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Dyrek P, Tsitsilianos N, McInnis KC, Tenforde AS, Borg-Stein J. Staying in the Game: Interventions for Managing Achilles Tendinopathy in the In-Season Athlete. Curr Sports Med Rep 2024; 23:237-244. [PMID: 38838687 DOI: 10.1249/jsr.0000000000001174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
ABSTRACT Achilles tendinopathy is a common overuse injury that is traditionally managed with activity modification and a progressive eccentric strengthening program. This narrative review describes the available evidence for adjunctive procedural interventions in the management of midportion and insertional AT, specifically in the athletic population. Safety and efficacy data from available literature on extracorporeal shockwave therapy, platelet-rich plasma, high-volume injectate with or without tendon scraping, and percutaneous needle tenotomy are used to propose an algorithm for treatment of Achilles tendinopathy for the in-season athlete.
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Affiliation(s)
- Paige Dyrek
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA
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2
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Najafi Z, Rahmanian-Devin P, Baradaran Rahimi V, Nokhodchi A, Askari VR. Challenges and opportunities of medicines for treating tendon inflammation and fibrosis: A comprehensive and mechanistic review. Fundam Clin Pharmacol 2024:e12999. [PMID: 38468183 DOI: 10.1111/fcp.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 01/20/2024] [Accepted: 02/19/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Tendinopathy refers to conditions characterized by collagen degeneration within tendon tissue, accompanied by the proliferation of capillaries and arteries, resulting in reduced mechanical function, pain, and swelling. While inflammation in tendinopathy can play a role in preventing infection, uncontrolled inflammation can hinder tissue regeneration and lead to fibrosis and impaired movement. OBJECTIVES The inability to regulate inflammation poses a significant limitation in tendinopathy treatment. Therefore, an ideal treatment strategy should involve modulation of the inflammatory process while promoting tissue regeneration. METHODS The current review article was prepared by searching PubMed, Scopus, Web of Science, and Google Scholar databases. Several treatment approaches based on biomaterials have been developed. RESULTS This review examines various treatment methods utilizing small molecules, biological compounds, herbal medicine-inspired approaches, immunotherapy, gene therapy, cell-based therapy, tissue engineering, nanotechnology, and phototherapy. CONCLUSION These treatments work through mechanisms of action involving signaling pathways such as transforming growth factor-beta (TGF-β), mitogen-activated protein kinases (MAPKs), and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), all of which contribute to the repair of injured tendons.
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Affiliation(s)
- Zohreh Najafi
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Pouria Rahmanian-Devin
- Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vafa Baradaran Rahimi
- Department of Cardiovascular Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Nokhodchi
- Lupin Pharmaceutical Research Center, 4006 NW 124th Ave., Coral Springs, Florida, Florida, 33065, USA
- Pharmaceutics Research Laboratory, School of Life Sciences, University of Sussex, Brighton, BN1 9QJ, UK
| | - Vahid Reza Askari
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Ohana N, Segal D, Kots E, Feldman V, Nyska M, Palmanovich E, Slevin O. A pilot study exploring the use of hyaluronic acid in treating insertional achilles tendinopathy. J Orthop Surg (Hong Kong) 2024; 32:10225536241242086. [PMID: 38589277 DOI: 10.1177/10225536241242086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
PURPOSE This study explores the use of ultrasound-guided Hyaluronic Acid (HA) injections for Insertional Achilles Tendinopathy (IAT). METHODS A cohort of 15 ankles diagnosed with IAT received three weekly ultrasound-guided HA injections. The Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire scored the severity of symptoms and functional impairment before treatment, and at one and six months post-treatment. RESULTS Significant improvement was observed in VISA-A scores post-treatment, rising from an average baseline of 34.8 ± 15.2 (11-63) to 53.6 ± 20.9 (15-77) after one month, and then to 50.7 ± 18.6 (20-75) after six months. No adverse reactions were noted, underscoring the safety of the intervention. CONCLUSION The pilot study presents HA injections as a potentially effective treatment for IAT, while interpretation of these findings must take into account the variability in results, indicating a range of patient responses. It encourages further research to confirm these findings and to explore HA's full potential in managing IAT, despite the limitations of a small sample size and lack of control group.
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Affiliation(s)
- Nissim Ohana
- Department of Orthopaedic Surgery, Meir Medical Center, Kfar-Saba, Israel
- Faculty of medicine, Tel-Aviv University, Tel Aviv, Israel
| | - David Segal
- Department of Orthopaedic Surgery, Meir Medical Center, Kfar-Saba, Israel
- Faculty of medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eugene Kots
- Faculty of medicine, Tel-Aviv University, Tel Aviv, Israel
- Department of Radiology, Musculoskeletal and Invasive Radiology unit, Meir Medical Center, Kfar-Saba, Israel
| | - Viktor Feldman
- Department of Orthopaedic Surgery, Meir Medical Center, Kfar-Saba, Israel
- Faculty of medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Meir Nyska
- Faculty of medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ezequiel Palmanovich
- Department of Orthopaedic Surgery, Meir Medical Center, Kfar-Saba, Israel
- Faculty of medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Omer Slevin
- Faculty of medicine, Tel-Aviv University, Tel Aviv, Israel
- Hand surgery unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
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Bello Baez A, Nieto Morales ML, Mora Guanche P, Cavada Laza A, Pérez Méndez LI. Can Achilles tendinosis be treated effectively with lidocaine and glucose infiltrations, and if so, is the effect lasting? A longitudinal, observational on 27 consecutive patients. RADIOLOGIA 2023; 65 Suppl 2:S41-S49. [PMID: 37858352 DOI: 10.1016/j.rxeng.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 05/09/2022] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Our aim was to add to the small but growing body of evidence on the effectiveness of ultrasound-guided Achilles intratendinous hyperosmolar dextrose prolotherapy and introduce a novel, preceding step of paratenon hydrodissection with lidocaine in patients with chronic Achilles tendinosis resistant to rehabilitation therapy. METHODS We conducted a longitudinal, observational study on 27 consecutive patients diagnosed with Achilles tendinosis, in whom conservative treatment, ie, physiotherapy or shock wave therapy, had failed. A 2% lidocaine paratenon anesthesia and hydrodissection was followed by ultrasound-guided, intratendinous injections of 25% glucose every 5 weeks. Visual analogue scales (VAS) were used for pain assessment at rest, for activities of daily living, and after moderate exercise at the begining and at the end of the treatment. Moreover, tendon thickness and vascularisation were recorded at baseline and final treatment consultation. Effectiveness was estimated from scoring and relative pain reduction using a 95% CI. The non-parametric Wilcoxon test and a general linear model for repeated measures were applied. Statistical significance was established as p < 0.05. RESULTS A median of 5 (1-11) injection consultations per patient were required. Pain scores decreased significantly in all three conditions (p < 0.001). Relative reductions were 75% in pain at rest (95% CI;61-93%), 69% in pain with daily living activities (95% CI; 55-83%), and 70% in pain after moderate exercise (95% CI; 57-84%). Tendon neo-vascularisation was significantly reduced (p < 0.001). We did not observe significant changes in tendon thickness (p = 0.083). CONCLUSIONS Achilles tendinosis treatment with paratenon lidocaine hydrodissection and subsequent prolotherapy with hyperosmolar glucose solution is safe, effective, inexpensive, and virtually painless with results maintained over time.
