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Guenoun D, Deniel C, Champsaur P, Pauly V, Moraux A, Creze M, Le Corroller T. High-resolution ultrasound of the paratenon of the Achilles calcaneal tendon: anatomical study and description of the paratendinous injection technique. Surg Radiol Anat 2024:10.1007/s00276-024-03415-9. [PMID: 38916631 DOI: 10.1007/s00276-024-03415-9] [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: 04/05/2024] [Accepted: 06/12/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE The aim of this study is to determine if ultrasound (US) allows a precise assessment of the paratenon (PT) of the Achilles calcaneal tendon (AT), and to anatomically describe the US-guided paratendinous injection technique. METHODS This study was initially conducted on eight cadaveric specimens using high-resolution ultrasound (HRUS) to examine the PT appearance, thickness, and its relationships with the AT, plantaris tendon (PLT), Kager's fat pad (KFP), sural nerve (SN), and fascia cruris (FC). US-guided paratendinous injection of China ink was performed in all specimens, followed by anatomical dissection to assess injectate distribution. Then, HRUS study of the PT was carried out bilaterally in twenty asymptomatic volunteers (40 legs). Two musculoskeletal radiologists recorded all data in consensus except PT thickness in volunteers which was recorded independently in order to calculate intra and inter-observer reliability. RESULTS The PT was consistently identified with HRUS along its entire course in both cadaveric specimens (8/8) and volunteers (40/40). The mean PT thickness was 0.54 mm in cadavers and 0.39 mm in vivo, without any correlation with the AT thickness. Intra- and inter observer reliability were respectively excellent and good for PT thickness. All eight (100%) ex vivo China ink injections were accurate, demonstrating a circumferential distribution of the injectate between the PT and the AT, associated with an anterior spread to the KFP. CONCLUSION HRUS allows visualization of the PT along its entire length, and assessment of its relationships to adjacent structures. US-guided paratendinous injections can accurately and safely deliver injectates in the paratendinous sheath.
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Affiliation(s)
- Daphne Guenoun
- Institute for Locomotion, Department of Radiology, APHM, Sainte-Marguerite Hospital, 270 Bd Sainte Marguerite, Marseille, 13009, France.
- Aix Marseille Univercity, CNRS, ISM, Institute Movement Science, Marseille, 13009, France.
| | - Cecile Deniel
- Institute for Locomotion, Department of Radiology, APHM, Sainte-Marguerite Hospital, 270 Bd Sainte Marguerite, Marseille, 13009, France
| | - Pierre Champsaur
- Institute for Locomotion, Department of Radiology, APHM, Sainte-Marguerite Hospital, 270 Bd Sainte Marguerite, Marseille, 13009, France
- Aix Marseille Univercity, CNRS, ISM, Institute Movement Science, Marseille, 13009, France
| | - Vanessa Pauly
- D?partement d'Informatique M?dical, Faculté de medecine, Centre d'Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix- Marseille Université, 147 Bd Baille, Marseille, 13005, France
| | - Antoine Moraux
- Imagerie Medicale Jacquemars Gielee, 73 Rue Jacquemars Gielee, Lille, 59000, France
| | - Maud Creze
- Hôpital Bicêtre, APHP, Le Kremlin-Bicêtre, 94270, France
- Université Paris-Saclay, Laboratoire d'imagerie biomédicale multimodale (Biomaps), Le Kremlin-Bicêtre, 94270, France
| | - Thomas Le Corroller
- Institute for Locomotion, Department of Radiology, APHM, Sainte-Marguerite Hospital, 270 Bd Sainte Marguerite, Marseille, 13009, France
- Aix Marseille Univercity, CNRS, ISM, Institute Movement Science, Marseille, 13009, France
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Liu M, Kang N, Zhang Y, Wen E, Mei D, Hu Y, Chen G, Wang D. Influence of motor capacity of the lower extremity and mobility performance on foot plantar pressures in community-dwelling older women. Heliyon 2024; 10:e28114. [PMID: 38560666 PMCID: PMC10979215 DOI: 10.1016/j.heliyon.2024.e28114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
Objectives To investigate the associations of motor capacity of the lower extremity and mobility performance in daily physical activities with peak foot plantar pressures during walking among older women. Methods Using the data collected among 58 community-dwelling older women (68.66 ± 3.85 years), Pearson correlation and multiple linear regression analyses were performed to analyze the associations of motor capacity of the lower extremity (the 30-s chair stand test, the timed one-leg stance with eyes closed, and the Fugl-Meyer assessment of lower extremity), mobility performance in daily physical activities (the average minutes of moderate to vigorous physical activity every day and the metabolic equivalents), and foot plantar pressures (peak force and peak pressure) with the age and body fat percentage as covariates. Results (1) The motor capacity of the lower extremity has higher explanatory power for peak foot plantar pressures compared with the mobility performance in daily physical activities. (2) Higher body fat percentage was positively associated with peak force and pressure, while a lower score on the Fugl-Meyer assessment of lower extremity was negatively associated with both of them. (3) The metabolic equivalents were positively associated with the peak force, while the 30-s chair stand test was negatively associated with it. Conclusions Mobility performance in daily physical activities can be significant predictors for peak foot plantar pressures among older women. The significant predictor variables include the Fugl-Meyer assessment of lower extremity, the 30-s chair stand test, and metabolic equivalents.
