Glucocorticoid injections in lesions of the achilles tendon

Inhibition of IKKβ via a DNA-Based In Situ Delivery System Improves Achilles Tendinopathy Healing in a Rat Model

BACKGROUND

The inhibition of IKKβ by the inhibitor 2-amino-6-[2-(cyclopropylmethoxy)-6-hydroxyphenyl]-4-(4-piperidinyl)-3-pyridine carbonitrile (ACHP) is a promising strategy for the treatment of Achilles tendinopathy. However, the poor water solubility of ACHP severely hinders its in vivo application. Moreover, the effective local delivery of ACHP to the tendon and its therapeutic effects have not been reported.

PURPOSE

To investigate the therapeutic effects of IKKβ inhibition via injection of ACHP incorporated into a DNA supramolecular hydrogel in a collagenase-induced tendinopathy rat model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Dendritic DNA, a Y-shaped monomer, and a crosslinking monomer were mixed with ACHP and self-assembled into an ACHP-DNA supramolecular hydrogel (ACHP-Gel). The effects of ACHP-Gel in tendon stem/progenitor cells were investigated via RNA sequencing and validated using quantitative reverse transcription polymerase chain reaction (qRT-PCR). A total of 120 collagenase-induced rats were randomly assigned to 5 groups: blank, phosphate-buffered saline (PBS), DNA-Gel, ACHP, and ACHP-Gel. Healing outcomes were evaluated using biomechanic and histologic evaluations at 4 and 8 weeks.

RESULTS

ACHP-Gel enhanced the solubility of ACHP and sustained its release for ≥21 days in vivo, which significantly increased the retention time of ACHP and markedly reduced the frequency of administration. RNA sequencing and qRT-PCR showed that ACHP effectively downregulated genes related to inflammation and extracellular matrix remodeling and upregulated genes related to tenogenic differentiation. The cross-sectional area (P = .024), load to failure (P = .002), stiffness (P = .039), and elastic modulus (P = .048) significantly differed between the ACHP-Gel and PBS groups at 8 weeks. The ACHP-Gel group had better histologic scores than the ACHP group at 4 (P = .042) and 8 weeks (P = .009). Type I collagen expression (COL-I; P = .034) and the COL-I/collagen type III ratio (P = .015) increased while interleukin 6 expression decreased (P < .001) in the ACHP-Gel group compared with the ACHP group at 8 weeks.

CONCLUSION

DNA supramolecular hydrogel significantly enhanced the aqueous solubility of ACHP and increased its release-retention time. Injection frequency was markedly reduced. ACHP-Gel suppressed inflammation in Achilles tendinopathy and promoted tendon healing in a rat model.

CLINICAL RELEVANCE

ACHP-Gel injection is a promising strategy for the treatment of Achilles tendinopathy in clinical practice.

Clinical efficacy of botulinum toxin in lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Botulinum toxin injections for lateral elbow tendinopathy have been used as an alternative therapeutic option. However, few studies have quantitatively summarized the effect of botulinum toxin as well as its clinical significance. We aimed to evaluate the clinical efficacy (based on pain and grip strength) and adverse events of botulinum toxin on lateral elbow tendinopathy.

PATIENTS AND METHODS

The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched until March 2023 for randomized controlled trials reporting the effects of botulinum toxin injections on lateral elbow tendinopathy. A random- or fixed-effects model (depending of inter-study variability) and generic inverse variance method were used to pool quantitative data from outcomes. The risk of bias was assessed with the Cochrane Risk of Bias 2.0 tool.

RESULTS

A total of 8 clinical trials recruiting 438 subjects were included for meta-analysis. Pooled analysis revealed that botulinum toxin significantly reduced pain (mean difference [MD] -0.95, 95% CI [-1.63, -0.26], p=0.007) but it was not clinically relevant. No significant effect was detected for grip strength (MD-0.62kg, 95% CI [-2.25, 1.02], p=0.46) or in the risk for adverse events (odds ratio [OR] 0.41, 95% CI [0.05, 3.56], p=0.42) between botulinum toxin injection and control interventions.

