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Goldberg AJ, Masci L, O'Donnell P, Green R, Brooking D, Bassett P, Lowdell MW, Smith RKW. Autologous bone marrow derived mesenchymal stem cells are safe for the treatment of Achilles tendinopathy. Sci Rep 2024; 14:11421. [PMID: 38763976 PMCID: PMC11102920 DOI: 10.1038/s41598-024-61399-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/06/2024] [Indexed: 05/21/2024] Open
Abstract
Achilles tendinopathy is a disabling condition that affects more than 50% of runners. Pre-clinical studies in a large animal model of naturally-occurring tendinopathy similar to human Achilles tendinopathy has shown benefits of autologous bone marrow-derived mesenchymal stem cell (MSC) implantation. However, MSCs are advanced therapies medicinal products (ATMPs), with strict regulatory requirements. Guided by the regulator we carried out a first in man study to assess the safety and efficacy of autologous MSC injection in human patients with non-insertional Achilles tendinopathy. Ten patients, mean age 47 with mid-portion Achilles tendon pain and swelling for more than 6 months, underwent autologous cultured cell injections (median 12.2 × 106, range 5-19 × 106 cells) into their Achilles tendon. At 24 weeks follow-up, no serious adverse reactions or important medical events were observed. MOXFQ, EQ-5D-5L, and VISA-A scores improved clinically at 12 and 24 weeks. VAS pain improved increasingly at 6, 12 and 24 weeks. MOXFQ Pain and VISA-A Scores improved > 12 points from baseline to 24 weeks in 8 patients. Maximum anteroposterior tendon thickness as measured by greyscale US decreased by mean 0.8 mm at 24 weeks. This phase IIa study demonstrated the safety of autologous MSC injection for non-insertional Achilles tendinopathy and provides proof-of-concept of the technique in patients, all of whom had previously failed conservative treatments for chronic disease and leads the way for a larger randomised controlled trial.
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Affiliation(s)
- Andrew J Goldberg
- Division of Surgery, UCL Institute of Orthopaedics & Musculoskeletal Science, Royal Free Hospital, 9th Floor (East), 2QG, 10 Pond St, London, NW3 2PS, UK.
- Department of Research and Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, UK.
- MSK Lab, Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London, SW7 2AZ, UK.
- The London Ankle & Arthritis Centre, The Wellington Hospital, Wellington Place, London, NW8 9LE, UK.
| | - Lorenzo Masci
- Institute of Sport Exercise and Health, Tottenham Court Road, London, UK
| | - Paul O'Donnell
- Division of Surgery, UCL Institute of Orthopaedics & Musculoskeletal Science, Royal Free Hospital, 9th Floor (East), 2QG, 10 Pond St, London, NW3 2PS, UK
- Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Ruth Green
- Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Deirdre Brooking
- Department of Research and Innovation, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, Middlesex, UK
| | - Paul Bassett
- Statsconsultancy Ltd., 40 Longwood Lane, Amersham, Bucks, HP7 9EN, UK
| | - Mark W Lowdell
- Centre for Cell, Gene & Tissue Therapeutics, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
| | - Roger K W Smith
- Department of Veterinary Clinical Sciences and Services, The Royal Veterinary College, Hawkshead Lane, Hatfield, Hertfordshire, AL9 7TA, UK
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Sleeswijk Visser TSO, Brul SL, O'Neill S, van Es EM, Eygendaal D, de Vos RJ. Measuring Ultrasonographic Thickness of the Achilles Tendon Insertion Is Less Reliable Than the Midportion in Healthy Tendons and Patients With Tendinopathy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:713-722. [PMID: 38140763 DOI: 10.1002/jum.16396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Ultrasound is the preferred imaging method in the diagnostic process of Achilles tendinopathy (AT). Ultrasound tissue characterization (UTC) is a frequently used, standardized and valid method to assess tendon geometry in AT patients. It is unknown whether UTC is reliable for measuring Achilles tendon thickness. The aim of the study was to assess intra- and inter-rater reliability of Achilles tendon thickness measurements using UTC in both asymptomatic individuals and patients with AT, and to evaluate if the reliability of thickness measurements differs between the midportion and insertional area. METHODS Exactly 50 patients with AT and 50 asymptomatic individuals were included. Using the conventional US and standardized UTC procedure maximum thickness was measured in the midportion and insertion region. To determine inter- and intra-rater reliabilities, the intraclass correlation coefficient (ICC) was used. RESULTS The ICC values for inter- and intra-rater reliability were classified as "excellent," for the AT group (0.93 [95% CI: 0.88-0.96] and 0.95 [0.92-0.97]) and asymptomatic participants (0.91 [0.87-0.94] and 0.94 [0.92-0.96]). The reliability of measuring tendon thickness in the midportion region was "excellent," with both inter-rater (0.97 [0.95-0.98]) and intra-rater (0.98 [0.96-0.99]) ICC values indicating high levels of agreement. In the insertional region, ICC values for inter-rater (0.79 [0.69-0.87]) and intra-rater (0.89 [0.84-0.93]) reliability were "moderate to good." CONCLUSION We showed excellent reliability for measuring the US thickness of the midportion and good reliability of measuring the insertional region in patients with AT. Significantly lower ICCs were observed for the reliability of thickness measurements in the insertional region when compared with the midportion.
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Affiliation(s)
- Tjerk S O Sleeswijk Visser
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Stefano L Brul
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Seth O'Neill
- Department of Life Sciences, School of Allied Health, University of Leicester, Leicester, UK
| | - Eline M van Es
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Denise Eygendaal
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Scott I, Connell D, Moulton D, Waters S, Namburete A, Arnab A, Malliaras P. An automated method for tendon image segmentation on ultrasound using grey-level co-occurrence matrix features and hidden Gaussian Markov random fields. Comput Biol Med 2024; 169:107872. [PMID: 38160500 DOI: 10.1016/j.compbiomed.2023.107872] [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: 04/10/2023] [Revised: 12/07/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Despite knowledge of qualitative changes that occur on ultrasound in tendinopathy, there is currently no objective and reliable means to quantify the severity or prognosis of tendinopathy on ultrasound. OBJECTIVE The primary objective of this study is to produce a quantitative and automated means of inferring potential structural changes in tendinopathy by developing and implementing an algorithm which performs a texture based segmentation of tendon ultrasound (US) images. METHOD A model-based segmentation approach is used which combines Gaussian mixture models, Markov random field theory and grey-level co-occurrence (GLCM) features. The algorithm is trained and tested on 49 longitudinal B-mode ultrasound images of the Achilles tendons which are labelled as tendinopathic (24) or healthy (25). Hyperparameters are tuned, using a training set of 25 images, to optimise a decision tree based classification of the images from texture class proportions. We segment and classify the remaining test images using the decision tree. RESULTS Our approach successfully detects a difference in the texture profiles of tendinopathic and healthy tendons, with 22/24 of the test images accurately classified based on a simple texture proportion cut-off threshold. Results for the tendinopathic images are also collated to gain insight into the topology of structural changes that occur with tendinopathy. It is evident that distinct textures, which are predominantly present in tendinopathic tendons, appear most commonly near the transverse boundary of the tendon, though there was a large variability among diseased tendons. CONCLUSION The GLCM based segmentation of tendons under ultrasound resulted in distinct segmentations between healthy and tendinopathic tendons and provides a potential tool to objectively quantify damage in tendinopathy.
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Affiliation(s)
- Isabelle Scott
- Mathematical Institute, University of Oxford, Oxford, United Kingdom; Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Parkville, Melbourne, Australia.
| | | | - Derek Moulton
- Mathematical Institute, University of Oxford, Oxford, United Kingdom
| | - Sarah Waters
- Mathematical Institute, University of Oxford, Oxford, United Kingdom
| | - Ana Namburete
- Oxford Machine Learning in Neuroimaging laboratory, OMNI, Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | | | - Peter Malliaras
- Imaging at Olympic Park, Melbourne, Australia; Department of Physiotherapy, Monash University, Melbourne, Australia
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Burk J, Wittenberg-Voges L, Schubert S, Horstmeier C, Brehm W, Geburek F. Treatment of Naturally Occurring Tendon Disease with Allogeneic Multipotent Mesenchymal Stromal Cells: A Randomized, Controlled, Triple-Blinded Pilot Study in Horses. Cells 2023; 12:2513. [PMID: 37947591 PMCID: PMC10650642 DOI: 10.3390/cells12212513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/13/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023] Open
Abstract
The treatment of tendinopathies with multipotent mesenchymal stromal cells (MSCs) is a promising option in equine and human medicine. However, conclusive clinical evidence is lacking. The purpose of this study was to gain insight into clinical treatment efficacy and to identify suitable outcome measures for larger clinical studies. Fifteen horses with early naturally occurring tendon disease were assigned to intralesional treatment with allogeneic adipose-derived MSCs suspended in serum or with serum alone through block randomization (dosage adapted to lesion size). Clinicians and horse owners remained blinded to the treatment during 12 months (seven horses per group) and 18 months (seven MSC-group and five control-group horses) of follow-up including clinical examinations and diagnostic imaging. Clinical inflammation, lameness, and ultrasonography scores improved more over time in the MSC group. The lameness score difference significantly improved in the MSC group compared with the control group after 6 months. In the MSC group, five out of the seven horses were free of re-injuries and back to training until 12 and 18 months. In the control group, three out of the seven horses were free of re-injuries until 12 months. These results suggest that MSCs are effective for the treatment of early-phase tendon disease and provide a basis for a larger controlled study.
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Affiliation(s)
- Janina Burk
- Institute of Physiology, Pathophysiology and Biophysics, University of Veterinary Medicine Vienna, Veterinaerplatz 1, 1210 Vienna, Austria
| | - Liza Wittenberg-Voges
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559 Hannover, Germany;
| | - Susanna Schubert
- Institute of Human Genetics, University of Leipzig Medical Center, Philipp-Rosenthal-Strasse 55, 04103 Leipzig, Germany;
| | - Carolin Horstmeier
- Department for Horses, Veterinary Teaching Hospital, University of Leipzig, An den Tierkliniken 21, 04103 Leipzig, Germany; (C.H.); (W.B.)
| | - Walter Brehm
- Department for Horses, Veterinary Teaching Hospital, University of Leipzig, An den Tierkliniken 21, 04103 Leipzig, Germany; (C.H.); (W.B.)
| | - Florian Geburek
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559 Hannover, Germany;
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Pereira CS, Klauznicer J, Maree D, McAuliffe S, Farooq A, Whiteley R, Finni T. Quadriceps strength, patellar tendon quality, relative load exposure, and knee symptoms in male athletes before the anterior cruciate ligament reconstruction. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1283635. [PMID: 37928751 PMCID: PMC10624220 DOI: 10.3389/fresc.2023.1283635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023]
Abstract
Introduction Anterior cruciate ligament (ACL) injuries cause knee instability, knee pain, weight-bearing adjustments, and functional deficits but their association to patellar tendon quality is unknown. Our purpose was to investigate quadriceps strength, patellar tendon quality, relative load exposure, perceived knee stability, knee pain, extension angle, and time from ACL injury; in addition to examining their relative associations. Methods Injured and uninjured legs of 81 male athletes of different sports with a unilateral ACL injury (18-45 years) were examined. Participants reported location and intensity of knee pain and their perceived stability using a numerical rating scale (NRS 0-10). Strength was tested with an isokinetic device. Tendon quality was measured using ultrasound tissue characterization. Means ± standard deviation (SD) of perceived knee stability, knee extension angle, knee pain, isokinetic quadriceps strength in relation to body mass, proportion of echo-types (I-IV), tendon volume, and number of days from ACL injury to assessment are reported. Values of effect sizes (ES) and correlations (rs) were calculated. Results ACL injured leg demonstrated reduced reported knee stability (6.3 ± 2.5), decreased knee extension angle (-0.7 ± 3.1° vs. -2.7 ± 2.2°; ES = 0.7; P < 0.001), greater knee pain (NRS 3.1 ± 2.2 vs. 0.0 ± 0.1; ES = 2.0; P < 0.001), and 22% lower quadriceps strength (228.0 ± 65.0 vs. 291.2 ± 52.9 Nm/kg: ES = 1.2; P < 0.001) as compared to the uninjured leg. However, patellar tendons in both legs displayed similar quality. Quadriceps strength was associated with stability (rs = -0.54; P < 0.001), pain (rs = -0.47; P < 0.001), extension angle (rs = -0.39; P < 0.001), and relative load exposure (rs = -0.34; P < 0.004). Echo-types distribution was beneficially associated with time from ACL injury (rs range: -0.20/ -0.32; P < 0.05). Discussion ACL injured athletes displayed knee pain, extension deficit, and weaker quadriceps in the injured leg. While there were no differences in patellar tendon quality between legs, longer time from ACL injury showed better tendon quality.
