The distribution of microvascular response in Achilles tendonopathy assessed by colour and power Doppler

Reliability of a New Semi-automatic Image Analysis Method for Evaluating the Doppler Signal and Intratendinous Vascular Resistance in Patellar Tendinopathy

The aim of this study was to determine the intra- and inter-rater reliability of a new semi-automatic image analysis method for quantification of the shape of the Doppler signal and the intratendinous vascular resistance in patellar tendinopathy. Thirty athletes (27.4 y, standard deviation = 8.57 y) with patellar intratendinous vascularity were included in a cross-sectional study (42 tendons analyzed). The intratendinous blood flow was assessed with power Doppler and ImageJ (Version 1.50b, National Institutes of Health, Bethesda, MD, USA) quantification software over a manually selected region of interest. Two blinded observers performed the analysis of the Doppler signal (vascular resistance) and shape descriptors (number of signals, pixel intensity, area, perimeter, major diameter, minor diameter, circularity and solidity). The intraclass correlation coefficient (ICC) was calculated, and the Bland-Altman mean of differences (MoD) and 95% limits of agreement (LoA) were determined. Also, small real differences (SRDs) and the standard error of measurement (SEM) were calculated. Intra-rater reliability was at a maximum for area (ICC = 0.999, 95% confidence interval [CI] = 0.998-0.999) and at a minimum for solidity (ICC = 0.782, 95% CI: 0.682-0.853). The MoD and 95% LoA were very low, and the relative SRD and SEM were below 5.3% and 2%, respectively. The inter-rater reliability was the maximum for area (ICC = 0.993, 95% CI = 0.989-0.996) and the minimum for circularity (ICC = 0.73; 95% CI=0.611-0.817). The MoD and 95% LoA were low, with the SRD and SEM below 6% and 2.2%. The proposed quantitative method for studying the intratendinous Doppler signal in the patellar tendon is reliable and reproducible.

Equine flexor tendon imaging part 1: Recent developments in ultrasonography, with focus on the superficial digital flexor tendon

Flexor tendon injuries are a major cause of lameness in performance horses and have considerable impact on equine welfare and the wider horse industry. Ageing and repetitive strain frequently cause varying degrees of tendon micro-damage prior to the recognition of clinical tendinopathy. Whilst B-mode ultrasonography is most commonly utilised for detection and monitoring of tendon lesions at the metacarpal/metatarsal level, the emphasis of recent research has focused on the identification of subclinical tendon damage in order to prevent further tendon injury and improve outcomes. The introduction of elastography, acoustoelastography and ultrasound tissue characterisation in the field of equine orthopaedics shows promising results and might find wider use in equine practice as clinical development continues. Based on the substantial number of research studies on tendon imaging published over the past decade this literature review aims to examine the currently used ultrasonographic imaging techniques and their limitations, and to introduce and critically appraise new modalities that could potentially change the clinical approach to equine flexor tendon imaging.

Ultrasound Color Doppler Measures Neovascularization in Achilles Tendinopathy: Review

Purpose: Color Doppler ultrasonography (CD) has been used to employ in Achilles tendinopathy, there is a need to measure neovascularization in Achilles tendinopathy to reach a consensus for CD application. The object of this systematic retrospect is to summarize the literature regarding whether is a relationship between the neovascularization and Achilles tendinopathy by CD detecting. Method: The databases search of PubMed, Scopus, and Embase extracted 543 articles for title and abstract review. After deleting duplicate papers and evaluating which one meets the inclusion criteria, a total of 8 articles were selected. Results and conclusion: Differentiate a physiological and pathological color Doppler flow in Achilles tendon is important to further clinically diagnose, since neovascularization in tissue structure can be influenced by variation reasons. The standardized tenoangiography protocol be supposed to develop when assessment asymptomatic or symptomatic tendons.

Intraindividual Doppler Flow Response to Exercise Differs Between Symptomatic and Asymptomatic Achilles Tendons

Objective

This study investigated intraindividual differences of intratendinous blood flow (IBF) in response to running exercise in participants with Achilles tendinopathy.

Design

This is a cross-sectional study.

Setting

The study was conducted at the University Outpatient Clinic.

Participants

Sonographic detectable intratendinous blood flow was examined in symptomatic and contralateral asymptomatic Achilles tendons of 19 participants (42 ± 13 years, 178 ± 10 cm, 76 ± 12 kg, VISA-A 75 ± 16) with clinically diagnosed unilateral Achilles tendinopathy and sonographic evident tendinosis.

Intervention

IBF was assessed using Doppler ultrasound “Advanced Dynamic Flow” before (Upre) and 5, 30, 60, and 120 min (U5–U120) after a standardized submaximal constant load run.

Main Outcome Measure

IBF was quantified by counting the number (n) of vessels in each tendon.

Results

At Upre, IBF was higher in symptomatic compared with asymptomatic tendons [mean 6.3 (95% CI: 2.8–9.9) and 1.7 (0.4–2.9), p < 0.01]. Overall, 63% of symptomatic and 47% of asymptomatic Achilles tendons responded to exercise, whereas 16 and 11% showed persisting IBF and 21 and 42% remained avascular throughout the investigation. At U5, IBF increased in both symptomatic and asymptomatic tendons [difference to baseline: 2.4 (0.3–4.5) and 0.9 (0.5–1.4), p = 0.05]. At U30 to U120, IBF was still increased in symptomatic but not in asymptomatic tendons [mean difference to baseline: 1.9 (0.8–2.9) and 0.1 (-0.9 to 1.2), p < 0.01].

Conclusion

Irrespective of pathology, 47–63% of Achilles tendons responded to exercise with an immediate acute physiological IBF increase by an average of one to two vessels (“responders”). A higher amount of baseline IBF (approximately five vessels) and a prolonged exercise-induced IBF response found in symptomatic ATs indicate a pain-associated altered intratendinous “neovascularization.”

Power Doppler to investigate superficial digital flexor tendinopathy in the horse

Background:

Recent advances in tendinopathy research have focused on tendon vascularization detected with Color Doppler (CD) ultrasound. The use of CD has also been described in horses in a study on chronic lesions of superficial digital flexor tendon and suspensory ligament.

Aim:

The aim of this study was to investigate the occurrence and distribution of power Doppler (PD) signal in horses with superficial digital flexor tendinopathy.

Methods:

Twenty-five horses with tendinopathy were included and 10 healthy horses with no lameness and no ultrasonographic abnormalities were used for comparison.

Results:

In all horses with tendinopathy, the PD signal was visible while normal tendons with no abnormalities in B-mode were PD signal-free.