DISCUSSION

The use of botulinum toxin reached greater pain relief than control interventions and normal saline after a period of 12 to 24 weeks. However, changes in pain relief did not reach clinical significance. The studies that had the greatest reduction in pain used higher doses of botulinum toxin (60 U). Additionally, differences in grip strength and adverse events did not reach statistical or clinical importance. A subanalysis indicated that botulinum toxin outperformed corticosteroid injections in terms of improving grip strength. Botulinum toxin only causes local and minimal side effects such as irritation, ecchymosis, and paralysis.

LEVEL OF EVIDENCE

I.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle

Objectives

Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.

Methods

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.

Results

A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.

Conclusion

According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.

Key Points

• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.

• Strong consensus was obtained for all statements.

• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08125-z.

Foot and Ankle Injections in Athletes

CONTEXT

Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety.

EVIDENCE ACQUISITION

An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections, athletes, sports, foot and ankle, corticosteroids, platelet-rich plasma, and placental tissue. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results.

CONCLUSIONS

Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.

Effect of Metformin on Development of Tendinopathy Due to Mechanical Overloading in an Animal Model

BACKGROUND

Tendinopathy is a debilitating tendon disorder that affects millions of Americans and costs billions of health care dollars every year. High mobility group box 1 (HMGB1), a known tissue damage signaling molecule, has been identified as a mediator in the development of tendinopathy due to mechanical overloading of tendons in mice. Metformin (Met), a drug approved by the Food and Drug Administration used for the treatment of type 2 diabetes, specifically inhibits HMGB1. This study tested the hypothesis that Met would prevent mechanical overloading-induced tendinopathy in a mouse model of tendinopathy created by intensive treadmill running (ITR).

METHODS

C57BL/6J mice (female, 3 months old) were equally separated into 4 groups and treated for 24 weeks as follows: group 1 had cage control activities, group 2 received a single intraperitoneal injection of Met (50 mg/kg body weight) daily, group 3 underwent ITR to induce tendinopathy, and group 4 received daily Met injection along with ITR to inhibit HMGB1. Tendinopathic changes were assessed in Achilles tendons of all mice using histology, immunohistochemistry, and enzyme-linked immunosorbent assays.

RESULTS

ITR induced HMGB1 release into the tendon matrix and developed characteristics of tendinopathy as evidenced by the expression of macrophage marker CD68, proinflammatory molecules (COX-2, PGE₂), cell morphological changes from normal elongated cells to round cells, high levels of expression of chondrogenic markers (SOX-9, collagen type II), and accumulation of proteoglycans in tendinopathic tendons. Daily injection of Met inhibited HMGB1 release and decreased these degenerative changes in ITR tendons.

CONCLUSIONS

Inhibition of HMGB1 by injections of Met prevented tendinopathy development due to mechanical overloading in the Achilles tendon in mice.

CLINICAL RELEVANCE

Met may be able to be repurposed as a therapeutic option for preventing the development of tendinopathy in high-risk patients.

Molecular and Structural Effects of Percutaneous Interventions in Chronic Achilles Tendinopathy

Achilles tendinopathy (AT) is a common problem, especially in people of working age, as well as in the elderly. Although the pathogenesis of tendinopathy is better known, therapeutic management of AT remains challenging. Various percutaneous treatments have been applied to tendon lesions: e.g., injectable treatments, platelet-rich plasma (PRP), corticosteroids, stem cells, MMP inhibitors, and anti-angiogenic agents), as well as percutaneous procedures without any injection (percutaneous soft tissue release and dry needling). In this review, we will describe and comment on data about the molecular and structural effects of these treatments obtained in vitro and in vivo and report their efficacy in clinical trials. Local treatments have some impact on neovascularization, inflammation or tissue remodeling in animal models, but evidence from clinical trials remains too weak to establish an accurate management plan, and further studies will be necessary to evaluate their value.

