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Dyrek P, Tsitsilianos N, McInnis KC, Tenforde AS, Borg-Stein J. Staying in the Game: Interventions for Managing Achilles Tendinopathy in the In-Season Athlete. Curr Sports Med Rep 2024; 23:237-244. [PMID: 38838687 DOI: 10.1249/jsr.0000000000001174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
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.
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Affiliation(s)
- Paige Dyrek
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA
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2
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Najafi Z, Rahmanian-Devin P, Baradaran Rahimi V, Nokhodchi A, Askari VR. Challenges and opportunities of medicines for treating tendon inflammation and fibrosis: A comprehensive and mechanistic review. Fundam Clin Pharmacol 2024:e12999. [PMID: 38468183 DOI: 10.1111/fcp.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 01/20/2024] [Accepted: 02/19/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Tendinopathy refers to conditions characterized by collagen degeneration within tendon tissue, accompanied by the proliferation of capillaries and arteries, resulting in reduced mechanical function, pain, and swelling. While inflammation in tendinopathy can play a role in preventing infection, uncontrolled inflammation can hinder tissue regeneration and lead to fibrosis and impaired movement. OBJECTIVES The inability to regulate inflammation poses a significant limitation in tendinopathy treatment. Therefore, an ideal treatment strategy should involve modulation of the inflammatory process while promoting tissue regeneration. METHODS The current review article was prepared by searching PubMed, Scopus, Web of Science, and Google Scholar databases. Several treatment approaches based on biomaterials have been developed. RESULTS This review examines various treatment methods utilizing small molecules, biological compounds, herbal medicine-inspired approaches, immunotherapy, gene therapy, cell-based therapy, tissue engineering, nanotechnology, and phototherapy. CONCLUSION These treatments work through mechanisms of action involving signaling pathways such as transforming growth factor-beta (TGF-β), mitogen-activated protein kinases (MAPKs), and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), all of which contribute to the repair of injured tendons.
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Affiliation(s)
- Zohreh Najafi
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Pouria Rahmanian-Devin
- Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vafa Baradaran Rahimi
- Department of Cardiovascular Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Nokhodchi
- Lupin Pharmaceutical Research Center, 4006 NW 124th Ave., Coral Springs, Florida, Florida, 33065, USA
- Pharmaceutics Research Laboratory, School of Life Sciences, University of Sussex, Brighton, BN1 9QJ, UK
| | - Vahid Reza Askari
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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3
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Martin S, Moriñigo JG. Ultrasonography-guided Intervention in the Achilles Tendon and Plantar Fascia. Semin Musculoskelet Radiol 2023; 27:351-366. [PMID: 37230134 DOI: 10.1055/s-0043-1766095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Tendinopathy is very common in the foot and ankle. Achilles tendinopathy is a painful overuse injury that often occurs in athletes, especially those who participate in running and jumping sports. Plantar fasciitis is the most frequent cause of plantar pain in the adult heel. Initial treatment of these conditions is conservative. However, in some cases symptoms only improve slowly, and many cases are intractable. When conservative management fails, ultrasonography guided injections are indicated. We discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, retrocalcaneal bursitis, and plantar fasciitis. We describe the different agents that can be used and the various ultrasonography-guided procedures that offer technical and practical information to improve daily clinical practice.
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Affiliation(s)
- Silvia Martin
- Department of Radiology, Clínica Rotger, Palma de Mallorca, Spain
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Mariadoss AVA, Subramanian SA, Kwon YM, Shin S, Kim SJ. Epigallocatechin gallate protects the hydrogen peroxide-induced cytotoxicity and oxidative stress in tenocytes. Process Biochem 2023. [DOI: 10.1016/j.procbio.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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5
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Do High-Volume Injections Affect the Ultrasonographic Neovascularization in Chronic Achilles Tendinopathy? A Randomized Placebo-Controlled Clinical Trial. Clin J Sport Med 2022; 32:451-457. [PMID: 36083324 DOI: 10.1097/jsm.0000000000000998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 11/01/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE High-volume injections (HVIs) are thought to target neovascularization in chronic midportion Achilles tendinopathy (AT), yet the mechanism has not been clarified. Therefore, we aim to evaluate whether a HVI decreases ultrasonographic Doppler flow in patients with chronic midportion AT. DESIGN A double-blind, randomized, placebo-controlled clinical trial. SETTING Sports medicine department at a district general hospital. PATIENTS Sixty-two patients with clinically diagnosed chronic midportion AT were included and randomized into the intervention group (HVI-group, n = 30) and placebo group (n = 32). INTERVENTION A daily calf-muscle exercise program combined with either (1) a HVI (HVI-group: 50 mL) or (2) a placebo-injection (placebo-group: 2 mL) with a mixture of saline and lidocaine. MAIN OUTCOME MEASURES Primary outcome was the surface area quantification (SAQ) score (%) of the Doppler flow during a 24-week follow-up period. Secondary outcome was the association between SAQ scores and symptoms [Victorian Institute of Sports Assessment-Achilles (VISA-A)]. Outcomes were measured before, directly after, and 1 hour after the injection and at 2, 6, 12, and 24 weeks of follow-up. RESULTS There was no significant between-group difference at 24 weeks [-0.1%; 95% confidence interval (CI), -4.9 to 4.7] or at any of the other time points. Change in SAQ score did not correlate with the change in VISA-A score (P = 0.93). CONCLUSION A HVI does not affect Doppler flow in patients with chronic midportion AT. Also, changes in Doppler flow were not associated with the clinical outcome. These findings challenge the theoretical basis of a HVI. TRIAL REGISTRATION NCT02996409.
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Barker-Davies RM, Baker P, Watson J, Goodall D, Wheeler PC, Nicol AM, Fong DT, Lewis MP, Bennett AN. High-Volume Image-Guided Injections in Achilles and Patellar Tendinopathy in a Young Active Military Population: A Double-Blind Randomized Controlled Trial. Orthop J Sports Med 2022; 10:23259671221088326. [PMID: 35425844 PMCID: PMC9003662 DOI: 10.1177/23259671221088326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Chronic Achilles and patellar tendinopathy are a significant burden in physically active populations. High-volume image-guided injection (HVIGI) proposes to strip away associated neovascularity, disrupt painful nerve ingrowth, and facilitate rehabilitation. Purpose: To investigate the efficacy of HVIGI with and without steroid relative to placebo. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 62 participants were recruited between May 25, 2016, and March 5, 2020. Participants were men aged 18 to 55 years with Achilles or patellar tendinopathy of at least 6-month chronicity that had not improved with nonoperative management (including physical therapy and shockwave therapy), with ultrasound evidence of neovascularization, tendon thickening, and echogenic changes. They were assigned to the following groups: control (3 mL of subcutaneous 0.5% bupivacaine), HVIGI (10 mL of 0.5% bupivacaine and 30 mL of normal saline, ultrasound-guided between tendon and underlying fat pad), or HVIGI with steroid (HVIGIwSteroid; 0.25 mL of 100 mg/mL hydrocortisone). Clinicians and assessors were blinded. All participants were supervised through a pain-guided progressive loading program for 6 months postinjection. The main outcome measures were the Victoria Institute of Sport Assessments (VISA) for Achilles and patellar tendinopathy and the visual analog scale (VAS) for pain at 6 months postinjection. Results: The VISA score improved by a mean of 22.8 points (95% CI, 10.4-35.3 points; effect size [ES], 1.51) in the control group (n = 21), 18.6 points (95% CI, 9.1-28.0 points; ES, 1.31) in the HVIGI group (n = 21), and 18.5 points (95% CI, 3.4-33.6 points; ES, 0.88) in the HVIGIwSteroid group (n = 20). VAS pain improved by a mean of 15 points (interquartile range [IQR], –38.75, 8 points; ES, 0.39) in controls, 13 points (IQR,–34.0, 3.75 points; ES, 0.47) in the HVIGI group, and 27 points (IQR,–38.0, –1.0 points; ES, 0.54) in the HVIGIwSteroid group. The main effects were significant for time (P < .001) but not group (P ≥ .48), with no group × time interaction (P = .71). One participant was lost to follow-up from each group, multiple imputation was used for missing data points. No adverse events occurred. Conclusion: Study findings did not demonstrate superiority of HVIGI over control injection. Registration: EU Clinical Trials Register (EudraCT: 2015-003587-36).
