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Kuder IM, Rock M, Jones GG, Amis AA, Cegla FB, van Arkel RJ. An Optimization Approach for Creating Application-specific Ultrasound Speckle Tracking Algorithms. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1108-1121. [PMID: 38714465 DOI: 10.1016/j.ultrasmedbio.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 03/04/2024] [Accepted: 03/24/2024] [Indexed: 05/09/2024]
Abstract
OBJECTIVE Ultrasound speckle tracking enables in vivo measurement of soft tissue deformation or strain, providing a non-invasive diagnostic tool to quantify tissue health. However, adoption into new fields is challenging since algorithms need to be tuned with gold-standard reference data that are expensive or impractical to acquire. Here, we present a novel optimization approach that only requires repeated measurements, which can be acquired for new applications where reference data might not be readily available or difficult to get hold of. METHODS Soft tissue motion was captured using ultrasound for the medial collateral ligament (MCL) of three quasi-statically loaded porcine stifle joints, and medial ligamentous structures of a dynamically loaded human cadaveric knee joint. Using a training subset, custom speckle tracking algorithms were created for the porcine and human ligaments using surrogate optimization, which aimed to maximize repeatability by minimizing the normalized standard deviation of calculated strain maps for repeat measurements. An unseen test subset was then used to validate the tuned algorithms by comparing the ultrasound strains to digital image correlation (DIC) surface strains (porcine specimens) and length change values of the optically tracked ligament attachments (human specimens). RESULTS After 1500 iterations, the optimization routine based on the porcine and human training data converged to similar values of normalized standard deviations of repeat strain maps (porcine: 0.19, human: 0.26). Ultrasound strains calculated for the independent test sets using the tuned algorithms closely matched the DIC measurements for the porcine quasi-static measurements (R > 0.99, RMSE < 0.59%) and the length change between the tracked ligament attachments for the dynamic human dataset (RMSE < 6.28%). Furthermore, strains in the medial ligamentous structures of the human specimen during flexion showed a strong correlation with anterior/posterior position on the ligaments (R > 0.91). CONCLUSION Adjusting ultrasound speckle tracking algorithms using an optimization routine based on repeatability led to robust and reliable results with low RMSE for the medial ligamentous structures of the knee. This tool may be equally beneficial in other soft-tissue displacement or strain measurement applications and can assist in the development of novel ultrasonic diagnostic tools to assess soft tissue biomechanics.
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Affiliation(s)
- Isabelle M Kuder
- Imperial College London Department of Mechanical Engineering, London, UK
| | | | - Gareth G Jones
- Imperial College London Department of Surgery and Cancer, London, UK
| | - Andrew A Amis
- Imperial College London Department of Mechanical Engineering, London, UK
| | - Frederic B Cegla
- Imperial College London Department of Mechanical Engineering, London, UK
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Mora KE, Mlawer SJ, Loiselle AE, Buckley MR. The Micromechanical Environment of the Impinged Achilles Tendon. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024:e2401015. [PMID: 38966889 DOI: 10.1002/smll.202401015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 06/13/2024] [Indexed: 07/06/2024]
Abstract
Although tendon predominantly experiences longitudinal tensile forces, transverse forces due to impingement from bone are implicated in both physiological and pathophysiological processes. However, prior studies have not characterized the micromechanical strain environment in the context of tendon impingement. To address this knowledge gap, mouse hindlimb explants are imaged on a multiphoton microscope, and image stacks of the same population of tendon cells are obtained in the Achilles tendon before and after dorsiflexion-induced impingement by the heel bone. Based on the acquired images, multiaxial strains are measured at the extracellular matrix (ECM), pericellular matrix (PCM), and cell scales. Impingement generated substantial transverse compression at the matrix-scale, which led to longitudinal stretching of cells, increased cell aspect ratio, and enormous volumetric compression of the PCM. These experimental results are corroborated by a finite element model, which further demonstrated that impingement produces high cell surface stresses and strains that greatly exceed those brought about by longitudinal tension. Moreover, in both experiments and simulations, impingement-generated microscale stresses and strains are highly dependent on initial cell-cell gap spacing. Identifying factors that influence the microscale strain environment generated by impingement could contribute to a more mechanistic understanding of impingement-induced tendinopathies.
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Affiliation(s)
- Keshia E Mora
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, 14627, USA
- Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, 14642, USA
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Samuel J Mlawer
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, 14627, USA
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, USA
| | - Alayna E Loiselle
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, 14627, USA
- Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Mark R Buckley
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, 14627, USA
- Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, 14642, USA
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Alghamdi NH, Pohlig RT, Seymore KD, Sions JM, Crenshaw JR, Grävare Silbernagel K. Immediate and Short-Term Effects of In-Shoe Heel-Lift Orthoses on Clinical and Biomechanical Outcomes in Patients With Insertional Achilles Tendinopathy. Orthop J Sports Med 2024; 12:23259671231221583. [PMID: 38332846 PMCID: PMC10851750 DOI: 10.1177/23259671231221583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 07/31/2023] [Indexed: 02/10/2024] Open
Abstract
Background Physical therapists frequently employ heel lifts as an intervention to reduce Achilles tendon pain and restore function. Purpose To determine the short-term effect of heel lifts on clinical and gait outcomes in participants with insertional Achilles tendinopathy (IAT). Study Design Case series; Level of evidence, 4. Methods Participants with IAT underwent eligibility screening and completed assessments at baseline and 2 weeks later. Primary outcomes included symptom severity (Victoria Institute of Sports Assessment-Achilles [VISA-A]), gait analysis with the 10-m walk-test at 2 speeds (normal and fast), and pain during walking. Pain and gait analysis were assessed under 3 conditions: before fitting 20-mm heel lifts, immediately after heel-lift fitting, and after 2 weeks of wearing heel lifts. Ultrasound images and measurements at the Achilles insertion were obtained from prone and standing positions (with and without heel lifts). Spatiotemporal gait parameters and tibial tilt angles were evaluated at normal speed using inertia measurement units during the 3 study conditions. Differences between the conditions were analyzed using paired t test or analysis of variance. Results Overall, 20 participants (12 female, 13 with bilateral IAT; mean age, 51 ± 9.3 years; mean body mass index 31.6 ± 6.8 kg/m2) completed all assessments. Symptom severity (VISA-A) of the more symptomatic side significantly improved at 2 weeks (60 ± 20.6) compared with baseline (52.2 ± 20.4; P < .01). Pain during gait (Numeric Pain Rating Scale) was significantly reduced immediately after heel-lift fitting (0.7 ± 2.0) when compared with baseline (2.2 ± 2.7, P = .043). Spatiotemporal gait parameters and tibial tilt angle before and after using heel lifts at normal walking speed were not significantly different; however, gait speed, stride length, and tibial tilt angle on both sides increased significantly immediately after using heel lifts and were maintained after 2 weeks of wear. Conclusion Using heel lifts not only improved symptom severity after 2 weeks but also immediately reduced pain during gait and had a positive impact on gait pattern and speed.
