The effects of local steroid injections on tendons: a biomechanical and microscopic correlative study

Comparison of the Effectiveness of Platelet-Rich Plasma Injection Versus Plantar-Specific Calf Stretching Exercises in Patients With Plantar Fasciitis: A Randomized Controlled Trial

Background Plantar fasciitis is a common foot condition with multifactorial etiology. It is the most frequent cause of heel pain and has been categorized as an overuse syndrome. A clinical examination and history are crucial for diagnosis. There are several different forms of treatment available, two of which are frequently used: physical therapy and steroid injections. Recent research on platelet-rich plasma (PRP) has demonstrated encouraging outcomes and fewer side effects when compared to steroid injections. Methods A randomized controlled trial was conducted and randomization was done of indoor patients into two groups. Group 1, ending with odd numbers, was given PRP injections, and Group 2, ending with even numbers, was advised plantar-specific calf stretching exercises. Visual analog scale (VAS) scores were evaluated before and after the intervention and follow-up was done on the second, sixth, and 12th weeks. Results Comparing the VAS scores between the two groups, we found that in the pre-intervention phase, the VAS score of Group 1 was 5.4±0.56 and that of Group 2 was 5.4±0.59. In the post-intervention phase, the VAS score in Group 1 was 4.6±0.89, while in Group 2 it was 5.2±0.62. In the second week after intervention, the VAS score was observed to be 3.3±0.97 in Group 1, while in Group 2, it was 3.3±0.80. After the sixth week of intervention, the observed VAS score was 2.7±0.78, while in Group 2 it was 2.9±0.82. The mean VAS score after 12weeks of intervention was observed to be 2.3±0.91 in Group 1, while in Group 2, it was 2.2±0.80. Conclusion PRP injections and plantar-specific calf stretching exercises are equally effective in providing pain relief in plantar fasciitis. PRP injections have complications and problems which have been discussed. Exercises are devoid of such complications. No recurrences occurred in the exercise group and four cases had recurrence in the PRP group.

Patellar tendinopathy: an overview of prevalence, risk factors, screening, diagnosis, treatment and prevention

Patellar tendinopathy (PT), or jumper's knee, is an overuse injury that occurs in professional, as well as recreational, athletes. This condition is a noncontact injury, typically characterized by gradually increasing pain in the patellar tendon. It is prevalent in participants of several sports, but it occurs mostly in jumping sports. The diagnosis of PT is primarily clinical; however, imaging techniques can be useful as well. Risk factors differ between sexes, playing conditions, the kind of sport, playing level and personal characteristics. Screening is an essential tool to assess PT. This condition affects athletic performance and often persists for years. The use of preventative methods is imperative because of the persistence of this condition, especially in elite athletes who sometimes end their career after long and failed treatments. There are a wide variety of treatment and rehabilitation options available, the majority of which are non-operative, such as eccentric exercises, cryotherapy, platelet-rich plasma (PRP) injections, and anti-inflammatory strategies. If conservative treatment fails, surgery is the next most preferable step. Even though there are many surgical treatment methods, there is no clear evidence on what is the most effective approach to address PT. Taking this into consideration, as well as the extent of this clinical entity, novel therapeutic techniques, as well as screening and prevention methods, are expected to emerge in the near future.

Suture Anchor Versus Allogenic Tendon Suture in Treatment of Haglund Syndrome

Background

Haglund’s deformity is an abnormal bony enlargement on the back of the heel. It can cause the impact of the posterior calcaneal bursa and Achilles tendon insertion, and finally result in pain. This syndrome is called Haglund syndrome. The purpose of this study was to explore the effect of the suture anchor and allogeneic tendon suture in the treatment of Haglund syndrome.

Material/Methods

We retrospectively studied 20 patients with Haglund syndrome treated from January 2015 to December 2016. The patients were randomly divided into Group 1 (the suture anchor group) and Group 2 (the allogeneic tendon group), with 10 patients in each group and an average follow-up of 32 months after surgery. The AOFAS, VAS, and Arner-Lindholm scales were used to summarize the patient follow-up results and complications.

Results

In the 2 groups of patients, the postoperative AOFAS, VAS scores, and the Arner-Lindholm scale showed good results. However, the postoperative AOFAS score and VAS of the suture anchor group were better than those of the allogeneic tendon group, with shorter operation times. No Achilles tendon rupture or wound infection occurred during the entire postoperative period in either group. These results show the superiority of suture anchors.

Conclusions

The higher AOFAS and VAS score and shorter operation time in the suture anchor group suggest it is the better alternative for treatment of Haglund syndrome.

Impact of fluoroscopic injection location on immediate and delayed pain relief in patients with greater trochanteric pain syndrome

OBJECT

The purpose of this study was to assess whether fluoroscopically guided corticosteroid injections into the extrabursal tissues, trochanteric (subgluteus maximus) bursa, or subgluteus medius bursa provide better immediate and short-term pain relief.

MATERIALS AND METHODS

All fluoroscopically guided corticosteroid injections performed over a 67-month period for greater trochanteric pain syndrome were retrospectively reviewed. Procedural images were reviewed by two musculoskeletal radiologists to determine the dominant injection site based on final needle positioning and contrast spread pattern, with discrepancies resolved by consensus. Statistical analysis of the association between pain score reduction and dominant injection site was performed.

RESULTS

One hundred forty injections in 121 patients met the inclusion criteria. The immediate and 1-week post-injection pain reduction was statistically significant for trochanteric bursa, subgluteus medius bursa, and non-bursal injections. However, there was no statistically significant difference in the degree of pain reduction between the groups. There was statistically significant increase in the 1-week post-injection mean pain score compared with immediate post-injection mean pain score in the subgluteus medius bursa and non-bursal injection groups (p < 0.01) but not in the trochanteric bursa group.

