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Cocco G, Ricci V, Corvino A, Abate M, Vaccaro A, Bernabei C, Cantisani V, Vallone G, Caiazzo C, Caulo M, Pizzi AD. Musculoskeletal disorders in padel: from biomechanics to sonography. J Ultrasound 2024; 27:335-354. [PMID: 38578364 PMCID: PMC11178742 DOI: 10.1007/s40477-023-00869-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 04/06/2024] Open
Abstract
Padel is a racket sport, combining high-frequency and low-intensity athletic gestures, that has been gaining growing scientific interest in recent years. Musculoskeletal injuries are very common among padel players with an incidence rate of 3 per 1000 h of training and 8 per 1000 matches. To the best of our knowledge, a comprehensive collection describing the most common sonographic findings in padel players with musculoskeletal injuries is lacking in the pertinent literature. In this sense, starting from the biomechanical features of padel-specific gestures we have reported the ultrasonographic patterns of most frequent injuries involving the upper limb, the trunk, and the lower limb. Indeed, comprehensive knowledge of the biomechanical and clinical features of musculoskeletal injuries in padel is paramount to accurately perform a detailed ultrasound examination of the affected anatomical site. So, the present investigation aims to provide a practical guide, simple and ready-to-use in daily practice, to optimize the sonographic assessment of padel players by combining it with the clinical findings and the biomechanical features of athletic gestures.
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Affiliation(s)
- Giulio Cocco
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, 6610, Chieti, Italy
- Unit of Ultrasound in Internal Medicine, Department of Medicine and Aging Sciences, University "G. D'Annunzio", Chieti, Italy
| | - Vincenzo Ricci
- Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, 20157, Milan, Italy
| | - Antonio Corvino
- Medical, Movement and Wellbeing Sciences Department, University of Naples "Parthenope", Via Medina 40, 80133, Naples, Italy.
| | - Michele Abate
- IRCSS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Adele Vaccaro
- Department of Radiology, SS. Annunziata Hospital of Chieti, University "G. D'Annunzio", Chieti, Italy
| | - Carlotta Bernabei
- Department of Radiology, SS. Annunziata Hospital of Chieti, University "G. D'Annunzio", Chieti, Italy
| | - Vito Cantisani
- Department of Radiology, Oncology, Sapienza-University of Rome, Anatomo-Pathology, Rome, Italy
| | - Gianfranco Vallone
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Corrado Caiazzo
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100, Campobasso, Italy
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, 6610, Chieti, Italy
| | - Andrea Delli Pizzi
- Department of Innovative Technologies in Medicine and Dentistry, University "G. D'Annunzio", Chieti, Italy
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Alfredson H, Waldén M, Roberts D, Spang C. Tendinopathic Plantaris but Normal Achilles Tendon Found in About One-Fifth of Patients Not Responding to Conservative Achilles Tendon Management - Results from a Prospective WALANT Surgical Case Series on 105 Tendons. Open Access J Sports Med 2024; 15:41-45. [PMID: 38617130 PMCID: PMC11016245 DOI: 10.2147/oajsm.s456389] [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] [Received: 12/23/2023] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
Purpose Midportion Achilles tendinopathy is a relatively common condition. This study aimed to investigate the presence of a normal Achilles tendon, but a tendinopathic plantaris tendon, in a large and consecutive prospective sample of patients referred to a specialised tendon clinic for midportion Achilles tendon pain not responding to non-surgical treatment. Patients and Methods A total of 105 consecutive tendons were operated on in 81 patients (62 males) suffering from painful midportion Achilles tendon pain. Clinical examination, ultrasound (US) and colour Doppler (CD) examination, and wide awake local anaesthetic no tourniquet (WALANT) surgery were performed in all patients. Results For 19/105 (18%) tendons from 14 patients, clinical examination suspected plantaris tendinopathy alone as there was a distinct tenderness on the medial side, but no thickening of the Achilles tendon. US examination followed by surgery confirmed the diagnosis. Conclusion Midportion Achilles tendon pain is not always related to Achilles tendinopathy since pain related to the plantaris tendon alone was found in almost every fifth patient. Consequently, there is an obvious need for proper examination to identify the pain source and establish a correct diagnosis before treatment.