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Affiliation(s)
- A Bello Baez
- Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - M L Nieto Morales
- Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - P Mora Guanche
- Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - A Cavada Laza
- Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Lina Inmaculada Pérez Méndez
- Departamento de Epidemiología Clínica y Bioestadística, Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
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Li H, Yao W, Xue X, Li Y, Hua Y. Therapeutic effects following extracorporeal shock wave therapy for insertional and non-insertional Achilles tendinopathy. Asia Pac J Sports Med Arthrosc Rehabil Technol 2023; 34:38-45. [PMID: 37860635 PMCID: PMC10582256 DOI: 10.1016/j.asmart.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/14/2023] [Accepted: 09/02/2023] [Indexed: 10/21/2023] Open
Abstract
Background The treatment for Achilles tendinopathy varies widely, and there is no consensus regarding the optimal treatment for both non-insertional and insertional Achilles tendinopathy. The purpose of this study was to evaluate the clinical efficacy of extracorporeal shock wave therapy (ESWT) in the treatment of insertional and non-insertional Achilles tendinopathy (AT). Methods Sixty patients with AT were invited to participate in this study. Patients were allocated to one of two groups according to the site of the AT, including an insertional AT (IAT) group and a non-insertional AT (NIAT) group. ESWT was performed once a week for five weeks for both groups. The Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) score and the visual analog scale (VAS) were used five times to evaluate the clinical outcomes, including before treatment, immediately after treatment, as well as one month, three months, and five years after treatment. Results At three months after treatment, the IAT group exhibited a significantly higher VISA-A score (82 ± 6 vs. 76 ± 11; p = 0.01) and a significantly lower VAS score (1 ± 1 vs. 2 ± 1; p < 0.001) when compared with the NIAT group. At the five-year assessment, the IAT group (1 ± 1) had a significantly lower VAS score than the NIAT group (2 ± 1) (p = 0.02), while no significant difference for the VISA-A score was observed between the groups (84 ± 8 vs. 84 ± 10; p = 0.98). Conclusions Extracorporeal shock wave treatment can improve the symptoms of both insertional and non-insertional AT. The IAT patients experienced better clinical outcomes compared with the NIAT patients.
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Affiliation(s)
| | | | | | - Yunxia Li
- Corresponding author. No 12, Wulumuqi Zhong Road, Shanghai, 200040, China.
| | - Yinghui Hua
- Corresponding author. No 12, Wulumuqi Zhong Road, Shanghai, 200040, China.
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Prolotherapy. Phys Med Rehabil Clin N Am 2023; 34:165-180. [DOI: 10.1016/j.pmr.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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7
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Kajbaf J. Prolotherapy. Regen Med 2023. [DOI: 10.1007/978-3-030-75517-1_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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8
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Ferreira GF, Caruccio FRC, Guerrero Bou Assi JR, Pedroso JP, Dos Santos TF, Arliani GG, Filho MVP. Ultrasound-guided hyaluronic acid injection for the treatment of insertional Achilles tendinopathy: A prospective case series. Foot Ankle Surg 2022; 28:879-882. [PMID: 34906404 DOI: 10.1016/j.fas.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/09/2021] [Accepted: 12/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Heel pain is a common condition and often involves the Achilles tendon and is classified as insertional or non-insertional. Several operative and non-operative treatments have been described, but there is no consensus on the most effective therapy. The aim of this study is to evaluate a case series of patients with insertional Achilles tendinopathy refractory to conservative treatment submitted to a single-dose ultrasound-guided injection of hyaluronic acid (40 mg/2.0 mL). METHODS We prospectively included 25 patients (29 feet) who underwent a single ultrasound-guided injection of hyaluronic acid after conservative treatment failure. Clinical outcomes such as pain (using the Visual Analog Scale - VAS), function (using the American Orthopedic Foot & Ankle Society - AOFAS score), personal satisfaction, and complications were evaluated. Statistical analysis was performed using the R software. RESULTS Most patients were female (80%) and there was a right-side predominance (55%). The median VAS was 8 points [range 4-10] at baseline, decreasing to 3 points [range 0-8] at the six-month follow-up, with statistical significance (p < .001). The median AOFAS score was 71 points [range 38-87] at baseline, increasing to 90 points [range 48-100] at the six-month follow-up (p < .001). The personal satisfaction level was 69%, and 48% of patients considered the result excellent. There were no Achilles tendon ruptures, infections, or allergic reactions post injection. CONCLUSION Single-dose injection of hyaluronic acid is a safe treatment option, improving function and reducing pain for six months in patients with insertional Achilles tendinopathy after conservative treatment failure. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Gabriel Ferraz Ferreira
- Foot and Ankle Surgery Group, Orthopaedics and Traumatology Unit, Prevent Senior, São Paulo, Brazil.
| | | | | | - João Paulo Pedroso
- Foot and Ankle Surgery Group, Orthopaedics and Traumatology Unit, Prevent Senior, São Paulo, Brazil.
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Bello Baez A, Nieto Morales M, Mora Guanche P, Cavada Laza A, Pérez Méndez LI. ¿Puede tratarse la tendinosis aquílea de forma eficaz con lidocaína e infiltraciones de glucosa y, de ser así, es duradero su efecto? Estudio observacional longitudinal en 27 pacientes consecutivos. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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The Achilles Tendon: Imaging Diagnoses and Image-Guided Interventions- AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 219:355-368. [PMID: 35506554 DOI: 10.2214/ajr.22.27632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Achilles tendon is commonly affected by both chronic repetitive overuse and traumatic injuries. Achilles tendon injuries can potentially affect any individual but have a particularly high incidence in professional athletes. Appropriate imaging evaluation and diagnosis are paramount to guiding appropriate management. In this AJR Expert Panel Narrative Review, we discuss the role of various imaging modalities (particularly ultrasound and MRI) in the assessment of Achilles tendon pathology, focusing on modalities' relative advantages and technical considerations. We describe the most common diagnoses affecting the Achilles tendon and adjacent structures, highlighting key imaging findings and providing representative examples. Various image-guided interventions that may be employed in the management of Achilles tendon pathology are also reviewed, including high-volume injection, tendon fenestration, prolotherapy, and corticosteroid injection. The limited evidence supporting such interventions are summarized, noting an overall paucity of large-scale studies showing benefit. Finally, a series of consensus statements by the panel on imaging and image-guided intervention for Achilles tendon pathology are provided.
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Grävare Silbernagel K, Malliaras P, de Vos RJ, Hanlon S, Molenaar M, Alfredson H, van den Akker-Scheek I, Antflick J, van Ark M, Färnqvist K, Haleem Z, Kaux JF, Kirwan P, Kumar B, Lewis T, Mallows A, Masci L, Morrissey D, Murphy M, Newsham-West R, Norris R, O'Neill S, Peers K, Sancho I, Seymore K, Vallance P, van der Vlist A, Vicenzino B. ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy. Sports Med 2022; 52:613-641. [PMID: 34797533 PMCID: PMC8891092 DOI: 10.1007/s40279-021-01588-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated. OBJECTIVE To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains. DESIGN Systematic review. DATA SOURCES Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series. RESULTS 9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain. CONCLUSION 233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures. PROSPERO REGISTRATION CRD42020156763.
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Affiliation(s)
- Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA.
