Percutaneous Ultrasonic Tenotomy Reduces Insertional Achilles Tendinopathy Pain With High Patient Satisfaction and a Low Complication Rate

Histo-Anatomy and Sonographic Examination for the Retrocalcaneal Bursal Complex: EURO-MUSCULUS/USPRM Approach

Insertional Achilles tendinopathy is an umbrella medical term referring to pain and swelling on the posterior aspect of the calcaneus. High-resolution ultrasound imaging is commonly used in daily practice to assess the pathological changes of the Achilles tendon, cortical bone of the calcaneus, and soft tissues located inside the retrocalcaneal space to optimize the management of relevant patients. To the best of our knowledge, a standardized ultrasound protocol to evaluate the retrocalcaneal bursal complex is lacking in the pertinent literature. In this sense, our step-by-step sonographic approach is intended to be an easy and ready-to-use guide for sonographers/physicians in daily practice to assess this anatomical complex in patients with Achilles tendinopathy. Needless to say, the peculiar histological features of this V-shaped synovial/fibrocartilaginous bursa surrounding the posteroinferior wedge of the Kager's fat pad and the retrocalcaneal space make the examination challenging.

Advances in Ultrasound-Guided Surgery and Artificial Intelligence Applications in Musculoskeletal Diseases

Ultrasound imaging is a vital imaging tool in musculoskeletal medicine, with the number of publications on ultrasound-guided surgery increasing in recent years, especially in minimally invasive procedures of sports, foot and ankle, and hand surgery. However, ultrasound imaging has drawbacks, such as operator dependency and image obscurity. Artificial intelligence (AI) and deep learning (DL), a subset of AI, can address these issues. AI/DL can enhance screening practices for hip dysplasia and osteochondritis dissecans (OCD) of the humeral capitellum, improve diagnostic accuracy for carpal tunnel syndrome (CTS), and provide physicians with better prognostic prediction tools for patients with knee osteoarthritis. Building on these advancements, DL methods, including segmentation, detection, and localization of target tissues and medical instruments, also have the potential to allow physicians and surgeons to perform ultrasound-guided procedures more accurately and efficiently. This review summarizes recent advances in ultrasound-guided procedures for musculoskeletal diseases and provides a comprehensive overview of the utilization of AI/DL in ultrasound for musculoskeletal medicine, particularly focusing on ultrasound-guided surgery.

Superficial retrocalcaneal bursae and nerves: From anatomy to ultrasound-guided procedures

The pertinent literature widely describes ultrasound-guided procedures targeting the retrocalcaneal bursa and the tendon tissue to manage insertional Achilles tendinopathy. Synovial bursae and cutaneous nerves of the superficial retrocalcaneal pad are often overlooked pain generators and are poorly considered by clinicians and surgeons. A layer-by-layer dissection of the superficial soft tissues in the retrocalcaneal region of two fresh frozen cadavers was matched with historical anatomical tables of the textbook Traite d'Anatomie Topographique Avec Applications Médico-Chirurgicales (1909 by Testut and Jacob). An accurate and detailed description of the superficial retrocalcaneal pad with its synovial bursae and cutaneous nerves was provided. Cadaveric dissections confirmed the compartmentalized architecture of the superficial retrocalcaneal fat pad and its histological continuum with the superficial lamina of the crural fascia. Superficial synovial tissue islands have been demonstrated on the posterior aspect of the Achilles tendon in one cadaver and on the posterolateral surface of the tendon in the other one. Digitalization of the original anatomical tables of the textbook Traite d'Anatomie Topographique Avec Applications Médico-Chirurgicales (1909 by Testut and Jacob) showed five potential locations of the superficial calcaneal bursa and a superficial retrocalcaneal nerve plexus within the Achilles tendon-fat pad interface. In clinical practice, in addition to the previously described interventions regarding the retrocalcaneal bursa and the tendon tissue, ultrasound-guided procedures targeting the synovial and neural tissues of the superficial retrocalcaneal pad should be considered to optimize the management of insertional Achilles tendinopathy.