Conclusion:

We can speculate that PD could provide essential information about the healing process than the grayscale ultrasound.

In Achilles tendinopathy, the neovascularization, detected by contrast-enhanced ultrasound (CEUS), is abundant but not related to symptoms

PURPOSE AND HYPOTHESIS

Mid-portion Achilles tendinopathy is characterized by a proliferation of small vessels, called neovascularization, which can be demonstrated by power Doppler sonography (PD). Neovascularization can be correlated with diagnosis and consequent therapies focused on vascular supply. Published data regarding the relationship between neovascularisation and symptoms, such as pain and disability, are contradictory. The hypothesis that contrast-enhanced ultrasound (CEUS) could detect with more sensibility than PD the new vessel ingrowth in human degenerated Achilles tendons and therefore the correlation of neovascularization with pain and disability, was evaluated.

METHODS

Thirty consecutive patients of recalcitrant Achilles tendinopathy were studied with ultrasound greyscale (US), PD, CEUS and magnetic resonance imaging. Neovascularization was recorded as percentage on the whole extension of examined area. The vascularization time was recorded as venous and arterial type. Imaging data were classified both concurrently with the examination and in a secondary blinded assessment; any difference in the subjective assessment was discussed and a consensus view formed. Pain and disability were assessed by Western Ontario McMaster Universities Arthritis Index (WOMAC) and EuroQuality of life 5-dimension-5-level questionnaire and visual analogue scale (EQ-VAS). All results were analysed with suitable statistical methods.

RESULTS

76.7% of cases were degenerated; 23.3% had also partial discontinuity of the fibres. PD detected vascularization in 54% of cases, whereas CEUS in 83% of cases: in 13 cases, PD did not detect vascularization. The vascularization time was rapid (< 20 s, arterial type) in 60% of cases. WOMAC pain mean value is 6.4 and SD 3.4; WOMAC total score mean value is 21.6 and SD 12.8. EQ-VAS mean value is 56 and SD 18.3. No statistically significant correlation emerged between vascularization and pain/disability.

CONCLUSIONS

CEUS showed a greater ability to detect neovessels than PD in chronic Achilles tendinopathies. Nevertheless in 30 consecutive tendinopathies, no correlation between pain/disability and neovascularization was found: the role of multiple neovessels continue to be unclear. The possibility to discriminate arterial from venous vessels ('vascularization time') could be useful to understand the pathophysiology of tendinopathies and its healing process.

STUDY TYPE

Diagnostic study.

LEVEL OF EVIDENCE

II.

Reliability of Evaluating Achilles Tendon Vascularization Assessed With Doppler Ultrasound Advanced Dynamic Flow

OBJECTIVES

The reliability of quantifying intratendinous vascularization by high-sensitivity Doppler ultrasound advanced dynamic flow has not been examined yet. Therefore, this study aimed to investigate the intraobserver and interobserver reliability of evaluating Achilles tendon vascularization by advanced dynamic flow using established scoring systems.

METHODS

Three investigators evaluated vascularization in 67 recordings in a test-retest design, applying the Ohberg score, a modified Ohberg score, and a counting score. Intraobserver and interobserver agreement for the Ohberg score and modified Ohberg score was analyzed by the Cohen κ and Fleiss κ coefficients (absolute), Kendall τ b coefficient, and Kendall coefficient of concordance (W; relative). The reliability of the counting score was analyzed by intraclass correlation coefficients (ICC) 2.1 and 3.1, the standard error of measurement (SEM), and Bland-Altman analysis (bias and limits of agreement [LoA]).

RESULTS

Intraobserver and interobserver agreement (absolute/relative) ranged from 0.61 to 0.87/0.87 to 0.95 and 0.11 to 0.66/0.76 to 0.89 for the Ohberg score and from 0.81 to 0.87/0.92 to 0.95 and 0.64 to 0.80/0.88 to 0.93 for the modified Ohberg score, respectively. The counting score revealed an intraobserver ICC of 0.94 to 0.97 (SEM, 1.0-1.5; bias, -1; and LoA, 3-4 vessels). The interobserver ICC for the counting score ranged from 0.91 to 0.98 (SEM, 1.0-1.9; bias, 0; and LoA, 3-5 vessels).

CONCLUSIONS

The modified Ohberg score and counting score showed excellent reliability and seem convenient for research and clinical practice. The Ohberg score revealed decent intraobserver but unexpected low interobserver reliability and therefore cannot be recommended.

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

BACKGROUND

Supraspinatus tendinopathy is one of the common causes of subacromial pain syndrome (SAPS) in overhead athletes. Changes in tendon vascularity have been reported in painful tendons; however, the prevalence and distribution have not been investigated in young overhead athletes.

METHODS

We conducted a cross-sectional study of 47 overhead athletes (male, 31; female, 16) aged 18 to 36 years with SAPS for >3 months. A sonographer graded the severity of the tendinopathy and area of vascularization. Ultrasound imaging was used to measure supraspinatus tendon thickness, vascularity, and resting subacromial space. A self-written program was used to semiquantify the intensity of vascularity, expressed as the vascular index.

RESULTS

The majority (87.2%) of the participants had signs of tendinopathy in the supraspinatus tendon, and 40 (85.1%) of the tendinopathic tendons had vascularity. The majority (66.0%) of the vascularized subjects presented with minimal increase in vascularity, and 19.1% had moderate to severe vascularization. Most (79.2%) of the vascularization was observed in the pericortical region. The vascular index was negatively correlated with the resting subacromial space in male athletes with a reduced subacromial space (ρ = -0.63; P = .038).

CONCLUSION

Of overhead athletes with SAPS, 87.2% had supraspinatus tendinopathy with minimal to moderate vascularization, with the majority of vascularization occurring in the pericortical region. In male athletes with a reduced subacromial space, greater vascularity in the supraspinatus tendon was associated with a smaller resting subacromial space.

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

PURPOSE

The purpose of this study was to investigate the consistency between different Doppler ultrasound (DU) modes as well as the intra- and inter-observer reliability of investigators with different experience level in assessing intratendinous blood flow (IBF) in Achilles tendinopathy patients.

MATERIAL AND METHODS

18 participants (36 Achilles tendons, AT) with Achilles tendinopathy (24 AT) were examined with power Doppler ultrasound (PDU), colour Doppler ultrasound (CDU) and "Advanced Dynamic Flow" (ADF) (Toshiba Xario SSA-660 A; 14MHz transducer) by 2 investigators (experienced, EI; inexperienced, II) in a test-retest design (M1/M2). A modified Öhberg score was used to quantify IBF. Data was analysed descriptively (absolute and relative). Consistency of the 3 modes was presented by Kendall's Coefficient of Concordance (Kendall's W). Intra- and inter-observer reliability were calculated by use of Kendall's tau b correlation coefficient.