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Robert-Jan de Vos
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Zuid-Holland, The Netherlands
| | - Shawn Hanlon
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Mitchel Molenaar
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jarrod Antflick
- Department of Bioengineering, School of Engineering, Imperial College, London, UK
| | - Mathijs van Ark
- Department of Physiotherapy, School of Health Care Studies, Hanze University of Applied Sciences and Peescentrum, Centre of Expertise Primary Care Groningen (ECEZG), Groningen, The Netherlands
| | | | - Zubair Haleem
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Arsenal Football Club, London, UK
| | - Jean-Francois Kaux
- Department of Physical and Rehabilitation Medicine and Sports Traumatology, University and University Hospital of Liège, Liège, Belgium
| | - Paul Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bhavesh Kumar
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Trevor Lewis
- Aintree University Hospital, Liverpool Foundation Trust, Liverpool, UK
| | - Adrian Mallows
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, UK
| | - Lorenzo Masci
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
| | - Myles Murphy
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Richard Newsham-West
- School of Allied Health, Department of Physiotherapy, La Trobe University, Melbourne, VIC, Australia
| | - Richard Norris
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- Liverpool University Hospitals, NHS Foundation Trust, Liverpool, UK
| | - Seth O'Neill
- School of Allied Health, University of Leicester, Leicester, UK
| | - Koen Peers
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Igor Sancho
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, University of Deusto, San Sebastian, Spain
| | - Kayla Seymore
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Patrick Vallance
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Clayton, VIC, Australia
| | - Arco van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, QLD, Australia
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Lin CL, Chen YW, Wu CW, Liou TH, Huang SW. Effect of Hypertonic Dextrose Injection on Pain and Shoulder Disability in Patients with Chronic Supraspinatus Tendinosis: A Randomized Double-Blind Controlled Study. Arch Phys Med Rehabil 2021; 103:237-244. [PMID: 34610286 DOI: 10.1016/j.apmr.2021.07.812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To investigate the effect of hypertonic dextrose injection on pain and disability in patients with chronic supraspinatus tendinosis. The secondary aim was to evaluate its effect on the tendon range of motion (ROM) and morphology. DESIGN Randomized double-blind placebo-controlled trial. SETTING Outpatient clinic. PARTICIPANTS Individuals (N=57) with symptomatic chronic supraspinatus tendinosis. INTERVENTIONS Participants were randomly administered ultrasound-guided injections of 20% hypertonic dextrose (study group, n=29) or 5% normal saline (control group, n=28). MAIN OUTCOME MEASURES The primary outcome measure was visual analog scale (VAS) scores for pain and Shoulder Pain and Disability Index (SPADI) scores. Secondary outcomes included the ROM and ultrasound examination findings of the supraspinatus tendon at baseline and at 2, 6, and 12 weeks postintervention. RESULTS The study group exhibited significant improvements in the VAS (mean difference [MD], -2.1; 95% confidence interval [CI], -2.7 to -1.4; P<.001) and SPADI (MD, -11.6; 95% CI, -16.5 to -6.7; P<.001) scores compared with baseline scores at week 2. However, the effect was not sustained to week 6. Flexion ROM increased at weeks 2 (MD, 14.1; 95% CI, 5.7-22.5; P<.001) and 6 (MD, 8.9; 95% CI, 2.4-15.4; P=.003) compared with baseline. The thickness of the supraspinatus tendon improved at weeks 6 (MD, .50; 95% CI, .26-.74; P<.001) and 12 (MD, .61; 95% CI, .37-.84; P<.001) compared with baseline. The ratio of histograms also improved at weeks 6 (MD, .19; 95% CI, .06-.32; P=.002) and 12 (MD, .26; 95% CI, .10-.41; P<.001) compared with baseline. CONCLUSION Hypertonic dextrose injection could provide short-term pain and disability relief in patients with chronic supraspinatus tendinosis. Ultrasound imaging at week 6 revealed changed tendon morphology.
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Affiliation(s)
- Che-Li Lin
- From the Department of Orthopedic Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Wen Chen
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Wen Wu
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tsan-Hon Liou
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shih-Wei Huang
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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von Rickenbach KJ, Borgstrom H, Tenforde A, Borg-Stein J, McInnis KC. Achilles Tendinopathy: Evaluation, Rehabilitation, and Prevention. Curr Sports Med Rep 2021; 20:327-334. [PMID: 34099611 DOI: 10.1249/jsr.0000000000000855] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Achilles tendinopathy is a common overuse condition that is characterized by degenerative, cumulative tissue microtrauma. It is largely a clinical diagnosis in which the patient typically presents with localized pain that is worse with tendon-loading activities. Imaging modalities may be helpful with the diagnosis of difficult cases or in the planning of interventional procedures. Midportion (noninsertional) and insertional tendinopathy have distinct features and differences for therapeutic paradigms. Overall, Achilles tendinopathy has a good clinical prognosis with most patients improving with activity modification and rehabilitation, with a focus on progressive tendon-loading. Recalcitrant cases may require adjuvant treatment with procedures (e.g., injections, shockwave therapy) and rarely surgical intervention.
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Mao J, Xiang L. Ultrasound Diagnosis Technology for Sports Injury Detection and Prevention: A Mini Review. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2021. [DOI: 10.1166/jmihi.2021.3592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ultrasound as a medical diagnosis tool, comprising the strengths of noninvasive, portable and cost-saving, and it allows the evaluation of soft tissue pathology. In sports medicine field, sonography technology is used for the detection and prevention of injuries of upper and lower limbs,
mainly including elbow, shoulder, knee and ankle joints. The implement of ultrasound diagnosis technology was discussed in this narrative literature review. Sonographic images of elbows could provide a dynamic assessment of medial joint laxity. Due to the importance of ultrasound assessment
in lower-limb muscles, tendons, and ligaments, this technology has been applied extensively for many types of extra-articular injuries in the lower limb. Most muscle injuries can be assessed and graded using the ultrasound apparatus. Overall, sonographic image evaluation is a reliable and
handy method for the initial examination of acute or chronic sports injuries.
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Affiliation(s)
- Jiansheng Mao
- Department of Physical Education, Zhejiang Wanli University, Zhejiang, 315100, China
| | - Liangliang Xiang
- Auckland Bioengineering Institute, University of Auckland, Auckland, 1010, New Zealand
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Zhi X, Liu X, Han J, Xiang Y, Wu H, Wei S, Xu F. Nonoperative treatment of insertional Achilles tendinopathy: a systematic review. J Orthop Surg Res 2021; 16:233. [PMID: 33785026 PMCID: PMC8008511 DOI: 10.1186/s13018-021-02370-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insertional Achilles tendinopathy is difficult to manage, and there is no definite consensus on which nonoperative treatment is superior over the others. We aim to provide a clear summary of the best available evidence for nonoperative treatment specific to insertional Achilles tendinopathy. METHODS Literatures were searched in PubMed, Embase, and Web of Science databases from inception to October 2020. The results were evaluated independently by two reviewers and assessed against the inclusion/exclusion criteria. All included articles were assessed for methodological quality, and study characteristics were extracted. RESULTS Twenty-three studies (containing 35 groups) were eligible for the final review. The treatments included eccentric training, extracorporeal shockwave therapy (ESWT), injections, and combined treatment. Visual analog scale (VAS), Victorian Institute of Sport Assessment-Achilles questionnaire, AOFAS, satisfaction rate, and other scales were used to assess the clinical outcome. CONCLUSION Current evidence for nonoperative treatment specific for insertional Achilles tendinopathy favors ESWT or the combined treatment of ESWT plus eccentric exercises.
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Affiliation(s)
- Xiaosong Zhi
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), NO. 627, Wuluo Road, Wuhan, 430030, Hubei Province, P. R. China
| | - Xinyuan Liu
- Department of Emergency, Taikang Tongji (Wuhan) Hospital, Wuhan, Hubei Province, P. R. China
| | - Jing Han
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), NO. 627, Wuluo Road, Wuhan, 430030, Hubei Province, P. R. China
| | - Yang Xiang
- Graduate School of Wuhan University of Science and Technology, Wuhan, Hubei Province, P. R. China
| | - Helin Wu
- The First Clinical Medical School Of Southern Medical University, Guangzhou, Guangdong Province, P. R. China
| | - Shijun Wei
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), NO. 627, Wuluo Road, Wuhan, 430030, Hubei Province, P. R. China. .,The First Clinical Medical School Of Southern Medical University, Guangzhou, Guangdong Province, P. R. China.
| | - Feng Xu
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), NO. 627, Wuluo Road, Wuhan, 430030, Hubei Province, P. R. China. .,The First Clinical Medical School Of Southern Medical University, Guangzhou, Guangdong Province, P. R. China.
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16
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El Gharbawy NH, Labib HS. Role of Platelet Rich Plasma (PRP) injection in treatment of rotator cuff tear. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2020. [DOI: 10.1186/s43166-020-00032-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
One of the commonest causes of shoulder pain and disability is partial thickness tear of the rotator cuff. Platelet-rich plasma (PRP) therapy is a volume of the plasma fraction of autologous blood that has platelet concentration above the baseline. It is theorized that PRP may help stimulate the development of normal-appearing histologic tissue characteristics at the repair site and improve clinical outcomes. Our purpose is to assess the efficacy of PRP therapy in treatment of rotator cuff tear. This prospective single-center study involved 30 patients (aged 31.7 ± 7.7 years, 63.3% males) complaining of symptomatic rotator cuff tear. Platelet-rich plasma (PRP) injection was done to all patients. Before and after injection of PRP, scoring was done using visual analog score, Shoulder Pain and Disability Index (SPADI), and musculoskeletal ultrasound scoring of the tear. Reassessment was done 4 weeks after the injections.