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Affiliation(s)
- Min Liu
- Institute of Population Research, Peking University, Beijing, 100871, China
| | - Ning Kang
- Institute of Population Research, Peking University, Beijing, 100871, China
| | - Yalu Zhang
- School of Social Welfare, Stony Brook University, New York, 11794, United States
| | - Erya Wen
- Department of Physical Education, Peking University, Beijing, 100871, China
| | - Donghui Mei
- Institute of Population Research, Peking University, Beijing, 100871, China
| | - Yizhe Hu
- Department of Physical Education, Peking University, Beijing, 100871, China
| | - Gong Chen
- Institute of Population Research, Peking University, Beijing, 100871, China
| | - Dongmin Wang
- Department of Physical Education, Peking University, Beijing, 100871, China
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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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Bello Baez A, Nieto Morales ML, Mora Guanche P, Cavada Laza A, Pérez Méndez LI. Can Achilles tendinosis be treated effectively with lidocaine and glucose infiltrations, and if so, is the effect lasting? A longitudinal, observational on 27 consecutive patients. RADIOLOGIA 2023; 65 Suppl 2:S41-S49. [PMID: 37858352 DOI: 10.1016/j.rxeng.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 05/09/2022] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Our aim was to add to the small but growing body of evidence on the effectiveness of ultrasound-guided Achilles intratendinous hyperosmolar dextrose prolotherapy and introduce a novel, preceding step of paratenon hydrodissection with lidocaine in patients with chronic Achilles tendinosis resistant to rehabilitation therapy. METHODS We conducted a longitudinal, observational study on 27 consecutive patients diagnosed with Achilles tendinosis, in whom conservative treatment, ie, physiotherapy or shock wave therapy, had failed. A 2% lidocaine paratenon anesthesia and hydrodissection was followed by ultrasound-guided, intratendinous injections of 25% glucose every 5 weeks. Visual analogue scales (VAS) were used for pain assessment at rest, for activities of daily living, and after moderate exercise at the begining and at the end of the treatment. Moreover, tendon thickness and vascularisation were recorded at baseline and final treatment consultation. Effectiveness was estimated from scoring and relative pain reduction using a 95% CI. The non-parametric Wilcoxon test and a general linear model for repeated measures were applied. Statistical significance was established as p < 0.05. RESULTS A median of 5 (1-11) injection consultations per patient were required. Pain scores decreased significantly in all three conditions (p < 0.001). Relative reductions were 75% in pain at rest (95% CI;61-93%), 69% in pain with daily living activities (95% CI; 55-83%), and 70% in pain after moderate exercise (95% CI; 57-84%). Tendon neo-vascularisation was significantly reduced (p < 0.001). We did not observe significant changes in tendon thickness (p = 0.083). CONCLUSIONS Achilles tendinosis treatment with paratenon lidocaine hydrodissection and subsequent prolotherapy with hyperosmolar glucose solution is safe, effective, inexpensive, and virtually painless with results maintained over time.
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Affiliation(s)
- A Bello Baez
- Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - M L Nieto Morales
- Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - P Mora Guanche
- Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - A Cavada Laza
- Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Lina Inmaculada Pérez Méndez
- Departamento de Epidemiología Clínica y Bioestadística, Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
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Tarantino D, Mottola R, Resta G, Gnasso R, Palermi S, Corrado B, Sirico F, Ruosi C, Aicale R. Achilles Tendinopathy Pathogenesis and Management: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6681. [PMID: 37681821 PMCID: PMC10487940 DOI: 10.3390/ijerph20176681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/09/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023]
Abstract
The Achilles tendon is the thickest and strongest tendon of the human body, and it is frequently injured during sports activity. The incidence of Achilles tendon pathologies has increased over recent decades, especially in the last few years, because of increased sports participation among the general population and due to the diffusion of competitive sports at a high level. Tendinopathies are common in athletes and in middle-aged overweight patients. The term "tendinopathy" refers to a condition characterised clinically by pain and swelling, with functional limitations of tendon and nearby structures, and consequently to chronic failure of healing response process. Tendinopathies can produce marked morbidity, and at present, scientifically validated management modalities are limited. Despite the constantly increasing interest and number of studies about Achilles tendinopathy (AT), there is still not a consensual point of view on which is the best treatment, and its management is still controversial. AT can be treated conservatively primarily, with acceptable results and clinical outcomes. When this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions with a relatively high rate of success with few complications and the decision for treatment in patients with AT should be tailored on patient's needs and level of activity. The aim of this article is to give insights about the pathogenesis and most used and recent treatment options for AT.
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Affiliation(s)
- Domiziano Tarantino
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Rosita Mottola
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Giuseppina Resta
- Department of Orthopaedic and Trauma Surgery, Casa di Cura di Bernardini, 74121 Taranto, Italy;
| | - Rossana Gnasso
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Stefano Palermi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Bruno Corrado
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Felice Sirico
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Carlo Ruosi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy;
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Dosal GC, Schroeder JD, Oh RC. Low-volume Hydrodissection for the Treatment of Chronic Achilles Tendinopathy. Mil Med 2023; 188:e3269-e3272. [PMID: 36515159 DOI: 10.1093/milmed/usac384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/03/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Chronic Achilles tendinopathy (AT) is a common ailment for many active duty service members that adversely affects readiness. Patients present with pain, swelling, and limited functional ability. Kager's fat pad is a mass of adipose tissue that protects the blood vessels supplying the Achilles tendon and preserves its function. A popular hypothesis is that scarring, tethering, and neovascularization play a significant role in the pathogenesis of AT. Current literature supports the effectiveness of high-volume (40-50 mL) hydrodissection, a procedure in which fluid is injected under ultrasound guidance into the tissues surrounding the Achilles tendon to mechanically separate the paratenon from the underlying Kager's fat pad. There may also be a beneficial effect of scar tissue and neoneurovascular breakdown. However, high-volume injections result in short-term discomfort and decreased mobility. Lowering injection volume (2-10 mL) may reduce this morbidity and facilitate use in limited-resource environments. This case report presents a 29-year-old active duty male with recalcitrant post-traumatic AT who achieved significant pain reduction and faster return to full service using low-volume hydrodissection. The use of 10 mL volume has not been described previously and provides additional support for using lower volumes in chronic AT. This technique is a direct adjunctive treatment option with rehabilitation at a military treatment facility or in the operational environment.