CONCLUSION

Fluoroscopy is frequently chosen over blind injection or ultrasound guidance for trochanteric steroid injections in patients with a high body mass index. Our results indicate that fluoroscopically guided steroid injections into the trochanteric bursa and subgluteus medius bursa significantly reduced immediate and 1-week post-injection pain scores, as do non-bursal injections. Steroid injection into the subgluteus medius bursa and non-bursal sites may be less effective in maintaining pain reduction at 1-week post-injection.

Effect of Mn3O4 Nanoparticles on Lipopolysaccharide-Induced Inflammatory Factors in the Human Tendon Cells and Its Mechanism

Objective. To investigate the effect of Mn3O4 nanoparticles (Mn3O4NPs) on inflammatory factors induced by lipopolysaccharide (LPS) in human tendon cells and its mechanism. Methods. The Mn3O4NPs were synthesized by a hydrothermal method. RT-qPCR was used to detect the expression levels of miRNAs related to inflammation in human tendon cells. The expression level of NLRP1 (NOD-like receptor containing pyrin domain 1) was measured by Western blotting. ELISA assay was used to measure the level of TNF-α, IL-1β, IL-4, and IL-10. The relationship between miR-181a-5p and NLRP1 was verified by dual-luciferase reporter assay. Results. Mn3O4NPs produced in this study were brown spherical particles with an average size of 7-10 nm. Mn3O4NP treatment significantly reduced the levels of TNF-α and IL-1β but increased the levels of IL-4 and IL-10 in the human tendon cells induced by LPS. In addition, Mn3O4NP treatment remarkably increased the expression level of miR-181a-5p. NLRP1 is one of the targets of miR-181a-5p, and miR-181a-5p downregulated its expression. Further study showed that Mn3O4NPs could alleviate the inflammatory response of human tendon cells induced by LPS by upregulating miR-181a-5p and thus downregulating the expression of NLRP1. Conclusion. Mn3O4NPs affect the expression of inflammatory cytokines in the human tendon cells induced by LPS by modulating the molecular axis of miR-181a-5p/NLRP1.

Rotator Cuff-Related Shoulder Pain: To Inject or Not to Inject?

The most common source of shoulder pain is thought to involve the tendons of the rotator cuff and associated structures around the subacromial space. A generic diagnostic term has been suggested, rotator cuff-related shoulder pain (RCRSP), which is an overarching clinical term that includes a number of conditions, such as subacromial impingement syndrome, subacromial pain syndrome, and rotator cuff tendinopathy. The management of RCRSP may include exercise, surgery, or injection therapy. Those who perform or recommend injection therapy for RCRSP have a duty of care to provide advice on the expected benefits and outcomes, as well as the potential risks and associated harms. Clinicians also need to consider what medication to inject, where to inject it, and how to inject it. The aim of this Viewpoint is to discuss these issues. J Orthop Sports Phys Ther 2019;49(5):289-293. doi:10.2519/jospt.2019.0607.

Short-term Changes After Corticosteroid Injections Into the Normal Tendons of Rabbits: A Controlled Randomized Study

BACKGROUND

Corticosteroid injections in or around tendons for the treatment of athletic injuries are a common practice among orthopaedic surgeons and are apparently efficacious in the short term, although controversies persist related to local complications.

PURPOSE

This study evaluated short-term (48 hours) biomechanical, biochemical, and histological alterations after a single injection of betamethasone into the normal tendons of rabbits.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 72 New Zealand White rabbits were randomly divided into 2 groups: the test group-in which 36 animals underwent 1 intratendinous injection of betamethasone (1.4 mg / 0.2 mL) in the right calcaneal tendon; the control group-in which the right calcaneal tendon of 36 animals was injected with saline (placebo control group) and the left calcaneal tendon was left untreated for normal standards (normal control). Forty-eight hours later, animals were euthanized and tendons were harvested. Metalloproteinase (MMP1 and MMP2) and interleukin (IL1 and IL6) expression levels, biomechanical resistance (load × elongation parameters), and histomorphometry (hematoxylin and eosin and picrosirius red stains for collagen fibers, tenocytes, and inflammatory cells) were analyzed in the tendons.

RESULTS

The test group had a significant reduction in MMP2 expression as compared with the control groups ( P = .027). Regarding the other parameters, there were no additional significant differences between the groups.

CONCLUSION

A single injection of corticosteroid into normal calcaneal tendons did not trigger acute local morphological, structural, or biomechanical injuries at 48 hours, but it did promote a significant decrease in MMP2 levels. Additional studies are needed with increased duration of follow-up, various doses, and multiple injections and in tendinopathic models.

CLINICAL RELEVANCE

Some previous studies demonstrated early structural changes in tendons after a single corticosteroid injection, which was not corroborated by the present study. Metalloproteinase decrease is usually associated with a reduction in collagen degradation, which would be protective for the healing process. More studies are necessary to confirm the possible beneficial effect of these results in the long term and for tendinopathies.

Long Head of Biceps Injury: Treatment Options and Decision Making

The long head of the biceps brachii is a well-known "pain generator" in the shoulder. Biceps tendinitis, instability, and rupture encompass the majority of symptomatic lesions. Clinical diagnosis, particularly of biceps tendinitis, can be difficult, given the nonspecific physical examination findings. Treatment options are initially nonoperative, with surgical management reserved for specific presentations or refractory cases. In recent years, biceps tenodesis and tenotomy have become the mainstays of operative treatment. Management of biceps lesions must also involve consideration of other shoulder pathology, as they are often not an isolated finding. Although there remains debate on the best treatment options for long head of the biceps injuries, a review of current literature provides important principles that can help guide clinical decision making.

Rescue plan for Achilles: Therapeutics steering the fate and functions of stem cells in tendon wound healing

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.