Comparative Efficacy and Tolerability of Nonsurgical Therapies for the Treatment of Midportion Achilles Tendinopathy: A Systematic Review With Network Meta-analysis

Background:

Achilles tendinopathy (AT) is a common cause of overuse injury in both athletes and nonactive individuals, especially at older ages. Due to the limited number of direct comparisons among interventions, determining the best treatment option can be difficult.

Purpose:

To evaluate the comparative efficacy and tolerability of nonsurgical therapies for midportion AT.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

PubMed, MEDLINE, EMBASE, and Google Scholar were searched from database inception through June 20, 2019. Randomized controlled trials investigating the effect of nonsurgical therapies for midportion AT using the Victorian Institute of Sports Assessment–Achilles (VISA-A) assessment were eligible for inclusion. Primary outcome was mean change in VISA-A score from baseline. Comparisons between interventions were made through use of random-effects network meta-analysis over the short term (≤3 months) and longer term (>3 to <12 months). A safety profile was defined for each intervention by rate of all-cause discontinuation (dropout) during follow-up. Relative ranking of therapies was assessed by the surface-under-the–cumulative ranking possibilities.

Results:

A total of 22 studies with 978 patients met the inclusion criteria. In short-term studies, high-volume injection with corticosteroid (HVI+C) along with eccentric exercise (ECC) significantly improved the change of VISA-A score compared with that of ECC alone (standardized mean difference [SMD], 1.08; 95% CI, 0.58-1.58). Compared with ECC, acupuncture showed benefits over both the short term (SMD, 1.57; 95% CI, 1.00-2.13) and longer term (SMD, 1.23; 95% CI, 0.69-1.76). In longer-term studies, the wait-and-see approach resulted in unfavorable outcomes compared with ECC (SMD, −1.51; 95% CI, −2.02 to −1.01). Improvement was higher when ECC was combined with HVI+C (SMD, 0.53; 95% CI, 0.05-1.02) and extracorporeal shockwave therapy (ESWT) (SMD, 0.99; 95% CI, 0.48-1.49). All interventions had a similar safety profile.

Conclusion:

From available high-level studies, HVI+C and ESWT may be possible interventions to add along with ECC to improve longer-term outcomes.

Downregulation of type I collagen expression in the Achilles tendon by dexamethasone: a controlled laboratory study

Background

Spontaneous Achilles tendon rupture associated with long-term dexamethasone (Dex) use has been reported. However, few studies have investigated the potential mechanism. The aim of this study was to evaluate the effects of oral Dex on type I collagen in humans and rats and its association with tendon rupture.

Methods

First, six Achilles tendons from patients who received long-term Dex treatment, and another six normal tendons were harvested for histological evaluation. Secondly, 8-week-old rats (n = 72) were randomly assigned to a Dex group or a control group. Type I collagen was studied at the mechanical, histological, and molecular levels after 3 and 5 weeks. Tenocytes isolated from normal human and rat tendon were used to investigate the effect of Dex on cellular scale.

Results

Histological analysis of human and rat tendon tissue revealed an irregular, disordered arrangement of type I collagen in the Dex group compared with the control group. In addition, In the Dex+ group, type I collagen expression decreased in comparison with the Dex− group in both human and rat tenocytes. The mechanical strength of tendons was significantly reduced in the Dex group (68.87 ± 11.07 N) in comparison with the control group (81.46 ± 7.62 N, P = 0.013) after 5 weeks. Tendons in the Dex group were shorter with smaller cross-sectional areas (10.71 ± 0.34 mm², 1.44 ± 0.22 mm², respectively) after 5 weeks than those in the control group (11.13 ± 0.50 mm², P = 0.050, 2.74 ± 0.34 mm², P < 0.001, respectively).

Conclusions

This finding suggests long-term use of Dex that decreases the expression of type I collagen at molecular and tissue levels both in human and rat Achilles tendons. Furthermore, Dex decreases the mechanical strength of the tendon, thereby increasing the risk of Achilles tendon rupture.

