Achilles tendons: clinical relevance of neovascularization diagnosed with power Doppler US

Value of ultrasound and magnetic resonance imaging in the assessment of Achilles tendon healing following percutaneous repair with the Dresden instrument

BACKGROUND

Percutaneous Achilles tendon (AT) repair with the Dresden instrument is a safe and effective treatment for AT rupture within 15 days after injury. Follow-up includes clinical examination and imaging to assess the healing process and detect possible complications. The findings of each control visit determine the progression of the rehabilitation of each patient.

METHODS

We assessed the postoperative findings of all patients who underwent AT with the Dresden technique from May 2022 to September 2023, during a follow-up period of 6 months. The study population included 40 male patients between 18 and 59 years of age. Ultrasound (US) and magnetic resonance imaging (MRI) were performed in all patients at day 15 postoperatively and then monthly for 6 months.

RESULTS

All patients completed 6 months follow-up and 2 (5%) presented with postoperative wound dehiscence. No sural nerve lesions, reruptures, reoperations or other complications were seen. Both imaging methods showed excellent correlation of findings at all time points. Both methods were effective to assess the hematoma and structural changes of the healing process during the first 3 months. The use of US with Doppler was a useful tool to evaluate blood flow to the tendon stumps. After 3 months no significant morphological changes were observed but the US enabled a dynamic functional assessment of the tendon. After 4 months tissues showed homogenization and decrease of volume without further major changes.

CONCLUSION

Both US and MRI proved to be excellent methods to assess the healing process after percutaneous AT repair. The US performed by an experienced investigator showed advantages over MRI in evaluating the gap between the tendon stumps, the possibility of evaluating the vascularity with Doppler US and assessing the functionality of the healing tendon with dynamic examination, besides being a cheap and easily accessible imaging method.

Widespread Vascularization and Correlation of Glycosaminoglycan Accumulation to Tendon Pain in Human Plantar Fascia Tendinopathy

BACKGROUND

Plantar fasciitis is a painful tendinous condition (tendinopathy) with a high prevalence in athletes. While a healthy tendon has limited blood flow, ultrasound has indicated elevated blood flow in tendinopathy, but it is unknown if this is related to a de facto increase in the tendon vasculature. Likewise, an accumulation of glycosaminoglycans (GAGs) is observed in tendinopathy, but its relationship to clinical pain is unknown.

PURPOSE

To explore to what extent vascularization, inflammation, and fat infiltration were present in patients with plantar fasciitis and if they were related to clinical symptoms.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Biopsy specimens from tendinopathic plantar fascia tissue were obtained per-operatively from both the primary site of tendon pain and tissue swelling ("proximal") and a region that appeared macroscopically healthy at 1 to 2 cm away from the primary site ("distal") in 22 patients. Biopsy specimens were examined with immunofluorescence for markers of blood vessels, tissue cell density, fat infiltration, and macrophage level. In addition, pain during the first step in the morning (registered during an earlier study) was correlated with the content of collagen and GAGs in tissue.

RESULTS

High vascularization (and cellularity) was present in both the proximal (0.89%) and the distal (0.96%) plantar fascia samples, whereas inconsistent but not significantly different fat infiltration and macrophage levels were observed. The collagen content was similar in the 2 plantar fascia regions, whereas the GAG content was higher in the proximal region (3.2% in proximal and 2.8% in distal; P = .027). The GAG content in the proximal region was positively correlated with the subjective morning pain score in the patients with tendinopathy (n = 17).

CONCLUSION

In patients with plantar fasciitis, marked tissue vascularization was present in both the painful focal region and a neighboring nonsymptomatic area. In contrast, the accumulation of hydrophilic GAGs was greater in the symptomatic region and was positively correlated with increased clinical pain levels in daily life.

CLINICAL RELEVANCE

The accumulation of GAGs in tissue rather than the extent of vascularization appears to be linked with the clinical degree of pain symptoms of the disease.

Prevalence of Sonographic Achilles Tendon, Patellar Tendon, and Plantar Fascia Abnormalities in Division I Collegiate Athletes From a Variety of Sports

OBJECTIVE

This study aimed to determine the prevalence of ultrasound abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among a large cohort of collegiate student-athletes.

DESIGN

Observational cross-sectional study.

SETTING

Three Division I institutions.

PARTICIPANTS

243 student-athletes participated in this study. Exclusion criteria included those younger than 18 years or who underwent prior surgery/amputation of structures, including anterior cruciate ligament (ACL) surgeries with patellar tendon grafts.

INTERVENTIONS

Ultrasound examination of the Achilles tendon, patellar tendon, and plantar fascia of each leg was performed. An experienced sonographer reviewed each tendon video in a blinded manner, with a separate experienced sonographer separately reviewing to establish inter-rater reliability.

MAIN OUTCOME MEASURES

The primary outcome measured was the presence of any sonographic abnormality including hypoechogenicity, thickening, or neovascularity.

RESULTS

Ultrasound abnormalities were identified in 10.1%, 37.2%, and 3.9% of all Achilles tendons, patellar tendons, and plantar fasciae, respectively. Abnormalities were significantly associated with the presence of concurrent pain for all structures ( P < 0.01). Specifically, athletes with sonographic abnormalities were approximately 4 times [relative risk (RR) = 4.25; 95% confidence interval (CI), 2.05-8.84], 6 times (RR = 5.69; 95% CI, 2.31-14.00), and 5 times (RR = 5.17; 95% CI, 1.76-15.25) more likely to self-report pain in the Achilles tendon, patellar tendon, and plantar fascia, respectively.

CONCLUSIONS

This multi-institutional study completed at 3 Division I institutions is the largest study of its kind to identify the prevalence of sonographic abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among collegiate student-athletes of various sports.

Ultrasound imaging in professional soccer: when is it adequate?

Ultrasound imaging plays an important role in the diagnosis, monitoring and treatment of injuries in professional soccer players. With the rapid increase in the availability of hand-held portable ultrasound devices and the pressure to make timely and accurate diagnosis in professional soccer where return to play time is crucial, ultrasound imaging is an essential diagnostic tool. In this article, we discuss examples of injuries that can be adequately assessed by ultrasound imaging alone and injuries where ultrasound imaging provides a useful first step to guide further investigation and management.