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Affiliation(s)
- Robert M. Barker-Davies
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Polly Baker
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
| | - James Watson
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
| | - Duncan Goodall
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
| | - Patrick C. Wheeler
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Alastair M. Nicol
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Daniel T.P. Fong
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Mark P. Lewis
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Alexander N. Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Grävare Silbernagel K, Malliaras P, de Vos RJ, Hanlon S, Molenaar M, Alfredson H, van den Akker-Scheek I, Antflick J, van Ark M, Färnqvist K, Haleem Z, Kaux JF, Kirwan P, Kumar B, Lewis T, Mallows A, Masci L, Morrissey D, Murphy M, Newsham-West R, Norris R, O'Neill S, Peers K, Sancho I, Seymore K, Vallance P, van der Vlist A, Vicenzino B. ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy. Sports Med 2022; 52:613-641. [PMID: 34797533 PMCID: PMC8891092 DOI: 10.1007/s40279-021-01588-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA.
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Robert-Jan de Vos
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Zuid-Holland, The Netherlands
| | - Shawn Hanlon
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Mitchel Molenaar
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jarrod Antflick
- Department of Bioengineering, School of Engineering, Imperial College, London, UK
| | - Mathijs van Ark
- Department of Physiotherapy, School of Health Care Studies, Hanze University of Applied Sciences and Peescentrum, Centre of Expertise Primary Care Groningen (ECEZG), Groningen, The Netherlands
| | | | - Zubair Haleem
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Arsenal Football Club, London, UK
| | - Jean-Francois Kaux
- Department of Physical and Rehabilitation Medicine and Sports Traumatology, University and University Hospital of Liège, Liège, Belgium
| | - Paul Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bhavesh Kumar
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Trevor Lewis
- Aintree University Hospital, Liverpool Foundation Trust, Liverpool, UK
| | - Adrian Mallows
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, UK
| | - Lorenzo Masci
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
| | - Myles Murphy
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Richard Newsham-West
- School of Allied Health, Department of Physiotherapy, La Trobe University, Melbourne, VIC, Australia
| | - Richard Norris
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- Liverpool University Hospitals, NHS Foundation Trust, Liverpool, UK
| | - Seth O'Neill
- School of Allied Health, University of Leicester, Leicester, UK
| | - Koen Peers
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Igor Sancho
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, University of Deusto, San Sebastian, Spain
| | - Kayla Seymore
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Patrick Vallance
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Clayton, VIC, Australia
| | - Arco van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, QLD, Australia
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8
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Malliaras P, Connell D, Boesen AP, Kearney RS, Menz HB, Morrissey D, Munteanu SE, Silbernagel KG, Underwood M, Haines TP. Efficacy of high-volume injections with and without corticosteroid compared with sham for Achilles tendinopathy: a protocol for a randomised controlled trial. BMJ Open Sport Exerc Med 2021; 7:e001136. [PMID: 34765229 PMCID: PMC8543648 DOI: 10.1136/bmjsem-2021-001136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 11/03/2022] Open
Abstract
Introduction Achilles tendinopathy (AT) is a common and disabling musculoskeletal condition. First-line management involving Achilles tendon loading exercise with, or without, other modalities may not resolve the problem in up to 44% of cases. Many people receive injections. Yet there are no injection treatments with demonstrated long-term efficacy. The aim of the trial is to examine the 12-month efficacy of high-volume injection (HVI) with corticosteroid and HVI without corticosteroid versus sham injection among individuals with AT. Methods and analysis The trial is a three-arm, parallel group, double-blind, superiority randomised controlled trial that will assess the efficacy of HVI with and without corticosteroid versus sham up to 12 months. We will block-randomise 192 participants to one of the three groups with a 1:1:1 ratio, and both participants and outcome assessors will be blinded to treatment allocation. All participants will receive an identical evidence-based education and exercise intervention. The primary outcome measure will be the Victorian Institute of Sport Assessment - Achilles (VISA-A) at 12 months post-randomisation, a validated, reliable and disease-specific measure of pain and function. Choice of secondary outcomes was informed by core outcome domains for tendinopathy. Data will be analysed using the intention-to-treat principle. Ethics and dissemination Ethics approval was obtained via the Monash University Human Ethics Committee (no: 13138). The study is expected to be completed in 2024 and disseminated via peer review publication and conference presentations. Trial registration number Australia and New Zealand Clinical trials registry (ACTRN12619001455156).
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Affiliation(s)
- Peter Malliaras
- School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia
| | - David Connell
- School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia.,Imaging @ Olympic Park, Melbourne, Victoria, Australia
| | | | - Rebecca S Kearney
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK.,University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Hylton B Menz
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK.,Physiotherapy Department, Barts Health NHS Trust, London, UK
| | - Shannon E Munteanu
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | | | - Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Terry P Haines
- School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia
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9
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Kakkos GA, Klontzas ME, Koltsakis E, Karantanas AH. US-guided high-volume injection for Achilles tendinopathy. J Ultrason 2021; 21:e127-e133. [PMID: 34258037 PMCID: PMC8264817 DOI: 10.15557/jou.2021.0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 11/22/2022] Open
Abstract
Achilles tendinopathy is a common overuse condition affecting the adult population. The incidence is on the rise because of greater participation of people in recreational or competitive sporting activities. Chronic Achilles tendinopathy occurs most commonly in the tendon’s mid-portion, and it is challenging to manage, leading to significant patient morbidity. Despite conservative management many patients still require surgical intervention. The mechanism underlying pain is not entirely understood; however, high-resolution color Doppler ultrasound has shown that neovascularisation could be involved. Minimally-invasive treatments for chronic Achilles tendinopathy may prevent the need for surgery when conservative methods have failed. Ultrasound provides an option to guide therapeutic interventions accurately, so that treatment is delivered to the desired site of pathology. High-volume image-guided injection is a relatively new technique where a high volume of liquid is injected between the anterior aspect of the Achilles tendon and the Kager’s fat pad, used to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases of Achilles tendinopathy. High-volume image-guided injection has shown promising results in terms of reducing pain and improving function in patients where conservative measures have failed. This review aims to describe the fundamental technical factors, and investigate the efficacy of high-volume image-guided injection with reference to the available literature.
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Affiliation(s)
- George A Kakkos
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece
| | - Michail E Klontzas
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece.,Advanced Hybrid Imaging Systems, Institute of Computer Science, FORTH, Crete, Greece.,Department of Radiology, School of Medicine, University of Crete, Greece
| | - Emmanouil Koltsakis
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece
| | - Apostolos H Karantanas
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece.,Advanced Hybrid Imaging Systems, Institute of Computer Science, FORTH, Crete, Greece.,Department of Radiology, School of Medicine, University of Crete, Greece
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10
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Romero-Morales C, Bravo-Aguilar M, Abuín-Porras V, Almazán-Polo J, Calvo-Lobo C, Martínez-Jiménez EM, López-López D, Navarro-Flores E. Current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Dis Mon 2021; 67:101210. [PMID: 34099238 DOI: 10.1016/j.disamonth.2021.101210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The present review summarized the current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Different invasive approaches were proposed in the physical therapy field for the management of musculoskeletal disorders, such as ultrasound-guided percutaneous needle electrolysis, dry needling, acupuncture and other invasive therapy techniques, discussing about their worldwide status, safety and interventional ultrasound imaging. Indeed, dry needling may be one of the most useful and studies invasive physical therapy applications in musculoskeletal disorders of different body regions, such as back, upper limb, shoulder, arm, hand, pelvis, lower limb, neck, head, or temporomandibular joint, and multiple soreness location disorders, such as fibromyalgia. In addition, the assessment and treatment by acupuncture or electro-acupuncture was considered and detailed for different conditions such as plantar fasciitis, osteoarthritis, spasticity, myofascial pain syndrome, osteoporosis and rheumatoid arthritis. As an increasing technique in physical therapy, the use of ultrasound-guided percutaneous needle electrolysis was discussed in injuries of the musculoskeletal system and entrapment neuropathies. Also, ultrasound-guided percutaneous neuromodulation was established as a rising technique combined with ultrasound evaluation of the peripheral nerve system with different clinical applications which need further studies to detail their effectiveness in different musculoskeletal conditions. Thus, invasive physical therapy may be considered as a promising approach with different novel applications in several musculoskeletal disorders and a rising use in the physiotherapy field.
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Affiliation(s)
- Carlos Romero-Morales
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain.
| | - María Bravo-Aguilar
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain.
| | - Vanesa Abuín-Porras
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain.
| | - Jaime Almazán-Polo
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain.
| | - César Calvo-Lobo
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain.
| | - Eva María Martínez-Jiménez
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain.
| | - Daniel López-López
- Research, Health and Podiatry Group, Department of Health Sciences, Faculty of Nursing and Podiatry, Universidade da Coruña, 15403 Ferrol, Spain.
| | - Emmanuel Navarro-Flores
- Frailty and Cognitive Impairment Research Group (FROG), University of Valencia, 46010 Valencia, Spain.
