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Pasurka M, Falck T, Kubach J, Simon M, Söllner S, Strobel D, Perl M, Betsch M. Comparison of In Vivo Stiffness of Tendons Commonly Used for Anterior Cruciate Ligament Reconstruction - A Shear Wave Elastography Study. Acad Radiol 2024:S1076-6332(24)00060-6. [PMID: 38378326 DOI: 10.1016/j.acra.2024.01.037] [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: 01/08/2024] [Revised: 01/25/2024] [Accepted: 01/27/2024] [Indexed: 02/22/2024]
Abstract
RATIONALE AND OBJECTIVES There are currently no studies investigating the in vivo stiffness of the most commonly used autografts for anterior cruciate ligament reconstruction (ACLR) using Shear wave elastography (SWE). We hypothesize that there are differences regarding the elastic properties between the three tendons commonly used for ACLR and that they are influenced by patient-related factors. MATERIALS AND METHODS 80 healthy subjects (25 females, 55 males, age: 25.33 ± 4.76 years, BMI: 23.76 ± 3.14 kg/m2, 40 semiprofessional athletes, athlete group [AG], age: 25.51 [19-29]; 40 healthy controls, control group [CG], age: 25.50 [20-29]) were recruited as participants. In addition to patient reported outcome scores, every participant underwent a standardized multimodal ultrasound protocol consisting of B-mode-ultrasound (B-US), Color Doppler-ultrasound (CD-US) and a SWE examination of the bilateral quadriceps tendon (QT), patellar tendon (PT) and semitendinosus tendon (ST). RESULTS The highest shear wave velocity (SWV) were observed in ST (4.88 (4.35-5.52) m/s, ST vs QT, p = 0.005; ST vs PT, p < 0.001) followed by QT (4.61 (4.13-5.26) m/s, QT vs PT, p < 0.001) and PT (3.73 (3.30-4.68) m/s). Median QT, PT and ST stiffness was significantly higher in AG compared to CG. Male subjects tend to have stiffer QT and PT than female subjects. Positive correlation with SWV was obtained for age and activity level. CONCLUSION There are significant differences regarding in vivo tendon stiffness between the most frequently used autograft tendon options for ACLR. The quantitative information obtained by SWE could be of particular interest for graft choice for ACLR.
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Affiliation(s)
- Mario Pasurka
- Department of Orthopaedics and Trauma Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany.
| | - Theo Falck
- Department of Orthopaedics and Trauma Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Joshua Kubach
- Department of Orthopaedics and Trauma Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Michael Simon
- Department of Orthopaedics and Trauma Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Stefan Söllner
- Department of Orthopaedics and Trauma Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Deike Strobel
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany
| | - Mario Perl
- Department of Orthopaedics and Trauma Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Marcel Betsch
- Department of Orthopaedics and Trauma Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
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Vidal L, Lopez-Garzon M, Venegas V, Vila I, Domínguez D, Rodas G, Marotta M. A Novel Tendon Injury Model, Induced by Collagenase Administration Combined with a Thermo-Responsive Hydrogel in Rats, Reproduces the Pathogenesis of Human Degenerative Tendinopathy. Int J Mol Sci 2024; 25:1868. [PMID: 38339145 PMCID: PMC10855568 DOI: 10.3390/ijms25031868] [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: 12/22/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Patellar tendinopathy is a common clinical problem, but its underlying pathophysiology remains poorly understood, primarily due to the absence of a representative experimental model. The most widely used method to generate such a model is collagenase injection, although this method possesses limitations. We developed an optimized rat model of patellar tendinopathy via the ultrasound-guided injection of collagenase mixed with a thermo-responsive Pluronic hydrogel into the patellar tendon of sixty male Wistar rats. All analyses were carried out at 3, 7, 14, 30, and 60 days post-injury. We confirmed that our rat model reproduced the pathophysiology observed in human patients through analyses of ultrasonography, histology, immunofluorescence, and biomechanical parameters. Tendons that were injured by the injection of the collagenase-Pluronic mixture exhibited a significant increase in the cross-sectional area (p < 0.01), a high degree of tissue disorganization and hypercellularity, significantly strong neovascularization (p < 0.01), important changes in the levels of types I and III collagen expression, and the organization and presence of intra-tendinous calcifications. Decreases in the maximum rupture force and stiffness were also observed. These results demonstrate that our model replicates the key features observed in human patellar tendinopathy. Collagenase is evenly distributed, as the Pluronic hydrogel prevents its leakage and thus, damage to surrounding tissues. Therefore, this model is valuable for testing new treatments for patellar tendinopathy.
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Affiliation(s)
- Laura Vidal
- Leitat Technological Center, Carrer de la Innovació 2, 08225 Terrassa, Spain
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations Laboratory, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona (UAB), 08035 Barcelona, Spain
| | - Maria Lopez-Garzon
- Leitat Technological Center, Carrer de la Innovació 2, 08225 Terrassa, Spain
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations Laboratory, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona (UAB), 08035 Barcelona, Spain
| | - Vanesa Venegas
- Leitat Technological Center, Carrer de la Innovació 2, 08225 Terrassa, Spain
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations Laboratory, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona (UAB), 08035 Barcelona, Spain
| | - Ingrid Vila
- Leitat Technological Center, Carrer de la Innovació 2, 08225 Terrassa, Spain
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations Laboratory, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona (UAB), 08035 Barcelona, Spain
| | - David Domínguez
- Medical Department of Futbol Club Barcelona (FIFA Medical Center of Excellence) and Barça Innovation, 08970 Sant Joan Despí, Spain
| | - Gil Rodas
- Leitat Technological Center, Carrer de la Innovació 2, 08225 Terrassa, Spain
- Medical Department of Futbol Club Barcelona (FIFA Medical Center of Excellence) and Barça Innovation, 08970 Sant Joan Despí, Spain
- Sports Medicine Unit, Hospital Clínic and Sant Joan de Déu, 08950 Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, 08007 Barcelona, Spain
| | - Mario Marotta
- Leitat Technological Center, Carrer de la Innovació 2, 08225 Terrassa, Spain
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations Laboratory, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona (UAB), 08035 Barcelona, Spain
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Burk J, Wittenberg-Voges L, Schubert S, Horstmeier C, Brehm W, Geburek F. Treatment of Naturally Occurring Tendon Disease with Allogeneic Multipotent Mesenchymal Stromal Cells: A Randomized, Controlled, Triple-Blinded Pilot Study in Horses. Cells 2023; 12:2513. [PMID: 37947591 PMCID: PMC10650642 DOI: 10.3390/cells12212513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/13/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023] Open
Abstract
The treatment of tendinopathies with multipotent mesenchymal stromal cells (MSCs) is a promising option in equine and human medicine. However, conclusive clinical evidence is lacking. The purpose of this study was to gain insight into clinical treatment efficacy and to identify suitable outcome measures for larger clinical studies. Fifteen horses with early naturally occurring tendon disease were assigned to intralesional treatment with allogeneic adipose-derived MSCs suspended in serum or with serum alone through block randomization (dosage adapted to lesion size). Clinicians and horse owners remained blinded to the treatment during 12 months (seven horses per group) and 18 months (seven MSC-group and five control-group horses) of follow-up including clinical examinations and diagnostic imaging. Clinical inflammation, lameness, and ultrasonography scores improved more over time in the MSC group. The lameness score difference significantly improved in the MSC group compared with the control group after 6 months. In the MSC group, five out of the seven horses were free of re-injuries and back to training until 12 and 18 months. In the control group, three out of the seven horses were free of re-injuries until 12 months. These results suggest that MSCs are effective for the treatment of early-phase tendon disease and provide a basis for a larger controlled study.
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Affiliation(s)
- Janina Burk
- Institute of Physiology, Pathophysiology and Biophysics, University of Veterinary Medicine Vienna, Veterinaerplatz 1, 1210 Vienna, Austria
| | - Liza Wittenberg-Voges
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559 Hannover, Germany;
| | - Susanna Schubert
- Institute of Human Genetics, University of Leipzig Medical Center, Philipp-Rosenthal-Strasse 55, 04103 Leipzig, Germany;
| | - Carolin Horstmeier
- Department for Horses, Veterinary Teaching Hospital, University of Leipzig, An den Tierkliniken 21, 04103 Leipzig, Germany; (C.H.); (W.B.)
| | - Walter Brehm
- Department for Horses, Veterinary Teaching Hospital, University of Leipzig, An den Tierkliniken 21, 04103 Leipzig, Germany; (C.H.); (W.B.)
| | - Florian Geburek
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559 Hannover, Germany;
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4
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Li H, Yao W, Xue X, Li Y, Hua Y. Therapeutic effects following extracorporeal shock wave therapy for insertional and non-insertional Achilles tendinopathy. Asia Pac J Sports Med Arthrosc Rehabil Technol 2023; 34:38-45. [PMID: 37860635 PMCID: PMC10582256 DOI: 10.1016/j.asmart.2023.09.001] [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: 03/15/2023] [Revised: 08/14/2023] [Accepted: 09/02/2023] [Indexed: 10/21/2023] Open
Abstract
Background The treatment for Achilles tendinopathy varies widely, and there is no consensus regarding the optimal treatment for both non-insertional and insertional Achilles tendinopathy. The purpose of this study was to evaluate the clinical efficacy of extracorporeal shock wave therapy (ESWT) in the treatment of insertional and non-insertional Achilles tendinopathy (AT). Methods Sixty patients with AT were invited to participate in this study. Patients were allocated to one of two groups according to the site of the AT, including an insertional AT (IAT) group and a non-insertional AT (NIAT) group. ESWT was performed once a week for five weeks for both groups. The Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) score and the visual analog scale (VAS) were used five times to evaluate the clinical outcomes, including before treatment, immediately after treatment, as well as one month, three months, and five years after treatment. Results At three months after treatment, the IAT group exhibited a significantly higher VISA-A score (82 ± 6 vs. 76 ± 11; p = 0.01) and a significantly lower VAS score (1 ± 1 vs. 2 ± 1; p < 0.001) when compared with the NIAT group. At the five-year assessment, the IAT group (1 ± 1) had a significantly lower VAS score than the NIAT group (2 ± 1) (p = 0.02), while no significant difference for the VISA-A score was observed between the groups (84 ± 8 vs. 84 ± 10; p = 0.98). Conclusions Extracorporeal shock wave treatment can improve the symptoms of both insertional and non-insertional AT. The IAT patients experienced better clinical outcomes compared with the NIAT patients.
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Affiliation(s)
| | | | | | - Yunxia Li
- Corresponding author. No 12, Wulumuqi Zhong Road, Shanghai, 200040, China.
| | - Yinghui Hua
- Corresponding author. No 12, Wulumuqi Zhong Road, Shanghai, 200040, China.
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5
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Lagas IF, Tol JL, Weir A, de Jonge S, van Veldhoven PLJ, Bierma-Zeinstra SMA, Verhaar JAN, de Vos RJ. One fifth of patients with Achilles tendinopathy have symptoms after 10 years: A prospective cohort study. J Sports Sci 2023; 40:2475-2483. [PMID: 36617848 DOI: 10.1080/02640414.2022.2163537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients with midportion Achilles tendinopathy (AT) are thought to experience a gradual symptomatic improvement over time. The aim of this study was to prospectively investigate if patients with midportion AT have symptoms at 10-year follow-up. Patients withmidportion AT were invited to complete an online questionnaire 10 years after inclusion in an intervention trial. The primary outcomewas the presence of AT symptoms. Secondary outcomes were: the Victorian Institute of Sports Assessment-Achilles tendinopathy (VISA-A, 0-100) score and sports activity level. Of the 54 patientsincluded, 43 (80%) completed the questionnaire at an average follow-up of 10.4 years. Persisting symptoms were reported by 19%. The mean (standard deviation-SD) VISA-A score improved from 52 (17) at baseline to 79 (21) at 10-years follow-up with a mean change of 27 points (95% confidence interval: 21; 35, p < 0.001). Of the 38 active patients, 16 (42%) returned to their pre-injury level sports,of whom 14 (37%) performed them pain free. One-fifth of patients with conservatively treated midportion AT still have symptoms after 10years. One-third of patients were able to perform sports pain-free atpre-injury level. Patients should be adequately counselled to giverealistic expectations. Trial registration number: clinicaltrials.gov (identifier: NCT00761423).