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Affiliation(s)
- Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umeå, Sweden
- Alfredson Tendon Clinic, Capio Ortho Center Skåne, Malmö, Sweden
| | - Markus Waldén
- Capio Ortho Center Skåne, Malmö, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | - Christoph Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden
- Private Orthopaedic Spine Center, Würzburg, Germany
- Institute for Sports Science, Würzburg University, Würzburg, Germany
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Combined Midportion Achilles and Plantaris Tendinopathy: A 1-Year Follow-Up Study after Ultrasound and Color-Doppler-Guided WALANT Surgery in a Private Setting in Southern Sweden. Medicina (B Aires) 2023; 59:medicina59030438. [PMID: 36984438 PMCID: PMC10056337 DOI: 10.3390/medicina59030438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Background and Objectives: Chronic painful midportion Achilles combined with plantaris tendinopathy can be a troublesome condition to treat. The objective was to prospectively follow patients subjected to ultrasound (US)- and color doppler (CD)-guided wide awake, local anesthetic, no-tourniquet (WALANT) surgery in a private setting. Material and Methods: Twenty-six Swedish patients (17 men and 9 women, mean age 50 years (range 29–62)) and eight international male patients (mean age of 38 years (range 25–71)) with combined midportion Achilles and plantaris tendinopathy in 45 tendons altogether were included. All patients had had >6 months of pain and had tried non-surgical treatment with eccentric training, without effect. US + CD-guided surgical scraping of the ventral Achilles tendon and plantaris removal under local anesthesia was performed on all patients. A 4–6-week rehabilitation protocol with an immediate full-weight-bearing tendon loading regime was used. The VISA-A score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation. Results: At the 1-year follow-up, 32/34 patients (43 tendons) were satisfied with the treatment result and had returned to their pre-injury Achilles tendon loading activity. There were two dropouts (two tendons). For the Swedish patients, the mean VISA-A score increased from 34 (0–64) before surgery to 93 (61–100) after surgery (p < 0.001). There were two complications, one wound rupture and one superficial skin infection. Conclusions: For patients suffering from painful midportion Achilles tendinopathy and plantaris tendinopathy, US + CD-guided surgical Achilles tendon scraping and plantaris tendon removal showed a high satisfaction rate and good functional results 1 year after surgery.
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Park JH, Cho J, Kim D, Kwon HW, Lee M, Choi YJ, Yoon KH, Park KR. Anatomical Classification for Plantaris Tendon Insertion and Its Clinical Implications: A Cadaveric Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5795. [PMID: 35627332 PMCID: PMC9140714 DOI: 10.3390/ijerph19105795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/20/2022] [Accepted: 05/09/2022] [Indexed: 02/06/2023]
Abstract
The purposes of this study were to ascertain the morphological characteristics of a plantaris tendon (PT) insertion using a larger-scale dissection of Korean cadavers and to classify the types of PT insertion related to the calcaneal tendon (CT). A total of 108 feet from adult formalin-fixed cadavers (34 males, 20 females) were dissected. The morphological characteristics and measurements of the PT insertion were evaluated. Five types of PT insertion were classified, wherein the most common type was Type 1 (39 feet, 63.1%). Type 2 and Type 3 were similar, with 16 feet (14.8%) and 15 feet (13.9%), respectively. Type 4 (6 feet, 5.6%) was the rarest type, and Type 5 had 25 feet (23.1%). The case of an absent PT was noted in 7 feet (6.5%). In the proximal portion, the tendon had a thick and narrow shape, became thin and wide in the middle portion, and then changed to thick and narrow again just before the insertion into the calcaneal tuberosity. This study confirmed the five types according to the location of the PT and the area of its insertion-related CT. The morphology of the PT insertion may be anatomically likely to influence the occurrence of tendinopathy in the CT.
