Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients

Low-Intensity Pulsed Ultrasound Promotes the Repair of Achilles Tendinopathy by Downregulating the JAK/STAT Signaling Pathway in Rabbits

Tendinopathy is a complex tendon injury or pathology outcome, potentially leading to permanent impairment. Low-intensity pulsed ultrasound (LIPUS) is emerging as a treatment modality for tendon disorders. However, the optimal treatment duration and its effect on tendons remain unclear. This study aims to investigate the efficacy of LIPUS in treating injured tendons, delineate the appropriate treatment duration, and elucidate the underlying treatment mechanisms through animal experiments. Ninety-six three-month-old New Zealand white rabbits were divided into normal control (NC) and model groups. The model group received Prostaglandin E2 (PGE2) injections to induce Achilles tendinopathy. They were then divided into model control (MC) and LIPUS treatment (LT) groups. LT received LIPUS intervention with a 1-MHz frequency, a pulse repetition frequency (PRF) of 1 kHz, and spatial average temporal average sound intensity ( [Formula: see text]) of 100 mW/cm2. MC underwent a sham ultrasound, and NC received no treatment. Assessments on 1, 4, 7, 14, and 28 days after LT included shear wave elastography (SWE), mechanical testing, histologic evaluation, ribonucleic acid sequencing (RNA-seq), polymerase chain reaction (PCR), and western blot (WB) analysis. SWE results showed that the shear modulus in the LT group was significantly higher than that in the MC group after LT for seven days. Histological results demonstrated improved tendon tissue alignment and fibroblast distribution after LT. Molecular analyses suggested that LIPUS may downregulate the Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling pathway and regulate inflammatory and matrix-related factors. We concluded that LT enhanced injured tendon elasticity and accelerated Achilles tendon healing. The study highlighted the JAK/STAT signaling pathway as a potential therapeutic target for LT of Achilles tendinopathy, guiding future research.

Two-Year Clinical and Radiologic Outcomes Following Surgical Treatment of Insertional Achilles Tendinopathy Using a Central Tendon-Splitting Approach

BACKGROUND

If conservative treatment of insertional Achilles tendinopathy (IAT) fails, surgery is often considered. Various surgical approaches have been used including the central Achilles tendon splitting approach. This study aimed to report the 2-year clinical and radiologic outcomes after surgical treatment of IAT with a central tendon-splitting approach.

METHODS

Seventy-five cases of IAT treated surgically via the open central tendon-splitting approach were analyzed. Clinical outcomes included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36) physical (PCS) and mental (MCS) component summary scores, all measured at baseline and 6 and 24 months postoperatively. Radiologic parameters measured included the Fowler-Philip angle (FPA) and parallel pitch lines (PPL).

RESULTS

Three patients had clinically significant wound issues but healed completely by 3 weeks. Mean AOFAS score improved from 45.63 preoperatively to 94.71 at 24 months. Mean VAS score improved from 6.73 preoperatively to 0.55, mean SF-36 PCS from 35.98 to 48.74, and mean SF-36 MCS from 53.04 to 55.43 at 24 months. Satisfaction at 2 years was 94.3%. Mean FPA decreased from 62.0 degrees preoperatively to 34.0 degrees postoperatively. PPL was positive in 82.7% (62 of 75) of cases preoperatively, decreasing to 1.3% (1 of 75) postoperatively. Increasing age and higher preoperative VAS and SF-36 MCS scores were significantly associated with improvements in postoperative AOFAS, SF-36 PCS, and MCS scores.

CONCLUSION

Surgical treatment of IAT via the central tendon-splitting approach achieved substantial improvements in all patient-reported outcome measures measured. These excellent clinical outcomes continued to show improvement 2 years postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Combined Midportion Achilles and Plantaris Tendinopathy: A 1-Year Follow-Up Study after Ultrasound and Color-Doppler-Guided WALANT Surgery in a Private Setting in Southern Sweden

Background and Objectives: Chronic painful midportion Achilles combined with plantaris tendinopathy can be a troublesome condition to treat. The objective was to prospectively follow patients subjected to ultrasound (US)- and color doppler (CD)-guided wide awake, local anesthetic, no-tourniquet (WALANT) surgery in a private setting. Material and Methods: Twenty-six Swedish patients (17 men and 9 women, mean age 50 years (range 29–62)) and eight international male patients (mean age of 38 years (range 25–71)) with combined midportion Achilles and plantaris tendinopathy in 45 tendons altogether were included. All patients had had >6 months of pain and had tried non-surgical treatment with eccentric training, without effect. US + CD-guided surgical scraping of the ventral Achilles tendon and plantaris removal under local anesthesia was performed on all patients. A 4–6-week rehabilitation protocol with an immediate full-weight-bearing tendon loading regime was used. The VISA-A score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation. Results: At the 1-year follow-up, 32/34 patients (43 tendons) were satisfied with the treatment result and had returned to their pre-injury Achilles tendon loading activity. There were two dropouts (two tendons). For the Swedish patients, the mean VISA-A score increased from 34 (0–64) before surgery to 93 (61–100) after surgery (p < 0.001). There were two complications, one wound rupture and one superficial skin infection. Conclusions: For patients suffering from painful midportion Achilles tendinopathy and plantaris tendinopathy, US + CD-guided surgical Achilles tendon scraping and plantaris tendon removal showed a high satisfaction rate and good functional results 1 year after surgery.

Clinical Outcomes of Transarterial Embolization for Chronic Achilles Tendinopathy Refractory to Conservative Treatment: A Pilot Study

PURPOSE

To evaluate the effectiveness and safety of transarterial embolization (TAE) for chronic Achilles tendinopathy (AT) refractory to conservative treatment.

