Utility of Ultrasound for Imaging Osteophytes in Patients With Insertional Achilles Tendinopathy

Musculoskeletal disorders in padel: from biomechanics to sonography

Padel is a racket sport, combining high-frequency and low-intensity athletic gestures, that has been gaining growing scientific interest in recent years. Musculoskeletal injuries are very common among padel players with an incidence rate of 3 per 1000 h of training and 8 per 1000 matches. To the best of our knowledge, a comprehensive collection describing the most common sonographic findings in padel players with musculoskeletal injuries is lacking in the pertinent literature. In this sense, starting from the biomechanical features of padel-specific gestures we have reported the ultrasonographic patterns of most frequent injuries involving the upper limb, the trunk, and the lower limb. Indeed, comprehensive knowledge of the biomechanical and clinical features of musculoskeletal injuries in padel is paramount to accurately perform a detailed ultrasound examination of the affected anatomical site. So, the present investigation aims to provide a practical guide, simple and ready-to-use in daily practice, to optimize the sonographic assessment of padel players by combining it with the clinical findings and the biomechanical features of athletic gestures.

[Treatment of Achilles insertional calcific tendinosis using a longitudinal midline incision approach/central tendon splitting approach]

OBJECTIVE

Treatment of Achilles insertional calcific tendinosis through a longitudinal midline incision approach with optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity).

INDICATIONS

Calcific Achilles tendinosis, dorsal heel spur, insertional tendinosis.

CONTRAINDICATIONS

General medical contraindications to surgical interventions. Fracture, infection.

SURGICAL TECHNIQUE

Longitudinal skin incision medial of the Achilles tendon. Exposure and midline incision of the Achilles tendon with plantar detachment from the insertion site preserving medial and lateral attachment. Resection of a dorsal heel spur and intratendinous calcifications. Optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity).

POSTOPERATIVE MANAGEMENT

Partial weight bearing 20 kg in 30° plantar flexion in a long walker boot for 2 weeks. Afterwards 2 weeks of progressively weight bearing in 15° plantar flexion and another 2 weeks in neutral ankle joint position in a long walker boot.

RESULTS

A total of 26 feet of 26 patients with calcific Achilles tendinosis were treated with midline incision of the tendon. In all feet calcific tendon parts were resected. In 10 (38%) feet, a prominent dorsal spur was resected, in 12 feet (38%) retrocalcaneal bursa, and in 24 (92%) feet a calcaneal tuberosity. Mean follow-up was 34.5 months (range 2-64 months). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 58.2 (±8.1) and postoperatively the score was 22.75 (±6.0). In all, 7 (26.9%) patients stated delayed wound healing; 1 suffered from deep vein thrombosis. Shoe problems were reported by 50% of patients, and 23.1% suffered from par- or dysesthesia. No revision surgery was required.

The clinical diagnosis of Achilles tendinopathy: a scoping review

Background

Achilles tendinopathy describes the clinical presentation of pain localised to the Achilles tendon and associated loss of function with tendon loading activities. However, clinicians display differing approaches to the diagnosis of Achilles tendinopathy due to inconsistency in the clinical terminology, an evolving understanding of the pathophysiology, and the lack of consensus on clinical tests which could be considered the gold standard for diagnosing Achilles tendinopathy. The primary aim of this scoping review is to provide a method for clinically diagnosing Achilles tendinopathy that aligns with the nine core health domains.

Methodology

A scoping review was conducted to synthesise available evidence on the clinical diagnosis and clinical outcome measures of Achilles tendinopathy. Extracted data included author, year of publication, participant characteristics, methods for diagnosing Achilles tendinopathy and outcome measures.

Results

A total of 159 articles were included in this scoping review. The most commonly used subjective measure was self-reported location of pain, while additional measures included pain with tendon loading activity, duration of symptoms and tendon stiffness. The most commonly identified objective clinical test for Achilles tendinopathy was tendon palpation (including pain on palpation, localised tendon thickening or localised swelling). Further objective tests used to assess Achilles tendinopathy included tendon pain during loading activities (single-leg heel raises and hopping) and the Royal London Hospital Test and the Painful Arc Sign. The VISA-A questionnaire as the most commonly used outcome measure to monitor Achilles tendinopathy. However, psychological factors (PES, TKS and PCS) and overall quality of life (SF-12, SF-36 and EQ-5D-5L) were less frequently measured.

Conclusions

There is significant variation in the methodology and outcome measures used to diagnose Achilles tendinopathy. A method for diagnosing Achilles tendinopathy is proposed, that includes both results from the scoping review and recent recommendations for reporting results in tendinopathy.

Tensile mechanical changes in the Achilles tendon due to Insertional Achilles tendinopathy

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.

FREQUENCY OF PATHOLOGY ON DIAGNOSTIC ULTRASOUND AND RELATIONSHIP TO PATIENT DEMOGRAPHICS IN INDIVIDUALS WITH INSERTIONAL ACHILLES TENDINOPATHY

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.

Insertional achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion

The purposes of this case-control study (N = 20) were to examine the effects of insertional Achilles tendinopathy (IAT) and tendon region on tendon strain in patients with IAT compared to a control group without tendinopathy. An ultrasound transducer was positioned over the Achilles tendon insertion during dorsiflexion tasks, which included standing and partial squat. A non-rigid image registration-based algorithm was used to estimate transverse compressive and axial tensile strains of the tendon from radiofrequency ultrasound images, which was segmented into two regions (superficial tendon and deep). For transverse compressive strain, two-way mixed effects ANOVAs demonstrated that there were interaction effects between group and tendon region for both dorsiflexion tasks (Heel lowering, p = 0.004; Partial squat, p = 0.008). For axial tensile strain, the IAT group demonstrated a main effect of lower tensile strain than the control group (Standing, p = 0.001; Partial squat, p = 0.033). There was also a main effect of greater tensile strain in the superficial region of the tendon compared to the deep during standing (p = 0.002), but not during partial squat (p = 0.603). Reduced transverse compressive and axial tensile strains in the IAT group indicate altered mechanical properties specific to the region of IAT pathology. Additionally, patterns of compressive strain are consistent with the theory of calcaneal impingement contributing to IAT pathology. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:910-915, 2017.