Results
The pre-injection VAS pain score was 7.1 ± 0.99 after injection, and it became 3.7 ± 1.09. Also, SPADI score decreased from 78.03 ± 8.25 pre-injection to 42.1 ± 13.97 post-injection. There was a highly statistically significant difference in VAS pain score and SPADI score before and after PRP injection (p < 0.001). There was highly statistically significant positive correlation between the improvement of US grading score change and the improvement of VAS score change, and between it and SPADI improvement change (r = 0.695, p < 0.001 and r = 0.693, p < 0.001, respectively). There was a highly statistically significant difference between US grading score before and after PRP injection (p < 0.001).
Conclusion
PRP can be considered an effective method for treatment of rotator cuff tear and less invasive compared to surgical treatment. It improves the pain, shoulder function, and tear size.
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Sederberg M, Cushman DM. Current Treatments of Insertional Achilles Tendinopathy. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00288-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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18
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Aicale R, Bisaccia RD, Oliviero A, Oliva F, Maffulli N. Current pharmacological approaches to the treatment of tendinopathy. Expert Opin Pharmacother 2020; 21:1467-1477. [DOI: 10.1080/14656566.2020.1763306] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Rocco Domenico Bisaccia
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Department of Pharmacology, School of Medicine and Surgery, University of Salerno , Baronissi, Italy
| | - Antonio Oliviero
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London , London, UK
- Keele University, Faculty of Medicine, School of Pharmacology and Bioengineering, Guy Hilton Research Centre , Stoke-on-Trent, UK
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Abstract
PURPOSE OF REVIEW Osgood-Schlatter disease (OSD) is one of the most common causes for anterior knee pain in children and adolescents resulting from a traction apophysitis of the tibial tubercle. While a peak in boys aged 12-15 years old was well documented, there seems to be no difference in sex distribution nowadays. This may result from increased participation of young females in high-impact sports. This review provides an up-to-date account on contemporary prophylaxis as well as diagnostic and therapeutic approaches. RECENT FINDINGS Numerous studies have examined risk factors for OSD. These include body weight, muscle tightness, muscle weakness during knee extension and flexibility of hamstring muscles. In particular, shortening of the rectus femoris may substantially alter biomechanical functions of the knee. Conservative management remains successful in over 90% of patients. However, if disabling symptoms and pain persistent after physeal closure, operative treatment may be necessary. SUMMARY OSD is a mostly self-limiting apophysitis of the tibial tubercle and the adjacent patella tendon in young active patients with open physis. Prevention strategies include quadriceps and hamstring stretching and therefore should be implemented in everyday practice routines for children who partake in regular sports activities.
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Nakase J, Oshima T, Takata Y, Shimozaki K, Asai K, Tsuchiya H. No superiority of dextrose injections over placebo injections for Osgood-Schlatter disease: a prospective randomized double-blind study. Arch Orthop Trauma Surg 2020; 140:197-202. [PMID: 31713082 DOI: 10.1007/s00402-019-03297-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tuberosity. Patellar tendinopathy and deep infrapatellar bursitis have recently been shown to contribute to pain in patients with OSD. We compared the effects of dextrose injection and saline injection. METHODS We performed a clinical trial from April 2012 to January 2016 and included 49 knees from 37 boys and 1 girl (mean age, 12.3 ± 1.1 years) for whom conventional conservative therapy for > 1 month was ineffective. They were randomly assigned to receive double-blind injections of 1% lidocaine (1 mL) with 20% dextrose (1 mL; dextrose group) or 1% lidocaine (1 mL) with saline (1 mL; saline group). Injections were administered monthly for 3 months by a single investigator. The Victorian Institute of Sport Assessment (VISA) score was used to evaluate anterior knee pain. RESULTS Overall, 43 knees were included; 6 knees were lost to follow-up. The mean pre-injection VISA scores in the dextrose and saline groups were 58.7 ± 18.3 and 63.4 ± 16.4, respectively. No significant differences were found between the two groups at any time point. The mean VISA score before injections significantly increased at the 1-month follow-up in both groups (P < .01). The injection had no adverse effects. CONCLUSIONS We were not able to show the efficacy of dextrose injections compared to that of saline. LEVEL OF EVIDENCE Randomized controlled trial. Level I.
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Affiliation(s)
- Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan.
| | - Takeshi Oshima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
| | - Yasushi Takata
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
| | - Kengo Shimozaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
| | - Kazuki Asai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
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21
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Zhang S, Li H, Yao W, Hua Y, Li Y. Therapeutic Response of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy Between Sports-Active and Nonsports-Active Patients With 5-Year Follow-up. Orthop J Sports Med 2020; 8:2325967119898118. [PMID: 32030348 PMCID: PMC6977229 DOI: 10.1177/2325967119898118] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 10/10/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Insertional Achilles tendinopathy (IAT) is a common cause of posterior heel pain. Extracorporeal shock wave therapy (ESWT) has proven to be an effective treatment, but the relationship between therapeutic responses and sports activity levels has not been studied. Purpose: To compare the clinical outcomes of ESWT used to treat IATs between sports-active and nonsports-active patients over 5 years. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was conducted on 33 patients with IAT who received ESWT from October 2012 to September 2013. Patients were classified into 2 groups according to their preinjury Tegner activity level: a sports-active group, defined as patients who self-reported to be regular joggers (SA group; Tegner activity level >3; n = 16), and a nonsports-active group (control group; Tegner activity level ≤3; n = 17). The mean age was 31 ± 7 years for the SA group and 37 ± 10 years for the control group. The Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire scores and visual analog scale (VAS) pain scores were used to evaluate the clinical outcomes before treatment, immediately after treatment, and 5 years after treatment. Ultrasonography was also used to assess the insertional Achilles tendon quality. Results: Before treatment, there were no significant differences between the groups with regard to VAS scores, while the VISA-A score in the SA group was higher than that in the control group. After ESWT, both groups had increased VISA-A scores and decreased VAS scores, indicating improvement. At 5-year follow-up, the SA group had a significantly lower mean VAS score (0.3 ± 0.8 vs 1.6 ± 1.3; P = .001) and a significantly higher mean VISA-A score (90 ± 4 vs 78 ± 7; P < .001) compared with the control group. There was no significant difference between the groups regarding the calcification and neovascularization of the Achilles tendon based on ultrasonography. Conclusion: ESWT can improve the symptoms of Achilles tendinopathy, and patients with IAT who had greater sports activity levels had better therapeutic responses than nonsports-active patients after 5-year follow-up.