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Affiliation(s)
- Jeong-Hyun Park
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon 24253, Korea;
| | - Digud Kim
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Hyung-Wook Kwon
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Mijeong Lee
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Yu-Jin Choi
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Kwan Hyun Yoon
- Division in Biomedical Art, Incheon Catholic University Graduate School, Incheon 21987, Korea;
| | - Kwang-Rak Park
- Department of Anatomy, School of Medicine, Keimyung University, Daegu 42601, Korea
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Alfredson H, Masci L, Spang C. Sharp pain in a normal Achilles tendon of a professional female football player was related to a plantaris tendon in a rare position: a case report. J Med Case Rep 2021; 15:513. [PMID: 34657632 PMCID: PMC8522164 DOI: 10.1186/s13256-021-03131-7] [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] [Received: 02/01/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Plantaris tendinopathy and plantaris-associated Achilles tendinopathy can be responsible for chronic pain in the Achilles tendon midportion, often accompanied by medial tenderness. As conservative treatments are less successful for this patient group, proper diagnosis is important for decision making. This report presents a case with plantaris tendinopathy in a rare (superficial) location. CASE PRESENTATION This article describes a pain history and treatment timeline of a professional Swedish female soccer player (32 years old, Northern European ethnicity, white) who suffered from sharp pain in the Achilles tendon midportion and tenderness on the medial and superficial side for about 2 years. Conservative treatments, including eccentric exercises, were not successful and, to some extent, even caused additional irritation in that region. Ultrasound showed a wide and thick plantaris tendon located on the superficial side of the Achilles tendon midportion. The patient was surgically treated with local removal of the plantaris tendon. After surgery there was a relatively quick (4-6 weeks) rehabilitation, with immediate weight bearing, gradual increased loading, and return to running activities after 4 weeks. At follow-up at 8 weeks, the patient was running and had not experienced any further episodes of sharp pain during change of direction or sprinting. CONCLUSIONS The plantaris tendon should be considered as a possible source of Achilles tendon pain. This case study demonstrates that the plantaris tendon can be found in unexpected (superficial) positions and needs to be carefully visualized during clinical and imaging examinations.
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Affiliation(s)
- Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Sports Medicine Unit, Umeå University, 901 87, Umeå, Sweden.,Institute of Sports Exercise and Health, University College Hospital London, London, UK
| | - Lorenzo Masci
- Institute of Sports Exercise and Health, University College Hospital London, London, UK.,Sports and Exercise Medicine, Queen Mary University of London, London, UK
| | - Christoph Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden. .,Private Orthopaedic Spine Center Dr. Alfen, Schürerstraße 5, 97080, Würzburg, Germany.
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Masci L, Neal BS, Wynter Bee W, Spang C, Alfredson H. Achilles Scraping and Plantaris Tendon Removal Improves Pain and Tendon Structure in Patients with Mid-Portion Achilles Tendinopathy-A 24 Month Follow-Up Case Series. J Clin Med 2021; 10:jcm10122695. [PMID: 34207436 PMCID: PMC8233944 DOI: 10.3390/jcm10122695] [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: 05/12/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 01/21/2023] Open
Abstract
Background: Studies have demonstrated that a sub-group of patients with medial Achilles pain exhibit Achilles tendinopathy with plantaris tendon involvement. This clinical condition is characterised by structural relationships and functional interference between the two tendons, resulting in compressive or shearing forces. Surgical plantaris tendon removal together with an Achilles scraping procedure has demonstrated positive short-term clinical results. The aim of this case series was to determine the long-term outcomes on pain and Achilles tendon structure. Methods: 18 consecutive patients (13 males; 5 females; mean age 39 years; mean symptom duration 28 months), of which three were elites, were included. Clinical examination, b-mode ultrasound (US) and Ultrasound Tissue Characterisation (UTC) confirmed medial Achilles tendon pain and tenderness, medial Achilles tendinopathy plus a plantaris tendon located close to the medial side of the Achilles tendon. Patients underwent US-guided local Achilles scraping and plantaris tendon removal followed by a structured rehabilitation program. Outcomes were VISA-A score for pain and function and UTC for Achilles structure. Results: 16 of 18 patients completed the 24 months follow-up. Mean VISA-A scores increased from 58.2 (±15.9) to 92.0 (±9.2) (mean difference = 33.8, 95% CI 25.2, 42.8, p < 0.01). There was an improvement in Achilles structure with mean organised echo pixels (UTC type I+II, in %) increasing from 79.9 (±11.5) to 86.4 (±10.0) (mean difference = 6.5%, 95% CI 0.80, 13.80, p =0.01), exceeding the 3.4% minimum detectable change. All 16 patients reported satisfaction with the procedure and 14 returned to pre-injury activity levels. There were no reported complications. Conclusions: Improved pain, function and tendon structure were observed 24 months after treatment with Achilles scraping and plantaris excision. The improvement in structure on the medial side of the Achilles after plantaris removal indicates that compression from the plantaris tendon might be an important presenting factor in this sub-group.