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Affiliation(s)
- Carla S. Pereira
- Rehabilitation Department, ASPETAR, Orthopaedic and Sports Medicine Hospital, FIFA Medical Centre of Excellence, Doha, Qatar
- Neuromuscular Research Center, Biology of PhysicalActivity, Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Jasenko Klauznicer
- Rehabilitation Department, ASPETAR, Orthopaedic and Sports Medicine Hospital, FIFA Medical Centre of Excellence, Doha, Qatar
| | - Dustin Maree
- Rehabilitation Department, ASPETAR, Orthopaedic and Sports Medicine Hospital, FIFA Medical Centre of Excellence, Doha, Qatar
| | - Sean McAuliffe
- Department of Physical Therapy & Rehabilitation Science, College of Health Sciences, Qatar University, Doha, Qatar
| | - Abdulaziz Farooq
- Rehabilitation Department, ASPETAR, Orthopaedic and Sports Medicine Hospital, FIFA Medical Centre of Excellence, Doha, Qatar
| | - Rod Whiteley
- Rehabilitation Department, ASPETAR, Orthopaedic and Sports Medicine Hospital, FIFA Medical Centre of Excellence, Doha, Qatar
| | - Taija Finni
- Neuromuscular Research Center, Biology of PhysicalActivity, Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
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Steinberg N, Funk S, Zeev A, Waddington G, Svorai-Litvak S, Pantanowitz M. Achilles Tendon and Patellar Tendon Structure in Combat Soldiers Following Prevention Exercises. Mil Med 2023; 188:678-688. [PMID: 35134964 DOI: 10.1093/milmed/usac009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Military training that increases physical stress on musculoskeletal morphology also increases the risk of orthopedic injuries. Somatosensory prevention programs that reduce stress and improve functionality could be beneficial for better organization of tendon structure. The aim of this study was to investigate the impact of a somatosensory prevention exercise on the tendon structure (percentage of echo-type fibers; A-P and M-L diameters and cross-sectional area) of the Achilles tendon and patellar tendon among combat soldiers. MATERIALS AND METHODS These tendons of male Infantry soldiers aged 18-21 were screened before and after a 14-week training course. The intervention group, who performed preventative exercises, included 108 soldiers (BMI = 23.85 ± 2.76), while the control group, who participated in the same military course without these exercises, included 98 soldiers (BMI = 24.26 ± 4.03). Ultrasound scanning for tendon structure included percent of echo-type I-IV fibers, A-P diameter, M-L diameter, and cross-sectional area parameters. RESULTS Time by group interaction was found for echo-type I and II in both tendons. No significant differences were found between the two groups in the pretesting percentage of echo-type IV fibers of the Achilles tendon (P = .522), in echo-type III fibers of the Achilles tendon (P = .833), and echo-type IV fibers of the patellar tendon (P = .162). Greater pre-post differences in echo-type III and IV fibers were found in the control group compared with the intervention group for both the Achilles tendon (P = .021, P = .002) and the patellar tendon (P < .001, P < .001). CONCLUSION Increased damaged fibers (echo-type III and IV) of both tendons were found among the control group, yet not among soldiers who performed prevention exercises.
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Affiliation(s)
- Nili Steinberg
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya 42902, Israel
| | - Shani Funk
- Combat Fitness Department, Doctrine and Research Branch, IDF, Netanya 01443, Israel
| | - Aviva Zeev
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya 42902, Israel
| | - Gordon Waddington
- Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia
| | | | - Michal Pantanowitz
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya 42902, Israel
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Steinberg N, Pantanowitz M, Zeev A, Svorai Band S, Funk S, Nemet D. Achilles and patellar tendon structure following a prevention program in male combat soldiers. PHYSICIAN SPORTSMED 2022; 50:531-540. [PMID: 34488525 DOI: 10.1080/00913847.2021.1976601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aims of the study were to compare the prevalence of soldiers with musculoskeletal symptoms between soldiers that participated in a prevention program (INT) and a control group (CONT); and, to assess whether 'high risk' for a symptom indicator [participants with patellar tendon (PT) echo-type III+IV >10% or Achilles tendon (AT) echo-type III >8.5%] applies when a prevention intervention is used. METHODS Soldiers from two consecutive infantry commanders courses (year 1-CONT, n = 165; year 2-INT, n = 196) were examined pre-course for AT and PT structure using ultrasound tissue characterization (UTC), and their musculoskeletal overuse symptoms were assessed and recorded by military physicians throughout the course. A prevention program was provided to the INT group (year 2) during the 14-week course. RESULTS No significant differences were found in the prevalence of soldiers with symptoms between the two groups [INT: 39 (19.9%), CONT: 40 (24.2%); p = .32]. Using the indicator at baseline, 20 soldiers (10.2%) were suggested to be at 'high risk.' Of those 20 soldiers, 17 actually had symptoms during the course (positive predictive value-85%). The prevalence of soldiers with a suggested 'high risk' according to our indicator who had no symptoms during the course was low (3/20, 15%). Twenty-two soldiers who had symptoms during the course had not been suggested to be at 'high risk' by our indicator. CONCLUSION Our intervention did not reduce the prevalence of soldiers with symptoms. Our 'high risk' pre-course, AT and PT structure indicator is valid and can be used as a screening tool to reduce the prevalence of symptoms in combat soldiers; with the caution that soldiers that were not identified by the indicator, might also have symptoms along the course.
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Affiliation(s)
- Nili Steinberg
- Life science, Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya, Israel
| | - Michal Pantanowitz
- Life science, Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya, Israel
| | - Aviva Zeev
- Life science, Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya, Israel
| | | | - Shany Funk
- Combat Fitness Department, Doctrine and Research Branch, Israel
| | - Dan Nemet
- Child Health and Sport Center, Pediatric Department, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
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Equine flexor tendon imaging part 1: Recent developments in ultrasonography, with focus on the superficial digital flexor tendon. Vet J 2021; 278:105764. [PMID: 34678500 DOI: 10.1016/j.tvjl.2021.105764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 09/14/2021] [Accepted: 10/15/2021] [Indexed: 12/15/2022]
Abstract
Flexor tendon injuries are a major cause of lameness in performance horses and have considerable impact on equine welfare and the wider horse industry. Ageing and repetitive strain frequently cause varying degrees of tendon micro-damage prior to the recognition of clinical tendinopathy. Whilst B-mode ultrasonography is most commonly utilised for detection and monitoring of tendon lesions at the metacarpal/metatarsal level, the emphasis of recent research has focused on the identification of subclinical tendon damage in order to prevent further tendon injury and improve outcomes. The introduction of elastography, acoustoelastography and ultrasound tissue characterisation in the field of equine orthopaedics shows promising results and might find wider use in equine practice as clinical development continues. Based on the substantial number of research studies on tendon imaging published over the past decade this literature review aims to examine the currently used ultrasonographic imaging techniques and their limitations, and to introduce and critically appraise new modalities that could potentially change the clinical approach to equine flexor tendon imaging.
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Johnson SA, Valdés-Martínez A, Turk PJ, Wayne McIlwraith C, Barrett MF, McGilvray KC, Frisbie DD. Longitudinal tendon healing assessed with multi-modality advanced imaging and tissue analysis. Equine Vet J 2021; 54:766-781. [PMID: 34101888 DOI: 10.1111/evj.13478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/25/2021] [Accepted: 05/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The range of diagnostic modalities available to evaluate superficial digital flexor tendon (SDFT) injury includes magnetic resonance imaging (MRI), computed tomography (CT) and ultrasonography (US). Direct, comprehensive comparison of multi-modality imaging characteristics to end-point data has not previously been performed using a model of tendinopathy but is required to obtain a better understanding of each modality's diagnostic capabilities. OBJECTIVE To compare CT, MRI and US evaluation to outcome measures for histologic, biochemical and biomechanical parameters using an equine surgical model of tendinopathy. STUDY DESIGN Controlled experiment. METHODS Lesions were surgically created in both forelimb SDFTs of eight horses and imaged using MRI, CT and US at seven time points over 12 months. Imaging characteristics were then correlated to end point histologic, biochemical and biomechanical data using lasso regression. Longitudinal lesion size was compared between imaging modalities. RESULTS Lesion to tendon isoattenuation on CT evaluation correlated with the greatest levels of aggrecan deposition. A significant correlation between cellular density and percentage of tendon involvement on the T2-weighted sequence and signal intensity on the proton density fat saturated (PD FS) sequence was appreciated at the 12-month time point (P = .006, P = .02 respectively). There was no significant correlation between end-point data and US or contrast imaging characteristics. Cross sectional area lesion to tendon measurements were significantly largest on CT evaluation, followed by MRI and then US (P < .001). MAIN LIMITATIONS Experimentally induced tendon injury with singular end-point data correlation. CONCLUSIONS Lesion isoattenuation on CT evaluation suggested scar tissue deposition, while T2-weighted hyperintensity indicated hypercellular tendinopathy even in chronic stages of healing. Non contrast-enhanced MRI and CT evaluation correlated most closely to cellular characteristics of surgically damaged tendons assessed over a twelve month study period. Ultrasonographic evaluation underestimates true lesional size and should be interpreted with caution.
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Affiliation(s)
- Sherry A Johnson
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Orthopaedic Research Center at the C. Wayne McIlwraith Translational Medicine Institute, Colorado State University, Fort Collins, CO, USA
| | | | - Philip J Turk
- Atrium Health, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Cyril Wayne McIlwraith
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Orthopaedic Research Center at the C. Wayne McIlwraith Translational Medicine Institute, Colorado State University, Fort Collins, CO, USA
| | - Myra F Barrett
- Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
| | - Kirk C McGilvray
- Orthopaedic Bioengineering Research Laboratory, Department of Mechanical Engineering, School of Biomedical Engineering, Colorado State University, Fort Collins, CO, USA
| | - David D Frisbie
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Orthopaedic Research Center at the C. Wayne McIlwraith Translational Medicine Institute, Colorado State University, Fort Collins, CO, USA
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Steinberg N, Funk S, Svorai-Band S, Yavnai N, Pantanowitz M, Zeev A, Dar G. The Influence of a 14-Week Infantry Commanders Courses on the Achilles Tendon and Patellar Tendon Structure. Mil Med 2021; 187:e377-e386. [PMID: 33533888 DOI: 10.1093/milmed/usab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/06/2020] [Accepted: 01/15/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Alternated tendon structure may raise stress to the musculoskeletal structures and may increase the potential for overuse injury. Screening the tendon structure of soldiers pre- and post-participation in a strenuous combat course is essential. The aim of the present study was to investigate the influence of a 14-week infantry commanders courses on the Achilles tendon (AT) structure and patellar tendon (PT) structure in combat soldiers. MATERIALS AND METHODS Ninety-eight participants from an infantry commanders course were screened pre- and post-course for the AT and PT structures, using ultrasonographic tissue characterizaton (UTC) imaging to capture a 3D structure of four echo-type fibers (I-IV). RESULTS In both tendons, the mean relative frequency of echo-type I fibers significantly decreased from pre- to post-testing, with a significant increase in the relative frequency of echo-types II, III, and IV fibers. In the AT, 60.2% of the subjects showed positive differences (between pre- and post-testing in the echo-type III + IV fiber ("worsened" tendon structure), whereas in the PT, 92.2% of the subject showed an increased frequency. No significant correlation (r = 0.108; P = .324) was found between the differences of echo-type III + IV fibers of the AT and that of the PT. CONCLUSIONS Loads to the musculoskeletal structures along the combat course increased the mean relative frequency of the "reduced" echo-type fibers (III + IV) in both the AT structure and the PT structure. Yet, whereas in the AT around 40% of the soldiers showed an improved tendon structure along the course, in the PT less than 10% of the soldiers showed that improvement. Soldiers and commanders should be aware of the different influence of the loading exercises along the course on the AT and on the PT structure, as "reduced" tendons structure might put the soldiers at higher risk for injury in the future.
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Affiliation(s)
- Nili Steinberg
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya 42902, Israel
| | - Shany Funk
- Combat Fitness Department, Doctrine and Research Branch, IDF, Military post #01443, Israel
| | - Shani Svorai-Band
- Military Medical Corps, IDF Medical Corps, Tel Hashomer, Ramat Gan, Military post #02149, Israel
| | - Nirit Yavnai
- Research Directorate, IDF Medical Corps, Tel Hashomer, Ramat Gan, Military post #02149, Israel
| | - Michal Pantanowitz
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya 42902, Israel
| | - Aviva Zeev
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya 42902, Israel
| | - Gali Dar
- Department of Physical Therapy Faculty of Social Welfare, Health Studies University of Haifa, 3498838, Israel
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11
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The influence of a multidisciplinary intervention program on Achilles tendon structure in children with overweight and obesity. Eur J Pediatr 2020; 179:1787-1796. [PMID: 32451724 DOI: 10.1007/s00431-020-03685-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
The effects of childhood obesity on tendon structure and its relation to physical activity are barely known. We aimed to investigate the influence of a 6-month multidisciplinary childhood obesity management program (which included dietary intervention and an exercise program) on Achilles tendon structure in overweight/obese children. Twenty-five overweight/obese children (overweight group) who participated in a 6-month multidisciplinary childhood obesity program, and 27 normal-weight controls were examined for anthropometric measurements and for Achilles tendon structure (using ultrasound tissue characterization to capture a three-dimensional structure of four echo type fibers and the cross-sectional area) at baseline, 3, and 6 months. The BMI of the overweight group significantly decreased from the pre- to the post-intervention period, (p = .002, η2 = .229), yet among the control group, the BMI significantly increased (p = .002, η2 = .222). Interactions (pre-post × group) showed a significant decrease in the prevalence of echo type I and in echo type III fibers and a significant increase in the prevalence of echo type II fibers and in the cross-sectional area along the intervention. No significant changes in echo type fibers were found in the control group along the 6 months.Conclusion: At pre-intervention, the overweight group had significantly "worse" tendon structure, with a lower prevalence of echo type II fiber and a higher prevalence of echo type III fibers compared with the control group. Following the 6-month intervention, the tendon structure of the overweight group was "positively" changed, with reduced echo type III fibers and increased echo type II fibers. What is Known: • Physical activity and weight reduction programs are efficient for obese children. • Obese children tend to suffer orthopedic problems and pain during physical activity. What is New: • Pre-intervention, obese children had 'worse' tendon structure compared to controls. • Following 6-month program, tendon structure of obese children 'positively' changed.