Musculoskeletal disorders in padel: from biomechanics to sonography

Padel is a racket sport, combining high-frequency and low-intensity athletic gestures, that has been gaining growing scientific interest in recent years. Musculoskeletal injuries are very common among padel players with an incidence rate of 3 per 1000 h of training and 8 per 1000 matches. To the best of our knowledge, a comprehensive collection describing the most common sonographic findings in padel players with musculoskeletal injuries is lacking in the pertinent literature. In this sense, starting from the biomechanical features of padel-specific gestures we have reported the ultrasonographic patterns of most frequent injuries involving the upper limb, the trunk, and the lower limb. Indeed, comprehensive knowledge of the biomechanical and clinical features of musculoskeletal injuries in padel is paramount to accurately perform a detailed ultrasound examination of the affected anatomical site. So, the present investigation aims to provide a practical guide, simple and ready-to-use in daily practice, to optimize the sonographic assessment of padel players by combining it with the clinical findings and the biomechanical features of athletic gestures.

Staying in the Game: Interventions for Managing Achilles Tendinopathy in the In-Season Athlete

ABSTRACT

Achilles tendinopathy is a common overuse injury that is traditionally managed with activity modification and a progressive eccentric strengthening program. This narrative review describes the available evidence for adjunctive procedural interventions in the management of midportion and insertional AT, specifically in the athletic population. Safety and efficacy data from available literature on extracorporeal shockwave therapy, platelet-rich plasma, high-volume injectate with or without tendon scraping, and percutaneous needle tenotomy are used to propose an algorithm for treatment of Achilles tendinopathy for the in-season athlete.

Three-Month Complication Rate of Ultrasound-Guided Soft Tissue Surgical Procedures Across Six Sports Medicine Clinics

OBJECTIVES

To 1) determine the types and frequency of complications within 3 months following ultrasound-guided surgical procedures, and 2) identify any patient demographics, co-morbidities, or procedural characteristics that were associated with an increased risk of complications.

METHODS

A retrospective chart review was performed at six Sports Medicine clinics across the United States. The Clavien-Dindo classification was used to categorize procedural complications on a 5-point scale from 1, representing any deviation in post-procedure care without requiring pharmacological or invasive treatment to 5, representing death. Generalized Estimating Equations for binomial outcomes with a logit link were used to estimate the overall and procedure-specific 3-month complication rates.

RESULTS

Among 1902 patients, 8.1% (n = 154) had diabetes and 6.3% (n = 119) were current smokers. The analysis included 2,369 procedures, which were performed in either the upper extremity (44.1%, n = 1045) or lower extremity (55.2%, n = 1308) regions. The most common procedure was ultrasound-guided tenotomy (69.9%, n = 1655). Additional procedures included, trigger finger release (13.1%, n = 310), tendon scraping (8.0%, n = 189), carpal tunnel release (5.4%, n = 128), soft tissue release (2.1%, n = 50), and compartment fasciotomy (1.6%, n = 37). Overall, there was a complication rate of 1.2% (n = 29 complications; 95% CI: 0.8-1.7%). Individual procedures had complication rates that ranged from 0 to 2.7%. There were 13 Grade I complications in 13 patients, 12 Grade II complications in 10 patients, 4 Grade III complications in 4 patients, and 0 Grade IV or V complications. No associations between complication risk and any patient demographics (age, sex, BMI), co-morbidities (diabetes, smoker), or procedure characteristics (type, region) were identified.

CONCLUSION

This retrospective review provides an evidence-based estimate supporting the low level of risk associated with ultrasound-guided surgical procedures for patients from a variety of geographical settings who are seeking care at private and academic-affiliated clinics.

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review

Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.