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11
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Edwards S, Sivan M. High volume distension injection (HVDI) for chronic mid-portion Achilles tendinopathy: A service evaluation of clinical outcomes. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720979321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: High Volume Distension Injection (HVDI) is a treatment adjunct in chronic mid-portion Achilles tendinopathy. This study analysed whether HVDI is safe and effective in an outpatient clinic setting. Methods: Retrospective service evaluation of 18 participants over 18 months. Ultrasound-guided saline, corticosteroid and bupivacaine was injected to disrupt vasculo-neural ingrowth, with post-procedure eccentric exercises. Mean follow-up was 8 weeks. Outcomes used were Numeric rating Scale (NRS) of pain, tendon thickness and Modified Ohberg score (MOS) of neovascularisation measured on Ultrasound and Doppler imaging. Results: Mean reduction in NRS was 5.30 ± 2.53 ( P < 0.001). Mean tendon thickness reduction was 0.21 ± 0.17 cm ( P < 0.001). Median MOS improved from 2.00 ± 2.00 to 1.00 ± 3.00 ( P = 0.009). No complications occurred. 11 participants had successful primary HVDI, 3 responded to a second injection. Two non-responders were referred for surgery and two referred for alternative therapy by patient preference. Conclusion: Significant reduction in pain, tendon thickness and neovascularity was observed in 78% of patients. Recurrence in 39%. HVDI with eccentric training is safe and effective intervention in outpatient clinic setting.
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Affiliation(s)
- Samuel Edwards
- Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Manoj Sivan
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Musculoskeletal Service, Leeds Community Healthcare NHS Trust, UK
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12
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van der Vlist AC, van Oosterom RF, van Veldhoven PLJ, Bierma-Zeinstra SMA, Waarsing JH, Verhaar JAN, de Vos RJ. Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial. BMJ 2020; 370:m3027. [PMID: 33315586 PMCID: PMC7479639 DOI: 10.1136/bmj.m3027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To study whether a high volume injection without corticosteroids improves clinical outcome in addition to usual care for adults with chronic midportion Achilles tendinopathy. DESIGN Patient and assessor blinded, placebo controlled randomised clinical trial. SETTING Sports medicine department of a large district general hospital, the Netherlands. PARTICIPANTS 80 adults (aged 18-70 years) with clinically diagnosed chronic midportion Achilles tendinopathy and neovascularisation on ultrasonography. 39 were randomised to a high volume injection without corticosteroids and 41 to placebo. INTERVENTIONS Participants were instructed to perform an exercise programme for 24 weeks (usual care) combined with one 50 mL high volume injection of saline and lidocaine (intervention group) or one 2 mL placebo injection of saline and lidocaine (placebo group) at baseline. MAIN OUTCOME MEASURES Primary outcome was pain and function assessed using the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire at 24 weeks (analysed using a generalised estimation equations model). Secondary outcomes were patient satisfaction, return to sport, degree of ultrasonographic Doppler flow, visual analogue scale on 10 hop test, power and flexibility of the gastrocnemius and soleus muscles, pain detect questionnaire for neuropathic pain, and pain coping inventory. Participants were evaluated at baseline and at 2, 6, 12, and 24 weeks. RESULTS Only one participant (1%) was lost to follow-up. The estimated mean VISA-A score improved significantly, from 40.4 (95% confidence interval 32.0 to 48.7) at baseline to 59.1 (50.4 to 67.8) at 24 weeks in the high volume injection group and from 36.9 (27.1 to 46.8) to 58.5 (47.9 to 69.1) in the placebo group. The VISA-A score over time did not differ between the groups (adjusted between group difference at 24 weeks 0.5 points, 95% confidence interval -17.8 to 18.8). No significant between group differences were found for patient satisfaction (21/37 (57%) v 19/39 (49%) patients, P=0.50) and return to desired sport (15/29 (52%) v 19/31 (61%) patients active in sports, P=0.65) at 24 weeks. None of the other secondary outcomes differed between the two groups. CONCLUSIONS A high volume injection without corticosteroids in addition to usual care is not effective for symptom reduction in patients with chronic midportion Achilles tendinopathy. On the basis of our findings, we cannot recommend the use of a high volume injection in this patient group. TRIAL REGISTRATION ClinicalTrials.gov NCT02996409.
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Affiliation(s)
- Arco C van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Robert F van Oosterom
- Department of Sports Medicine, Haaglanden Medical Centre, 2262 BA Leidschendam, Netherlands
| | | | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC University Medical Centre, 3000 CA Rotterdam, Netherlands
| | - Jan H Waarsing
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, Netherlands
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Rhim HC, Kim MS, Choi S, Tenforde AS. Comparative Efficacy and Tolerability of Nonsurgical Therapies for the Treatment of Midportion Achilles Tendinopathy: A Systematic Review With Network Meta-analysis. Orthop J Sports Med 2020; 8:2325967120930567. [PMID: 32728589 PMCID: PMC7366412 DOI: 10.1177/2325967120930567] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/10/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Achilles tendinopathy (AT) is a common cause of overuse injury in both
athletes and nonactive individuals, especially at older ages. Due to the
limited number of direct comparisons among interventions, determining the
best treatment option can be difficult. Purpose: To evaluate the comparative efficacy and tolerability of nonsurgical
therapies for midportion AT. Study Design: Systematic review; Level of evidence, 1. Methods: PubMed, MEDLINE, EMBASE, and Google Scholar were searched from database
inception through June 20, 2019. Randomized controlled trials investigating
the effect of nonsurgical therapies for midportion AT using the Victorian
Institute of Sports Assessment–Achilles (VISA-A) assessment were eligible
for inclusion. Primary outcome was mean change in VISA-A score from
baseline. Comparisons between interventions were made through use of
random-effects network meta-analysis over the short term (≤3 months) and
longer term (>3 to <12 months). A safety profile was defined for each
intervention by rate of all-cause discontinuation (dropout) during
follow-up. Relative ranking of therapies was assessed by the
surface-under-the–cumulative ranking possibilities. Results: A total of 22 studies with 978 patients met the inclusion criteria. In
short-term studies, high-volume injection with corticosteroid (HVI+C) along
with eccentric exercise (ECC) significantly improved the change of VISA-A
score compared with that of ECC alone (standardized mean difference [SMD],
1.08; 95% CI, 0.58-1.58). Compared with ECC, acupuncture showed benefits
over both the short term (SMD, 1.57; 95% CI, 1.00-2.13) and longer term
(SMD, 1.23; 95% CI, 0.69-1.76). In longer-term studies, the wait-and-see
approach resulted in unfavorable outcomes compared with ECC (SMD, −1.51; 95%
CI, −2.02 to −1.01). Improvement was higher when ECC was combined with HVI+C
(SMD, 0.53; 95% CI, 0.05-1.02) and extracorporeal shockwave therapy (ESWT)
(SMD, 0.99; 95% CI, 0.48-1.49). All interventions had a similar safety
profile. Conclusion: From available high-level studies, HVI+C and ESWT may be possible
interventions to add along with ECC to improve longer-term outcomes.
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Affiliation(s)
- Hye Chang Rhim
- Department of Orthopedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Seo Kim
- Korea University College of Medicine, Seoul, Republic of Korea
| | - Seungil Choi
- Department of Biostatistics, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
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14
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Nielsen TG, Miller LL, Mygind-Klavsen B, Lind M. The effect of high-volume image-guided injection in the chronic non-insertional Achilles tendinopathy: a retrospective case series. J Exp Orthop 2020; 7:45. [PMID: 32594331 PMCID: PMC7320968 DOI: 10.1186/s40634-020-00264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/15/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To evaluate if High-volume Image-guided Injection (HVIGI)-treatment for chronic mid-portion Achilles tendinopathy (AT) improve function and reduce pain at 12-months follow-up. METHODS Patients with resistant mid-portion AT who failed to improve after a three-month eccentric loading program were included in the study. Maximal tendon thickness was assessed with ultrasound. All patients were injected with 10 mL of 0.5% Marcaine, 0.5 mL Triamcinolonacetonid (40 mg/mL) and 40 mL of 0.9% NaCl saline solution under real-time ultrasound-guidance and high pressure. All outcome measures were recorded at baseline and 12 months. A standardized eccentric rehabilitation protocol was prescribed after HVIGI-treatment. Clinical outcome was assessed with the Victorian Institute of Sports Assessment-Achilles tendon questionnaire (VISA-A) and statistically analyses were performed. RESULTS The study included 30 single treatment HVIGI procedures in AT in 28 patients (23 men, 5 women) with a mean age of 45.1 (range 16-63). The mean duration of symptoms before HVIGI was 37 months. The baseline VISA-A score of 50 ± 15 (range 14-74) improved to 61 ± 21 (range 31-94) after 1 year (p = 0.04). Of the 30 AT procedures 10 patients (11 AT) were not satisfied after the initial HVIGI procedure. Of these, 8 patients (9 AT) needed additional HVIGI and two patients needed surgery. Of the remaining 18 patients (19 AT), 10 patients had more than a 10-point improvement in the VISA-A score after 1 year. CONCLUSIONS In this retrospective case-study, only 10 patients (33%) did benefit of a single HVIGI treatment at 12-months and an 11-point significant improvement was seen at on the VISA-A score.