The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis - 2019

Spondyloarthritis is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular manifestations. The classification axial spondyloarthritis is adopted when the spine and/or the sacroiliac joints are predominantly involved. This version of recommendations replaces the previous guidelines published in May 2013.A systematic literature review was performed, and two hundred thirty-seven studies were selected and used to formulate 29 recommendations answering 15 clinical questions, which were divided into four sections: diagnosis, non-pharmacological therapy, conventional drug therapy and biological therapy. For each recommendation the level of evidence supporting (highest available), the strength grade according to Oxford, and the degree of expert agreement (inter-rater reliability) is informed.These guidelines bring evidence-based information on clinical management of axial SpA patients, including, diagnosis, treatment, and prognosis.

[Differential diagnosis of heel pain]

"Heel pain" describes a very common reason for foot orthopedic consultation and the further differential diagnostic investigation is crucial for the choice of correct treatment. In the treatment of frequent underlying diseases, such as plantar fasciitis or insertional tendinopathy of the Achilles tendon, a variety of modern strategies are available. Rarer diseases, such as tumors or nerve entrapment syndromes must be delineated and correctly classified. This article provides the current state of the diagnostics and treatment of the most common entities of heel pathologies.

High volume injection with and without corticosteroid in chronic midportion achilles tendinopathy

BACKGROUND

High volume injection (HVI) shows promising results in the treatment of chronic midportion Achilles tendinopathy (AT). HVI consists of a large volume of saline with a small amount of corticosteroid and local anesthetic.

OBJECTIVE

To determine the effect of corticosteroid in HVI in AT.

METHODS

A total of 28 men (18-59 years) with chronic (>3 months) AT were included in a double-blinded RCT and followed for 24 weeks. All performed eccentric training and randomized to either (a) HVI injection with corticosteroid or (b) HVI injection without corticosteroid. Outcomes included self-reported function (VISA-A score) and pain (VAS score) and ultrasound imaging (tendon thickness, Doppler flow).

RESULTS

VISA-A and VAS score improved in both groups at all time-points (P < 0.05). VISA-A improvement was significantly greater in HVI with corticosteroid (mean ± SEM; 6-weeks = 31 ± 3 points; 12-weeks = 32 ± 5 points) vs HVI without corticosteroid (6 weeks = 14 ± 3; 12-weeks = 17 ± 3) at 6 and 12 weeks (P < 0.05), but not at 24 weeks. Decrease in VAS scores was significantly greater in HVI with corticosteroid (6 weeks = 55 ± 3 mm; 12 weeks = 53 ± 5 mm) vs HVI without corticosteroid (6 weeks = 16 ± 3 mm; 12 weeks = 25 ± 5 mm) at 6 and 12 weeks (P < 0.05) but not at 24 weeks. Tendon thickness decreased significantly in both groups at all time-points (P < 0.05), but more in the HVI with corticosteroid vs HVI without corticosteroid at 6 and 12 weeks (P < 0.05) but not at 24 weeks.

CONCLUSION

High volume injection with or without corticosteroid in combination with eccentric training seems effective in AT. HVI with corticosteroid showed a better short-term improvement than HVI without corticosteroid indicating a short-term effect of corticosteroid in HVI treatment of AT.

Effect of High-Volume Injection, Platelet-Rich Plasma, and Sham Treatment in Chronic Midportion Achilles Tendinopathy: A Randomized Double-Blinded Prospective Study

BACKGROUND

Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse.

PURPOSE

To determine whether eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment-Achilles [VISA-A]). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up.