The value of ultrasonography in predicting the outcomes of simple long bone fractures treated by closed intramedullary nail fixation

PURPOSE

Ultrasonography has been used increasingly in orthopaedic practice credited to its low cost, easy accessibility, non-invasiveness, reproducibility, and safety from radiation. The purpose of this study was to test the validity and efficacy of ultrasonography as an adjunct in the assessment of fracture healing in long bones treated with intramedullary interlocking devices and its predictive value in determining the need for a secondary surgical procedure.

METHODS

This was a descriptive longitudinal study of 40 skeletally mature patients who sustained long bone fractures of the tibia or femur treated using intramedullary interlocking nails. Patients with comminuted and segmental fracture patterns were excluded from the study. Each patient was evaluated at 6- and 12-week post-surgery using standard orthogonal radiographs and ultrasonography to assess fracture healing. Patients were then followed up until fracture union. Quantitative data was analyzed using frequency statistics and descriptive data with inferential statistics.

RESULTS

Ultrasonography predicted 87.5% union and 12.5% delayed or non-union as early as 6 weeks after surgery, while radiographs predicted 22.5% union as late as 3 months of follow-up. The sensitivity and specificity of ultrasonography in assessing fracture healing were 100% and 97.2%, respectively, with a positive predictive value of 80.0%. Vascular resistance index was less than 0.5 in all patients who developed delayed or non-union.

CONCLUSION

Ultrasonography is able to predict fracture outcomes much earlier than standardized radiographs with comparable sensitivity and specificity. Vascular resistance index is an objective parameter in assessing callus quality and predicting fracture outcomes.

Infrared Thermography, Intratendon Vascular Resistance, and Echotexture in Athletes with Patellar Tendinopathy: A Cross-Sectional Study

Ultrasonographic signs of tendinopathies are an increase in thickness, loss of alignment in collagen fibers and the presence of neovascularization. Nevertheless, analysis of intratendinous vascular resistance (IVR) can be more useful for understanding the physiological state of the tissue. To show thermal, echotextural, and Doppler signal differences in athletes with patellar tendinopathy and controls. Twenty-six athletes with patellar tendinopathy (PT) participants (30.1 years; SD = 9.0 years) and 27 asymptomatic athletes (23.3 years; SD = 5.38 years) were evaluated with thermographic and Doppler ultrasonography (DS). Area of Doppler signals (DS), echotextural parameters (echointensity and echovariation) and IVR were determined by image analysis. The statistical analysis was performed by Bayesian methods and the results were showed by Bayes Factor (BF10: probability of alternative hypothesis over null hypothesis), and Credibility intervals (CrI) of the effect. The absolute differences of temperature (TD) were clearly greater (BF10 = 19) in the tendinopathy group (patients) than in controls. Regarding temperature differences between the affected and healthy limb, strong evidence was found (BF₁₀ = 14) for a higher temperature (effect = 0.53°C; 95% CrI = 0.15°C-0.95°C) and very strong for reduced IVR compared (BF₁₀ = 71) (effect = -0.67; 95% CrI = -1.10 to 0.25). The differences in area of DS (BF₁₀ = 266) and EV (BF₁₀ = 266) were higher in tendinopathy group. TD showed a moderate positive correlation with VISA-P scores (tau-B = .29; 95% CrI = .04-.51) and strong correlation with IVR (r = -.553; 95%CrI = -.75 to .18). Athletes with patellar tendinopathy showed a more pronounced thermal difference, a larger area of Doppler signal, a lower IVR and a moderately higher echovariaton than controls. The correlation between temperature changes and IVR might be related with the coexistence of degenerative and inflammatory process in PT.

Evidence-Based High-Loading Tendon Exercise for 12 Weeks Leads to Increased Tendon Stiffness and Cross-Sectional Area in Achilles Tendinopathy: A Controlled Clinical Trial

BACKGROUND

Assuming that the mechanisms inducing adaptation in healthy tendons yield similar responses in tendinopathic tendons, we hypothesized that a high-loading exercise protocol that increases tendon stiffness and cross-sectional area in male healthy Achilles tendons may also induce comparable beneficial adaptations in male tendinopathic Achilles tendons in addition to improving pain and function.

OBJECTIVES

We investigated the effectiveness of high-loading exercise in Achilles tendinopathy in terms of inducing mechanical (tendon stiffness, maximum strain), material (Young's modulus), morphological (tendon cross-sectional area (CSA)), maximum voluntary isometric plantar flexor strength (MVC) as well as clinical adaptations (Victorian Institute of Sports Assessment-Achilles (VISA-A) score and pain (numerical rating scale (NRS))) as the primary outcomes. As secondary outcomes, drop (DJ) and counter-movement jump (CMJ) height and intratendinous vascularity were assessed.

METHODS

We conducted a controlled clinical trial with a 3-month intervention phase. Eligibility criteria were assessed by researchers and medical doctors. Inclusion criteria were male sex, aged between 20 and 55 years, chronic Achilles tendinopathy confirmed by a medical doctor via ultrasound-assisted assessment, and a severity level of less than 80 points on the VISA-A score. Thirty-nine patients were assigned by sequential allocation to one of three parallel arms: a high-loading intervention (training at ~ 90% of the MVC) (n = 15), eccentric exercise (according to the Alfredson protocol) as the standard therapy (n = 15) and passive therapy (n = 14). Parameters were assessed pre- and-post-intervention. Data analysis was blinded.

RESULTS

Primary outcomes: Plantar flexor MVC, tendon stiffness, mean CSA and maximum tendon strain improved only in the high-loading intervention group by 7.2 ± 9.9% (p = 0.045), 20.1 ± 20.5% (p = 0.049), 8.98 ± 5.8% (p < 0.001) and -12.4 ± 10.3% (p = 0.001), respectively. Stiffness decreased in the passive therapy group (-7.7 ± 21.2%; p = 0.042). There was no change in Young's modulus in either group (p > 0.05). The VISA-A score increased in all groups on average by 19.8 ± 15.3 points (p < 0.001), while pain (NRS) dropped by -0.55 ± 0.9 points (p < 0.001).