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Affiliation(s)
- Iris F Lagas
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johannes L Tol
- Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,Amsterdam University Medical Center, Academic Medical Center, Amsterdam Movement Sciences, Academic Center for Evidence-based Sports Medicine (ACES), Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
| | - Adam Weir
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,Sports Medicine and Exercise Clinic Haarlem (SBK), IJsbaanlaan 4B, 2024 AV Haarlem, The Netherlands
| | - Suzan de Jonge
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Sita M A Bierma-Zeinstra
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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6
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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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Qiu XR, Wang MT, Huang H, Kuo LC, Hsu HY, Yang TH, Su FC, Huang CC. Estimating the neovascularity of human finger tendon through high frequency ultrasound micro-Doppler imaging. IEEE Trans Biomed Eng 2022; 69:2667-2678. [PMID: 35192458 DOI: 10.1109/tbme.2022.3152151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Neovascularization of injured tendons prolongs the proliferative phase of healing, but prolonged neovascularization may cause improper healing and pain. Currently, ultrasound Doppler imaging is used for measuring the neovascularization of injured tendons (e.g., Achilles tendon). However, the resolution of state-of-the-art clinical ultrasound machines is insufficient for visualizing the neovascularization in finger tendons. In this study, a high-resolution micro-Doppler imaging (HFDI) based on 40-MHz ultrafast ultrasound imaging was proposed for visualizing the neovascularization in injured finger tendons during multiple rehabilitation phases. METHOD The vessel visibility was enhanced through a block-wise singular value decomposition filter and several curvilinear structure enhancement strategies, including the bowler-hat transform and Hessian-based vessel enhancement filtering. HFDI was verified through small animal kidney and spleen imaging because the related vessel structure patterns of mice are well studied. Five patients with finger tendon injuries underwent HFDI examination at various rehabilitation phases after surgery (weeks 1156), and finger function evaluations were performed for comparisons. RESULTS The results of small animal experiments revealed that the proposed HFDI provides excellent microvasculature imaging performance; the contrast-to-noise ratio of HFDI was approximately 15 dB higher than that of the conventional singular value decomposition filter, and the minimum detectable vessel size for mouse kidney was 35 m without the use of contrast agent. In the human study, neovascularization was clearly observed in injured finger tendons during the early phase of healing (weeks 1121), but it regressed from week 52 to 56. Finger rehabilitation appears to help reduce neovascularization; neovascular density decreased by approximately 1.8%8.0% in participants after 4 weeks of rehabilitation. CONCLUSION The experimental results verified the performance of HFDI for microvasculature imaging and its potential for injured finger tendon evaluations.
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8
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Merkel MFR, Hellsten Y, Magnusson SP, Kjaer M. Tendon blood flow, angiogenesis, and tendinopathy pathogenesis. TRANSLATIONAL SPORTS MEDICINE 2021. [DOI: 10.1002/tsm2.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Max Flemming Ravn Merkel
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Stig Peter Magnusson
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Center for Healthy Aging Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Center for Healthy Aging Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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9
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Hirschmüller A, Morath O. [Tendinopathies of the Achilles tendon]. Z Rheumatol 2021; 80:629-640. [PMID: 34287670 DOI: 10.1007/s00393-021-01006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 10/20/2022]
Abstract
Disorders of the Achilles tendon are among the most frequent musculoskeletal injuries in athletes as well as in the general population. It is very important to differentiate the different clinical pictures summarized under the general term achillodynia and to understand the pathogenesis in order to undertake the correct therapeutic measures. In the case of insertional tendinopathies in particular, a rheumatological origin should be clarified. Doppler ultrasound is the most important diagnostic tool. Evidence-based treatment methods include various training programs, shock wave treatment, diverse injection and surgical procedures, each of which are discussed in detail in this article.
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Affiliation(s)
- Anja Hirschmüller
- Altius Swiss Sportmed Center Ag, Habich-Dietschy-Str. 5a, 4310, Rheinfelden, Schweiz. .,Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland.
| | - Oliver Morath
- Institut Bewegungs- und Arbeitsmedizin, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
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10
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Risch L, Stoll J, Schomöller A, Engel T, Mayer F, Cassel M. Intraindividual Doppler Flow Response to Exercise Differs Between Symptomatic and Asymptomatic Achilles Tendons. Front Physiol 2021; 12:617497. [PMID: 34295255 PMCID: PMC8290144 DOI: 10.3389/fphys.2021.617497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
Objective This study investigated intraindividual differences of intratendinous blood flow (IBF) in response to running exercise in participants with Achilles tendinopathy. Design This is a cross-sectional study. Setting The study was conducted at the University Outpatient Clinic. Participants Sonographic detectable intratendinous blood flow was examined in symptomatic and contralateral asymptomatic Achilles tendons of 19 participants (42 ± 13 years, 178 ± 10 cm, 76 ± 12 kg, VISA-A 75 ± 16) with clinically diagnosed unilateral Achilles tendinopathy and sonographic evident tendinosis. Intervention IBF was assessed using Doppler ultrasound “Advanced Dynamic Flow” before (Upre) and 5, 30, 60, and 120 min (U5–U120) after a standardized submaximal constant load run. Main Outcome Measure IBF was quantified by counting the number (n) of vessels in each tendon. Results At Upre, IBF was higher in symptomatic compared with asymptomatic tendons [mean 6.3 (95% CI: 2.8–9.9) and 1.7 (0.4–2.9), p < 0.01]. Overall, 63% of symptomatic and 47% of asymptomatic Achilles tendons responded to exercise, whereas 16 and 11% showed persisting IBF and 21 and 42% remained avascular throughout the investigation. At U5, IBF increased in both symptomatic and asymptomatic tendons [difference to baseline: 2.4 (0.3–4.5) and 0.9 (0.5–1.4), p = 0.05]. At U30 to U120, IBF was still increased in symptomatic but not in asymptomatic tendons [mean difference to baseline: 1.9 (0.8–2.9) and 0.1 (-0.9 to 1.2), p < 0.01]. Conclusion Irrespective of pathology, 47–63% of Achilles tendons responded to exercise with an immediate acute physiological IBF increase by an average of one to two vessels (“responders”). A higher amount of baseline IBF (approximately five vessels) and a prolonged exercise-induced IBF response found in symptomatic ATs indicate a pain-associated altered intratendinous “neovascularization.”
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Affiliation(s)
- Lucie Risch
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany
| | - Josefine Stoll
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany
| | - Anne Schomöller
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany
| | - Tilman Engel
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany
| | - Frank Mayer
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany.,Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
| | - Michael Cassel
- University Outpatient Clinic, Sports Medicine and Orthopedics, University of Potsdam, Potsdam, Germany.,Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
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11
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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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12
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Gatz M, Bode D, Betsch M, Quack V, Tingart M, Kuhl C, Schrading S, Dirrichs T. Multimodal Ultrasound Versus MRI for the Diagnosis and Monitoring of Achilles Tendinopathy: A Prospective Longitudinal Study. Orthop J Sports Med 2021; 9:23259671211006826. [PMID: 33912619 PMCID: PMC8047827 DOI: 10.1177/23259671211006826] [Citation(s) in RCA: 4] [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: 01/20/2021] [Accepted: 02/08/2021] [Indexed: 02/03/2023] Open
Abstract
Background: The diagnosis and monitoring of Achilles tendinopathy with imaging are challenging. There is a lack of studies comparing the diagnostic accuracy of magnetic resonance imaging (MRI), brightness mode ultrasound (B-mode), and power Doppler ultrasound with recent technologies such as ultrasound tissue characterization (UTC) and shear wave elastography (SWE). Purpose: To assess whether SWE and UTC, which offer quantitative values, show a superior diagnostic accuracy and capacity to detect structural improvement in Achilles tendinopathy compared with MRI, B-mode, or power Doppler. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients with insertional (n = 28) and midportion (n = 38) Achilles tendinopathy were evaluated at baseline and 6-month follow-up using MRI, B-mode, power Doppler, SWE, and UTC. Asymptomatic controls (n = 37) were evaluated at T0. Diagnostic accuracy was analyzed based on a quantitative receiver operating characteristic (ROC) analysis with quantitative cutoff values (anteroposterior diameter, Öhberg score, UTC echo type, Young modulus) and by semiquantitative Likert scale–based assessment of experienced physicians. Results: For diagnosing insertional Achilles tendinopathy, semiquantitative MRI and power Doppler were most favorable (diagnostic accuracy, 95%), while the cross-sectional area of MRI revealed 89% accuracy in the ROC analyses (area under the curve [AUC], 0.911; P < .001). For diagnosing midportion Achilles tendinopathy, semiquantitative MRI and B-mode were most favorable (diagnostic accuracy, 87%), while UTC echo types 3 and 4 revealed 86% and 87% accuracy, respectively, in the ROC analyses (AUC, 0.911 and 0.941, respectively; P < .001). However, for quantitative and semiquantitative evaluation of diagnostic accuracy in both insertional and midportion Achilles tendinopathy, there was no significant difference in favor of one imaging modality over the others. Compared with baseline, only SWE showed a significant change at the 6-month follow-up (P = .003-.035), but there were only fair to poor monitoring accuracies of 71% (insertion) and 60% (midportion). However, compared with the other modalities, the monitoring accuracy of SWE was significantly higher (P = .002-.039). Conclusion: There was no statistically significant difference in favor of one imaging modality over the others, but MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy.
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Affiliation(s)
- Matthias Gatz
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Daniela Bode
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany.,Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marcel Betsch
- University of Toronto Orthopaedic Sports Medicine Program (UTOSM), Women's College Hospital, Toronto, Ontario, Canada
| | - Valentin Quack
- Department for Trauma and Reconstructive Surgery, University Hospital Aachen, Aachen, Germany
| | - Markus Tingart
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Simone Schrading
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany.,Department of Radiology and Nuclear Medicine, Kantonsspital Luzern, Luzern, Switzerland
| | - Timm Dirrichs
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
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13
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Zhi X, Liu X, Han J, Xiang Y, Wu H, Wei S, Xu F. Nonoperative treatment of insertional Achilles tendinopathy: a systematic review. J Orthop Surg Res 2021; 16:233. [PMID: 33785026 PMCID: PMC8008511 DOI: 10.1186/s13018-021-02370-0] [Citation(s) in RCA: 4] [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: 01/27/2021] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insertional Achilles tendinopathy is difficult to manage, and there is no definite consensus on which nonoperative treatment is superior over the others. We aim to provide a clear summary of the best available evidence for nonoperative treatment specific to insertional Achilles tendinopathy. METHODS Literatures were searched in PubMed, Embase, and Web of Science databases from inception to October 2020. The results were evaluated independently by two reviewers and assessed against the inclusion/exclusion criteria. All included articles were assessed for methodological quality, and study characteristics were extracted. RESULTS Twenty-three studies (containing 35 groups) were eligible for the final review. The treatments included eccentric training, extracorporeal shockwave therapy (ESWT), injections, and combined treatment. Visual analog scale (VAS), Victorian Institute of Sport Assessment-Achilles questionnaire, AOFAS, satisfaction rate, and other scales were used to assess the clinical outcome. CONCLUSION Current evidence for nonoperative treatment specific for insertional Achilles tendinopathy favors ESWT or the combined treatment of ESWT plus eccentric exercises.
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Affiliation(s)
- Xiaosong Zhi
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), NO. 627, Wuluo Road, Wuhan, 430030, Hubei Province, P. R. China
| | - Xinyuan Liu
- Department of Emergency, Taikang Tongji (Wuhan) Hospital, Wuhan, Hubei Province, P. R. China
| | - Jing Han
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), NO. 627, Wuluo Road, Wuhan, 430030, Hubei Province, P. R. China
| | - Yang Xiang
- Graduate School of Wuhan University of Science and Technology, Wuhan, Hubei Province, P. R. China
| | - Helin Wu
- The First Clinical Medical School Of Southern Medical University, Guangzhou, Guangdong Province, P. R. China
| | - Shijun Wei
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), NO. 627, Wuluo Road, Wuhan, 430030, Hubei Province, P. R. China. .,The First Clinical Medical School Of Southern Medical University, Guangzhou, Guangdong Province, P. R. China.
| | - Feng Xu
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), NO. 627, Wuluo Road, Wuhan, 430030, Hubei Province, P. R. China. .,The First Clinical Medical School Of Southern Medical University, Guangzhou, Guangdong Province, P. R. China.