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Affiliation(s)
- Shurong Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Hong Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Wei Yao
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yunxia Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
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22
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Lin CL, Huang CC, Huang SW. Effects of hypertonic dextrose injection in chronic supraspinatus tendinopathy of the shoulder: a randomized placebo-controlled trial. Eur J Phys Rehabil Med 2019; 55:480-487. [DOI: 10.23736/s1973-9087.18.05379-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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23
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Eroglu A, Sari A. Efficacy of dextrose prolotherapy in elite professional male soccer players with chronic osteitis pubis. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2019. [DOI: 10.23736/s0393-3660.18.03838-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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24
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Baumbach SF, Braunstein M, Mack MG, Maßen F, Böcker W, Polzer S, Polzer H. [Insertional Achilles tendinopathy : Differentiated diagnostics and therapy]. Unfallchirurg 2019; 120:1044-1053. [PMID: 28980027 DOI: 10.1007/s00113-017-0415-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Achilles tendinopathy at the calcaneal insertion is classified into insertional tendinopathy, retrocalcaneal and superficial bursitis. The aim of this study was to present the current evidence on conservative and surgical treatment of insertional tendinopathy of the Achilles tendon. Conservative first-line therapy includes reduction of activity levels, administration of non-steroidal anti-inflammatory drugs (NSAID), adaptation of footwear, heel wedges and orthoses or immobilization. In addition, further conservative therapy options are also available. Eccentric stretching exercises should be integral components of physiotherapy and can achieve a 40% reduction in pain. Extracorporeal shock wave therapy has been shown to reduce pain by 60% with a patient satisfaction of 80%. Due to the limited evidence, injections with platelet-rich plasma (PRP), dextrose (prolotherapy) or polidocanol (sclerotherapy) cannot currently be recommended. Operative therapy is indicated after 6 months of unsuccessful conservative therapy. Open debridement allows all pathologies to be addressed, including osseous abnormalities and intratendinous necrosis. The success rate of over 70% is contrasted by complication rates of up to 40%. The Achilles tendon should be reattached, if detached by >50%. No valid data are available for the transfer of the tendon of the flexor hallucis longus (FHL) muscle but it is frequently applied in cases of more than 50% debridement of the diameter of the Achilles tendon. Lengthening of the gastrocnemius muscle cannot be recommended because insufficient data are available. Tendoscopy is a promising treatment option for isolated retrocalcaneal bursitis and has shown similar success rates to open debridement with significantly lower complication rates.
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Affiliation(s)
- S F Baumbach
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - M Braunstein
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - M G Mack
- Radiologie München, München, Deutschland
| | - F Maßen
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - W Böcker
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - S Polzer
- Praxis für Hand‑, Ellenbogen- und Fußchirurgie, ATOS-Klinik Heidelberg, Heidelberg, Deutschland
| | - H Polzer
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland.
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26
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Matthews W, Ellis R, Furness J, Hing W. Classification of Tendon Matrix Change Using Ultrasound Imaging: A Systematic Review and Meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2059-2080. [PMID: 30007477 DOI: 10.1016/j.ultrasmedbio.2018.05.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/17/2018] [Accepted: 05/29/2018] [Indexed: 06/08/2023]
Abstract
Ultrasound imaging (US) is an accurate and reliable method used to diagnose tendinopathy. This systematic review was aimed at identifying common criteria and parameters used to diagnose tendinopathy, the methodological quality of studies and the predictive value of US. Nineteen studies met the inclusion criteria, with the Achilles, quadriceps and patella tendons being investigated. Overall, there was significant heterogeneity between the criteria used to diagnose tendinopathy utilising US. The methodological quality of included studies was "good." Additionally, meta-analysis revealed that US-identified abnormalities were predictive of future symptoms, and classification of tendinopathy using three US defined parameters indicated a higher relative risk of developing clinical tendinopathy compared with the use of two US-defined parameters. Further research into the development of a standardised US criterion that incorporates both clinical and US findings is required to allow for greater consistency in the diagnosis of tendinopathy.
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Affiliation(s)
- Wesley Matthews
- Bond Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, Queensland, Australia.
| | - Richard Ellis
- Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - James Furness
- Bond Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, Queensland, Australia
| | - Wayne Hing
- Bond Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, Queensland, Australia
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Borg-Stein J, Osoria HL, Hayano T. Regenerative Sports Medicine: Past, Present, and Future (Adapted From the PASSOR Legacy Award Presentation; AAPMR; October 2016). PM R 2018; 10:1083-1105. [PMID: 30031963 DOI: 10.1016/j.pmrj.2018.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/06/2018] [Indexed: 12/14/2022]
Abstract
Regenerative medicine has shown dramatic expanse and evolution in the past decade. Within that milieu, physiatrists are taking an active role in research, clinical care delivery, and education. The purpose of this review is to provide a balance among evidence, theory, experience, clinical trends, and the foreseeable future. We focus on the literature that reports the research with the best methodology in each practice area, recognizing that the level of evidence varies substantially among different treatment modalities and conditions. The following elements are included: an overview of the evolution of currently available regenerative techniques, evidence base for each available modality (prolotherapy, platelet rich plasma, bone marrow aspirate concentrate and stem cells, adipose-derived stem cells, and amniotic tissue products), general principles in the application of these treatments, and discussion and a vision of what lies ahead. We expect that practitioners will use this review to facilitate clinical decision making and to provide a core knowledge base to assist when counseling patients. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Joanne Borg-Stein
- Spaulding Newton Wellesley Rehab Hospital Rehabilitation Center, 65 Walnut St, Wellesley, MA 02481
| | | | - Todd Hayano
- Spaulding Rehabilitation Hospital, Charlestown, MA
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28
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Cole B, Lam P, Hackett L, Murrell GAC. Ultrasound-guided injections for supraspinatus tendinopathy: corticosteroid versus glucose prolotherapy - a randomized controlled clinical trial. Shoulder Elbow 2018; 10:170-178. [PMID: 29796104 PMCID: PMC5960868 DOI: 10.1177/1758573217708199] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/06/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Subacromial corticosteroid injections are frequently performed for pain associated with supraspinatus tendinopathy. Glucose prolotherapy has been used clinically for multiple tendinopathies and is hypothesized to be an alternate injection therapy for supraspinatus tendinopathy. METHODS A prospective, randomized, double blinded clinical trial was conducted. Thirty-six patients with supraspinatus tendinopathy were randomized into two groups: 17 received an ultrasound-guided injection of glucose into the tendinopathic parts of the supraspinatus tendon and 19 received an ultrasound-guided injection of corticosteroid into the subacromial bursa. Primary outcome was level of pain with overhead activities at 3 months. Secondary outcome measures included level and frequency of pain and function, shoulder range of motion, impingement tests, strength and tendon changes on ultrasound. RESULTS Level of pain with overhead activities was significantly reduced at the 3-month follow-up in the prolotherapy group and at the 6-month follow-up for both the prolotherapy and corticosteroid groups. There were no significant differences between the groups at any time point. CONCLUSIONS Both glucose prolotherapy and corticosteroid were generally well tolerated; however, glucose prolotherapy offered no additional benefit over subacromial corticosteroid injection for supraspinatus tendinopathy.
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Affiliation(s)
- Brandi Cole
- Orthopaedic Research Institute, St George Hospital
Campus, Sydney, NSW, Australia
| | - Patrick Lam
- Orthopaedic Research Institute, St George Hospital
Campus, Sydney, NSW, Australia
| | - Lisa Hackett
- Orthopaedic Research Institute, St George Hospital
Campus, Sydney, NSW, Australia
| | - George A. C. Murrell
- Orthopaedic Research Institute, St George Hospital
Campus, Sydney, NSW, Australia
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29
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Mead MP, Gumucio JP, Awan TM, Mendias CL, Sugg KB. Pathogenesis and Management of Tendinopathies in Sports Medicine. TRANSLATIONAL SPORTS MEDICINE 2017; 1:5-13. [PMID: 31131372 DOI: 10.1002/tsm2.6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective Tendinopathy is a major clinical problem in sports medicine and is often difficult to treat. Traditional therapeutic approaches have focused on reducing inflammation, yet research suggests that little to no inflammation is present in the tendons that fail to heal. The purpose of this review was to evaluate the effectiveness of the available treatment options for tendinopathy and to inform best clinical practices. Design A narrative review. Methods A comprehensive search of electronic databases (PubMed, Google Scholar and Web of Science) was conducted to identify relevant studies through June 2016. Studies were deemed relevant if they were published in English and contained original research on the management of tendinopathy in humans. Results Studies varied in methodological quality and were often limited by small sample size and lack of sufficient control groups. Critical evaluation of the literature suggests that physical therapy with or without eccentric exercise should be considered a first-line treatment. Corticosteroids and nonsteroidal anti-inflammatory drugs provide short-term symptomatic relief, but long-term efficacy has not been demonstrated. Inconsistent results do not support the routine use of prolotherapy, platelet-rich plasma injections and topical nitric oxide patches. Operative intervention should be reserved until conservative measures fail or an obvious operative lesion is present. Conclusions While numerous therapeutic modalities exist for tendinopathy in the athlete, the ideal treatment protocol has not been clearly defined. The development of new targeted therapies for tendinopathy is likely to follow a greater understanding of the cellular and molecular mechanisms that underlie its pathogenesis.