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12
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Docking SI, Girdwood MA, Cook J, Fortington LV, Rio E. Reduced Levels of Aligned Fibrillar Structure Are Not Associated With Achilles and Patellar Tendon Symptoms. Clin J Sport Med 2020; 30:550-555. [PMID: 30067515 DOI: 10.1097/jsm.0000000000000644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate whether the mean cross-sectional area (mCSA) of aligned fibrillar structure (AFS) was associated with the presence and severity of symptoms. DESIGN Prospective cohort study. PARTICIPANTS One hundred seventy-five elite male Australian football players completed monthly Oslo Sports Trauma Research Center overuse injury questionnaires for both the Achilles and patellar tendon over the season to ascertain the presence and severity of symptoms. At the start of the preseason, participants underwent ultrasound tissue characterization (UTC) imaging of the Achilles and patellar tendon. MAIN OUTCOME MEASURES Images were classified as normal or abnormal based on gray-scale ultrasound. Based on UTC quantification, the mCSA of AFS was compared between those with and without current symptoms. RESULTS No difference in the mCSA of AFS was observed between those with or without tendon symptoms (P < 0.05). Similar to previous findings, 80% to 92% of abnormal tendons had similar amounts of mCSA of AFS compared with normal tendon. If reduced mCSA of AFS was present, it was not associated with the presence or severity of symptoms. CONCLUSIONS The prevalence, development, or severity of symptoms was not associated with decreased levels of AFS in the Achilles or patellar tendon. This suggests that a lack of structural integrity is not linked to symptoms and questions the rationale behind regenerative medicine. Most tendons are able to compensate for areas of disorganization and maintain tissue homeostasis.
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Affiliation(s)
- Sean I Docking
- La Trobe Sport and Exercise Medicine Research Center, College of Science, Health and Engineering; La Trobe University; Australia; and
- Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University, Ballarat, Australia
| | - Michael A Girdwood
- La Trobe Sport and Exercise Medicine Research Center, College of Science, Health and Engineering; La Trobe University; Australia; and
- Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University, Ballarat, Australia
| | - Jill Cook
- La Trobe Sport and Exercise Medicine Research Center, College of Science, Health and Engineering; La Trobe University; Australia; and
- Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University, Ballarat, Australia
| | - Lauren V Fortington
- Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University, Ballarat, Australia
| | - Ebonie Rio
- La Trobe Sport and Exercise Medicine Research Center, College of Science, Health and Engineering; La Trobe University; Australia; and
- Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University, Ballarat, Australia
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13
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Steinberg N, Pantanowitz M, Funk S, Svorai Band S, Waddington G, Yavnai N, Zeev A. Can Achilles and patellar tendon structures predict musculoskeletal injuries in combat soldiers? Scand J Med Sci Sports 2020; 31:205-214. [PMID: 32885496 DOI: 10.1111/sms.13820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 08/01/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023]
Abstract
Aiming to investigate whether Achilles tendon (AT) structure and patellar tendon (PT) structure are risk factors for musculoskeletal injuries in combat soldiers, 168 participants were recruited from an infantry commander's course. The AT and PT were examined pre-course using UTC to capture the structure of four echo-type fibers (I-IV). All injuries were assessed by military physicians pre-course and throughout the 14-week course. Soldiers who were injured during the course had a significantly higher pre-course prevalence of AT and PT echo-type III and echo-type IV compared to soldiers that were not injured during the course. Variables that were found to be associated with injured/non-injured participants were echo-type III + IV of the PT (OR = 1.44, 95% CI = 1.24-1.68) and echo-type III of the AT (OR = 1.69, 95% CI = 1.35-2.12). ROC analyses showed that the best model, exhibiting both high sensitivity and low specificity, was that participants with PT echo-type III + IV > 10% or AT echo-type III >8.5% had the highest risk of being injured during the course. In conclusions, the tendon structure at the beginning of high-intensity activity or physical training program might be a risk factor for subsequent injury during the course. Soldiers and high-level athletes should be aware of the cutoff points for fiber types in tendon structure that might put them at high risk for future injury. At-risk soldiers/athletes should be provided with an intervention program before they start their training program, with the aim of improving the tendon structure and preventing subsequent injury.
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Affiliation(s)
- Nili Steinberg
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya, Israel
| | - Michal Pantanowitz
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya, Israel
| | - Shany Funk
- Combat Fitness Department, Doctrine and Research Branch, Israel Defense Forces, Netanya, Israel
| | | | | | - Nirit Yavnai
- Research Directorate, Israel Defense Forces Medical Corps, Tel-Hashomer, Israel
| | - Aviva Zeev
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya, Israel
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14
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Crawford SK, Lee KS, Bashford GR, Heiderscheit BC. Intra-session and inter-rater reliability of spatial frequency analysis methods in skeletal muscle. PLoS One 2020; 15:e0235924. [PMID: 32649705 PMCID: PMC7351217 DOI: 10.1371/journal.pone.0235924] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/25/2020] [Indexed: 11/23/2022] Open
Abstract
Spatial frequency analysis (SFA) is a quantitative ultrasound (US) method originally developed to assess intratendinous tissue structure. This method may also be advantageous in assessing other musculoskeletal tissues. Although SFA has been shown to be a reliable assessment strategy in tendon tissue, its reliability in muscle has not been investigated. The purpose of this study was to examine the reliability of spatial frequency parameter measurement for a large muscle group within a healthy population. Ten participants with no history of lower extremity surgery or hamstring strain injury volunteered. Longitudinal B-mode images were collected in three different locations across the hamstring muscles. Following a short rest, the entire imaging procedure was repeated. B-mode images were processed by manually drawing a region of interest (ROI) about the entire muscle thickness. Four spatial frequency parameters of interest were extracted from the image ROIs. Intra- and inter-rater reliabilities of extracted SFA parameters were performed. Test-retest reliability of the image acquisition procedure was assessed between repeat trials. Intraclass correlation coefficients showed high intra- and inter-rater reliability (ICC(3,1) > 0.9 for all parameters) and good to moderate test-retest reliability (ICC(3,1) > 0.50) between trials. No differences in parameter values were observed between trials across all muscles and locations (p > 0.05). The high reliability metrics suggest that SFA will be useful for future studies assessing muscle tissue structure, and may have value in assessing muscular adaptations following injury and during recovery.
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Affiliation(s)
- Scott K. Crawford
- Department of Orthopedics & Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- * E-mail:
| | - Kenneth S. Lee
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Greg R. Bashford
- Department of Biological Systems Engineering, University of Nebraska, Lincoln, Nebraska, United States of America
| | - Bryan C. Heiderscheit
- Department of Orthopedics & Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
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15
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Dar G, Waddington G, Stern M, Dotan N, Steinberg N. Differences Between Long Distance Road Runners and Trail Runners in Achilles Tendon Structure and Jumping and Balance Performance. PM R 2020; 12:794-804. [PMID: 31762215 DOI: 10.1002/pmrj.12296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 11/19/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Load and joint kinematics change with differences in running surface. Running regularly on trails compared to roads might influence the load on the Achilles tendon and its adaptations, along with other factors such as balance, strength, and proprioception. OBJECTIVE To investigate Achilles tendon structure and functional tests in road and trail runners. DESIGN Cross-sectional study. SETTING Laboratory, sport sciences college. PARTICIPANTS The study included 26 road and 17 trail runners who run at least three times per week with a minimum of 20 km per week and who participated in running competitions over the preceding 2 years. METHODS Each participant was examined for Achilles tendon structure (via ultrasound tissue characterization [UTC] imaging) and underwent functional tests in addition to completing a demographic questionnaire. MAIN OUTCOME MEASUREMENTS The percentages of echo types I, II, III, and IV (degree of structural homogeneity) within the tendon, tendon length and width, tendon cross-sectional area (via UTC imaging); Ankle inversion movement discrimination ability (via Active Movement Extent Discrimination Apparatus device); dynamic postural balance (via Y balance test); jumping performance (by Triple hop distance test); and Hip muscle abduction muscle strength (by hand-held dynamometry). RESULTS Percentage of echo type I was significantly lower while echo type II was higher in the road group compared with the trail group (67.3% type I and 28.9% type II in the road group compared with 74.1% type I and 22.1% type II in the trail group, P < .001). No differences between genders were found and no significant differences between groups were found for the other tests. CONCLUSION Tendon integrity as examined with UTC is different between road and trail runners. This suggests an influence of running surface on Achilles tendon structure. This difference was not reflected in other tests, thus the influence of tendon structure on function needs further examination.
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Affiliation(s)
- Gali Dar
- Department of Physical Therapy Faculty of Social Welfare & Health Studies, University of Haifa, Haifa, Israel.,Department of Physical Therapy, The Ribstein Center for Sport Medicine Sciences and Research, Wingate Institute, Netanya, Israel
| | - Gordon Waddington
- University of Canberra Research Institute for Sport and Exercise, Canberra, Australia
| | - Myriam Stern
- Department of Radiology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Dotan
- The Wingate College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
| | - Nili Steinberg
- University of Canberra Research Institute for Sport and Exercise, Canberra, Australia.,The Wingate College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
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16
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Rabello LM, Albers IS, van Ark M, Diercks RL, van den Akker-Scheek I, Zwerver J. Running a Marathon-Its Influence on Achilles Tendon Structure. J Athl Train 2020; 55:176-180. [PMID: 31935137 DOI: 10.4085/1062-6050-49-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
CONTEXT Several studies have been conducted to better understand the effect of load on the Achilles tendon structure. However, the effect of a high cumulative load consisting of repetitive cyclic movements, such as those that occur during the running of a marathon, on Achilles tendon structure is not yet clear. Clinicians, coaches, and athletes will benefit from knowledge about the effects of a marathon on the structure of the Achilles tendon. OBJECTIVE To investigate the short-term response of the Achilles tendon structure to running a marathon. DESIGN Case series (prospective). SETTING Sports medicine centers. PATIENTS OR OTHER PARTICIPANTS Ten male nonelite runners who ran in a marathon. MAIN OUTCOMES MEASURE(S) Tendon structure was assessed before and 2 and 7 days after a marathon using ultrasound tissue characterization (UTC), an imaging tool that quantifies tendon organization in 4 echo types (I-IV). Echo type I represents the most stable echo pattern, and echo type IV, the least stable. RESULTS At 7 days postmarathon, both the insertional and midportion structure changed significantly. At both sites, the percentage of echo type II increased (insertion P < .01; midportion P = .02) and the percentages of echo types III and IV decreased (type III: insertion P = .01; midportion P = .02; type IV: insertion P = .01; midportion P < .01). Additionally, at the insertion, the percentage of echo type I decreased (P < .01). CONCLUSIONS We observed the effects of running a marathon on the Achilles tendon structure 7 days after the event. Running the marathon combined with the activity performed shortly thereafter might have caused the changes in tendon structure. This result emphasizes the importance of sufficient recovery time after running a marathon to prevent overuse injuries.
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Affiliation(s)
- Lucas Maciel Rabello
- Department of Sports and Exercise Medicine, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Iris Sophie Albers
- Department of Sports and Exercise Medicine, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Mathijs van Ark
- Department of Sports and Exercise Medicine, University of Groningen, University Medical Center Groningen, The Netherlands.,Department of Physiotherapy, Hanze University of Applied Sciences, Groningen, The Netherlands.,Centre of Expertise Primary Care Groningen (ECEZG), Peescentrum (Tendon Centre), The Netherlands
| | - Ron L Diercks
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Sports and Exercise Medicine, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Johannes Zwerver
- Department of Sports and Exercise Medicine, University of Groningen, University Medical Center Groningen, The Netherlands
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17
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Steinberg N, Eliakim A, Elbaz L, Pantanowitz M, Zeev A, Nemet D. Achilles Tendon Tissue Structure in Children with Overweight and Children with Obesity. Phys Occup Ther Pediatr 2020; 40:330-344. [PMID: 31591918 DOI: 10.1080/01942638.2019.1672848] [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] [Indexed: 02/08/2023]
Abstract
Aim: To investigate differences in Achilles tendon structure between children with overweight/obesity and children with normal weight.Methods: Twenty-two children with obesity, 10 children with overweight, and 44 children with normal weight participated in the study. BMI% was calculated. The Achilles tendon was examined using ultrasound tissue characterization (UTC) imaging to capture a three-dimensional structure of four echo-type fibers and a cross-sectional area.Results: A significantly higher percentile of echo-types II, a lower percentile of echo-types III and IV, and a lower cross-sectional area were found for children with normal weight compared with children with overweight/obesity (p < .05). Following a piecewise linear regression model according to tendon structure, a BMI percentile of 75% was found to be the most accurate cutoff point of the children into the "unaffected" (BMI% <75%) and "affected" tendon structure groups (BMI% ≥ 75%), as the children with BMI%≥75% already had an Achilles tendon structure similar to that of the children with overweight/obesity.Conclusions: Tendon integrity as examined with UTC differs between children with obesity and children with normal weight. Children with a BMI percentile of ≥75 already demonstrate a different tendon structure pattern compared with children with BMI percentile of <75. This may put children with obesity at a greater risk of injury and should be addressed when applying an exercise program for children with overweight/obesity.