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14
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Laubach M, Hellmann JT, Dirrichs T, Gatz M, Quack V, Tingart M, Betsch M. Anterior knee pain after total knee arthroplasty: A multifactorial analysis. J Orthop Surg (Hong Kong) 2021; 28:2309499020918947. [PMID: 32338135 DOI: 10.1177/2309499020918947] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Dissatisfaction and an impaired quality of life after total knee arthroplasty (TKA) is often associated with postsurgical anterior knee pain (AKP). The underlying pathological mechanisms are not yet fully understood. Therefore, a multifactorial approach encompassing clinical and radiological parameters seemed reasonable and promising to investigate postsurgical AKP. METHODS In this cross-sectional study, 25 patients without and 25 patients with postsurgical AKP after unilateral TKA were randomly recruited from a larger cohort of patients. Multiple clinical and radiological parameters-including real-time shear wave elastography (SWE) to measure the patellar and quadriceps tendon elasticity-were acquired and subsequently associated with AKP. For statistical analysis, SPSS (IBM, version 25) was used. RESULTS In total 50 participants (58.0% men, mean age 63.42 years, mean body mass index 29.75 kg/m2), having different prosthetic designs implanted, were included. Independently of key covariates, the strength of the quadriceps muscle (p = 0.021), a thinner inlay (p = 0.041), and a lower position of the patella (p = 0.041) were associated with AKP. Although no correlation with AKP was found (p = 0.346, resp. p = 0.154), we observed significantly decreased Young's modulus of the patellar and quadriceps tendons for the involved knee compared to the uninvolved knee (p < 0.001). CONCLUSION In conclusion, quadriceps muscle strength, inlay thickness, and the patella position might be of particular relevance in avoiding postsurgical AKP. Future studies with larger sample sizes are needed to clarify the impact of quadriceps muscle strength and the postoperative patella position as well as the role of SWE as a personalized modifiable prediction marker.
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Affiliation(s)
- Markus Laubach
- Department of Orthopaedics, RWTH Aachen University Hospital, Aachen, Germany
| | - Julian Tr Hellmann
- Department of Orthopaedics, RWTH Aachen University Hospital, Aachen, Germany
| | - Timm Dirrichs
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Matthias Gatz
- Department of Orthopaedics, RWTH Aachen University Hospital, Aachen, Germany
| | - Valentin Quack
- Department of Orthopaedics, RWTH Aachen University Hospital, Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedics, RWTH Aachen University Hospital, Aachen, Germany
| | - Marcel Betsch
- Department of Orthopaedics, RWTH Aachen University Hospital, Aachen, Germany
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15
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Evaluation of Current Symptoms in Postoperative Achilles Tendons: A Multimodal Ultrasound Study. Healthcare (Basel) 2021; 9:healthcare9030288. [PMID: 33807841 PMCID: PMC8000856 DOI: 10.3390/healthcare9030288] [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: 01/28/2021] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: It is unknown which imaging parameters are associated with clinical persistent symptoms in postoperative Achilles tendons. This study used B-Mode, Power Doppler (PD-US), Ultrasound Tissue Characterization (UTC) and Shear Wave Elastography (SWE) to investigate which imaging parameters are associated with persistent symptoms in postoperative Achilles tendon tissue. (2) Methods: Retrospective, cross-sectional, multimodal imaging study. Based on the VISA-A score, postoperative tendons were assigned to two groups: 1. asymptomatic (VISA-A ≥ 90, n = 18); 2. symptomatic (VISA-A < 90, n = 10). The following imaging parameters were analyzed: UTC (echo type I, II, III, IV), B-Mode (diameter, cross sectional area, calcification, fiber irregularity), PD-US (Öhberg score) and SWE (SWE 3 mm, SWE area) using a t-test and a Mann–Whitney U test. (3) Results: SWE and PD-US showed significantly reduced elasticity and increased neovascularization in symptomatic tendons (SWE 3 mm p = 0.031, SWE area p = 0.046, Öhberg score p < 0.001). The only significant correlation between imaging parameters and the VISA-A score was assessed for SWE 3 mm (r = 0.378; p = 0.047) and the Öhberg score (r = −0.737; p < 0.001). Conclusions: Symptomatic postoperative Achilles tendons showed increased neovascularization and lower SWE values than asymptomatic ones. Future studies should examine the diagnostic accuracy of PD-US and SWE in detecting current symptoms in postoperative Achilles tendons.
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16
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Fares MY, Khachfe HH, Salhab HA, Zbib J, Fares Y, Fares J. Achilles tendinopathy: Exploring injury characteristics and current treatment modalities. Foot (Edinb) 2021; 46:101715. [PMID: 33039245 DOI: 10.1016/j.foot.2020.101715] [Citation(s) in RCA: 6] [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: 04/04/2020] [Revised: 06/19/2020] [Accepted: 07/03/2020] [Indexed: 02/04/2023]
Abstract
Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.
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Affiliation(s)
- Mohamad Y Fares
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon; College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, Scotland, UK.
| | - Hussein H Khachfe
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Hamza A Salhab
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Jad Zbib
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Youssef Fares
- Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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17
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López-Royo MP, Ríos-Díaz J, Galán-Díaz RM, Herrero P, Gómez-Trullén EM. A Comparative Study of Treatment Interventions for Patellar Tendinopathy: A Randomized Controlled Trial. Arch Phys Med Rehabil 2021; 102:967-975. [PMID: 33556350 DOI: 10.1016/j.apmr.2021.01.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/28/2020] [Accepted: 01/16/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To determine the additional effect of dry needling (DN) or percutaneous needle electrolysis (PNE) combined with eccentric exercise (EE) and determine which is the most effective for patients with patellar tendinopathy (PT). DESIGN Blinded, randomized controlled trial, with follow-up at 10 and 22 weeks. SETTINGS Recruitment was performed in sport clubs. Diagnosis and intervention were conducted at San Jorge University. PARTICIPANTS Patients (N=48) with PT with pain for at least 3 months between the ages of 18 and 45 years. INTERVENTIONS Three interventions were carried out: DN and EE, PNE and EE, and EE with sham needle as the control group. MAIN OUTCOME MEASURES Disability was measured using the Victorian Institute of Sports Assessment Questionnaire, patellar tendon. Visual analog scale was used to measure pain over time, the Short Form-36 was used to measure quality of life, and ultrasound was used to measure structural abnormalities. RESULTS A total of 48 participants (42 men, 6 women; average age, 32.46y; SD, 7.14y) were enrolled. The improvement in disability and pain in each group between baseline and post-treatment and baseline and follow-up was significant (P≤.05), without differences among groups. CONCLUSION DN or PNE combined with an EE program has not shown to be more effective than a program of only EE to improve disability and pain in patients with PT in the short (10wk) and medium (22wk) terms. Clinical improvements were not associated with structural changes in the tendon.
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Affiliation(s)
- María Pilar López-Royo
- iPhysio Research Group, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain; Universidad de Zaragoza, Faculty of Health Sciences, Zaragoza, Spain
| | - José Ríos-Díaz
- San Juan De Dios Foundation, Health Sciences University Centre, Antonio de Nebrija University, Madrid, Spain
| | - Rita María Galán-Díaz
- iPhysio Research Group, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - Pablo Herrero
- Universidad de Zaragoza, Faculty of Health Sciences, Zaragoza, Spain.
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18
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Morath O, Beck M, Taeymans J, Hirschmüller A. Sclerotherapy and prolotherapy for chronic patellar tendinopathies - a promising therapy with limited available evidence, a systematic review. J Exp Orthop 2020; 7:89. [PMID: 33165667 PMCID: PMC7652964 DOI: 10.1186/s40634-020-00303-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/23/2020] [Indexed: 12/13/2022] Open
Abstract
Chronic Patellar tendinopathy (CPT) is a frequent overuse disorder in athletes and active people. Sclerotherapy (ST) and prolotherapy (PT) are, among a wide range of conservative treatment options, two promising therapies and have shown positive results in other tendinopathies. Since the treatments' efficacy and safety are still not defined, this review sought to answer questions on recommendations for use in clinical utility, safety, and how to perform the injection in the most effective way. An electronic database search was conducted following the PRISMA guidelines. Inclusion criteria were set up according to the PICOS-scheme. Included were athletes and non-athletes of all ages with diagnosed painful CPT. Studies including patients suffering from patellar tendinopathy which can be originated to any systemic condition affecting the musculoskeletal system (e.g. disorders associated with rheumatism) and animal studies were excluded. Methodological quality (modified Coleman Methodology Score) and risk of bias (Cochrane Risk of Bias Assessment Tool 2.0) were assessed by two independent reviewers, with disagreements resolved with a third reviewer. The search yielded a total of 416 entries. After screening titles, abstracts, and full texts, ten articles were found for qualitative analysis. The mean Coleman Score was 64.57. Three randomized-controlled trials showed positive results with an increase in VISA-P score or a decrease in VAS or NPPS, respectively. The non-randomized studies confirmed the positive results as well. Among all ten studies no serious adverse events were reported. Based on this limited set of studies, there seems to be some evidence that ST and PT may be effective treatment options to treat pain and to improve function in patients with CPT. To strengthen this recommendation, more research is needed with larger volume studies and randomized controlled studies with long term follow up. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Oliver Morath
- Institute of Exercise and Occupational Medicine, Department of Medicine, Faculty of Medicince, Medical Center-University of Freiburg, Hugstetter Str. 55, D-79106, Freiburg im Breisgau, Germany.
| | - Manuel Beck
- Clinic for Orthopaedics and Traumatology, Department of Surgery, Faculty of Medicine, Medical Center-University of Freiburg, Hugstetter Str. 55, D-79106, Freiburg im Breisgau, Germany
| | - Jan Taeymans
- Bern University of Applied Sciences - Health, Murtenstrasse 10, CH-3008, Berne, Switzerland
| | - Anja Hirschmüller
- Clinic for Orthopaedics and Traumatology, Department of Surgery, Faculty of Medicine, Medical Center-University of Freiburg, Hugstetter Str. 55, D-79106, Freiburg im Breisgau, Germany
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19
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Otter S, Payne C, Jones AM, Webborn N, Watt P. Differences in Achilles tendon stiffness in people with gout: a pilot study. BMC Musculoskelet Disord 2020; 21:658. [PMID: 33028270 PMCID: PMC7542740 DOI: 10.1186/s12891-020-03598-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022] Open
Abstract
Background Gout has been associated with weaker foot/leg muscles and altered gait patterns. There is also evidence of on-going foot pain and an increased risk of tendinopathy, with the Achilles and patella tendons most frequently affected in gout. Additionally, the inflammation associated with gout may change tissue elasticity. Ultrasound imaging utilising shear wave elastography (SWE) offers a non-invasive method of quantifying changes in tendon stiffness. SWE findings have not previously been reported in individuals with gout. We sought to determine differences in Achilles tendon stiffness in people with gout compared to controls (non-gout). Methods A cross sectional study comparing 24 people with gout and 26 age/sex-matched controls. Clinical and demographic data were collated, and US imaging used to determine tendon thickness, presence of gouty tophi and/or aggregates and levels of angiogenesis. Ten shear wave elastography (SWE) measures were taken along the centre of a longitudinal section of the mid-portion of each Achilles tendon. Prior to data collection, intra-observer error was good (>0.69). Data were summarised using descriptive statistics and a repeated measures ANCOVA was used to compare SWE measures between the two groups for the left and right foot separately after accounting for Body Mass Index (BMI). Results A small proportion of those with gout presented with intra-tendon aggregates and/or intra-tendon tophi in one or both tendons. There was no statistically significant difference in tendon thickness between groups. Neo-vascularity was present in a third of gout participants. SWE findings demonstrated significantly reduced tendon stiffness in those with gout compared to controls: right Achilles mdiff =1.04 m/s (95% CI (0.38 to 1.7) p = 0.003 and left Achilles mdiff = 0.7 m/s (95% CI 0.09 to 1.32) p = 0.025. No relationship between the presence of tophi and SWE values were detected. Conclusion Subjects with chronic gout show significantly reduced Achilles tendon stiffness compared to non-gout controls. From a clinical standpoint, our findings were similar to SWE measurements in subjects with Achilles tendinopathy and who did not have gout.