Surgical management and follow-up of triceps tendon avulsion after repeated local infiltration of steroids: two cases

Disruption of the triceps tendon insertion is an uncommon injury, with only a few reports of traumatic triceps tendon avulsion in dogs or cats present in the veterinary literature. Although this injury has been previously described in two dogs that had received a local injection of corticosteroids for the treatment of soft tissue injuries, reports with long term clinical follow-up and outcome in working dogs are lacking.

This report describes two surgically treated cases of complete triceps tendon avulsion rupture in Malinois police dogs. These two dogs had a history of repeated local infiltration of a corticosteroid preparation used to treat adventitial bursitis. The clinical features, surgical treatment, long-term management and outcome are reported. A modified triple locking loop pattern was used to suture the tendons. The long-term outcome was considered excellent with both dogs resuming work. Although it is an uncommon condition in small animals, avulsion of the triceps tendon should remain on the differential diagnosis list for acute onset forelimb lameness, particularly if there is a history of local infiltration with corticosteroids. The diagnosis should be based on clinical, radiographic and ultrasonographic examination.

Management of plantar fasciitis in the outpatient setting

Plantar fasciitis is a very common cause of inferior heel pain that can be triggered and aggravated by prolonged standing, walking, running and obesity, among other factors. Treatments are largely noninvasive and efficacious. Supportive treatments, including the plantar fascia-specific stretch, calf stretching, appropriate orthotics and night dorsiflexion splinting, can alleviate plantar fascia pain. While local injections of corticosteroids can help with pain relief, the effects are short-lived and must be weighed against the risk of fat pad atrophy and plantar fascia rupture. Ultrasonography-guided focal extracorporeal shock wave therapy is useful for patients with chronic plantar fasciitis and referrals for this treatment can be made in recalcitrant cases. Activity modification to decrease cyclical repetitive loading of the plantar fascia should be advised during the treatment phase regardless of the chosen treatment modality.

Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies

INTRODUCTION

local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported. the characteristics of the tendinopathies, the clinical peculiarities of the patient, and the technique used to administer glucocorticoids, can influence the therapeutic response. Areas covered: After reviewing the pertinent literature on the clinical results, basic information, both on the pathogenesis of tendinopathies and the effects of glucocorticoids on tendons, is reported. The pharmacological properties of glucocorticoids are useful to counteract some pathogenetic mechanisms of tendinopathies. However, several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties have been observed. Expert opinion: Drawbacks of local glucocorticoids injections could be predicted on an individual basis, after a careful appraisal of patient characteristics and concomitant medications, along with the specific stage of tendon disease.

The Double-Row Suture Technique: A Better Option for the Treatment of Haglund Syndrome

Purpose. The purpose of this study is to investigate whether double-row suture technique is a better option for the treatment of Haglund syndrome than single-row suture technique regarding the surgical outcomes. Methods. Thirty-two patients with Haglund syndrome were recruited in this study. Patients were divided into Group 1 (treated with single-row suture technique) and Group 2 (treated with double-row suture technique). There were 16 patients in each group. The AOFAS-ankle-hindfoot scale, VISA-A scores, and Arner-Lindholm standard were used to assess the clinical outcomes. The pre- and postoperative X-rays were used to assess the radiological outcome. Results. Both AOFAS-ankle-hindfoot scale score and VISA-A score had varying degrees of improvement in both groups. In latest follow-up assessment, the Arner-Lindholm standard investigation showed there were 7 excellent, 7 good, and 2 bad outcomes in Group 1 and 12 excellent and 4 good outcomes in Group 2. In Group 2 patients, there were no more posterosuperior bony prominence of the calcaneum in post-op X-rays and there were no recurrent cases. The ankle-related scale score was statistically significantly higher in Group 2 than in Group 1 (P = 0.029). Conclusion. The double-row suture technique seems to be a better option to treat Haglund syndrome than single-row suture technique.

The comparative efficacy of kinesio taping and local injection therapy in patients with subacromial impingement syndrome

Objective

The aim of this study was to compare the therapeutic effects of kinesio taping (KT) and local subacromial injection in patients with subacromial impingement, syndrome (SIS) with regard to pain, range of motion (ROM) and disability.

Methods

Sixty-one patients (48 females and 13 males; mean age: 43.04 ± 6.31, years) with SIS were enrolled into the study. The patients were randomized into two treatment groups receiving either a single corticosteroid and local anesthetic (LA) injection, or kinesio taping performed three times by intervals of 3 day. Visual analog scale (VAS) was used to assess pain intensity, range of motion (ROM) degrees of, shoulder were recorded and Shoulder Pain and Disability Index (SPADI) was, performed to evaluate functional disability, before treatment, at the first and fourth, weeks after therapies. A exercise program was prescribed for both groups including pendulum, active range of motion (ROM) and strengthening exercises.

Results

Pain, functional outcome measures were determined to have improved significantly in both groups at the end of therapies at first and fourth weeks (p < 0.05), but these improvements were more significant in the injection group than in kinesio taping group (p < 0.05). The improvements in pain at rest, shoulder abduction degrees, and SPADI scores at first and fourth weeks were statistically higher in injection group than in kinesio taping group.

Conclusion

Although the improvement in pain intensity at rest, ROM and disability were better with local injection, KT may be an alternative noninvasive method to local subacromial injection for patients suffering from subacromial impingement syndrome.

Level of Evidence

Level I, Therapeutic study.