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Affiliation(s)
- Torsten Grønbech Nielsen
- Orthopedic Department, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Lene Lindberg Miller
- Orthopedic Department, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Bjarne Mygind-Klavsen
- Orthopedic Department, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Martin Lind
- Orthopedic Department, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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15
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Francis P, Thornley I, Jones A, I. Johnson M. Pain and Function in the Runner a Ten (din) uous Link. ACTA ACUST UNITED AC 2020; 56:medicina56010021. [PMID: 31936119 PMCID: PMC7023329 DOI: 10.3390/medicina56010021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/27/2019] [Indexed: 11/30/2022]
Abstract
A male runner (30 years old; 10-km time: 33 min, 46 s) had been running with suspected insertional Achilles tendinopathy (AT) for ~2 years when the pain reached a threshold that prevented running. Diagnostic ultrasound (US), prior to a high-volume stripping injection, confirmed right-sided medial insertional AT. The athlete failed to respond to injection therapy and ceased running for a period of 5 weeks. At the beginning of this period, the runner completed the Victoria institute of sports assessment–Achilles questionnaire (VISA-A), the foot and ankle disability index (FADI), and FADI sport prior to undergoing an assessment of bi-lateral gastrocnemius medialis (GM) muscle architecture (muscle thickness (MT) and pennation angle (PA); US), muscle contractile properties (maximal muscle displacement (Dm) and contraction time (Tc); Tensiomyography (TMG)) and calf endurance (40 raises/min). VISA-A and FADI scores were 59%/100% and 102/136 respectively. Compared to the left leg, the right GM had a lower MT (1.60 cm vs. 1.74 cm), a similar PA (22.0° vs. 21.0°), a lower Dm (1.2 mm vs. 2.0 mm) and Tc (16.5 ms vs. 17.7 ms). Calf endurance was higher in the right leg compared to the left (48 vs. 43 raises). The athlete began a metronome-guided (15 BPM), 12-week progressive eccentric training protocol using a weighted vest (1.5 kg increments per week), while receiving six sessions of shockwave therapy concurrently (within 5 weeks). On returning to running, the athlete kept daily pain (Numeric Rating Scale; NRS) and running scores (miles*rate of perceived exertion (RPE)). Foot and ankle function improved according to scores recorded on the VISA-A (59% vs. 97%) and FADI (102 vs. 127/136). Improvements in MT (1.60 cm vs. 1.76 cm) and PA (22.0° vs. 24.8°) were recorded via US. Improvements in Dm (1.15 mm vs. 1.69 mm) and Tc (16.5 ms vs. 15.4 ms) were recorded via TMG. Calf endurance was lower in both legs and the asymmetry between legs remained (L: 31, R: 34). Pain intensity (mean weekly NRS scores) decreased between week 1 and week 12 (6.6 vs. 2.9), while running scores increased (20 vs. 38) during the same period. The program was maintained up to week 16 at which point mean weekly NRS was 2.2 and running score was 47.
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Affiliation(s)
- Peter Francis
- Department of Science and Health, Institute of Technology Carlow, Carlow, Ireland
- Musculoskeletal Health Research Group, Leeds Beckett University, Leeds LS13HE, UK; (I.T.); (A.J.); (M.I.J.)
- Correspondence: ; Tel.: +353-59917-5000
| | - Isobel Thornley
- Musculoskeletal Health Research Group, Leeds Beckett University, Leeds LS13HE, UK; (I.T.); (A.J.); (M.I.J.)
| | - Ashley Jones
- Musculoskeletal Health Research Group, Leeds Beckett University, Leeds LS13HE, UK; (I.T.); (A.J.); (M.I.J.)
| | - Mark I. Johnson
- Musculoskeletal Health Research Group, Leeds Beckett University, Leeds LS13HE, UK; (I.T.); (A.J.); (M.I.J.)
- Centre for Pain for Research, Leeds Beckett University, Leeds LS13HE, UK
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16
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Novel Interventions for Recalcitrant Achilles Tendinopathy: Benefits Seen Following High-Volume Image-Guided Injection or Extracorporeal Shockwave Therapy-A Prospective Cohort Study. Clin J Sport Med 2020; 30:14-19. [PMID: 29781907 DOI: 10.1097/jsm.0000000000000580] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the outcomes for patients with chronic noninsertional Achilles tendinopathy following extracorporeal shockwave therapy (ESWT) and high-volume image-guided injection (HVIGI). DESIGN Prospective cohort study. SETTING Hospital-based Sports Medicine Outpatient Clinic. PATIENTS Sixty-three consecutive patients with chronic noninsertional Achilles tendinopathy, treated with ESWT (n = 22) or HVIGI (n = 41), with minimum 3-month follow-up. Mean age was 51.2 years, and mean duration of symptoms was 27.8 months. INTERVENTIONS Patients received either 3 sessions of ESWT (1 session per week) or a single ultrasound-guided HVIGI (10 mL of 1% lidocaine and 40 mLs of sterile saline). All patients received standardized aftercare, including continuation of a structured home exercise program of flexibility and eccentric strengthening exercises. MAIN OUTCOME MEASURES Zero to 10 visual analog scale (VAS) for self-reported "average pain" and "average stiffness" values. In addition, Victoria Institute of Sport-Achilles questionnaire, (VISA-A), and Manchester-Oxford Foot Questionnaire (MOXFQ). RESULTS This study demonstrated statistically significant improvements in self-reported measures of pain and stiffness following either procedure. At 3 months, VAS (pain) was improved from 6.74 ± 1.31 to 3.57 ± 2.37 (P < 0.001) following HVIGI and from 6.57 ± 1.61 to 4.35 ± 2.55 (P = 0.002) following ESWT. At 3 months, VISA-A improved from 35% ± 17% to 51% ± 22% (P < 0.001) following HVIGI and from 34% ± 15% to 49% ± 15% (P < 0.001) following ESWT. Statistically significant improvements were only recorded at 6 weeks for ESWT and at 3 months for HVIGI using MOXFQ. No statistically significant differences were seen between the groups at any period studied. CONCLUSIONS Patients improved to statistically significant extent following either a HVIGI or ESWT procedure, with no significant differences seen between the groups. The small sample sizes in this pragmatic study are noted, which limit interpretation, and larger more robust studies are required to investigate this further. CLINICAL RELEVANCE This pragmatic prospective cohort study demonstrates improvements following either ESWT or HVIGI procedures, with no significant differences seen between the groups.
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17
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Boesen AP, Langberg H, Hansen R, Malliaras P, Boesen MI. High volume injection with and without corticosteroid in chronic midportion achilles tendinopathy. Scand J Med Sci Sports 2019; 29:1223-1231. [PMID: 31044450 DOI: 10.1111/sms.13450] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 04/06/2019] [Accepted: 04/25/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND High volume injection (HVI) shows promising results in the treatment of chronic midportion Achilles tendinopathy (AT). HVI consists of a large volume of saline with a small amount of corticosteroid and local anesthetic. OBJECTIVE To determine the effect of corticosteroid in HVI in AT. METHODS A total of 28 men (18-59 years) with chronic (>3 months) AT were included in a double-blinded RCT and followed for 24 weeks. All performed eccentric training and randomized to either (a) HVI injection with corticosteroid or (b) HVI injection without corticosteroid. Outcomes included self-reported function (VISA-A score) and pain (VAS score) and ultrasound imaging (tendon thickness, Doppler flow). RESULTS VISA-A and VAS score improved in both groups at all time-points (P < 0.05). VISA-A improvement was significantly greater in HVI with corticosteroid (mean ± SEM; 6-weeks = 31 ± 3 points; 12-weeks = 32 ± 5 points) vs HVI without corticosteroid (6 weeks = 14 ± 3; 12-weeks = 17 ± 3) at 6 and 12 weeks (P < 0.05), but not at 24 weeks. Decrease in VAS scores was significantly greater in HVI with corticosteroid (6 weeks = 55 ± 3 mm; 12 weeks = 53 ± 5 mm) vs HVI without corticosteroid (6 weeks = 16 ± 3 mm; 12 weeks = 25 ± 5 mm) at 6 and 12 weeks (P < 0.05) but not at 24 weeks. Tendon thickness decreased significantly in both groups at all time-points (P < 0.05), but more in the HVI with corticosteroid vs HVI without corticosteroid at 6 and 12 weeks (P < 0.05) but not at 24 weeks. CONCLUSION High volume injection with or without corticosteroid in combination with eccentric training seems effective in AT. HVI with corticosteroid showed a better short-term improvement than HVI without corticosteroid indicating a short-term effect of corticosteroid in HVI treatment of AT.