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Affiliation(s)
- Simon Otter
- School of Health Sciences, University of Brighton, 49 Darley Rd, Eastbourne, BN20 7UR, UK. .,Centre for Regenerative Medicine and Devices, University of Brighton, Lewes Road, Brighton, BN2 4AT, UK.
| | - Catherine Payne
- School of Sport and Service Management, University of Brighton, Hillbrow, Denton Road, Eastbourne, BN20 7SR, UK
| | - Anna-Marie Jones
- Research and Development, Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, BN13 3EP, UK
| | - Nick Webborn
- Centre for Regenerative Medicine and Devices, University of Brighton, Lewes Road, Brighton, BN2 4AT, UK
| | - Peter Watt
- Centre for Regenerative Medicine and Devices, University of Brighton, Lewes Road, Brighton, BN2 4AT, UK.,School of Sport and Service Management, University of Brighton, Hillbrow, Denton Road, Eastbourne, BN20 7SR, UK
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Minimum 3.5-year outcomes of operative treatment for Achilles tendon partial tears in the midportion and retrocalcaneal area. J Orthop Surg Res 2020; 15:395. [PMID: 32912202 PMCID: PMC7488251 DOI: 10.1186/s13018-020-01856-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/31/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Achilles tendon partial tears are not easy to diagnose and to manage. Most frequently, they are located in the midportion and insertional area. These entities result from different pathologic pathways, and different treatment strategies are applied. The outcome is rarely investigated. METHODS This study includes patients who underwent surgery for partial tears in the midportion or retrocalcaneal Achilles tendon area between the years 2009 and 2015 by a single surgeon. Patients were prospectively assessed preoperatively and 3, 6, and 12 months postoperatively, using the VISA-A-G questionnaire. The final retrospective follow-up was performed after a minimum of 3.5 years postoperatively. Forty-eight Achilles tendon partial tears at the level of the retrocalcaneal bursa (impingement lesions) and 27 midportion Achilles tendon partial tears were identified. After applying rigorous exclusion criteria, 21 and 16 cases, respectively, remained for the final follow-up. Results were analysed by inferential and descriptive statistics. RESULTS The VISA-A-G outcome scores improved significantly from preoperative to 6 months, 12 months, and final postoperative assessment. Preoperatively, the average VISA-A-G score was 42.1 (range, 18-73) for patients operated for Achilles tendon partial tears at the level of the retrocalcaneal bursa and 44.6 (range, 10-73) for the midportion Achilles tendon partial tear group, respectively. At final follow-up 88.8 (range, 15 to 100) and 96.9 (range, 71 to 100) were scored in the respective treatment groups. A repeated measures ANOVA determined that mean performance levels showed a statistically significant difference between measurements (p < 0.001). There was no systematic effect found between groups (p = 0.836). CONCLUSIONS In Achilles tendon partial tears recalcitrant to conservative treatment, operative intervention is highly successful in most cases, irrespective of the level of the injury. Results were statistically equal when comparing the midportion and retrocalcaneal Achilles tendon partial tear groups. TRIAL REGISTRATION DRKS, DRKS00014266. Registered 06 April 2018. 'Retrospectively registered', https://www.drks.de/drks_web/navigate.do?navigationId=results .
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21
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Mkumbuzi NS, Jørgensen OH, Mafu TS, September AV, Posthumus M, Collins M. Ultrasound findings are not associated with tendon pain in recreational athletes with chronic Achilles tendinopathy. TRANSLATIONAL SPORTS MEDICINE 2020. [DOI: 10.1002/tsm2.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Nonhlanhla S. Mkumbuzi
- Division of Exercise Science and Sports Medicine Department of Human Biology University of Cape Town Cape Town South Africa
- Department of Physiology College of Health Sciences University of Zimbabwe Harare Zimbabwe
| | - Oscar H. Jørgensen
- Department of Orthopaedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging Faculty of Health and Medical Sciences Institute of Sports Medicine Copenhagen University of Copenhagen Copenhagen Denmark
| | - Trevor S. Mafu
- Division of Exercise Science and Sports Medicine Department of Human Biology University of Cape Town Cape Town South Africa
| | - Alison V. September
- Division of Exercise Science and Sports Medicine Department of Human Biology University of Cape Town Cape Town South Africa
| | - Michael Posthumus
- Division of Exercise Science and Sports Medicine Department of Human Biology University of Cape Town Cape Town South Africa
- High Performance Centre Sports Science Institute of South Africa Cape Town South Africa
| | - Malcolm Collins
- Division of Exercise Science and Sports Medicine Department of Human Biology University of Cape Town Cape Town South Africa
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22
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Gatz M, Betsch M, Bode D, Schweda S, Dirrichs T, Migliorini F, Tingart M, Quack V. Intra individual comparison of unilateral Achilles tendinopathy using B-mode, power Doppler, ultrasound tissue characterization and shear wave elastography. J Sports Med Phys Fitness 2020; 60:1462-1469. [PMID: 32586084 DOI: 10.23736/s0022-4707.20.11031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The asymptomatic side of unilateral Achilles tendinopathy (AT) is used as a reference in ultrasound. However, this procedure has not been evaluated in a comparative analysis using B-mode (B-US), power Doppler (PD-US), ultrasound tissue characterization (UTC) and shear wave elastography (SWE). METHODS Retrospective cross-sectional study. Tendons were assigned to 3 groups: 1) asymptomatic side of unilateral AT N.=55; 2) symptomatic side of unilateral AT N.=55; and 3) young reference group N.=29. The following parameters were analyzed separately for the insertion and midportion: UTC (echo type I, II, III, IV), B-US (diameter, cross sectional area), PD-US (Öhberg Score) and SWE (SWE 3 mm, SWE area) using a Wilcoxon Test (group 1 vs. 2) and a Kruskal-Wallis Test (group 1 vs. 2 vs. 3). RESULTS The Wilcoxon Test making an isolated comparison between group 1 vs. 2 revealed a significant difference for all parameters of B-US, PD-US, UTC and SWE (P<0.001, P=0.042), except for the insertion in UTC. However, in the overall analysis including the reference group, the Kruskal-Wallis Test could only detect a significant difference between group 1 vs. 2 for PD-US (P<0.001). Thus, group 1 and 2 had significantly more pathological parameters in B-US (P<0.001, P=0.027), SWE (P<0.001, P=0.008) and UTC (type I, III, IV P<0.001) in both, insertion and midportion, compared to the reference group. CONCLUSIONS The asymptomatic side of unilateral AT seems to show subclinical tendons alterations in B-US, SWE and UTC in comparison to a young and healthy control group. The asymptomatic side of unilateral AT especially with detectable neovascularization might be at risk for future symptoms. Further studies must examine whether the asymptomatic side can still serve as a reference for intra individual comparison in clinical evaluation.
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Affiliation(s)
- Matthias Gatz
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany -
| | - Marcel Betsch
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Daniela Bode
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany.,Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sebastian Schweda
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Timm Dirrichs
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Markus Tingart
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Valentin Quack
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
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23
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Quack V, Betsch M, Hellmann J, Eschweiler J, Schrading S, Gatz M, Rath B, Tingart M, Laubach M, Kuhl CK, Dirrichs T. Evaluation of Postoperative Changes in Patellar and Quadriceps Tendons after Total Knee Arthroplasty-A Comprehensive Analysis by Shear Wave Elastography, Power Doppler and B-mode Ultrasound. Acad Radiol 2020; 27:e148-e157. [PMID: 31526688 DOI: 10.1016/j.acra.2019.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 02/04/2023]
Abstract
RATIONALE AND OBJECTIVES Up to now, the diagnosis of tendinopathies is based on conventional B-mode-ultrasound (B-US), Power Doppler-ultrasound (PD-US), and magnetic resonance imaging. In the past decade, Shear Wave Elastography (SWE) has been introduced in tendon imaging, for example in athletes or patients suffering from tendinopathy. SWE allows real-time quantification of tissue stiffness, and, by this, the assessment of the mechanical properties of a tendon and its changes during acute disease and tendon healing. So far there are no ultrasound-based studies that have evaluated postoperative tendon changes, anatomical and mechanical properties and tendon healing of the patellar, and quadriceps tendon following Total Knee Arthroplasty (TKA). The purpose of this prospective study was two-fold: first to analyze morphologic, vascular, and mechanical properties of patellar and quadriceps tendons in patients following TKA; and, second to evaluate possible changes thereof and their visibility in the course of time. MATERIALS AND METHODS Observational cross-sectional, IRB-approved study in 63 postoperative patients with a total of 76 total knee arthroplasties (50 unilateral, 13 bilateral) and 50 nonoperated knees for comparison, resulting in 152 postoperative patellar- and quadriceps and 100 nonoperated patellar- and quadriceps-tendons for comparative analysis. For further examination, we divided the 63 patients into two groups according to the duration since surgery (group A < 24 months; group B > 24 months). All patients completed a standardized questionnaire, furthermore the Knee Society score and the Knee Society function score. The amount of experienced pain was assessed using the ordinal numeric rating scale and the presence of anterior knee pain was examined. Subsequently every participant underwent a standardized multimodal ultrasound protocol consisting of B-US, PD-US, and SWE of the left and right patellar and quadriceps tendons. RESULTS Using the different US-modalities, operated patellar, and quadriceps tendons (n = 152) were significantly more frequent classified as pathological (B-US) (p < 0.001), the mean Ohberg score was significantly higher (PD-US) (p < 0.001), and the tendons were significantly softer (SWE) than their nonoperated counterparts (n = 100). Mean SWE-value of postoperative patellar tendons was 45.66 ± 14.84 kPa versus 60.08 ± 19.13 kPa in nonoperated knees (p < 0.001). Mean SWE-value of postoperative quadriceps tendons was 35.73 ± 15.66 kPa versus 52.69 ± 16.20 kPa in nonoperated knees (p < 0.001). Comparing the two postoperative groups (group A and B), we recognized a significant decrease of pathologically classified patellar and quadriceps tendons (B-US and PD-US) in group B. The early postoperatively reduced SWE values slightly increased during the course of time. CONCLUSION After TKA, patellar, and quadriceps tendons show significant measurable alterations in B-US, PD-US, and SWE. Especially a significant decrease of tendon stiffness in operated knees, as assessed by SWE, might be a surrogate marker for changed mechanical properties. These alterations improve, the longer ago the surgery was. The quantitative information obtained by SWE could be of particular interest in follow-up and therapy monitoring after TKA. Knowledge about tendon stiffness and it's varieties in different population groups (e.g. athletes, elderly, postoperative patients) is crucial to sonographically rate a tendon as "healthy" or "diseased."
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Affiliation(s)
- Valentin Quack
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Marcel Betsch
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Julian Hellmann
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Simone Schrading
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen 52074, Germany
| | - Matthias Gatz
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Björn Rath
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Markus Tingart
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Markus Laubach
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen 52074, Germany
| | - Timm Dirrichs
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen 52074, Germany.
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van den Boom NAC, Winters M, Haisma HJ, Moen MH. Efficacy of Stem Cell Therapy for Tendon Disorders: A Systematic Review. Orthop J Sports Med 2020; 8:2325967120915857. [PMID: 32440519 PMCID: PMC7227154 DOI: 10.1177/2325967120915857] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Stem cell therapy is an emerging treatment for tendon disorders. Purpose: To systematically review the efficacy of stem cell therapy for patients with tendon disorders. Study Design: Systematic review; Level of evidence, 4. Methods: MEDLINE/PubMed, EMBASE, CINAHL, CENTRAL, PEDro, and SPORTDiscus; trial registers; and gray literature were searched to identify randomized controlled trials (RCTs) and non-RCTs, cohort studies, and case series with 5 or more cases. Studies investigating any type of stem cell therapy for patients with tendon disorders were eligible if they included patient-reported outcome measures or assessed tendon healing. Risk of bias was assessed through use of the Cochrane risk of bias tools. Results: This review included 8 trials (289 patients). All trials had moderate to high risk of bias (level 3 or 4 evidence). In Achilles tendon disorders, 1 trial found that allogenic-derived stem cells led to a faster recovery compared with platelet-rich plasma. Another study found no retears after bone marrow–derived stem cell therapy was used in addition to surgical treatment. There were 4 trials that studied the efficacy of bone marrow–derived stem cell therapy for rotator cuff tears. The controlled trials reported superior patient-reported outcomes and better tendon healing. A further 2 case series found that stem cell therapy improved patient-reported outcomes in patients with patellar tendinopathy and elbow tendinopathy. Conclusion: Level 3 evidence is available to support the efficacy of stem cell therapy for tendon disorders. The findings of available studies are at considerable risk of bias, and evidence-based recommendations for the use of stem cell therapy for tendon disorders in clinical practice cannot be made at this time. Stem cell injections should not be used in clinical practice given the lack of knowledge about potentially serious adverse effects.