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Affiliation(s)
- Gerardo Capo Dosal
- Department of Family Medicine,Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Jeremy D Schroeder
- Department of Family Medicine,Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Robert C Oh
- Department of Education, US Department of Veterans Affairs,VA Puget Sound Health System, Seattle, WA 98108, USA
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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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Burke CJ, Walter WR, Adler RS. Interventional Imaging Techniques as Alternative to Surgery of the Foot and Ankle. Semin Musculoskelet Radiol 2022; 26:744-754. [PMID: 36791742 DOI: 10.1055/s-0042-1760120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
A variety of foot and ankle pathologies can impair patient's daily activities, ultimately requiring surgical management. However, with improvements in image-guided intervention, the joints, soft tissues, and osseous structures may be accessible using various percutaneous techniques as a potential alternative therapeutic tool, avoiding the need for surgery with its associated risks and morbidity. This article discusses the potential range of image-guided interventional treatments. Injections, aspiration, biopsies, cryoablation, and radiofrequency ablation are described. Newer novel treatments are also covered. Finally, the common pathologies of Morton's neuroma, Achilles tendinopathy, and plantar fasciitis are addressed.
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Affiliation(s)
- Christopher J Burke
- Department of Radiology, NYU Langone Orthopedic Center, Center for Musculoskeletal Care, New York, New York
| | - William R Walter
- Department of Radiology, NYU Langone Orthopedic Center, Center for Musculoskeletal Care, New York, New York
| | - Ronald S Adler
- Department of Radiology, NYU Langone Orthopedic Center, Center for Musculoskeletal Care, New York, New York
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Wu Z, Tu X, Tu Z. Hyperosmolar dextrose injection for Osgood-Schlatter disease: a double-blind, randomized controlled trial. Arch Orthop Trauma Surg 2022; 142:2279-2285. [PMID: 34673998 DOI: 10.1007/s00402-021-04223-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/11/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Osgood-Schlatter disease (OSD) is one of the common causes of long-term knee pain, leading to functional limitations, long-term deformity of the tubercle interfering with kneeling, and impaired peer-important sport participation. Nonetheless, patient management continues to rely on the usual conservative methods. This study examined the use of hyperosmolar dextrose injection in patients with OSD. METHODS We conducted a randomized, double-blind clinical trial involving 70 patients with OSD. One group received a hyperosmolar dextrose injection (12.5%), while the other received a saline injection. The injections were conducted under ultrasound guidance. The Victorian Institute of Sport Assessment (VISA) score was used to assess each patient's pain and sport level. RESULTS The dextrose group outperformed the saline group in improvement in the VISA-Patella (VISA-P) score from baseline to 3 months (27.1 ± 6.5 vs. 1.4 ± 2.6; mean difference 25.4 (22.4 to 28.3); p < .0001), 6 months (31.7 ± 7.9 vs. 25.2 ± 7.8; mean difference 6.2 (3.2 to 9.4); p < .0001), and 12 months (34 ± 9.0 vs. 28.2 ± 7.5; mean difference 5.5 (1.9 to 9.1); p = .0026). The changes in both groups were clinically important, suggesting that both therapies were active treatments. The dextrose group improved too rapidly for spontaneous improvement to explain much of this change. CONCLUSION After three injections, at the 6-month and 12-month follow-up visits, the VISA-P scores of the two groups were significantly improved; the dextrose group score was better than the saline group score, and there were significant differences between the two groups.
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Affiliation(s)
- Zhe Wu
- Department of Orthopedics, Fujian Provincial Corps Hospital of Chinese People's Armed Police Force, Fuzhou, China.
| | - Xiaoxian Tu
- Department of Medical Records Management Room, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhiyuan Tu
- Department of Orthopedics, Fujian Provincial Corps Hospital of Chinese People's Armed Police Force, No. 159 North Second Ring West Road, Fuzhou, China
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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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Bello Baez A, Nieto Morales M, Mora Guanche P, Cavada Laza A, Pérez Méndez LI. ¿Puede tratarse la tendinosis aquílea de forma eficaz con lidocaína e infiltraciones de glucosa y, de ser así, es duradero su efecto? Estudio observacional longitudinal en 27 pacientes consecutivos. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Achilles Tendon: Imaging Diagnoses and Image-Guided Interventions- AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 219:355-368. [PMID: 35506554 DOI: 10.2214/ajr.22.27632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Achilles tendon is commonly affected by both chronic repetitive overuse and traumatic injuries. Achilles tendon injuries can potentially affect any individual but have a particularly high incidence in professional athletes. Appropriate imaging evaluation and diagnosis are paramount to guiding appropriate management. In this AJR Expert Panel Narrative Review, we discuss the role of various imaging modalities (particularly ultrasound and MRI) in the assessment of Achilles tendon pathology, focusing on modalities' relative advantages and technical considerations. We describe the most common diagnoses affecting the Achilles tendon and adjacent structures, highlighting key imaging findings and providing representative examples. Various image-guided interventions that may be employed in the management of Achilles tendon pathology are also reviewed, including high-volume injection, tendon fenestration, prolotherapy, and corticosteroid injection. The limited evidence supporting such interventions are summarized, noting an overall paucity of large-scale studies showing benefit. Finally, a series of consensus statements by the panel on imaging and image-guided intervention for Achilles tendon pathology are provided.
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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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14
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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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15
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Abe R, Ohzono H, Gotoh M, Nakamura Y, Honda H, Nakamura H, Kume S, Okawa T, Shiba N. Neurotropin protects rotator cuff tendon cells from lidocaine-induced cell death. Clin Shoulder Elb 2021; 24:224-230. [PMID: 34875729 PMCID: PMC8651596 DOI: 10.5397/cise.2021.00360] [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: 06/04/2021] [Accepted: 08/04/2021] [Indexed: 12/04/2022] Open
Abstract
Background Local anesthetics often are used in rotator cuff tears as therapeutic tools, although some cases have reported that they have detrimental effects. Neurotropin (NTP) is used widely in Japan as a treatment for various chronic pain conditions and is shown to have protective effects on cartilage and nerve cells. In this study, we investigated the protective effect of NTP against lidocaine-induced cytotoxicity. Methods Tenocytes from rotator cuff tendons were incubated with lidocaine, NTP, lidocaine with NTP, and a control medium. Cell viability was evaluated using the WST-8 assay. Cell apoptosis was detected via annexin V staining using flow cytometry. The expression of BCL-2 and cytochrome c, which are involved in the intrinsic mitochondrial pathway of apoptosis, was evaluated via Western blotting and immunohistochemical staining. Results In the cell viability assay, lidocaine decreased cell viability in a dose-dependent manner, and NTP did not affect cell viability. Moreover, NTP significantly inhibited the cytotoxic effect of lidocaine. The flow cytometry analysis showed that lidocaine significantly induced apoptosis in tenocytes, and NTP considerably inhibited this lidocaine-induced apoptosis. Western blotting experiments showed that lidocaine decreased the protein expression of BCL-2, and that NTP conserved the expression of BCL-2, even when used with lidocaine. Immunohistochemical staining for cytochrome c showed that 0.1% lidocaine increased cytochrome c-positive cells, and NTP suppressed lidocaine-induced cytochrome c expression. Conclusions NTP suppresses lidocaine-induced apoptosis of tenocytes by inhibiting the mitochondrial apoptotic pathway. Intra-articular/ bursal injection of NTP with lidocaine could protect tenocytes in rotator cuff tendons against lidocaine-induced apoptosis.