MATERIALS AND METHODS

This retrospective study included 20 patients (12 men and 8 women; mean age, 30.3 years) who received TAE using imipenem/cilastatin sodium for refractory chronic AT from May 2019 to April 2021. Nine patients had bilateral involvement. A total of 29 procedures were performed (8 for nonathletes and 21 for athletes). If feasible, embolization was performed superselectively of the arterial branch demonstrating hypervascularity, early venous drainage, and/or supplying the pain site noted using a radiopaque marker. The visual analog scale (VAS, 0-10) score was used to assess pain symptoms at baseline and during the follow-up period (1 day; 1 week; 1, 3, and 6 months; and open period). Clinical success was defined as a decrease of >50% in the VAS score at 6 months when compared with baseline.

RESULTS

In 25 (86.2%) of 29 procedures, clinical success was achieved. Significant decreases in the VAS scores were noted at 1 day, 1 week, 1 month, 3 months, and 6 months (6.86 at the baseline vs 3.48, 3.41, 3.10, 2.55, and 1.62, respectively; all P < .01). For patients available for the 12- and 24-month follow-ups (n = 19 and 6, respectively), the mean VAS scores significantly decreased (6.84 vs 2.00 and 7.33 vs 1.17, respectively; all P < .01). No serious adverse events were observed during follow-up.

CONCLUSIONS

TAE may alleviate pain for patients with chronic AT refractory to the conservative treatment with a low risk of adverse events.

A high-fat diet has negative effects on tendon resident cells in an in vivo rat model

BACKGROUND

Tendinopathy is a major complication of diet-induced obesity. However, the effects of a high-fat diet (HFD) on tendon have not been well characterised. We aimed to determine: [1] the impact of a HFD on tendon properties and gene expression; and [2] whether dietary transition to a control diet (CD) could restore normal tendon health.

METHODS

Sprague-Dawley rats were randomised into three groups from weaning and fed either a: CD, HFD or HFD for 12 weeks and then CD thereafter (HF-CD). Biomechanical, histological and structural evaluation of the Achilles tendon was performed at 17 and 27 weeks of age. Tail tenocytes were isolated with growth rate and collagen production determined. Tenocytes and activated THP-1 cells were exposed to conditioned media (CM) of visceral adipose tissue explants, and gene expression was analysed.

RESULTS

There were no differences in the biomechanical, histological or structural tendon properties between groups. However, tenocyte growth and collagen production were increased in the HFD group at 27 weeks. There was lower SOX-9 expression in the HFD and HF-CD groups at 17 weeks and higher expression of collagen-Iα1 and matrix metalloproteinase-13 in the HFD group at 27 weeks. THP-1 cells exposed to adipose tissue CM from animals fed a HFD or HF-CD had lower expression of Il-10 and higher expression of Il-1β.

CONCLUSIONS

In this rodent model, a HFD negatively altered tendon cell characteristics. Dietary intervention restored some gene expression changes; however, adipose tissue secretions from the HF-CD group promoted an increased inflammatory state in macrophages. These changes may predispose tendon to injury and adverse events later in life.

Adipose-derived Stromal Vascular Fraction Injection in a Competitive High-level Athlete Affected by Insertional Achilles Tendinopathy

Achilles tendinopathy is one of the most common ankle and foot overuse injuries, especially among athletes. Despite this, the management of this injury lacks an evidence-based support, and patients are at risk of long-term morbidity with unpredictable clinical outcome. Recently, injective approach has gained more and more attention, and in particular the intratendinous injection with adipose-derived stromal vascular fraction. We report a case of an insertional Achilles tendinopathy in a high-level professional athlete, who was treated avoiding surgical treatment in favor of this innovative biological approach. Patient's satisfaction and return to play was prospectively evaluated for a period of 6 months of follow-up. An improvement of all functional scores was yet appreciated after 1 month from the treatment, with a crescent trend until the last 6-month follow-up. The patient was able to return to train after 34 days, and returned to match after 68 days, playing 20 minutes. She returned to the complete full game 72 days after treatment. However subsequent ultrasound and MRI evaluations failed to show any substantial changes in the characteristics of the lesion from the preoperative images. This case report opens a new window for the treatment of insertional Achilles tendinopathy in competitive athletes. The current outcome deserves further investigation with higher quality studies in order to confirm the validity of this fascinating therapeutic option.

Achilles tendinopathy: Exploring injury characteristics and current treatment modalities

Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.

Mid-term results of open debridement and reattachment surgery for insertional Achilles tendinopathy: A retrospective clinical study

OBJECTIVE

The aim of this study was to determine the effects of age and body mass index (BMI) on the functional outcomes, satisfaction rates, and recovery time after open debridement and reattachment surgery in non-athletic patients with insertional Achilles tendinopathy (IAT).

METHODS

In this retrospective study, 33 non-athletic patients (34 ankles) in whom open debridement and reattachment surgery was performed for IAT from 2006 to 2016 were included. Change in pain intensity was assessed using a Visual Analogue Scale (VAS) preoperatively and at the final follow-up. Functional assessment was done by preoperative and postoperative American Orthopaedics Foot and Ankle Score (AOFAS) and final follow-up Victorian Institute of Sport Tendon Study Group-Achilles Tendinopathy score (VISA-A). Patient satisfaction was evaluated by Roles - Maudsley score (RMS). The recovery time was defined as the time interval from the first appearance to postoperative relief of symptoms and recording. In addition, the recurrent Haglund's deformity was determined by postoperative control radiographs.

RESULTS

The mean age at the time of the operation was 51.19 years. The mean follow-up was 61.75±8.49 months. According to BMI, 5 patients were determined as morbid obese, 19 as obese, 3 as overweight, and 6 as normal. The mean VAS score significantly decreased from 8.5 preoperatively to 1.3 postoperatively (p<0.001). The mean AOFAS score significantly improved from 55.8 preoperatively to 92 postoperatively (p<0.001). Postoperative VISA-A score was 86% (range=32%-100%). According to RMS, 22 patients reported the result as excellent, 8 as good, 2 as fair, and 1 as poor. The mean recovery time was 11.8 (range=2-60) months, but one patient did not reach a symptom free status and thus was not included in the recovery time analysis. Postoperative control radiographs revealed signs of recurrence deformity in four patients. Recovery time showed a negative correlation with the age of the patients (r=-0.65). Postoperative scores and BMI showed no significant correlations with the recovery time on the basis of Spearman's rho test (p=0.196).