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Affiliation(s)
| | - Marinus Winters
- Center for General Practice at Aalborg University, Aalborg, Denmark
| | - Hidde Jacobs Haisma
- Department of Chemical and Pharmaceutical Biology, Groningen Research Institute of Pharmacy, Groningen University, Groningen, the Netherlands
| | - Maarten Hendrik Moen
- The Sports Physician Group, Department of Sports Medicine, OLVG West, Amsterdam, the Netherlands.,Bergman Clinics, Naarden, the Netherlands.,Department of Elite Sports, NOCNSF, Medical Staff, Arnhem, the Netherlands
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25
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Gatz M, Betsch M, Dirrichs T, Schrading S, Tingart M, Michalik R, Quack V. Eccentric and Isometric Exercises in Achilles Tendinopathy Evaluated by the VISA-A Score and Shear Wave Elastography. Sports Health 2020; 12:373-381. [PMID: 32003647 PMCID: PMC7787566 DOI: 10.1177/1941738119893996] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Apart from eccentric exercises (EE), isometric exercises (ISO) might be a treatment option for Achilles tendinopathy. Shear wave elastography (SWE) provides information for diagnosis and for monitoring tissue elasticity, which is altered in symptomatic tendons. HYPOTHESIS Isometric exercises will have a beneficial effect on patients' outcome scores. Based on SWE, insertional and midportion tendon parts will differ in their elastic properties according to current symptoms. STUDY DESIGN Randomized clinical trial. LEVEL OF EVIDENCE Level 2. METHODS Group 1 (EE; n = 20; 12 males, 8 females; mean age, 52 ± 8.98 years) and group 2 (EE + ISO; n = 22; 15 males, 7 females; mean age, 47 ± 15.11 years) performed exercises for 3 months. Measurement points were before exercises were initiated as well as after 1 and 3 months using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score, American Orthopaedic Foot & Ankle Society score, and SWE (insertion and midportion). RESULTS Both groups improved significantly, but there were no significant interindividual differences (VISA-A; P = 0.362) between group 1 (n = 15; +15 VISA-A) and group 2 (n = 15; +15 VISA-A). The symptomatic insertion (symptomatic, 136.89 kPa; asymptomatic, 174.68 kPa; P = 0.045) and the symptomatic midportion of the Achilles tendon (symptomatic, 184.40 kPa; asymptomatic, 215.41 kPa; P = 0.039) had significantly lower Young modulus compared with the asymptomatic tendons. The midportion location had significantly higher Young modulus than the insertional part of the tendon (P = 0.005). CONCLUSION Isometric exercises do not have additional benefit when combined with eccentric exercises, as assessed over a 3-month intervention period. SWE is able to distinguish between insertional and midportion tendon parts in a symptomatic and asymptomatic state. CLINICAL RELEVANCE The present study shows no additional effect of ISO when added to baseline EE in treating Achilles tendinopathy. Different elastic properties of the insertional and midportion tendon have to be taken into consideration when rating a tendon as pathologic.
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Affiliation(s)
- Matthias Gatz
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Marcel Betsch
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Timm Dirrichs
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Simone Schrading
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Markus Tingart
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Roman Michalik
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
| | - Valentin Quack
- Department of Orthopedics, University Hospital RWTH Aachen, Aachen, Germany
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26
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Zhang S, Li H, Yao W, Hua Y, Li Y. Therapeutic Response of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy Between Sports-Active and Nonsports-Active Patients With 5-Year Follow-up. Orthop J Sports Med 2020; 8:2325967119898118. [PMID: 32030348 PMCID: PMC6977229 DOI: 10.1177/2325967119898118] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 10/10/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Insertional Achilles tendinopathy (IAT) is a common cause of posterior heel pain. Extracorporeal shock wave therapy (ESWT) has proven to be an effective treatment, but the relationship between therapeutic responses and sports activity levels has not been studied. Purpose: To compare the clinical outcomes of ESWT used to treat IATs between sports-active and nonsports-active patients over 5 years. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was conducted on 33 patients with IAT who received ESWT from October 2012 to September 2013. Patients were classified into 2 groups according to their preinjury Tegner activity level: a sports-active group, defined as patients who self-reported to be regular joggers (SA group; Tegner activity level >3; n = 16), and a nonsports-active group (control group; Tegner activity level ≤3; n = 17). The mean age was 31 ± 7 years for the SA group and 37 ± 10 years for the control group. The Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire scores and visual analog scale (VAS) pain scores were used to evaluate the clinical outcomes before treatment, immediately after treatment, and 5 years after treatment. Ultrasonography was also used to assess the insertional Achilles tendon quality. Results: Before treatment, there were no significant differences between the groups with regard to VAS scores, while the VISA-A score in the SA group was higher than that in the control group. After ESWT, both groups had increased VISA-A scores and decreased VAS scores, indicating improvement. At 5-year follow-up, the SA group had a significantly lower mean VAS score (0.3 ± 0.8 vs 1.6 ± 1.3; P = .001) and a significantly higher mean VISA-A score (90 ± 4 vs 78 ± 7; P < .001) compared with the control group. There was no significant difference between the groups regarding the calcification and neovascularization of the Achilles tendon based on ultrasonography. Conclusion: ESWT can improve the symptoms of Achilles tendinopathy, and patients with IAT who had greater sports activity levels had better therapeutic responses than nonsports-active patients after 5-year follow-up.
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Affiliation(s)
- Shurong Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Hong Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Wei Yao
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yunxia Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
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27
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Tillander B, Gauffin H, Lyth J, Knutsson A, Timpka T. Symptomatic Achilles Tendons are Thicker than Asymptomatic Tendons on Ultrasound Examination in Recreational Long-Distance Runners. Sports (Basel) 2019; 7:sports7120245. [PMID: 31817429 PMCID: PMC6955697 DOI: 10.3390/sports7120245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 12/03/2022] Open
Abstract
There is a need for clinical indicators that can be used to guide the treatment of Achilles tendon complaints in recreational runners. Diagnostic ultrasound has recently been introduced for clinical decision support in tendon pain management. The aim of this study was to determine whether tendon thickness and morphological changes in the Achilles tendon detected in ultrasound examinations are associated with local symptoms in middle-age recreational long-distance runners. Forty-two Achilles tendons (21 middle-aged runners) were investigated by ultrasound examination measuring tendon thickness and a morphology score indicating tendinosis. The Generalized Estimating Equations method was applied in multiple models of factors associated with reporting a symptomatic tendon. Eleven symptomatic and 31 asymptomatic Achilles tendons were recorded. In the multiple model that used tendon thickness measured 30 mm proximal to the distal insertion, an association was found between thickness and reporting a symptomatic tendon (p < 0.001; OR 12.9; 95% CI 3.1 to 53.2). A qualitative morphology score was not found to be significantly associated with reporting a symptomatic tendon (p = 0.10). We conclude that symptomatic Achilles tendons were thicker than asymptomatic tendons on ultrasound examination among recreational long-distance runners and that the importance of parallel morphological findings need to be further investigated in prospective studies.
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Affiliation(s)
- Bo Tillander
- Athletics Research Center, Linköping University, SE-581 83 Linköping, Sweden; (H.G.); (T.T.)
- Department of Orthopaedics, Linköping University, SE-581 83 Linköping, Sweden
- Correspondence:
| | - Håkan Gauffin
- Athletics Research Center, Linköping University, SE-581 83 Linköping, Sweden; (H.G.); (T.T.)
- Department of Orthopaedics, Linköping University, SE-581 83 Linköping, Sweden
| | - Johan Lyth
- Research and Development Unit in Region Östergötland, SE-581 85 Linköping, Sweden;
- Department of Medical and Health Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Anders Knutsson
- Department of Radiology, Linköping University, SE-581 83 Linköping, Sweden;
| | - Toomas Timpka
- Athletics Research Center, Linköping University, SE-581 83 Linköping, Sweden; (H.G.); (T.T.)
- Department of Medical and Health Sciences, Linköping University, SE-581 83 Linköping, Sweden
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28
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Lacitignola L, Rossella S, Pasquale DL, Crovace A. Power Doppler to investigate superficial digital flexor tendinopathy in the horse. Open Vet J 2019; 9:317-321. [PMID: 32042652 PMCID: PMC6971361 DOI: 10.4314/ovj.v9i4.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 10/15/2019] [Indexed: 12/02/2022] Open
Abstract
Background: Recent advances in tendinopathy research have focused on tendon vascularization detected with Color Doppler (CD) ultrasound. The use of CD has also been described in horses in a study on chronic lesions of superficial digital flexor tendon and suspensory ligament. Aim: The aim of this study was to investigate the occurrence and distribution of power Doppler (PD) signal in horses with superficial digital flexor tendinopathy. Methods: Twenty-five horses with tendinopathy were included and 10 healthy horses with no lameness and no ultrasonographic abnormalities were used for comparison. Results: In all horses with tendinopathy, the PD signal was visible while normal tendons with no abnormalities in B-mode were PD signal-free. Conclusion: We can speculate that PD could provide essential information about the healing process than the grayscale ultrasound.