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Affiliation(s)
- Ryunosuke Abe
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
| | - Hiroki Ohzono
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
| | - Masafumi Gotoh
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
| | - Yosuke Nakamura
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
| | - Hirokazu Honda
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
| | - Hidehiro Nakamura
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
| | - Shinichiro Kume
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
| | - Takahiro Okawa
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
| | - Naoto Shiba
- Department of Orthopedic Surgery, Kurume University Hospital, Fukuoka, Japan
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16
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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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17
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Nauwelaers AK, Van Oost L, Peers K. Evidence for the use of PRP in chronic midsubstance Achilles tendinopathy: A systematic review with meta-analysis. Foot Ankle Surg 2021; 27:486-495. [PMID: 32798020 DOI: 10.1016/j.fas.2020.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/14/2020] [Accepted: 07/25/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) injections have been proposed as an additional therapy in the treatment of chronic midsubstance Achilles tendinopathy (AT). The use of PRP injections as pharmacological treatment added to a conservative approach has gained growing interest, but the efficacy remains highly debated. The varying methodological quality of the available studies may contribute to these contradictory results. The aim of this systematic review with meta-analysis was to establish the existing evidence of PRP injections for chronic midsubstance AT on the functional outcome, with a risk of bias assessment of each included study. METHODS According to the PRISMA guidelines systematic searches were performed in Embase, the Cochrane library and Pubmed on June 12, 2020 for relevant literature. Only clinical trials comparing PRP injections with placebo, additional to an eccentric training program, in midsubstance AT were included. The primary outcome was Victorian Institute of Sport Assessment - Achilles (VISA-A) score at 3, 6 and 12 months post-injection. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (Rob 2). As secondary outcome we assessed reported changes in tendon structure after PRP injections. RESULTS A total of 367 studies were identified with the initial database search. Finally, four randomized controlled trials (RCTs) met inclusion criteria for systematic review and meta-analysis with data of 170 patients available for pooling. Results showed no difference in clinical outcome between the PRP and placebo group at different points in time using the VISA-A score as outcome parameter (3 months 0.23 (CI -0.45, 0.91); 6 months 0.83 (CI -0.26, 1.92); 12 months 0.83 (CI -0.77, 2.44)). The bias analysis showed a low or intermediate risk of bias profile for all studies which supports the good methodological quality of each included article. Finally, it is unclear whether PRP injections cause an improvement in tendon structure. However, no direct relationship between tendon structure and clinical presentation of AT could be found. CONCLUSION PRP has no clear additional value in management of chronic midsubstance Achilles tendinopathy and therefore should not be used as a first-line treatment option.
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Affiliation(s)
- An-Katrien Nauwelaers
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium
| | - Loïc Van Oost
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium.
| | - Koen Peers
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium
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18
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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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19
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Butt A, Umaskanth N, Sahu A. Image-guided intervention in the management of chronic patellar tendinopathy with calcification: a three-pronged approach. BMJ Case Rep 2021; 14:14/6/e240553. [PMID: 34116988 DOI: 10.1136/bcr-2020-240553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patellar tendinopathy is a common cause of knee pain and functional impairment in athletes. It is commonly managed using conservative measures such as physiotherapy, but cases that are refractory to such treatment may require a more invasive approach. Various forms of image-guided injection therapy have been described in the literature. We present a case of successful treatment of chronic patellar tendinopathy with calcification with the first reported use of a three-pronged image-guided approach, consisting of dry needling, high volume image-guided injection (but at a reduced dose) and barbotage applied in a single sitting. The patient reported resolution of symptoms persisting to 1 year postprocedure. We suggest that this management option, if supported by further positive research findings, could be used in the future in the management of certain cases of patellar tendinopathy with calcification where conservative measures have failed.
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Affiliation(s)
- Aqeel Butt
- Medicine, London North West University Healthcare NHS Trust, London, UK
| | - Neelan Umaskanth
- Medicine, London North West University Healthcare NHS Trust, London, UK
| | - Ajay Sahu
- Radiology, London North West University Healthcare NHS Trust, London, UK
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20
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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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21
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Nielsen TG, Miller LL, Mygind-Klavsen B, Lind M. High-volume image-guided injection in the chronic recalcitrant non-insertional patellar tendinopathy: a retrospective case series. J Exp Orthop 2020; 7:80. [PMID: 33037952 PMCID: PMC7547937 DOI: 10.1186/s40634-020-00299-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To evaluate if High-volume Image-guided Injection (HVIGI)-treatment for chronic Patellar tendinopathy (PT) improve function and reduce pain at 16-months follow-up. Methods Patients with resistant PT 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 at 16 months. A standardised Heavy Slow Resistance rehabilitation protocol was prescribed after HVIGI-treatment. Clinical outcome was assessed with the Victorian Institute of Sports Assessment-Patella tendon questionnaire (VISA-P) and statistically analyses were performed. Results The study included 28 single treatment HVIGI procedures in PT in 23 patients (19 men, 4 women) with a mean age of 30.3 (range 19–52). The mean duration of symptoms before HVIGI was 33 months. The baseline VISA-P score of 43 ± 17 (range 15–76) improved to 76 ± 16 (range 42–95) after 16 months (p < 0.01). Of the 28 HVIGI procedures 12 patients (15 PT) were not satisfied after the initial HVIGI procedure. Of these, 5 patients (5 PT) had additional HVIGI, 2 patients (2 PT) had corticoid injection and 6 patients (8 PT) needed surgery. Of the remaining 11 patients (13 PT), 9 patients had more than a 13-point improvement in the VISA-P score after 16 months. Conclusions In this retrospective case-study, only 9 patients (32%) did benefit of a single HVIGI treatment at 16-months and a 33-point significant improvement was seen on the VISA-P score.