CONCLUSION

The results of this study have shown that open debridement and reattachment surgery may be an effective surgical method in relieving pain and improving functional status with high satisfaction rate and acceptable recovery time in the management of non-athletic patients with IAT.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Meta-analysis of Noninsertional Achilles Tendinopathy

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional. A variety of treatment methods have been described, although little consensus exists on an optimal method or methods. We sought to investigate the current evidence on different treatment methods for noninsertional Achilles tendinopathy, with a focus on functional outcomes.

METHODS

We performed a review of the available literature in PubMed and the Cochrane Central Register of Controlled Trials. Data from included studies were categorized according to treatment method and analyzed with respect to functional outcome and complication rate.

RESULTS

In total, 1420 abstracts were reviewed, of which 72 articles containing 3523 patients met inclusion criteria. Within the 72 studies included, 6 operative techniques and 19 nonoperative treatments were evaluated.

CONCLUSION

A wide variety of treatments are available for noninsertional Achilles tendinopathy, although newer treatments and most operative methods lack high-level evidence. Eccentric exercise is the most thoroughly studied and supported nonoperative treatment, while tenotomy and debridement is the operative procedure with the most evidence of efficacy. Platelet-rich plasma injections and extracorporeal shockwave therapy have proven to be viable second-line nonoperative treatments. Gastrocnemius recession and flexor hallucis longus transfer have shown benefit in case series.

LEVEL OF EVIDENCE

Level II, systematic review.

Achilles tendinopathy

BACKGROUND

Achilles Tendinopathy (AT) is essentially a failed healing response with haphazard proliferation of tenocytes, abnormalities in tenocytes with disruption of collagen fibers, and subsequent increase in non-collagenous matrix.

METHODS

The diagnosis of Achilles tendinopathy is clinical, and MRI and utrasound imaging can be useful in differential diagnosis. Conservative manegement, open surgery or minimally invasive techniques are available. Injections and physical therapy are also vauable options.

RESULTS

Eccentric exercises are useful tools to manage the pathology. If the condition does not ameliorate, shock wave therapy, or nitric oxide patches might be considered. Peritendinous injections or injections at the interface between the Achilles tendon and Kager's triangle could be considered if physical therapy should fail. Surgery is indicated after 6 months of non-operative management.

CONCLUSIONS

The clinical diagnosis and management of AT are not straightforward. Hence, patients should understand that symptoms may recur with either conservative or surgical approaches.

Therapeutic Response of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy Between Sports-Active and Nonsports-Active Patients With 5-Year Follow-up

Background:

Insertional Achilles tendinopathy (IAT) is a common cause of posterior heel pain. Extracorporeal shock wave therapy (ESWT) has proven to be an effective treatment, but the relationship between therapeutic responses and sports activity levels has not been studied.

Purpose:

To compare the clinical outcomes of ESWT used to treat IATs between sports-active and nonsports-active patients over 5 years.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective study was conducted on 33 patients with IAT who received ESWT from October 2012 to September 2013. Patients were classified into 2 groups according to their preinjury Tegner activity level: a sports-active group, defined as patients who self-reported to be regular joggers (SA group; Tegner activity level >3; n = 16), and a nonsports-active group (control group; Tegner activity level ≤3; n = 17). The mean age was 31 ± 7 years for the SA group and 37 ± 10 years for the control group. The Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire scores and visual analog scale (VAS) pain scores were used to evaluate the clinical outcomes before treatment, immediately after treatment, and 5 years after treatment. Ultrasonography was also used to assess the insertional Achilles tendon quality.

Results:

Before treatment, there were no significant differences between the groups with regard to VAS scores, while the VISA-A score in the SA group was higher than that in the control group. After ESWT, both groups had increased VISA-A scores and decreased VAS scores, indicating improvement. At 5-year follow-up, the SA group had a significantly lower mean VAS score (0.3 ± 0.8 vs 1.6 ± 1.3; P = .001) and a significantly higher mean VISA-A score (90 ± 4 vs 78 ± 7; P < .001) compared with the control group. There was no significant difference between the groups regarding the calcification and neovascularization of the Achilles tendon based on ultrasonography.

Conclusion:

ESWT can improve the symptoms of Achilles tendinopathy, and patients with IAT who had greater sports activity levels had better therapeutic responses than nonsports-active patients after 5-year follow-up.

In Vitro Induction of Tendon-Specific Markers in Tendon Cells, Adipose- and Bone Marrow-Derived Stem Cells is Dependent on TGFβ3, BMP-12 and Ascorbic Acid Stimulation

Mesenchymal Stem Cells (MSCs) and tissue-specific progenitors have been proposed as useful tools for regenerative medicine approaches in bone, cartilage and tendon-related pathologies. The differentiation of cells towards the desired, target tissue-specific lineage has demonstrated advantages in the application of cell therapies and tissue engineering. Unlike osteogenic and chondrogenic differentiation, there is no consensus on the best tenogenic induction protocol. Many growth factors have been proposed for this purpose, including BMP-12, b-FGF, TGF-β3, CTGF, IGF-1 and ascorbic acid (AA). In this study, different combinations of these growth factors have been tested in the context of a two-step differentiation protocol, in order to define their contribution to the induction and maintenance of tendon marker expression in adipose tissue and bone marrow derived MSCs and tendon cells (TCs), respectively. Our results demonstrate that TGF-β3 is the main inducer of scleraxis, an early expressed tendon marker, while at the same time inhibiting tendon markers normally expressed later, such as decorin. In contrast, we find that decorin is induced by BMP-12, b-FGF and AA. Our results provide new insights into the effect of different factors on the tenogenic induction of MSCs and TCs, highlighting the importance of differential timing in TGF-β3 stimulation.