Therapeutic Potential of Exosomes in Tendon and Tendon-Bone Healing: A Systematic Review of Preclinical Studies

Exosomes have been proven to play a positive role in tendon and tendon-bone healing. Here, we systematically review the literature to evaluate the efficacy of exosomes in tendon and tendon-bone healing. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic and comprehensive review of the literature was performed on 21 January 2023. The electronic databases searched included Medline (through PubMed), Web of Science, Embase, Scopus, Cochrane Library and Ovid. In the end, a total of 1794 articles were systematically reviewed. Furthermore, a "snowball" search was also carried out. Finally, forty-six studies were included for analysis, with the total sample size being 1481 rats, 416 mice, 330 rabbits, 48 dogs, and 12 sheep. In these studies, exosomes promoted tendon and tendon-bone healing and displayed improved histological, biomechanical and morphological outcomes. Some studies also suggested the mechanism of exosomes in promoting tendon and tendon-bone healing, mainly through the following aspects: (1) suppressing inflammatory response and regulating macrophage polarization; (2) regulating gene expression, reshaping cell microenvironment and reconstructing extracellular matrix; (3) promoting angiogenesis. The risk of bias in the included studies was low on the whole. This systematic review provides evidence of the positive effect of exosomes on tendon and tendon-bone healing in preclinical studies. The unclear-to-low risk of bias highlights the significance of standardization of outcome reporting. It should be noted that the most suitable source, isolation methods, concentration and administration frequency of exosomes are still unknown. Additionally, few studies have used large animals as subjects. Further studies may be required on comparing the safety and efficacy of different treatment parameters in large animal models, which would be conducive to the design of clinical trials.

The effectiveness of percutaneous ultrasound-guided needle tenotomy compared to alternative treatments for chronic tendinopathy: a systematic review

OBJECTIVES

To compare percutaneous ultrasound-guided needle tenotomy (PUNT) to alternative treatments for chronic tendinopathy.

MATERIALS AND METHODS

A systematic literature search was performed with the following combination of keywords: ultrasound-guided, percutaneous, needling, tenotomy, Tenex, tendinopathy, and fasciotomy. Original studies comparing PUNT to alternative treatments for chronic tendinopathy were included in this systematic review.

RESULTS

Twelve (n = 12) studies with 481 subjects were included. Two (2/12) articles compared PUNT to surgical tenotomy and concluded that PUNT provides the same outcomes as surgical tenotomy. Six (6/12) studies compared PUNT to platelet-rich plasma (PRP) injections, and two of them found both treatment modalities effective with no significant between-group differences. Three trials claimed that PUNT followed by PRP injections showed superior clinical outcomes compared to PUNT alone. However, the difference at long-term follow-up was statistically significant only in one of them. One study found PUNT superior to PUNT + PRP injection at short-term follow-up, although there were no between-group differences at long-term follow-up. Four (4/12) studies compared PUNT to steroid injection (SI) and showed that SI causes fast (2 weeks) but temporary pain relief, PUNT results in persistent but relatively slower improvement to SI, and the combined procedure has a more rapid and steady reduction in symptoms.

CONCLUSION

PUNT is an effective treatment technique for chronic tendinopathy and should be considered when non-invasive treatments have failed. Effects of PRP and SI are transient and dissipate over time and do not contribute to long-term outcome.

Psychosocial and individual factors affecting Quality of Life (QoL) in patients suffering from Achilles tendinopathy: a systematic review

BACKGROUND

Achilles tendinopathy (AT) is a joint condition that causes functional restrictions and pain. This condition negatively impacts patients' social connectedness and psychological well-being, reducing their quality of life (QoL). This review aims to summarise the current information on QoL in patients suffering from AT from different angles: compared to a healthy population, reported individual factors that influence it and the effects of some AT interventions on QoL.

METHODS

A systematic review was conducted at PubMed, Cochrane, Google Scholar, and PsycINFO using tendinopathy and QoL-related keywords up to November 2021. Articles were included if they compared QoL to demographic factors such as age or gender, lifestyle factors (physical activity levels), comorbidity factors (diabetes, obesity), and/or a control group.