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Affiliation(s)
- Nabeel Hamdan Alghamdi
- Department of Physical Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ryan T. Pohlig
- Department of Epidemiology, University of Delaware, Newark, Delaware, USA
| | - Kayla D. Seymore
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark, Delaware, USA
- Biomechanics and Movements Science Program, University of Delaware, Newark, Delaware, USA
| | - Jaclyn Megan Sions
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark, Delaware, USA
- Biomechanics and Movements Science Program, University of Delaware, Newark, Delaware, USA
| | - Jeremy R. Crenshaw
- Biomechanics and Movements Science Program, University of Delaware, Newark, Delaware, USA
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Karin Grävare Silbernagel
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark, Delaware, USA
- Biomechanics and Movements Science Program, University of Delaware, Newark, Delaware, USA
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Dolphin M, Garn J, Miller M, Adams K. More Than the Achilles' Heel: Management of a Complex Recreational Athlete. Curr Sports Med Rep 2024; 23:32-34. [PMID: 38315428 DOI: 10.1249/jsr.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Affiliation(s)
- Michelle Dolphin
- Doctoral Physical Therapy Program, College of Health Professions, SUNY Upstate Medical University, Syracuse, NY
| | - Jesse Garn
- Doctoral Physical Therapy Program, College of Health Professions, SUNY Upstate Medical University, Syracuse, NY
| | - Michael Miller
- Doctoral Physical Therapy Program, College of Health Professions, SUNY Upstate Medical University, Syracuse, NY
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Kurashina W, Takahashi T, Sasanuma H, Saitsu A, Takeshita K. Relationship Between Achilles Tendon Stiffness Using Myoton PRO and Translation Using a Tensile Testing Machine: A Biomechanical Study of a Porcine Model. Cureus 2023; 15:e49359. [PMID: 38146575 PMCID: PMC10749689 DOI: 10.7759/cureus.49359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 12/27/2023] Open
Abstract
Background Achilles tendinopathy is a common ankle disorder in both the general population and athletes. This condition can alter the mechanical characteristics of the Achilles tendon (AT) by decreasing tendon stiffness. Achilles tendinopathy is primarily treated conservatively; however, few monitoring tools exist for evaluating the condition of the AT. The Myoton PRO (Myoton AS, Tallinn, Estonia) device is a handheld tool used to evaluate tissue stiffness. However, no basic studies have examined the validity of Myoton PRO for assessing the AT. This study aimed to assess the validity of Myoton PRO using animal ATs and to examine its clinical applicability. Methods We used 28 fresh porcine ankles and evaluated AT stiffness at the calcaneus insertion site (AT0) and 2.0 cm above the calcaneus (AT2) using Myoton PRO. We also measured changes in the AT length using a tensile testing machine during the cyclic loading test. We investigated the correlation between dynamic stiffness and length change. Furthermore, we assessed the difference in stiffness between AT0 and AT2. Results The dynamic stiffness was 717.6 ± 183.1 N/m at AT0 and 467.4 ± 152.3 N/m at AT2. The change in length during the cyclic loading test was 1.8 ± 0.7 mm. The correlation between dynamic stiffness and length change was as follows: AT0, r=-0.61; AT2, r=-0.64 (P<0.001). The dynamic stiffness at AT0 was significantly greater than that at AT2 (P<0.001). Conclusions AT assessment using Myoton PRO has potential clinical utility as an indicator of tissue stiffness.
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Affiliation(s)
- Wataru Kurashina
- Graduate School of Medicine, Jichi Medical University, Shimotsuke, JPN
- Department of Rehabilitation, Tochigi Medical Center Shimotsuga, Tochigi, JPN
| | - Tsuneari Takahashi
- Department of Orthopaedic Surgery, Ishibashi General Hospital, Shimotsuke, JPN
| | - Hideyuki Sasanuma
- Department of Orthopaedics, Jichi Medical University, Shimotsuke, JPN
| | - Akihiro Saitsu
- Department of Orthopaedics, Jichi Medical University, Shimotsuke, JPN
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Patch DA, Andrews NA, Scheinberg M, Jacobs RA, Harrelson WM, Rallapalle V, Sinha T, Shah A. Achilles tendon disorders: An overview of diagnosis and conservative treatment. JAAPA 2023; 36:1-8. [PMID: 37751268 DOI: 10.1097/01.jaa.0000977720.10055.c4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
ABSTRACT Achilles tendon-related pain affects up to 6% of the US population during their lifetime and is commonly encountered by primary care providers. An accurate diagnosis and early conservative management can improve patient quality of life and reduce unnecessary surgical consultations, saving healthcare dollars. Achilles tendon pathologies can be categorized into acute (pain lasting less than 6 weeks), chronic (pain lasting more than 6 weeks), and acute on chronic (worsening of pain with preexisting chronic Achilles tendon pathology). This article describes the diagnosis, conservative management, indications for imaging, and indications for surgical referral for acute and chronic Achilles tendon rupture, Achilles tendinitis, gastrocnemius strain, plantaris rupture, insertional Achilles tendinopathy, Haglund deformity, and noninsertional Achilles tendinopathy.
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Affiliation(s)
- David A Patch
- In the Department of Orthopedic Surgery at the University of Alabama Birmingham, David A. Patch and Nicholas A. Andrews are resident physicians; Mila Scheinberg and Roshan A. Jacobs are orthopedic research assistants; Whitt M. Harrelson, Vyshnavi Rallapalle, and Tanvee Sinha are research assistants; and Ashish Shah is a professor and director of clinical research. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Janowski AJ, Post AA, Heredia-Rizo AM, Mosby H, Dao M, Law LF, Bayman EO, Wilken JM, Sluka KA, Chimenti RL. Patterns of movement-evoked pain during tendon loading and stretching tasks in Achilles tendinopathy: A secondary analysis of a randomized controlled trial. Clin Biomech (Bristol, Avon) 2023; 109:106073. [PMID: 37657267 PMCID: PMC10543613 DOI: 10.1016/j.clinbiomech.2023.106073] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND This study aimed to characterize movement-evoked pain during tendon loading and stretching tasks in individuals with Achilles tendinopathy, and to examine the association between movement-evoked pain with the Achilles tendinopathy type (insertional and midportion), biomechanical, and psychological variables. METHODS In this laboratory-based, cross-sectional study, 37 individuals with chronic Achilles tendinopathy participated. Movement-evoked pain intensity (Numeric Rating Scale: 0 to 10) and sagittal-plane ankle biomechanics were collected simultaneously during standing, fast walking, single-leg heel raises, and weight-bearing calf stretch. Description of symptoms, including location of Achilles tendon pain and duration of tendon morning stiffness, as well as pain-related psychological measures, including the Tampa Scale of Kinesiophobia were collected. Linear mixed effects models were built around two paradigms of movement-evoked pain (tendon loading and stretching tasks) with each model anchored with pain at rest. FINDINGS Movement-evoked pain intensity increased as task demand increased in both models. Lower peak dorsiflexion with walking (β = -0.187, 95% CI: -0.305, -0.069), higher fear of movement (β = 0.082, 95% CI: 0.018, 0.145), and longer duration of tendon morning stiffness (β = 0.183, 95% CI: 0.07, 0.296) were associated with greater pain across tendon loading tasks (R2 = 0.47). Lower peak dorsiflexion with walking (β = -0.27, 95% CI: -0.41, -0.14), higher dorsiflexion with the calf stretch (β = 0.095, 95% CI: 0.02, 0.16), and insertional Achilles tendinopathy (β = -0.93, 95% CI: -1.65, -0.21) were associated with higher pain across tendon stretching tasks (R2 = 0.53). INTERPRETATION In addition to exercise, the ideal management of Achilles tendinopathy may require adjunct treatments to address the multifactorial aspects of movement-evoked pain.