RESULTS

VISA-A scores improved in all groups at all time points ( P < .05), with greater improvement in the HVI group (mean ± SEM, 6 weeks = 27 ± 3 points; 12 weeks = 29 ± 4 points) versus PRP (6 weeks = 14 ± 4; 12 weeks = 15 ± 3) and placebo (6 weeks = 10 ± 3; 12 weeks = 11 ± 3) at 6 and 12 weeks ( P < .01) and in the HVI (22 ± 5) and PRP (20 ± 5) groups versus placebo (9 ± 3) at 24 weeks ( P < .01). VAS scores improved in all groups at all time points ( P < .05), with greater decrease in HVI (6 weeks = 49 ± 4 mm; 12 weeks = 45 ± 6 mm; 24 weeks = 34 ± 6 mm) and PRP (6 weeks = 37 ± 7 mm; 12 weeks = 41 ± 7 mm; 24 weeks = 37 ± 6 mm) versus placebo (6 weeks = 23 ± 6 mm; 12 weeks = 30 ± 5 mm; 24 weeks = 18 ± 6 mm) at all time points ( P < .05) and in HVI versus PRP at 6 weeks ( P < .05). Tendon thickness showed a significant decrease only in HVI and PRP groups during the intervention, and this was greater in the HVI versus PRP and placebo groups at 6 and 12 weeks ( P < .05) and in the HVI and PRP groups versus the placebo group at 24 weeks ( P < .05). Muscle function improved in the entire cohort with no difference between the groups.

CONCLUSION

Treatment with HVI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. Registration: NCT02417987 ( ClinicalTrials.gov identifier).

The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study

Objectives

Inflammation of the retrocalcaneal bursa (RB) is a common clinical problem, particularly in professional athletes. RB inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon (AT) rupture. The aim of this cadaveric study was to describe the anatomical connections of the RB and to investigate whether it is possible for fluid to move from the RB into AT tissue.

Methods

A total of 20 fresh-frozen AT specimens were used. In ten specimens, ink was injected into the RB. The remaining ten specimens were split into two groups to be injected with radiological contrast medium into the RB either with or without ultrasonography guidance (USG).

Results

In specimens injected with ink, diffusion outside the RB was observed with staining of the anterior portion of the AT. In eight contrast-injected specimens (five USG, three non-USG), a similar localised diffusion pattern was observed, with the contrast identified superiorly and anteriorly. In two contrast-injected specimens (non-USG), the diffusion pattern was more extensive.

Conclusion

This study confirmed the existence of connections between the RB and the AT, especially rich in the anteroinferior portion of the tendon, which should be considered a weak zone for substances injected into the RB. We hypothesise that this part of the AT might be most vulnerable to rupture after corticosteroid injections.

Cite this article: P. A. Pękala, B. M. Henry, J. R. Pękala, K. Piska, K. A. Tomaszewski. The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study. Bone Joint Res 2017;6:446–451. DOI:10.1302/2046-3758.67.BJR-2016-0340.R1.

Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review

Achilles tendinopathy is a common overuse condition affecting the adult population. The incidence is on the rise because of greater participation of people in recreational or competitive sporting activities. There are several treatment options available both non-operative and operative. Ultrasound-guided dry needling and high-volume image-guided injection is relatively a new procedure. The aim of this study was to find out the effectiveness of dry needling and HVIGI in the management of mid-portion chronic Achilles tendinopathy by performing a literature review. Search strategy was devised to find the suitable articles for critical appraisal using the electronic databases. Four articles were selected for critical appraisal, and these papers showed good short- to long-term results of image-guided high-volume injection in the management of Achilles tendinopathy. We conclude that high-volume image-guided injection is effective in the management of Achilles tendinopathy. It provides good short- and medium-term relief of symptoms. It should be considered as one of the many options available for this condition.

Nonsurgical Management of Midsubstance Achilles Tendinopathy

Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery.

Fluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of short-term patient outcomes

OBJECTIVE

To describe a lateral fluoroscopically guided retrocalcaneal bursa injection technique, report patient outcomes at 1-4 weeks after steroid/anesthetic retrocalcaneal bursal therapeutic injection, and correlate pre-injection diagnostic heel ultrasound variables with improvement in patient pain scores.