RESULTS

Three hundred twenty-nine articles were reviewed; 23 met the inclusion criteria. SF-36, EQ-5D, and VISA-A were the most common instrument used. Patients with AT reported low QoL when compared to no AT population. When women were compared to men, women reported worse QoL. The patients who participated in different exercise programs (strengthening and stretching) showed improvements in QoL. Surgical AT intervention improved QoL, although results varied by age.

CONCLUSION

AT has a substantial impact on QoL. In AT patients, QoL is also influenced by specific individual factors, including gender and physical activity. Exercise, education, and surgical treatment improve QoL. We suggest more research on AT patients to better understand the aspects leading to poor QoL.

Plantar fasciitis: a comparison of ultrasound-guided fasciotomy with or without amniotic membrane allograft injection

Aim: The purpose of this study was to evaluate the clinical response to augmenting an ultrasound-guided percutaneous plantar fasciotomy (UGPF) with an amniotic membrane (AM) allograft injection. Design: Retrospective, single-center, matched, case-controlled study. Methods: Patients underwent either an UGPF (n = 15) or a combined UGPF and AM injection (n = 16). Results: The UGPF plus AM group demonstrated a significant reduction in pain (p = 0.02) from baseline at the short-term follow-up, but there was no significant difference in pain or patient satisfaction between groups at the 52-week follow-up. Conclusion: Both groups demonstrated a significant reduction in pain and high level of patient satisfaction, but the combination of UGPF with an AM injection may provide a greater reduction in pain earlier in the post-operative period.

Nonoperative Management of the Achilles Tendon Insertion

Insertional Achilles tendinopathy can be a very challenging clinical syndrome with various nonoperative measures typically attempted before surgical intervention. Associated complications are known with surgical repair and can be limb altering. Owing to the longevity of clinical symptoms before clinical presentation, changing the pathophysiologic process and halting the inflammatory changes becomes paramount. Here we discuss nonoperative techniques and updates in the foot and ankle literature.

Failed Surgery for Achilles Tendinopathy

Treatments of Achilles tendinopathy continue to evolve. The body of literature is inadequate to provide a comprehensive guide to evaluation and treat failed surgeries. Issues related to failed surgical treatment may be divided into infection/wound issue, mechanical failure, and persistent pain. Awareness of the potential problems described in this article will allow surgeons to have a foundation in clinical assessment and making accurate diagnoses. Various surgical treatment options are available and should be executed carefully to treat individualized patient conditions.

Management of Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.

Chronic Medial Collateral Ligament Sprain Treated With Percutaneous Ultrasonic Debridement: A Case Report

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee. Most grade I and II injuries respond to conservative management, but symptoms persist in some patients. In these cases, treatment options are limited. Percutaneous ultrasonic debridement is increasingly being used for tendinopathy and fasciopathy refractory to conservative management, but this has not been reported as a treatment for ligament injury. Here, we present a case of a chronic grade II MCL sprain successfully treated with percutaneous ultrasonic debridement.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Ultrasonic aspiration for vaccination-related shoulder dysfunction

Background

Chronic shoulder pain occurs rarely after a vaccination and is hypothesized to arise from the effects of unintentional vaccine injection into the subacromial bursa, rotator cuff, capsule or underlying bone. The avascular nature of the rotator cuff, as well as unknown genetic and environmental factors, may predispose to the persistence of pain and disability, referred to as vaccination-related shoulder dysfunction and shoulder injury related to vaccine administration (SIRVA).

Methods

Ultrasonography, sonopalpation and ultrasound-guided anesthetic injections were used to locate the anatomical source of chronic (mean 20, range 8–42 months) shoulder pain after a vaccination in a consecutive series of 5 patients. Subsequently ultrasound-guided ultrasonic aspiration and debridement was performed using a 2.1 mm outer cannula with an inner needle vibrating at 28 kHz. Outcomes were assessed using the Quick Disabilities of the Arm, Shoulder and Hand (QDASH) scale at 2, 4, 12, 24 weeks and 1 year.