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Affiliation(s)
- Anders P Boesen
- Ortopaedic Surgery M, Bispebjerg Hospital, Institute of Sports Medicine Copenhagen, Copenhagen, Denmark.,Arthroscopic Center and Sports Orthopaedic Research Center- Copenhagen (SORC-C), Hvidovre, Denmark
| | - Henning Langberg
- Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, CopenRehab, Institute of Social Medicine, Copenhagen, Denmark
| | - Rudi Hansen
- Ortopaedic Surgery M, Bispebjerg Hospital, Institute of Sports Medicine Copenhagen, Copenhagen, Denmark
| | - Peter Malliaras
- Department of Physiotherapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Morten I Boesen
- Department of Orthopedic Surgery, Sjaelland University Hospital, Køge, Denmark
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19
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de Cesar Netto C, da Fonseca LF, Simeone Nascimento F, O'Daley AE, Tan EW, Dein EJ, Godoy-Santos AL, Schon LC. ☆Diagnostic and therapeutic injections of the foot and ankle-An overview. Foot Ankle Surg 2018; 24:99-106. [PMID: 29409219 DOI: 10.1016/j.fas.2017.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 01/17/2017] [Accepted: 02/02/2017] [Indexed: 02/04/2023]
Abstract
Foot and ankle injections are useful diagnostic and therapeutic tools, particularly when the pain etiology is uncertain. A variety of foot and ankle injuries and pathologies, including degenerative joint disease, plantar fasciitis and different tendinopathies are amenable to injections. Understanding the foot and ankle anatomical landmarks, a thorough physical exam and knowledge of the different injection techniques is key for a successful approach to different pathologies. The objective of this study is to review the use of foot and ankle injections in the orthopaedic literature, present the readers with the senior author's experience and provide a comprehensive clinical guideline to the most common foot and ankle diagnostic and therapeutic injections.
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Affiliation(s)
- Cesar de Cesar Netto
- Medstar Union Memorial Hospital - 3333 Calvert Street, Baltimore, MD, 21218, USA; University of Alabama at Birmingham (UAB) - 1313 13th Street South, Birmingham, Alabama, 35205, USA.
| | | | | | - Andres Eduardo O'Daley
- University of Alabama at Birmingham (UAB) - 1313 13th Street South, Birmingham, Alabama, 35205, USA
| | - Eric W Tan
- University of Southern California (USC), Keck School of Medicine, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA
| | - Eric J Dein
- Johns Hopkins University, School of Medicine, 601 N Caroline Street, Baltimore, MD 21287, USA
| | | | - Lew Charles Schon
- Medstar Union Memorial Hospital - 3333 Calvert Street, Baltimore, MD, 21218, USA
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20
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Abstract
Noninsertional Achilles tendinosis is differentiated from insertional Achilles tendinosis based on anatomic location. Tendinosis, as opposed to tendonitis, is primarily a degenerative process and the role of inflammation is believed limited. The etiology of Achilles tendinopathy may include overuse leading to repetitive microtrauma, poor vascularity of the tissue, mechanical imbalances of the extremity, or combination of these elements. There is evidence to support eccentric exercise nonoperative management for patients with noninsertional Achilles tendinopathy. Operative treatment options include percutaneous longitudinal tenotomies, minimally invasive tendon scraping, open débridement and tubularization, and tendon augmentation with flexor hallucis longus.
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Affiliation(s)
- Avreeta Singh
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Arash Calafi
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Chris Diefenbach
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Chris Kreulen
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Eric Giza
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA.
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21
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Boesen AP, Hansen R, Boesen MI, Malliaras P, Langberg H. Effect of High-Volume Injection, Platelet-Rich Plasma, and Sham Treatment in Chronic Midportion Achilles Tendinopathy: A Randomized Double-Blinded Prospective Study. Am J Sports Med 2017; 45:2034-2043. [PMID: 28530451 DOI: 10.1177/0363546517702862] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse. PURPOSE To determine whether eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment-Achilles [VISA-A]). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up. RESULTS VISA-A scores improved in all groups at all time points ( P < .05), with greater improvement in the HVI group (mean ± SEM, 6 weeks = 27 ± 3 points; 12 weeks = 29 ± 4 points) versus PRP (6 weeks = 14 ± 4; 12 weeks = 15 ± 3) and placebo (6 weeks = 10 ± 3; 12 weeks = 11 ± 3) at 6 and 12 weeks ( P < .01) and in the HVI (22 ± 5) and PRP (20 ± 5) groups versus placebo (9 ± 3) at 24 weeks ( P < .01). VAS scores improved in all groups at all time points ( P < .05), with greater decrease in HVI (6 weeks = 49 ± 4 mm; 12 weeks = 45 ± 6 mm; 24 weeks = 34 ± 6 mm) and PRP (6 weeks = 37 ± 7 mm; 12 weeks = 41 ± 7 mm; 24 weeks = 37 ± 6 mm) versus placebo (6 weeks = 23 ± 6 mm; 12 weeks = 30 ± 5 mm; 24 weeks = 18 ± 6 mm) at all time points ( P < .05) and in HVI versus PRP at 6 weeks ( P < .05). Tendon thickness showed a significant decrease only in HVI and PRP groups during the intervention, and this was greater in the HVI versus PRP and placebo groups at 6 and 12 weeks ( P < .05) and in the HVI and PRP groups versus the placebo group at 24 weeks ( P < .05). Muscle function improved in the entire cohort with no difference between the groups. CONCLUSION Treatment with HVI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. Registration: NCT02417987 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Anders Ploug Boesen
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Orthopaedic Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Rudi Hansen
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Peter Malliaras
- Department of Physiotherapy, School of Primary Health Care Faculty of Medicine, Nursing and Health Science, Monash University, Frankston, Victoria, Australia
| | - Henning Langberg
- CopenRehab, Institute of Social Medicine, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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22
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Barker-Davies RM, Nicol A, McCurdie I, Watson J, Baker P, Wheeler P, Fong D, Lewis M, Bennett AN. Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population. BMC Musculoskelet Disord 2017; 18:204. [PMID: 28532478 PMCID: PMC5441076 DOI: 10.1186/s12891-017-1564-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 05/09/2017] [Indexed: 01/06/2023] Open
Abstract
Background Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%. High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT). Methods RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited. Inclusion criteria: male, 18–55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment. Discussion Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment. Trial Registration EudraCT: 2015-003587-36 3 Dec 2015
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Affiliation(s)
- Robert M Barker-Davies
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK. .,School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK.
| | - Alastair Nicol
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - I McCurdie
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - James Watson
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - Polly Baker
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - Patrick Wheeler
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Daniel Fong
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Mark Lewis
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
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Chaudhry FA. Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2017; 27:441-448. [PMID: 28424882 PMCID: PMC5403875 DOI: 10.1007/s00590-017-1957-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/04/2017] [Indexed: 12/31/2022]
Abstract
Achilles tendinopathy is a common overuse condition affecting the adult population. The incidence is on the rise because of greater participation of people in recreational or competitive sporting activities. There are several treatment options available both non-operative and operative. Ultrasound-guided dry needling and high-volume image-guided injection is relatively a new procedure. The aim of this study was to find out the effectiveness of dry needling and HVIGI in the management of mid-portion chronic Achilles tendinopathy by performing a literature review. Search strategy was devised to find the suitable articles for critical appraisal using the electronic databases. Four articles were selected for critical appraisal, and these papers showed good short- to long-term results of image-guided high-volume injection in the management of Achilles tendinopathy. We conclude that high-volume image-guided injection is effective in the management of Achilles tendinopathy. It provides good short- and medium-term relief of symptoms. It should be considered as one of the many options available for this condition.
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Affiliation(s)
- F A Chaudhry
- Department of Trauma and Orthopaedics, Russells Hall Hospital, Dudley, DY1 2HQ, UK.
- The University of Warwick, Coventry, CV4 7AL, UK.