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Affiliation(s)
- Adam J Janowski
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA.
| | - Andrew A Post
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Alberto M Heredia-Rizo
- Department of Physiotherapy, Faculty of Nursing, Physiotherapy, and Podiatry, University of Seville, Spain; Uncertainty, Mindfulness, Self, and Spirituality (UMSS) Research Group, Spain
| | - Hadley Mosby
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Megan Dao
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Laura Frey Law
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Emine O Bayman
- Department of Biostatistics and Department of Anesthesia, University of Iowa, Iowa City, IA, USA
| | - Jason M Wilken
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Kathleen A Sluka
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Ruth L Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
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8
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Adam NC, Smith CR, Herzog W, Amis AA, Arampatzis A, Taylor WR. In Vivo Strain Patterns in the Achilles Tendon During Dynamic Activities: A Comprehensive Survey of the Literature. SPORTS MEDICINE - OPEN 2023; 9:60. [PMID: 37466866 DOI: 10.1186/s40798-023-00604-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 07/02/2023] [Indexed: 07/20/2023]
Abstract
Achilles' tendon (AT) injuries such as ruptures and tendinopathies have experienced a dramatic rise in the mid- to older-aged population. Given that the AT plays a key role at all stages of locomotion, unsuccessful rehabilitation after injury often leads to long-term, deleterious health consequences. Understanding healthy in vivo strains as well as the complex muscle-tendon unit interactions will improve access to the underlying aetiology of injuries and how their functionality can be effectively restored post-injury. The goals of this survey of the literature with a systematic search were to provide a benchmark of healthy AT strains measured in vivo during functional activities and identify the sources of variability observed in the results. Two databases were searched, and all articles that provided measured in vivo peak strains or the change in strain with respect to time were included. In total, 107 articles that reported subjects over the age of 18 years with no prior AT injury and measured while performing functional activities such as voluntary contractions, walking, running, jumping, or jump landing were included in this review. In general, unclear anatomical definitions of the sub-tendon and aponeurosis structures have led to considerable confusion in the literature. MRI, ultrasound, and motion capture were the predominant approaches, sometimes coupled with modelling. The measured peak strains increased from 4% to over 10% from contractions, to walking, running, and jumping, in that order. Importantly, measured AT strains were heavily dependent on measurement location, measurement method, measurement protocol, individual AT geometry, and mechanical properties, as well as instantaneous kinematics and kinetics of the studied activity. Through a comprehensive review of approaches and results, this survey of the literature therefore converges to a united terminology of the structures and their common underlying characteristics and presents the state-of-knowledge on their functional strain patterns.
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Affiliation(s)
- Naomi C Adam
- Institute for Biomechanics, ETH Zürich, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland
| | - Colin R Smith
- Institute for Biomechanics, ETH Zürich, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland
| | - Walter Herzog
- Human Performance Laboratory, Faculty of Kinesiology, The University of Calgary, Calgary, Canada
| | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, London, UK
| | - Adamantios Arampatzis
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, and Berlin School of Movement Science, Berlin, Germany
| | - William R Taylor
- Institute for Biomechanics, ETH Zürich, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland.
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Camy C, Brioche T, Senni K, Bertaud A, Genovesio C, Lamy E, Fovet T, Chopard A, Pithioux M, Roffino S. Effects of hindlimb unloading and subsequent reloading on the structure and mechanical properties of Achilles tendon-to-bone attachment. FASEB J 2022; 36:e22548. [PMID: 36121701 DOI: 10.1096/fj.202200713r] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/10/2022] [Accepted: 09/02/2022] [Indexed: 11/11/2022]
Abstract
While muscle and bone adaptations to deconditioning have been widely described, few studies have focused on the tendon enthesis. Our study examined the effects of mechanical loading on the structure and mechanical properties of the Achilles tendon enthesis. We assessed the fibrocartilage surface area, the organization of collagen, the expression of collagen II, the presence of osteoclasts, and the tensile properties of the mouse enthesis both after 14 days of hindlimb suspension (HU) and after a subsequent 6 days of reloading. Although soleus atrophy was severe after HU, calcified fibrocartilage (CFc) was a little affected. In contrast, we observed a decrease in non-calcified fibrocartilage (UFc) surface area, collagen fiber disorganization, modification of morphological characteristics of the fibrocartilage cells, and altered collagen II distribution. Compared to the control group, restoring normal loads increased both UFc surface area and expression of collagen II, and led to a crimp pattern in collagen. Reloading induced an increase in CFc surface area, probably due to the mineralization front advancing toward the tendon. Functionally, unloading resulted in decreased enthesis stiffness and a shift in site of failure from the osteochondral interface to the bone, whereas 6 days of reloading restored the original elastic properties and site of failure. In the context of spaceflight, our results suggest that care must be taken when performing countermeasure exercises both during missions and during the return to Earth.
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Affiliation(s)
- Claire Camy
- Aix Marseille University, CNRS, ISM, Institute of Movement Sciences, Marseille, France
| | - Thomas Brioche
- DMEM, Montpellier University, INRAE, UMR 866, Montpellier, France
| | - Karim Senni
- Laboratoire EBInnov, Ecole de Biologie Industrielle-EBI, Cergy, France
| | - Alexandrine Bertaud
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Laboratoire de Biochimie, Faculté de Pharmacie, Marseille, France
| | - Cécile Genovesio
- Laboratoire de Biochimie, Faculté de Pharmacie, Marseille, France
| | - Edouard Lamy
- Aix Marseille University, CNRS, ISM, Institute of Movement Sciences, Marseille, France.,Laboratoire de Biochimie, Faculté de Pharmacie, Marseille, France
| | - Théo Fovet
- DMEM, Montpellier University, INRAE, UMR 866, Montpellier, France
| | - Angèle Chopard
- DMEM, Montpellier University, INRAE, UMR 866, Montpellier, France
| | - Martine Pithioux
- Aix Marseille University, CNRS, ISM, Institute of Movement Sciences, Marseille, France.,Department of Orthopaedics and Traumatology, Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Marseille, France.,Aix Marseille Univ, APHM, CNRS, Centrale Marseille, ISM, Mecabio Platform, Anatomy Laboratory, Timone, Marseille, France
| | - Sandrine Roffino
- Aix Marseille University, CNRS, ISM, Institute of Movement Sciences, Marseille, France.,Aix Marseille Univ, APHM, CNRS, Centrale Marseille, ISM, Mecabio Platform, Anatomy Laboratory, Timone, Marseille, France
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10
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Update on Fibrocartilaginous Disease Clinical Examination. Clin Podiatr Med Surg 2022; 39:371-392. [PMID: 35717056 DOI: 10.1016/j.cpm.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article provides an update on fibrocartilaginous disease clinical examination. Lesser metatarsophalangeal joint instability is a challenging entity for the foot and ankle surgeon. A correct diagnosis is crucial to instill an appropriate treatment plan that will result in a successful outcome and a satisfied patient. Insertional Achilles tendon disorders are common among active and inactive patients. There is also a high predilection for Achilles tendon pathology among athletes. In this article demographics and patient history, causative factors, differential diagnosis, physical examination, clinical tests, and radiographic evaluation are discussed for plantar plate disorders and insertional Achilles disorders.