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Affiliation(s)
- Torsten Grønbech Nielsen
- Aarhus University Hospital, Orthopedic Department, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Lene Lindberg Miller
- Aarhus University Hospital, Orthopedic Department, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Bjarne Mygind-Klavsen
- Aarhus University Hospital, Orthopedic Department, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Martin Lind
- Aarhus University Hospital, Orthopedic Department, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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22
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Aicale R, Oliviero A, Maffulli N. Management of Achilles and patellar tendinopathy: what we know, what we can do. J Foot Ankle Res 2020; 13:59. [PMID: 32993702 PMCID: PMC7523300 DOI: 10.1186/s13047-020-00418-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023] Open
Abstract
Tendinopathies are challenging conditions frequent in athletes and in middle-aged overweight patients with no history of increased physical activity. The term “tendinopathy” refers to a clinical condition characterised by pain, swelling, and functional limitations of tendons and nearby structures, the effect of chronic failure of healing response. Tendinopathies give rise to significant morbidity, and, at present, only limited scientifically proven management modalities exist. Achilles and patellar tendons are among the most vulnerable tendons, and among the most frequent lower extremity overuse injuries. Achilles and patellar tendinopathies can be managed primarily conservatively, obtaining good results and clinical outcomes, but, when this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions, and, if performed well, they lead to a relatively high rate of success with few complications. The purpose of this narrative review is to critically examine the recent available scientific literature to provide evidence-based opinions on these two common and troublesome conditions.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - Antonio Oliviero
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy. .,Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy. .,Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England. .,Institute of Science and Technology in Medicine, Keele University, School of Medicine, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, England.
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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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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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26
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Rabago D, Reeves KD, Topol GA, Podesta LA, Cheng AL, Fullerton BD. Infrapatellar bursal injection with dextrose and saline are both effective treatments for Osgood-Schlatter disease. Letter to editor for: No superiority of dextrose injections over placebo injections for Osgood-Schlatter disease: a prospective randomized double‑blind study https://doi.org/10.1007/s00402-019-03297-2. Arch Orthop Trauma Surg 2020; 140:591-592. [PMID: 31982926 DOI: 10.1007/s00402-020-03355-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Indexed: 11/24/2022]
Affiliation(s)
- David Rabago
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kenneth Dean Reeves
- Private Practice Physical Medicine and Rehabilitation, 4740 El Monte, Roeland Park, KS, 66205, USA.
| | - Gastón Andrés Topol
- Department of Physical Medicine and Rehabilitation, National University of Rosario, Rosario, Argentina
| | | | - An-Lin Cheng
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Bradley D Fullerton
- Department of Texas A&M, School of Medicine College Station, College Station, TX, USA
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Abstract
BACKGROUND Achilles Tendinopathy (AT) is essentially a failed healing response with haphazard proliferation of tenocytes, abnormalities in tenocytes with disruption of collagen fibers, and subsequent increase in non-collagenous matrix. METHODS The diagnosis of Achilles tendinopathy is clinical, and MRI and utrasound imaging can be useful in differential diagnosis. Conservative manegement, open surgery or minimally invasive techniques are available. Injections and physical therapy are also vauable options. RESULTS Eccentric exercises are useful tools to manage the pathology. If the condition does not ameliorate, shock wave therapy, or nitric oxide patches might be considered. Peritendinous injections or injections at the interface between the Achilles tendon and Kager's triangle could be considered if physical therapy should fail. Surgery is indicated after 6 months of non-operative management. CONCLUSIONS The clinical diagnosis and management of AT are not straightforward. Hence, patients should understand that symptoms may recur with either conservative or surgical approaches.
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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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Abstract
Use of orthobiologics in sports medicine and musculoskeletal surgery has gained significant interest. However, many of the commercially available and advertised products are lacking in clinical evidence. Widespread use of products before fully understanding their true indications may result in unknown adverse outcomes and may also lead to increased health care costs. As more products become available, it is important to remain judicial in use and to practice evidence-based medicine. Likewise, it is important to continue advances in research in hopes to improve surgical outcomes. This article reviews clinical evidence behind common orthobiologics in the treatment of foot and ankle pathology.
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30
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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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Ferguson A, Christophersen C, Elattar O, Farber DC. Achilles Tendinopathy and Associated Disorders. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419838294. [PMID: 35097320 PMCID: PMC8696945 DOI: 10.1177/2473011419838294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Degenerative disorders of the Achilles tendon are common, affecting up to 18% of the adult population. A thorough evaluation including a focused history, physical examination, and diagnostic studies helps in choosing the appropriate treatment. Initial treatment is usually nonoperative, consisting of activity modification, bracing, and physical therapy. Patents who fail nonoperative management may be treated operatively with a wide range of procedures from endoscopic surgery to open debridement and tendon transfer. Understanding a patient’s expectations and educating patients about potential treatments and their outcomes enables informed collaborative decision making. This article will review the evaluation and management Achilles tendinopathy and associated disorders.