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Peck E, Jelsing E, Onishi K. Advanced Ultrasound-Guided Interventions for Tendinopathy. Phys Med Rehabil Clin N Am 2017; 27:733-48. [PMID: 27468675 DOI: 10.1016/j.pmr.2016.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Tendinopathy is increasingly recognized as an important cause of musculoskeletal pain and disability. Tendinopathy is thought to be principally a degenerative process, rather than inflammatory as was traditionally believed. Consequently, traditional tendinopathy treatments focused solely on decreasing inflammation have often been ineffective or even harmful. The advancement of ultrasonography as for guidance of outpatient musculoskeletal procedures has facilitated the development of novel percutaneous procedures for the treatment of tendinopathy, mostly by using mechanical intervention to stimulate regeneration. Several of these techniques, including percutaneous needle tenotomy, percutaneous ultrasonic tenotomy, high-volume injection, and percutaneous needle scraping, are reviewed in this article.
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Affiliation(s)
- Evan Peck
- Section of Sports Health, Department of Orthopaedic Surgery, Cleveland Clinic Florida, 525 Okeechobee Boulevard, Suite 1400, West Palm Beach, FL 33401, USA; Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA.
| | - Elena Jelsing
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Minneapolis, MN 55403, USA
| | - Kentaro Onishi
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Zwiers R, Wiegerinck JI, van Dijk CN. Treatment of midportion Achilles tendinopathy: an evidence-based overview. Knee Surg Sports Traumatol Arthrosc 2016; 24:2103-11. [PMID: 25366192 DOI: 10.1007/s00167-014-3407-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 10/22/2014] [Indexed: 12/14/2022]
Abstract
UNLABELLED In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ruben Zwiers
- Department of Orthopaedic Surgery, Academical Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Johannes I Wiegerinck
- Department of Orthopaedic Surgery, Academical Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academical Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
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Pollock N, Dijkstra P, Calder J, Chakraverty R. Plantaris injuries in elite UK track and field athletes over a 4-year period: a retrospective cohort study. Knee Surg Sports Traumatol Arthrosc 2016; 24:2287-92. [PMID: 25362249 DOI: 10.1007/s00167-014-3409-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 10/27/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE The plantaris tendon is present in 98-100 % of people, and a potential relationship between the plantaris tendon and the development of Achilles tendinopathy has been postulated. There are no studies on the epidemiology of plantaris injuries in a sporting population. This retrospective cohort study presents the incidence, nature and outcome of plantaris injuries in elite British track and field athletes. METHOD All 214 elite athletes supported by the British Athletics Medical team from 2009 to 2013 were included in this cohort study. An injury was recorded if a plantaris injury was diagnosed and confirmed with imaging or surgical findings. Patient demographics, injury details and return to competitive elite track and field were recorded. RESULTS There were 33 new plantaris injuries, with an annual plantaris injury incidence of 3.9-9.3 %. There were significantly more right-sided plantaris injuries in bend running sprinters (15 right-sided vs. 4 left-sided). 74 % of the athletes who had a plantaris injury also had Achilles tendinopathy at some point during the study period. Seventeen plantaris tendons were surgically removed from 13 athletes during the course of the study with 12 of the 13 athletes returning to the same level on the Tegner activity scale. CONCLUSION This retrospective cohort study demonstrates that plantaris injuries are common in elite track and field athletes and may be underreported in the literature. There may be an association between the biomechanics bend sprinting and plantaris injury. Elite athletes may benefit from appropriate preventative and management strategies implemented by coaching and medical teams. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Noel Pollock
- British Athletics Team Doctor, Level 1 Outpatients, Hospital of St John and St Elizabeth, 60 Grove End Road, London, NW8 9NH, UK.
| | - Paul Dijkstra
- Sports Medicine Department, Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, PO Box 29222, Doha, Qatar
| | - James Calder
- Chelsea and Westminster Hospital NHS Foundation, London, UK
| | - Robin Chakraverty
- British Athletics Institute, Loughborough University, Loughborough, UK
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Wheeler PC, Mahadevan D, Bhatt R, Bhatia M. A Comparison of Two Different High-Volume Image-Guided Injection Procedures for Patients With Chronic Noninsertional Achilles Tendinopathy: A Pragmatic Retrospective Cohort Study. J Foot Ankle Surg 2016; 55:976-9. [PMID: 27286927 DOI: 10.1053/j.jfas.2016.04.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Indexed: 02/03/2023]
Abstract
We undertook a comparison evaluation of outcomes after 2 different high-volume image-guided injection (HVIGI) procedures performed under direct ultrasound guidance in patients with chronic noninsertional Achilles tendinopathy. In group A, the HVIGI involved high-volume (10 mL of 1% lidocaine combined with 40 mL of saline) and no dry needling. In group B, the HVIGI involved a smaller volume (10 mL of 1% lidocaine combined with 20 mL of saline) and dry needling of the Achilles tendon. A total of 34 patients were identified from the clinical records, with a mean overall age of 50.6 (range 26 to 83) years and an overall mean follow-up duration of 277 (range 49 to 596) days. The change between the preinjection and postinjection Victorian Institute of Sports Assessment-Achilles scores of 33.4 ± 22.5 points in group A and 6.94 ± 22.2 points in group B, was statistically significant (p = .002). In group A, 3 patients (16.7%) required surgical treatment compared with 6 patients (37.5%) in group B requiring surgical treatment (p = .180). Our results indicated that a higher volume without dry needling compared with a lower volume with dry needling resulted in greater improvement in noninsertional Achilles tendinopathy. However, confounding factors mean it is not possible to categorically state that this difference was solely due to different injection techniques.
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Affiliation(s)
- Patrick C Wheeler
- Consultant, Sport and Exercise Medicine, Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK; School for Sport, Exercise, and Health Sciences, Loughborough University, Loughborough, UK; National Centre for Sport and Exercise Medicine, East Midlands, Loughborough, UK.
| | - Dev Mahadevan
- Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK; and Orthopaedic Departments, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Raj Bhatt
- Consultant Musculoskeletal Radiologist, Radiology Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Maneesh Bhatia
- Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med 2016; 50:1187-91. [PMID: 27127294 PMCID: PMC5118437 DOI: 10.1136/bjsports-2015-095422] [Citation(s) in RCA: 213] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2016] [Indexed: 11/25/2022]
Abstract
The pathogenesis of tendinopathy and the primary biological change in the tendon that precipitates pathology have generated several pathoaetiological models in the literature. The continuum model of tendon pathology, proposed in 2009, synthesised clinical and laboratory-based research to guide treatment choices for the clinical presentations of tendinopathy. While the continuum has been cited extensively in the literature, its clinical utility has yet to be fully elucidated. The continuum model proposed a model for staging tendinopathy based on the changes and distribution of disorganisation within the tendon. However, classifying tendinopathy based on structure in what is primarily a pain condition has been challenged. The interplay between structure, pain and function is not yet fully understood, which has partly contributed to the complex clinical picture of tendinopathy. Here we revisit and assess the merit of the continuum model in the context of new evidence. We (1) summarise new evidence in tendinopathy research in the context of the continuum, (2) discuss tendon pain and the relevance of a model based on structure and (3) describe relevant clinical elements (pain, function and structure) to begin to build a better understanding of the condition. Our goal is that the continuum model may help guide targeted treatments and improved patient outcomes.
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Affiliation(s)
- J L Cook
- School of Allied Health, La Trobe University, Bundoora, Australia Australian Centre for Research into Injury in Sport and its Prevention, Federation University
| | - E Rio
- School of Allied Health, La Trobe University, Bundoora, Australia Australian Centre for Research into Injury in Sport and its Prevention, Federation University
| | - C R Purdam
- Australian Centre for Research into Injury in Sport and its Prevention, Federation University Department of Physical Therapies, Australian Institute of Sport, Bruce, Australian Capital Territory, Australia
| | - S I Docking
- School of Allied Health, La Trobe University, Bundoora, Australia Australian Centre for Research into Injury in Sport and its Prevention, Federation University
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Oliva F, Piccirilli E, Berardi AC, Frizziero A, Tarantino U, Maffulli N. Hormones and tendinopathies: the current evidence. Br Med Bull 2016; 117:39-58. [PMID: 26790696 DOI: 10.1093/bmb/ldv054] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tendinopathies negatively affect the quality of life of millions of people, but we still do not know the factors involved in the development of tendon conditions. SOURCES OF DATA Published articles in English in PubMed and Google Scholar up to June 2015 about hormonal influence on tendinopathies onset. One hundred and two papers were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. AREAS OF AGREEMENT In vitro and in vivo, tenocytes showed changes in their morphology and in their functional properties according to hormonal imbalances. AREAS OF CONTROVERSY Genetic pattern, sex, age and comorbidities can influence the hormonal effect on tendons. GROWING POINTS The increasing prevalence of metabolic disorders prompts to investigate the possible connection between metabolic problems and musculoskeletal diseases. AREAS TIMELY FOR DEVELOPING RESEARCH The influence of hormones on tendon structure and metabolism needs to be further investigated. If found to be significant, multidisciplinary preventive and therapeutic strategies should then be developed.