Results

The distal infraspinatus and teres minor tendons, their insertions and or the adjacent bone were the source of pain in all 5 patients. The mean QDASH score improved from 65 points to 11 points at 2 weeks (P = 0.001), and to 1 point at 4 weeks after the procedures (P = 0.003). Improvements in pain and function remained stable at 1 year in 3 patients, for at least 24 weeks in 1 patient who died of unrelated causes, and 1 year in 1 patient for posterior shoulder pain who after a pain free interval developed anterior shoulder pain related to his previously asymptomatic osteoarthritis (P = 0.013).

Conclusion

The distal infraspinatus and teres minor tendons, their insertions and adjacent bone are a common source of chronic shoulder pain after a vaccination. Ultrasound-guided ultrasonic aspiration and debridement is a potentially effective treatment for resolving pain and restoring function.

The Safety of Ultrasound Guided Tenotomy and Debridement for Upper and Lower Extremity Tendinopathies: A Retrospective Study

BACKGROUND

Ultrasound guided tenotomy (USGT) is a minimally invasive treatment option for patients with chronic tendinopathy. There are conflicting findings in the literature with some studies reporting severe complications and others reporting none. This variability is likely due to the small sample sizes of previous studies. We aimed to evaluate the risks associated with USGT and outcomes across multiple tendinopathy/fasciopathy sites in a large clinical sample.

METHODS

Patients who had USGT were identified by retrospective review of charts. Complications, satisfaction, and outcomes (pain, quality of life) were assessed at baseline prior to the procedure (outcomes only), short-term follow up, and long term follow up.

RESULTS

A total of 262 patients with 289 procedures were identified through chart review. There was a low complication rate of 0.7% including one superficial wound infection and one case of wound hypersensitivity. The majority of patients reported improvement in pain by short-term and long-term follow-up and improvement in function by long-term follow-up. The majority of responders reported being either 'very satisfied' or 'somewhat satisfied' with the procedure at short-term follow-up.

CONCLUSION

This study found that USGT is a safe procedure with a low complication rate in a heterogeneous sample. Study findings provide preliminary evidence on the utility of USGT to reduce pain and improve function with a high rate of patient satisfaction.Level of Evidence: IV.

Percutaneous ultrasound-guided resection of a painful osteophyte using novel Tenex-Bone device in a residual limb: A case report

Residual limb pain is common after amputation. Painful osteophytes are one of many causes of residual limb pain, and cases that fail conservative management may require open surgical resection. Here we present a novel percutaneous ultrasound-guided approach to remove a painful osteophyte in a transfemoral amputee. This procedure successfully treated this patient's residual limb pain while minimizing the risks associated with open surgical resection.

Achilles Tendinopathy, A Brief Review and Update of Current Literature

ABSTRACT

Chronic pain in the Achilles tendon is a common problem in both athletes and nonathletes alike. The etiology for the development of Achilles tendinopathy has not been fully elucidated, and there remains multiple theories to explain the pain and dysfunction accompanying this condition. The diagnosis of Achilles tendon problems continues to rely on the clinical history and physical examination. The optimal management of pain, restoration of function, and return-to-sports participation with Achilles tendinopathy are evolving because of the advancement in technologies and research regarding its pathophysiology. This article aims to provide a brief review of the relevant anatomy, differential diagnosis, imaging findings, and an update of the literature on conservative and minimally invasive managements of chronic Achilles tendinopathy.