Fasciotomy and Surgical Tenotomy for Chronic Achilles Insertional Tendinopathy A Retrospective Study Using Ultrasound-Guided Percutaneous Microresection

BACKGROUND

Achilles insertional tendon pathology is a common condition affecting a broad range of patients. When conservative treatments are unsuccessful, the traditional open resection, debridement, and reattachment of the Achilles tendon is a variably reliable procedure with significant risk of morbidity. Fasciotomy and surgical tenotomy using ultrasound-guided percutaneous microresection is used on various tendons in the body, but the efficacy has not been examined specifically for the Achilles tendon.

METHODS

A retrospective review evaluated 26 procedures in 25 patients who underwent Achilles fasciotomy and surgical tenotomy. The Foot Function Index was used to quantify pain, disability, activity limitation, and overall scores.

RESULTS

Mean Foot Function Index scores were as follows: pain, 8.53%; disability, 7.91%; activity limitation, 2.50%; and overall, 6.97%. Twenty index procedures were successful, and two patients repeated the procedure successfully for an overall 84.6% success rate in patients with chronic insertional pathology with mean surveillance of 16 months. There were no infections or systemic complications.

CONCLUSIONS

Ultrasound-guided percutaneous microresection is a safe and minimally invasive percutaneous alternative that can be used before proceeding to a more invasive open procedure.

Overuse injuries in sport: a comprehensive overview

BACKGROUND

The absence of a single, identifiable traumatic cause has been traditionally used as a definition for a causative factor of overuse injury. Excessive loading, insufficient recovery, and underpreparedness can increase injury risk by exposing athletes to relatively large changes in load. The musculoskeletal system, if subjected to excessive stress, can suffer from various types of overuse injuries which may affect the bone, muscles, tendons, and ligaments.

METHODS

We performed a search (up to March 2018) in the PubMed and Scopus electronic databases to identify the available scientific articles about the pathophysiology and the incidence of overuse sport injuries. For the purposes of our review, we used several combinations of the following keywords: overuse, injury, tendon, tendinopathy, stress fracture, stress reaction, and juvenile osteochondritis dissecans.

RESULTS

Overuse tendinopathy induces in the tendon pain and swelling with associated decreased tolerance to exercise and various types of tendon degeneration. Poor training technique and a variety of risk factors may predispose athletes to stress reactions that may be interpreted as possible precursors of stress fractures. A frequent cause of pain in adolescents is juvenile osteochondritis dissecans (JOCD), which is characterized by delamination and localized necrosis of the subchondral bone, with or without the involvement of articular cartilage. The purpose of this compressive review is to give an overview of overuse injuries in sport by describing the theoretical foundations of these conditions that may predispose to the development of tendinopathy, stress fractures, stress reactions, and juvenile osteochondritis dissecans and the implication that these pathologies may have in their management.

CONCLUSIONS

Further research is required to improve our knowledge on tendon and bone healing, enabling specific treatment strategies to be developed for the management of overuse injuries.

Peritenolysis and Debridement for Main Body (Mid-Portion) Achilles Tendinopathy in Athletic Patients: Results of 107 Procedures

Achilles tendinopathy in the main body (mid-portion) of the tendon is a common pathologic finding among active and athletic populations and can be debilitating without proper and adequate treatment. Numerous surgical approaches for this common pathologic finding have been reported, with variable outcomes. We evaluated the surgical outcomes of peritenolysis and debridement of main body Achilles tendinopathy among athletic populations using the return to activity (RTA) and decreased desired activity (DDA) as our primary outcome measures. A total of 100 patients underwent 107 procedures by the senior author (A.S.) from January 2001 through December 2015 met the inclusion criteria, 65 (65%) of whom were runners. The mean follow-up duration was 106.6 ± 55.5 months from the index procedure, and the mean interval necessary to RTA for the entire group was 10.9 ± 5.3 weeks. The average RTA after debridement was 14.1 ± 5.2 weeks and after peritenolysis was 7.3 ± 2.0 weeks (p = .00001). Of the 100 patients, 3 (3%) had experienced a DDA at the last follow-up visit. With >97% of the patients able to return to their desired activities, we have concluded that peritenolysis and debridement are favorable surgical techniques for main body Achilles tendinopathy.

Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population

Background

Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%.

High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT).

Methods

RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited. Inclusion criteria: male, 18–55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment.

Discussion

Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment.

Trial Registration

EudraCT: 2015-003587-36 3 Dec 2015

Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series

BACKGROUND

The intra-tendinous tear is a new pathology that is defined as a discontinuity of fibres situated entirely within the tendon. Prolotherapy involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain.

METHODS

43 consecutive patients diagnosed with an intra-tendinous tear were included (27 males: 16 females, mean (SD) age 41 (11.3). Patients were injected with 0.4ml-1.5ml (mean 0.8ml) of 50% dextrose and 0.5% marcaine mixed in a 1:1 ratio. A 4-6 week period of walking boot immobilisation was followed by progressive rehabilitation (6-8 weeks). Outcomes were assessed with a VISA-A questionnaire at baseline, 3 months and a mean 12.6 (7.0) months post-treatment. Ultrasound scans were conducted before treatment and 5.2 (2.3) weeks later to assess sonographic changes.

RESULTS

30 patients (70%) responded with VISA-A scores increasing by 31 (30.5) points after 3 months (f=0.62, p<0.05) and by 40 (29.3) points after 12.60 (7.0) months (f=0.87, p<0.05). After 5.2 (2.3) weeks, echogenicity was significantly reduced (p<0.05) and 27% of tears were no longer detectable. No significant differences were observed in remaining tears with respect to tear size, tendon thickness or neovascularisation.

CONCLUSION

Treatment resulted in clinically significant improvements and controlled trials are warranted.

LEVEL OF EVIDENCE

IV.

Midsubstance Tendinopathy, Surgical Management

Noninsertional Achilles tendinopathy often responds to nonoperative treatment. When nonoperative treatment fails, the clinician must distinguish between paratendinopathy and noninsertional tendinopathy. In paratendinopathy, myofibroblasts synthesize collagen, causing adhesions, and the paratenon may be released or excised. If a core area of tendinopathy is identified on MRI, the area is excised longitudinally and repaired with a side-to-side suture. If greater than 50% of the tendon diameter is excised, the authors recommend a short flexor hallucis longus tendon transfer with an interference screw. A turndown flap of the gastrocnemius aponeurosis is also described with good results.