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Affiliation(s)
- Adam Ferguson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Osama Elattar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel C. Farber
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Although the incidence of midportion Achilles tendinopathy is under 1% in the general population, it is quite a common disease in runners that is characterized by the symptom triad of pain, swelling and impaired physical performance. Pain and swelling are located in the area 2 to 7 cm proximal the tendon insertion onto the calcaneus.Diagnosis is made by adequate clinical symptoms and corresponding findings in sonography and/or magnetic resonance imaging scans. Histopathologically, mostly degenerative changes in the tendon structure are found, sometimes accompanied by intra- and paratendinous inflammation.Treatment options are conservative or surgical, but conservative ones should be tried first. The best evidence is available for eccentric exercise protocols, which represent the gold standard in conservative treatment options, followed by extracorporal shockwave (ECSW) therapy and corticoid injections.In about 25% of all cases, because of unsatisfactory nonoperative treatment results, surgery is recommended. Open, minimally invasive as well as tenoscopic methods exist, which show patients' satisfactory rates of about 80%. The return to sport or full physical performance is variable and may take up to 18 months for both treatment regimens.
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Aicale R, Tarantino D, Maffulli N. Overuse injuries in sport: a comprehensive overview. J Orthop Surg Res 2018; 13:309. [PMID: 30518382 PMCID: PMC6282309 DOI: 10.1186/s13018-018-1017-5] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/21/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The absence of a single, identifiable traumatic cause has been traditionally used as a definition for a causative factor of overuse injury. Excessive loading, insufficient recovery, and underpreparedness can increase injury risk by exposing athletes to relatively large changes in load. The musculoskeletal system, if subjected to excessive stress, can suffer from various types of overuse injuries which may affect the bone, muscles, tendons, and ligaments. METHODS We performed a search (up to March 2018) in the PubMed and Scopus electronic databases to identify the available scientific articles about the pathophysiology and the incidence of overuse sport injuries. For the purposes of our review, we used several combinations of the following keywords: overuse, injury, tendon, tendinopathy, stress fracture, stress reaction, and juvenile osteochondritis dissecans. RESULTS Overuse tendinopathy induces in the tendon pain and swelling with associated decreased tolerance to exercise and various types of tendon degeneration. Poor training technique and a variety of risk factors may predispose athletes to stress reactions that may be interpreted as possible precursors of stress fractures. A frequent cause of pain in adolescents is juvenile osteochondritis dissecans (JOCD), which is characterized by delamination and localized necrosis of the subchondral bone, with or without the involvement of articular cartilage. The purpose of this compressive review is to give an overview of overuse injuries in sport by describing the theoretical foundations of these conditions that may predispose to the development of tendinopathy, stress fractures, stress reactions, and juvenile osteochondritis dissecans and the implication that these pathologies may have in their management. CONCLUSIONS Further research is required to improve our knowledge on tendon and bone healing, enabling specific treatment strategies to be developed for the management of overuse injuries.
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Affiliation(s)
- R. Aicale
- Department of Musculoskeletal Disorders, School of Medicine and Dentistry, University of Salerno, Salerno, Italy
| | - D. Tarantino
- Department of Musculoskeletal Disorders, School of Medicine and Dentistry, University of Salerno, Salerno, Italy
| | - N. Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Dentistry, University of Salerno, Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG England
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Image guided injection therapies in athletes-Do they work and what should we be using? Eur J Radiol 2018; 110:193-202. [PMID: 30599860 DOI: 10.1016/j.ejrad.2018.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 12/01/2018] [Indexed: 12/18/2022]
Abstract
In the modern management of the injured elite athlete, the goals of guided injection therapies have extended beyond simple reduction of pain to enhancement of tissue healing and accelerated return to competition, faster than natural healing can allow. This article will review the injection therapies which are frequently used in elite sports injury management and describe other less commonly used injection therapies that are available to the treating clinician and athlete. The evidence base, where available, for each treatment option will be summarised.
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35
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Ultrasound guided injection in patellar tendinopathy; clinical outcomes of platelet-rich plasma compared to high-volume injection. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2018.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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37
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Abstract
Achilles tendinopathy is a common cause of disability. Despite the economic and social relevance of the problem, the causes and mechanisms of Achilles tendinopathy remain unclear. Tendon vascularity, gastrocnemius-soleus dysfunction, age, sex, body weight and height, pes cavus, and lateral ankle instability are considered common intrinsic factors. The essence of Achilles tendinopathy is a failed healing response, with haphazard proliferation of tenocytes, some evidence of degeneration in tendon cells and disruption of collagen fibers, and subsequent increase in noncollagenous matrix. Tendinopathic tendons have an increased rate of matrix remodeling, leading to a mechanically less stable tendon which is more susceptible to damage. The diagnosis of Achilles tendinopathy is mainly based on a careful history and detailed clinical examination. The latter remains the best diagnostic tool. Over the past few years, various new therapeutic options have been proposed for the management of Achilles tendinopathy. Despite the morbidity associated with Achilles tendinopathy, many of the therapeutic options described and in common use are far from scientifically based. New minimally invasive techniques of stripping of neovessels from the Kager's triangle of the tendo Achillis have been described, and seem to allow faster recovery and accelerated return to sports, rather than open surgery. A genetic component has been implicated in tendinopathies of the Achilles tendon, but these studies are still at their infancy.