RESULTS

IBF was detected in 79-92% of symptomatic AT and in 33-50% of contralateral asymptomatic AT. Comparing the 3 modes, Kendall's W ranged from 0.97-0.98. Analysis of intra-observer reliability resulted in Kendall's tau 0.90-0.92 for EI and 0.84-0.87 for II. Inter-observer reliability resulted in Kendall's tau 0.64-0.69 in M1 and 0.68-0.70 in M2.

CONCLUSION

The very good consistency between PDU, CDU and ADF indicates a comparable applicability for assessing IBF in ATs. Intra-observer reliability was high for both investigators, independent of experience. The moderate inter-observer reliability reflects the challenge in sonographic detection of intratendinous blood flow (IBF) amount.

High-Volume Image-Guided Injection for Recalcitrant Patellar Tendinopathy in Athletes

OBJECTIVE

To assess the effectiveness of high-volume image-guided injection in the middle term in patients with recalcitrant patellar tendinopathy.

DESIGN

Case series study; Level of evidence, 4.

SETTING

All tertiary referrals, public, and private healthcare.

PATIENTS

Forty-four patients (41 men and 3 women) with diagnosis of recalcitrant patellar tendinopathy were included.

INTERVENTION

Tendon injection of a mixture of 10 mL of 0.5% bupivacaine hydrochloride, 62 500 international units of aprotinin, and 40 mL of normal saline solution.

MAIN OUTCOME MEASURES

The Victorian Institute of Sport Assessment-patellar tendon (VISA-P), visual analogue scale, and Roles and Maudsley were assessed at baseline and at the last follow-up.

RESULTS

The baseline VISA-P score of 46 ± 18.2 (range, 28-75) improved to 75.3 ± 19.2 (range, 68-100) by 15 months (P = 0.003). The mean pain visual analogue scale changed from 91 mm (range, 66-92 mm) before the injection to 28 mm (2-52 mm) (P = 0.01). Of 32 physically active patients, 23 (72%) had returned to sport at the same level practiced before the onset of symptoms. Thirty-five of the 44 patients (80%) rated their condition as good or excellent.

CONCLUSIONS

High-volume injection at the interface between the deep surface of the patellar tendon and Hoffa body improves in the short-term symptoms and function of the knee.

CLINICAL RELEVANCE

This procedure is minimally invasive, safe, and effective in the short term in athletes.

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

AIMS

To investigate whether autologous adipose tissue-derived mesenchymal stem cells (AT-MSCs) treatment of tendon lesions increases neovascularization during tendon healing.

MATERIALS & METHODS

A standardized surgical model was used to create lesions in both front limb superficial digital flexor tendons (SDFTs) of nine horses. Either AT-MSCs or control substance was injected intralesionally 2 weeks post-surgery. Color Doppler ultrasonography of SDFTs was performed at regular intervals. Horses were euthanized 22 weeks post-treatment and SDFTs were harvested for histology.

RESULTS

The color Doppler ultrasonography signal was significantly more extensive at 2 weeks post-treatment and the number of vessels counted on histologic slides was significantly higher at 22 weeks post-treatment in AT-MSC-treated SDFTs.

CONCLUSION

Our findings indicate that AT-MSC treatment has a beneficial effect on neovascularization of healing tendons.

A soft patellar tendon on ultrasound elastography is associated with pain and functional deficit in volleyball players

OBJECTIVES

To investigate the diagnostic performance of grey scale Ultrasound (US), power Doppler (PD) and US elastography for diagnosing painful patellar tendinopathy, and to establish their relationship with Victorian Institute of Sport Assessment-Patella (VISA-P) scores in a group of volleyball players with and without symptoms of patellar tendinopathy.

DESIGN

Cross-sectional study.

METHODS

Thirty-five volleyball players (70 patellar tendons) were recruited during a national university volleyball competition. Players were imaged with conventional US followed by elastography. The clinical findings of painful patellar tendons were used as the reference standard for diagnosing patellar tendinopathy. In addition, all participants completed the VISA-P questionnaires.

RESULTS

Of the 70 patellar tendons, 40 (57.1%) were clinically painful. The diagnostic accuracy of grey scale US, PD and elastography were 60%, 50%, 62.9%, respectively, with sensitivity/specificity of 72.5%/43.3%, 12.5%/100%, and 70%/53.3%, respectively. Combined US elastography and grey scale imaging achieved 82.5% sensitivity, 33.3% specificity and 61.4% accuracy while routine combination technique of PD and grey scale imaging revealed 72.5% sensitivity, 43.3% specificity and 60.0% accuracy. Tendons in players categorized as soft on elastography had statistically significantly greater AP thickness (p<0.001) and lower VISA-P scores (p=0.004) than those categorized as hard. There was no significant association between grey scale US abnormalities (hypoechogenicities and/or fusiform swelling) and VISA-P scores (p=0.098).

CONCLUSIONS

Soft tendon properties depicted by US elastography may be more related to patellar tendon symptoms compared to grey scale US abnormalities. The supplementation of US elastography to conventional US may enhance the sensitivity for diagnosing patellar tendinopathy in routine clinical practice.

Ultrasound morphology of the Achilles in asymptomatic patients with and without diabetes

BACKGROUND

The prevalence of tendinopathies is increased in subjects with diabetes mellitus. However, there are few data on the structural abnormalities of Achilles tendons in asymptomatic diabetic patients. The aim of the study was to assess the morphologic characteristics of the Achilles tendon in subjects with diabetes in comparison with controls without diabetes.

METHODS

Participants were consecutively recruited from an outpatient population. Ultrasound longitudinal and transverse scans were performed bilaterally along the full length of Achilles tendon from the musculotendinous junction to the insertion. Degenerative features (abnormal fibrillar pattern, hypo-hyperechoic areas), signs of enthesopathy (bony erosion, enthesophytes, and bursitis), and intratendinous neovessel formation were recorded.

RESULTS

Asymptomatic sonographic abnormalities (ASA) were significantly increased in subjects with diabetes (35/136 [25.7%] vs 32/273 [11.7%], P = .0003). Sixty tendons with ASA were observed in the first group and 45 in the latter because ASA were bilateral in 25 and in 13 subjects, respectively. ASA were more frequently localized at the enthesis (32/60 [53.3%] vs 9/45 [20%], P = .0005) in the diabetes group, whereas, on the contrary, they were more prevalent at the midportion in controls (38/45 [84.4%] vs 36/60 [60%], P < .006).