SECONDARY OUTCOMES

CMJ height decreased for all groups (-0.63 ± 4.07 cm; p = 0.005). There was no change in DJ height and vascularity (p > 0.05) in either group.

CONCLUSION

Despite an overall clinical improvement, it was exclusively the high-loading intervention that induced significant mechanical and morphological adaptations of the plantar flexor muscle-tendon unit. This might contribute to protecting the tendon from strain-induced injury. Thus, we recommend the high-loading intervention as an effective (alternative) therapeutic protocol in Achilles tendinopathy rehabilitation management in males.

CLINICAL TRIALS REGISTRATION NUMBER

NCT02732782.

Do High-Volume Injections Affect the Ultrasonographic Neovascularization in Chronic Achilles Tendinopathy? A Randomized Placebo-Controlled Clinical Trial

OBJECTIVE

High-volume injections (HVIs) are thought to target neovascularization in chronic midportion Achilles tendinopathy (AT), yet the mechanism has not been clarified. Therefore, we aim to evaluate whether a HVI decreases ultrasonographic Doppler flow in patients with chronic midportion AT.

DESIGN

A double-blind, randomized, placebo-controlled clinical trial.

SETTING

Sports medicine department at a district general hospital.

PATIENTS

Sixty-two patients with clinically diagnosed chronic midportion AT were included and randomized into the intervention group (HVI-group, n = 30) and placebo group (n = 32).

INTERVENTION

A daily calf-muscle exercise program combined with either (1) a HVI (HVI-group: 50 mL) or (2) a placebo-injection (placebo-group: 2 mL) with a mixture of saline and lidocaine.

MAIN OUTCOME MEASURES

Primary outcome was the surface area quantification (SAQ) score (%) of the Doppler flow during a 24-week follow-up period. Secondary outcome was the association between SAQ scores and symptoms [Victorian Institute of Sports Assessment-Achilles (VISA-A)]. Outcomes were measured before, directly after, and 1 hour after the injection and at 2, 6, 12, and 24 weeks of follow-up.

RESULTS

There was no significant between-group difference at 24 weeks [-0.1%; 95% confidence interval (CI), -4.9 to 4.7] or at any of the other time points. Change in SAQ score did not correlate with the change in VISA-A score (P = 0.93).

CONCLUSION

A HVI does not affect Doppler flow in patients with chronic midportion AT. Also, changes in Doppler flow were not associated with the clinical outcome. These findings challenge the theoretical basis of a HVI.

TRIAL REGISTRATION

NCT02996409.

Sonographic Screening of Distance Runners for the Development of Future Achilles and Patellar Tendon Pain

OBJECTIVE

The 2 primary aims of this study were to identify ultrasonographic tendon abnormalities in asymptomatic runners and to examine the likelihood of developing pain in runners with ultrasound abnormalities compared with those without abnormalities.

DESIGN

Longitudinal, prospective cohort study.

SETTING

2019 Salt Lake City Marathon.

PARTICIPANTS

Recreational half-marathon and full-marathon runners.

ASSESSMENT OF RISK FACTORS

The Achilles and patellar tendons of asymptomatic runners were examined with ultrasound imaging before a running event. Runners were monitored for self-reported outcomes of pain in the examined tendons at 1, 3, 6, and 12 months after the event.

MAIN OUTCOME MEASURES

Development of pain based on the presence of asymptomatic tendon abnormalities.

RESULTS

One hundred thirty-eight runners (36.2 ± 12.0 years, 49.3% men, and 31.2% full-marathon runners) were included. Ultrasound abnormalities of the Achilles and patellar tendons were identified in 24.6% and 39.1% of the runners before the race, respectively. Ultrasound abnormalities were significantly associated with approximately a 3-fold increase [hazard ratio (HR) = 2.55, P = 0.004] in the hazard of developing pain in the Achilles tendon and patellar tendon (HR = 1.67, P = 0.042) over the year after the race. Positive and negative predictive values of developing pain over the year were 34.1% and 87.2%, respectively, for abnormal findings in the Achilles tendon, and 22.9% and 85.0%, respectively, for the patellar tendon.

CONCLUSIONS

The presence of ultrasonographic abnormalities is associated with increased development of pain in the Achilles and patellar tendons within 1 year of a marathon or half marathon.

Concepts of Entheseal Pain

Pain is the main symptom in entheseal diseases (enthesopathies) despite a paucity of nerve endings in the enthesis itself. Eicosanoids, cytokines, and neuropeptides released during inflammation and repeated nonphysiologic mechanical challenge not only stimulate or sensitize primary afferent neurons present in structures adjacent to the enthesis, but also trigger a "neurovascular invasion" that allows the spreading of nerves and blood vessels into the enthesis. Nociceptive pseudounipolar neurons support this process by releasing neurotransmitters from peripheral endings that induce neovascularization and peripheral pain sensitization. This process may explain the frequently observed dissociation between subjective symptoms such as pain and the structural findings on imaging in entheseal disease.

The Achilles Tendon: Imaging Diagnoses and Image-Guided Interventions-AJR Expert Panel Narrative Review

The Achilles tendon is commonly affected by both chronic repetitive overuse and traumatic injuries. Achilles tendon injuries can potentially affect any individual but have a particularly high incidence in professional athletes. Appropriate imaging evaluation and diagnosis are paramount to guiding appropriate management. In this AJR Expert Panel Narrative Review, we discuss the role of various imaging modalities (particularly ultrasound and MRI) in the assessment of Achilles tendon pathology, focusing on modalities' relative advantages and technical considerations. We describe the most common diagnoses affecting the Achilles tendon and adjacent structures, highlighting key imaging findings and providing representative examples. Various image-guided interventions that may be employed in the management of Achilles tendon pathology are also reviewed, including high-volume injection, tendon fenestration, prolotherapy, and corticosteroid injection. The limited evidence supporting such interventions are summarized, noting an overall paucity of large-scale studies showing benefit. Finally, a series of consensus statements by the panel on imaging and image-guided intervention for Achilles tendon pathology are provided.