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11
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Management of Insertional Achilles Tendinopathy. J Am Acad Orthop Surg 2022; 30:e751-e759. [PMID: 35286285 DOI: 10.5435/jaaos-d-21-00679] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/29/2022] [Indexed: 02/01/2023] Open
Abstract
Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.
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Aggouras AN, Chimenti RL, Flemister AS, Ketz J, Slane LC, Buckley MR, Richards MS. Impingement in Insertional Achilles Tendinopathy Occurs Across a Larger Range of Ankle Angles and Is Associated With Increased Tendon Thickness. Foot Ankle Int 2022; 43:683-693. [PMID: 35081809 PMCID: PMC9240994 DOI: 10.1177/10711007211069570] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Insertional Achilles tendinopathy (IAT) is characterized by tendon degeneration and thickening near the tendon-bone insertion.11 Calcaneal impingement is believed to contribute to the pathogenesis of IAT.5 However, it is unclear how increased tendon thickness in individuals with IAT influences impingement. This study aimed to compare Achilles tendon impingement in individuals with and without IAT. METHODS Eight healthy adults and 12 adults with clinically diagnosed symptomatic IAT performed a passive flexion exercise during which ankle flexion angle, anterior-posterior (A-P) thickness, and an ultrasonographic image sequence of the Achilles tendon insertion were acquired. The angle of ankle plantarflexion at which the calcaneus first impinges the Achilles tendon, defined as the impingement onset angle, was identified by (1) a anonymized observer (visual inspection method) and (2) a computational image deformation-based approach (curvature method). RESULTS Although the 2 methods provided different impingement onset angles, the measurements were strongly correlated (R2 = 0.751, P < .05). The impingement onset angle and the thickness of the Achilles tendon insertion were greater in subjects with clinically diagnosed IAT (P = .0048, P = .0047). Furthermore, impingement onset angle proved to have a moderate correlation with anterior-posterior thickness (R2 = 0.454, P < .05). CONCLUSION Our findings demonstrated that increased tendon thickness in IAT patients is associated with larger impingement onset angles, raising the range of ankle angles over which the tendon is exposed to impingement. CLINICAL RELEVANCE Increased susceptibility to impingement may exacerbate or perpetuate the pathology, highlighting the need for clinical strategies to reduce impingement in IAT patients.
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Affiliation(s)
- Anthony N. Aggouras
- Department of Biomedical Engineering, Rochester Institute of Technology, Rochester, New York,Department of Biomedical Engineering, University of Rochester, Rochester, New York
| | - Ruth L. Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, 2116 Westlawn, Iowa City 52245 Iowa
| | - A. Samuel Flemister
- University of Rochester, Department of Orthopaedic Surgery, Rochester, New York
| | - John Ketz
- University of Rochester, Department of Orthopaedic Surgery, Rochester, New York
| | - Laura C. Slane
- Department of Mechanical Engineering, University of Rochester, Rochester, New York
| | - Mark R. Buckley
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
| | - Michael S. Richards
- Department of Biomedical Engineering, Rochester Institute of Technology, Rochester, New York
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Mora KE, Mlawer SJ, Bae AJ, Richards MS, Loiselle AE, Buckley MR. Ultrasound strain mapping of the mouse Achilles tendon during passive dorsiflexion. J Biomech 2022; 132:110920. [PMID: 34998182 PMCID: PMC10564406 DOI: 10.1016/j.jbiomech.2021.110920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/21/2022]
Abstract
Immediately prior to inserting into bone, many healthy tendons experience impingement from nearby bony structures. However, super-physiological levels of impingement are implicated in insertional tendinopathies. Unfortunately, the mechanisms underlying the connection between impingement and tendon pathology remain poorly understood, in part due to the shortage of well-characterized animal models of impingement at clinically relevant sites. As a first step towards developing a model of excessive tendon impingement, the objective of this study was to characterize the mechanical strain environment in the mouse Achilles tendon insertion under passive dorsiflexion and confirm that - like humans - mice experience impingement of the tendon insertion from the calcaneus (heel bone) in dorsiflexed ankle positions. Based on previous work in humans, we hypothesized that during dorsiflexion, the mouse Achilles tendon insertion would experience high levels of transverse compressive strain due to calcaneal impingement. A custom-built loading platform was used to apply passive dorsiflexion, while an ultrasound transducer positioned over the Achilles tendon captured radiofrequency images. A non-rigid image registration algorithm was then used to map the transverse compressive strain based on the acquired ultrasound image sequences. Our results demonstrate that during passive dorsiflexion, transverse compressive strains were produced throughout the Achilles tendon, with significantly larger strain magnitudes at the tendon insertion than at the midsubstance. Furthermore, there was increasing transverse compressive strain observed within the Achilles tendon as a function of increasing dorsiflexion angle. This study enhances our understanding of the unique mechanical loading environment of the Achilles tendon under physiologically relevant conditions.
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Affiliation(s)
- Keshia E Mora
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA.