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Affiliation(s)
- Luca Lacitignola
- Dipartimento dell'Emergenza e dei Trapianti di Organi (D.E.T.O.), Sezione di Cliniche Veterinarie e P.A, Università degli Studi di Bari "Aldo Moro", s.p. per Casamassima Km 3, 70010 Valenzano, Italy
| | - Santovito Rossella
- Dipartimento dell'Emergenza e dei Trapianti di Organi (D.E.T.O.), Sezione di Cliniche Veterinarie e P.A, Università degli Studi di Bari "Aldo Moro", s.p. per Casamassima Km 3, 70010 Valenzano, Italy
| | - De Luca Pasquale
- Dipartimento dell'Emergenza e dei Trapianti di Organi (D.E.T.O.), Sezione di Cliniche Veterinarie e P.A, Università degli Studi di Bari "Aldo Moro", s.p. per Casamassima Km 3, 70010 Valenzano, Italy
| | - Antonio Crovace
- Dipartimento dell'Emergenza e dei Trapianti di Organi (D.E.T.O.), Sezione di Cliniche Veterinarie e P.A, Università degli Studi di Bari "Aldo Moro", s.p. per Casamassima Km 3, 70010 Valenzano, Italy
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29
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Fallows R, Lumsden G. Pitfalls in the study of neovascularisation in achilles and patellar tendinopathy: a review of important factors for clinicians to consider and the need for greater standardisation. PHYSICAL THERAPY REVIEWS 2019. [DOI: 10.1080/10833196.2019.1690216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Richard Fallows
- Telford Musculoskeletal Services, Shropshire Community Health NHS Trust, Shropshire, UK
| | - Gordon Lumsden
- Physiotherapy Department, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
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30
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Shear Wave Elastography (SWE) of Asymptomatic Achilles Tendons: A Comparison Between Semiprofessional Athletes and the Nonathletic General Population. Acad Radiol 2019; 26:1345-1351. [PMID: 30655054 DOI: 10.1016/j.acra.2018.12.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/03/2018] [Accepted: 12/16/2018] [Indexed: 11/24/2022]
Abstract
RATIONALE AND OBJECTIVES It has been shown that Shear Wave Elastography (SWE) is a useful tool to evaluate tendon stiffness, e.g. in diagnosing tendinopathies, as diseased or injured tendons are intra-individually softer than healthy ones. But reference values between different population groups are still missing. The purpose of this prospective clinical study was two-fold: First, to comparatively analyse Achilles tendon stiffness between asymptomatic semiprofessional athletes and an asymptomatic nonathletic control group. Second, to evaluate specificity, with which SWE is able to predict absence of clinical symptoms in asymptomatic individuals, compared to B-mode-Ultrasound (B-US) and Power Doppler-Ultrasound (PD-US). MATERIALS AND METHODS Prospective clinical study in 68 asymptomatic healthy participants, 33 (48.5%) of them semiprofessional athletes with at least five training units of running per week and 35 (51.5 %) normal nonathletic persons, asymptomatic respectively. A consecutive of 136 Achilles tendons underwent standardized multi-modal ultrasound, consisting of B-US, PD-US, and SWE (Aixplorer, Supersonic). Pathologic structural changes at B-US, increased Doppler signal PD-US and quantitative ROI-based-analysis of tendon elasticity in kilopascal (kPa) were performed in all participants. Tendon stiffness was compared intra-individually between right and left side in each participant. SWE values between athletes and nonathletes were compared by using student's t test (p < 0.05). To evaluate the ability of different sonographic modalities in predicting "absence of clinical symptoms", specificities of B-US, PD-US, and SWE were calculated and compared among each other. RESULTS Mean SWE-value for Achilles tendon was 183.8 kPa (± 98 kPa) in athletes and 103.6 kPa (± 30.5 kPa) in the nonathletic control group. The difference between athletes and non-athletes was statistically significant (p < 0.001). No significant differences were found intra-individually between right and left side: athlete mean: right: 187.2 kPa (SD ± 45.2 kPa)/left: 180.4 kPa (SD 39.7 kPa); nonathlete mean: right: 105.4 kPa (SD 34.9 kPa)/left: 101.8 kPa (SD 28.9 kPa). Specificity with which asymptomatic tendons were rated as "inconspicuous" was 60.6% for B-US, 93.9% for PD-US and 96.3% for SWE. CONCLUSION Healthy athletes exhibit significantly higher SWE-values in Achilles tendons than healthy nonathletic participants, which means that they have significantly stiffer tendons, possibly caused by repeated training. SWE is able to measure and display these effects. These interindividual differences should be taken into consideration, especially when rating a tendon as "healthy" or "diseased", because a "softer" tendon does not necessarily mean to be affected.
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Kaplan K, Olivencia O, Dreger M, Hanney WJ, Kolber MJ. Achilles Tendinopathy: An Evidence-Based Overview for the Sports Medicine Professional. Strength Cond J 2019. [DOI: 10.1519/ssc.0000000000000485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Splittgerber LE, Ihm JM. Significance of Asymptomatic Tendon Pathology in Athletes. Curr Sports Med Rep 2019; 18:192-200. [DOI: 10.1249/jsr.0000000000000600] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Cassel M, Risch L, Mayer F, Kaplick H, Engel A, Kulig K, Bashford G. Achilles tendon morphology assessed using image based spatial frequency analysis is altered among healthy elite adolescent athletes compared to recreationally active controls. J Sci Med Sport 2019; 22:882-886. [PMID: 31000456 DOI: 10.1016/j.jsams.2019.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/16/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Although expected, tendon adaptations in adolescent elite athletes have been underreported. Morphologically, adaptations may occur by an increase in collagen fiber density and/or organization. These characteristics can be captured using spatial frequency parameters extracted from ultrasound images. This study aims to compare Achilles tendon (AT) morphology among sports-specific cohorts of elite adolescent athletes and to compare these findings to recreationally active controls by use of spatial frequency analysis. DESIGN Cross-sectional observational study. METHOD In total, 334 healthy adolescent athletes from four sport categories (ball, combat, endurance, explosive strength) and 35 healthy controls were included. Longitudinal ultrasound scans were performed at the AT insertion and midportion. Intra-tendinous-morphology was quantified by performing spatial frequency analysis assessing eight parameters at standardized ROIs. Increased values in five parameters suggest a higher structural organization, and in two parameters higher fiber density. One parameter represents a quotient combining both organization and fiber density. RESULTS Among athletes, only ball sport athletes exhibited an increase in one summative parameter at pre-insertion site compared to athletes from other sport categories. When compared to athletes, controls had significantly higher values of four parameters at pre-insertion and three parameters at midportion site reflecting differences in both, fiber organization and density. CONCLUSIONS Intra-tendinous-morphology was similar in all groups of adolescent athletes. Higher values found in non-athletes might suggest higher AT fiber density and organization. It is yet unclear whether the lesser structural organization in young athletes represents initial AT pathology, or a physiological adaptive response at the fiber cross-linking level.
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Affiliation(s)
- Michael Cassel
- University Outpatient Clinic, Dept. Sports Medicine, University of Potsdam, Germany.
| | - Lucie Risch
- University Outpatient Clinic, Dept. Sports Medicine, University of Potsdam, Germany
| | - Frank Mayer
- University Outpatient Clinic, Dept. Sports Medicine, University of Potsdam, Germany
| | - Hannes Kaplick
- University Outpatient Clinic, Dept. Sports Medicine, University of Potsdam, Germany
| | - Aaron Engel
- Department of Biological Systems Engineering, University of Nebraska-Lincoln, USA
| | - Kornelia Kulig
- Division of Biokinesiology and Physical Therapy, University of Southern California, USA
| | - Greg Bashford
- Department of Biological Systems Engineering, University of Nebraska-Lincoln, USA
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Stefansson SH, Brandsson S, Langberg H, Arnason A. Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol. Orthop J Sports Med 2019; 7:2325967119834284. [PMID: 30915381 PMCID: PMC6429908 DOI: 10.1177/2325967119834284] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Eccentric exercises are the only conservative treatment that has shown good clinical results in studies of Achilles tendinopathy (AT), but success rates vary, indicating the need for alternative treatments. Soft tissue treatments are widely used for AT, but strong scientific evidence is lacking to support those treatments. Purpose/Hypotheses This study aimed to determine whether pressure massage to the calf muscles is a useful treatment for AT and to compare this treatment versus an eccentric exercise protocol. Our first hypothesis was that pressure massage treatment is equivalent or superior to eccentric exercises with regard to pain reduction time (ie, pain would be reduced more quickly with pressure massage). The second hypothesis was that pressure massage is equivalent or superior to eccentric exercises with regard to function of the calf muscles. Study Design Randomized controlled trial; Level of evidence, 1. Methods A total of 60 patients with AT were randomized into 3 groups: group 1 underwent an eccentric exercise protocol, group 2 underwent pressure massage, and group 3 underwent pressure massage and the eccentric exercise protocol. Patients were evaluated with the Icelandic version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-IS), an algometer to test the pressure pain threshold (PPT) of the Achilles tendon, tests for ankle range of motion (ROM), and real-time ultrasonographic (US) scanning of tendon thickness and degree of neovascularization. Measurements for VISA-A-IS, PPT, and ROM were taken at 0, 4, 8, 12, and 24 weeks. US scan measurements were taken at 0, 12, and 24 weeks. Mixed-model analysis of variance was used for statistical analysis. Results All groups improved when evaluated with VISA-A-IS scores (P < .0001). The pressure massage group improved significantly more than the eccentric exercise group at week 4, which was the only between-group difference. Ankle ROM increased significantly over time (ROM bent knee P = .006 and ROM straight knee P = .034), but no significant difference was found between groups. No significant difference was found in evaluations of PPT or US scan measurements. Conclusion Pressure massage is a useful treatment for Achilles tendinopathy. Compared with eccentric exercise treatment, pressure massage gives similar results. Combining the treatments did not improve the outcome.
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Affiliation(s)
- Stefan H Stefansson
- The Research Centre of Movement Science, Department of Physical Therapy, University of Iceland, Reykjavik, Iceland.,Physical Therapy and Medical Centre, Orkuhusid, Reykjavik, Iceland
| | | | - Henning Langberg
- CopenRehab, Institute of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Arni Arnason
- The Research Centre of Movement Science, Department of Physical Therapy, University of Iceland, Reykjavik, Iceland.,Gaski Physical Therapy, Reykjavik, Iceland
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Johannsen F, Jensen S, Wetke E. 10-year follow-up after standardised treatment for Achilles tendinopathy. BMJ Open Sport Exerc Med 2018; 4:e000415. [PMID: 30305926 PMCID: PMC6173232 DOI: 10.1136/bmjsem-2018-000415] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/19/2018] [Accepted: 09/03/2018] [Indexed: 11/04/2022] Open
Abstract
Background Achilles tendinopathy is a common and often long-lasting injury. We present a 10-year follow-up on a pragmatic study on Achilles tendinopathy treated with controlled exercises supplemented with corticosteroid injections if necessary in order to continue training. Methods All patients who completed the original study (n=93) were invited for a 10-year follow-up. 83% participated. Patients were evaluated with ultrasound scanning (n=58) and with a questionnaire (n=77) using the same outcome measures as in the primary study. The 10-year overall outcome on a 4-point scale (excellent, good, fair, poor), other treatments and adverse event and present activity level were recorded. Results Excellent outcome was reported in 63% and good outcome in 27%. 76% reported an activity level at 75%-100% of preinjury level. The average Victorian Institute of Sports Assessment-Achilles score for all patients was 84 (SD 19). 16% had surgery. Three ruptures occurred 5-8 years after the primary study. The improvement from entry to 6 months in the primary study was maintained until 10-year follow-up. Insertional tendinopathy did not differ from mid-substance tendinopathy in any outcome measure (short term and long term). We encountered no prognostic markers on ultrasound for the long-term outcome; however, present heterogeneity and increased flow resemble present pain. Thickened tendons seem to maintain their thickness despite improvement of symptoms. Conclusion One to two corticosteroid injections are a safe and effective supplement to controlled exercises in the treatment of Achilles tendon pain with no signs of deterioration in the very long term. Mid-substance and insertional tendinopathies benefit equally from this treatment.
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Affiliation(s)
- Finn Johannsen
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Copenhagen, Denmark.,Furesø-reumatologerne, Farum, Denmark
| | | | - Eva Wetke
- Department of Orthopedic Surgery, Næstved, Denmark
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Hullfish TJ, Hagan KL, Casey E, Baxter JR. Achilles tendon structure differs between competitive distance runners and nonrunners despite no clinical signs or symptoms of midsubstance tendinopathy. J Appl Physiol (1985) 2018; 125:453-458. [DOI: 10.1152/japplphysiol.00012.2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Achilles tendinopathy affects many running athletes and often leads to chronic pain and functional deficits. Although changes in tendon structure have been linked with tendinopathy, the effects of distance running on tendon structure are not well understood. Therefore, the purpose of this study was to characterize structural differences in the Achilles tendons in healthy young adults and competitive distance runners using quantitative ultrasound analyses. We hypothesized that competitive distance runners with no clinical signs or symptoms of tendinopathy would have quantitative signs of tendon damage, characterized by decreased collagen alignment and echogenicity, in addition to previous reports of thicker tendons. Longitudinal ultrasound images of the right Achilles tendon midsubstance were acquired in competitive distance runners and recreationally active adults. Collagen organization, mean echogenicity, and tendon thickness were quantified using image processing techniques. Clinical assessments confirmed that runners had no signs or symptoms of tendinopathy, and controls were only included if they had no history of Achilles tendon pain or injuries. Runner tendons were 40% less organized, 48% thicker, and 41% less echogenic compared with the control tendons ( P < 0.001). Young adults engaged in competitive distance running have structurally different tendons than recreationally active young adults. NEW & NOTEWORTHY In this study, we quantified the Achilles tendon substructure in distance runners, and a control group of young adults, to determine whether distance running elicits structural adaptations of the tendon. We found that competitive distance runners have structurally compromised Achilles tendons despite not showing any clinical signs or symptoms of tendon injury. These findings suggest that distance running may stimulate structural changes as a protective mechanism against tendon pain and dysfunction.