CONCLUSION

Diabetes may predispose to Achilles tendinopathy and particularly to Achilles enthesopathy. Longitudinal studies, evaluating the progression of the lesions not only in the midportion of the tendon but also at the insertion are needed to support this conclusion.

LEVEL OF EVIDENCE

Level III, comparative series.

Neovascularization prevalence in the supraspinatus of patients with rotator cuff tendinopathy

OBJECTIVE

A high prevalence of neovascularity in lower extremity tendinopathies has been reported. Neovascularity in those with rotator cuff tendinopathy exclusively has not been examined. The objective was to determine the prevalence of neovascularization in patients with rotator cuff tendinopathy compared with asymptomatic controls.

DESIGN

Single-blind cross-sectional study.

SETTING

Research laboratory.

PARTICIPANTS

Participants (n = 40; age = 44.9 years, 23-62 years; 20 females) with rotator cuff tendinopathy (n = 20) but without full-thickness rotator cuff tears, and asymptomatic controls that were age, gender, and hand dominance matched (n = 20) to the patients.

INTERVENTIONS

The participants laying in supine had their shoulder positioned in internal rotation and extension. Ultrasound images were collected of the supraspinatus tendon and subacromial bursae in the transverse and longitudinal planes using a linear transducer in color Doppler mode.

MAIN OUTCOME MEASURES

Images were assessed for neovascularization by 2 trained raters who were blinded to group (rotator cuff tendinopathy or asymptomatic group).

RESULTS

No statistically significant difference in neovascularization was identified between participants with and without rotator cuff tendinopathy (χ = 0.13, df = 1, P = 0.72). Neovascularization was identified in 6 of 20 patients with rotator cuff tendinopathy (30%) and 5 of 20 asymptomatic control participants (25%).

CONCLUSIONS

The authors found no differences in neovascularization rate in patients with rotator cuff tendinopathy (30%) and asymptomatic controls (25%). The study indicates that neovascularization is not related to presence of symptomatic tendinopathy in those with rotator cuff tendinopathy. Neovascularization may not be a relevant sonographic finding to aid the clinical assessment of those with rotator cuff tendinopathy.

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

Thirty-seven pathologic Achilles tendons from 27 patients were investigated by a three-dimensional (3-D) power Doppler ultrasound system. Both the volume of the neovascularity (VON) and the volume of Achilles tendon (VOAT) were investigated. VON-VOAT index (VVI), as the normalization of the neovascularization, was accordingly calculated. Patient's clinical indications were assessed using the visual analog scale for pain (VAS) and Victorian Institute of Sport Assessment Achilles (VISA-A). Relationships between VAS and VON, VISA-A and VON, VAS and VOAT, VISA-A and VOAT, VAS and VVI, and VISA-A and VVI, were statistically analyzed. The vascular mapping within and surrounding the symptomatic Achilles tendons was investigated. 97.3% of the Achilles tendons were found to have neovascularization. In 55.6% of these Achilles, the neovascularity was associated with the location of thickening. The VAS was found to be positively correlated with the VON and the VVI, the VON was found to be independent from the VOAT.

Real-time sonoelastography of the Achilles tendon: pattern description in healthy subjects and patients with surgically repaired complete ruptures

OBJECTIVE

The purpose of this study is to describe the elastographic appearance of the Achilles tendon in healthy subjects and patients with surgically repaired complete ruptures.

MATERIALS AND METHODS

Nineteen Achilles tendons of 16 amateur footballers with surgically repaired complete ruptures and their contralateral asymptomatic Achilles tendons were assessed with ultrasound and real-time sonoelastography. Additionally, 40 asymptomatic Achilles tendons of 20 healthy amateur footballers were assessed. The Achilles tendons were divided into the distal, middle, and proximal thirds for elastographic image evaluation. Tendons were classified into three main types according to the elasticity features: type 1, blue (hardest tissue); type 2, blue/green (hard tissue); or type 3, green (intermediate tissue). In addition, three subtypes were determined: homogeneous, relatively homogeneous, and heterogeneous.

RESULTS

Most of the Achilles tendons of the patients with surgically repaired complete ruptures were detected to have type 2 elasticity (64.9%), and the remaining had type 1 (35.1%). In contrast, most of the healthy tendons had type 2 (64.2%), and the remaining had either a type 3 (20.8%) or a type 1 (15%) elastographic pattern. All of the ruptured tendons had a heterogeneous structure, whereas all of the healthy Achilles tendons had a homogeneous or relatively homogeneous structure.

CONCLUSION

In sonoelastography, the recognition of normal tendon structure will be useful in assessing pathologies of the Achilles tendon. Additionally, in patients with excellent American Orthopedic Foot and Ankle Society (AOFAS) scores and surgically repaired complete ruptures, a hard and heterogeneous pattern of tendon structure may be a natural consequence of tendon healing.

Associations between abnormal ultrasound color Doppler measures and tendon pain symptoms in badminton players during a season: a prospective cohort study

BACKGROUND

Color Doppler ultrasound is widely used to examine intratendinous flow in individuals with overuse tendon problems, but the association between color Doppler and pain is still unclear.

HYPOTHESIS

Intratendinous flow is present and associated with pain in badminton players, and intratendinous flow and pain increase during a badminton season.

STUDY DESIGN

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

METHODS

Ninety-five semiprofessional badminton players were included in the study at a tournament at the start of the badminton season. All players were interviewed regarding pain. The anterior knee tendons and Achilles tendons were studied. Each tendon was scored using a quantitative grading system (grades 0-5) and a qualitative scoring system (color fraction) using color Doppler ultrasound. Eight months later, 86 of the players (91%) were retested by the same investigators during an equivalent badminton tournament (including 1032 tendon regions; 86 players with 4 tendons each with 3 regions), thus forming the study group.

RESULTS

At the start of the season, 24 players (28%) experienced pain in 37 tendons (11%), and at the end of the season, 31 players (36%) experienced pain in 51 tendons (15%), which was a statistically significant increase (P = .0002). Abnormal flow was found in 230 tendon regions in 71 players (83%) at the start of the season compared with 78 tendon regions in 41 players (48%) at the follow-up. The decrease in abnormal flow was statistically significant (P < .0001). Of the 37 painful tendons at the start of the season, 25 had abnormal flow (68%). In contrast, 131 tendons (85%) with abnormal flow at the start of the season were pain free. At the end of the season, 18 of the 51 painful tendons (35%) had abnormal flow. Ninety-six of the 131 pain-free tendons (73%) with abnormal flow at the start of the season were normalized (no pain and normal flow) at the end of the season.