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Affiliation(s)
- Nili Steinberg
- The Wingate College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
| | - Alon Eliakim
- Child Health and Sport Center, Pediatric Department, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liav Elbaz
- The Wingate College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
| | - Michal Pantanowitz
- The Wingate College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel.,Child Health and Sport Center, Pediatric Department, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviva Zeev
- The Wingate College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
| | - Dan Nemet
- Child Health and Sport Center, Pediatric Department, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Lawson A, Noorkoiv M, Masci L, Mohagheghi AA. Ankle Joint Position and the Reliability of Ultrasound Tissue Characterization of the Achilles Tendon: A Pilot Study. Med Sci Monit 2019; 25:6884-6893. [PMID: 31516131 PMCID: PMC6755937 DOI: 10.12659/msm.915685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Imaging of the Achilles tendon using ultrasound tissue characterization (UTC) involves taking up the slack of the tendon by including dorsiflexion of the ankle. This pilot study aimed to determine whether different longitudinal tension applied to the Achilles tendon during imaging affected the reliability of UTC. Material/Methods Nine asymptomatic active volunteers, aged between 23–49 years underwent imaging of 17 Achilles tendons. Three positions of tension included plantar grade, 50%, and 100% of maximal dorsiflexion, with a range of 18–32°. Ranges were established and standardized using an isokinetic dynamometer. A test and re-test process was conducted at each position to determine the intraclass correlation coefficients (ICCs) and minimum detectable change (MDC) per echotype. Images were analyzed using UTC software. Results Plantar grade positioning images could not be obtained. ICCs for each echotype I–IV between test 1 and test 2 were 0.965, 0.962, 0.858, 0.739 at 100% dorsiflexion (95% CI, 0.86–0.99, 0.84–0.99, 0.51–0.97, and 0.2–0.94), and 0.771, 0.551, 0.569, 0.429 at 50% dorsiflexion (95% CI, 0.29–0.94, −0.09–0.88, −0.01–0.88, and −0.15–0.82). The MDC per echotype I–IV ranged between 4.1–1.0% of echotype data at 100% dorsiflexion, and 17.2–6.3% at 50% dorsiflexion. Conclusions Testing at maximum dorsiflexion provided improved reliability when using UTC in healthy individuals. The ICC at 100% dorsiflexion was increased, and the MDC was reduced for all echotypes. Therefore, standardizing test positions when using UTC is advisable for reliable comparison of results between studies.
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Affiliation(s)
- Arturo Lawson
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University, London, United Kingdom
| | - Marika Noorkoiv
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University, London, United Kingdom
| | | | - Amir A Mohagheghi
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University, London, United Kingdom
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19
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Clinical Improvements Are Not Explained by Changes in Tendon Structure on Ultrasound Tissue Characterization After an Exercise Program for Patellar Tendinopathy. Am J Phys Med Rehabil 2019; 97:708-714. [PMID: 29649012 DOI: 10.1097/phm.0000000000000951] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the effects of a 4-wk in-season exercise program of isometric or isotonic exercises on tendon structure and dimensions as quantified by ultrasound tissue characterization (UTC). DESIGN This was a randomized clinical trial. Volleyball and basketball players (16-31 yrs, n = 29) with clinically diagnosed patellar tendinopathy were randomized to a 4-wk isometric or isotonic exercise program. The programs were designed to decrease patellar tendon pain. A baseline and 4-wk UTC scan was used to evaluate change in tendon structure. RESULTS No significant change in tendon structure or dimensions on UTC was detected after the exercise program despite patellar tendinopathy symptoms improving. The percentage and mean cross-sectional area of aligned fibrillar structure (echo types I + II) (Z = -0.414, P = 0.679) as well as disorganized structure (echo types III + IV) (Z = -0.370, P = 0.711) did not change over the 4-wk exercise program. Change in tendon structure and dimensions on UTC did not differ significantly between the groups. CONCLUSION Structural properties and dimensions of the patellar tendon on UTC did not change after a 4-wk isometric or isotonic exercise program for athletes with patellar tendinopathy in-season, despite an improvement in symptoms. It seems that structural improvements are not required for a positive clinical outcome.
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20
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Pereira CS, Santos RCG, Whiteley R, Finni T. Reliability and methodology of quantitative assessment of harvested and unharvested patellar tendons of ACL injured athletes using ultrasound tissue characterization. BMC Sports Sci Med Rehabil 2019; 11:12. [PMID: 31360525 PMCID: PMC6639951 DOI: 10.1186/s13102-019-0124-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 06/24/2019] [Indexed: 12/12/2022]
Abstract
Background Ultrasound tissue characterization (UTC) imaging has been previously used to describe the characteristics of patellar and Achilles tendons. UTC imaging compares and correlates successive ultrasonographic transverse tendon images to calculate the distribution of four color-coded echo-types that represent different tendon tissue types. However, UTC has not been used to describe the characteristics of patellar tendons after anterior cruciate ligament reconstruction (ACLR). The aim of this cross-sectional study was to assess the intra and inter-rater reliability of the UTC in unharvested and harvested patellar tendons of patients undergoing ACLR. Methods Intra and inter-rater reliability of both UTC data collection and analysis were assessed. Ten harvested and twenty unharvested patellar tendons from eighteen participants were scanned twice by the same examiner. Eleven harvested and ten unharvested patellar tendons from sixteen participants were scanned and analyzed twice by two different examiners. Twenty harvested and nineteen unharvested patellar tendons from twenty-three participants were analyzed twice by two examiners. Results Quantification of the proportion of echo-types I, II, III and IV in the areas of interest: (1) patella apex, (2) proximal tendon, (3) mid tendon, (4) distal tendon, and overall tendon of harvested and unharvested patellar tendons all displayed excellent intra-rater reliability (ICC2,1: 0.94 to 0.99), excellent inter-rater reliability for harvested and unharvested patellar tendon scanning and analysis (ICC2,1: 0.89 to 0.98), and excellent inter-rater reliability for analysis (ICC2,1: 0.95 to 0.99). Intra-rater reliability for the measure of volume was good (ICC2,1: 0.69 harvested, 0.67 unharvested), whilst mixed results were observed for the measure of mid tendon thickness (ICC2,1: 0.88 harvested, 0.57 unharvested). Inter-rater reliability for scanning and analysis was good for volume (ICC2,1: 0.67) and excellent for thickness (ICC2,1: 0.97), while the inter-rater reliability for analysis was fair to poor for volume (ICC2,1: 0.59 harvested, 0.30 unharvested), and excellent to poor for mid tendon thickness (ICC2,1: 0.85 harvested, 0.24 unharvested). Conclusion UTC imaging is a reliable tool to characterize the quality of most aspects of unharvested and harvested patellar tendons in subjects undergoing ACLR.
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Affiliation(s)
- Carla S Pereira
- 1ASPETAR Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St, Doha, PO Box 29222, Qatar.,2Faculty of Sport and Health Sciences, Biology of Physical Activity, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland
| | - Rafael C G Santos
- 1ASPETAR Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St, Doha, PO Box 29222, Qatar
| | - Rod Whiteley
- 1ASPETAR Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St, Doha, PO Box 29222, Qatar
| | - Taija Finni
- 2Faculty of Sport and Health Sciences, Biology of Physical Activity, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland
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King D, Yakubek G, Chughtai M, Khlopas A, Saluan P, Mont MA, Genin J. Quadriceps tendinopathy: a review-part 1: epidemiology and diagnosis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:71. [PMID: 30963066 DOI: 10.21037/atm.2019.01.58] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Historically, they have been labeled as Jumper's knee due to the high prevalence seen in the athletic community. In many published reports, the name "patellar tendinopathy" is used to describe this disorder of the quadriceps tendon at the patellar insertion, and the names are often used interchangeably. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the first part we review: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In the second part we discuss: (I) classification; (II) prognosis; and (III) treatment results.
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Affiliation(s)
- Dominic King
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - George Yakubek
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Saluan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Jason Genin
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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22
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Plevin S, McLellan J, Schie H, Parkin T. Ultrasound tissue characterisation of the superficial digital flexor tendons in juvenile Thoroughbred racehorses during early race training. Equine Vet J 2018; 51:349-355. [DOI: 10.1111/evj.13006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/29/2018] [Indexed: 12/28/2022]
Affiliation(s)
- S. Plevin
- Florida Equine Veterinary Associates Ocala Florida USA
| | - J. McLellan
- Florida Equine Veterinary Associates Ocala Florida USA
| | - H. Schie
- Department of Equine Sciences Utrecht University Utrecht the Netherlands
| | - T. Parkin
- University of Glasgow, School of Veterinary Medicine Glasgow UK
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Rudavsky A, Cook J, Docking S. Quantifying proximal patellar tendon changes during adolescence in elite ballet dancers, a 2-year study. Scand J Med Sci Sports 2018; 28:2369-2374. [PMID: 29862593 DOI: 10.1111/sms.13235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 12/20/2022]
Abstract
Patellar tendon pathology appears to develop in young athletes. It is not known how this tendon develops through adolescence. This longitudinal study investigated proximal patellar tendon development during the adolescent growth spurt in young ballet dancers and identified whether puberty (estimated by maturity offset) had an effect on tendon development. Fifty two dancers (32 female and 20 male dancers, ages 11-18 at baseline) had ultrasound images of their tendons every 6 months for 2 years. Changes in tendon size (anterior-posterior diameter) on grayscale images and echogenicity, as quantified using ultrasound tissue characterization, were recorded each time. Maturity offset was calculated used to estimate peak height velocity (adolescent growth spurt). Maturity offset did not affect effect tendon composition before peak height velocity; however, after participants passed peak height velocity, maturity offset increased the composition of stable echopattern (P < .05): a 4% differential increase in type I echopattern, indicative of normal tendon structure, and a decrease in type III echopattern (more disorganized echopattern) by 0.7% per year. Anterior-posterior thickness increased by 0.2 mm/y (P < .05) measured 2 cm below the patella. Following peak height velocity, the proximal patellar tendon attachment increased in thickness and demonstrated a more stable echopattern representative of aligned fibrillar structure. Future research is required to further understand this normal maturation and the factors that support this process, with the aim of reducing the development of patellar tendon pathology in the adolescent jumping athlete.
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Affiliation(s)
- A Rudavsky
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark
| | - J Cook
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, VIC, Australia
| | - S Docking
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, VIC, Australia
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Washburn N, Onishi K, Wang JHC. Ultrasound elastography and ultrasound tissue characterisation for tendon evaluation. J Orthop Translat 2018; 15:9-20. [PMID: 30258782 PMCID: PMC6148731 DOI: 10.1016/j.jot.2018.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 06/04/2018] [Accepted: 06/07/2018] [Indexed: 12/16/2022] Open
Abstract
Ultrasound elastography (UE) and ultrasound tissue characterisation (UTC) are two newer modes of ultrasound (US) which have begun to attract scientific interests as ways to improve tendon characterisation. These modes of US show early promise in improved diagnostic accuracy, prediction of at-risk tendons and prognostication capability beyond conventional grey-scale US. Here, we provide a review of the literature on UE and UTC for Achilles, patellar and rotator cuff tendons. The translational potential of this article: The present literature indicates that UE and UTC could potentially increase the clinician's ability to accurately diagnose the extent of tendon pathology, including preclinical injury.