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Affiliation(s)
- Lorenzo Masci
- Institute of Sports Exercise and Health, University College Hospital London, London W1T 7HA, UK; (L.M.); (W.W.B.); (H.A.)
- Sports & Exercise Medicine, Queen Mary University of London, London E1 4DG, UK;
| | - Bradley Stephen Neal
- Sports & Exercise Medicine, Queen Mary University of London, London E1 4DG, UK;
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Wivenhoe Park, Colchester CO4 3SQ, UK
| | - William Wynter Bee
- Institute of Sports Exercise and Health, University College Hospital London, London W1T 7HA, UK; (L.M.); (W.W.B.); (H.A.)
| | - Christoph Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, 901 87 Umeå, Sweden
- Private Orthopaedic Spine Center, 97080 Würzburg, Germany
- Correspondence:
| | - Håkan Alfredson
- Institute of Sports Exercise and Health, University College Hospital London, London W1T 7HA, UK; (L.M.); (W.W.B.); (H.A.)
- Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, 901 87 Umeå, Sweden
- Pure Sports Medicine, Canary Wharf, London E14 4QT, UK
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Snapping Plantaris Tendon: A Rare Case in a Competitive Dancer. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:e21.00008. [PMID: 33945519 PMCID: PMC8099407 DOI: 10.5435/jaaosglobal-d-21-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/11/2021] [Indexed: 12/03/2022]
Abstract
Pathology associated with the plantaris includes rupture of the tendon and an association with mid-substance Achilles tendinopathy in some patients. There have only been two previous case reports in the literature in English language describing snapping of the plantaris tendon. We present a case report of a 15-year-old female competitive dancer who described pain and an audible popping at the medial margin of the Achilles tendon while squatting. Physical examination revealed visible and audible popping of the plantaris, and ultrasonography confirmed the diagnosis. After symptoms persisted despite nonsurgical treatment with physical therapy, the patient underwent an open plantaris tenotomy. By 8 weeks after surgery, she had resumed dancing. Twenty-three months after her operation, she reported an excellent outcome and full recovery with no limitations to her physical activity. She reported having no pain, a Foot and Ankle Ability Measure Activities of Daily Living Subscale score of 100, and a Foot and Ankle Ability Measure Sports Subscale score of 100. This case demonstrates a successful course of treatment for this uncommon pathology within the context of a competitive dancer.
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Alfredson H, Masci L, Spang C. Ultrasound and surgical inspection of plantaris tendon involvement in chronic painful insertional Achilles tendinopathy: a case series. BMJ Open Sport Exerc Med 2021; 7:e000979. [PMID: 33786196 PMCID: PMC7986664 DOI: 10.1136/bmjsem-2020-000979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives Chronic painful insertional Achilles tendinopathy is known to be difficult to manage. The diagnosis is not always easy because multiple different tissues can be involved. The plantaris tendon has recently been described to frequently be involved in chronic painful mid-portion Achilles tendinopathy. This study aimed to evaluate possible plantaris tendon involvement in patients with chronic painful insertional Achilles tendinopathy. Methods Ninety-nine consecutive patients (74 males, 25 females) with a mean age of 40 years (range 24–64) who were surgically treated for insertional Achilles tendinopathy, were included. Clinical examination, ultrasound (US)+Doppler examination, and surgical findings were used to evaluate plantaris tendon involvement. Results In 48/99 patients, there were clinical symptoms of plantaris tendon involvement with pain and tenderness located medially at the Achilles tendon insertion. In all these cases, surgical findings showed a thick and wide plantaris tendon together with a richly vascularised fatty infiltration between the plantaris and Achilles tendon. US examination suspected plantaris involvement in 32/48 patients. Conclusion Plantaris tendon involvement can potentially be part of the pathology in chronic painful insertional Achilles tendinopathy and should be considered for diagnosis and treatment when there is distinct and focal medial pain and tenderness. Level of evidence IV case series.