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Affiliation(s)
- Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome 'Tor Vergata', Roma, Italy
| | - Eleonora Piccirilli
- School of Specialization of Orthopaedics and Traumatology, University of Rome 'Tor Vergata', Roma, Italy
| | - Anna C Berardi
- UOC Immunohematology and Transfusion Medicine Laboratories, Laboratory of Stem Cells, Spirito Santo Hospital, Pescara, Italy
| | - Antonio Frizziero
- Department of Physical and Rehabilitation Medicine, University of Padua, Padua, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, University of Rome 'Tor Vergata', Roma, Italy
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Queen Mary University of London Barts, London, UK The London School of Medicine and Dentistry, Mile End Hospital London, London, UK Department of Physical and Rehabilitation Medicine, University of Salerno, Fisciano, Italy
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Abstract
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.
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Benazzo F, Marullo M, Indino C, Zanon G. Achilles Tendinopathies. ARTHROSCOPY AND SPORT INJURIES 2016:69-76. [DOI: 10.1007/978-3-319-14815-1_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Morton S, Chan O, Ghozlan A, Price J, Perry J, Morrissey D. High volume image guided injections and structured rehabilitation in shoulder impingement syndrome: a retrospective study. Muscles Ligaments Tendons J 2015; 5:195-9. [PMID: 26605194 DOI: 10.11138/mltj/2015.5.3.195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND the aim was to establish the effect of a high volume-image guided injection and structured rehabilitation (HVIGI&SR) on both pain and function in shoulder impingement syndrome (SIS). METHODS 44 participants treated between January 2008 and January 2012 with a >3 month history of recalcitrant ultrasound-confirmed SIS were sent a retrospective questionnaire. All participants had received a HVIGI under ultrasound-guidance consisting of 20 mls of Marcaine with 50 mg of hydrocortisone, followed by a period of physiotherapist-led rehabilitation. The validated Shoulder Pain and Disability Index (SPADI) score was used to establish the change in the score between 1 week pre-injection and 3 weeks post-injection, along with an 11-point pain scale. RESULTS 59% of participants responded. There was a clinically and statistically significant decrease in the SPADI score of 58.7 ± 29.9 (p<0.01). 76% of participants had an improvement in their score of over 50% from their initial score. There was a clinically and statistically significant improvement in pain of 5.19 ± 2.62 (p<0.01) on the numerical rating scale of pain. CONCLUSION HVIGI&SR should be considered for short-term treatment of SIS as it showed a significant improvement in both pain and function. A prolonged period of physiotherapist-led rehabilitation can then be undertaken for long term benefits.
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Affiliation(s)
- Sarah Morton
- Centre for Sports and Exercise Medicine William Harvey Research Institute Queen Mary University of London Mile End Hospital, London, UK
| | - Otto Chan
- BMI London Independent Hospital, London, UK
| | - Asser Ghozlan
- Centre for Sports and Exercise Medicine William Harvey Research Institute Queen Mary University of London Mile End Hospital, London, UK
| | - Jessica Price
- Centre for Sports and Exercise Medicine William Harvey Research Institute Queen Mary University of London Mile End Hospital, London, UK
| | - John Perry
- Centre for Sports and Exercise Medicine William Harvey Research Institute Queen Mary University of London Mile End Hospital, London, UK ; BMI London Independent Hospital, London, UK
| | - Dylan Morrissey
- Centre for Sports and Exercise Medicine William Harvey Research Institute Queen Mary University of London Mile End Hospital, London, UK ; BMI London Independent Hospital, London, UK ; Physiotherapy Department, Bart's Health NHS Trust, London, UK
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Effectiveness of orthotic devices in the treatment of Achilles tendinopathy: a systematic review. Sports Med 2015; 45:95-110. [PMID: 25108348 DOI: 10.1007/s40279-014-0237-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Orthotic devices such as foot orthoses, splints, taping and bracing are recommended for Achilles tendinopathy (AT). This systematic review was conducted to review the current evidence for the effectiveness of orthotic devices for the treatment of mid-portion or insertional AT. Electronic bibliographic databases (MEDLINE, EMBASE, Current Contents, CINAHL and SPORTDiscus) were searched in May 2014. The methodological quality of included studies was evaluated using the Quality Index. Where possible, effects were determined using standardised mean differences. The strength of evidence for each intervention was determined according to the quality and number of studies. Twelve studies satisfied the inclusion criteria; nine studies investigated mid-portion AT, whilst three studies did not distinguish between mid-portion and insertional pathology. Weak evidence showed that foot orthoses were equivalent to physical therapy, and equivalent to no treatment. Very weak evidence supported the use of adhesive taping alone or when combined with foot orthoses. Moderate evidence showed that the AirHeel™ brace was as effective as a calf muscle eccentric exercise programme, and weak evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. Weak evidence showed that an ankle joint dorsiflexion night splint was equally effective to a calf muscle eccentric exercise programme, and strong evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. These findings may aid clinical decision making in the context of AT, however further high-quality studies are required.
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Maffulli N, Papalia R, D'Adamio S, Diaz Balzani L, Denaro V. Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials. Br Med Bull 2015; 113:101-15. [PMID: 25583629 DOI: 10.1093/bmb/ldu040] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Several pharmacological interventions have been proposed for the management of Achilles tendinopathy, with no agreement on which is the overall best option available. This systematic review investigates the efficacy and safety of different local pharmacological treatments for Achilles tendinopathy. SOURCES OF DATA We included only randomized controlled studies (RCTs) focusing on clinical and functional outcomes of therapies consisting in injection of a substance or local application. Assessment of the methodological quality was performed using a modified version of the Coleman methodology score (CMS) to determine possible risks of bias. AREAS OF AGREEMENT Thirteen RCTs were included with a total of 528 studied patients. Eleven studies reported the outcomes of injection therapies. Two studies examined the outcomes of patients who applied glyceryl trinitrate patch. The mean modified CMS was 70.6 out of 90. AREAS OF CONTROVERSY There was no significant evidence of remarkable benefits provided by any of the therapies studied. GROWING POINTS There is not univocal evidence to advise any particular pharmacological treatment as the best advisable non-operative option for Achilles tendinopathy as equivalent alternative to the most commonly used eccentric loading rehabilitation program. However, potential was shown by the combination of different substances administered with physical therapy. RESEARCH There is a need for more long-term investigations, studying large enough cohort with standardized scores and evaluations shared by all the investigations to confirm the healing potential, and provide a stronger statistical comparison of the available treatments.
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Via Salvador Allende, Baronissi, Salerno 84081, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Stefano D'Adamio
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Lorenzo Diaz Balzani
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
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37
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Wheeler PC. The use of high-volume image-guided injections (HVIGI) for Achilles tendinopathy – A case series and pilot study. ACTA ACUST UNITED AC 2014. [DOI: 10.1179/1753615414y.0000000035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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38
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom
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39
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Taneja AK, Santos DCB. Steroid-induced Kager's fat pad atrophy. Skeletal Radiol 2014; 43:1161-4. [PMID: 24615408 DOI: 10.1007/s00256-014-1851-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 02/09/2014] [Accepted: 02/13/2014] [Indexed: 02/02/2023]
Abstract
We report a rare case of Kager's fat pad atrophy and fibrosis in a 60-year-old woman 1 year after a steroid injection for Achilles tendinopathy. There are few published reports of steroid-induced atrophy affecting deeper layers of fat tissue. To our knowledge, this case report is the first to illustrate its features using magnetic resonance imaging. A review of the scientific literature is also presented.
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Affiliation(s)
- Atul K Taneja
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, Brazil, 05652-900,
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Kammar H, Carmont MR, Kots E, Laver L, Mann G, Nyska M, Mei-Dan O. Anatomy of the sural nerve and its relation to the achilles tendon by ultrasound examination. Orthopedics 2014; 37:e298-301. [PMID: 24762159 DOI: 10.3928/01477447-20140225-64] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 10/09/2013] [Indexed: 02/03/2023]
Abstract
Sural nerve injury is a relatively common complication after surgery on the Achilles tendon. Studies to determine the course of the sural nerve have been performed on cadaveric specimens. The purpose of this cross-sectional study was to use ultrasound to determine the relations of the sural nerve in a healthy population. The authors performed ultrasound examination of the posterior triangle of the ankle and Achilles tendon to determine the course of the sural nerve relative to the Achilles tendon in healthy participants. The mean distance between the nerve and the tendon was 21.48, 11.47, 5.8, and 0.81 mm lateral to the Achilles tendon as measured at the insertion and 4, 8, and 11 cm proximally, respectively. Male participants tended to have a nerve that was initially more lateral to the Achilles insertion compared with women. The distance between the sural nerve and the Achilles tendon was found to be lower in older participants, with the nerve passing significantly closer to the tendon at all levels (P<.01). Three anatomical variants were reported, with the nerve crossing the lateral border of the Achilles low or high or with multiple branches yet to converge. The course of the sural nerve can be visualized and plotted relative to the Achilles tendon using ultrasound examination in healthy participants. Older patients may be at an increased risk of iatrogenic nerve injury because the nerve courses closer to the Achilles tendon than that in young patients. Intraoperative ultrasound examination may be a useful modality to prevent sural nerve injury during Achilles tendon surgery.