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Affiliation(s)
- Neal Washburn
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Kaufman Building, 3471 Fifth Avenue, Suite 201, Pittsburgh, PA, 15213, USA
| | - Kentaro Onishi
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Kaufman Building, 3471 Fifth Avenue, Suite 201, Pittsburgh, PA, 15213, USA.,Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufman Building, 3471 Fifth Avenue, Suite 1011, Pittsburgh, PA, 15213, USA
| | - James H-C Wang
- MechanoBiology Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 210 Lothrop Street, BST, E1640, Pittsburgh, PA 15213, USA
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25
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Heyward OW, Rabello LM, van der Woude L, van den Akker-Scheek I, Gokeler A, van der Worp H, Zwerver J. The effect of load on Achilles tendon structure in novice runners. J Sci Med Sport 2018; 21:661-665. [DOI: 10.1016/j.jsams.2017.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 09/27/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
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Rudavsky A, Cook JL, Docking S. Proximal patellar tendon pathology can develop during adolescence in young ballet dancers-A 2-year longitudinal study. Scand J Med Sci Sports 2018; 28:2035-2041. [PMID: 29658150 DOI: 10.1111/sms.13095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2018] [Indexed: 12/21/2022]
Abstract
Patellar tendinopathy (tendon pain and dysfunction), or jumper's knee, is prevalent in adult jumping athletes. Pathology in the proximal patellar tendon is a key risk factor for developing patellar tendinopathy. When pathology develops in the proximal patellar tendon is not known, although it is reported to exist in adolescent athletes. The aim of this study was to follow young jumping athletes (ballet dancers) through adolescence to identify whether pathology develops and its relation to the adolescent growth spurt. Fifty-seven elite ballet students between ages 11 and 18 were monitored for 2 years. Data were collected every 6 months, including an ultrasound scan on their left tendons using ultrasound tissue characterization (UTC) to quantify intratendinous changes, anthropometric data to calculate peak height velocity (adolescent growth spurt), participant reports of any injuries or dance modifications, and a VISA-P and single leg decline squat for patellar tendon pain. Nine percentage of adolescent dancers developed pathology during this study, and development was not associated with growth spurt. Peak height velocity and dance participation/volume both at the start and throughout the study were similar in those who did develop pathology and those who did not. Only 2 of 5 participants who developed pathology reported pain associated with their tendon. Pathology in the proximal patellar tendon can develop during adolescence.
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Affiliation(s)
- A Rudavsky
- Department of Clinical Medicine, Institute of Sports Medicine Copenhagen, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - J L Cook
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Vic., Australia
| | - S Docking
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Vic., Australia
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Lin CY, Ooi CC, Chan E, Chew KT. Emerging Technological Advances in Musculoskeletal Ultrasound. PM R 2018; 10:112-119. [PMID: 29413117 DOI: 10.1016/j.pmrj.2017.08.444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/21/2017] [Accepted: 08/27/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Cindy Y Lin
- Sports and Spine Division, Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA; Sports, Spine, and Orthopaedic Health, University of Washington Husky Stadium Sports Medicine Center, 3800 Montlake Blvd NE, Seattle, WA 98195.,Department of Radiology, Singapore General Hospital, Singapore.,Singhealth Family Medicine, Singapore.,Department of Sports Medicine, Changi General Hospital, Singapore
| | - Chin Chin Ooi
- Sports and Spine Division, Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA; Sports, Spine, and Orthopaedic Health, University of Washington Husky Stadium Sports Medicine Center, 3800 Montlake Blvd NE, Seattle, WA 98195.,Department of Radiology, Singapore General Hospital, Singapore.,Singhealth Family Medicine, Singapore.,Department of Sports Medicine, Changi General Hospital, Singapore
| | - Eric Chan
- Sports and Spine Division, Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA; Sports, Spine, and Orthopaedic Health, University of Washington Husky Stadium Sports Medicine Center, 3800 Montlake Blvd NE, Seattle, WA 98195.,Department of Radiology, Singapore General Hospital, Singapore.,Singhealth Family Medicine, Singapore.,Department of Sports Medicine, Changi General Hospital, Singapore
| | - Kelvin T Chew
- Sports and Spine Division, Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA; Sports, Spine, and Orthopaedic Health, University of Washington Husky Stadium Sports Medicine Center, 3800 Montlake Blvd NE, Seattle, WA 98195.,Department of Radiology, Singapore General Hospital, Singapore.,Singhealth Family Medicine, Singapore.,Department of Sports Medicine, Changi General Hospital, Singapore
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28
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Rudavsky A, Cook J, Magnusson SP, Kjaer M, Docking S. Characterising the proximal patellar tendon attachment and its relationship to skeletal maturity in adolescent ballet dancers. Muscles Ligaments Tendons J 2017; 7:306-314. [PMID: 29264342 DOI: 10.11138/mltj/2017.7.2.306] [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: 12/13/2022]
Abstract
Background It is unknown how and when the proximal attachment of the patellar tendon matures; puberty may be key in ensuring normal tendon formation. The aim of this study was to investigate the features of the proximal patellar tendon attachment at different stages of skeletal maturity, to help gain an understanding of how and when the tendon attachment matures. Methods Sixty adolescent elite ballet students (ages 11-18) and eight mature adults participated. Peak height velocity (PHV) estimated skeletal maturity. Ultrasound tissue characterisation (UTC) scan was taken of the left knee and analysed for stability of echopattern. An image-based grading scale for greyscale ultrasound was developed to describe the tendon appearance. Anterior-posterior thickness was measured at the inferior pole of the patella, 1 and 2 centimetres distally. Outcomes were compared with skeletal maturity. Results Mid-portion patellar tendon thickness increased with skeletal maturity (p=0.001 at 1 cm and p=0.007 at 2 cm). There was more variance in structural appearance (greyscale classification and UTC echopattern) in pre and peri-PHV participants. Tendon attachment one-year post PHV appeared similar to mature tendons. Conclusions Early adolescence was associated with highly variable tendon appearance, whereas the tendon appeared mature after PHV. Adolescence may be a critical time for the formation of normal tendon attachment. Level of evidence IIb individual cohort study.
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Affiliation(s)
- Aliza Rudavsky
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Jillianne Cook
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Stig Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.,Musculoskeletal Rehabilitation Research Unit, Department of Physical Therapy, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Sean Docking
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
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Waugh CM, Alktebi T, de Sa A, Scott A. Impact of rest duration on Achilles tendon structure and function following isometric training. Scand J Med Sci Sports 2017; 28:436-445. [PMID: 28603874 DOI: 10.1111/sms.12930] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 12/14/2022]
Abstract
Intervention programs are often sought to strengthen the Achilles tendon (AT) due to its high injury rate. Long rest periods between loading cycles have been found to increase collagen synthesis by tenocytes, suggesting rest duration may be important for tendon adaptation in vivo; however, exercise programs comparing long and short rest duration have not been directly compared. Fourteen adults completed a 12-week progressive training intervention; training sessions consisted of 5×10 isometric plantarflexion contractions each of 3-s duration performed at 90% of MVC three times weekly. Each leg was randomly allocated to long (LRT, 10-s rest) or short rest training (SRT, 3-s rest). We hypothesized that the leg allocated to LRT would demonstrate superior AT collagen organization compared to the leg receiving SRT, which would be related to improved biomechanical function. AT collagen organization and morphology were measured using ultrasound tissue characterization. AT properties were assessed before and after the intervention using a combination of dynamometry, ultrasound imaging, EMG, and motion capture. Contrary to our hypothesis, collagen organization did not improve following either training protocol; conversely, an unexpected decrease in echotype I proportion was seen after SRT (P<.001) but not LRT (P=.58), indicating an apparent protective effect of rest on collagen organization during isometric training. In contrast, AT adaptation was not appreciably enhanced by increasing intercycle rest duration; both protocols were equally effective at inducing significant strength gains and AT mechanical and material adaptation (P≤.001). Further research is necessary to identify optimal loading characteristics for injury prevention and rehabilitation.
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Affiliation(s)
- C M Waugh
- Faculty of Medicine, Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - T Alktebi
- Faculty of Medicine, Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - A de Sa
- Faculty of Medicine, Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - A Scott
- Faculty of Medicine, Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
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30
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Payne C, Webborn N, Watt P, Cercignani M. Poor reproducibility of compression elastography in the Achilles tendon: same day and consecutive day measurements. Skeletal Radiol 2017; 46:889-895. [PMID: 28378201 DOI: 10.1007/s00256-017-2629-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/04/2017] [Accepted: 03/08/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the reproducibility of compression elastography (CE) when measuring strain data, a measure of stiffness of the human Achilles tendon in vivo, over consecutive measures, consecutive days and when using different foot positions. MATERIALS AND METHODS Eight participants (4 males, 4 females; mean age 25.5 ± 2.51 years, range 21-30 years; height 173.6 ± 11.7 cm, range 156-189 cm) had five consecutive CE measurements taken on one day and a further five CE measures taken, one per day, at the same time of day, every day for a consecutive 5-day period. These 80 measurements were used to assess both the repeatability and reproducibility of the technique. Means, standard deviations, coefficient of variation (CV), Pearson correlation analysis (R) and intra-class correlation coefficients (ICC) were calculated. RESULTS For CE data, all CVs were above 53%, R values indicated no-to-weak correlations between measures at best (range 0.01-0.25), and ICC values were all classified in the poor category (range 0.00-0.11). CVs for length and diameter measures were acceptably low indicating a high level of reliability. CONCLUSIONS Given the wide variation obtained in the CE results, it was concluded that CE using this specific system has a low level of reproducibility for measuring the stiffness of the human Achilles tendon in vivo over consecutive days, consecutive measures and in different foot positions.
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Affiliation(s)
- Catherine Payne
- Centre for Sport and Exercise Science and Medicine (SESAME), University of Brighton, Carlisle Road, Eastbourne, BN20 7SN, UK.
| | - Nick Webborn
- Centre for Sport and Exercise Science and Medicine (SESAME), University of Brighton, Carlisle Road, Eastbourne, BN20 7SN, UK
| | - Peter Watt
- Centre for Sport and Exercise Science and Medicine (SESAME), University of Brighton, Carlisle Road, Eastbourne, BN20 7SN, UK
| | - Mara Cercignani
- Clinical Imaging Sciences Centre, Brighton and Sussex Medical School, Falmer, BN1 9RR, UK
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31
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Stanley LE, Lucero A, Mauntel TC, Kennedy M, Walker N, Marshall SW, Padua DA, Berkoff DJ. Achilles tendon adaptation in cross-country runners across a competitive season. Scand J Med Sci Sports 2017; 28:303-310. [DOI: 10.1111/sms.12903] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2017] [Indexed: 02/03/2023]
Affiliation(s)
- L. E. Stanley
- University of North Carolina at Chapel Hill; Chapel Hill NC USA
- Human Movement Science Curriculum; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - A. Lucero
- University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - T. C. Mauntel
- Department of Orthopaedics; Walter Reed National Military Medical Center; Bethesda MD USA
| | - M. Kennedy
- University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - N. Walker
- University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - S. W. Marshall
- University of North Carolina at Chapel Hill; Chapel Hill NC USA
- Department of Epidemiology; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - D. A. Padua
- University of North Carolina at Chapel Hill; Chapel Hill NC USA
- Human Movement Science Curriculum; University of North Carolina at Chapel Hill; Chapel Hill NC USA
- Department of Orthopaedics; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - D. J. Berkoff
- University of North Carolina at Chapel Hill; Chapel Hill NC USA
- Department of Orthopaedics; University of North Carolina at Chapel Hill; Chapel Hill NC USA
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32
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Geburek F, Roggel F, van Schie HTM, Beineke A, Estrada R, Weber K, Hellige M, Rohn K, Jagodzinski M, Welke B, Hurschler C, Conrad S, Skutella T, van de Lest C, van Weeren R, Stadler PM. Effect of single intralesional treatment of surgically induced equine superficial digital flexor tendon core lesions with adipose-derived mesenchymal stromal cells: a controlled experimental trial. Stem Cell Res Ther 2017; 8:129. [PMID: 28583184 PMCID: PMC5460527 DOI: 10.1186/s13287-017-0564-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 03/15/2017] [Accepted: 04/26/2017] [Indexed: 12/31/2022] Open
Abstract
Background Adipose tissue is a promising source of mesenchymal stromal cells (MSCs) for the treatment of tendon disease. The goal of this study was to assess the effect of a single intralesional implantation of adipose tissue-derived mesenchymal stromal cells (AT-MSCs) on artificial lesions in equine superficial digital flexor tendons (SDFTs). Methods During this randomized, controlled, blinded experimental study, either autologous cultured AT-MSCs suspended in autologous inactivated serum (AT-MSC-serum) or autologous inactivated serum (serum) were injected intralesionally 2 weeks after surgical creation of centrally located SDFT lesions in both forelimbs of nine horses. Healing was assessed clinically and with ultrasound (standard B-mode and ultrasound tissue characterization) at regular intervals over 24 weeks. After euthanasia of the horses the SDFTs were examined histologically, biochemically and by means of biomechanical testing. Results AT-MSC implantation did not substantially influence clinical and ultrasonographic parameters. Histology, biochemical and biomechanical characteristics of the repair tissue did not differ significantly between treatment modalities after 24 weeks. Compared with macroscopically normal tendon tissue, the content of the mature collagen crosslink hydroxylysylpyridinoline did not differ after AT-MSC-serum treatment (p = 0.074) while it was significantly lower (p = 0.027) in lesions treated with serum alone. Stress at failure (p = 0.048) and the modulus of elasticity (p = 0.001) were significantly lower after AT-MSC-serum treatment than in normal tendon tissue. Conclusions The effect of a single intralesional injection of cultured AT-MSCs suspended in autologous inactivated serum was not superior to treatment of surgically created SDFT lesions with autologous inactivated serum alone in a surgical model of tendinopathy over an observation period of 22 weeks. AT-MSC treatment might have a positive influence on collagen crosslinking of remodelling scar tissue. Controlled long-term studies including naturally occurring tendinopathies are necessary to verify the effects of AT-MSCs on tendon disease. Electronic supplementary material The online version of this article (doi:10.1186/s13287-017-0564-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Florian Geburek
- Equine Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.