Possible Epidemiological Factors Associated with Rupture of the Posterior Tibial Tendon

Rupture of the posterior tibial tendon has been postulated to occur, in part, as a result of degenerative changes to the tendon. This possibility was examined by a review of 67 patients (average age 57 years) diagnosed with rupture of the posterior tibial tendon. Forty-five of the 67 patients (60%) had one or more of the following positive medical histories: (1) hypertension, (2) obesity, (3) diabetes mellitus, (4) previous surgery or trauma about the medial aspect of the foot, or (5) steroid exposure. Thirty-five patients (52%) had either hypertension, diabetes mellitus, or obesity. A statistical correlation was demonstrated between rupture of the posterior tibial tendon and obesity ( P = .005) and to a lesser extent hypertension ( P = .025). These disorders have been uniformly associated with an acceleration of the degenerative processes associated with aging, commonly via an acceleration of microvascular and macrovascular diseases. An additional vascular risk is implicated by the known zone of hypovascularity of the posterior tibial tendon and risk of rupture secondary to systemic or local injections of corticosteroids. The prevalence of posterior tibial tendon rupture parallels the degenerative processes of aging, hypertension, diabetes mellitus, and obesity. Additionally, the effects of corticosteroids and local surgical procedures may further be associated with local vascular impairment and eventual rupture.

Chronic Tendonopathy as a Unique Cause of Non Traumatic Triceps Tendon Rupture in a (Risk Factors Free) Bodybuilder: A Case Report

Introduction:

Distal triceps tendon rupture is an uncommon lesion rarely due to a non-traumatic mechanism. In these cases, the majority of patients show predisposing factors for tendon degeneration: underlying medical co-morbidities, previous systemic and locally injected corticosteroids and systemic anabolic steroids. A clear evidence for an etiopathogeneticroleforchronictendonopathy in triceps tendon rupture is sti 11 lacking.

Case Report:

We report the case of a rare non-traumatic complete rupture of the triceps tendon, at the olecranon insertion, occurring in a healthy male middle-aged non-professional bodybuilder. He presented to our attention with a five days history of weakness, swelling and pain at the left elbow, started after a snapping sound during a single arm triceps extension exercise. He was a healthy sportsman, no smoker and no drinker. He had suffered, in the two months before, of mild bilateral exercise-related elbow discomfort, never limiting his sport and daily activities. The man was treated by an early surgical repair. Histological analysis was conducted on intraoperative samples. The treatment allowed complete remission and return to sport practice without functional deficit.

Conclusion:

An overload-related chronic tendonopathy was identified as the unique factor with causal role in the determinism of the above described lesion. This case highlights, for the first time in literature, that just a chronic tendonopathy, in absence of any other predisposing condition, can lead to a non-traumatic complete triceps tendon rupture.

Ruptured Tendons in Anabolic-Androgenic Steroid Users: A Cross-Sectional Cohort Study

BACKGROUND

Accumulating case reports have described tendon rupture in men who use anabolic-androgenic steroids (AAS). However, no controlled study has assessed the history of tendon rupture in a large cohort of AAS users and comparison nonusers.

HYPOTHESIS

Men reporting long-term AAS abuse would report an elevated lifetime incidence of tendon rupture compared with non-AAS-using bodybuilders.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Medical histories were obtained from 142 experienced male bodybuilders aged 35 to 55 years recruited in the course of 2 studies. Of these men, 88 reported at least 2 years of cumulative lifetime AAS use, and 54 reported no history of AAS use. In men reporting a history of tendon rupture, the circumstances of the injury, prodromal symptoms, concomitant drug or alcohol use, and details of current and lifetime AAS use (if applicable) were recorded. Surgical records were obtained for most participants.

RESULTS

Nineteen (22%) of the AAS users, but only 3 (6%) of the nonusers, reported at least 1 lifetime tendon rupture. The hazard ratio for a first ruptured tendon in AAS users versus nonusers was 9.0 (95% CI, 2.5-32.3; P < .001). Several men reported 2 or more independent lifetime tendon ruptures. Interestingly, upper-body tendon ruptures occurred exclusively in the AAS group (15 [17%] AAS users vs 0 nonusers; risk difference, 0.17 [95% CI, 0.09-0.25]; P < .001 [hazard ratio not estimable]), whereas there was no significant difference between users and nonusers in risk for lower-body ruptures (6 [7%] AAS users, 3 [6%] nonusers; hazard ratio, 3.1 [95% CI, 0.7-13.8]; P = .13). Of 31 individual tendon ruptures assessed, only 6 (19%) occurred while weightlifting, with the majority occurring during other sports activities. Eight (26%) ruptures followed prodromal symptoms of nonspecific pain in the region. Virtually all ruptures were treated surgically, with complete or near-complete ultimate restoration of function.

CONCLUSION

AAS abusers, compared with otherwise similar bodybuilders, showed a markedly increased risk of tendon ruptures, particularly upper-body tendon rupture.

Endoscopic calcaneoplasty

Opinions differ regarding the surgical treatment of posterior calcaneal exostosis. After failure of conservative treatment, open surgical bursectomy and resection of the calcaneal prominence is indicated by many investigators. Clinical studies have shown high rates of unsatisfactory results and complications. Endoscopic calcaneoplasty (ECP) is a minimally invasive surgical option that can avoid some of these obstacles. ECP is an effective procedure for the treatment of patients with posterior calcaneal exostosis. The endoscopic exposure is superior to the open technique and has less morbidity, less operating time, fewer complications, and the disorders can be better differentiated.

Patellar Tendinopathy

Context:

Patellar tendinopathy is a common condition. There are a wide variety of treatment options available, the majority of which are nonoperative. No consensus exists on the optimal method of treatment.

Evidence Acquisition:

PubMed spanning 1962-2014.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

The majority of cases resolve with nonoperative therapy: rest, physical therapy with eccentric exercises, cryotherapy, anti-inflammatories, corticosteroid injections, extracorporeal shockwave therapy, glyceryl trinitrate, platelet-rich plasma injections, and ultrasound-guided sclerosis. Refractory cases may require either open or arthroscopic debridement of the patellar tendon. Corticosteroid injections provide short-term pain relief but increase risk of tendon rupture. Anti-inflammatories and injectable agents have shown mixed results. Surgical treatment is effective in many refractory cases unresponsive to nonoperative modalities.