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Affiliation(s)
- Håkan Alfredson
- Institute of Sports, Exercise and Health, University College Hospital, London, London, UK.,Department of Community Research and Rehabilitation, Sports Medicine Unit, Umeå University, Umeå, Sweden
| | - Lorenzo Masci
- Department of Sports and Exercise Medicine, Queen Mary University, London, UK
| | - Christoph Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden.,Research Unit, Orthopaedic Spine Center, Dr. Alfen, Würzburg, Germany
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Olewnik Ł, Kurtys K, Gonera B, Podgórski M, Sibiński M, Polguj M. Proposal for a new classification of plantaris muscle origin and its potential effect on the knee joint. Ann Anat 2020; 231:151506. [PMID: 32173563 DOI: 10.1016/j.aanat.2020.151506] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/29/2020] [Accepted: 03/01/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The plantaris muscle (PM) is typically characterized by a short, slim and spindle-shaped muscle belly and long, thin tendon. It is situated posterior to the popliteal muscle, and anterior to the lateral head of the gastrocnemius muscle (GM). Little information exists regarding the high variability of origin of the PM. The main aim of the study was hence to characterize the morphology of the PM and its place of origin, classify it and evaluate its prevalence. METHODS Classical anatomical dissection was performed on 142 lower limbs (77 left, and 65 right) fixed in 10% formalin solution. The morphology of the origin of the PM and its prevalence was evaluated. RESULTS The PM was present in 128 lower limbs (90.1%). Six types of origin were observed, the most common being Type I (48.4%). This type was divided into two subtypes (A-B): subtype A attaching to the lateral head of the GM, lateral femoral condyle and to the capsule of the knee joint, and subtype B, attaching to the lateral head of the GM, the lateral femoral condyle, knee joint capsule and the popliteal surface of the femur. The second most common type was Type II (25%), attaching to the capsule of the knee joint and, indirectly, to the lateral head of the GM through the lateral femoral condyle. The third most common type was Type III (10.15%), attaching to the lateral femoral condyle and the knee joint capsule. Type IV (6.25%), the rarest type, attached to the lateral femoral condyle, knee joint capsule and to the iliotibial band. Type V (8.6%) originated only from the lateral condyle of the femur. Type VI (1.6%) contains only "rare cases". CONCLUSION The PM presents high morphological variability, and its status as a residual muscle should be reconsidered. Our presented classification of its types of origin is a valuable addition for both clinicians and anatomists. Level of Evidence - II Basic Science Research.
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Affiliation(s)
- Ł Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland.
| | - K Kurtys
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - B Gonera
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - M Podgórski
- Polish Mother's Memorial Hospital Research Institute, Lodz, Department of Diagnostic Imaging, Lodz, Poland
| | - M Sibiński
- Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Lodz, Poland
| | - M Polguj
- Department of Normal and Clinical Anatomy, Medical University of Lodz, Poland
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It is possible to release the plantaris tendon under ultrasound guidance: a technical description of ultrasound guided plantaris tendon release (UPTR) in the treatment of non-insertional Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 2019; 27:2858-2862. [PMID: 30847522 DOI: 10.1007/s00167-019-05451-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 02/25/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Open plantaris tendon excision and ventral paratendinous stripping is a recognised treatment option in selected patients with non-insertional Achilles tendinopathy. The aim of this study was to develop a minimally invasive outpatient technique of ultrasound guided plantaris tendon release (UPTR). METHODS A 19 gauge needle, 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and a beaver blade (Arthrex, Naples, FL, USA), were used under ultrasound guidance to identify and divide the plantaris tendon in 12 cadaveric legs. Specimens were dissected to identify whether division of the plantaris tendon had been successful. UPTR was subsequently performed on patients. RESULTS The 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and beaver blade (Arthrex, Naples, FL, USA) were all able to cut the plantaris tendon. However, on dissection the hook knife (Smith and Nephew, Boston MA) caused less damage to surrounding structures. Subsequently, the plantaris tendon was successfully divided in three patients using UPTR technique without complication. CONCLUSION UPTR is a viable technique for treating plantaris related non-insertional Achilles tendinopathy.