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Affiliation(s)
- Matthew P Mead
- Departments of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Jonathan P Gumucio
- Departments of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, MI.,Departments of Molecular & Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI
| | - Tariq M Awan
- Departments of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Christopher L Mendias
- Departments of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, MI.,Departments of Molecular & Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI
| | - Kristoffer B Sugg
- Departments of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, MI.,Departments of Molecular & Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI.,Departments of Surgery, Section of Plastic & Reconstructive Surgery, University of Michigan Medical School, Ann Arbor, MI
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30
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Musculoskeletal Injuries and Regenerative Medicine in the Elderly Patient. Phys Med Rehabil Clin N Am 2017; 28:777-794. [DOI: 10.1016/j.pmr.2017.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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31
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Morath O, Kubosch EJ, Taeymans J, Zwingmann J, Konstantinidis L, Südkamp NP, Hirschmüller A. The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy-a systematic review including meta-analysis. Scand J Med Sci Sports 2017; 28:4-15. [PMID: 28449312 DOI: 10.1111/sms.12898] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2017] [Indexed: 01/29/2023]
Abstract
Chronic painful Achilles tendinopathy (AT) is a common disorder among athletes. Sclerotherapy (ST) and prolotherapy (PT) are two promising options among the numerous other conservative therapies. As their efficacy and potential adverse effects (AE) are still unclear, we systematically searched, analyzed, and synthesized the available literature on ST and PT for treating AT. Electronic databases, Google Scholar and articles' reference lists were searched according to PRISMA guidelines. Eligibility criteria were set up according to the PICOS-scheme including human and animal studies. Three authors independently reviewed the results and evaluated methodological quality (Coleman Methodology Score and Cochrane Risk of Bias Assessment). The initial search yielded 1104 entries. After screening, 18 articles were available for qualitative synthesis, six of which were subjected to meta-analysis. The mean Coleman Score of the 13 human studies was 50. Four RCTs were ranked as having a low risk of selection bias. Three of those reported a statistically significant drop in the visual analog scale (VAS) score, one a significant increase in the VISA-A Score. 12 of 13 human studies reported positive results in achieving pain relief and patient satisfaction, whereas only one study's finding differed. Meta-analysis revealed an unambiguous result in favor of the intervention (weighted mean difference D=-4.67 cm, 95% CI -5.56 to -3.76 cm [P<.001]). Only one serious AE and two minor AEs were reported in the entire literature. This systematic review suggests that ST and PT may be effective treatment options for AT and that they can be considered safe. Long-term studies and RCTs are still needed to support their recommendation.
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Affiliation(s)
- O Morath
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - E J Kubosch
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - J Taeymans
- Bern University of Applied Sciences - Health, Berne, Switzerland
| | - J Zwingmann
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - L Konstantinidis
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - N P Südkamp
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - A Hirschmüller
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany.,ALTIUS Swiss Sportmed Center, Rheinfelden, Switzerland
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Barker-Davies RM, Nicol A, McCurdie I, Watson J, Baker P, Wheeler P, Fong D, Lewis M, Bennett AN. Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population. BMC Musculoskelet Disord 2017; 18:204. [PMID: 28532478 PMCID: PMC5441076 DOI: 10.1186/s12891-017-1564-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 05/09/2017] [Indexed: 01/06/2023] Open
Abstract
Background Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%. High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT). Methods RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited. Inclusion criteria: male, 18–55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment. Discussion Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment. Trial Registration EudraCT: 2015-003587-36 3 Dec 2015
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Affiliation(s)
- Robert M Barker-Davies
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK. .,School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK.
| | - Alastair Nicol
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - I McCurdie
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - James Watson
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - Polly Baker
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - Patrick Wheeler
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Daniel Fong
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Mark Lewis
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
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Chan O, Morton S, Pritchard M, Parkes T, Malliaras P, Crisp T, Padhiar N, Maffulli N, King J, Morrissey D. Intratendinous tears of the Achilles tendon - a new pathology? Analysis of a large 4-year cohort. Muscles Ligaments Tendons J 2017; 7:53-61. [PMID: 28717612 DOI: 10.11138/mltj/2017.7.1.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Achillodynia is common and includes Achilles tendinopathy, partial Achilles tears and Achilles tendon ruptures. However, we believe an additional pathology should be considered for Achillodynia differentials - the intratendinous tear (ITT). METHODS Examinations of 740 achillodynic patients in one specialist centre were reviewed. ITTs were defined as a clearly visualised echopoor area situated centrally and extending to, but not through the tendon periphery, with pain on palpation and no clinical findings consistent with Achilles rupture. Descriptive statistics were used to analyse differences between pathological sub-groups, and images described qualitatively. RESULTS 5% (29 males, 8 females) of 740 patients had an ITT. Patients typically presented with a history of sudden onset localised pain and the ability to train but not reach maximal loading. Average age was 36.3 years (range 20-64), significantly lower than mid-tendon tendinopathy (8.48 years; p<0.01). 92% had concurrent Achilles tendinopathy. Elite sportspeople were more highly represented in the ITT than mid-tendon tendi nopathy groups (86.2% ITT group vs 13.8% mid-tendon AT group; p<0.01). CONCLUSIONS ITTs should be actively searched for in patients with Achilles pathology, especially in elite male athletes with a history of high-impact pain. Prospective research is warranted concerning diagnosis and management. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Otto Chan
- BMI London Independent Hospital, London, UK
| | - Sarah Morton
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | | | | | - Peter Malliaras
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Tom Crisp
- BMI London Independent Hospital, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK.,Bart's Health NHS Trust, London, UK
| | - Nat Padhiar
- BMI London Independent Hospital, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | | | - John King
- BMI London Independent Hospital, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Dylan Morrissey
- BMI London Independent Hospital, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK.,Bart's Health NHS Trust, London, UK
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34
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Chan O, Havard B, Morton S, Pritchard M, Maffulli N, Crisp T, Padhiar N, Perry JD, King J, Morrissey D. Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series. Muscles Ligaments Tendons J 2017; 7:78-87. [PMID: 28717615 DOI: 10.11138/mltj/2017.7.1.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The intra-tendinous tear is a new pathology that is defined as a discontinuity of fibres situated entirely within the tendon. Prolotherapy involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain. METHODS 43 consecutive patients diagnosed with an intra-tendinous tear were included (27 males: 16 females, mean (SD) age 41 (11.3). Patients were injected with 0.4ml-1.5ml (mean 0.8ml) of 50% dextrose and 0.5% marcaine mixed in a 1:1 ratio. A 4-6 week period of walking boot immobilisation was followed by progressive rehabilitation (6-8 weeks). Outcomes were assessed with a VISA-A questionnaire at baseline, 3 months and a mean 12.6 (7.0) months post-treatment. Ultrasound scans were conducted before treatment and 5.2 (2.3) weeks later to assess sonographic changes. RESULTS 30 patients (70%) responded with VISA-A scores increasing by 31 (30.5) points after 3 months (f=0.62, p<0.05) and by 40 (29.3) points after 12.60 (7.0) months (f=0.87, p<0.05). After 5.2 (2.3) weeks, echogenicity was significantly reduced (p<0.05) and 27% of tears were no longer detectable. No significant differences were observed in remaining tears with respect to tear size, tendon thickness or neovascularisation. CONCLUSION Treatment resulted in clinically significant improvements and controlled trials are warranted. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Otto Chan
- BMI London Independent Hospital, Stepney Green, London, UK
| | - Ben Havard
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Sarah Morton
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Mel Pritchard
- BMI London Independent Hospital, Stepney Green, London, UK
| | | | - Tom Crisp
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Nat Padhiar
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Jeremy David Perry
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - John King
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK
| | - Dylan Morrissey
- BMI London Independent Hospital, Stepney Green, London, UK.,Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, London, UK.,Bart's Health NHS Trust, London, UK
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Smith WB, Melton W, Davies J. Midsubstance Tendinopathy, Percutaneous Techniques (Platelet-Rich Plasma, Extracorporeal Shock Wave Therapy, Prolotherapy, Radiofrequency Ablation). Clin Podiatr Med Surg 2017; 34:161-174. [PMID: 28257672 DOI: 10.1016/j.cpm.2016.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The focus of this article is to present the current options available for noninvasive and percutaneous treatment options for noninsertional Achilles tendinopathy. An attempt is made to offer recommendations for both the treatment techniques as well as postprocedure protocols to be considered. Additionally, because there are numerous treatment options in this category, the different techniques are summarized in a chart format with a short list of pros and cons as well as the levels of evidence in the literature to support the different modalities.