| | - Samuel J Mlawer
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA
| | - Albert J Bae
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA
| | - Michael S Richards
- Department of Biomedical Engineering, Rochester Institute of Technology, Rochester, NY 14623, USA
| | - Alayna E Loiselle
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA
| | - Mark R Buckley
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA
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14
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Strasser NL, Farina KA. Haglund's Syndrome and Insertional Achilles Tendinopathy. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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15
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Matsui T, Kumai T, Kamijo S, Shinohara Y, Kurokawa H, Taniguchi A, Mahakkanukrauh P, Tanaka Y. Effect of Ankle Motion and Tensile Stress at the Achilles Tendon on the Contact Pressure Between the Achilles Tendon and the Calcaneus. J Foot Ankle Surg 2021; 60:753-756. [PMID: 33766480 DOI: 10.1053/j.jfas.2021.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/08/2020] [Accepted: 02/22/2021] [Indexed: 02/03/2023]
Abstract
Impingement between the Achilles tendon and the posterosuperior prominence of the calcaneus is considered to be a cause of insertional Achilles tendinopathy. The corresponding treatment intends to reduce tensile stress from calf muscles and avoid hyper-dorsiflexion of the ankle joint for decreasing the contact pressure; however, no study has reported on whether these treatments can decrease impingement. Thus, this study investigated the hypothesis that the tensile stress of the Achilles tendon and ankle motion affect the contact pressure between the Achilles tendon and the posterosuperior prominence of the calcaneus. Six fresh-frozen cadaveric lower leg specimens were procured. Each specimen was set to a custom foot-loading frame and loaded with a ground reaction force of 40 N and a tensile load of 70 N along the Achilles tendon. The contact pressure between the Achilles tendon and the posterosuperior prominence of the calcaneus was measured using a miniature pressure sensor under different tensile loadings of the Achilles tendon at the neutral ankle position. Similarly, the contact pressures during the ankle motion from a neutral position to maximum dorsiflexion were measured. The tensile load of the Achilles tendon and ankle motion affected the contact pressure between the Achilles tendon and the posterosuperior prominence of the calcaneus. The contact pressure increased with tensile load or ankle dorsiflexion. Conditions with increasing the tensile load of the Achilles tendon or under ankle dorsiflexion increase the contact pressure between the Achilles tendon and the posterosuperior prominence of the calcaneus.
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Affiliation(s)
- Tomohiro Matsui
- Surgeon, Department of Orthopedic Surgery, Saiseikai Nara Hospital, Nara City, Japan.
| | - Tsukasa Kumai
- Professor, Faculty of Sport Sciences, Waseda University, Tokorozawa, Japan
| | - Satoshi Kamijo
- Surgeon, Department of Orthopaedic Surgery, Fujimori Hospital, Matsumoto, Japan
| | - Yasushi Shinohara
- Professor, Faculty of Sport and Health Science, Ritsumeikan University, Kusatsu, Japan
| | - Hiroaki Kurokawa
- Surgeon, Department of Orthopedic Surgery, Nara Medical University, Kashihara, Japan
| | - Akira Taniguchi
- Surgeon, Department of Orthopedic Surgery, Nara Medical University, Kashihara, Japan
| | | | - Yasuhito Tanaka
- Professor, Department of Orthopedic Surgery, Nara Medical University, Kashihara, Japan
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Nauwelaers AK, Van Oost L, Peers K. Evidence for the use of PRP in chronic midsubstance Achilles tendinopathy: A systematic review with meta-analysis. Foot Ankle Surg 2021; 27:486-495. [PMID: 32798020 DOI: 10.1016/j.fas.2020.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/14/2020] [Accepted: 07/25/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) injections have been proposed as an additional therapy in the treatment of chronic midsubstance Achilles tendinopathy (AT). The use of PRP injections as pharmacological treatment added to a conservative approach has gained growing interest, but the efficacy remains highly debated. The varying methodological quality of the available studies may contribute to these contradictory results. The aim of this systematic review with meta-analysis was to establish the existing evidence of PRP injections for chronic midsubstance AT on the functional outcome, with a risk of bias assessment of each included study. METHODS According to the PRISMA guidelines systematic searches were performed in Embase, the Cochrane library and Pubmed on June 12, 2020 for relevant literature. Only clinical trials comparing PRP injections with placebo, additional to an eccentric training program, in midsubstance AT were included. The primary outcome was Victorian Institute of Sport Assessment - Achilles (VISA-A) score at 3, 6 and 12 months post-injection. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (Rob 2). As secondary outcome we assessed reported changes in tendon structure after PRP injections. RESULTS A total of 367 studies were identified with the initial database search. Finally, four randomized controlled trials (RCTs) met inclusion criteria for systematic review and meta-analysis with data of 170 patients available for pooling. Results showed no difference in clinical outcome between the PRP and placebo group at different points in time using the VISA-A score as outcome parameter (3 months 0.23 (CI -0.45, 0.91); 6 months 0.83 (CI -0.26, 1.92); 12 months 0.83 (CI -0.77, 2.44)). The bias analysis showed a low or intermediate risk of bias profile for all studies which supports the good methodological quality of each included article. Finally, it is unclear whether PRP injections cause an improvement in tendon structure. However, no direct relationship between tendon structure and clinical presentation of AT could be found. CONCLUSION PRP has no clear additional value in management of chronic midsubstance Achilles tendinopathy and therefore should not be used as a first-line treatment option.
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Affiliation(s)
- An-Katrien Nauwelaers
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium
| | - Loïc Van Oost
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium.
| | - Koen Peers
- Faculty of Medicine KU Leuven, Department: Physical medicine and rehabilitation, Herestraat 49, 3000 Leuven Belgium
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Roffino S, Camy C, Foucault-Bertaud A, Lamy E, Pithioux M, Chopard A. Negative impact of disuse and unloading on tendon enthesis structure and function. LIFE SCIENCES IN SPACE RESEARCH 2021; 29:46-52. [PMID: 33888287 DOI: 10.1016/j.lssr.2021.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/19/2021] [Accepted: 03/05/2021] [Indexed: 06/12/2023]
Abstract
Exposure to chronic skeletal muscle disuse and unloading that astronauts experience results in muscle deconditioning and bone remodeling. Tendons involved in the transmission of force from muscles to skeleton are also affected. Understanding the changes that occur in muscle, tendon, and bone is an essential step toward limiting or preventing the deleterious effects of chronic reduction in mechanical load. Numerous reviews have reported the effects of this reduction on both muscle and bone, and to a lesser extent on the tendon. However, none focused on the tendon enthesis, the tendon-to-bone attachment site. While the enthesis structure appears to be determined by mechanical stress, little is known about enthesis plasticity. Our review first looks at the relationship between entheses and mechanical stress, exploring how tensile and compressive loads determine and influence enthesis structure and composition. The second part of this review addresses the deleterious effects of skeletal muscle disuse and unloading on enthesis structure, composition, and function. We discuss the possibility that spaceflight-induced enthesis remodeling could impact both the capacity of the enthesis to withstand compressive stress and its potential weakness. Finally, we point out how altered compressive strength at entheses could expose astronauts to the risk of developing enthesopathies.