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Affiliation(s)
- Todd J. Hullfish
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenton L. Hagan
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellen Casey
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Josh R. Baxter
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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In Achilles tendinopathy, the neovascularization, detected by contrast-enhanced ultrasound (CEUS), is abundant but not related to symptoms. Knee Surg Sports Traumatol Arthrosc 2018; 26:2051-2058. [PMID: 29079961 DOI: 10.1007/s00167-017-4710-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE AND HYPOTHESIS Mid-portion Achilles tendinopathy is characterized by a proliferation of small vessels, called neovascularization, which can be demonstrated by power Doppler sonography (PD). Neovascularization can be correlated with diagnosis and consequent therapies focused on vascular supply. Published data regarding the relationship between neovascularisation and symptoms, such as pain and disability, are contradictory. The hypothesis that contrast-enhanced ultrasound (CEUS) could detect with more sensibility than PD the new vessel ingrowth in human degenerated Achilles tendons and therefore the correlation of neovascularization with pain and disability, was evaluated. METHODS Thirty consecutive patients of recalcitrant Achilles tendinopathy were studied with ultrasound greyscale (US), PD, CEUS and magnetic resonance imaging. Neovascularization was recorded as percentage on the whole extension of examined area. The vascularization time was recorded as venous and arterial type. Imaging data were classified both concurrently with the examination and in a secondary blinded assessment; any difference in the subjective assessment was discussed and a consensus view formed. Pain and disability were assessed by Western Ontario McMaster Universities Arthritis Index (WOMAC) and EuroQuality of life 5-dimension-5-level questionnaire and visual analogue scale (EQ-VAS). All results were analysed with suitable statistical methods. RESULTS 76.7% of cases were degenerated; 23.3% had also partial discontinuity of the fibres. PD detected vascularization in 54% of cases, whereas CEUS in 83% of cases: in 13 cases, PD did not detect vascularization. The vascularization time was rapid (< 20 s, arterial type) in 60% of cases. WOMAC pain mean value is 6.4 and SD 3.4; WOMAC total score mean value is 21.6 and SD 12.8. EQ-VAS mean value is 56 and SD 18.3. No statistically significant correlation emerged between vascularization and pain/disability. CONCLUSIONS CEUS showed a greater ability to detect neovessels than PD in chronic Achilles tendinopathies. Nevertheless in 30 consecutive tendinopathies, no correlation between pain/disability and neovascularization was found: the role of multiple neovessels continue to be unclear. The possibility to discriminate arterial from venous vessels ('vascularization time') could be useful to understand the pathophysiology of tendinopathies and its healing process. STUDY TYPE Diagnostic study. LEVEL OF EVIDENCE II.
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Maffulli N, Oliva F, Maffulli GD, Giai Via A, Gougoulias N. Minimally Invasive Achilles Tendon Stripping for the Management of Tendinopathy of the Main Body of the Achilles Tendon. J Foot Ankle Surg 2018; 56:938-942. [PMID: 28659242 DOI: 10.1053/j.jfas.2017.05.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Indexed: 02/03/2023]
Abstract
Achilles tendinopathy is a common cause of disability. New nerves fibers grow from the paratenon into the Achilles tendon, and they could play a central role in the development of pain. We report the results of minimally invasive Achilles tendon stripping for Achilles tendinopathy in 47 active patients. The Victorian Institute of Sports Assessment-Achilles questionnaire score improved from 53.8 preoperatively to 85.3 postoperatively (p < .001). After a mean follow-up period of 40.5 months, 41 patients had resumed sporting activities at an average of 3.5 months postoperatively. A sural nerve injury was recorded in 5 patients (10.6%), and all 5 complications occurred during the first 12 cases. As a result, the technique was slightly modified, and no sural nerve neuropathy was observed subsequently. One superficial infection (2.1%) was recorded. Minimally invasive Achilles tendon stripping seems to be an effective, technically simple, and inexpensive treatment of Achilles tendinopathy. Further randomized controlled trials involving more patients are needed to confirm these outcomes.
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Affiliation(s)
- Nicola Maffulli
- Professor, Department of Musculoskeletal Disorders, Faculty of Medicine, University of Salerno, Salerno, Italy; Professor, Queen Mary University of London, Barts, United Kingdom; Professor, The London School of Medicine and Dentistry, William Harvey Research Institute, Centre for Sports and Exercise Medicine, Mile End Hospital, London, United Kingdom.
| | - Francesco Oliva
- Orthopedist, Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, Rome, Italy
| | - Gayle D Maffulli
- Assistant Professor, Surgical Trials Unit, Curis Consulting, London, United Kingdom
| | - Alessio Giai Via
- Orthopedist, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, Milano, Italy
| | - Nikolaos Gougoulias
- Orthopedist, Department of Orthopaedics, Frimley Health National Health Service Foundation Trust, Frimley Park Hospital, Camberley, United Kingdom
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Wengler K, Fukuda T, Tank D, Huang M, Gould ES, Schweitzer ME, He X. Intravoxel incoherent motion (IVIM) imaging in human achilles tendon. J Magn Reson Imaging 2018; 48:1690-1699. [PMID: 29741808 DOI: 10.1002/jmri.26182] [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: 01/31/2018] [Accepted: 04/19/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Limited microcirculation has been implicated in Achilles tendinopathy and may affect healing and disease progression. Existing invasive and noninvasive approaches to evaluate tendon microcirculation lack sensitivity and spatial coverage. PURPOSE To develop a novel Achilles tendon intravoxel incoherent motion (IVIM) MRI protocol to overcome the limitations from low tendon T2 /T2 * value and low intratendinous blood volume and blood velocity to evaluate tendon microcirculation. STUDY TYPE Prospective. SUBJECTS Sixteen healthy male participants (age 31.0 ± 2.1) were recruited. FIELD STRENGTH/SEQUENCE A stimulated echo readout-segmented echo planar imaging (ste-RS-EPI) IVIM sequence at 3.0T. ASSESSMENT The feasibility of the proposed ste-RS-EPI IVIM protocol combined with Achilles tendon magic angle effect was evaluated. The sensitivity of the protocol was assessed by an exercise-induced intratendinous hemodynamic response in healthy participants. The vascular origin of the observed IVIM signal was validated by varying the diffusion mixing time and echo time. STATISTICAL TESTS Two-tailed t-tests were used to evaluate differences (P < 0.05 was considered significant). RESULTS Consistent with known tendon hypovascularity, the midportion Achilles tendon at baseline showed significantly lower IVIM-derived perfusion fraction (fp ) (3.1 ± 0.9%) compared to the proximal and distal Achilles tendon (6.0 ± 1.8% and 6.1 ± 2.0%, respectively; P < 0.01). Similarly, the midportion Achilles tendon exhibited significantly lower baseline blood flow index (D*×fp ) (40.9 ± 19.2, 18.3 ± 5.3, and 32.0 ± 9.4 in proximal, midportion, and distal Achilles tendon, respectively; P < 0.01). Eccentric heel-raise exercise led to ∼2 times increase of Achilles tendon blood flow in healthy participants. Consistent with its vascular origin, the estimated fp demonstrated a high dependency to IVIM protocol parameters, while the T1 /T2 -corrected absolute intratendinous microvascular blood volume fraction (Vb ) did not vary. DATA CONCLUSION Achilles tendon ste-RS-EPI IVIM noninvasively assessed baseline values and exercise-induced changes to tendon microcirculation in healthy tendon. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1690-1699.
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Affiliation(s)
- Kenneth Wengler
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Takeshi Fukuda
- Department of Radiology, Stony Brook University, Stony Brook, New York, USA
| | - Dharmesh Tank
- Department of Radiology, Stony Brook University, Stony Brook, New York, USA
| | - Mingqian Huang
- Department of Radiology, Stony Brook University, Stony Brook, New York, USA
| | - Elaine S Gould
- Department of Radiology, Stony Brook University, Stony Brook, New York, USA
| | - Mark E Schweitzer
- Department of Radiology, Stony Brook University, Stony Brook, New York, USA
| | - Xiang He
- Department of Radiology, Stony Brook University, Stony Brook, New York, USA
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Schneider M, Angele P, Järvinen TA, Docheva D. Rescue plan for Achilles: Therapeutics steering the fate and functions of stem cells in tendon wound healing. Adv Drug Deliv Rev 2018; 129:352-375. [PMID: 29278683 DOI: 10.1016/j.addr.2017.12.016] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 12/01/2017] [Accepted: 12/22/2017] [Indexed: 02/07/2023]
Abstract
Due to the increasing age of our society and a rise in engagement of young people in extreme and/or competitive sports, both tendinopathies and tendon ruptures present a clinical and financial challenge. Tendon has limited natural healing capacity and often responds poorly to treatments, hence it requires prolonged rehabilitation in most cases. Till today, none of the therapeutic options has provided successful long-term solutions, meaning that repaired tendons do not recover their complete strength and functionality. Our understanding of tendon biology and healing increases only slowly and the development of new treatment options is insufficient. In this review, following discussion on tendon structure, healing and the clinical relevance of tendon injury, we aim to elucidate the role of stem cells in tendon healing and discuss new possibilities to enhance stem cell treatment of injured tendon. To date, studies mainly apply stem cells, often in combination with scaffolds or growth factors, to surgically created tendon defects. Deeper understanding of how stem cells and vasculature in the healing tendon react to growth factors, common drugs used to treat injured tendons and promising cellular boosters could help to develop new and more efficient ways to manage tendon injuries.
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Risch L, Wochatz M, Messerschmidt J, Engel T, Mayer F, Cassel M. Reliability of Evaluating Achilles Tendon Vascularization Assessed With Doppler Ultrasound Advanced Dynamic Flow. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:737-744. [PMID: 28960372 DOI: 10.1002/jum.14414] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The reliability of quantifying intratendinous vascularization by high-sensitivity Doppler ultrasound advanced dynamic flow has not been examined yet. Therefore, this study aimed to investigate the intraobserver and interobserver reliability of evaluating Achilles tendon vascularization by advanced dynamic flow using established scoring systems. METHODS Three investigators evaluated vascularization in 67 recordings in a test-retest design, applying the Ohberg score, a modified Ohberg score, and a counting score. Intraobserver and interobserver agreement for the Ohberg score and modified Ohberg score was analyzed by the Cohen κ and Fleiss κ coefficients (absolute), Kendall τ b coefficient, and Kendall coefficient of concordance (W; relative). The reliability of the counting score was analyzed by intraclass correlation coefficients (ICC) 2.1 and 3.1, the standard error of measurement (SEM), and Bland-Altman analysis (bias and limits of agreement [LoA]). RESULTS Intraobserver and interobserver agreement (absolute/relative) ranged from 0.61 to 0.87/0.87 to 0.95 and 0.11 to 0.66/0.76 to 0.89 for the Ohberg score and from 0.81 to 0.87/0.92 to 0.95 and 0.64 to 0.80/0.88 to 0.93 for the modified Ohberg score, respectively. The counting score revealed an intraobserver ICC of 0.94 to 0.97 (SEM, 1.0-1.5; bias, -1; and LoA, 3-4 vessels). The interobserver ICC for the counting score ranged from 0.91 to 0.98 (SEM, 1.0-1.9; bias, 0; and LoA, 3-5 vessels). CONCLUSIONS The modified Ohberg score and counting score showed excellent reliability and seem convenient for research and clinical practice. The Ohberg score revealed decent intraobserver but unexpected low interobserver reliability and therefore cannot be recommended.