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Prevalence of Coexistent Plantaris Tendon Pathology in Patients with Mid-Portion Achilles Pathology: A Retrospective MRI Study. Sports (Basel) 2019; 7:sports7050124. [PMID: 31121856 PMCID: PMC6571766 DOI: 10.3390/sports7050124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 11/17/2022] Open
Abstract
Co-existence of Plantaris tendinopathy (PT) in patients with mid-Achilles tendinopathy (Mid-AT) is of clinical significance. This study aims to describe the MRI-based pathological characteristics of co-existing PT and Mid-AT. One-hundred MRI studies of patients diagnosed with Mid-AT were retrospectively analysed by an experienced musculoskeletal radiologist. Presence or absence of a Plantaris tendon, co-existing PT with Mid-AT, insertional characteristics of Plantaris tendon, and maximum anteroposterior thickness of the tendon in Mid-AT (axial images) were evaluated. When PT co-existed with Mid-AT, the location of the tendon pathologies in relation to calcaneal insertion was assessed (sagittal images) and their association was analysed using the coefficient of variation (CV) and Pearson’s correlation coefficient. Plantaris was present in 84 cases (84%), and Mid-AT and PT co-existed in 10 cases (10%). A greater variability in the location of Plantaris pathology (CV = 42%) than Achilles tendinopathy (CV = 42%) was observed. The correlation coefficient also revealed a low and non-significant association between the location of two pathologies when they exist together (r = +0.06; p = 0.88). Clinical evaluation of Achilles tendon pain needs careful consideration into the possible co-existence of Plantaris pathology. The considerable difference observed in the location of PT and Mid-AT suggest possible isolated pathologies and differentials for Achilles tendon pain.
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Smith J, Alfredson H, Masci L, Sellon JL, Woods CD. Sonographically Guided Plantaris Tendon Release: A Cadaveric Validation Study. PM R 2019; 11:56-63. [PMID: 29908296 DOI: 10.1016/j.pmrj.2018.05.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 05/28/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND The plantaris tendon (PT) has been implicated in the pathogenesis of symptoms in a subset of patients with Achilles region pain syndromes and traditionally has been managed via open surgical resection. Although the PT can be visualized on ultrasound, a minimally invasive technique for sonographically guided PT release has not been formally described. OBJECTIVE To validate a technique to perform sonographically guided PT release in an unembalmed cadaveric model. DESIGN Prospective, cadaveric laboratory investigation. SETTING Procedural skills laboratory in a tertiary medical center. SUBJECTS Twenty unembalmed cadaveric knee-ankle-foot specimens (10 right, 10 left) obtained from 16 donors (6 male, 10 female) ages 55-96 years (mean 82.6 years) with body mass indexes of 14.1-33.2 kg/m2 (mean 23.3 kg/m2 ). METHODS After simulated local anesthesia and sonographically guided hydrodissection of the plantaris tendon-Achilles tendon interval, a single experienced operator performed sonographically guided PT release on each specimen using an in-plane, lateral-to-medial approach, a commercially available, disposable 3.0-mm hook knife, and either a 17-5 MHz or 15-7 MHz linear array transducer. Each specimen was subsequently dissected to assess for PT release and iatrogenic injury. MAIN OUTCOME Status of the PT, Achilles tendon, and regional neurovascular structures as determined by dissection. RESULTS All 20 PT releases were completed in a single attempt through a 3- to 5-mm incision. Dissection confirmed complete PT release in all specimens without damage to the adjacent Achilles tendon or regional neurovascular structures. CONCLUSION Sonographically guided PT release is technically feasible and can be performed while avoiding injury to the Achilles tendon and regional neurovascular structures. Additional research is warranted to further define the role of sonographically guided PT release in patients with suspected PT-mediated Achilles region pain syndromes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jay Smith
- Departments of Physical Medicine & Rehabilitation, Radiology, and Anatomy, Mayo Clinic Sports Medicine Center, Mayo Clinic, 200 1st St, SW, Rochester, MN 55905
| | - Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden.,Alfredson Tendon Clinic, Pure Sports Medicine Clinic, London, United Kingdom
