A total of 35 patients were treated with a single dose of ESWT (3000 shocks of 0.20 mJ/mm(2), ESWT group), while 33 patients were treated with traditional non-operative measures (control group).

RESULTS

At 3 months post treatment, the mean VAS for the control and ESWT groups were 2.9 and 7.2 respectively. Using the Roles and Maudsley scale, 39% of the control patients and 51% of the ESWT patients were assigned an excellent or good result.

CONCLUSIONS

ESWT as applied is a safe and effective treatment for chronic insertional Achilles tendinopathy.

IGF-I activates PKB and prevents anoxic apoptosis in Achilles tendon cells

Anoxia and apoptosis are both implicated in chronic tendon pathology, however the influence of anoxia on the viability of tendon cells is not known. The objectives of the current study were to (i) investigate the effect of oxygen withdrawal on the viability of porcine Achilles tendon cells (ATCs), and (ii) examine the ability of IGF-I, a factor with known regenerative properties in tendon, to prevent ATC death. Cultured ATCs were enclosed in an anaerobic chamber. The mechanism of cell death was examined by flow cytometry of ATCs double labeled with Annexin-V and propidium iodide (PI). Caspase activity was determined by a fluorometric assay, and nuclear morphology was examined by Hoechst staining. The cell death induced by anoxia was time-dependent, and was characterized by phosphatidylserine exposure on the outer membrane, caspase activation and DNA fragmentation. Death was inhibited by the addition of IGF-I in a dose-dependent manner. The ability of IGF-I to activate the pro-survival PKB pathway in ATCs was inhibited by LY294002, indicating the importance of PI3K in the response of ATCs to IGF-I. These data suggest that cell death induced by lack of oxygen is predominantly apoptotic and can be prevented by pro-survival IGF-I signaling. This mechanism may contribute to the beneficial effect of IGF-I on tendon.

Golf and upper limb injuries: a summary and review of the literature

BACKGROUND

Golf is a popular past time that provides exercise with social interaction. However, as with all sports and activities, injury may occur. Many golf-related injuries occur in the upper limb, yet little research on the potential mechanisms of these injuries has been conducted.

OBJECTIVE

To review the current literature on golf-related upper limb injuries and report on potential causes of injury as it relates to the golf swing.

DISCUSSION

An overview of the golf swing is described in terms of its potential to cause the frequently noted injuries. Most injuries occur at impact when the golf club hits the ball. This paper concludes that more research into golf-related upper limb injuries is required to develop a thorough understanding of how injuries occur. Types of research include epidemiology studies, kinematic swing analysis and electromyographic studies of the upper limb during golf. By conducting such research, preventative measures maybe developed to reduce golf related injury.

Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes

OBJECTIVE

To study the cumulative incidence of Achilles tendon rupture and tendinopathy among former top-level athletes.

DESIGN

Historical cohort study.

SETTING

Finland.

PARTICIPANTS

Male former elite athlete cohort members (n = 785; median age, 69 years when responding to the questionnaire; range, 54-97) and their matched controls (n = 416; median age, 68 years; range, 56-94).

OUTCOME MEASUREMENTS

Questionnaire-reported Achilles tendinopathy and tendon rupture diagnosed by physicians before the age of 45 years and within the subjects' lifetimes.

RESULTS

Cumulative incidence of Achilles tendinopathy before the age of 45 was high for middle and long-distance runners (adjusted odds ratio, 31.2 compared with controls; P < 0.001), and cumulative incidence of Achilles tendon rupture was high for sprinters (odds ratio, 14.9; P < 0.001).

CONCLUSIONS

Achilles tendon problems seem to constitute clinically significant and common problems in specific sports.

Ankle and Foot Injuries in Pediatric and Adult Athletes

Foot and ankle injuries are among the most common in athletes.Differential diagnosis, imaging decisions, and treatment plan should be influenced by the age of the athlete. A thorough history and physical examination, with an understanding of the anatomy of the foot and ankle anatomy and the mechanism of injury, will give the best opportunity to make the correct diagnosis. For most athletes, the prognosis for returning to play after a foot or ankle injury is very good. The recipe for keeping our athletes healthy includes early intervention, undergoing proper rehabilitation, applying braces or orthotics when indicated, and preventing injuries when appropriate.

Inflammatory and angiogenic mRNA levels are altered in a supraspinatus tendon overuse animal model

Shoulder overuse injuries, especially those to the supraspinatus tendon of the rotator cuff, are common musculoskeletal disorders. Unfortunately, little is known about the disease etiology and pathogenesis. The objective of this study was to determine the levels of specific inflammatory and angiogenic markers in a rat supraspinatus tendon overuse injury model. We hypothesized that inflammation would not be present early in the overuse protocol. Conversely, we hypothesized that the overuse protocol would result in increased angiogenesis early. Increases in five-lipoxygenase activating protein, cyclooxygenase-2, vascular endothelial growth factor, and von Willebrand factor were evaluated by use of reverse transcription-polymerase chain reaction from 1 day through 16 weeks of treadmill running (overuse protocol). These results provide important information on the role of angiogenesis and inflammation in the disease process. Future studies will further evaluate the mechanisms of the disease process as well as potential targeted treatment modalities.