MATERIALS AND METHODS

After IRB approval, fluoroscopically guided therapeutic retrocalcaneal bursa injections performed using a lateral approach were retrospectively reviewed. Pre-injection heel ultrasound results and pre- and post-injection patient VAS pain scores (scale 0-10) were recorded. The Wilcox matched-pair test compared pain scores, and Spearman's rho assessed for correlation between pain score changes and heel ultrasound results.

RESULTS

Thirty-two injections were performed in 30 patients (25 females, 5 males; mean 56.5 ± 9.3 years, range 39-75 years; 21 left heel, 11 right heel) with technical success in 32 of 32 cases (100 %). Insertional Achilles tendon pathology and retrocalcaneal bursitis were present in 31 of 32 cases (97 %) and 16 of 32 cases (50 %), respectively. Median pre- and post-procedure pain scores were 8 (IQR 7, 10) and 1.75 (IQR 0, 6). A statistically significant decrease in pain score was observed following injection, with a median change of 4.75 (IQR 3, 8; p < 0.001). Clinically significant response (>50 % reduction in pain score) was present in 69 % (95 % CI, 0.52-0.86; p < 0.001). No significant correlation was identified between a decrease in pain score and a sonographically abnormal Achilles tendon or retrocalcaneal bursa.

CONCLUSION

Fluoroscopically guided retrocalcaneal bursal steroid/anesthetic using a lateral approach is an effective technique. This technique yielded 100 % technical success and a clinically significant decrease in patient pain scores (p < 0.001).

Preliminary Treatment of Achilles Tendinopathy Using Low-Intensity Pulsed Ultrasound

BACKGROUND

Achilles tendinopathy is a degenerative process of the tendon associated with diminished vascularity, microtrauma, and aging. Nonoperative treatments such as activity modification, immobilization, night splints, and physical therapy have good outcomes for the majority of patients. However, there are cohorts of patients that remain symptomatic despite use of all nonoperative measures that eventually require surgical intervention. The present study reports the preliminary short-term clinical outcomes of low-intensity pulsed ultrasound (LIPUS) for treatment for Achilles tendinopathy.

MATERIALS AND METHODS

Fourteen patients with clinically diagnosed Achilles tendinopathy who failed previous nonoperative treatments underwent LIPUS stimulation directly over the area of maximum tendon tenderness for 20 min/d for 8 weeks total. No other treatment modalities were used during the period of LIPUS stimulation. All patients had serial clinical exams and evaluations with an average follow-up of 12 months (range, 6-50 months).

RESULTS

Excellent clinical outcomes with complete resolution of pain and other symptoms were obtained in 7 patients (50%). Two patients (14%) had good outcomes with mild tendon irritation and stiffness not requiring further intervention. Five patients (36%) had minimal benefit with continued pain, swelling, and tenderness over the Achilles and functional deficits. No patients had worsening pain or progression of disability requiring surgery.

CONCLUSIONS

LIPUS is an additional noninvasive treatment modality for chronic Achilles tendinopathy that may potentially help improve clinical symptoms and delay and/or prevent the need for surgical intervention. While LIPUS is easy to use, well-tolerated, and has promising early clinical results, further research is needed to determine the long-term benefits, disadvantages, and cost-effectiveness of this alternative treatment for tendinopathy.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Lower Extremity Injury Patterns in Elite Ballet Dancers: Ultrasound/MRI Imaging Features and an Institutional Overview of Therapeutic Ultrasound Guided Percutaneous Interventions

BACKGROUND

Altered biomechanics from repetitive microtrauma, such as long practice hours in en pointe (tip of the toes) or demi pointe (balls of the feet) predispose ballet dancers to a multitude of musculoskeletal pathologies particularly in the lower extremities. Both ultrasound and magnetic resonance imaging (MRI) are radiation-sparing modalities which can be used to confidently evaluate these injuries, with ultrasound (US) offering the added utility of therapeutic intervention at the same time in experienced hands.