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Affiliation(s)
- S Roffino
- ISM Inst Movement Sci, Aix-Marseille University, CNRS, Marseille, France.
| | - C Camy
- ISM Inst Movement Sci, Aix-Marseille University, CNRS, Marseille, France
| | - A Foucault-Bertaud
- INSERM 1263, INRA 1260, C2VN, Aix-Marseille University, Marseille, France
| | - E Lamy
- ISM Inst Movement Sci, Aix-Marseille University, CNRS, Marseille, France
| | - M Pithioux
- ISM Inst Movement Sci, Aix-Marseille University, CNRS, Marseille, France
| | - A Chopard
- DMEM, Montpellier University, INRAE, Montpellier, France
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Bah I, Fernandes NRJ, Chimenti RL, Ketz J, Flemister AS, Buckley MR. Tensile mechanical changes in the Achilles tendon due to Insertional Achilles tendinopathy. J Mech Behav Biomed Mater 2020; 112:104031. [PMID: 32882677 DOI: 10.1016/j.jmbbm.2020.104031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 03/05/2020] [Accepted: 08/07/2020] [Indexed: 01/20/2023]
Abstract
Insertional Achilles tendinopathy (IAT) is a painful condition that is challenging to treat non-operatively. Although previous studies have characterized the gross histological features, in vivo strain patterns and transverse compressive mechanical properties of tissue affected by IAT, it is not known how IAT impacts the tensile mechanical properties of the Achilles tendon insertion along the axial/longitudinal direction (i.e., along the predominant direction of loading). To address this knowledge gap, the objectives of this study were to 1) apply ex vivo mechanical testing, nonlinear elastic analysis and quasilinear viscoelastic (QLV) analysis to compare the axial tensile mechanical properties of the Achilles tendon insertion in individuals with and without IAT; and 2) use biochemical analysis and second harmonic generation (SHG) imaging to assess structural and compositional changes induced by IAT in order to help explain IAT-associated tensile mechanical changes. Tissue from the Achilles tendon insertion was acquired from healthy donors and from patients undergoing debridement surgery for IAT. Tissue specimens were mechanically tested using a uniaxial tensile (stress relaxation) test applied in the axial direction. A subset of the donor specimens was used for SHG imaging and biochemical analysis. Linear and non-linear elastic analyses of the stress relaxation tests showed no significant tensile mechanical changes in IAT specimens compared to healthy controls. However, SHG analysis showed that fibrillar collagen was significantly more disorganized in IAT tissue as compared with healthy controls, and biochemical analysis showed that sulfated glycosaminoglycan (sGAG) content and water content were higher in IAT specimens. Collectively, these findings suggest that conservative interventions for IAT should target restoration of ultrastructural organization, reduced GAG content, and reduced resistance to transverse compressive strain.
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Affiliation(s)
- Ibrahima Bah
- University of Rochester Department of Biomedical Engineering, United States.
| | | | - Ruth L Chimenti
- University of Iowa Department of Physical Therapy and Rehabilitation Science, United States
| | - John Ketz
- University of Rochester Department of Orthopaedics, United States
| | | | - Mark R Buckley
- University of Rochester Department of Biomedical Engineering, United States.
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Ackerman JE, Studentsova V, Myers M, Buckley MR, Richards MS, Loiselle AE. Non-Invasive Ultrasound Quantification of Scar Tissue Volume Identifies Early Functional Changes During Tendon Healing. J Orthop Res 2019; 37:2476-2485. [PMID: 31231903 PMCID: PMC6816309 DOI: 10.1002/jor.24397] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 06/18/2019] [Indexed: 02/04/2023]
Abstract
Tendon injuries are very common and disrupt the transmission of forces from muscle to bone, leading to impaired function and quality of life. Successful restoration of tendon function after injury is a challenging clinical problem due to the pathological, scar-mediated manner in which the tendons heal. Currently, there are no standard treatments to modulate scar tissue formation and improve tendon healing. A major limitation to the identification of therapeutic candidates has been the reliance on terminal endpoint metrics of healing in pre-clinical studies, which require a large number of animals and result in destruction of the tissue. To address this limitation, we have identified quantification of scar tissue volume (STV) from ultrasound (US) imaging as a longitudinal, non-invasive metric of tendon healing. STV was strongly correlated with established endpoint metrics of gliding function including gliding resistance and metatarsophalangeal (MTP) flexion angle. However, no associations were observed between STV and structural or material properties. To define the sensitivity of STV to identify differences between functionally discrete tendon healing phenotypes, we utilized S100a4 haploinsufficient mice (S100a4GFP/+ ), which heal with improved gliding function relative to wild-type (WT) littermates. A significant decrease in STV was observed in S100a4GFP/+ repairs, relative to WT at day 14. Taken together, these data suggest US quantification of STV as a means to facilitate the rapid screening of biological and pharmacological interventions to improve tendon healing, and identify promising therapeutic targets, in an efficient, cost-effective manner. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2476-2485, 2019.
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Affiliation(s)
- Jessica E. Ackerman
- Center for Musculoskeletal Research, Department of Orthopaedics & Rehabilitation, University of Rochester, Rochester, New York, United States of America
| | - Valentina Studentsova
- Center for Musculoskeletal Research, Department of Orthopaedics & Rehabilitation, University of Rochester, Rochester, New York, United States of America
| | - Marlin Myers
- Center for Musculoskeletal Research, Department of Orthopaedics & Rehabilitation, University of Rochester, Rochester, New York, United States of America
| | - Mark R. Buckley
- Center for Musculoskeletal Research, Department of Orthopaedics & Rehabilitation, University of Rochester, Rochester, New York, United States of America,Department of Biomedical Engineering, University of Rochester, Rochester, New York, United States of America
| | - Michael S. Richards
- Department of Biomedical Engineering, Rochester Institute of Technology, Rochester, New York, United States of America
| | - Alayna E. Loiselle
- Center for Musculoskeletal Research, Department of Orthopaedics & Rehabilitation, University of Rochester, Rochester, New York, United States of America,Corresponding Author Alayna E. Loiselle, PhD, Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY, 14642, Phone: 585-275-7239, Fax: 585-276-2177,
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20
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Reliability of a two-probe ultrasound imaging procedure to measure strain in the Achilles tendon. J Foot Ankle Res 2019; 12:49. [PMID: 31548870 PMCID: PMC6751664 DOI: 10.1186/s13047-019-0358-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/30/2019] [Indexed: 01/23/2023] Open
Abstract
Background Alteration in the strain properties of the Achilles tendon may lead to adaptations such as pathological stiffening. Stiff tendons have reduced adaptive ability, which may increase the risk for developing tendinopathy. Strain can be measured using musculoskeletal ultrasound imaging. A two-probe ultrasound procedure may reduce the measurement error associated with a one-probe procedure. However, the reliability of the two-probe procedure has not been established. This study aimed to determine the within-session intra- and inter-rater reliability and between-session reliability of a two-probe ultrasound procedure to measure Achilles tendon strain. Methods Participants were 29 healthy individuals (19 females, 10 males; mean age 33.6 years). Achilles tendon images were acquired with a two-probe ultrasound procedure as the ankle moved through a standardised range of motion (20° plantarflexion to 10° dorsiflexion). Both probes were positioned longitudinally, one over the musculotendinous junction and the second over the calcaneal insertion of the Achilles tendon. Repeat measurements were taken for all participants at the initial study visit, and for 10 participants in a second measurement session 4 weeks later. Strain measures were calculated from pre-captured images using Motion Analysis 2014v1 software by two independent raters. Within-session intra- and inter-rater reliability and between-session intra-rater reliability were calculated using intraclass correlation coefficients (ICC) with 95% confidence intervals. The standard error of measurement was also calculated. Results The two-probe procedure to measure Achilles tendon strain showed excellent within-session intra-rater (ICC = 0.84, p < 0.001) and inter-rater reliability (ICC = 0.88, p = 0.003), but poor between-session intra-rater reliability (ICC = 0.18, p = 0.397). Conclusion The two-probe procedure to measure Achilles tendon strain is reliable for repeated measurements on the same day. However, measurement error increased when strain was measured on different days, which may be attributable to a combination of examiner error and participant factors. Measurement of Achilles tendon strain offers an additional tool for evaluating the tendon's mechanical characteristics. The ability to reliably quantify strain may allow clinicians to identify those at risk for Achilles tendinopathy and formulate more effective management plans.