Posterior tibial tendinopathy: what are the risk factors?

BACKGROUND

Posterior tibial tendinopathy (PTT) is the most common cause of acquired (progressive) flatfoot deformity in adults. To date, PTT research has mainly focused on management rather than on causal mechanisms. The etiology of PTT is likely to be multifactorial because both intrinsic and extrinsic risk factors have been reported. We sought to critically evaluate reported etiologic factors for PTT and consider the concept of genetic risk factors.

METHODS

A detailed review of the literature published after 1936 was undertaken using English-language medical databases.

RESULTS

No clear consensus exists as to the relative importance of the risk factors reported, and neither has any consideration been given to a possible genetic basis for PTT.

CONCLUSIONS

To date, studies have examined various intrinsic and extrinsic risk factors implicated in the etiology of PTT. The interaction of these factors with an individual's genetic background may provide valuable data and help offer a more complete risk profile for PTT. A properly constructed genetic association study to determine the genetic basis of PTT would provide a novel and alternative approach to understanding this condition.

Clinical and Functional Outcomes of Gastrocnemius Recession for Chronic Achilles Tendinopathy

BACKGROUND

Although gastrocnemius recession has been proposed and used in the treatment of chronic noninsertional Achilles tendinopathy, only weak evidence exists to support this operative indication. The purpose of our study was to assess the clinical and functional outcomes of patients treated with gastrocnemius recession at 2 institutions for this problem.

METHODS

Thirty-four patients were identified through our medical records and asked to participate in this study. Thirty patients (35 legs) responded to the invitation. Sixteen patients were eligible for clinical follow-up, and 14 patients responded by letter or telephone interview. Two patients did not want to participate, and 2 patients could not be reached. Data were collected by a satisfaction questionnaire, the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, a visual analog scale (VAS) for pain, a functional test battery, and a clinical examination.

RESULTS

A subgroup with preoperative data (n = 8) showed an increase in the mean VISA-A score from 39.5 to 91.9. The mean overall VISA-A score (n = 30) was 91.4 at follow-up. The mean VAS for pain score when walking decreased from 7.5 before surgery to 0.8 after surgery. Twenty-eight of 30 patients reported that they were satisfied with their results after surgery. Functional testing showed no difference in gastrocnemius-soleus function between the operated and nonoperated leg (n = 10).

CONCLUSION

The findings support the promising results from other studies regarding gastrocnemius recession as an effective and safe way of treating chronic Achilles tendinopathy. The patients recovered both in terms of pain and function.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Surgical treatment for achilles tendinopathy - a systematic review

Background

The purpose of this systematic review is to analyse the results of operative treatment for midportion Achilles tendinopathy and to provide evidence based recommendation for the indication of the individual published techniques.

Methods

MEDLINE, Cochrane Database, ISI Web of Knowledge and Google databases (1945 till September 2014) were electronically searched. The quality of the included articles was evaluated using the Coleman Methodology Score. Success rates, patient satisfaction, and the complication rates were determined.

Results

Twenty studies met our inclusion criteria. A total of 801 tendons were treated in 714 patients with open or minimally invasive techniques. The mean success rate was 83.4 %. Complications were reported in 6.3 % of the cases. The articles on minimally invasive techniques and open procedures reported on an average success rate of 83.6 % and 78.9 (p = 0.987). Patient satisfaction rates for minimally invasive techniques and open procedures were 78.5 % and 78.1 % (p = 0.211). The complication rate was 5.3 % for the minimally invasive techniques and 10.5 % for the open procedures (p = 0.053).

Conclusion

We conclude that success rates of minimally invasive and open treatments are not different and that there is no difference in patient satisfaction but there is a tendency for more complications to occur in open procedures.

How Obesity Affects Tendons?

Several epidemiological and clinical observations have definitely demonstrated that obesity has harmful effects on tendons. The pathogenesis of tendon damage is multi-factorial. In addition to overload, attributable to the increased body weight, which significantly affects load-bearing tendons, systemic factors play a relevant role. Several bioactive peptides (chemerin, leptin, adiponectin and others) are released by adipocytes, and influence tendon structure by means of negative activities on mesenchymal cells. The ensuing systemic state of chronic, sub-clinic, low-grade inflammation can damage tendon structure. Metabolic disorders (diabetes, impaired glucose tolerance, and dislipidemia), frequently associated with visceral adiposity, are concurrent pathogenetic factors. Indeed, high glucose levels increase the formation of Advanced Glycation End-products, which in turn form stable covalent cross-links within collagen fibers, modifying their structure and functionality.Sport activities, so useful for preventing important cardiovascular complications, may be detrimental for tendons if they are submitted to intense acute or chronic overload. Therefore, two caution rules are mandatory: first, to engage in personalized soft training program, and secondly to follow regular check-up for tendon pathology.

Analysing the outcome of surgery for chronic Achilles tendinopathy over the last 50 years

AIM

To determine an association between when the study was performed, the robustness of the study and the outcomes for insertional and non-insertional Achilles tendinopathy surgery.

METHODS

We performed a systematic review in accordance with the PRISMA guidelines to assess the methodology of studies investigating the outcome of surgery in chronic Achilles tendinopathy over the last 50 years to identify any trends that would account for the variable results. The Coleman Methodology Scores were correlated with the reported percentage success rates and with the publication year to determine any trends using Pearson's correlation.

RESULTS

We identified 62 studies published between 1964 and 2014 reporting on a total of 2923 surgically treated Achilles tendinopathies. The average follow-up time was 40 mo (range 5-204 mo), and the mean reported success rate was 83.5% (range 36%-100%). The Coleman Methodology Scores were highly reproducible (r = 0.99, P < 0.01), with a mean of 40.1 (SD 18.9, range 2-79). We found a negative correlation between reported success rate and overall methodology scores (r = -0.40, P < 0.001), and a positive correlation between year of publication and overall methodology scores (r = 0.46, P < 0.001).