Diffuse Peripheral Enthesitis in Metabolic Syndrome: A Retrospective Clinical and Power Doppler Ultrasound Study

OBJECTIVES

To investigate peripheral enthesitis with power Doppler ultrasound (PDUS) in patients presenting low back pain (LBP) and metabolic syndrome (MetS) in comparison with patients with only LBP, to correlate US scores with clinical-anthropometric characteristics, and to define any relationship between enthesitis and concurrent diffuse idiopathic hyperostosis syndrome (DISH).

METHODS

Sixty outpatients with LBP and MetS, evaluated with multi-site entheseal PDUS, scoring inflammatory and structural damage changes, were retrospectively analyzed. A group of 60 subjects with LBP, without MetS and evaluated with the same protocol, was analyzed as the control group.

RESULTS

Patients showed overweight (BMI 29.8) and low-grade inflammatory state (C-reactive protein [CRP] 0.58mg/dL, erythrosedimentation rate [ESR] 20.2mm/h). Enthesitis was demonstrated in 52 (86%) patients (17.6% entheses), and in 8 controls (13.3%) (p<.00001). PD signals (15% of patients) were associated with entheseal pain (p=.0138). US scores correlated with body mass index (BMI), pain, type 2 diabetes. In 28 (46%) patients a concurrent DISH was diagnosed, correlating with older age (p<.0001), CRP (p=.0428), ESR (p=.0069) and PDUS scores (p=.0312 inflammatory, p=.0071 structural). MetS had a strong association (OR 4.375, p=.0007) with concurrent DISH.

CONCLUSIONS

Diffuse peripheral enthesitis is very common in MetS. Almost half of MetS patients can have a concurrent diagnosis of DISH; they are older, with higher inflammation, and higher PDUS enthesitis scores.

Estimating the neovascularity of human finger tendon through high frequency ultrasound micro-Doppler imaging

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.

Possible Neoangiogenesis in Achilles Tendon Xanthoma with Familial Hypercholesterolemia: A Novel Approach to Achilles Tendon Xanthoma

Achilles tendon xanthoma (ATX) is one of the typical features of familial hypercholesterolemia (FH). The morphological evaluation of ATX by X-ray radiography is widely recognized; however, the utility of other imaging modalities remains unclear. We herein report two cases of FH in which Doppler ultrasound imaging demonstrated a microvascular flow in ATX that only rarely could be observed in normal Achilles tendons. Neoangiogenesis accompanies chronic inflammation and it may play an important role in the deposition of cholesterol crystals leading to ATX. In addition to the morphological evaluation of ATX, the assessment of neoangiogenesis may therefore be essential for the evaluation of ATX.

A problem-based approach in musculoskeletal ultrasonography: heel pain in adults

Musculoskeletal ultrasonography (US) has unique advantages, such as excellent spatial resolution for superficial structures, the capability for dynamic imaging, and the ability for direct correlation and provocation of symptoms. For these reasons, US is increasingly used to evaluate problems in small joints, such as the foot and ankle. However, it is almost impossible to evaluate every anatomic structure within a limited time. Therefore, US examinations can be faster and more efficient if radiologists know where to look and image patients with typical symptoms. In this review, common etiologies of heel pain are discussed in a problem-based manner. Knowing the common pain sources and being familiar with their US findings will help radiologists to perform accurate and effective US examinations.

Problem Solved: Integral Applications of Musculoskeletal Ultrasound

Musculoskeletal ultrasound has grown substantially in use over the past several years as an indispensable companion to magnetic resonance imaging and other imaging modalities. This article reviews 10 integral applications of musculoskeletal ultrasound as a problem-solving tool with correlative case examples. These applications include the following: (1) accessibility and portability, (2) targeted imaging, (3) dynamic imaging, (4) contralateral comparison, (5) Doppler imaging, (6) increased spatial resolution, (7) solid versus cystic comparison, (8) posttraumatic imaging, (9) postsurgical imaging, and (10) treatment delivery and optimization. The review will help the radiologist recognize the complementary uses of musculoskeletal ultrasound with radiography, computed tomography, and magnetic resonance imaging.

Ultrasound Color Doppler Measures Neovascularization in Achilles Tendinopathy: Review

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

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

Objective

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

Design

This is a cross-sectional study.

Setting

The study was conducted at the University Outpatient Clinic.

Participants

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

Intervention

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

Main Outcome Measure

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

Results

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

Conclusion

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

US-guided high-volume injection for Achilles tendinopathy

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.

Multimodal Ultrasound Versus MRI for the Diagnosis and Monitoring of Achilles Tendinopathy: A Prospective Longitudinal Study

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.

Diffuse Peripheral Enthesitis in Metabolic Syndrome: A Retrospective Clinical and Power Doppler Ultrasound Study

OBJECTIVES

To investigate peripheral enthesitis with power Doppler ultrasound (PDUS) in patients presenting low back pain (LBP) and metabolic syndrome (MetS) in comparison with patients with only LBP, to correlate US scores with clinical-anthropometric characteristics, and to define any relationship between enthesitis and concurrent diffuse idiopathic hyperostosis syndrome (DISH).

METHODS

Sixty outpatients with LBP and MetS, evaluated with multi-site entheseal PDUS, scoring inflammatory and structural damage changes, were retrospectively analyzed. A group of 60 subjects with LBP, without MetS and evaluated with the same protocol, was analyzed as the control group.

RESULTS

Patients showed overweight (BMI 29.8) and low-grade inflammatory state (C-reactive protein [CRP] 0.58mg/dL, erythrosedimentation rate [ESR] 20.2mm/h). Enthesitis was demonstrated in 52 (86%) patients (17.6% entheses), and in 8 controls (13.3%) (p<.00001). PD signals (15% of patients) were associated with entheseal pain (p=.0138). US scores correlated with body mass index (BMI), pain, type 2 diabetes. In 28 (46%) patients a concurrent DISH was diagnosed, correlating with older age (p<.0001), CRP (p=.0428), ESR (p=.0069) and PDUS scores (p=.0312 inflammatory, p=.0071 structural). MetS had a strong association (OR 4.375, p=.0007) with concurrent DISH.