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Affiliation(s)
- William Bret Smith
- Department of Orthopedics, University of South Carolina, 2 Medical Park, Columbia, SC, USA.
| | - Will Melton
- Department of Orthopedics, University of South Carolina, 2 Medical Park, Columbia, SC, USA
| | - James Davies
- Department of Orthopedics, University of South Carolina, 2 Medical Park, Columbia, SC, USA
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Abstract
Posterior heel pain is a common condition of the foot and ankle and is seen in a variety of foot types. Nonoperative treatment methods consisting of shoes inserts, heel lifts, stretching, physical therapy, nonsteroidal antiinflammatory drugs, eccentric strength training, and other modalities have been shown to have mixed results. When indicated, surgical repair can produce good long-term results. Complications, although uncommon, most commonly result from wound healing complications.
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Technical Innovation Case Report: Ultrasound-Guided Prolotherapy Injection for Insertional Achilles Calcific Tendinosis. Case Rep Orthop 2016; 2016:1560161. [PMID: 27974984 PMCID: PMC5126415 DOI: 10.1155/2016/1560161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 10/26/2016] [Indexed: 11/17/2022] Open
Abstract
We describe the use of ultrasound guidance for hyperosmolar dextrose (prolotherapy) injection of the distal calcaneal tendon specifically just anterior to identified enthesophytes in patients with insertional Achilles calcific tendinosis refractory to conservative treatment. This specific technique has not to our knowledge been described or used in literature previously.
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38
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Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6492597. [PMID: 27885357 PMCID: PMC5112330 DOI: 10.1155/2016/6492597] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/20/2016] [Indexed: 12/30/2022]
Abstract
Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options.
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Abstract
CONTEXT Musculoskeletal ultrasound (US) research is expanding due to increased clinical utility of sonography. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS Ultrasound is widely applied in musculoskeletal imaging and sports medicine. The real-time capabilities and favorable cost profile of US make it ideal for use in diagnosis of musculoskeletal conditions. The enthusiasm for the use of US in musculoskeletal imaging has led to an increase in US research to broaden its applications. CONCLUSION Several recent advances have been made in conventional and novel US imaging techniques, quantitative US imaging, and US-guided interventions. STRENGTH OF RECOMMENDATIONS TAXONOMY SORT C.
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Affiliation(s)
- O Kenechi Nwawka
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York Weill Cornell Medical College of Cornell University, New York, New York
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42
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Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2016; 9:139-59. [PMID: 27429562 PMCID: PMC4938120 DOI: 10.4137/cmamd.s39160] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/20/2016] [Accepted: 05/03/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to systematically review dextrose (d-glucose) prolotherapy efficacy in the treatment of chronic musculoskeletal pain. DATA SOURCES Electronic databases PubMed, Healthline, OmniMedicalSearch, Medscape, and EMBASE were searched from 1990 to January 2016. STUDY SELECTION Prospectively designed studies that used dextrose as the sole active prolotherapy constituent were selected. DATA EXTRACTION Two independent reviewers rated studies for quality of evidence using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs, for level of evidence using a modified Sackett scale, and for clinically relevant pain score difference using minimal clinically important change criteria. Study population, methods, and results data were extracted and tabulated. DATA SYNTHESIS Fourteen RCTs, 1 case–control study, and 18 case series studies met the inclusion criteria and were evaluated. Pain conditions were clustered into tendinopathies, osteoarthritis (OA), spinal/pelvic, and myofascial pain. The RCTs were high-quality Level 1 evidence (Physiotherapy Evidence Database ≥8) and found dextrose injection superior to controls in Osgood–Schlatter disease, lateral epicondylitis of the elbow, traumatic rotator cuff injury, knee OA, finger OA, and myofascial pain; in biomechanical but not subjective measures in temporal mandibular joint; and comparable in a short-term RCT but superior in a long-term RCT in low back pain. Many observational studies were of high quality and reported consistent positive evidence in multiple studies of tendinopathies, knee OA, sacroiliac pain, and iliac crest pain that received RCT confirmation in separate studies. Eighteen studies combined patient self-rating (subjective) with psychometric, imaging, and/or biomechanical (objective) outcome measurement and found both positive subjective and objective outcomes in 16 studies and positive objective but not subjective outcomes in two studies. All 15 studies solely using subjective or psychometric measures reported positive findings. CONCLUSION Use of dextrose prolotherapy is supported for treatment of tendinopathies, knee and finger joint OA, and spinal/pelvic pain due to ligament dysfunction. Efficacy in acute pain, as first-line therapy, and in myofascial pain cannot be determined from the literature.
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Affiliation(s)
- Ross A Hauser
- Caring Medical Regenerative Medicine Clinics, Oak Park, IL, USA
| | | | | | - David K Harris
- Center for Healing and Regenerative Medicine, Austin, TX, USA
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Topol GA, Podesta LA, Reeves KD, Giraldo MM, Johnson LL, Grasso R, Jamín A, Clark T, Rabago D. Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis. PM R 2016; 8:1072-1082. [PMID: 27058744 DOI: 10.1016/j.pmrj.2016.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 03/24/2016] [Accepted: 03/25/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Dextrose injection is reported to improve knee osteoarthritis (KOA)-related clinical outcomes, but its effect on articular cartilage is unknown. A chondrogenic effect of dextrose injection has been proposed. OBJECTIVE To assess biological and clinical effects of intra-articular hypertonic dextrose injections (prolotherapy) in painful KOA. DESIGN Case series with blinded arthroscopic evaluation before and after treatment. SETTING Physical medicine and day surgery practice. PARTICIPANTS Symptomatic KOA for at least 6 months, arthroscopy-confirmed medial compartment exposed subchondral bone, and temporary pain relief with intra-articular lidocaine injection. INTERVENTION Four to 6 monthly 10-mL intra-articular injections with 12.5% dextrose. MAIN OUTCOME MEASURES Visual cartilage growth assessment of 9 standardized medial condyle zones in each of 6 participants by 3 arthroscopy readers masked to pre-/postinjection status (total 54 zones evaluated per reader); biopsy of a cartilage growth area posttreatment, evaluated using hematoxylin and eosin and Safranin-O stains, quantitative polarized light microscopy, and immunohistologic cartilage typing; self-reported knee specific quality of life using the Western Ontario McMaster University Osteoarthritis Index (WOMAC, 0-100 points). RESULTS Six participants (1 female and 5 male) with median age of 71 years, WOMAC composite score of 57.5 points, and a 9-year pain duration received a median of 6 dextrose injections and follow-up arthroscopy at 7.75 months (range 4.5-9.5 months). In 19 of 54 zone comparisons, all 3 readers agreed that the posttreatment zone showed cartilage growth compared with the pretreatment zone. Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibro- and hyaline-like cartilage. Compared with baseline status, the median WOMAC score improved 13 points (P = .013). Self-limited soreness after methylene blue instillation was noted. CONCLUSIONS Positive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA, suggesting disease-modifying effects and the need for confirmation in controlled studies. Minimally invasive arthroscopy (single-compartment, single-portal) enabled collection of robust intra-articular data. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Gastón Andrés Topol
- Department of Physical Medicine and Rehabilitation, National University of Rosario, Rosario, Argentina(∗)
| | | | - Kenneth Dean Reeves
- Private Practice Physical Medicine and Rehabilitation, Roeland Park, Kansas City, KS 66205; Department of PM&R, University of Kansas Medical Center, Kansas City, KS(‡).