CONCLUSION

We conclude that although the success rate of surgery for chronic Acilles tendinopathy described in the literature has fallen over the last 50 years, this is probably due to a more rigorous methodology of the studies.

Achilles tendinosis: treatment options

Athletes usually complain of an ongoing or chronic pain over the Achilles tendon, but recently even non-athletes are experiencing the same kind of pain which affects their daily activities. Achilles tendinosis refers to a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation. Treatment is based on whether to stimulate or prevent neovascularization. Thus, until now, there is no consensus as to the best treatment for this condition. This paper aims to review the common ways of treating this condition from the conservative to the surgical options.

Release of the medial head of the gastrocnemius for Achilles tendinopathy in sedentary patients: a retrospective study

PURPOSE

Our aim was to ascertain whether releasing the medial head of he gastrocnemius improves clinical and functional outcomes of sedentary patients with long-standing tendinopathy of the main body of the Achilles tendon and allows return to daily activities.

METHODS

Eighteen patients (seven men, 11 women) underwent release of the gastrocnemius medial head to manage chronic unilateral Achilles tendinopathy. Pre- and postoperatively, each patient completed the Victorian Institute of Sports Assessment-Achilles tendon (VISA-A) questionnaire. The maximum calf circumference and isometric plantar flexion strength of the gastrocsoleus complex were measured in both the affected and the contralateral leg. Function was scored using the 4-point Boyden scale at the last assessment.

RESULTS

At the last appointment, at an average follow-up of 54 months, maximum calf circumference and strength of the operated leg were not significantly different than pre-operatively and were significantly lower than the contralateral leg. All patients could satisfactorily perform the same work and daily activities as before symptom onset. At the last follow-up, the average VISA-A score was improved from a preoperative average value of 52.3 to 75 (range 51-94) (p < .001).

CONCLUSIONS

This approach to managing isolated Achiles tendinopathy is safe, effective, low cost and allows safe return to preinjury daily activities.

Results of operative treatment for recalcitrant retrocalcaneal bursitis and midportion Achilles tendinopathy in athletes

BACKGROUND

The results of operative treatment for recalcitrant midportion Achilles tendinopathy and recalcitrant retrocalcaneal bursitis were evaluated using the patient administered, disease specific, and validated VISA-A-G questionnaire.

METHODS

A cohort of 89 patients was prospectively followed. These patients underwent operations for sport induced midportion Achilles tendinopathy (39 procedures) or retrocalcaneal bursitis (55 procedures). Depending on the individual intraoperative findings the patients of either disease were treated with two respective operative modifications (tendon repair or no tendon repair). Preoperative and follow-up status (3, 6, and 12 months) were investigated using the VISA-A-G questionnaire.

RESULTS

Preoperatively, the four groups scored from 37.0 ± 17.6 to 45.9 ± 15.2 (p = 0.376-0.993) on the VISA-A-G questionnaire. Six and 12 months postoperatively, the VISA-A-G scores improved significantly (p < 0.001). Twelve months postoperatively, the groups' scores were not different (p = 0.100-0.952) and ranged from 80.8 ± 17.9 to 90.3 ± 10.6.

CONCLUSION

Retrocalcaneal bursitis and midportion Achilles tendinopathy responded equally well to operative treatment. When repaired, additional tendon lesions did not influence this result. We demand to differentiate not only between midportion Achilles tendinopathy and retrocalcaneal bursitis but also to identify additional Achilles tendon lesions to specifically address these lesions during operative procedures.

Chronic sinus formation using non absorbable braided suture following open repair of Achilles tendon

This study reports a case of a 34 year old man who sustained an Achilles tendon rupture which was surgically repaired using a non-absorbable suture that was complicated by a deep sinus and chronic infection. Despite antibiotics, surgical debridement and skin grafting, his condition did not resolve. Further imaging revealed a sinus leading to the core suture knot that was eccentrically placed but not buried within the healed tendon repair, and the offending suture was subsequently removed. This case highlights the importance of meticulous surgical technique when performing Achilles tendon repair and a high index of suspicion for early imaging when patients present with chronic wound infection post-operatively. The authors urge surgeons to use routinely use an absorbable non-braided suture, which remains buried within the core when performing Achilles tendon repair.

Overweight and obesity alters the cumulative transverse strain in the Achilles tendon immediately following exercise

This research evaluated the effect of obesity on the acute cumulative transverse strain of the Achilles tendon in response to exercise. Twenty healthy adult males were categorized into 'low normal-weight' (BMI <23 kg m(-2)) and 'overweight' (BMI >27.5 kg m(-2)) groups based on intermediate cut-off points recommended by the World Health Organization. Longitudinal sonograms of the right Achilles tendon were acquired immediately prior and following weight-bearing ankle exercises. Achilles tendon thickness was measured 20-mm proximal to the calcaneal insertion and transverse tendon strain was calculated as the natural log of the ratio of post- to pre-exercise tendon thickness. The Achilles tendon was thicker in the overweight group both prior to (t18 = -2.91, P = 0.009) and following (t18 = -4.87, P < 0.001) exercise. The acute transverse strain response of the Achilles tendon in the overweight group (-10.7 ± 2.5%), however, was almost half that of the 'low normal-weight' (-19.5 ± 7.4%) group (t18 = -3.56, P = 0.004). These findings suggest that obesity is associated with structural changes in tendon that impairs intra-tendinous fluid movement in response to load and provides new insights into the link between tendon pathology and overweight and obesity.

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.

Fascial incision and adhesiolysis combined with radiofrequency microtenotomy in treatment of chronic midportion Achilles tendinopathy

BACKGROUND AND AIMS

Achilles tendinopathy is a common problem that can cause disturbing symptoms in activities of daily living as well as prevent sports activities. The purpose of this study was to evaluate the effects of fascial incision and adhesiolysis combined with radiofrequency microtenotomy in treatment of chronic midportion Achilles tendinopathy.