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38
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Zhang YJ, Xu SZ, Gu PC, Du JY, Cai YZ, Zhang C, Lin XJ. Is Platelet-rich Plasma Injection Effective for Chronic Achilles Tendinopathy? A Meta-analysis. Clin Orthop Relat Res 2018; 476:1633-1641. [PMID: 29601383 PMCID: PMC6259774 DOI: 10.1007/s11999.0000000000000258] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Chronic Achilles tendinopathy is common in the general population, and platelet-rich plasma (PRP) is seeing increased use to treat this problem. However, studies disagree as to whether PRP confers a beneficial effect for chronic Achilles tendinopathy, and no one to our knowledge has pooled the available randomized trials in a formal meta-analysis to try to reconcile those differences. QUESTIONS/PURPOSES In the setting of a systematic review and meta-analysis of randomized controlled trials (RCTs), we asked: Does PRP plus eccentric strength training result in (1) greater improvements in Victorian Institute of Sports Assessment-Achilles (VISA-A) scores; (2) differences in tendon thickness; or (3) differences in color Doppler activity compared with placebo (saline) injections plus eccentric strength training in patients with chronic Achilles tendinopathy? METHODS A search of peer-reviewed articles was conducted to identify all RCTs using PRP injection with eccentric training for chronic Achilles tendinopathy in the electronic databases of PubMed, Web of Science (SCI-E/SSCI/A&HCI), and EMBASE from January 1981 to August 2017. Results were limited to human RCTs and published in all languages. Two reviewers assessed study quality using the Cochrane Collaboration risk-of-bias tool. All the included studies had low risk of bias. The primary endpoint was improvement in the VISA-A score, which ranges from 0 to 100 points, with higher scores representing increased activity and less pain; we considered the minimum clinically important difference on the VISA-A to be 12 points. Secondary outcomes were tendon thickness change (with a thicker tendon representing more severe disease), color Doppler activity (with more activity representing a poorer result), and other functional measures (such as pain and return to sports activity). Four RCTs involving 170 participants were eligible and included 85 participants treated with PRP injection and eccentric training and 85 treated with saline injection and eccentric training. The patients in both PRP and placebo (saline) groups seemed comparable at baseline. We assessed for publication bias using a funnel plot and saw no evidence of publication bias. Based on previous studies, we had 80% power to detect a 12-point difference on the VISA-A score with the available sample size in each group. RESULTS With the numbers available, there was no difference between the PRP and saline groups regarding the primary outcome (VISA-A score: mean difference [MD], 5.3; 95% confidence interval [CI], -0.7 to 11.3; p = 0.085). Likewise, we found no difference between the PRP and saline groups in terms of our secondary outcomes of tendon thickness change (MD, 0.2 mm; 95% CI, 0.6-1.0 mm; p = 0.663) and color Doppler activity (MD, 0.1; 95% CI, -0.7 to 0.4; p = 0.695). CONCLUSIONS PRP injection with eccentric training did not improve VISA-A scores, reduce tendon thickness, or reduce color Doppler activity in patients with chronic Achilles tendinopathy compared with saline injection. Larger randomized trials are needed to confirm these results, but until or unless a clear benefit has been demonstrated in favor of the new treatment, we cannot recommend it for general use. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Yi-Jun Zhang
- Yi-Jun Zhang, San-Zhong Xu, Peng-Cheng Gu, Jing-Yu Du, You-Zhi Cai, Chi Zhang, Xiang-Jin Lin, Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
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39
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Gerdesmeyer L, Saxena A, Klueter T, Harrasser N, Fullem B, Krath A. Electromagnetic Transduction Therapy for Achilles Tendinopathy: A Preliminary Report on a New Technology. J Foot Ankle Surg 2018; 56:964-967. [PMID: 28842106 DOI: 10.1053/j.jfas.2017.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 02/03/2023]
Abstract
A parallel prospective feasibility study was performed on 53 patients with chronic mid-portion Achilles tendinopathy (age 44.7 ± 9.1 years). Of the 53 patients, 28 (active group) were treated using a new electromagnetic (pulsed electromagnetic field) transduction therapy device (Cellactor® MT1) and heel cushions. The device produces an electromagnetic field of 80 milliTesla; a total of 8 treatments was performed within 4 weeks in an outpatient setting, without anesthesia, immobilization, or rest. A control group of 25 patients with a similar duration of symptoms was treated with heel cushions only. At the 12-week assessment point, the visual analog scale scores in both groups had significantly decreased, although the active group had significantly improved visual analog scale scores compared with those of the controls. The Role-Maudsley scores had also significantly improved in both the active and the control groups (p < .00001 and p = .0002, respectively). Electromagnetic transduction therapy could potentially be a useful modality for the treatment of Achilles tendinopathy. It should be compared with the current reference standard of extracorporeal shockwave therapy/radial soundwave therapy with similar level I, II, and III studies.
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Affiliation(s)
- Ludger Gerdesmeyer
- Professor and Orthopedist, Department of Orthopaedic Surgery and Traumatology, University Schleswig Holstein, Campus Kiel, Kiel, Germany; Professor and Orthopedist, Department of Orthopaedic and Traumatology, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Amol Saxena
- Podiatrist, Department of Sports Medicine, Palo Alto Foundation Medical Group, Palo Alto, CA.
| | - Tim Klueter
- Orthopedist, Department of Orthopaedic Surgery and Traumatology, University Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Norbert Harrasser
- Professor and Orthopedist, Department of Orthopaedic and Traumatology, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Brian Fullem
- Podiatrist, Elite Sports Podiatry, Clearwater, FL
| | - Andre Krath
- Professor and Orthopedist, Department of Orthopaedic Surgery and Traumatology, University Schleswig Holstein, Campus Kiel, Kiel, Germany
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40
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Saxena A, Hong BK, Hofer D. Peritenolysis and Debridement for Main Body (Mid-Portion) Achilles Tendinopathy in Athletic Patients: Results of 107 Procedures. J Foot Ankle Surg 2018; 56:922-928. [PMID: 28579127 DOI: 10.1053/j.jfas.2017.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Indexed: 02/03/2023]
Abstract
Achilles tendinopathy in the main body (mid-portion) of the tendon is a common pathologic finding among active and athletic populations and can be debilitating without proper and adequate treatment. Numerous surgical approaches for this common pathologic finding have been reported, with variable outcomes. We evaluated the surgical outcomes of peritenolysis and debridement of main body Achilles tendinopathy among athletic populations using the return to activity (RTA) and decreased desired activity (DDA) as our primary outcome measures. A total of 100 patients underwent 107 procedures by the senior author (A.S.) from January 2001 through December 2015 met the inclusion criteria, 65 (65%) of whom were runners. The mean follow-up duration was 106.6 ± 55.5 months from the index procedure, and the mean interval necessary to RTA for the entire group was 10.9 ± 5.3 weeks. The average RTA after debridement was 14.1 ± 5.2 weeks and after peritenolysis was 7.3 ± 2.0 weeks (p = .00001). Of the 100 patients, 3 (3%) had experienced a DDA at the last follow-up visit. With >97% of the patients able to return to their desired activities, we have concluded that peritenolysis and debridement are favorable surgical techniques for main body Achilles tendinopathy.