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Affiliation(s)
- Lucie Risch
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Monique Wochatz
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Janin Messerschmidt
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Tilman Engel
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Frank Mayer
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
| | - Michael Cassel
- University Outpatient Clinic, Sports Medicine and Sports Orthopedics, University of Potsdam, Potsdam, Germany
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Paratendinous Scraping and Excision of Plantaris for Achilles Tendinopathy. TECHNIQUES IN FOOT AND ANKLE SURGERY 2018. [DOI: 10.1097/btf.0000000000000168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dirrichs T, Quack V, Gatz M, Tingart M, Rath B, Betsch M, Kuhl CK, Schrading S. Shear Wave Elastography (SWE) for Monitoring of Treatment of Tendinopathies: A Double-blinded, Longitudinal Clinical Study. Acad Radiol 2018; 25:265-272. [PMID: 29153963 DOI: 10.1016/j.acra.2017.09.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/16/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
RATIONALE AND OBJECTIVES We aimed to investigate the diagnostic accuracy with which shear wave elastography (SWE) can be used to monitor response to treatment of tendinopathies, and to compare it to conventional ultrasound (US)-imaging methods (B-mode US (B-US) and power Doppler US (PD-US)). MATERIALS AND METHODS A prospective Institutional Review Board-approved longitudinal study on 35 patients with 47 symptomatic tendons (17 Achilles-, 15 patellar-, and 15 humeral-epicondylar) who underwent standardized multimodal US and standardized clinical assessment before and after 6 months of treatment (tailored stretching exercise, sport break, and local Polidocanol) was carried out. All US studies were performed by radiologists blinded to the clinical symptoms on both tendon sides to avoid biased interpretations, by B-US, PD-US, and SWE, conducted in the same order, using a high-resolution linear 15 MHz probe (Aixplorer). Orthopedic surgeons who were in turn blinded to US imaging results used established orthopedic scores (Victorian Institute of Sports Assessment questionnaire for Achilles, Victorian Institute of Sports Assessment questionnaire for patellar tendons, and Disability Arm Shoulder Hand scoring system) to rate presence, degree, and possible resolution of symptoms. We analyzed the diagnostic accuracy with which the different US imaging methods were able to detect symptomatic tendons at baseline as well as treatment effects, with orthopedic scores serving as reference standard. RESULTS B-US, PD-US, and SWE detected symptomatic tendons with a sensitivity of 66% (31 of 47), 72% (34 of 47), and 87.5% (41 of 47), respectively. Positive predictive value was 0.67 for B-US, 0.87 for PD-US, and 1 for SWE. After treatment, clinical scores improved in 68% (32 of 47) of tendons. Treatment effects were observable by B-US, PD-US, and SWE with a sensitivity of 3.1% (1 of 32), 28.1% (9 of 32), and 81.3% (26 of 32), respectively. B-US was false-positive in 68.8% (20 of 32), PD-US in 46.9% (15 of 32), and SWE in 12.5% (4 of 32) (SWE). Clinical scores and B-US, PD-US, and SWE findings correlated poorly (r = 0.24), moderately (r = 0.59), and strongly (r = 0.80). CONCLUSION Unlike B-US or PD-US, SWE is able to depict processes associated with tendon healing and may be a useful tool to monitor treatment effects.
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44
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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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45
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Fenelon C, Galbraith JG, Hession P, D'Souza LG. Complete tendon Achilles rupture following injection of Aethoxysklerol (polidocanol) for the treatment of chronic Achilles tendinopathy. Foot Ankle Surg 2017; 23:e7-e8. [PMID: 29203002 DOI: 10.1016/j.fas.2016.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/18/2016] [Accepted: 11/06/2016] [Indexed: 02/04/2023]
Abstract
Achilles tendinopathy can be a chronic disabling condition affecting both athletic and sedentary patients. Multiple new treatment approaches have developed, including shock wave therapy and various types of injection. One of the novel treatment methods used is the injection of Aethoxysklerol or polidocanol, a sclerosing substance injected under ultrasound guidance targeting areas of neovascularisation. We report the case of a 78-year-old lady who suffered a complete Achilles tendon rupture following injection of Aethoxysklerol. This is the first case of Achilles tendon rupture following Aethoxysklerol injection in isolation to our knowledge in the literature and the first published complication of this treatment.
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Affiliation(s)
- Christopher Fenelon
- Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland.
| | - John G Galbraith
- Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland.
| | - Paul Hession
- Department of Radiology,University Hospital Limerick, Limerick, Ireland.
| | - Lester G D'Souza
- Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland.
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46
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Federer AE, Steele JR, Dekker TJ, Liles JL, Adams SB. Tendonitis and Tendinopathy: What Are They and How Do They Evolve? Foot Ankle Clin 2017; 22:665-676. [PMID: 29078821 DOI: 10.1016/j.fcl.2017.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The development of tendinitis and tendinopathy is often multifactorial and the result of both intrinsic and extrinsic factors. Intrinsic factors include anatomic factors, age-related factors, and systemic factors, whereas extrinsic factors include mechanical overload and improper form and equipment. Although tendinitis and tendinopathy are often incorrectly used interchangeably, they are in 2 distinct pathologies. Due to their chronicity and high prevalence in tendons about the ankle, including the Achilles tendon, the posterior tibialis tendon, and the peroneal tendons, tendinitis and tendinopathies cause significant morbidity and are important pathologies for physicians to recognize.
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Affiliation(s)
- Andrew E Federer
- Foot and Ankle Division, Department of Orthopedic Surgery, Duke University Medical Center, 2301 Erwin Road, Box 3000, Durham, NC 27710, USA
| | - John R Steele
- Foot and Ankle Division, Department of Orthopedic Surgery, Duke University Medical Center, 2301 Erwin Road, Box 3000, Durham, NC 27710, USA
| | - Travis J Dekker
- Foot and Ankle Division, Department of Orthopedic Surgery, Duke University Medical Center, 2301 Erwin Road, Box 3000, Durham, NC 27710, USA
| | - Jordan L Liles
- Foot and Ankle Division, Department of Orthopedic Surgery, Duke University Medical Center, 2301 Erwin Road, Box 3000, Durham, NC 27710, USA
| | - Samuel B Adams
- Foot and Ankle Division, Department of Orthopedic Surgery, Duke University Medical Center, 2301 Erwin Road, Box 3000, Durham, NC 27710, USA.
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47
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Cassel M, Intziegianni K, Risch L, Müller S, Engel T, Mayer F. Physiological Tendon Thickness Adaptation in Adolescent Elite Athletes: A Longitudinal Study. Front Physiol 2017; 8:795. [PMID: 29075203 PMCID: PMC5643477 DOI: 10.3389/fphys.2017.00795] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/28/2017] [Indexed: 11/13/2022] Open
Abstract
Increased Achilles (AT) and Patellar tendon (PT) thickness in adolescent athletes compared to non-athletes could be shown. However, it is unclear, if changes are of pathological or physiological origin due to training. The aim of this study was to determine physiological AT and PT thickness adaptation in adolescent elite athletes compared to non-athletes, considering sex and sport. In a longitudinal study design with two measurement days (M1/M2) within an interval of 3.2 ± 0.8 years, 131 healthy adolescent elite athletes (m/f: 90/41) out of 13 different sports and 24 recreationally active controls (m/f: 6/18) were included. Both ATs and PTs were measured at standardized reference points. Athletes were divided into 4 sport categories [ball (B), combat (C), endurance (E) and explosive strength sports (S)]. Descriptive analysis (mean ± SD) and statistical testing for group differences was performed (α = 0.05). AT thickness did not differ significantly between measurement days, neither in athletes (5.6 ± 0.7 mm/5.6 ± 0.7 mm) nor in controls (4.8 ± 0.4 mm/4.9 ± 0.5 mm, p > 0.05). For PTs, athletes presented increased thickness at M2 (M1: 3.5 ± 0.5 mm, M2: 3.8 ± 0.5 mm, p < 0.001). In general, males had thicker ATs and PTs than females (p < 0.05). Considering sex and sports, only male athletes from B, C, and S showed significant higher PT-thickness at M2 compared to controls (p ≤ 0.01). Sport-specific adaptation regarding tendon thickness in adolescent elite athletes can be detected in PTs among male athletes participating in certain sports with high repetitive jumping and strength components. Sonographic microstructural analysis might provide an enhanced insight into tendon material properties enabling the differentiation of sex and influence of different sports.
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Affiliation(s)
- Michael Cassel
- Department of Sports Medicine, University Outpatient Clinic, University of Potsdam, Brandenburg, Germany
| | - Konstantina Intziegianni
- Department of Sports Medicine, University Outpatient Clinic, University of Potsdam, Brandenburg, Germany
| | - Lucie Risch
- Department of Sports Medicine, University Outpatient Clinic, University of Potsdam, Brandenburg, Germany
| | - Steffen Müller
- Department of Sports Medicine, University Outpatient Clinic, University of Potsdam, Brandenburg, Germany
| | - Tilman Engel
- Department of Sports Medicine, University Outpatient Clinic, University of Potsdam, Brandenburg, Germany
| | - Frank Mayer
- Department of Sports Medicine, University Outpatient Clinic, University of Potsdam, Brandenburg, Germany
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48
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Maffulli N, Oliva F, Loppini M, Aicale R, Spiezia F, King JB. The Royal London Hospital Test for the clinical diagnosis of patellar tendinopathy. Muscles Ligaments Tendons J 2017; 7:315-322. [PMID: 29264343 DOI: 10.11138/mltj/2017.7.2.315] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose To ascertain whether the Royal London Hospital test is reproducible, sensitive, and specific for diagnosis of patellar tendinopathy. Methods Fifteen consecutive athletes with patellar tendinopathy were prospectively enrolled and compared with a control group of 15 non consecutive athletes with Achilles tendinopathy. Two testers examined separately each patient, using manual palpation and the Royal London Hospital test for diagnosis of patellar tendinopathy. High resolution real time ultrasonography was used as standard for diagnosis of tendinopathy and assessment of tendon thickness. Results The palpation test presented significantly higher sensitivity compared to the Royal London Hospital test (98 vs 88%; P=0.01); specificity was 94% for the palpation test and 98% for the Royal London Hospital test (P>0.05). Positive and negative predictive values were 94 and 98% for palpation test, 98 and 89% for the Royal London Hospital test, respectively. The two tests showed good to very good intra-tester and inter-tester agreement. At ultrasonography, pathological patellar tendons were significantly thicker compared to controlateral healthy tendon (P<0.001). Conclusions In symptomatic patients with patellar tendinopathy, the Royal London Hospital test showed lower sensitivity and higher specificity than manual palpation. Both tests should be performed for a correct clinical diagnosis of patellar tendinopathy. Imaging assessment should be performed as a confirmatory test. Level of Evidence III.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospita, London, England
| | - Francesco Oliva
- Department of Orthopedics and Traumatology, University of Rome "Tor Vergata" School of Medicine, Rome, Italy
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Filippo Spiezia
- Department Upper and Lower Limb Surgery Unit, University Campus Bio-Medico, Rome, Italy
| | - John B King
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospita, London, England
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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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50
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Morath O, Kubosch EJ, Taeymans J, Zwingmann J, Konstantinidis L, Südkamp NP, Hirschmüller A. The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy-a systematic review including meta-analysis. Scand J Med Sci Sports 2017; 28:4-15. [PMID: 28449312 DOI: 10.1111/sms.12898] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2017] [Indexed: 01/29/2023]
Abstract
Chronic painful Achilles tendinopathy (AT) is a common disorder among athletes. Sclerotherapy (ST) and prolotherapy (PT) are two promising options among the numerous other conservative therapies. As their efficacy and potential adverse effects (AE) are still unclear, we systematically searched, analyzed, and synthesized the available literature on ST and PT for treating AT. Electronic databases, Google Scholar and articles' reference lists were searched according to PRISMA guidelines. Eligibility criteria were set up according to the PICOS-scheme including human and animal studies. Three authors independently reviewed the results and evaluated methodological quality (Coleman Methodology Score and Cochrane Risk of Bias Assessment). The initial search yielded 1104 entries. After screening, 18 articles were available for qualitative synthesis, six of which were subjected to meta-analysis. The mean Coleman Score of the 13 human studies was 50. Four RCTs were ranked as having a low risk of selection bias. Three of those reported a statistically significant drop in the visual analog scale (VAS) score, one a significant increase in the VISA-A Score. 12 of 13 human studies reported positive results in achieving pain relief and patient satisfaction, whereas only one study's finding differed. Meta-analysis revealed an unambiguous result in favor of the intervention (weighted mean difference D=-4.67 cm, 95% CI -5.56 to -3.76 cm [P<.001]). Only one serious AE and two minor AEs were reported in the entire literature. This systematic review suggests that ST and PT may be effective treatment options for AT and that they can be considered safe. Long-term studies and RCTs are still needed to support their recommendation.
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Affiliation(s)
- O Morath
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - E J Kubosch
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - J Taeymans
- Bern University of Applied Sciences - Health, Berne, Switzerland
| | - J Zwingmann
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - L Konstantinidis
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - N P Südkamp
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - A Hirschmüller
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany.,ALTIUS Swiss Sportmed Center, Rheinfelden, Switzerland
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