CONCLUSIONS

Diffuse peripheral enthesitis is very common in MetS. Almost half of MetS patients can have a concurrent diagnosis of DISH; they are older, with higher inflammation, and higher PDUS enthesitis scores.

Advanced Musculoskeletal Ultrasound Techniques: What Are the Applications?

OBJECTIVE. The purpose of this article is to cover technical advances in musculo-skeletal ultrasound from the viewpoint of the radiologist. CONCLUSION. Among the advances in musculoskeletal ultrasound that we highlight the use of ultrahigh-frequency transducers to visualize ever-finer anatomic detail, the expanding practical clinical applications for microvascular imaging, and the use of elastography to predict function and, possibly, healing potential.

Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial

OBJECTIVE

To study whether a high volume injection without corticosteroids improves clinical outcome in addition to usual care for adults with chronic midportion Achilles tendinopathy.

DESIGN

Patient and assessor blinded, placebo controlled randomised clinical trial.

SETTING

Sports medicine department of a large district general hospital, the Netherlands.

PARTICIPANTS

80 adults (aged 18-70 years) with clinically diagnosed chronic midportion Achilles tendinopathy and neovascularisation on ultrasonography. 39 were randomised to a high volume injection without corticosteroids and 41 to placebo.

INTERVENTIONS

Participants were instructed to perform an exercise programme for 24 weeks (usual care) combined with one 50 mL high volume injection of saline and lidocaine (intervention group) or one 2 mL placebo injection of saline and lidocaine (placebo group) at baseline.

MAIN OUTCOME MEASURES

Primary outcome was pain and function assessed using the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire at 24 weeks (analysed using a generalised estimation equations model). Secondary outcomes were patient satisfaction, return to sport, degree of ultrasonographic Doppler flow, visual analogue scale on 10 hop test, power and flexibility of the gastrocnemius and soleus muscles, pain detect questionnaire for neuropathic pain, and pain coping inventory. Participants were evaluated at baseline and at 2, 6, 12, and 24 weeks.

RESULTS

Only one participant (1%) was lost to follow-up. The estimated mean VISA-A score improved significantly, from 40.4 (95% confidence interval 32.0 to 48.7) at baseline to 59.1 (50.4 to 67.8) at 24 weeks in the high volume injection group and from 36.9 (27.1 to 46.8) to 58.5 (47.9 to 69.1) in the placebo group. The VISA-A score over time did not differ between the groups (adjusted between group difference at 24 weeks 0.5 points, 95% confidence interval -17.8 to 18.8). No significant between group differences were found for patient satisfaction (21/37 (57%) v 19/39 (49%) patients, P=0.50) and return to desired sport (15/29 (52%) v 19/31 (61%) patients active in sports, P=0.65) at 24 weeks. None of the other secondary outcomes differed between the two groups.

CONCLUSIONS

A high volume injection without corticosteroids in addition to usual care is not effective for symptom reduction in patients with chronic midportion Achilles tendinopathy. On the basis of our findings, we cannot recommend the use of a high volume injection in this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02996409.

Ultrasound Doppler Flow in Patients With Chronic Midportion Achilles Tendinopathy: Is Surface Area Quantification a Reliable Method?

OBJECTIVES

Ultrasound assessments of patients with chronic midportion Achilles tendinopathy include determining the degree of neovascularization using Doppler flow. A frequently used measure to quantify neovascularization is the modified Öhberg score. It is unknown whether the semiquantitative modified Öhberg score (0-4+) has higher reliability than a quantified measure of Doppler flow (0-100%). The purpose of this cross-sectional study was to evaluate the interobserver reliability of the modified Öhberg score and a surface area quantification (SAQ) method for Doppler flow in patients with chronic midportion Achilles tendinopathy.

METHODS

Two observers examined the degree of Doppler flow independently using SAQ and the modified Öhberg score during a single consultation. The intraclass correlation coefficient, standard error of measurement, and minimal detectable difference were determined to evaluate the reliability and measurement properties of the SAQ method and the modified Öhberg score.

RESULTS

In total, 28 consecutive patients with chronic midportion Achilles tendinopathy participated. The intraclass correlation coefficient for interobserver reliability of the SAQ method was 0.81 (95% confidence interval, 0.58-0.91), compared to 0.64 (95% confidence interval, 0.45-0.81) for the modified Öhberg score. The standard error of measurement and minimal detectable difference values for the SAQ method were 2.9% and 8.0%, respectively, and for the modified Öhberg score, they were 0.55 and 1.53 points.

CONCLUSIONS

The SAQ method shows good reliability to evaluate the degree of Doppler flow in patients with chronic midportion Achilles tendinopathy, and it overcomes the ceiling effect of the modified Öhberg score. Future research should focus on the relationship between the SAQ method and clinical outcomes and use this method to monitor treatment responses.

Ultrasound imaging features of the Achilles tendon in dancers. Is there a correlation between the imaging and clinical findings? A cross-sectional study

OBJECTIVES

To analyze the prevalence of tendon pathology and performance associated in pre-professional classic dancers with no history of Achilles tendon (AT) pain.

DESIGN

A cross-sectional study was conducted.

PARTICIPANTS

Twenty-nine classic ballet dancers without AT pain (58 tendons) were recruited. The tendons were classified (normal, abnormal) using ultrasound imaging (USI). Cross-sectional area (CSA) and thickness of flexor hallucis longus (FHL) muscle were measured using USI. Range of movement (ROM) of the first metatarsophalangeal join, balance test, endurance test and vertical jump were measured (bilaterally) as performance variables.

RESULTS

More than a half (62%) of the participants had at least one abnormal tendon, with 45% of the dancers in the abnormal group having bilateral abnormalities. Dancers with AT pathology had significantly more years of dancing and number of weekly pointe hours than those with no pathology on US imaging. No significant differences between the groups were identified for the rest of the variables. Dancing years were moderately correlated with AT thickness.