CONCLUSION

It was not possible to verify any association between intratendinous flow and pain at the start of the season or at the follow-up (end of the season). Intratendinous flow at the start of the season could not predict symptomatic outcome at the end of the season. The decrease in Doppler flow during the season might suggest that intratendinous flow could be part of a physiological adaptive response to loading and that intratendinous flow as previously believed is not always a sign of pathological changes.

A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy

Background

Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results.

Aim

To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson's heel-drop exercise programme.

Study design

Part of a 5-year follow-up of a previously conducted randomised controlled trial.

Methods

58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded.

Results

In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051).

Conclusion

At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson's heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.

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

Lower limb tendon changes detected at imaging are common among asymptomatic athletes. We aimed to prospectively assess the clinical status, tendon structure, and vascularity of lower limb tendons of elite fencers, and predict the risk of developing symptoms over time. Clinical examination, changes at ultrasonography (US), and Power Doppler (PD) flow of both the Achilles, patellar, and quadriceps tendon were assessed in 37 elite fencers in January 2007 and 3 years after. Two hundred and twenty-two tendons were examined. At the last appointment, patellar tendons diagnosed as abnormal at baseline were more likely to develop symptoms than those normal at baseline (P < 0.05, Fisher's exact test), while US and PD abnormalities on Achilles and quadriceps tendons were no predictive for development of symptoms over years. A very low percentage of tendons diagnosed as normal at baseline (1.45%) showed US abnormalities at 3-year follow-up. In asymptomatic elite fencers, structural changes are relatively common at US and PD assessment of Achilles, quadriceps, and patellar tendons. It seems unlikely that additional PD investigations provide further information or change prognosis in patients with US diagnosis of tendinopathy.

Analysis of achilles tendon vascularity with second-generation contrast-enhanced ultrasound

PURPOSE

To compare morphological, power Doppler, and contrast-enhanced ultrasound (CEUS) features of the Achilles tendon between asymptomatic athletes and athletes who had undergone surgical repair of a previous rupture.

METHODS

Twenty-four athletes were divided in two groups (A and B). Group A included 14 patients with a median age of 32 years (range 27 to 47 years) who had undergone surgical repair for unilateral Achilles tendon rupture. Group B (control group) included 10 subjects with a median age of 34 years (range 27 to 40 years) with no previous or present history of tendinopathy. All patients were evaluated with ultrasound, power Doppler, and CEUS with second-generation contrast agent. We studied the uninjured Achilles tendon in athletes of group A and either the left or the right Achilles tendon of the athletes in group B.

RESULTS

CEUS showed a significantly greater ability to detect a greater number of vascular spots within the uninjured tendon of group A compared to group B (<0.05).

CONCLUSIONS

In athletes who had suffered a tear of an Achilles tendon, CEUS detected small vessels that were not identified by power Doppler ultrasound in the uninjured contralateral Achilles tendon. CEUS is useful to evaluate vascularity not detected by other imaging techniques. Vascularity in the uninjured tendon seems to be increased in patients who had a previous rupture.

Evidence of accumulated stress in Achilles and anterior knee tendons in elite badminton players

Tendon-related injuries are a major problem, but the aetiology of tendinopathies is unknown. In tendinopathies as well as during unaccustomed loading, intra-tendinous flow can be detected indicating that extensive loading can provoke intra-tendinous flow. The aim of present study is to evaluate the vascular response as indicated by colour Doppler (CD) activity in both the Achilles and patella tendon after loading during high-level badminton matches. The Achilles tendon was subdivided into a mid-tendon, pre-insertional, and insertional region and the anterior knee tendons into a quadriceps-, patella- and tuberositas region. Intra-tendinous flow was measured using both a semi-quantitative grading system (CD grading) and a quantitative scoring system (CF) on colour Doppler. Intra-tendinous flow in the Achilles and anterior knee tendons was examined in fourteen single players before tournament and after 1st and 2nd match, respectively on both the dominant and non-dominant side. All players had abnormal intra-tendinous flow (Colour Doppler ≥ grade 2) in at least one tendon in at least one scan during the tournament. At baseline, only two of the 14 players had normal flow in all the tendons examined. After 1st match, tendencies to higher intra-tendinous flow were observed in both the dominant patella tendon and non-dominant quadriceps tendon (P-values n.s.). After 2nd match, intra-tendinous flow was significant increased in the dominant patella tendon (P = 0.009). In all other locations, there was a trend towards a stepwise increase in intra-tendinous flow. The preliminary results indicate that high amount of intra-tendinous flow was found in elite badminton players at baseline and was increased after repetitive loading, especially in the patella tendon (dominant leg). The colour Doppler measurement can be used to determine changes in intra-tendinous flow after repetitive loading.

Retro-trochanteric sciatica-like pain: current concept

The aim of this manuscript is to review the current knowledge in terms of retro-trochanteric pain syndrome, make recommendations for diagnosis and differential diagnosis and offer suggestions for treatment options. The terminology in the literature is confusing and these symptoms can be referred to as 'greater trochanteric pain syndrome', 'trochanteric bursitis' and 'trochanteritis', among other denominations. The authors focus on a special type of sciatica, i.e. retro-trochanteric pain radiating down to the lower extremity. The impact of different radiographic assessments is discussed. The authors recommend excluding pathology in the spine and pelvic area before following their suggested treatment algorithm for sciatica-like retro-trochanteric pain.

Longitudinal microvascularity in Achilles tendinopathy (power Doppler ultrasound, magnetic resonance imaging time-intensity curves and the Victorian Institute of Sport Assessment-Achilles questionnaire): a pilot study

AIM

To evaluate the imaging of the natural history of Achilles tendinopathy microvascularisation in comparison with symptoms, using a validated disease-specific questionnaire [the Victorian Institute of Sport Assessment-Achilles (VISA-A)].

METHOD

A longitudinal prospective pilot study of nine patients with post-contrast magnetic resonance imaging (MRI), time-intensity curve (TIC) enhancement, ultrasound (US) and power Doppler (PD) evaluation of tendinopathy of the mid-Achilles tendon undergoing conservative management (eccentric exercise) over 1 year.