Achilles Tendinopathy: Evaluation, Rehabilitation, and Prevention

ABSTRACT

Achilles tendinopathy is a common overuse condition that is characterized by degenerative, cumulative tissue microtrauma. It is largely a clinical diagnosis in which the patient typically presents with localized pain that is worse with tendon-loading activities. Imaging modalities may be helpful with the diagnosis of difficult cases or in the planning of interventional procedures. Midportion (noninsertional) and insertional tendinopathy have distinct features and differences for therapeutic paradigms. Overall, Achilles tendinopathy has a good clinical prognosis with most patients improving with activity modification and rehabilitation, with a focus on progressive tendon-loading. Recalcitrant cases may require adjuvant treatment with procedures (e.g., injections, shockwave therapy) and rarely surgical intervention.

ANOVA-Based Analysis of Early Blood Transfusions on Hemodynamics with Severely Injured Trauma Using Bedside Ultrasound Imaging

The focus of the study was to quantitatively analyze the influence of early massive blood transfusions (MBTs) on the hemodynamics and prognostic living quality of patients with severely injured trauma. 114 patients with severely injured trauma were enrolled into MBT group (67 cases) and nonmassive blood transfusions (NBT) group (47 cases) according to whether they accepted MBTs within 24 hours after the admission. All patients had bedside ultrasound technology scanning. Furthermore, the indexes were calculated for inferior vena cava (IVC), peripheral arteries, and heart. The prognostic deaths were recorded. It was found that, in the MBT group, the mortality was lower (7.55% vs. 24.23%) (P < 0.05), and these indexes were higher for the IVC expansion (IVCE), the respiration variation index (RVI) of IVC (ΔIVC2), the peak flow velocity RVI of brachial artery (ΔVpeakBA), femoral artery (ΔVpeakFA), left ventricular outflow tract (ΔVpeakL), and aorta (ΔVpeakAO), as well as peak flow velocity time integral RVI of aorta (ΔVTIAO) (P < 0.05). In conclusion, early MBTs can elevate survival rate and prognostic living quality and alleviate the atrophy degree of IVC, peripheral artery, and blood vessel of patients with severely injured trauma. Furthermore, bedside ultrasound scanning demonstrated superb capabilities in quantitatively displaying hemodynamics and outcomes of MBTs of patients with severely injured trauma.

Functional Outcomes of Insertional Achilles Tendinopathy Treatment: A Systematic Review

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional, and effective treatment of each type can vary. We sought to investigate the current evidence on different treatment methods for insertional Achilles tendinopathy with a focus on functional outcomes.

METHODS

We performed a systematic review of the available literature using the PubMed/MEDLINE and Cochrane Central Register of Controlled Trials databases. Data from included studies were categorized according to treatment method and reported with respect to functional outcomes and complications.

RESULTS

A total of 1,457 abstracts were reviewed; 54 studies with 2,177 patients met the inclusion criteria. Among the 54 studies, 6 operative techniques and 6 nonoperative treatments were evaluated.

CONCLUSIONS

Eccentric exercises and low-energy extracorporeal shockwave therapy (ESWT) have the greatest evidence for the initial management of insertional Achilles tendinopathy. ESWT has been increasingly studied in recent years, but more high-quality evidence is needed. Operative treatment with tenotomy, debridement, retrocalcaneal bursectomy, and calcaneal exostectomy is effective. Flexor hallucis longus tendon transfer may benefit cases of more severe disease. Minimally invasive procedures have a potential role in the treatment algorithm and require more rigorous study.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound-Guided Percutaneous Tenotomy and Its Associated Pain Reduction and Functionality Outcomes in Nonelite Active Adults

OBJECTIVE

The aim of this study was to evaluate changes in pain and functionality after ultrasound-guided percutaneous tenotomy (USGPT) for treatment of tendinopathy.

DESIGN

This was a prospective cohort study of patients undergoing USGPT as an alternative to surgery. Nonelite, active adults completed pain and functionality assessments before USGPT. The visual analog scale (VAS) was used to quantify pain. The Lower Extremity Functionality Scale and the Disabilities of the Arm, Shoulder, and Hand were used to evaluate functionality. Repeat VAS scores were obtained at 1 wk, 1 mo, 2 mos, 3 mos, 6 mos, and 1 yr postprocedure, and repeat functionality assessments, at 1 yr postprocedure. Changes in VAS and functionality were analyzed with paired-sample t-tests.