| | - Lorenzo Masci
- Alfredson Tendon Clinic, Pure Sports Medicine Clinic, London, United Kingdom
| | - Jacob L Sellon
- Department of Physical Medicine & Rehabilitation, Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, MN
| | - Charonn D Woods
- Department of Physical Medicine & Rehabilitation, Rochester, MN
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Alfredson H, Masci L, Spang C. Surgical plantaris tendon removal for patients with plantaris tendon-related pain only and a normal Achilles tendon: a case series. BMJ Open Sport Exerc Med 2018; 4:e000462. [PMID: 30588327 PMCID: PMC6280899 DOI: 10.1136/bmjsem-2018-000462] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 11/28/2022] Open
Abstract
Objectives Surgical removal of the plantaris tendon can cure plantaris-associated Achilles tendinopathy, a condition in which Achilles and plantaris tendinopathy coexist. However, rare cases with plantaris tendinopathy alone are often misdiagnosed due to a normal Achilles tendon. Design and setting Prospective case series study at one centre. Participants Ten consecutive patients (9 men and one woman, mean age 35 years, range 19–67) with plantaris tendon-related pain alone in altogether 13 tendons were included. All had had a long duration (median 10 months, range 3 months to 10 years) of pain symptoms on the medial side of the Achilles tendon mid-portion. Preoperative ultrasound showed thickened plantaris tendon but a normal Achilles tendon. Interventions Operative treatment consisting of ultrasound-guided excision of the plantaris tendon. Primary and secondary outcome measures Scores from Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A)were taken preoperatively and postoperatively (median duration 10 months). Patient satisfaction and time until full return to sports activity level was asked by a questionnaire. Results The VISA-A scores increased from 61 (range 45–81) preoperatively to 97 (range 94–100) postoperatively (p<0.01). Follow-up results at 10 months (range 7–72 months) on 9/10 patients showed full satisfaction and return to their preinjury sports or recreational activity Conclusion The plantaris tendon should be kept in mind when evaluating painful conditions in the Achilles tendon region, especially when no Achilles tendinopathy is present. Excision of the plantaris tendon via a minor surgical procedure in local anaesthesia results in a good outcome.
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Affiliation(s)
- Håkan Alfredson
- Sports Medicine Unit, Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden.,ISEH, UCLH, London, UK.,Pure Sports Medicine Clinic, London, UK
| | | | - Christoph Spang
- Anatomy Section, Department of Integrative Medical Biology, Umea University, Umeå, Sweden
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14
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The Plantaris Muscle Tendon and Its Relationship with the Achilles Tendinopathy. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9623579. [PMID: 29955614 PMCID: PMC6000875 DOI: 10.1155/2018/9623579] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 04/30/2018] [Indexed: 11/21/2022]
Abstract
Purpose Although the plantaris muscle (PM) is vestigial in humans, it has a significant clinical role in procedures such as grafting. However, recent reports suggest its potential involvement in the tendinopathy of the midportion of the Achilles tendon. The aim of the study is therefore to evaluate morphological variation of the PM with regard to its potential conflict with the Achilles tendon. Material and Methods Classical anatomical dissection was performed on 130 lower limbs (71 right, 59 left) fixed in 10% formalin solution. The morphology of the PM was assessed regarding the relationship between the course of the plantaris tendon and the calcaneal tendon. Results The PM was present in 89.2% of cases. The findings indicate the presence of a new type of PM tendon insertion in which the tendon is inserted into the tarsal canal flexor retinaculum, potentially affecting the tendinopathy of the tibialis posterior muscle. In 26 cases (22.4%), insertion blended with the Achilles tendon (Type II), which may increase the risk of Achilles tendinopathy. Conclusion The anatomical variation of PM tendon morphology may create a potential conflict with the Achilles tendon and the tibialis posterior tendon, thus increasing the possibility of tendinopathy.