| | - Florian Roggel
- Equine Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
| | - Hans T M van Schie
- Department of Equine Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM, Utrecht, The Netherlands
| | - Andreas Beineke
- Institute for Pathology, University of Veterinary Medicine Hannover, Foundation, Bünteweg 17, 30559, Hannover, Germany
| | - Roberto Estrada
- Department of Equine Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM, Utrecht, The Netherlands
| | - Kathrin Weber
- Pferdeklink Kirchheim, Nürtinger Straße 200, 73230, Kirchheim unter Teck, Germany
| | - Maren Hellige
- Equine Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
| | - Karl Rohn
- Institute for Biometry, Epidemiology and Information Processing, University of Veterinary Medicine Hannover, Foundation, Bünteweg 2, 30559, Hannover, Germany
| | - Michael Jagodzinski
- Department of Orthopedic Trauma, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Bastian Welke
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic Surgery, Hannover Medical School, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | - Christof Hurschler
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic Surgery, Hannover Medical School, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | | | - Thomas Skutella
- Institute for Anatomy and Cell Biology, University of Heidelberg, Im Neuenheimer Feld 307, 69120, Heidelberg, Germany
| | - Chris van de Lest
- Department of Equine Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM, Utrecht, The Netherlands
| | - René van Weeren
- Department of Equine Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM, Utrecht, The Netherlands
| | - Peter M Stadler
- Equine Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
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Tamura N, Nukada T, Kato T, Kuroda T, Kotoyori Y, Fukuda K, Kasashima Y. The use of sonoelastography to assess the recovery of stiffness after equine superficial digital flexor tendon injuries: A preliminary prospective longitudinal study of the healing process. Equine Vet J 2017; 49:590-595. [PMID: 28083881 DOI: 10.1111/evj.12665] [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] [Received: 07/04/2016] [Accepted: 01/04/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND The objective assessment of the mechanical properties of the superficial digital flexor tendon (SDFT) could provide useful information for the rehabilitation of horses with SDFT injuries. Assessment of strain ratio (the strain of a standard reference divided by that of lesions) is a quantitative method in sonoelastography for evaluating tissue stiffness in vivo. As yet, no longitudinal studies have used strain ratio to evaluate the progression of stiffness in SDFT injuries. OBJECTIVES To test the hypothesis that strain ratio can evaluate the recovery of stiffness during the healing of SDFT injuries. STUDY DESIGN Prospective and longitudinal study with observer-blinded evaluation. METHODS Ultrasonography, including sonoelastography, was performed in seven Thoroughbred horses with naturally occurring SDFT injuries at five time points: within 20 days of the injury, and at 2, 3, 6 and 9 months after the injury. Blinded sonoelastographic images were independently evaluated by two veterinarians to assess interobserver agreement. The recovery of stiffness and echogenicity in lesions were evaluated using the strain ratio and grey-scale ratio (echogenicity of lesions divided by that of the surrounding area), respectively. RESULTS Interobserver agreement was assessed as 'almost perfect'. Strain ratios were significantly higher at 9 months after injury than at the other time points (all P<0.05). Strain ratios at 6 months after injury were significantly higher than those at earlier time points (P<0.05). Grey-scale ratios within 20 days of injury were significantly lower than those at the other time points (all P<0.05). MAIN LIMITATIONS Validations of SDFT status were evaluated only by recovery of the echogenicity in lesions and not by histopathological examination. CONCLUSIONS Although further studies are needed to validate the relationships between injured SDFT status and sonoelastographic findings, this preliminary study shows that strain ratio may provide a means to monitor the recovery of stiffness in lesions during rehabilitation, even when the grey-scale ratio remains unchanged from a few months after SDFT injury. The Summary is available in Chinese - see Supporting Information.
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Affiliation(s)
- N Tamura
- Rehabilitation Research Centre, Equine Research Institute, Japan Racing Association, Fukushima, Japan.,Clinical Science and Pathobiology Division, Equine Research Institute, Japan Racing Association, Tochigi, Japan
| | - T Nukada
- Rehabilitation Research Centre, Equine Research Institute, Japan Racing Association, Fukushima, Japan
| | - T Kato
- Rehabilitation Research Centre, Equine Research Institute, Japan Racing Association, Fukushima, Japan
| | - T Kuroda
- Clinical Science and Pathobiology Division, Equine Research Institute, Japan Racing Association, Tochigi, Japan
| | - Y Kotoyori
- Clinical Science and Pathobiology Division, Equine Research Institute, Japan Racing Association, Tochigi, Japan
| | - K Fukuda
- Clinical Science and Pathobiology Division, Equine Research Institute, Japan Racing Association, Tochigi, Japan
| | - Y Kasashima
- Clinical Science and Pathobiology Division, Equine Research Institute, Japan Racing Association, Tochigi, Japan
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Geburek F, Gaus M, van Schie HTM, Rohn K, Stadler PM. Effect of intralesional platelet-rich plasma (PRP) treatment on clinical and ultrasonographic parameters in equine naturally occurring superficial digital flexor tendinopathies - a randomized prospective controlled clinical trial. BMC Vet Res 2016; 12:191. [PMID: 27604193 PMCID: PMC5015224 DOI: 10.1186/s12917-016-0826-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/01/2016] [Indexed: 12/13/2022] Open
Abstract
Background Regenerative and anti-inflammatory effects on tendinopathies have been attributed to blood-derived biologicals. To date the evidence for the efficacy of autologous platelet-rich plasma (PRP) treatment of naturally occurring equine tendinopathies is limited. The purpose of this placebo-controlled clinical trial was to describe the effect of a single treatment of equine superficial digital flexor tendon (SDFT) disease with PRP on clinical and ultrasonographic parameters. Twenty horses with naturally occurring tendinopathies of forelimb SDFTs were randomly assigned to the PRP-treated group (n = 10) or control group (n = 10) after clinical and ultrasonographic examination. The SDFTs received an intralesional treatment with autologous PRP or were injected with saline, respectively (day 0). All horses participated in a standardized exercise programme and were re-examined clinically, with B-mode ultrasonography (5 times at regular intervals) and ultrasound tissue characterization (week 12 and 24 after treatment) until week 24. Long-term performance was estimated via telephone inquiry. Results Compared to day 0, lameness decreased significantly by week 8 after treatment with PRP and by week 12 in the control group. Ultrasonographically there was no difference in the summarized cross sectional area between the groups at any time point. Ultrasound tissue characterization showed that echo types representing disorganized matrix decreased significantly throughout the observation period in the PRP-treated group. Echo type II, representing discontinuous fascicles, not yet aligned into lines of stress was significantly higher 24 weeks after PRP treatment. Eighty percent of the PRP treated horses reached their previous or a higher level of performance after 12 months compared to 50 % in the CG. After 24 months these proportions were 60 % and 50 %, respectively. Conclusions A single intralesional treatment with PRP up to 8 weeks after onset of clinical signs of tendinopathy contributes to an earlier reduction of lameness compared to saline treatment and to an advanced organization of repair tissue as the fibrillar matrix is getting organized into fascicles while remodelling continues. Long term, PRP treatment has the potential to increase the number of horses reaching their previous level of performance. Earlier treatment of tendinopathy with PRP should be considered to enhance these effects.
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Affiliation(s)
- Florian Geburek
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.
| | - Moritz Gaus
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
| | - Hans T M van Schie
- Department of Equine Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM, Utrecht, Netherlands
| | - Karl Rohn
- Institute for Biometry, Epidemiology and Information Processing, University of Veterinary Medicine Hannover, Foundation, Bünteweg 2, 30559, Hannover, Germany
| | - Peter M Stadler
- Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
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Spinella G, Britti D, Loprete G, Musella V, Romagnoli N, Vilar JM, Valentini S. Relative Echogenicity of Tendons and Ligaments of the Palmar Metacarpal Region in Foals from Birth to 4 Months of Age: A Longitudinal Study. PLoS One 2016; 11:e0159953. [PMID: 27441630 PMCID: PMC4956061 DOI: 10.1371/journal.pone.0159953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/11/2016] [Indexed: 11/25/2022] Open
Abstract
The objective of this study was to evaluate relative echogenicity of superficial and deep digital flexor tendons, the accessory ligament of the deep digital flexor tendon and interosseous muscle of the metacarpal region in foals ages 1 week to 4 months; and assess the association between echogenicity and sex or side/laterality. Seven Standardbred trotter foals were examined. Right and left metacarpal regions (palmar surface) were ultrasonographically investigated, and four regions of interest were assessed. A significant increase in echogenicity was seen in superficial and deep digital flexor tendons, accessory ligament of deep digital flexor tendon, and interosseous muscle during growth from 1 week to 4 months of age. Echogenicity of examined tendons and ligaments was not influenced by gender nor laterality. Reference values for tendon and ligament echogenicity could function as a tool to discriminate between physiological and abnormal conditions such as congenital contractural conditions.
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Affiliation(s)
- Giuseppe Spinella
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia (BO), Italy
- * E-mail:
| | - Domenico Britti
- Department of Health Sciences, University Magna Graecia of Catanzaro, Germaneto (CZ), Italy
| | - Giovanni Loprete
- Department of Health Sciences, University Magna Graecia of Catanzaro, Germaneto (CZ), Italy
| | - Vincenzo Musella
- Department of Health Sciences, University Magna Graecia of Catanzaro, Germaneto (CZ), Italy
| | - Noemi Romagnoli
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia (BO), Italy
| | - Jose M. Vilar
- Department of Animal Pathology, Faculty of Veterinary Medicine, University of Las Palmas de Gran Canaria, Trasmontaña S/N, Arucas, Las Palmas, Spain
| | - Simona Valentini
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia (BO), Italy
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Bedi HS, Jowett C, Ristanis S, Docking S, Cook J. Plantaris Excision and Ventral Paratendinous Scraping for Achilles Tendinopathy in an Athletic Population. Foot Ankle Int 2016; 37:386-93. [PMID: 26637273 DOI: 10.1177/1071100715619989] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Achilles tendinopathy is a frequent problem in high-level athletes. Recent research has proposed a combined etiologic role for the plantaris tendon and neovascularization. Both pathologies can be observed on ultrasound imaging.(1,13) However, little is known about the change in structure of the Achilles tendon following the surgical treatment of these issues. The purpose of the study was to assess if excising the plantaris and performing ventral paratendinous "scraping" of the neovascularization improved symptoms of Achilles tendinopathy and whether there was a change in the fibrillar structure of the tendon with ultrasound tissue characterization (UTC) following this operation. METHODS This prospective consecutive case series included 15 professional/semiprofessional athletes (17 Achilles tendons) who underwent plantaris excision and paratendinous scraping to treat noninsertional Achilles tendinopathy. The plantaris tendon was excised if adherent to the Achilles tendon, and the area of neovascularization for scraping was demarcated on preoperative imaging. Preoperative and postoperative Victorian Institute of Sports Assessment-Achilles (VISA-A) scores were taken. UTC was performed on 11 of 17 tendons preoperatively and postoperatively. The mean follow-up was for 25 months. RESULTS Fourteen of 15 patients had a successful outcome after the surgery. The mean VISA-A improved from 51 to 95 (p=.0001). There was a statistically significant (p=.04) improvement in the aligned fibrillar structure of the tendon confirmed with UTC scanning following surgery from 90% (±8) to 96% (±5). CONCLUSION This group of high-level athletes derived an excellent clinical result from this operation. Furthermore, UTC scanning offered an objective method to evaluate the healing of Achilles tendons. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - Charlie Jowett
- Foot and Ankle fellow, The Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Sean Docking
- Monash Tendon Research group (MONSTERs), Monash University, Victoria, Australia; Australian Centre of Research into Injury in Sport and its Prevention (ACRISP), Federation University, Victoria, Australia
| | - Jill Cook
- LaTrobe University, Victoria, Australia
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Kulig K, Chang YJ, Winiarski S, Bashford GR. Ultrasound-Based Tendon Micromorphology Predicts Mechanical Characteristics of Degenerated Tendons. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:664-673. [PMID: 26718836 DOI: 10.1016/j.ultrasmedbio.2015.11.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/10/2015] [Accepted: 11/15/2015] [Indexed: 06/05/2023]
Abstract
The purpose of this study was to explore the relationship between tendon micro-morphology quantified from a sonogram and tendon mechanical characteristics measured in vivo. Nineteen adults (nine with unilateral Achilles tendinosis) participated. A commercial ultrasound scanner was used to capture longitudinal B-mode ultrasound images from the mid-portion of bilateral Achilles tendons and a custom image analysis program was used to analyze the spatial frequency content of manually defined regions of interest; in particular, the average peak spatial frequency of the regions of interest was acquired. In addition, a dynamometer and a motion analysis system indirectly measured the tendon mechanical (stiffness) and material (elastic modulus) properties. The peak spatial frequency correlated with tendon stiffness (r = 0.74, p = 0.02) and elastic modulus (r = 0.65, p = 0.05) in degenerated tendons, but not healthy tendons. This is the first study relating the mechanical characteristics of degenerated human Achilles tendon using a non-invasive micro-morphology analysis approach.