RESULTS

A total of 103 subjects (61 women, 42 men) underwent USGPT in the following tendons: Achilles, patellar, plantar fascia, flexor carpi ulnaris, extensor carpi radialis brevis, and supraspinatus. Subjects experienced statistically significant decreases in VAS and functionality scores at all time points. The mean VAS score decreased from 7.3 to 3.8 (P < 0.0001) 1 wk postprocedure, with a 5.8-point mean decrease at 1 yr (P < 0.0001). Lower Extremity Functionality Scale scores improved from 42.5 to 65.8 (P < 0.001) and Disabilities of the Arm, Shoulder, and Hand scores improved from 41.5 to 10.4 (P < 0.001) at 1 yr.

CONCLUSION

Recipients of USGPT procedures can expect to benefit from less invasive procedures and improved pain and functionality without invasive surgical procedures.

Sonographically Guided Percutaneous Sectioning of the Coracohumeral Ligament for the Treatment of Refractory Adhesive Capsulitis: Proof of Concept

INTRODUCTION

Treatment options are limited for nonsurgical chronic refractory cases of adhesive capsulitis. We describe a novel percutaneous tenotomy technique for coracohumeral ligament interruption with cadaveric validation.

OBJECTIVE

The objective of this study was to describe and validate a novel technique for percutaneous interruption of the coracohumeral ligament.

DESIGN

Cadaveric study.

SETTING

Academic tertiary care center.

METHODS

Eight cadavers underwent ultrasound (US)-guided percutaneous incision of the coracohumeral (CHL) ligament. Performance of the procedure requires that the practitioner make oscillatory motions with a needle that uses ultrasound energy to cut through tissue. Each pass removes a pinhead-sized amount of tissue. The number of passes and the cutting time are recorded during the procedure. As a standard for this procedure does not exist, the authors created their own based on the preclinical information presented here. Postprocedure dissection was performed to assess the extent of CHL interruption and injury to surrounding tissue.

RESULTS

The average resection time was seven minutes, requiring 500 passes. The technique described in this paper completely interrupted the CHL in all subjects. Cadaveric analysis demonstrated interruption of the CHL with respect to control shoulders requiring an average of seven minutes of cutting time and ∼500 micro-perforations.

CONCLUSION

US-guided percutaneous CHL ligament sectioning is possible with a commercially available ultrasonic probe.

Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review

CONTEXT

Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results.

OBJECTIVE

To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure.

DATA SOURCES

PubMed, MEDLINE, EMBASE, and Google Scholar.

STUDY SELECTION

The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected.

RESULTS

There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking.

CONCLUSION

PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.

Taping, Bracing, and Injection Treatment for Patellofemoral Pain and Patellar Tendinopathy

PURPOSE OF REVIEW

This article will focus on additional treatment options for the two most common causes of anterior knee pain, patellofemoral pain syndrome, and patellar tendinopathy. Conservative management is the first-line treatment for these conditions. For clinicians to maximize the efficacy of conservative treatment options for their patients, they must understand the most up-to-date literature evaluating the potential benefit of taping, bracing, and injections as adjunctive treatments for maximizing treatment success.

RECENT FINDINGS

Recent studies of bracing and taping have found them to be helpful for patients in the short-term management of pain and improving function. However, less is known about their exact mechanism but studies are encouraging that they have a subtle role in changing patellofemoral biomechanics. Injections remain a commonly used treatment for musculoskeletal conditions; however, the evidence for their use in patellofemoral pain and patellar tendinopathy is limited. The use of platelet-rich plasma (PRP), sclerosing, high volume, or stem cell injections is an exciting new area in the treatment of patellar tendinopathy. However, evidence at this time to recommend these treatments is lacking, and more well-designed studies are needed. The treatment of patellofemoral pain and patellar tendinopathy consists of a multi-faceted approach of physiotherapy and physical modalities. There is evidence for short-term use of taping and bracing for these conditions. The evidence for injections at this time is limited and remains under investigation. Future well-designed randomized controlled studies will provide insight into the efficacy of several different types of injections in the treatment of patellar tendinopathy. Physicians should feel comfortable integrating taping and bracing into their anterior knee pain treatment paradigm while making cautious use of invasive injections as adjunctive therapy.