CONCLUSIONS

Asymptomatic classic dancers had a high incidence of tendon pathology. Increased dancing years was associated with pathology in the AT. Nevertheless, these abnormalities may not affect dance performance.

Power Doppler to investigate superficial digital flexor tendinopathy in the horse

Background:

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

Aim:

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

Methods:

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

Results:

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

Conclusion:

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

Early development of tendinopathy in humans: Sequence of pathological changes in structure and tissue turnover signaling

Overloading of tendon tissue with resulting chronic pain (tendinopathy) is a common disorder in occupational-, leisure- and sports-activity, but its pathogenesis remains poorly understood. To investigate the very early phase of tendinopathy, Achilles and patellar tendons were investigated in 200 physically active patients and 50 healthy control persons. Patients were divided into three groups: symptoms for 0-1 months (T1), 1-2 months (T2) or 2-3 months (T3). Tendinopathic Achilles tendon cross-sectional area determined by ultrasonography (US) was ~25% larger than in healthy control persons. Both Achilles and patellar anterior-posterior diameter were elevated in tendinopathy, and only later in Achilles was the width increased. Increased tendon size was accompanied by an increase in hypervascularization (US Doppler flow) without any change in mRNA for angiogenic factors. From patellar biopsies taken bilaterally, mRNA for most growth factors and tendon components remained unchanged (except for TGF-beta1 and substance-P) in early tendinopathy. Tendon stiffness remained unaltered over the first three months of tendinopathy and was similar to the asymptomatic contra-lateral tendon. In conclusion, this suggests that tendinopathy pathogenesis represents a disturbed tissue homeostasis with fluid accumulation. The disturbance is likely induced by repeated mechanical overloading rather than a partial rupture of the tendon.

What is the role of ultrasound in fracture management?: Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection

Objectives

The aim of this study was to review the current evidence and future application for the role of diagnostic and therapeutic ultrasound in fracture management.

Methods

A review of relevant literature was undertaken, including articles indexed in PubMed with keywords "ultrasound" or "sonography" combined with "diagnosis", "fracture healing", "impaired fracture healing", "nonunion", "microbiology", and "fracture-related infection".

Results

The use of ultrasound in musculoskeletal medicine has expanded rapidly over the last two decades, but the diagnostic use in fracture management is not routinely practised. Early studies have shown the potential of ultrasound as a valid alternative to radiographs to diagnose common paediatric fractures, to detect occult injuries in adults, and for rapid detection of long bone fractures in the resuscitation setting. Ultrasound has also been shown to be advantageous in the early identification of impaired fracture healing; with the advent of 3D image processing, there is potential for wider adoption. Detection of implant-related infection can be improved by ultrasound mediated sonication of microbiology samples. The use of therapeutic ultrasound to promote union in the management of acute fractures is currently a controversial topic. However, there is strong in vitro evidence that ultrasound can stimulate a biological effect with potential clinical benefit in established nonunions, which supports the need for further investigation.

Conclusion

Modern ultrasound image processing has the potential to replace traditional imaging modalities in several areas of trauma practice, particularly in the early prediction of impaired fracture healing. Further understanding of the therapeutic application of ultrasound is required to understand and identify the use in promoting fracture healing.Cite this article: J. A. Nicholson, S. T. J. Tsang, T. J. MacGillivray, F. Perks, A. H. R. W. Simpson. What is the role of ultrasound in fracture management? Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection. Bone Joint Res 2019;8:304-312. DOI: 10.1302/2046-3758.87.BJR-2018-0215.R2.

Achilles tendon complex: The anatomy of its insertional footprint on the calcaneus and clinical implications

The Achilles tendon is the largest, and most commonly torn tendon in the body. The Achilles is usually torn at a region of relative hypo-vascularity proximal to its insertion. However, partial thickness tears and other pathologies often occur at its insertion on the calcaneus. Anatomically, the insertion is a confluence of the gastrocnemius and soleus muscles that fuse to form a myotendinous unit on the posterosuperior aspect of the calcaneus. This review aims to reveal the insertional footprint as individual fascicular components attaching to facets of calcaneal tuberosity. Understanding this anatomy is essential for interpreting tear patterns and surgical implications.

Power Doppler Ultrasound Findings before and after Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Pilot Study on Pain Reduction and Neovascularization Effect

Extracorporeal shock wave therapy (ESWT) has been found to have a positive effect in the treatment of pain in Achilles tendinopathy, although the exact mechanism is not yet completely understood. Among the mechanisms suggested to underlie ESWT effects are direct stimulation of healing, neovascularization and direct suppressive effects on nociceptors and hyperstimulation, which would block the gate-control system. The neovascularization observed in flogistic tissue is associated with stimulated nerve fibers around tendons and induces a painful condition. The objectives of the present study were to evaluate the effect of ESWT on pain and function in patients with non-insertional Achilles tendinopathy (NIAT) and to assess the neovascularization phenomenon using power Doppler ultrasound (PDU). Twelve patients with NIAT underwent five sessions of focused ESWT over 5 wk. Outcome measures were the visual analogue scale, the Victorian Institute of Sport Assessment-Achilles questionnaire and active dorsiflexion and plantar flexion ankle articular range of motion. Moreover, the patients' clinical impressions of treatment results after ESWT were investigated using the Roles and Maudsley score. Patients were assessed at baseline and 1 and 3 mo after treatment. They had a significant reduction in pain with improvement of arthrokinematic motion and functionality and a positive clinical impression of treatment outcome (50% of patients considered their clinical picture as good/excellent after 3 mo). However, the pulse Doppler ultrasound exam did not reveal neovascularization in 91.7% of the patients 1 and 2 mo after focused ESWT, and in some patients there was a reduction in blood vessels related to flogistic processes. The present observational study confirmed the efficacy of ESWT in pain reduction in NIAT, with a higher degree of patient satisfaction, although doubt persists over the neovascularization effect on the Achilles tendons treated.

Predictors of Outcome Following Tenotomy in Patients with Recalcitrant Epicondylopathy

BACKGROUND

Elbow tendinopathies are associated with tenderness, pain, and functional disability with ensuing socioeconomic costs. There is lack of consensus regarding the best treatment for patients recalcitrant to first-line conservative treatments. Percutaneous needle tenotomy is considered a regenerative approach that injures the tendon to elicit a healing response.