Conclusion:

Physical therapy with an eccentric exercise program is the mainstay of treatment for patellar tendinopathy. Platelet-rich plasma has demonstrated mixed results; evidence-based recommendations on its efficacy cannot be made. In the event that nonoperative treatment fails, surgical intervention has produced good to excellent outcomes in the majority of patients.

Chronic Achilles Tendon Rupture Reconstructed With Achilles Tendon Allograft and Xenograft Combination

More than 20% of acute Achilles tendon injuries are misdiagnosed, leading to chronic or neglected ruptures. Some controversy exists regarding how to best manage an acute Achilles tendon rupture. However, a general consensus has been reached that chronic rupture with ≥3 cm of separation is associated with functional morbidity and, therefore, should be managed operatively. It has been demonstrated that the functional outcomes of surgically treated Achilles ruptures are superior to the nonoperative outcomes in a chronic setting. In the present report, we reviewed 4 patients with chronic Achilles tendon ruptures that were successfully treated with an Achilles tendon interposition allograft and simultaneous augmentation with a xenograft. The median duration of rupture was 11 (range 8 to 16) weeks, the median gap between the proximal and distal segments of the tendon was 4.75 (range 3.5 to 6) cm, and the patients were able to return pain-free to all preinjury activities at a median of 14.5 (range 13.8 to 15.5) weeks, without the need for tendon transfer, lengthening, or additional intervention. The median duration of follow up was 37.25 (range 15.25 to 51.5) months, at which point the mean Foot and Ankle Outcomes Instrument core scale score was 97 ± 1 (mean normative score 53 ± 1), and the Foot and Ankle Outcomes Instrument shoe comfort core scale score was 100 ± 0 (mean normative score 59 ± 0). The combined Achilles allograft plus xenograft augmentation technique appears to be a reasonable option for the surgical treatment of chronic Achilles tendon rupture.

Risk factors affecting chronic rupture of the plantar fascia

BACKGROUND

Prior to 1994, plantar fascia ruptures were considered as an acute injury that occurred primarily in athletes. However, plantar fascia ruptures have recently been reported in the setting of preexisting plantar fasciitis. We analyzed risk factors causing plantar fascia rupture in the presence of preexisting plantar fasciitis.

METHODS

We retrospectively reviewed 286 patients with plantar fasciitis who were referred from private clinics between March 2004 and February 2008. Patients were divided into those with or without a plantar fascia rupture. There were 35 patients in the rupture group and 251 in the nonrupture group. The clinical characteristics and risk factors for plantar fascia rupture were compared between the 2 groups. We compared age, gender, the affected site, visual analog scale pain score, previous treatment regimen, body mass index, degree of ankle dorsiflexion, the use of steroid injections, the extent of activity, calcaneal pitch angle, the presence of a calcaneal spur, and heel alignment between the 2 groups.

RESULTS

Of the assessed risk factors, only steroid injection was associated with the occurrence of a plantar fascia rupture. Among the 35 patients with a rupture, 33 had received steroid injections. The odds ratio of steroid injection was 33.

CONCLUSION

Steroid injections for plantar fasciitis should be cautiously administered because of the higher risk for plantar fascia rupture.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Optimal management of shoulder impingement syndrome

Shoulder impingement is a progressive orthopedic condition that occurs as a result of altered biomechanics and/or structural abnormalities. An effective nonoperative treatment for impingement syndrome is aimed at addressing the underlying causative factor or factors that are identified after a complete and thorough evaluation. The clinician devises an effective rehabilitation program to regain full glenohumeral range of motion, reestablish dynamic rotator cuff stability, and implement a progression of resistive exercises to fully restore strength and local muscular endurance in the rotator cuff and scapular stabilizers. The clinician can introduce stresses and forces via sport-specific drills and functional activities to allow a return to activity.

Update on evidence-based treatments for plantar fasciopathy

Plantar fasciopathy, a common, painful condition of the foot, is often diagnosed by a musculoskeletal physiatrist in an outpatient practice setting. This focused review examines the most recent recommendations for the management of plantar fasciopathy in acute, subacute, and chronic phases. The evidence for treatment with various interventions is discussed, and suggestions for clinical care (along with the respective rationales for those therapies) are provided. The purpose of this review is to enable clinicians to make informed evidence-based decisions about the best available treatments for patients with any phase of plantar fasciopathy. Emerging technologies for the treatment of the condition are also addressed.

The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon

OBJECTIVE

Our primary objective was to summarise the known effects of locally administered glucocorticoid on tendon tissue and tendon cells.

METHODS

We conducted a systematic review of the scientific literature using the PRISMA and Cochrane guidelines of the Medline database using specific search criteria. The search yielded 50 articles, which consisted of 13 human studies, 36 animal studies and one combined human/animal study.

RESULTS

Histologically, there was a loss of collagen organisation (6 studies) and an increase in collagen necrosis (3 studies). The proliferation (8 studies) and viability (9 studies) of fibroblasts was reduced. Collagen synthesis was decreased in 17 studies. An increased inflammatory cell infiltrate was shown in 4 studies. Increased cellular toxicity was demonstrated by 3 studies. The mechanical properties of tendon were investigated by 18 studies. Descriptively, 6 of these studies showed a decrease in mechanical properties, 3 showed an increase, while the remaining 9 showed no significant change. A meta-analysis of the mechanical data revealed a significant deterioration in mechanical properties, with an overall effect size of -0.67 (95% CI = 0.01 to -1.33) (data from 9 studies).

CONCLUSIONS

Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.