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Affiliation(s)
- Kornelia Kulig
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, USA.
| | - Yu-Jen Chang
- Division of Physical Therapy, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Slawomir Winiarski
- Department of Biomechanics, University School of Physical Education in Wroclaw, Wroclaw, Poland
| | - Gregory R Bashford
- Department of Biological Systems Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
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Masci L, Spang C, van Schie HTM, Alfredson H. How to diagnose plantaris tendon involvement in midportion Achilles tendinopathy - clinical and imaging findings. BMC Musculoskelet Disord 2016; 17:97. [PMID: 26912241 PMCID: PMC4765029 DOI: 10.1186/s12891-016-0955-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 02/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this investigation was to evaluate if clinical assessment, Ultrasound + Colour Doppler (US + CD) and Ultrasound Tissue Characterisation (UTC) can be useful in detecting plantaris tendon involvement in patients with midportion Achilles tendinopathy. Methods Twenty-three tendons in 18 patients (14 men, mean age: 37 years and 4 women: 44 years) (5 patients with bilateral tendons) with midportion Achilles tendinopathy were surgically treated with a scraping procedure and plantaris tendon removal. For all tendons, clinical assessment, Ultrasound + Colour Doppler (US + CD) examination and Ultrasound Tissue Characterisation (UTC) were performed. Results At surgery, all 23 cases had a plantaris tendon located close to the medial side of the Achilles tendon. There was vascularised fat tissue in the interface between the Achilles and plantaris tendons. Clinical assessment revealed localised medial activity-related pain in 20/23 tendons and focal medial tendon tenderness in 20/23 tendons. For US + CD, 20/23 tendons had a tendon-like structure interpreted to be the plantaris tendon and localised high blood flow in close relation to the medial side of the Achilles. For UTC, 19/23 tendons had disorganised (type 3 and 4) echopixels located only in the medial part of the Achilles tendon indicating possible plantaris tendon involvement. Conclusions US + CD directly, and clinical assessment indirectly, can detect a close by located plantaris tendon in a high proportion of patients with midportion Achilles tendinopathy. UTC could complement US + CD and clinical assessment by demonstrating disorganised focal medial Achilles tendon structure indicative of possible plantaris involvement.
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Affiliation(s)
| | - Christoph Spang
- Department of Integrative Medical Biology (IMB), Anatomy Section, Umea University, 90187, Umea, Sweden.
| | - Hans T M van Schie
- Department of Scientific Research, UTC Imaging, Stein, The Netherlands. .,ISEH, University College London Hospitals, London, UK.
| | - Håkan Alfredson
- Pure Sports Medicine Clinic, London, UK. .,Department of Surgical and Perioperative Sciences, Sports Medicine Unit, Umea University, Umea, Sweden. .,ISEH, University College London Hospitals, London, UK.
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de Jonge S, Tol JL, Weir A, Waarsing JH, Verhaar JAN, de Vos RJ. The Tendon Structure Returns to Asymptomatic Values in Nonoperatively Treated Achilles Tendinopathy but Is Not Associated With Symptoms: A Prospective Study. Am J Sports Med 2015; 43:2950-8. [PMID: 26464495 DOI: 10.1177/0363546515605077] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tendinopathy is characterized by alterations in the tendon structure, but there are conflicting results on the potential of tendon structure normalization and no large studies on the quantified, ultrasonographic tendon structure and its association with symptoms. PURPOSE To determine whether the tendon structure returns to values of asymptomatic individuals after treatment with 2 substances injected within the tendon, to assess the association between the tendon structure and symptoms, and to assess the prognostic value of the baseline tendon structure on treatment response. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS This study was part of a randomized trial on chronic midportion Achilles tendinopathy using eccentric exercises with either a platelet-rich plasma or saline injection. Symptoms were recorded using the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. The tendon structure was quantified with ultrasound tissue characterization (UTC); echo types I + II (as a percentage of total tendon types I-IV) are structure related. Follow-up was at 6, 12, 24, and 52 weeks. A control group of asymptomatic subjects (similar age) was selected to compare the tendon structure. Patient symptoms were correlated with the tendon structure using a linear model. RESULTS Fifty-four patients were included in the symptomatic group. The mean (± SD) echo types I + II in the symptomatic group increased significantly from 74.6% ± 10.8% at baseline to 85.6% ± 6.0% at 24-week follow-up. The result for echo types I + II at 24 weeks was not significantly different (P = .198) from that of the asymptomatic control group (87.5% ± 6.0%). In 54 repeated measurements at 5 time points, the adjusted percentage of echo types I + II was not associated with the VISA-A score (main effect: β = .12; 95% CI, -0.12 to 0.35; P = .338). The adjusted baseline echo types I + II were not associated with a change in the VISA-A score from baseline to 52 weeks (β = -.15; 95% CI, -0.67 to 0.36; P = .555). CONCLUSION In symptomatic, tendinopathic Achilles tendons, the ultrasonographic tendon structure improved during nonoperative treatment and normalized after 24 weeks to values of matched asymptomatic controls. There was no association between the tendon structure and symptoms. The percentage of echo types I + II before treatment was not associated with change in symptoms over time. This study demonstrates that restoration of the tendon structure is not required for an improvement of symptoms.
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Affiliation(s)
- Suzan de Jonge
- Department of Orthopaedics, Erasmus Medical Centre, Rotterdam, the Netherlands Department of Sports Medicine, The Hague Medical Center Antoniushove, Leidschendam, the Netherlands
| | - Johannes L Tol
- The Sports Physician Group, Department of Sports Medicine, St Lucan Andreas Hospital, Amsterdam, the Netherlands Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar Academic Center for Evidence Based Sports Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Adam Weir
- Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Jan H Waarsing
- Department of Orthopaedics, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedics, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedics, Erasmus Medical Centre, Rotterdam, the Netherlands
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Does type 1 diabetes mellitus affect Achilles tendon response to a 10 km run? A case control study. BMC Musculoskelet Disord 2015; 16:345. [PMID: 26556589 PMCID: PMC4641391 DOI: 10.1186/s12891-015-0803-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 11/03/2015] [Indexed: 11/10/2022] Open
Abstract
Background Achilles tendon structure deteriorates 2-days after maximal loading in elite athletes. The load-response behaviour of tendons may be altered in type 1 diabetes mellitus (T1DM) as hyperglycaemia accelerates collagen cross-linking. This study compared Achilles tendon load-response in participants with T1DM and controls. Methods Achilles tendon structure was quantified at day-0, day-2 and day-4 after a 10 km run. Ultrasound tissue characterisation (UTC) measures tendon structural integrity by classifying pixels as echo-type I, II, III or IV. Echo-type I has the most aligned collagen fibrils and IV has the least. Results Participants were 7 individuals with T1DM and 10 controls. All regularly ran distances greater than 5 km and VISA-A scores indicated good tendon function (T1DM = 94 ± 11, control = 94 ± 10). There were no diabetic complications and HbA1c was 8.7 ± 2.6 mmol/mol for T1DM and 5.3 ± 0.4 mmol/mol for control groups. Baseline tendon structure was similar in T1DM and control groups – UTC echo-types (I-IV) and anterior-posterior thickness were all p > 0.05. No response to load was seen in either T1DM or control group over the 4-days post exercise. Conclusion Active individuals with T1DM do not have a heightened Achilles tendon response to load, which suggests no increased risk of tendon injury. We cannot extrapolate these findings to sedentary individuals with T1DM.
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Abstract
Synopsis Tendinopathy is frequently associated with structural disorganization within the tendon. As such, the clinical use of ultrasound and magnetic resonance imaging for tendinopathy has been the focus of numerous academic studies and clinical discussions. However, similar to other musculoskeletal conditions (osteoarthritis and intervertebral disc degeneration), there is no direct link between tendon structural disorganization and clinical symptoms, with findings on imaging potentially creating a confusing clinical picture. While imaging shows the presence and extent of structural changes within the tendon, the clinical interpretation of the images requires context in regard to the features of pain and the aggravating loads. This review will critically evaluate studies that have investigated the accuracy and sensitivity of imaging in the detection of clinical tendinopathy and the methodological issues associated with these studies (subject selection, lack of a robust gold standard, reliance on subjective measures). The advent of new imaging modalities allowing for the quantification of tendon structure or mechanical properties has allowed new critical insight into tendon pathology. A strength of these novel modalities is the ability to quantify properties of the tendon. Research utilizing ultrasound tissue characterization and sonoelastography will be discussed. This narrative review will also attempt to synthesize current research on whether imaging can predict the onset of pain or clinical outcome, the role of monitoring tendon structure during rehabilitation (ie, does tendon structure need to improve to get a positive clinical outcome?), and future directions for research, and to propose the clinical role of imaging in tendinopathy. J Orthop Sports Phys Ther 2015;45(11):842-852. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5880.
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Spinella G, Loprete G, Castagnetti C, Musella V, Antonelli C, Vilar JM, Britti D, Capitani O, Valentini S. Evaluation of mean echogenicity of tendons and ligaments of the metacarpal region in neonatal foals: A preliminary study. Res Vet Sci 2015; 101:11-4. [PMID: 26267082 DOI: 10.1016/j.rvsc.2015.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 04/20/2015] [Accepted: 05/19/2015] [Indexed: 11/18/2022]
Abstract
The aims of this research were to evaluate mean echogenicity (ME) of the deep and superficial digital flexor tendons (DDFT and SDFT), the interosseous muscle (IM), and the accessory ligament of the deep digital flexor tendon (ALDDFT) of the metacarpal region in neonatal foals, and determine the effect of sex, side and body weight on this quantitative ultrasonographic evaluation. Thirteen orthopedically sound neonatal foals were examined. Four areas of study (1A, 1B, 2A, 2B) were identified. Transverse scans of the DDFT, SDFT, IM and ALDDFT were obtained, recorded, and analyzed. The most echogenic structures were the ALDDFT and DDFT, while the SDFT was significantly less echogenic than all other structures (P<0.05). No influence of sex, forelimb, or body weight was observed. The echogenicity of the tenodesmic structures of foals partially overlapped that reported in the metacarpal region in adult horses, except for IM.
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Affiliation(s)
- G Spinella
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, BO, Italy.
| | - G Loprete
- Department of Health Sciences, University Magna Graecia of Catanzaro, 88100 Germaneto, CZ, Italy
| | - C Castagnetti
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, BO, Italy
| | - V Musella
- Department of Health Sciences, University Magna Graecia of Catanzaro, 88100 Germaneto, CZ, Italy
| | - C Antonelli
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, BO, Italy
| | - J M Vilar
- Department of Animal Pathology, Faculty of Veterinary Medicine, University of Las Palmas de Gran Canaria, Trasmontaña S/N, Arucas 35413, Las Palmas, Spain
| | - D Britti
- Department of Health Sciences, University Magna Graecia of Catanzaro, 88100 Germaneto, CZ, Italy
| | - O Capitani
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, BO, Italy
| | - S Valentini
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, BO, Italy
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Geburek F, Lietzau M, Beineke A, Rohn K, Stadler PM. Effect of a single injection of autologous conditioned serum (ACS) on tendon healing in equine naturally occurring tendinopathies. Stem Cell Res Ther 2015; 6:126. [PMID: 26113022 PMCID: PMC4513386 DOI: 10.1186/s13287-015-0115-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 02/27/2015] [Accepted: 06/11/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction Autologous blood-derived biologicals, including autologous conditioned serum (ACS), are frequently used to treat tendinopathies in horses despite limited evidence for their efficacy. The purpose of this study was to describe the effect of a single intralesional injection of ACS in naturally occurring tendinopathies of the equine superficial digital flexor tendon (SDFT) on clinical, ultrasonographic, and histological parameters. Methods Fifteen horses with 17 naturally occurring tendinopathies of forelimb SDFTs were examined clinically and ultrasonographically (day 0). Injured tendons were randomly assigned to the ACS-treated group (n = 10) receiving a single intralesional ACS injection or included as controls (n = 7) which were either untreated or injected with saline on day 1. All horses participated in a gradually increasing exercise programme and were re-examined nine times at regular intervals until day 190. Needle biopsies were taken from the SDFTs on days 0, 36 and 190 and examined histologically and for the expression of collagen types I and III by immunohistochemistry. Results In ACS-treated limbs lameness decreased significantly until day 10 after treatment. Swelling (scores) of the SDFT region decreased within the ACS group between 50 and 78 days after treatment. Ultrasonographically, the percentage of the lesion in the tendon was significantly lower and the echogenicity of the lesion (total echo score) was significantly higher 78 and 106 days after intralesional ACS injection compared to controls. Histology revealed that, compared to controls, tenocyte nuclei were more spindle-shaped 36 days after ACS injection. Immunohistochemistry showed that collagen type I expression significantly increased between days 36 and 190 after ACS injection. Conclusions Single intralesional ACS injection of equine SDFTs with clinical signs of acute tendinopathy contributes to an early significant reduction of lameness and leads to temporary improvement of ultrasonographic parameters of repair tissue. Intralesional ACS treatment might decrease proliferation of tenocytes 5 weeks after treatment and increase their differentiation as demonstrated by elevated collagen type I expression in the remodelling phase. Potential enhancement of these effects by repeated injections should be tested in future controlled clinical investigations.