| | | | - Lanny L Johnson
- Department of Radiology, College of Human Medicine, Michigan State University, East Lansing, MI; Department of Orthopaedic Surgery, Michigan State University, East Lansing, MI(‖)
| | - Raul Grasso
- Deceased; previously private practice anatamopathology consultation, Rosario, Argentina; Provincial Hospital Domingo Funes, Santa Maria de Punilla, Argentina(¶)
| | - Alexis Jamín
- Department of Radiology, Hospital Emergencia Clemente Alvarez, Rosario, Argentina(#)
| | - Tom Clark
- Private practice ultrasonographic training, Vista, CA(∗∗)
| | - David Rabago
- Department of Family Medicine and Community Health, University of Wisconsin, School of Medicine and Public Health, Madison, WI(††)
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Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy Versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil 2016; 97:17-25. [DOI: 10.1016/j.apmr.2015.08.412] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/03/2015] [Indexed: 11/29/2022]
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45
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Benazzo F, Marullo M, Indino C, Zanon G. Achilles Tendinopathies. ARTHROSCOPY AND SPORT INJURIES 2016:69-76. [DOI: 10.1007/978-3-319-14815-1_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Howell MA, Catanzariti AR. Flexor Hallucis Longus Tendon Transfer for Calcific Insertional Achilles Tendinopathy. Clin Podiatr Med Surg 2016; 33:113-23. [PMID: 26590729 DOI: 10.1016/j.cpm.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Calcific insertional Achilles tendinopathy can result in significant pain and disability. Although some patients respond to nonoperative therapy, many patients are at risk for long-term morbidity and unpredictable clinical outcomes. There is no evidence-based data to support the timing of operative invention, choice of procedures, or whether equinus requires treatment. This article suggests the need for a classification system based on physical examination and imaging to help guide treatment. There is an obvious need for evidence-based studies evaluating outcomes and for properly conducted scientific research to establish appropriate treatment protocols.
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Affiliation(s)
- Michael A Howell
- Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, 4800 Friendship Avenue, Pittsburgh, PA 15224, USA
| | - Alan R Catanzariti
- Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, 4800 Friendship Avenue, Pittsburgh, PA 15224, USA.
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Finnoff JT, Hall MM, Adams E, Berkoff D, Concoff AL, Dexter W, Smith J. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. PM R 2015; 7:151-68.e12. [PMID: 25708351 DOI: 10.1016/j.pmrj.2015.01.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 01/09/2015] [Indexed: 12/23/2022]
Abstract
The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based upon the evidence, the official AMSSM position relevant to each subject is made.
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Affiliation(s)
- Jonathan T Finnoff
- Department of Physical Medicine and Rehabilitation, University of California, Davis School of Medicine, Sacramento, CA; Tahoe Orthopedics and Sports Medicine, 1139 Third St, South Lake Tahoe, CA 96150.(∗); Department of Orthopedics and Rehabilitation, Department of Family Medicine, University of Iowa Sports Medicine, Iowa City, IA(†).
| | - Mederic M Hall
- Department of Orthopedics and Rehabilitation, Department of Family Medicine, University of Iowa Sports Medicine, Iowa City, IA(†)
| | - Erik Adams
- Midwest Sports Medicine Institute, Middleton, WI(‡)
| | - David Berkoff
- Department of Orthopaedics and Emergency Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC(§)
| | - Andrew L Concoff
- Outpatient Musculoskeletal Rehabilitation, St Jude Medical Center, Fullerton, CA(¶)
| | - William Dexter
- Maine Medical Center, Portland, ME; Tufts University School of Medicine, Boston, MA(#)
| | - Jay Smith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Rochester, MN; Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN(∗∗)
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Should We Care About Tendon Structure? The Disconnect Between Structure and Symptoms in Tendinopathy. J Orthop Sports Phys Ther 2015; 45:823-5. [PMID: 27136287 DOI: 10.2519/jospt.2015.0112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We can visualize tendons better than ever before. Medical imaging today provides increasingly higher-resolution images, enabling larger fields of view that allow clinicians and researchers to more precisely characterize tendon structure. Yet, does seeing a patient's tendon provide any meaningful benefit to our clinical reasoning, and will it make a difference to treatment outcomes? It is little surprise that concomitant with this imaging availability is a renewed debate over the relationship between the appearance of tendon structure and symptomology. Despite the advances in medical imaging, as well as the clinical and research interest in tendinopathy, there does not appear to be any greater clarity on reconciling a patient's clinical presentation with either baseline characterization of structural abnormalities or the time series of changes following selected interventions. It may be helpful, therefore, to take a step back and give renewed consideration to the anatomical and physiological role of tendon structure, and to consider this in the context of what we know about tendon pathology. J Orthop Sports Phys Ther 2015;45(11):823-825. doi:10.2519/jospt.2015.0112.
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Sanderson LM, Bryant A. Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review. J Foot Ankle Res 2015; 8:57. [PMID: 26500703 PMCID: PMC4617485 DOI: 10.1186/s13047-015-0114-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 10/12/2015] [Indexed: 11/24/2022] Open
Abstract
Introduction The aim of this review was to identify and evaluate existing research to determine the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy. Review Nine databases were searched (Medline, Science Direct, AMED, Australian Medical Index, APAIS-Health, ATSIhealth, EMBASE, Web of Science, OneSearch) without language, publication or data restrictions for all relevant articles between January 1960 and September 2014. All prospective randomised and non-randomised trials, cohort studies, case-series, cross-sectional studies and controlled trials assessing the effectiveness of one or more prolotherapy injections for tendinopathy or fasciopathy at or below the superior aspect of the tibia/fibula were included. Methodological quality of studies was determined using a modified evaluation tool developed by the Cochrane Musculoskeletal Injuries Group. Data analysis was carried out to determine the mean change of outcome measure scores from baseline to final follow-up for trials with no comparative group, and for randomised controlled trials, standardised mean differences between intervention groups were calculated. Pooled SMD data were calculated where possible to determine the statistical heterogeneity and overall effect for short-, intermediate- and long-term data. Adverse events were also reported. Two hundred and three studies were identified, eight of which met the inclusion criteria. These were then grouped according to tendinopathy or fasciopathy being treated with prolotherapy injections: Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease. The methodological quality of the eight included studies was generally poor, particularly in regards to allocation concealment, intention to treat analysis and blinding procedures. Results of the analysis provide limited support for the hypothesis that prolotherapy is effective in both reducing pain and improving function for lower limb tendinopathy and fasciopathy, with no study reporting a mean negative or non-significant outcome following prolotherapy injection. The analysis also suggests prolotherapy injections provide equal or superior short-, intermediate- and long-term results to alternative treatment modalities, including eccentric loading exercises forAchilles tendinopathy, platelet-rich plasma for plantar fasciopathy and usual care or lignocaine injections for Osgood-Schlatter disease. No adverse events following prolotherapy injections were reported in any study in this review. Conclusions The conclusions of this review were derived from the best available scientific evidence. It is intended that the results of this study will assist clinical decision-making by practitioners. The results of this review found limited evidence that prolotherapy injections are a safe and effective treatment for Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease, however more robust research using large, methodologically-sound randomised controlled trials is required to substantiate these findings. Electronic supplementary material The online version of this article (doi:10.1186/s13047-015-0114-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lane M Sanderson
- School of Surgery, University of Western Australia, Perth, Australia
| | - Alan Bryant
- School of Surgery, University of Western Australia, Perth, Australia ; M422 UWA Podiatric Medicine, 35 Stirling Highway, Crawley, WA 6009 Australia
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Mautner K, Blazuk J. Where Do Injectable Stem Cell Treatments Apply in Treatment of Muscle, Tendon, and Ligament Injuries? PM R 2015; 7:S33-S40. [DOI: 10.1016/j.pmrj.2014.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 11/28/2014] [Accepted: 12/04/2014] [Indexed: 12/16/2022]
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