Acute achilles tendon rupture in athletes

The incidence of AT rupture has increased in recent decades. AT ruptures frequently occur in the third or fourth decade of life in sedentary individuals who play sport occasionally. Ruptures also occur in elite athletes. Clinical examination must be followed by imaging. Conservative management and early mobilization can achieve excellent results, but the rerupture rate is not acceptable for the management of young, active, or athletic individuals. Open surgery is the most common option for AT ruptures, but there are risks of superficial skin breakdown and wound problems. These problems can be prevented with percutaneous repair.

The ruptured Achilles tendon: a current overview from biology of rupture to treatment

The Achilles tendon (AT) is the most frequently ruptured tendon in the human body yet the aetiology remains poorly understood. Despite the extensively published literature, controversy still surrounds the optimum treatment of complete rupture. Both non-operative management and percutaneous repair are attractive alternatives to open surgery, which carries the highest complication and cost profile. However, the lack of a universally accepted scoring system has limited any evaluation of treatment options. A typical UK district general hospital treats approximately 3 cases of AT rupture a month. It is therefore important for orthopaedic surgeons to correctly diagnose and treat these injuries with respect to the best current evidence-based practice. In this review article, we discuss the relevant pathophysiology and diagnosis of the ruptured AT and summarize the current evidence for treatment.

Platelet-rich plasma as an effective treatment for proximal hamstring injuries

Proximal hamstring injuries can be disabling, and several traditional conservative treatments, including physiotherapy and nonsteroidal anti-inflammatory drugs, have been inconsistent. Corticosteroid injections have demonstrated success but can adversely affect local tissues. Platelet-rich plasma (PRP) has emerged as a safe, effective treatment for several orthopedic pathologies. The authors propose a PRP injection at the muscle origin as a novel treatment for proximal hamstring injuries. A retrospective review yielded 15 patients with 17 proximal hamstring injuries. Twelve injuries failed traditional conservative treatment and were ultimately treated with a PRP injection at the hamstrings muscle origin. Five patients were treated with traditional conservative treatment alone. Analysis included pre- and posttreatment visual analog scale scores, Nirschl Phase Rating Scale scores, and return to sport. No significant difference existed between the groups' pretreatment visual analog scale scores (P=.28) and Nirschl Phase Rating Scale scores (P=.15) and their posttreatment visual analog scale scores (P=.38) and Nirschl Phase Rating Scale scores (P=.22). The PRP group demonstrated a reduction in visual analog scale scores (P<.01) and Nirschl Phase Rating Scale scores (P<.01), but the traditional conservative treatment group did not demonstrate the same reduction (P=.06 and .06, respectively). All athletes returned to their desired activity level with no major complications.

Biomechanical effects of steroid injections used to treat pyogenic flexor tenosynovitis

BACKGROUND

A recent study from our laboratory has demonstrated improved range of motion in the toes of broiler chickens afflicted with pyogenic flexor tenosynovitis when treated with local antibiotic and corticosteroid injections, without surgical drainage. However, the use of corticosteroids as an adjunct treatment raised peer concern, as steroids are thought to have deleterious effects on tendon strength. The purpose of this study was to compare the tensile strength of the aforementioned steroid treated tendons, to a group of tendons administered with the current standard treatment: systemic antibiotics, surgical drainage and no corticosteroids.

METHODS

Twenty-three tendons' structural and material properties were investigated (fifteen receiving the standard treatment, eight receiving the steroid treatment). The measurements from each group were interpreted via Student's unpaired t-test and a post-hoc power analysis.

RESULTS

The steroid treated tendons did demonstrate a trend toward decreased mechanical properties when compared with the standard treatment group, but the results were not statistically significant.

CONCLUSIONS

Treatment of septic tenosynovitis with local corticosteroid and local antibiotic injections resulted in better digital motion, without a significant loss of tendon strength, over a twenty-eight day recovery period.

Platelet-rich plasma (PRP): an adjuvant to hasten hamstring muscle recovery. A randomized controlled trial protocol (ISCRTN66528592)

BACKGROUND

Muscle injuries are one of the commonest injuries affecting athletes. It often leads to significant pain and disability causing loss of training and competition time. With current treatment, the duration to return-to-play ranges form six weeks to never, depending on injury severity. Recent researches have suggested that autologous platelet-rich plasma (PRP) injection into the injured site may hasten soft tissues healing. To-date, there has been no randomised clinical trials to evaluate the effects of PRP on muscle healing. The aim of this study is to examine the effects of autologous PRP on duration to return-to-play after muscle injury.

METHODS AND DESIGN

A randomised, single blind controlled trial will be conducted. Twenty-eight patients aged 18 years and above with a recent grade-2 hamstring injury will be invited to take part. Participants will be randomised to receive either autologous PRP injection with rehabilitation programme, or rehabilitation programme only. Participants will be followed up at day three of study and then weekly for 16 weeks. At each follow up visit, participants will be assessed on readiness to return-to-play using a set of criteria. The primary end-point is when participants have fulfilled the return-to-play criteria or end of 16 weeks.The main outcome measure of this study is the duration to return-to-play after injury.

CONCLUSION

This study protocol proposes a rigorous and potential significant evaluation of PRP use for grade-2 hamstring injury. If proven effective such findings could be of great benefit for patients with similar injuries.

TRIAL REGISTRATION

Current Controlled Trials ISCRTN66528592.

Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis a prospective randomized controlled study

Long bicipital tenosynovitis is regarded as one of the common causes of shoulder pain and dysfunction. The traditional therapeutic approach includes a variety of conservative treatments, but these treatments are not substantiated, owing to the lack of proven clinical efficacy. Radial extracorporeal shock wave therapy (rESWT) uses a pneumatically generated and radially propagating low-energy pressure pulse and has been clinically shown to be a new alternative form of treating refractory soft tissue inflammation. While treating patients suffering from long bicipital tenosynovitis, a randomized, controlled trial was conducted to analyze the effects of radial shock wave therapy on pain and function. Seventy-nine adults with long bicipital tenosynovitis were randomized to receive either active (1500 pulses, 8 Hz, 3 bars) or sham treatment through four sessions that were held once a week. All of these adults were assessed before treatment and at time intervals of 1, 3 and 12 months since the completion of the treatment. The outcomes were measured through the visual analogue scale (VAS) and L'Insalata shoulder questionnaire. Mean VAS in the rESWT group showed significant and sustained reduction from 5.67 ± 1.32 at baseline to 2.58 ± 1.49 at one month, 1.83 ± 1.25 at three months and 1.43 ± 0.94 at 12 months from baseline, whereas the sham group's mean VAS was 6.04 ± 0.97 before treatment and stabilized at 5.57 ± 0.84 at 12 months. Similar trends were found for the function scores. Mean scores were increased after rESWT from 60.57 ± 6.91 at baseline to 79.85 ± 6.59 at 1 month and 83.44 ± 5.21 at 12 months from baseline. Both pain and function scores showed significant differences between the two groups (p < 0.001). The rESWT group consisted of "invalid conservative treatment subgroup" and "none conservative treatment subgroup." Both groups showed good recovery and prognosis. Therefore, we recommend rESWT in treating primary long bicipital tenosynovitis.

Distal partial ruptures of triceps brachii tendon in an athlete

Distal brachii triceps tendon rupture is rare. Partial lesions are not so well defined. If functionally they are well tolerated in patients with low functional demand, management guideline is not so clear for sportsmen. To our best knowledge, there is no reported technique for the repair of partial forms. A 28-year-old patient was operated on for a partial triceps rupture. He underwent a transosseous olecranon suture of the tricipital tendon, with a side-to-side suture to the healthy residual tendon. The patient was assessed at 2 years follow-up with the DASH score. He had painless and mobile elbow with no effusion and returned to sport 4 months after his surgical repair. The extension strength was comparable to the healthy side (5/5). The DASH score was 1,7 for global score, and 6,3 for work and sport modules. Partial rupture of brachii triceps tendon is not well tolerated in high functional demand patients. We think that patients should be operated in these situations and may achieve excellent results. Postoperative management is crucial to achieve good results as well as in complete rupture.

Acute Achilles tendon rupture

Achilles tendon rupture is a common sports-related injury, with the incidence of acute ruptures continuing to increase. Achilles ruptures can be missed, or presentation may be delayed. Clinical tests assist diagnosis, with the Thompson and Matles tests being the most sensitive and specific. Ultrasound provides a valuable adjunct for diagnosing acute Achilles tendon ruptures. Traditionally, operative management has led to lower re-rupture rates than conservative treatment, but surgery increases the risk of complications such as adhesions and wound infection. More recently, however, non-operative treatment consisting of early mobilisation and rehabilitation, produces comparable re-rupture rates and functional outcomes to surgery. Percutaneous surgery may reduce the risk of operative complications, but needs to be more widely practised. In the present review we discuss the anatomy, aetiology, mechanism of injury, clinical assessment and investigations for diagnosing acute Achilles tendon ruptures. The debate regarding operative versus non-operative management is also considered.

German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) - a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment

The German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) comprised 424 outpatients with chronic shoulder pain (CSP) > or =6 weeks and an average pain score of VAS > or =50 mm, who were randomly assigned to receive Chinese acupuncture (verum), sham acupuncture (sham) or conventional conservative orthopaedic treatment (COT). The patients were blinded to the type of acupuncture and treated by 31 office-based orthopaedists trained in acupuncture; all received 15 treatments over 6 weeks. The 50% responder rate for pain was measured on a VAS 3 months after the end of treatment (primary endpoint) and directly after the end of the treatment (secondary endpoint).

RESULTS

In the ITT (n=424) analysis, percentages of responders for the primary endpoint were verum 65% (95% CI 56-74%) (n=100), sham 24% (95% CI 9-39%) (n=32), and COT 37% (95% CI 24-50%) (n=50); secondary endpoint: verum 68% (95% CI 58-77%) (n=92), sham 40% (95% CI 27-53%) (n=53), and COT 28% (95% CI 14-42%) (n=38). The results are significant for verum over sham and verum over COT (p<0.01) for both the primary and secondary endpoints. The PPP analysis of the primary (n=308) and secondary endpoints (n=360) yields similar responder results for verum over sham and verum over COT (p<0.01). Descriptive statistics showed greater improvement of shoulder mobility (abduction and arm-above-head test) for the verum group versus the control group immediately after treatment and after 3 months. The trial indicates that Chinese acupuncture is an effective alternative to conventional orthopaedic treatment for CSP.

Comparative survey of pain-alleviating effects between ultrasound-guided injection and blind injection of lidocaine alone in patients with painful shoulder

BACKGROUND

Complaints of shoulder pain are very frequent in clinical practice. To relieve this type of pain, intra-subacromial bursa (SAB) injection therapy is commonly employed. Injection procedures include blind and ultrasound-guided injection. In clinical practice, blind injection is routinely performed. However, the SAB is a very thin tissue. Poor response to blind injection may be due to a misplaced injection. It is assumed that ultrasound-guided injections are more effective than blind injections. The purpose of this study was to compare pain-alleviating effects between ultrasound-guided injection and blind injection with lidocaine alone.

MATERIALS AND METHODS

The subjects were 16 patients (20 shoulders) in whom pain was possibly derived from inflammation of the SAB. Initially, ultrasound-guided injection was performed with 2 ml of 1% lidocaine. After 1 week, blind injection was conducted in the same patient. They subjectively expressed the grade of pain at each time point (before and 1, 5, 10, 15, 20, 25, and 30 min after injection) as pain scores. We calculated the amelioration rate by dividing differences between the scores at each time point and before injection by the pre-injection score.