QUESTIONS/PURPOSES

The purposes of this paper were: (1) to illustrate the US and MRI features of lower extremity injury patterns in ballet dancers, focusing on pathologies commonly encountered at a single orthopedic hospital; (2) to present complementary roles of both ultrasound and MRI in the evaluation of these injuries whenever possible; (3) to review and present our institutional approach towards therapeutic ultrasound-guided interventions by presenting explicit cases.

METHODS

Online searches were performed using the search criteria of "ballet biomechanics" and "ballet injuries." The results were then further narrowed down by limiting articles published in the past 15 years, modality (US and MRI), anatomical region (foot and ankle, hip and knee) and to major radiology, orthopedics, and sports medicine journals.

RESULTS

Performing ballet poses major stress to lower extremities and predisposes dancer to several musculoskeletal injuries. These can be adequately evaluated by both US and MRI. US is useful for evaluating superficial structures such as soft tissues, tendons, and ligaments, particularly in the foot and ankle. MRI provides superior resolution of deeper structures such as joints, bone marrow, and cartilage. In addition, US can be used as a therapeutic tool for providing quick symptomatic improvement in these athletes for who "time is money".

CONCLUSION

Performing ballet may cause major stress to the lower extremities, predominantly affecting the foot and ankle, followed by the knee and hip. US and MRI play complementary roles in evaluating various orthopedic conditions in ballet dancers, with US allowing for dynamic evaluation and guidance for interventions.

American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

OBJECTIVE

To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).

METHODS

A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework.

RESULTS

In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS.

CONCLUSION

These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.

American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

OBJECTIVE

To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).

METHODS

A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework.

RESULTS

In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS.

CONCLUSION

These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.

Achilles tendon disorders

Achilles tendon disorders include tendinosis, paratenonitis, insertional tendinitis, retrocalcaneal bursitis, and frank rupture. Patients present with pain and swelling in the posterior aspect of the ankle. Magnetic resonance imaging and ultrasound are helpful in confirming the diagnosis and guiding treatment. Nonsurgical management of Achilles tendon disorders includes nonsteroidal anti-inflammatory drugs, physical therapy, bracing, and footwear modification. Surgical treatment includes debridement of the diseased area of the tendon with direct repair. Tendon transfer may be necessary to augment the strength of the Achilles tendon.

Injectable treatments for noninsertional achilles tendinosis: a systematic review

BACKGROUND

Although there has been a recent increase in interest regarding injectable therapy for noninsertional Achilles tendinosis, there are currently no clear treatment guidelines for managing patients with this condition. The objective of this study was (1) to conduct a systematic review of clinical outcomes following injectable therapy of noninsertional Achilles tendinosis, (2) to identify patient-specific factors that are prognostic of treatment outcomes, (3) to provide treatment recommendations based on the best available literature, and (4) to identify knowledge deficits that require further investigation.

METHODS

We searched MEDLINE (1948 to March week 1 2012) and EMBASE (1980 to 2012 week 9) for clinical studies evaluating the efficacy of injectable therapies for noninsertional Achilles tendinosis. Specifically, we included randomized controlled trials and cohort studies with a comparative control group. Data abstraction was performed by 2 independent reviewers. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations.

RESULTS

Nine studies fit the inclusion criteria for our review, constituting 312 Achilles tendons at final follow-up. The interventions of interest included platelet-rich plasma (n = 54), autologous blood injection (n = 40), sclerosing agents (n = 72), protease inhibitors (n = 26), hemodialysate (n = 60), corticosteroids (n = 52), and prolotherapy (n = 20). Only 1 study met the criteria for a high-quality randomized controlled trial. All of the studies were designated as having a low quality of evidence. While some studies showed statistically significant effects of the treatment modalities, often studies revealed that certain injectables were no better than a placebo.

CONCLUSIONS

The literature surrounding injectable treatments for noninsertional Achilles tendinosis has variable results with conflicting methodologies and inconclusive evidence concerning indications for treatment and the mechanism of their effects on chronically degenerated tendons. Prospective, randomized studies are necessary in the future to guide Achilles tendinosis treatment recommendations using injectable therapies.