MATERIAL AND METHODS

Twenty-four patients were included in this study. The cases were studied retrospectively. The mean age of the patients was 54 years (range, 39 to 72) and there were 12 women and 12 men. A final evaluation was done at an average of 30 months (range, 18 to 45) after surgery, including radiofrequency microtenotomy.

RESULTS

In all cases the Nirschl Pain Phase Scale of Athletic Overuse Injuries score improved and the difference was statistically significant (p < 0.0001). The patients themselves rated the result excellent in 14 cases and good in 10 cases.

CONCLUSION

Fascial incision and adhesiolysis combined with radiofrequency microtenotomy seems to be a useful alternative in treatment of chronic midportion Achilles tendinopathy in cases of unsuccessful non-operative treatment.

What are the validated animal models for tendinopathy?

Chronic tendinopathy refers to a broad spectrum of pathological conditions in tendons and their insertion, with symptoms including activity-related chronic pain. To study the pathogenesis and management strategies of chronic tendinopathy, studies in animal models are essential. The different animal models in the literature present advantages and limitations, and there is no consensus regarding the criteria of a universal tendinopathy animal model. Based on the review of literature and the discussion in the International Symposium on Ligaments and Tendons-X, we concluded that established clinical, histopathological and functional characteristics of human tendinopathy were all important and relevant criteria to be met, if possible, by animal models. As tendinopathy is a progressive, multifactorial tendon disorder affecting different anatomical structures, it may not be realistic to expect a single animal model to study all aspects of tendinopathy. Staging of tendinopathy over time and clearer definition of tendinopathies in relation to severity and type would enable realistic targets with any animal model. The existing animal models can be used for answering specific questions (horses for courses) but should not be used to conclude the general aspects of tendinopathy neither in animals nor in human.

Diabetes mellitus alters the mechanical properties of the native tendon in an experimental rat model

The purpose of this study was to determine the effect of the diabetic phenotype on the mechanical properties of the native patellar tendon and its enthesis. Diabetes was induced via intraperitoneal injection of streptozotocin in Lewis rats. Control (n = 18) and diabetic animals (n = 20) were killed at 12 and 19 days for analysis. Statistical comparisons were performed using Student's t-tests and a two-tailed Fisher test with significance set at p < 0.05. Pre- and post-injection intraperitoneal glucose tolerance tests demonstrated significant impairment of glycemic control in the diabetic compared to control animals (p = 0.001). Mean serum hemoglobin A1c levels at 19 days was 10.6 ± 2.7% and 6.0 ± 1.0% for the diabetic and control groups, respectively (p = 0.0001). Fifteen of sixteen diabetic animals demonstrated intrasubstance failure of the patellar tendon, while only 7 of 14 control specimens failed within the tendon substance. The Young's modulus of the diabetic tendon was significantly lower than control specimens by 19 days post-induction (161 ± 10 N m(-2) compared to 200 ± 46 N m(-2) , respectively) (p = 0.02). The metabolic condition of poorly controlled diabetes negatively affects the mechanical properties of the native patellar tendon. These altered structural properties may predispose diabetic patients to a greater risk of tendinopathy and/or traumatic rupture.

[Surgical treatment for pain syndromes of the Achilles tendon]

Pain syndromes of the Achilles tendon (AT) include both insertional and non-insertional tendinopathy, two distinct disorders with different underlying pathophysiologies and management options, characterized by pain, impaired performance and swelling in and around the tendon. This article gives an overview of the operative treatment of pain syndromes of the Achilles tendon, including both insertional tendinopathy of the AT and tendinopathy of the main body of the AT. New minimally invasive techniques for the management of this condition, including endoscopy are also reported.

Achilles tendon rehabilitation

The operative management of acute Achilles tendon rupture marks the beginning of a comprehensive rehabilitation program. The goals of the rehabilitation program start with the reduction of pain and swelling and the recovery of ankle motion and power. They conclude with the restoration of coordinated activity and safe return to athletic activity. The rehabilitation protocol is directed by the injury and the quality of the repair, along with the patient's age, medical and social history, and athletic inclination. The protocol is dynamic and responsive to changing clinical findings.

Management of tendinopathy

Overuse disorders of tendons, or tendinopathies, present a challenge to sports physicians, surgeons, and other health care professionals dealing with athletes. The Achilles, patellar, and supraspinatus tendons are particularly vulnerable to injury and often difficult to manage successfully. Inflammation was believed central to the pathologic process, but histopathologic evidence has confirmed the failed healing response nature of these conditions. Excessive or inappropriate loading of the musculotendinous unit is believed to be central to the disease process, although the exact mechanism by which this occurs remains uncertain. Additionally, the location of the lesion (for example, the midtendon or osteotendinous junction) has become increasingly recognized as influencing both the pathologic process and subsequent management. The mechanical, vascular, neural, and other theories that seek to explain the pathologic process are explored in this article. Recent developments in the nonoperative management of chronic tendon disorders are reviewed, as is the rationale for surgical intervention. Recent surgical advances, including minimally invasive tendon surgery, are reviewed. Potential future management strategies, such as stem cell therapy, growth factor treatment, and gene transfer, are also discussed.

No influence of age, gender, weight, height, and impact profile in achilles tendinopathy in masters track and field athletes

BACKGROUND

Achilles tendinopathy is commonly reported by athletes involved in activities that include running and jumping. Despite the prevalence of the problem, causative factors in Achilles tendinopathy remain poorly understood.

HYPOTHESIS

In Masters track and field athletes, there is no influence of age, gender, weight, height, and impact profile in developing Achilles tendinopathy.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

During the European Veterans Athletics Championships in Poznań, Poland, in July 2006, 178 athletes (110 men and 68 women; mean age, 54.1 years; range, 35-94 years) were evaluated with the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. A fully trained orthopaedic surgeon made a diagnosis of Achilles tendinopathy according to clinical criteria.