RESULTS

Pain scores of ultrasound-guided injection were lower than blind injection. Ultrasound-guided injection achieved higher mean amelioration rates compared to blind injection, showing significant differences at all time points (P < 0.01).

CONCLUSIONS

Ultrasound-guided technique achieved higher effectiveness compared to blind technique.

Painful prominences of the heel

Heel pain is a common malady, with reported prevalence ranging from 4% to 21%. Referral to foot and ankle specialists for heel pain is also common, but patient awareness of the cause of heel pain may be limited. Many misconceptions about how heel exostoses relate to heel pain exist in the medical community and the general patient population, with many patients referred for or presenting with the simple complaint ''I have a heel spur.'' This article reviews the common exostoses of the heel, including plantar, lateral, and posterior spurs, with specific attention to the cause and treatments.

The natural history and management of hamstring injuries

Hamstring injuries in sport can be debilitating. The anatomical complexity of this muscle makes uniform assessment of injury epidemiology difficult and insures that post-injury management strategies must be individually focused. This article reviews the anatomy of the hamstring, its role in athletic movement, common mechanisms of injury, and management guidelines with the goal of return into sporting activity in mind.

Functional management of Achilles tendon rupture: A viable option for non-operative management

BACKGROUND

Functional management of the ruptured Achilles tendon can be effective using orthoses like the removable walker boot (Foam Walker Boot, Air Cast UK Limited, Lincolnshire, United Kingdom). We conducted this study to look at the outcome of our protocol using this orthosis.

MATERIALS AND METHODS

We retrospectively reviewed 107 non-operatively managed Achilles tendon ruptures over the last 5 years. Case notes were analyzed for demographics and immediate outcomes. Long term outcomes were assessed by a postal questionnaire using the Achilles Tendon Total Rupture Score (ATRS).

RESULTS

Of the 107 tendons (male:female=71:36, mean age=50 years), 105 tendons (98%) healed with an average discharge time of 22 weeks. Six patients reported major complications and 6 reported minor complications. We received 56 questionnaires with a mean ATRS score of 21. Seventy-seven percent returned to pre-injury level of activity.

CONCLUSION

Functional management of Achilles tendon rupture, under appropriate supervision, provides a viable option for non-operative management.

A double-blind randomised controlled study comparing subacromial injection of tenoxicam or methylprednisolone in patients with subacromial impingement

We have carried out a prospective double-blind randomised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug, tenoxicam, with a single injection of methylprednisolone in patients with subacromial impingement. A total of 58 patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine. The Constant-Murley shoulder score was used as the primary outcome measure and the Disability of Arm, Shoulder and Hand (DASH) and the Oxford Shoulder Score (OSS) as secondary measures. Six weeks after injection the improvement in the Constant-Murley score was significantly greater in the methylprednisolone group (p = 0.003) than in the tenoxicam group. The improvement in the DASH score was greater in the steroid group and the difference was statistically significant and consistent two (p < 0.01), four (p < 0.01) and six weeks (p < 0.020) after the injection. The improvement in the OSS was consistently greater in the steroid group than in the tenoxicam group. Although the difference was statistically significant at two (p < 0.001) and four (p = 0.003) weeks after the injection, it was not at six weeks (p = 0.055). Subacromial injection of tenoxicam does not offer an equivalent outcome to subacromial injection of corticosteroid at six weeks. Corticosteroid is significantly better than tenoxicam for improving shoulder function in tendonitis of the rotator cuff after six weeks.

Multiple pulley rupture following corticosteroid injection for trigger digit: case report

We report a case of pulley rupture following repeated local corticosteroid injections for trigger digit. The treatment involved exploration, tenolysis, and reconstruction using the palmaris longus tendon.

Acute ruptures of the achilles tendon

The Achilles tendon (AT) is the most frequently ruptured tendon in the human body, but the etiology of AT ruptures is still not completely understood. Percutaneous repair and conservative management are viable alternatives to open surgery, which carries higher complication rates and is the most costly of the 3 management options. Individual patients will have different needs due to their age, occupation, or level of sporting activity. If the studies reporting a rising incidence of AT rupture are accurate, the field of AT surgery will become an increasingly important one for orthopedic surgeons. A major problem in the evaluation of the outcome of management of AT ruptures has been the lack of a universally accepted scoring system for the evaluation of results of management of AT rupture. The AT Total Rupture Score is a self-administered instrument with high clinical utility, and it can be used for measuring the outcome, related to symptoms and physical activity, after treatment in patients with a total AT rupture. Future developments may include the use of adhesives in tendon surgery. An understanding of the role, which cytokines play in tendon healing may also lead to the advent of new treatments, possibly based on gene therapy. However, such novel interventions are unlikely to be in routine clinical use for some time.

Glucocorticoid injections in lesions of the achilles tendon

BACKGROUND

A number of non-operative interventions are used to manage Achilles tendinopathy. In particular, local glucocorticoid injections have generated controversy. Although a number of case reports indicate symptomatic relief following glucocorticoid injection, one systematic review found little evidence to support their efficacy. Furthermore, local glucocorticoid injections may be associated with rupture of the Achilles tendon. This systematic review considered all available clinical trials measuring the effect of local glucocorticoid injections on symptom relief in patients with Achilles tendinopathy.

MATERIALS AND METHODS

The search strategy encompassed five databases: Medline, EMBASE, CINAHL, AMED and the Cochrane Library. Only studies reporting the outcome of glucocorticoid injection for Achilles tendinopathy were included.

RESULTS

A total of 72 articles were identified, five of which met the inclusion criteria. These included one randomized controlled trial, three retrospective studies, and one prospective case series.

CONCLUSION

There is no consensus as to whether local glucocorticoid injections have a therapeutic role in the treatment of Achilles tendinopathy However, they may incur a risk of tendon damage and therefore further research is required before glucocorticoid injections can be recommended for use in Achilles tendinopathy.