OBJECTIVE

To investigate whether demographic characteristics, clinical factors, baseline sonographic entities, or their interactions are related to the likelihood of responding positively to needle tenotomy over a 1-year follow-up period.

DESIGN

Prospective case series.

SETTING

Tertiary institutional hospital.

PARTICIPANTS

Patients with elbow tendinopathy for whom conservative treatments had failed and who had persistent symptoms lasting for at least 3 months.

METHODS

Patients underwent needle tenotomy with or without PRP followed by a lighter needle tenotomy within a 2-week interval as part of treatment.

MAIN OUTCOME MEASUREMENTS

Disabilities of the Arm, Shoulder and Hand (DASH) and Visual Analogue Scale for pain (VAS-P) scores were assessed before intervention (baseline) and at 6 weeks and 3, 6, and 12 months after intervention. A generalized linear mixed effects model was created to examine whether injectate type, clinical, demographic, or pretreatment sonographic entities or their interactions influenced clinical outcomes.

RESULTS

The authors analyzed 74 elbows (71 patients). At baseline, analyzed patients (mean age: 49.48 years; 51.35% women) scored 43.30 and 5.83 on the DASH and VAS-P, respectively. Pretreatment tendon vascularization was a predictor of pain (P = .011) and DASH score changes (P = .019). The linear mixed effect model revealed that male gender and hypercholesterolemia were associated with enhanced functional recovery, (P = .020 and P < .001, respectively). Moreover, the interactions between pretreatment vascular status (P = .039), echotexture (P = .037) and enthesophytes (P = .028) influenced the temporal pattern of functional recovery after needle tenotomy.

CONCLUSIONS

Baseline patient characteristics, such as gender and hypercholesterolemia, along with ultrasound features may be predictive of outcomes following needle tenotomy for elbow tendinopathy.

LEVEL OF EVIDENCE

IV (NCT01945528).

Extracellular matrix supports healing of transected rabbit Achilles tendon

Extracellular matrix (ECM) has been intensively used in cardio surgery. The main goal of this research was to determine if Achilles tendon healing could be promoted by applying extracellular matrix scaffold (CorMatrix®, USA). Sixteen (n = 16) New Zealand white mature rabbits (Oryctolagus cuniculus) were randomly allocated into two groups. Following complete surgical transection, rabbits in group A (ECM applied) (n = 8) had their Achilles tendons reconstructed using both, nylon suture and extracellular matrix scaffold, whereas in group B (without ECM) the tendons were reconstructed using nylon suture only. After four weeks, the rabbits were euthanized and tendon samples harvested and stained with hematoxylin eosin, Mallory, and Gomory and subsequently histologically analyzed according to modified Bonnar scale. Group B had significantly stronger inflammatory response, including abundant cell infiltration and neovascularization. In group A collagen fibers were predominantly found, whereas in group B reticular fibers were more abundant. Extracellular matrix scaffold has been found to have the real potential for promoting tendon healing through accelerating collagen formation, which is crucial for restoring biomechanical properties of a tendon, decreasing peritendineous adhesion formation, and reducing inflammatory edema and subsequently pain.

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

PURPOSE AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

STUDY TYPE

Diagnostic study.

LEVEL OF EVIDENCE

II.

Intravoxel incoherent motion (IVIM) imaging in human achilles tendon

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 (f_p ) (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*×f_p ) (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 f_p demonstrated a high dependency to IVIM protocol parameters, while the T₁ /T₂ -corrected absolute intratendinous microvascular blood volume fraction (V_b ) 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.

Diagnostic Performance of Superb Microvascular Imaging and Other Sonographic Modalities in the Assessment of Lateral Epicondylosis

OBJECTIVES

The aim of this study was to compare the diagnostic performance of different sonographic modalities for diagnosing lateral epicondylosis.

METHODS

A total of 50 symptomatic and 50 asymptomatic common extensor tendons in 44 patients with lateral epicondylosis, and 25 healthy participants were prospectively examined by B-mode sonography, color Doppler imaging, power Doppler imaging, Superb Microvascular Imaging (SMI; Toshiba Medical Systems Corporation, Tokyo, Japan), and strain elastography. We evaluated blood flow in common extensor tendons by using a grading system with color Doppler imaging, power Doppler imaging, and SMI. The diagnostic performance of the modalities was compared.

RESULTS

When a cutoff value of hypoechogenicity was used for the mean strain ratio, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rates were 92.0%, 94%.0, 93.9%, 92.2%, and 93.0%, respectively. When a cutoff point of grade 1 was used, the sensitivity, specificity, PPV, NPV, and accuracy rates were 26.0%, 10.0%, 10.0%, 57.5%, and 63.0, for color Doppler imaging; 40.0%, 10.0%, 10.0%, 62.5%, and 70.0% for power Doppler imaging; and 84.0%, 94.0%, 93.0%, 85.5%, and 89.0% for SMI. When a cutoff value of 3.94 was used for the mean strain ratio, the sensitivity, specificity, PPV, NPV, and accuracy rates were 78.0%, 92.0%, 90.7%, 80.7%, and 85.0%, respectively. A statistically significant correlation was detected between SMI, strain elastography, and visual analog scale scores (P < .001).

CONCLUSIONS

The combination of SMI and B-mode sonography was found to have excellent diagnostic performance for lateral epicondylosis. Neovascularzation in patients' tendons with lateral epicondylosis was identified much better with SMI compared to color or power Doppler imaging.