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Affiliation(s)
- Amol Saxena
- Fellowship Director, Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA.
| | - Brian K Hong
- Fellow, Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA
| | - Deann Hofer
- Fellow, Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA
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41
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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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42
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Watson J, Barker-Davies RM, Bennett AN, Fong DTP, Wheeler PC, Lewis M, Ranson C. Sport and exercise medicine consultants are reliable in assessing tendon neovascularity using ultrasound Doppler. BMJ Open Sport Exerc Med 2018; 4:e000298. [PMID: 29527321 PMCID: PMC5841524 DOI: 10.1136/bmjsem-2017-000298] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Several lower limb tendinopathy treatment modalities involve identification of pathological paratendinous or intratendinous neovascularisation to target proposed co-location of painful neoneuralisation. The ability to reliably locate and assess the degree of neovascularity is therefore clinically important. The Modified Ohberg Score (MOS) is frequently used to determine degree of neovascularity, but reliability has yet to be established among Sport and Exercise Medicine (SEM) consultants. This study aims to determine inter-rater and intra-rater reliability of an SEM consultant cohort when assessing neovascularity using the 5-point MOS. METHOD Eleven participants (7 male and 4 female) provided 16 symptomatic Achilles and patella tendons. These were sequentially examined using power Doppler (PD) enabled ultrasound (US) imaging by 6 SEM consultants who rated neovascular changes seen using the MOS. Representative digital scan images were saved for rescoring 3 weeks later. Inter-rater and intra-rater reliability of the MOS was examined using intraclass correlation coefficient (ICC) and Kappa Agreement scores. RESULTS Neovascular changes were reported in 65.6% of 96 scans undertaken. ICC for inter-rater reliability was 0.86 and Fleiss Kappa 0.52. ICC for intra-rater reliability was 0.95 and Weighted Kappa 0.91. CONCLUSIONS Neovascular changes were present in two-thirds of symptomatic tendons. Excellent SEM consultant inter-rater and intra-rater reliability was demonstrated. These findings support the use of PD-enabled US to assess neovascularity by appropriately experienced SEM consultants. Furthermore, future interventional research using a similarly experienced SEM consultant cohort can be undertaken with assurance that assessment of neovascularity will be reliable.
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Affiliation(s)
- James Watson
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, London, UK
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK
| | - Robert M Barker-Davies
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, London, UK
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, London, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, London, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
| | - Daniel T P Fong
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, London, UK
| | - Patrick C Wheeler
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, London, UK
| | - Mark Lewis
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, London, UK
| | - Craig Ranson
- Athlete Health Department, English Institute of Sport, Manchester, UK
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43
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Abstract
This article is a comprehensive review of the current utilizations of ultrasound in the treatment of orthopedic conditions of the foot and ankle. It reviews the diagnostic and interventional applications to commonly encountered lower-extremity ailments, including plantar fasciosis, tendinosis, and peripheral nerve disorders. It also outlines minimally invasive ultrasound-guided procedures and emerging therapies as alternatives to current treatments. These emerging therapies can be used to assist surgeons and provide options for patients needing intervention. Techniques such as hydrodissection, injection, aspiration, tenotomy, and fasciotomy are discussed, giving readers insight into different treatment modalities and options to help manage their patients.
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Affiliation(s)
- Nahum Michael Beard
- Department of Family Medicine, University of Tennessee Health Science Center, Saint Francis Family Medicine, 1301 Primacy Parkway, Memphis, TN 38119, USA; Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue Suite 520, Memphis, TN 38104.
| | - Robert Patrick Gousse
- Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue Suite 520, Memphis, TN 38104
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44
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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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45
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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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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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Chan O, Havard B, Morton S, Pritchard M, Maffulli N, Crisp T, Padhiar N, Perry JD, King J, Morrissey D. Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series. Muscles Ligaments Tendons J 2017; 7:78-87. [PMID: 28717615 DOI: 10.11138/mltj/2017.7.1.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The intra-tendinous tear is a new pathology that is defined as a discontinuity of fibres situated entirely within the tendon. Prolotherapy involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain. METHODS 43 consecutive patients diagnosed with an intra-tendinous tear were included (27 males: 16 females, mean (SD) age 41 (11.3). Patients were injected with 0.4ml-1.5ml (mean 0.8ml) of 50% dextrose and 0.5% marcaine mixed in a 1:1 ratio. A 4-6 week period of walking boot immobilisation was followed by progressive rehabilitation (6-8 weeks). Outcomes were assessed with a VISA-A questionnaire at baseline, 3 months and a mean 12.6 (7.0) months post-treatment. Ultrasound scans were conducted before treatment and 5.2 (2.3) weeks later to assess sonographic changes. RESULTS 30 patients (70%) responded with VISA-A scores increasing by 31 (30.5) points after 3 months (f=0.62, p<0.05) and by 40 (29.3) points after 12.60 (7.0) months (f=0.87, p<0.05). After 5.2 (2.3) weeks, echogenicity was significantly reduced (p<0.05) and 27% of tears were no longer detectable. No significant differences were observed in remaining tears with respect to tear size, tendon thickness or neovascularisation. CONCLUSION Treatment resulted in clinically significant improvements and controlled trials are warranted. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Otto Chan
- BMI London Independent Hospital, Stepney Green, London, UK
| | - Ben Havard
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Sarah Morton
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Mel Pritchard
- BMI London Independent Hospital, Stepney Green, London, UK
| | | | - Tom Crisp
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Nat Padhiar
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Jeremy David Perry
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - John King
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Dylan Morrissey
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK.,Bart's Health NHS Trust, London, UK
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48
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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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49
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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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Abstract
Non-insertional Achilles tendinopathy is a degenerative condition characterised by pain on activity.Eccentric stretching is the most effective treatment.Surgical treatment is reserved for recalcitrant cases.Minimally-invasive and tendinoscopic treatments are showing promising results. Cite this article: Pearce CJ, Tan A. Non-insertional Achilles tendinopathy. EFORT Open Rev 2016;1:383-390. DOI: 10.1302/2058-5241.1.160024.
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Affiliation(s)
| | - Audrey Tan
- Jurong Health Services Pte Ltd, Singapore
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