RESULTS

There were five men and four women [mean age 47 (range 30-62) years]. Six asymptomatic tendons with normal US and MRI appearance showed less enhancement than the tibial metaphysis did and showed a flat, constant, but very low rate of enhancement in the bone and Achilles tendon (9-73 arbitrary TIC units). These normal Achilles tendons on imaging showed a constant size throughout the year (mean 4.9 mm). At baseline the TIC enhancement in those with tendinopathy ranged from 90 arbitrary units to 509 arbitrary units. Over time, 11 abnormal Achilles tendons, whose symptoms settled, were associated with a reduction in MRI enhancement mirrored by a reduction in the number of vessels on power Doppler (8.0 to 2.7), with an improvement in morphology and a reduction in tendon size (mean 15-10.6 mm). One tendon did not change its abnormal imaging features, despite improving symptoms. Two patients developed contralateral symptoms and tendinopathy, and one had more abnormal vascularity on power Doppler and higher MRI TIC peaks in the asymptomatic side.

CONCLUSIONS

In patient with conservatively managed tendinopathy of the mid-Achilles tendon over 1 year there was a reduction of MRI enhancement and number of vessels on power Doppler, followed by morphological improvements and a reduction in size. Vessels per se related to the abnormal morphology and size of the tendon rather than symptoms. Symptoms improve before the Achilles size reduces and the restoration of normal imaging over time.

Site of maximum neovascularisation correlates with the site of pain in recalcitrant mid-tendon Achilles tendinopathy

BACKGROUND

Neovascularisation is associated with pain in Achilles tendinopathy (AT). The anatomical relationship between ultrasound (US)-defined indicators of tendinopathy and clinically determined pain sites has not been investigated.

PURPOSE

To measure the spatial correlation between the sites of maximum palpated tenderness, site of patient-indicated pain, maximum US-determined neovascularisation and maximum antero-posterior tendon thickness in patients with chronic recalcitrant AT (CRAT).

METHODS

A custom-designed measuring apparatus and clinical examination were used to measure the sites of maximum tenderness and subjectively defined pain on 29 tendons from patients diagnosed with mid-tendon CRAT. All tendons had been previously non-responsive to eccentric loading. Maximal neovascularisation and tendon thickness were measured by US scanning in conjunction with the measuring device.

RESULTS

A significant association exists between clinically determined pain and neovascularisation (r = 0.85, p < 0.001), patient reported pain (r = 0.91, p < 0.001), maximal tendon thickness (r = 0.91, p < 0.001), maximal thickness and maximal neovascularisation (r = 0.86, p < 0.001).

CONCLUSION

Sites of subjectively defined pain, clinically palpated tenderness, tendon thickness and neovascularisation are anatomically associated. Palpation can be reliably used as a clinical guide when planning interventions in patients with CRAT.

The use of ultrasound in the assessment and treatment of Achilles tendinosis

The use of ultrasound in the diagnosis and management of disorders of the tendo Achillis is discussed. Some of the pathological processes which occur in Achilles tendinopathy can be identified by ultrasound, which may also be used to direct local treatment.

Interobserver reliability of neovascularization score using power Doppler ultrasonography in midportion achilles tendinopathy

BACKGROUND

Power Doppler ultrasonography is widely used to examine neovascularization in midportion Achilles tendinopathy. The reliability of the grading of the degree of neovascularization has not been examined previously.

HYPOTHESIS

Power Doppler ultrasonography can be performed with a high interobserver reliability to determine the neovascularization score in patients with midportion Achilles tendinopathy.

STUDY DESIGN

Case control study (diagnosis); Level of evidence, 4.

METHODS

Thirty-three symptomatic and 17 asymptomatic Achilles tendons from 25 consecutive patients were included for ultrasound examination. Victorian Institute of Sport Assessment-Achilles score was used to assess the severity of the Achilles tendinopathy. Each tendon was scored twice by different radiologists using the modified Ohberg score for neovascularization.

RESULTS

The intraclass correlation coefficient for interobserver reliability was 0.85. Neovascularization was observed in 70% (23/33) of the symptomatic tendons and in 29% (5/17) of the asymptomatic tendons. The Spearman correlation coefficient between the Victorian Institute of Sport Assessment-Achilles score and the degree of neovascularization was - 0.16 (P = .10).

CONCLUSION

An excellent interobserver reliability was found for determining the degree of neovascularization on power Doppler ultrasonography examination. Neovessels were present in a majority of symptomatic tendons. The severity of symptoms was not correlated with the neovascularization score.

CLINICAL RELEVANCE

Power Doppler ultrasonography is widely used to evaluate tendinopathy without knowledge of the difference in observations between several testers. Interobserver reliability of the evaluation of the degree of neovascularization in chronic midportion Achilles tendinopathy is excellent.

[Ultrasound of the Achilles tendon after percutaneous repair]

PURPOSE

To evaluate clinical and ultrasound (US) results following percutaneous repair of the Achilles tendon.

MATERIALS AND METHODS

Thirty-four patients underwent percutaneous Achilles tendon repair between 2004 and 2006. Seventeen patients (11 males and 6 females aged 30 to 59 years) underwent clinical and US follow-up at a mean of 15 months. US evaluation included assessment of the bilateral Achilles tendons with recording of maximum tendon diameter, echotexture, and presence of intratendonous neovascularization on power Doppler US.

RESULTS

On clinical evaluation, all patients were satisfied with the outcome and able to resume their normal level of activity. On US evaluation, there was no tendon discontinuity, and all tendons showed hypoechoic thickening with mean maximal diameter of 13 mm. Focal changes in echotexture were noted in 11 patients, hypoechoic in 5 cases and echogenic in 6 cases. A normal fibrillar echotexture was noted in 5 cases, at more than on eyear after surgery. Intratendonous neovascularization was present in 10 cases, mild in 6 cases, moderate in 2 cases and marked in 2 cases. The degree of neovascularization decreased with increasing postsurgical time.

CONCLUSION

Postsurgical Achilles tendons were characterized on US by hypoechoic thickening and loss of normal fibrillar echotexture. The presence of intratendonous neovascularization probably corresponds to postsurgical scarring that decreases over time.

High volume ultrasound guided injections at the interface between the patellar tendon and Hoffa's body are effective in chronic patellar tendinopathy: A pilot study

PURPOSE

To evaluate a novel conservative management modality for patellar tendinopathy.

METHODS

We recruited nine patients with patellar tendinopathy who had failed conservative management and showed evidence of neovascularisation on power Doppler scanning. A high volume ultrasound guided injection at the interface between the patellar tendon and Hoffa's body. The injection contained 10 ml 0.5% Bupivacaine, 25 mg Hydrocortisone, and between 12 and 40 ml normosaline. 100 mm visual analogue scales (VAS) for pain and for function, and Victorian Institute of Sport Assessment - Patellar tendon (VISA-P) questionnaires at an average of 9 months from the injection.