Percutaneous ultrasonic tenotomy effectively debrides tendons of the extensor mechanism of the knee: A technical note

BACKGROUND

Percutaneous ultrasonic tenotomy (PUT) is a minimally-invasive method of treating patellar tendinosis, but its immediate effect on tendon structure has never been studied. Given the crucial nature of the extensor mechanism of the knee, it is important to understand the procedure's effect on tendon structure prior to clinical implementation. The aim of this study was to analyze the tendon structure of the extensor mechanism of the knee after PUT in a cadaveric model.

METHODS

Four fresh-frozen cadaveric specimens (two patellar and two quadriceps tendons) underwent PUT. The tendons were then sectioned and stained with hematoxilin & eosin (H&E). The sections were analyzed for a clear area of debridement. The area of debridement was calculated as an average of three measurements.

RESULTS

All four tendons demonstrated a clear area of debridement limited to the treatment area without damaging any surrounding tissue. The area of debridement for the patellar and quadriceps tendons treated was 2.89 mm2, 1.5 mm2, 2.98 mm2 and 7.29 mm2, respectively.

CONCLUSIONS

Percutaneous ultrasonic tenotomy effectively debrided the treatment area in all tendons without damaging surrounding tissue. Further work is needed to report clinical outcomes, assess the risk of post-procedure tendon rupture and define return-to-sport progression.

Ultrasound-Guided Percutaneous Tenotomy for Gluteal Tendinopathy

Background:

Gluteal tendinopathy is a common cause of lateral hip pain. Percutaneous ultrasonic tenotomy (PUT) has been used successfully for the treatment of tendinopathy of the elbow, knee, and ankle, but its use in the hip has not been described.

Purpose:

To evaluate the efficacy of PUT in patients who did not respond to nonsurgical management of gluteal tendinopathy.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 29 patients with gluteal tendinopathy (mean age, 62 years) who did not respond to nonsurgical treatment were enrolled in this prospective study and underwent ultrasound-guided PUT in an outpatient setting. Patients with a history of ipsilateral hip surgery were excluded. All patients initially underwent magnetic resonance imaging or a computed tomography arthrogram demonstrating tendinopathy and/or partial tearing of the gluteus minimus or medius tendon or both tendons. Outcomes were assessed with a visual analog scale (VAS) for pain, the Harris Hip Score evaluation, and the 12-Item Short Form Health Survey (SF-12) before the procedure and at subsequent follow-up visits or by telephone interviews at 3 weeks, 3 months, 6 months, and final follow-up (range, 18-30 months).

Results:

The mean final follow-up was at 22 months postoperatively. At final follow-up, VAS scores had improved from a preprocedural mean ± SD of 5.86 ± 1.73 to 2.82 ± 2.22 (P < .01). Harris Hip Scores improved from a preprocedural mean of 60.03 ± 10.86 to 77.47 ± 14.34 (P < .01). Total SF-12 scores improved from a mean of 29.93 ± 5.39 (51% optimal) to 34.41 ± 4.88 (64% optimal) (P < .01). No complications were reported. At final follow-up, when asked whether they would have the procedure again, 15 patients replied “yes definitely,” 3 replied “yes probably,” 3 replied “maybe,” 1 replied “likely not,” and 2 replied “definitely not.” There were 3 patients who eventually had hip abductor tendon repair, and their PUT procedures were considered failures.

Conclusion:

PUT is an effective treatment, with good results for patients with gluteal tendinopathy.