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Stephen JM, Marsland D, Masci L, Calder JDF, Daou HE. Differential Motion and Compression Between the Plantaris and Achilles Tendons: A Contributing Factor to Midportion Achilles Tendinopathy? Am J Sports Med 2018; 46:955-960. [PMID: 29253349 DOI: 10.1177/0363546517745291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The plantaris tendon (PT) has been thought to contribute to symptoms in a proportion of patients with Achilles midportion tendinopathy, with symptoms improving after PT excision. HYPOTHESIS There is compression and differential movement between the PT and Achilles tendon (AT) during ankle plantarflexion and dorsiflexion. STUDY DESIGN Descriptive laboratory study. METHODS Eighteen fresh-frozen cadaveric ankles (mean ± SD age: 35 ± 7 years, range = 27-48 years; men, n = 9) were mounted in a customized testing rig, where the tibia was fixed but the forefoot could be moved freely. A Steinmann pin was drilled through the calcaneus, enabling a valgus torque to be applied. The soleus, gastrocnemius, and plantaris muscles were loaded with 63 N with a weighted pulley system. The test area was 40 to 80 mm above the os calcis, corresponding to where the injury is observed clinically. Medially, the AT and PT were exposed, and a calibrated flexible pressure sensor was inserted between the tendons. Pressure readings were recorded with the ankle in full dorsiflexion, full plantarflexion, and plantargrade and repeated in these positions with a 5 N·m torque, simulating increased hindfoot valgus. The pressure sensor was removed and the PT and AT marked with ink at the same level, with the foot held in neutral rotation and plantargrade. Videos and photographs were taken to assess differential motion between the tendons. After testing, specimens were dissected to identify the PT insertion. One-way analysis of variance and paired t tests were performed to make comparisons. RESULTS The PT tendons with an insertion separate from the AT demonstrated greater differential motion through range (14 ± 4 mm) when compared with those directly adherent to the AT (2 ± 2 mm) ( P < .001). Mean pressure between the PT and AT rose in terminal plantarflexion for all specimens ( P < .001) and was more pronounced with hindfoot valgus ( P < .001). CONCLUSION The PT inserting directly into the calcaneus resulted in significantly greater differential motion as compared with the AT. Tendon compression was elevated in terminal plantarflexion, suggesting that adapting rehabilitation tendon-loading programs to avoid this position may be beneficial. CLINICAL RELEVANCE The insertion pattern of the PT may be a factor in plantaris-related midportion Achilles tendinopathy. Terminal range plantarflexion and hindfoot valgus both increased AT and PT compression, suggesting that these should be avoided in this patient population.
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Affiliation(s)
- Joanna M Stephen
- Fortius Clinic, London, UK.,The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
| | - Daniel Marsland
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
| | | | - James D F Calder
- Fortius Clinic, London, UK.,The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
| | - Hadi El Daou
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
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Olewnik Ł, Wysiadecki G, Polguj M, Podgórski M, Jezierski H, Topol M. Anatomical variations of the palmaris longus muscle including its relation to the median nerve - a proposal for a new classification. BMC Musculoskelet Disord 2017; 18:539. [PMID: 29258498 PMCID: PMC5738140 DOI: 10.1186/s12891-017-1901-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 12/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The palmaris longus (PL) muscle is characterised by high morphological diversity, and its tendon crosses the median nerve (MN) at different levels. Due to the fact that the palmaris longus tendon is routinely harvested for reconstruction of other tendons, knowledge of its morphological variations is clinically important. Therefore, the purpose of the study was to suggest a new morphological classification of the PL muscle and characterise the relationship of its tendon to the median nerve. METHODS Standard dissection was performed on 80 randomised and isolated upper limbs (40 left and 40 right) fixed in a 10% formalin solution. Measurements of muscle belly and tendon were obtained. The course and location of tendon insertion, as well as its relationship to the median nerve, were noted. RESULTS The palmaris longus muscle was present in 92.5% of specimens. Three types of palmaris longus muscle were identified based on the morphology of its insertion (types I-III) and these were further subdivided into three subgroups (A-C) according to the ratio of the length of the muscle belly and its tendon. The most frequent was type I (78.8%), where the tendon attached to the palmar aponeurosis, and subtype B, where the tendon-to-belly ratio was 1-1.5 (41.1%). The mean distance from the interstyloid line to the crossing between the median nerve and the palmaris longus tendon was 31.6 mm. In addition, two types of palmaris longus were described. CONCLUSION The presented classification of palmaris longus muscle types allows a better characterization of its diversity and may be useful in planning tendon grafting.
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Affiliation(s)
- Łukasz Olewnik
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, ul. Narutowicza 60, 90-136, Łódź, Poland.
| | - Grzegorz Wysiadecki
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, ul. Narutowicza 60, 90-136, Łódź, Poland
| | - Michał Polguj
- Department of Angiology, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Lodz, Poland
| | - Michał Podgórski
- Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Hubert Jezierski
- Department of Trauma and Orthopaedic Surgery, Hospital of Ministry of Interior and Administration in Lodz, ul. Północna 42, 91-425, Łódź, Poland
| | - Mirosław Topol
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, ul. Narutowicza 60, 90-136, Łódź, Poland
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