RESULTS

All but one patient (whose pain was unchanged) improved (p = 0.028). The mean improvement in function 2 weeks after injection was 58 mm on VAS (interquartile range 27 - 88, p = 0.018). The mean improvement in pain 2 weeks after injection was 56 mm on a VAS scale (interquartile range 32 - 80, p = 0.018). At a mean follow up of 9 months, an improvement of 22 points from a baseline score of 46 on the VISA-P questionnaire (100 being normal) was established.

CONCLUSION

High volume injections to mechanically disrupt the neovascularisation in patellar tendinopathy are helpful in the management of this condition. Controlled trials would be warranted to investigate in a more conclusive fashion this management modality.

Achilles and patellar tendinopathy: current understanding of pathophysiology and management

PURPOSE

Achilles and patellar tendinopathy cause significant morbidity in professional and recreational athletes. Both the Achilles and patellar tendons are weight-bearing tendons that lack a true tendon sheath but are surrounded by paratenon.

METHOD

A review of the literature to outline the characteristics of tendinopathy in these two tendons, and to discuss current concepts of pathophysiology, use of imaging in the diagnosis and aid to clinical management strategies in tendinopathy.

RESULTS

Achilles and patellar tendinopathy share common histopathology such as intratendinous failed healing response and neoangiogenesis.

CONCLUSION

Achilles and patellar tendinopathy cause much morbidity in the athletic and non athletic population attending sports medicine and rheumatology clinics. Tendinopathy is essentially an 'overuse', degenerative condition. Neovascularisation evident on Doppler ultrasound correlates well with pain and poor function. Peritendinous injections and eccentric training decrease neovascularity, relieve pain and improve outcome. Although surgery is the last resort in those patients failing conservative management, it is still unclear how the removal of adhesions and excision of affected tendinopathic areas affects healing and vascularity, or resolves pain.

Achilles tendon ossification: pathology, imaging and aetiology

BACKGROUND

We report a patient with ossification of the Achilles tendon, presenting plain radiographs, ultrasound, power doppler, computed tomography and magnetic resonance findings. The majority of the tendon was ossified, and there was adjacent soft tissue oedema. The appearance of peritendinous oedema associated with ossification has not, to our knowledge, been reported in the literature, and could account for hindfoot pain in cases of tendon ossification.

METHOD

A review of 44 articles on aetiology, histology and imaging was performed.

RESULTS

Trauma, either accidental or from surgery, rather than tendinopathy is the likely aetiological factor.

CONCLUSION

The Achilles tendon usually responds to an insult with the development of mature bone, not dystrophic calcification, with no evidence of inflammatory or degenerative changes.

High volume image guided injections in chronic Achilles tendinopathy

PURPOSE

To determine the effectiveness of high volume image guided injections (HVIGI) for chronic Achilles tendinopathy.

METHODS

We included in the study 30 consecutive patients (mean age 37.2 years, range 24 - 58 years) with Achilles tendinopathy for a mean of 35.8 months (range 2 - 276 months) who had failed to improve after a three-month programme of eccentric loading of the gastro-soleus complex. Patients were injected with 10 ml of 0.5% Bupivacaine Hydrochloride, 25 mg Hydrocortisone acetate, and up to 40 ml of injectable normal saline. A study-specific questionnaire and the Victorian Institute of Sport Assessment - Achilles tendon (VISA-A) were retrospectively administered to assess short- and long-term pain and functional improvement.

RESULTS

Some 21 patients (70%) responded. Patients reported significant short-term improvement at 4 weeks of both pain (mean change 50 mm, [SD 28, p < 0.0001], from a mean of 76 mm [SD 18.2], to a mean of 25 mm [SD 23.3]), and function scores (mean change 51 mm, [SD 31.2, p < 0.0001], from a mean of 78 mm [SD 20.8], to a mean of 27 mm [SD 28.4]). Patients also reported significant long-term improvement in symptoms using the VISA-A questionnaire (mean change 31.2 points, [SD = 28, p < 0.0001], from a mean of 44.8 points [SD 17.7], to a mean of 76.2 points [SD 24.6]) at a mean of 30.3 weeks from the injection.

CONCLUSIONS

HVIGI significantly reduces pain and improves function in patients with resistant Achilles tendinopathy in the short- and long-term.

Mid-portion Achilles tendinopathy--current options for treatment

PURPOSE

To report on the present option for management of tendinopathy of the main body of the Achilles tendon.

BACKGROUND

Tendinopathy of the main body of tendo Achillis affects athletic and sedentary patients. Mechanical loading is thought to be a major causative factor. However, the exact mechanical loading conditions which cause tendinopathy are poorly defined. Repetitive mechanical loading induces a non-inflammatory pathology, and repetitive microtrauma ultimately exceeds the healing response. The management of Achilles tendinopathy is primarily conservative. Although many non-operative options are available, few have been tested under controlled conditions. This review article specifically focuses on eccentric training, and on shock wave therapy. Surgical intervention can be successful in refractory cases. However, surgery does not usually completely eliminate symptoms and complications are not rare.

CONCLUSIONS

Further studies are needed to discern the optimal non-operative and surgical management of midsubstance Achilles tendinopathy.

Achilles tendon Doppler flow may be associated with mechanical loading among active athletes

BACKGROUND

Tendon Doppler flow may be associated with tendon pain in symptomatic patients, but the relationship between Doppler flow and pain among athletes who are still competing is unclear.

HYPOTHESIS

Among active athletes, Doppler flow may partly reflect tendon adaptation to increased mechanical load and/or asymptomatic tendinopathy.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The Achilles tendons of 61 badminton players (24 elite, 37 recreational) were examined with gray-scale and color Doppler ultrasound. Achilles tendon pain and activity level (badminton training, badminton playing, badminton years) were measured.

RESULTS

Doppler flow was not associated with current Achilles tendon pain but was associated with an increased anteroposterior tendon diameter (an indicator of tendinopathy) (P = .02). Athletes who had been playing badminton for longer were more likely to have Doppler flow (P < .01), and there was a trend toward an association between a greater number of badminton playing hours per week and Doppler flow (P = .07).

CONCLUSION

Achilles tendon Doppler flow appears to be a sign of asymptomatic tendinopathy rather than pain among active athletes. The association between weekly badminton hours and badminton years and Doppler flow suggests that Doppler flow may be a response to mechanical load in this cohort.