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21
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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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Abstract
Most nonoperative treatments for insertional Achilles tendinopathy (IAT) have insufficient evidence to support treatment recommendations. Exercise has the highest level of evidence supporting the ability of this treatment option to reduce IAT pain. The effects of exercise may be enhanced by a wide variety of other treatments, including soft tissue treatment, nutritional supplements, iontophoresis, education, stretching, and heel lifts. When exercise is unsuccessful, extracorporeal shock wave therapy seems to be the next best nonoperative treatment option to reduce IAT pain. After other nonoperative treatment options have been exhausted, injections may be considered, particularly to facilitate participation in an exercise program.
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Affiliation(s)
- Connor P Dilger
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, 500 Newton Road, 1-252 Medical Education Building, Iowa City, IA 52242, USA
| | - Ruth L Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, 500 Newton Road, 1-252 Medical Education Building, Iowa City, IA 52242, USA.
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Zellers JA, Bley BC, Pohlig RT, Alghamdi NH, Silbernagel KG. FREQUENCY OF PATHOLOGY ON DIAGNOSTIC ULTRASOUND AND RELATIONSHIP TO PATIENT DEMOGRAPHICS IN INDIVIDUALS WITH INSERTIONAL ACHILLES TENDINOPATHY. Int J Sports Phys Ther 2019; 14:761-769. [PMID: 31598414 PMCID: PMC6769280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Insertional tendinopathy is likely caused by different pathologies. This variation could account for the recalcitrant nature of this condition to treatment. Ultrasound imaging may assist in identifying underlying pathology to inform patient management. HYPOTHESIS/PURPOSE The primary purpose of this study was to quantify the presence of underlying pathology using ultrasound in individuals with a clinical diagnosis of insertional Achilles tendinopathy. Secondarily, we sought to examine the relationship of abnormal ultrasound findings to age and body mass index (BMI). STUDY DESIGN Cross-sectional study. METHODS Fifty-six individuals with insertional tendinopathy were included in this study. B-mode ultrasound imaging was used to descriptively and quantitatively describe tendon pathology. RESULTS A greater proportion of bone defect (p<0.001), intratendinous calcifications (p = 0.01) and midportion tendinosis (p<0.001) were observed on the injured side compared to the uninjured side. Higher BMI was associated with presence of bone deformity, intratendinous calcifications and distal tendinosis (p = 0.001-0.04); adding age did not significantly improve the regression model. CONCLUSION Patients with insertional tendinopathy present with multiple underlying pathologies. This may account for variable response to treatment. It may be helpful to include imaging to better identify underlying pathology when trying to determine an appropriate treatment strategy. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
| | | | - Ryan T. Pohlig
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
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Rowlett CA, Hanney WJ, Pabian PS, McArthur JH, Rothschild CE, Kolber MJ. Efficacy of instrument-assisted soft tissue mobilization in comparison to gastrocnemius-soleus stretching for dorsiflexion range of motion: A randomized controlled trial. J Bodyw Mov Ther 2019; 23:233-240. [PMID: 31103101 DOI: 10.1016/j.jbmt.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/01/2018] [Accepted: 02/05/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To determine the efficacy of IASTM of the gastrocnemius-soleus complex in comparison to a traditional stretching intervention on dorsiflexion ROM. METHODS Sixty healthy participants were randomly allocated to one of 3 groups: IASTM (n = 20), stretching (n = 20), or control group (n = 20). The dependent variables for this study was dorsiflexion range of motion (ROM) via three measurement methods which included Modified root position 1- knee extended (MRP1), Modified root position 2- knee flexed (MRP2), and weight bearing lunge test (WBLT). A multivariate analysis of variance (MANOVA) was utilized to analyze the ROM differences between the groups (IASTM, stretching, and control groups), with a post-hoc Tukey and pairwise least significant difference tests to assess individual pairwise differences between the groups. RESULTS The MANOVA found significant ROM differences between the three intervention groups (F6,110 = 2.40, p = .032). Statistically significant differences were identified between both the IASTM and control as well as the stretching and control group through the WBLT and MRP2 assessments, but not in the MRP1 assessment. Further, there was no statistically significant difference between the IASTM and stretching groups using any of the three methods. CONCLUSION A single session of IASTM or stretching increased ankle dorsiflexion ROM in WBLT and MRP2. No significant difference was noted in the MRP1. Both IASTM and stretching appear to have a greater effect on soleus muscle flexibility as evidenced by ROM gains measured with the knee in a flexed position. No clinically significant difference was identified between the intervention groups in weight-bearing conditions; thus empowering patients with the use of self-stretching would seemingly be reasonable and efficient. Combined effects of stretching and IASTM warrant further investigation for increasing dorsiflexion range of motion as a summative effect is unknown.
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Affiliation(s)
- Carrie A Rowlett
- University of Central Florida, Department of Health Professions, USA
| | - William J Hanney
- University of Central Florida, Department of Health Professions, USA.
| | - Patrick S Pabian
- University of Central Florida, Department of Health Professions, USA
| | - Jordon H McArthur
- University of Central Florida, Department of Health Professions, USA
| | | | - Morey J Kolber
- Nova Southeastern University, Department of Physical Therapy, USA
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25
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Obst SJ, Heales LJ, Schrader BL, Davis SA, Dodd KA, Holzberger CJ, Beavis LB, Barrett RS. Are the Mechanical or Material Properties of the Achilles and Patellar Tendons Altered in Tendinopathy? A Systematic Review with Meta-analysis. Sports Med 2018; 48:2179-2198. [DOI: 10.1007/s40279-018-0956-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Fusini F, Langella F, Busilacchi A, Tudisco C, Gigante A, Massé A, Bisicchia S. Real-time sonoelastography: principles and clinical applications in tendon disorders. A systematic review. Muscles Ligaments Tendons J 2018; 7:467-477. [PMID: 29387640 DOI: 10.11138/mltj/2017.7.3.467] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Sonoelastography (SE) is a new ultrasound-based method adopted in an increased number of scientific reports to analyse normal and pathological tendons. The aim of this study is to provide a systematic overview of clinical applications of SE in normal and pathological tendons. Methods A systematic research of PubMed, Ovid, and Cochrane Library electronic databases was performed according to PRISMA guideline. Two Authors searched and evaluated the articles independently; a third Author was involved to solve any disagreement. The Oxford Level of Evidence (LoE) was used to assess each article. Results There is an increasing interest in the application of SE in the evaluation of healthy and diseased tendons. Many different tendons are amenable for SE evaluation, such as the Achilles and patellar tendons, rotator cuff, common extensor tendons, quadriceps tendon, and the plantar fascia. Conclusion SE appears to be a very useful diagnostic tool, in particular in tendon pathology. This is a dynamic examination, provides an immediate evaluation of the tissue elasticity, and may be useful in recognizing tendon abnormalities and in implementing the information available with conventional US. Level of evidence IV.