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Gross CE, Hsu AR, Chahal J, Holmes GB. Injectable treatments for noninsertional achilles tendinosis: a systematic review. Foot Ankle Int 2013; 34:619-28. [PMID: 23637232 DOI: 10.1177/1071100713475353] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although there has been a recent increase in interest regarding injectable therapy for noninsertional Achilles tendinosis, there are currently no clear treatment guidelines for managing patients with this condition. The objective of this study was (1) to conduct a systematic review of clinical outcomes following injectable therapy of noninsertional Achilles tendinosis, (2) to identify patient-specific factors that are prognostic of treatment outcomes, (3) to provide treatment recommendations based on the best available literature, and (4) to identify knowledge deficits that require further investigation. METHODS We searched MEDLINE (1948 to March week 1 2012) and EMBASE (1980 to 2012 week 9) for clinical studies evaluating the efficacy of injectable therapies for noninsertional Achilles tendinosis. Specifically, we included randomized controlled trials and cohort studies with a comparative control group. Data abstraction was performed by 2 independent reviewers. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations. RESULTS Nine studies fit the inclusion criteria for our review, constituting 312 Achilles tendons at final follow-up. The interventions of interest included platelet-rich plasma (n = 54), autologous blood injection (n = 40), sclerosing agents (n = 72), protease inhibitors (n = 26), hemodialysate (n = 60), corticosteroids (n = 52), and prolotherapy (n = 20). Only 1 study met the criteria for a high-quality randomized controlled trial. All of the studies were designated as having a low quality of evidence. While some studies showed statistically significant effects of the treatment modalities, often studies revealed that certain injectables were no better than a placebo. CONCLUSIONS The literature surrounding injectable treatments for noninsertional Achilles tendinosis has variable results with conflicting methodologies and inconclusive evidence concerning indications for treatment and the mechanism of their effects on chronically degenerated tendons. Prospective, randomized studies are necessary in the future to guide Achilles tendinosis treatment recommendations using injectable therapies. LEVEL OF EVIDENCE Level II, systematic review.
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Affiliation(s)
- Christopher E Gross
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
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Abstract
Overuse injuries are a common and important cause of morbidity in elite and recreational athletes. They are increasingly recognized in the sedentary population. This article reviews the major classes of overuse injuries of the lower extremity. The underlying pathologic condition is correlated with the imaging appearances, and the often variable relationship between the imaging appearances and patients' symptoms are reviewed. Attempts at imaged-based grading systems and the ability of imaging to predict patients' prognosis are considered. Image-guided injection therapy for tendinopathy is an important and rapidly changing area; the indications, risks, and potential benefits of these interventions are reviewed.
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Sara Muñoz C. Procedimientos intervencionales musculoesqueléticos. REVISTA MÉDICA CLÍNICA LAS CONDES 2013. [DOI: 10.1016/s0716-8640(13)70134-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Neovascularization in Achilles tendinopathy: have we been chasing a red herring? Knee Surg Sports Traumatol Arthrosc 2012; 20:1891-4. [PMID: 22890896 DOI: 10.1007/s00167-012-2172-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 07/28/2012] [Indexed: 01/08/2023]
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Sánchez M, Albillos J, Angulo F, Santisteban J, Andia I. Platelet-Rich Plasma in Muscle and Tendon Healing. ACTA ACUST UNITED AC 2012. [DOI: 10.1053/j.oto.2011.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Backman LJ, Andersson G, Fong G, Alfredson H, Scott A, Danielson P. Alpha-2 adrenergic stimulation triggers Achilles tenocyte hypercellularity: Comparison between two model systems. Scand J Med Sci Sports 2012; 23:687-96. [PMID: 22292987 PMCID: PMC3933766 DOI: 10.1111/j.1600-0838.2011.01442.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2011] [Indexed: 11/29/2022]
Abstract
The histopathology of tendons with painful tendinopathy is often tendinosis, a fibrosis-like condition of unclear pathogenesis characterized by tissue changes including hypercellularity. The primary tendon cells (tenocytes) have been shown to express adrenoreceptors (mainly alpha-2A) as well as markers of catecholamine production, particularly in tendinosis. It is known that adrenergic stimulation can induce proliferation in other cells. The present study investigated the effects of an exogenously administered alpha-2 adrenergic agonist in an established in vivo Achilles tendinosis model (rabbit) and also in an in vitro human tendon cell culture model. The catecholamine producing enzyme tyrosine hydroxylase and the alpha-2A-adrenoreceptor (α2A AR) were expressed by tenocytes, and alpha-2 adrenergic stimulation had a proliferative effect on these cells, in both models. The proliferation was inhibited by administration of an α2A AR antagonist, and the in vitro model further showed that the proliferative alpha-2A effect was mediated via a mitogenic cell signaling pathway involving phosphorylation of extracellular-signal-regulated kinases 1 and 2. The results indicate that catecholamines produced by tenocytes in tendinosis might contribute to the proliferative nature of the pathology through stimulation of the α2A AR, pointing to a novel target for future therapies. The study furthermore shows that animal models are not necessarily required for all aspects of this research.
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Affiliation(s)
- L J Backman
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
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Wiegerinck JI, Reilingh ML, de Jonge MC, van Dijk CN, Kerkhoffs GM. Injection techniques of platelet-rich plasma into and around the Achilles tendon: a cadaveric study. Am J Sports Med 2011; 39:1681-6. [PMID: 21505081 DOI: 10.1177/0363546511401577] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) injections are used to treat (Achilles) tendinopathies. Platelet-rich plasma has been injected at different locations, but the feasibility of PRP injections and the distribution after injection have not been studied. PURPOSE To evaluate (1) the feasibility of ultrasound-guided PRP injections into the Achilles tendon (AT) and in the area between the paratenon and the AT and (2) the distribution of PRP after injection into the AT and in the area between the paratenon and AT. STUDY DESIGN Descriptive laboratory study. METHODS Fifteen cadaveric lower limbs were injected under ultrasound guidance with Indian blue-dyed PRP. Five injections were placed into the AT at the midportion level; 5 injections were located anterior between the paratenon and AT and 5 posterior between the paratenon and AT. The limbs were anatomically dissected and evaluated for the presence and distribution of PRP. RESULTS All injections into the AT showed PRP infiltration in the AT as well as in the area between the paratenon and AT (median craniocaudal spread, 100 mm; range, 75-110 mm); 1 of 5 limbs showed PRP leakage into the Kager fat pad after AT injection. Allanterior and posterior injections showed PRP infiltration in the area between the paratenon and AT (median, 100 mm; range, 75-150 mm). The AT was infiltrated with PRP after 3 of 10 paratenon injections. CONCLUSION The "AT" and "paratenon" injections under ultrasound guidance proved to be accurate. Injections into the AT showed distribution of PRP into the AT as well as in the area between the paratenon and AT. All injections between the paratenon and AT showed PRP distribution in that area, as well as in the Kager fat pad. CLINICAL RELEVANCE Different PRP injection techniques were evaluated. This aids in the optimization of PRP injections in the treatment of midportion Achilles tendinopathy.
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Affiliation(s)
- Johannes I Wiegerinck
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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Maffulli N, Longo UG, Loppini M, Denaro V. Current treatment options for tendinopathy. Expert Opin Pharmacother 2011; 11:2177-86. [PMID: 20569088 DOI: 10.1517/14656566.2010.495715] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management. AREAS COVERED IN THIS REVIEW We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy. WHAT THE READER WILL GAIN The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined. TAKE-HOME MESSAGE Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.
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Affiliation(s)
- Nicola Maffulli
- Queen Mary University of London, Mile End Hospital, Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, 275 Bancroft Road, London E1 4 DG, UK.
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van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc 2011; 19:1367-75. [PMID: 21567177 PMCID: PMC3136709 DOI: 10.1007/s00167-011-1535-8] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 04/28/2011] [Indexed: 02/06/2023]
Abstract
Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented. Level of evidence V.
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Affiliation(s)
- Maayke N. van Sterkenburg
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
| | - C. Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
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Andia I, Sanchez M, Maffulli N. Tendon healing and platelet-rich plasma therapies. Expert Opin Biol Ther 2010; 10:1415-26. [DOI: 10.1517/14712598.2010.514603] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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