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Affiliation(s)
- Florian Geburek
- Equine Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.
| | - Maren Lietzau
- Equine Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.
| | - Andreas Beineke
- Institute for Pathology, University of Veterinary Medicine Hannover, Foundation, Bünteweg 17, 30559, Hannover, Germany.
| | - Karl Rohn
- Institute for Biometry, Epidemiology and Information Processing, University of Veterinary Medicine Hannover, Foundation, Bünteweg 2, 30559, Hannover, Germany.
| | - Peter M Stadler
- Equine Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany.
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Docking SI, Cook J. Pathological tendons maintain sufficient aligned fibrillar structure on ultrasound tissue characterization (UTC). Scand J Med Sci Sports 2015; 26:675-83. [DOI: 10.1111/sms.12491] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 12/31/2022]
Affiliation(s)
- S. I. Docking
- Monash Tendon Research Group (MONSTERs); Monash University; Frankston Victoria Australia
- Australian Centre of Research into Injury in Sport and its Prevention (ACRISP); Federation University; Ballarat Victoria Australia
| | - J. Cook
- Monash Tendon Research Group (MONSTERs); Monash University; Frankston Victoria Australia
- Australian Centre of Research into Injury in Sport and its Prevention (ACRISP); Federation University; Ballarat Victoria Australia
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Docking SI, Rosengarten SD, Cook J. Achilles tendon structure improves on UTC imaging over a 5-month pre-season in elite Australian football players. Scand J Med Sci Sports 2015; 26:557-63. [PMID: 25943892 DOI: 10.1111/sms.12469] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2015] [Indexed: 01/28/2023]
Abstract
Pre-season injuries are common and may be due to a reintroduction of training loads. Tendons are sensitive to changes in load, making them vulnerable to injury in the pre-season. This study investigated changes in Achilles tendon structure on ultrasound tissue characterization (UTC) over the course of a 5-month pre-season in elite male Australian football players. Eighteen elite male Australian football players with no history of Achilles tendinopathy and normal Achilles tendons were recruited. The left Achilles tendon was scanned with UTC to quantify the stability of the echopattern. Participants were scanned at the start and completion of a 5-month pre-season. Fifteen players remained asymptomatic over the course of the pre-season. All four echo-types were significantly different at the end of the pre-season, with the overall echopattern suggesting an improvement in Achilles tendon structure. Three of the 18 participants developed Achilles tendon pain that coincided with a change in the UTC echopattern. This study demonstrates that the UTC echopattern of the Achilles tendon improves over a 5-month pre-season training period, representing increased fibrillar alignment. However, further investigation is needed to elucidate with this alteration in the UTC echopattern results in improved tendon resilience and load capacity.
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Affiliation(s)
- S I Docking
- Monash Tendon Research Group (MONSTERs), Monash University, Melbourne, Victoria, Australia.,Australian Centre of Research into Injury in Sport and its Prevention (ACRISP), Federation University, Ballarat, Victoria, Australia
| | - S D Rosengarten
- Department of Physiotherapy, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - J Cook
- Monash Tendon Research Group (MONSTERs), Monash University, Melbourne, Victoria, Australia.,Australian Centre of Research into Injury in Sport and its Prevention (ACRISP), Federation University, Ballarat, Victoria, Australia
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Masci L, Spang C, van Schie HTM, Alfredson H. Achilles tendinopathy-do plantaris tendon removal and Achilles tendon scraping improve tendon structure? A prospective study using ultrasound tissue characterisation. BMJ Open Sport Exerc Med 2015; 1:e000005. [PMID: 27900118 PMCID: PMC5117009 DOI: 10.1136/bmjsem-2015-000005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/13/2015] [Accepted: 03/14/2015] [Indexed: 11/16/2022] Open
Abstract
Objectives The plantaris tendon has recently been described as a possible important factor in midportion Achilles tendinopathy. Ultrasound tissue characterisation (UTC) is a method to study tendon structure (matrix integrity). The effect of plantaris tendon removal on Achilles tendon structure was studied using UTC. Design and setting Prospective case series study at one centre. Participants Nine tendons in eight physically active and healthy patients (mean age 39 years) with chronic painful midportion Achilles tendinopathy were included. Preoperative two-dimensional ultrasound and UTC showed midportion Achilles tendinopathy (tendinosis) with medial tendon changes and suspected plantaris tendon involvement. Patients with previous operations to the Achilles tendon were excluded. Interventions Operative treatment consisted of excision of the plantaris tendon and scraping of the ventromedial surface of the Achilles tendon under a local anaesthetic. Primary and secondary outcome measures UTC examination and clinical scoring with the VISA-A questionnaire were performed preoperatively and 6 months postoperatively. Results At 6 months follow-up, UTC demonstrated a statistically significant (t=5.40, p<0.001) increase in the mean organised matrix (echo-type I+II) and a decrease in the mean disorganised matrix (echo-type III+IV). Seven out of eight patients were satisfied, and the VISA-A score had increased significantly (p<0.001) from 56.8 (range 34–73) preoperatively to 93.3 (range 87–100) postoperatively. Conclusions Excision of the plantaris tendon and scraping of the ventromedial Achilles tendon in chronic midportion tendinopathy seem to have the potential to improve tendon structure and reduce tendon pain. Studies on a larger group of patients and with a longer follow-up period are needed.
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Affiliation(s)
| | - Christoph Spang
- Department of Integrative Medical Biology (IMB) , Anatomy Section, Umea University , Umeå , Sweden
| | - Hans T M van Schie
- Department of Scientific Research , UTC Imaging , Stein , The Netherlands
| | - Håkan Alfredson
- Pure Sports Medicine Clinic, London, UK; Department of Community Medicine and Rehabilitation, Umeå University, Sweden; ISEH, University College London Hospitals, London, UK
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van Ark M, Docking SI, van den Akker-Scheek I, Rudavsky A, Rio E, Zwerver J, Cook JL. Does the adolescent patellar tendon respond to 5 days of cumulative load during a volleyball tournament? Scand J Med Sci Sports 2015; 26:189-96. [PMID: 25694241 DOI: 10.1111/sms.12426] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2015] [Indexed: 12/15/2022]
Abstract
Patellar tendinopathy (jumper's knee) has a high prevalence in jumping athletes. Excessive load on the patellar tendon through high volumes of training and competition is an important risk factor. Structural changes in the tendon are related to a higher risk of developing patellar tendinopathy. The critical tendon load that affects tendon structure is unknown. The aim of this study was to investigate patellar tendon structure on each day of a 5-day volleyball tournament in an adolescent population (16-18 years). The right patellar tendon of 41 players in the Australian Volleyball Schools Cup was scanned with ultrasound tissue characterization (UTC) on every day of the tournament (Monday to Friday). UTC can quantify structure of a tendon into four echo types based on the stability of the echo pattern. Generalized estimating equations (GEE) were used to test for change of echo type I and II over the tournament days. Participants played between eight and nine matches during the tournament. GEE analysis showed no significant change of echo type percentages of echo type I (Wald chi-square = 4.603, d.f. = 4, P = 0.331) and echo type II (Wald chi-square = 6.070, d.f. = 4, P = 0.194) over time. This study shows that patellar tendon structure of 16-18-year-old volleyball players is not affected during 5 days of cumulative loading during a volleyball tournament.
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Affiliation(s)
- M van Ark
- Center for Sports Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
| | - S I Docking
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
| | - I van den Akker-Scheek
- Center for Sports Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Rudavsky
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
| | - E Rio
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
| | - J Zwerver
- Center for Sports Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J L Cook
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
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48
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de Jonge S, Rozenberg R, Vieyra B, Stam HJ, Aanstoot HJ, Weinans H, van Schie HTM, Praet SFE. Achilles tendons in people with type 2 diabetes show mildly compromised structure: an ultrasound tissue characterisation study. Br J Sports Med 2015; 49:995-9. [PMID: 25586910 DOI: 10.1136/bjsports-2014-093696] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Musculotendinous overuse injuries are prevalent in people with type 2 diabetes. Non-enzymatic glycosylation of collagen resulting in tendon stiffening may play a role. In this case-control study we determined whether patients with diabetes had poorer ultrasonographic structure in their Achilles tendons compared to age-matched controls. METHODS People with type 1 diabetes or type 2 diabetes, and age-matched controls, had computerised ultrasound tissue characterisation of both Achilles tendons. In contiguous ultrasonographic images of the tendon, echopatterns were quantified and categorised into four echo-types. Tendon abnormality was quantified as sum of echo-types III+IV. Furthermore, skin autofluorescence (AF) of the forearm (AF-value) was gathered. RESULTS Twenty four type 2 diabetes patients, 24 controls, 24 type 1 diabetes patients and 20 controls were included. AF-value was higher in type 1 diabetes (1.55±0.17) than in their controls (1.39±0.18, p<0.001) and in type 2 diabetes (2.28±0.38) compared to their controls (1.84±0.32, p<0.001) Achilles tendons of type 2 diabetes patients contained more echo-types III+IV (14.1±7.9%) than matched controls (8.0±5.4%, p<0.001). There was a trend towards a difference in echo-types III+IV between type 1 diabetes patients (9.5±5.3%) and their controls (6.5±3.7%, p=0.055). In a stepwise linear regression analysis, body mass index (BMI) was moderately associated with tendon abnormality in patients with diabetes and controls (β=0.393, p<0.001). CONCLUSIONS Type 2, and possibly type 1, diabetes patients showed poorer ultrasonographic Achilles tendon structure that may be a risk factor for tendinopathy. Although markers for accumulation of advanced glycation end products were elevated in both diabetes populations, only BMI was associated with these abnormalities. TRIAL REGISTRATION NUMBER NTR2209.
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Affiliation(s)
- Suzan de Jonge
- Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert Rozenberg
- MOVEFIT-Sports Medicine, Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bruno Vieyra
- MOVEFIT-Sports Medicine, Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk J Stam
- MOVEFIT-Sports Medicine, Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk-Jan Aanstoot
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and -Research, Rotterdam, The Netherlands
| | - Harrie Weinans
- Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hans T M van Schie
- Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands Department Scientific Research, UTC Imaging, Stein, The Netherlands
| | - Stephan F E Praet
- MOVEFIT-Sports Medicine, Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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49
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Quantification of sonographic echogenicity by the gray-level histogram in patients with supraspinatus tendinopathy. J Med Ultrason (2001) 2014; 41:343-9. [PMID: 27277909 DOI: 10.1007/s10396-013-0516-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study was to compare the gray-level value of the supraspinatus tendon of a painful shoulder with that of a normal shoulder measured by ultrasonography, and to investigate whether a low mean gray-level value of the supraspinatus tendon could indicate a partial-thickness or incomplete full-thickness tear. METHODS Two hundred and ten patients had significant unilateral shoulder pain with the clinical suspicion of rotator cuff tendinopathy. They underwent bilateral shoulder ultrasonography, and the mean echogenicity of the histogram was calculated on the screen. The mean gray-level value of each patient's contralateral asymptomatic shoulder was compared with that of the painful shoulder. RESULTS Based on the scan of transverse and longitudinal planes, a significant difference existed between the symptomatic shoulder and contralateral asymptomatic shoulder (p < 0.0001). The mean gray-level values of symptomatic shoulders showed no statistically significant difference between the patients who underwent surgery and the patients who underwent conservative treatment. CONCLUSIONS We demonstrated that the ultrasound gray-level histogram is a promising tool for detecting the hypoechogenic appearance of supraspinatus tendinopathy. A decrease in the mean gray-level value on the symptomatic shoulder may be used as an alternative sonographic indicator of rotator cuff partial-thickness tear or tendinopathy. LEVEL OF EVIDENCE Diagnostic level III.
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50
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McCreesh K, Lewis J. Continuum model of tendon pathology - where are we now? Int J Exp Pathol 2013; 94:242-7. [PMID: 23837792 DOI: 10.1111/iep.12029] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 04/16/2013] [Indexed: 12/01/2022] Open
Abstract
Chronic tendon pathology is a common and often disabling condition, the causes of which remain poorly understood. The continuum model of tendon pathology was proposed to provide a model for the staging of tendon pathology and to assist clinicians in managing this often complex condition (Br. J. Sports Med., 43, 2009, 409). The model presents clinical, histological and imaging evidence for the progression of tendon pathology as a three-stage continuum: reactive tendinopathy, tendon disrepair and degenerative tendinopathy. It also provides clinical information to assist in identifying the stage of pathology, in addition to proposed treatment approaches for each stage. The usefulness of such a model is determined by its ability to incorporate and inform new and emerging research. This review examines the degree to which recent research supports or refutes the continuum model and proposes future directions for clinical and research application of the model.
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Affiliation(s)
- Karen McCreesh
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
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