The basic science of tendinopathy

Tendinopathy is a common clinical problem with athletes and in many occupational settings. Tendinopathy can occur in any tendon, often near its insertion or enthesis where there is an area of stress concentration, and is directly related to the volume of repetitive load to which the tendon is exposed. Recent studies indicate tendinopathy is more likely to occur in situations that increase the "dose" of load to the tendon enthesis - including increased activity, weight, advancing age, and genetic factors. The cells in tendinopathic tendon are rounder, more numerous, and show evidence of oxidative damage and more apoptosis. These cells also produce a matrix that is thicker and weaker with more water, more immature and cartilage-like matrix proteins, and less organization. There is now evidence of a population of regenerating stem cells within tendon. These studies suggest prevention of tendinopathy should be directed at reducing the volume of repetitive loads to below that which induces oxidative-induced apoptosis and cartilage-like genes. The management strategies might involve agents or cells that induce tendon stem cell proliferation, repair and restoration of matrix integrity.

Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: age- and activity-related changes in the intact asymptomatic rotator cuff

The natural history of the blood supply to the rotator cuff and its role in the etiology of rotator cuff disease has not been definitively established. To date, there has not been an in-vivo dynamic assessment of the baseline vascularity of the asymptomatic rotator cuff. This study was designed to test the hypothesis that regional variations in supraspinatus tendon vascularity exist with an age-dependent decrease in asymptomatic individuals with intact rotator cuffs. Lipid microsphere, contrast-enhanced ultrasound shoulder examinations were done in 31 patients with a mean age of 41.5 years (range, 22-65 years). Images were obtained at baseline, after contrast administration at rest, and after contrast administration following exercise to visualize the intratendinous blood flow to the supraspinatus tendon. Qualitative and quantitative analysis was performed by determining 4 regions of interest (bursal medial, articular medial, bursal lateral, and articular lateral) with quantification and analysis software (QLAB Philips, Andover, MA) to examine each region of interest and normalize data for interpretation of the mean intensity per pixel. A statistically significant decrease in blood flow to the supraspinatus tendon with age was observed in a comparative analysis of patients aged younger than 40 and older than 40, (P < .05 for all 4 zones after exercise and for the bursal medial, articular medial, and bursal lateral zones after exercise; P = .07 for the articular lateral zone after exercise). A statistically significant increase in blood flow with exercise was observed in an analysis of all patients (P < .001). The age-related decrease in the vascular supply of the tendon observed in this study is consistent with published reports demonstrating an increasing prevalence of rotator cuff pathology with age and may predispose to the development of rotator cuff tendinopathy and, ultimately, attritional tears.

Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial

BACKGROUND

Nonoperative management of chronic tendinopathy of the Achilles tendon insertion has been poorly studied. With the recently demonstrated effectiveness of eccentric loading and of repetitive low-energy shock wave therapy in patients with midsubstance Achilles tendinopathy, the aim of the present randomized, controlled trial was to verify the effectiveness of both procedures exclusively in patients with insertional Achilles tendinopathy.

METHODS

Fifty patients with chronic (six months or more) recalcitrant insertional Achilles tendinopathy were enrolled in a randomized, controlled study. All patients had received treatment, including local injections of an anesthetic and/or corticosteroids, a prescription of nonsteroidal anti-inflammatory drugs, and physiotherapy, without success for at least three months. A computerized random-number generator was used to draw up an allocation schedule. Twenty-five patients were allocated to receive eccentric loading (Group 1), and twenty-five patients were allocated to treatment with repetitive low-energy shock wave therapy (Group 2). Analysis was on an intention-to-treat basis. Primary follow-up was at four months, and afterward patients were allowed to cross over. The last follow-up evaluation was at one year after completion of the initial treatment. The patients were assessed for pain, function, and activity with use of a validated questionnaire (the Victorian Institute of Sport Assessment-Achilles [VISA-A] questionnaire).

RESULTS

At four months from baseline, the mean VISA-A score had increased in both groups, from 53 to 63 points in Group 1 and from 53 to 80 points in Group 2. The mean pain rating decreased from 7 to 5 points in Group 1 and from 7 to 3 points in Group 2. Seven patients (28%) in Group 1 and sixteen patients (64%) in Group 2 reported that they were completely recovered or much improved. For all outcome measures, the group that received shock wave therapy showed significantly more favorable results than the group treated with eccentric loading (p = 0.002 through p = 0.04). At four months, eighteen of the twenty-five patients from Group I had opted to cross over, as did eight of the twenty-five patients from Group 2. The favorable results after shock wave therapy at four months were stable at the one-year follow-up evaluation.

CONCLUSIONS

Eccentric loading as applied in the present study showed inferior results to low-energy shock wave therapy as applied in patients with chronic recalcitrant tendinopathy of the insertion of the Achilles tendon at four months of follow-up. Further research is warranted to better define the indications for this treatment modality.

Imaging modalities in the evaluation of soft tissue complaints

A number of imaging modalities are available for the assessment of soft tissue complaints. The strengths and advantages of each modality must be seen in the context of any corresponding weakness or disadvantage. The sensitivity and specificity of the imaging technique must also be understood. In this article, each main radiological technique will be considered in turn. Fundamental technical aspects and common variations of the basic imaging theme will be explained and their relative strengths and limitations will be explored. Typical common clinical uses in the context of soft-tissue complaints will be considered.

Ultrasound guided dry needling and autologous blood injection for patellar tendinosis

OBJECTIVE

To evaluate the efficacy of ultrasound guided dry needling and autologous blood injection for the treatment of patellar tendinosis.

DESIGN

Prospective cohort study.

SETTING

Hospital/clinic based.

PATIENTS

47 knees in 44 patients (40 men, 7 women, mean age 34.5 years, age range 17 to 54 years) with refractory tendinosis underwent sonographic examination of the patellar tendon following referral with a clinical diagnosis of patellar tendinosis (mean symptom duration 12.9 months).

INTERVENTIONS

Ultrasound guided dry needling and injection of autologous blood into the site of patellar tendinosis was performed on two occasions four weeks apart.

MAIN OUTCOME MEASURES

Pre- and post-procedure Victorian Institute of Sport Assessment scores (VISA) were collected to assess patient response to treatment. Follow up ultrasound examination was done in 21 patients (22 knees).

RESULTS

Therapeutic intervention led to a significant improvement in VISA score: mean pre-procedure score = 39.8 (range 8 to 72) v mean post procedure score = 74.3 (range 29 to 100), p<0.001; mean follow up 14.8 months (range 6 to 22 months). Patients were able to return to their sporting interests. Follow up sonographic assessment showed a reduction in overall tendon thickness and in the size of the area of tendinosis (hypoechoic/anechoic areas within the proximal patellar tendon). A reduction was identified in interstitial tears within the tendon substance. Neovascularity did not reduce significantly or even increased.

CONCLUSIONS

Dry needling and autologous blood injection under ultrasound guidance shows promise as a treatment for patients with patellar tendinosis.