B-mode and power Doppler ultrasonography of the equine suspensory ligament branches: A descriptive study on 13 horses

Ultrasonography is routinely used to achieve the diagnosis of equine suspensory ligament desmopathy. In human medicine, power Doppler ultrasonography has also been found to be useful for the diagnosis of tendon/ligament injuries. The aim of this prospective, pilot study was to assess the presence or absence of power Doppler signal in suspensory ligament branches and compare B-mode findings with power Doppler findings in suspensory ligament branches of lame and non-lame limbs. Thirteen horses were used (eight lame horses, with lameness related to pain in the suspensory ligament branches, and five non-lame horses). Ten lame limbs and 24 sound limbs were assessed by B-mode and power Doppler ultrasonography. The severity of power Doppler signal was scored by two independent readers. The B-mode ultrasonographic examination revealed abnormalities in branches of lame limbs and in branches of sound limbs. Suspensory ligament branches that were considered normal in B-mode showed no power Doppler signal. However, power Doppler signal was detected in suspensory ligament branches that were abnormal in B-mode, both in lame and sound limbs. Power Doppler scores were subjectively higher in suspensory ligament branches of lame limbs and in branches with more severe B-mode changes. Findings supported the use of power Doppler as an adjunctive diagnostic test for lame horses with suspected suspensory desmopathy.

Sport and exercise medicine consultants are reliable in assessing tendon neovascularity using ultrasound Doppler

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.

Insertional Tendinopathy of the Achilles: Debridement, Primary Repair, and When to Augment

Insertional Achilles tendinopathy is a degenerative enthesopathy associated with pain and dysfunction. Nonsurgical management is first attempted for a period of 3 to 6 months and may consist of physical therapy with eccentric training and other modalities. Surgical treatment can be successful with a variety of approaches. A thorough debridement through a midline tendon-splitting approach is associated with high satisfaction rates. Flexor hallucis longus transfer to augment the repair is considered in older, heavier patients or if more than 50% of the tendon was debrided. Early functional rehabilitation is associated with excellent outcomes.

Complete tendon Achilles rupture following injection of Aethoxysklerol (polidocanol) for the treatment of chronic Achilles tendinopathy

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.

Tendonitis and Tendinopathy: What Are They and How Do They Evolve?

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Acute effect of running exercise on physiological Achilles tendon blood flow

Sonographically detectable intratendinous blood flow (IBF) is found in 50%-88% of Achilles tendinopathy patients as well as in up to 35% of asymptomatic Achilles tendons (AT). Although IBF is frequently associated with tendon pathology, it may also represent a physiological regulation, for example, due to increased blood flow in response to exercise. Therefore, this study aimed to investigate the acute effects of a standardized running exercise protocol on IBF assessed with Doppler ultrasound (DU) "Advanced dynamic flow" in healthy ATs. 10 recreationally active adults (5 f, 5 m; 29±3 years, 1.72±0.12 m, 68±16 kg, physical activity 206±145 minute/wk) with no history of AT pain and inconspicious tendon structure performed 3 treadmill running tasks on separate days (M1-3) with DU examinations directly before and 5, 30, 60, and 120 minutes after exercise. At M1, an incremental exercise test was used to determine the individual anaerobic threshold (IAT). At M2 and M3, participants performed 30- minute submaximal constant load tests (CL₁ /CL₂ ) with an intensity 5% below IAT. IBF in each tendon was quantified by counting the number of vessels. IBF increased in five ATs from no vessels at baseline to one to four vessels solely detectable 5 minutes after CL₁ or CL₂ . One AT had persisting IBF (three vessels) throughout all examinations. Fourteen ATs revealed no IBF at all. Prolonged running led to a physiological, temporary appearance of IBF in 25% of asymptomatic ATs. To avoid exercise-induced IBF in clinical practice, DU examinations should be performed after 30 minutes of rest.

[Tendinopathies of the foot and ankle : Evidence for the origin, diagnostics and therapy]

Tendinopathies of the foot and ankle result in substantial impairment of the mobility of patients and have a high clinical significance. Knowledge of the origin of these diseases has been accumulated over decades from the multitude of intrinsic and extrinsic triggering factors based on biomechanical considerations with an evidence-based medicine (EBM) level 5. A high correlation between tendinopathy and hypervascularization of the Achilles tendon was found in a double-blind randomized prospective study using Doppler ultrasound (EBM level 1) but these results were not reproducible; therefore, the importance of these findings is unclear. Inspection and clinical examination supplemented by ultrasound and magnetic resonance imaging (MRI) are essential to achieve the correct diagnosis. The varying extent of load-dependent irritation of tendons and the surrounding tissues and the individual variation in experience of investigators mean that the results of clinical examinations are difficult to collate or not reproducible and cannot be investigated in studies. The expression of the varying results is difficult to assess even by the use of sonography and magnetic resonance imaging (MRI). Conservative treatment of tendinopathy is based on medical experience (EBM level 5). The effectiveness of physiotherapeutic eccentric loading and extracorporal shock wave treatment (ESWT) for Achilles tendinopathy was demonstrated in several case control studies and series (EBM level 3). Due to the high rate of healing with physiotherapy, surgery should only be performed following a minimum of 6-12 weeks of unsuccessful conservative treatment, because formation of scar tissue on the foot can result in permanent complaints (EBM level 4).

Sonography of the Achilles Tendon After Complete Rupture Repair: What the Radiologist Should Know

This review aims to provide the radiologist with simple and systematic guidelines for evaluation of the Achilles tendon after complete rupture repair. Currently, there is a plethora of nonsurgical and surgical treatments, but sonographic examination has shown no significant differences between them. A systematic analysis of several parameters (morphologic characteristics, structure, color Doppler vascularization, and mobility) should be undertaken. Morphologically, the repaired tendon is larger, wider, or both. The loss of the fibrillary structure, inhomogeneity, and the surgical material in the context of the tendon are "normal" aspects after a repaired rupture. The presence of fluid collections when affecting greater than 50% of the surface of the tendon and extensive calcifications should be considered pathologic aspects. In the immediate postoperative period, there is the absence of vascularization detectable by color Doppler imaging. During the first 3 months, there is an increase in intratendinous vascularization with hypervascularization. From 3 to 6 months, stabilization and regression of the vascularization occur. Beyond the first 6 months, the hypervascularization is pathologic. The pattern of motion is, generally, reduced considerably more often in surgically treated tendons than in non-surgically treated ones. Elastography generally shows a hard appearance, with only a relatively heterogeneous pattern. In conclusion, a treated tendon will never regain a normal sonographic appearance, and the operator must distinguish between normal posttreatment changes and real pathologic characteristics.