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Affiliation(s)
- Federico Fusini
- University of Turin, School of Orthopaedic and Traumatology, Turin, Italy
| | - Francesco Langella
- Clinical Orthopedics, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alberto Busilacchi
- Clinical Orthopedics, Department of Molecular Pathology and Innovative Therapies, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Cosimo Tudisco
- Department of Orthopaedic Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Antonio Gigante
- Clinical Orthopedics, Department of Molecular Pathology and Innovative Therapies, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Alessandro Massé
- University of Turin, School of Orthopaedic and Traumatology, Turin, Italy
| | - Salvatore Bisicchia
- Orthopaedics and Traumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
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Chimenti RL, Cychosz CC, Hall MM, Phisitkul P. Current Concepts Review Update: Insertional Achilles Tendinopathy. Foot Ankle Int 2017; 38:1160-1169. [PMID: 28789557 PMCID: PMC5956523 DOI: 10.1177/1071100717723127] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Ruth L. Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Chris C. Cychosz
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Mederic M. Hall
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA,Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
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Bogaerts S, De Brito Carvalho C, Scheys L, Desloovere K, D’hooge J, Maes F, Suetens P, Peers K. Evaluation of tissue displacement and regional strain in the Achilles tendon using quantitative high-frequency ultrasound. PLoS One 2017; 12:e0181364. [PMID: 28727745 PMCID: PMC5519157 DOI: 10.1371/journal.pone.0181364] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/29/2017] [Indexed: 01/08/2023] Open
Abstract
The Achilles tendon has a unique structure-function relationship thanks to its innate hierarchical architecture in combination with the rotational anatomy of the sub-tendons from the triceps surae muscles. Previous research has provided valuable insight in global Achilles tendon mechanics, but limitations with the technique used remain. Furthermore, given the global approach evaluating muscle-tendon junction to insertion, regional differences in tendon mechanical properties might be overlooked. However, recent advancements in the field of ultrasound imaging in combination with speckle tracking have made an intratendinous evaluation possible. This study uses high-frequency ultrasound to allow for quantification of regional tendon deformation. Also, an interactive application was developed to improve clinical applicability. A dynamic ultrasound of both Achilles tendons of ten asymptomatic subjects was taken. The displacement and regional strain in the superficial, middle and deep layer were evaluated during passive elongation and isometric contraction. Building on previous research, results showed that the Achilles tendon displaces non-uniformly with a higher displacement found in the deep layer of the tendon. Adding to this, a non-uniform regional strain behavior was found in the Achilles tendon during passive elongation, with the highest strain in the superficial layer. Further exploration of tendon mechanics will improve the knowledge on etiology of tendinopathy and provide options to optimize existing therapeutic loading programs.
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Affiliation(s)
- Stijn Bogaerts
- Department of Development & Regeneration, KULeuven / Department of Physical Medicine & Rehabilitation, University Hospitals Leuven, Leuven, Belgium
- * E-mail:
| | | | - Lennart Scheys
- Department of Development & Regeneration, Institute for Orthopedic Research and Training (IORT), KULeuven / Division of Orthopedics, University Hospitals Leuven, Leuven, Belgium
| | - Kaat Desloovere
- Clinical Motion Analysis Laboratory, Department of Rehabilitation Sciences, KULeuven and University Hospitals Leuven, Leuven, Belgium
| | - Jan D’hooge
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Frederik Maes
- ESAT/PSI & UZ Leuven, MIRC, KULeuven and University Hospitals Leuven, Leuven, Belgium
| | - Paul Suetens
- ESAT/PSI & UZ Leuven, MIRC, KULeuven and University Hospitals Leuven, Leuven, Belgium
| | - Koen Peers
- Department of Development & Regeneration, KULeuven / Department of Physical Medicine & Rehabilitation, University Hospitals Leuven, Leuven, Belgium
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Chimenti RL, Forenza A, Previte E, Tome J, Nawoczenski DA. Forefoot and rearfoot contributions to the lunge position in individuals with and without insertional Achilles tendinopathy. Clin Biomech (Bristol, Avon) 2016; 36:40-5. [PMID: 27209257 DOI: 10.1016/j.clinbiomech.2016.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 03/14/2016] [Accepted: 05/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Clinicians use the lunge position to assess and treat restricted ankle dorsiflexion. However, the individual forefoot and rearfoot contributions to dorsiflexion and the potential for abnormal compensations are unclear. The purposes of this case-control study were to 1) compare single- (representing a clinical lunge position measure) versus multi-segment contributions to dorsiflexion, and 2) determine if differences are present in patients with tendinopathy. METHODS 32 individuals (16 with insertional Achilles tendinopathy and 16 age- and gender-matched controls) participated. Using three-dimensional motion analysis, the single-segment model was defined as tibial inclination relative to the whole foot. The multi-segment model consisted of rearfoot (tibia relative to calcaneus) and forefoot (1st metatarsal relative to calcaneus) motion. Two-way (kinematic model and group) analyses of variance were used to assess differences in knee bent and straight positions. Associations between models were tested with Pearson correlations. FINDINGS Single-segment modeling resulted in ankle DF values 5° greater than multi-segment modeling that isolated rearfoot dorsiflexion for knee bent and straight positions (P<0.01). Compared to controls, the tendinopathy group had 10° less dorsiflexion with the knee bent (P<0.01). For the tendinopathy group, greater dorsiflexion was strongly associated with greater rearfoot (r=0.95, P<0.01) and forefoot (r=0.81, P<0.01) dorsiflexion. For controls, dorsiflexion was strongly associated with rearfoot (r=0.87, P<0.01) but not forefoot dorsiflexion (r=0.23, P=0.39). INTERPRETATION Clinically used single-segment models of ankle dorsiflexion overestimate rearfoot dorsiflexion. Participants with insertional Achilles tendinopathy may compensate for restricted and/or painful ankle dorsiflexion by increased lowering of the medial longitudinal arch (forefoot dorsiflexion) with the lunge position.
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Affiliation(s)
- R L Chimenti
- University of Rochester, School of Nursing, 255 Crittenden Blvd, Rochester, NY 14642, United States.
| | - A Forenza
- Ithaca College, Program in Physical Therapy, 953 Danby Rd, Ithaca, NY 14850, United States
| | - E Previte
- Ithaca College, Program in Physical Therapy, 953 Danby Rd, Ithaca, NY 14850, United States
| | - J Tome
- Ithaca College, Program in Physical Therapy, 953 Danby Rd, Ithaca, NY 14850, United States
| | - D A Nawoczenski
- University of Rochester, Department of Orthopaedics, 601 Elmwood Ave, Rochester, NY 14642, United States
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