LEVEL OF EVIDENCE

Level II, systematic review.

Is percutaneous radiofrequency coblation for treatment of Achilles tendinosis safe and effective?

Insertional Achilles tendinosis results in isolated pain at the Achilles tendon insertion site due to intratendinous degeneration. When conservative measures fail, surgical treatment may be necessary. Radiofrequency coblation has been suggested to be an effective procedure for treatment of tendon pathologies. Percutaneous execution of this procedure is very simple as well as minimally invasive, and thus if effective, would be an excellent alternative to an open treatment of insertional Achilles tendinopathy. A review of 47 cases with this percutaneous technique was conducted. In our relatively short-term follow-up (mean = 8.6 months, SD = 9.71, range 1 to 40), the incidence of reoperation was 14.9% (7/47). Rupture of the Achilles tendon was identified in 3 (6.4%) patients. Our cohort had a relatively high body mass index (mean = 37.1, SD = 6.96, range 24.3 to 52.8). We recommend surgeons to be cautious about selecting this procedure in similar, high body mass index patient cohorts for treatment of Achilles tendinosis.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Is calcaneal inclination higher in patients with insertional Achilles tendinosis? A case-controlled, cross-sectional study

Insertional Achilles tendinosis is a condition where a patient complains of isolated pain at the Achilles tendon insertion site due to intratendinous degeneration. It has been suggested that this condition is associated with cavus foot deformity. However, to our knowledge, there is no study that has confirmed this observation. We carried out a cross-sectional, case-controlled study to explore the association of increased calcaneal inclination-a surgically important characteristic of cavus foot deformity-with insertional Achilles tendinosis. Patients with Achilles tendinosis and matched controls without the pathology were compared. Although a statistically significant difference was detected in calcaneal inclination angle between these 2 groups (p = .038), we felt that the difference was not clinically significant (calcaneal inclination angle = 20.9 vs. 18.9, respectively). Within the limitations of the study, we conclude that there is no clinically significant difference in calcaneal inclination between those with or without insertional Achilles tendinosis.

Injection techniques of platelet-rich plasma into and around the Achilles tendon: a cadaveric study

BACKGROUND

Platelet-rich plasma (PRP) injections are used to treat (Achilles) tendinopathies. Platelet-rich plasma has been injected at different locations, but the feasibility of PRP injections and the distribution after injection have not been studied.

PURPOSE

To evaluate (1) the feasibility of ultrasound-guided PRP injections into the Achilles tendon (AT) and in the area between the paratenon and the AT and (2) the distribution of PRP after injection into the AT and in the area between the paratenon and AT.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Fifteen cadaveric lower limbs were injected under ultrasound guidance with Indian blue-dyed PRP. Five injections were placed into the AT at the midportion level; 5 injections were located anterior between the paratenon and AT and 5 posterior between the paratenon and AT. The limbs were anatomically dissected and evaluated for the presence and distribution of PRP.

RESULTS

All injections into the AT showed PRP infiltration in the AT as well as in the area between the paratenon and AT (median craniocaudal spread, 100 mm; range, 75-110 mm); 1 of 5 limbs showed PRP leakage into the Kager fat pad after AT injection. Allanterior and posterior injections showed PRP infiltration in the area between the paratenon and AT (median, 100 mm; range, 75-150 mm). The AT was infiltrated with PRP after 3 of 10 paratenon injections.

CONCLUSION

The "AT" and "paratenon" injections under ultrasound guidance proved to be accurate. Injections into the AT showed distribution of PRP into the AT as well as in the area between the paratenon and AT. All injections between the paratenon and AT showed PRP distribution in that area, as well as in the Kager fat pad.

CLINICAL RELEVANCE

Different PRP injection techniques were evaluated. This aids in the optimization of PRP injections in the treatment of midportion Achilles tendinopathy.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.