RESULTS

There was no effect of gender on the presence of Achilles tendinopathy (P = .14). No significant track and field specialty effect upon the frequency of Achilles tendinopathy was found on the VISA-A questionnaire scores (P = .32). Equally, there was no effect of track and field specialty on the VISA-A score (P = .31). No correlation was found between age and VISA-A score (P = .36). There was no statistically significant difference in either prevalence of Achilles tendinopathy or VISA-A score between high-impact and low-impact athletes (P = .19 and P = .31, respectively).

CONCLUSION

In competing Masters track and field athletes, we did not find any influence of age, gender, weight, height, or impact profile on the development of Achilles tendinopathy. Additional research is required to improve our understanding of the causative factors in Achilles tendinopathy.

Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial

BACKGROUND

Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.

PURPOSE

To compare the effectiveness of 2 management strategies--group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis.

RESULTS

At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery.

CONCLUSION

At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.

Achilles and patellar tendinopathy: current understanding of pathophysiology and management

PURPOSE

Achilles and patellar tendinopathy cause significant morbidity in professional and recreational athletes. Both the Achilles and patellar tendons are weight-bearing tendons that lack a true tendon sheath but are surrounded by paratenon.

METHOD

A review of the literature to outline the characteristics of tendinopathy in these two tendons, and to discuss current concepts of pathophysiology, use of imaging in the diagnosis and aid to clinical management strategies in tendinopathy.

RESULTS

Achilles and patellar tendinopathy share common histopathology such as intratendinous failed healing response and neoangiogenesis.

CONCLUSION

Achilles and patellar tendinopathy cause much morbidity in the athletic and non athletic population attending sports medicine and rheumatology clinics. Tendinopathy is essentially an 'overuse', degenerative condition. Neovascularisation evident on Doppler ultrasound correlates well with pain and poor function. Peritendinous injections and eccentric training decrease neovascularity, relieve pain and improve outcome. Although surgery is the last resort in those patients failing conservative management, it is still unclear how the removal of adhesions and excision of affected tendinopathic areas affects healing and vascularity, or resolves pain.

High volume image guided injections in chronic Achilles tendinopathy

PURPOSE

To determine the effectiveness of high volume image guided injections (HVIGI) for chronic Achilles tendinopathy.

METHODS

We included in the study 30 consecutive patients (mean age 37.2 years, range 24 - 58 years) with Achilles tendinopathy for a mean of 35.8 months (range 2 - 276 months) who had failed to improve after a three-month programme of eccentric loading of the gastro-soleus complex. Patients were injected with 10 ml of 0.5% Bupivacaine Hydrochloride, 25 mg Hydrocortisone acetate, and up to 40 ml of injectable normal saline. A study-specific questionnaire and the Victorian Institute of Sport Assessment - Achilles tendon (VISA-A) were retrospectively administered to assess short- and long-term pain and functional improvement.

RESULTS

Some 21 patients (70%) responded. Patients reported significant short-term improvement at 4 weeks of both pain (mean change 50 mm, [SD 28, p < 0.0001], from a mean of 76 mm [SD 18.2], to a mean of 25 mm [SD 23.3]), and function scores (mean change 51 mm, [SD 31.2, p < 0.0001], from a mean of 78 mm [SD 20.8], to a mean of 27 mm [SD 28.4]). Patients also reported significant long-term improvement in symptoms using the VISA-A questionnaire (mean change 31.2 points, [SD = 28, p < 0.0001], from a mean of 44.8 points [SD 17.7], to a mean of 76.2 points [SD 24.6]) at a mean of 30.3 weeks from the injection.

CONCLUSIONS

HVIGI significantly reduces pain and improves function in patients with resistant Achilles tendinopathy in the short- and long-term.

Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation

PURPOSE

To compare eccentric training and the combination of eccentric training with the AirHeel Brace for the management of tendinopathy of the main body of the Achilles tendon.

METHODS

We recruited 116 subjects with unilateral tendinopathy of the main body of the Achilles tendon, who were randomized in two groups. Group A performed a regimen of daily eccentric training associated with the AirHeel Brace (Donjoy Orthopedics, Vista, CA, USA). Group B performed the same eccentric training without the AirHeel Brace. Tendon microcirculatory mapping was performed using combined Laser-Doppler and spectrophotometry. Pre- and post-operative FAOS score and VAS score were used to evaluate the patients.

RESULTS

The FAOS score and the VAS score showed significant improvements from pre-operative to post-operative values in both groups (A 5.1 +/- 2 vs. 2.9 +/- 2.4, 43% reduction and B: 5.4 +/- 2.1 vs. 3.6 +/- 2.4, 33% reduction, both p = 0.0001). There were no statistically significant differences in FAOS score and VAS score when comparing the two groups after the end of the intervention. In Group A, tendon oxygen saturation in the main body of the Achilles tendon showed significant increase from pre- to post-management values (68 +/- 12 vs.74 +/- 8%, p = 0.003). Post-capillary venous filling pressures showed significant reduction from pre- to post-intervention values.

CONCLUSION

Eccentric training, associated or not with the AirHeel Brace, produces the same effect in patients with tendinopathy of the main body of the Achilles tendon. The combination of eccentric training with the AirHeel Brace can optimize tendon microcirculation, but these micro-circulator advantages do not translate into superior clinical performance when compared with eccentric training alone.

Neuropeptides in tendinopathy

Overuse tendinopathy remains a major clinical burden for sports medicine and general practitioners. Recent studies have highlighted the role of sensory and autonomic nerves in generating or perpetuating the symptoms and tissue abnormalities associated with tendinopathy. We outline the neuroanatomy and potential roles of nerves and associated neuropeptides in tendinopathy. In addition, intriguing new data is reviewed which suggests that there may be a substantial intrinsic source of neuropeptides within tendons - namely, the tenocytes themselves. The potential roles of Substance P and mast cells are highlighted in particular. We discuss the implications for conservative management including sclerosing injections and exercise training.

Treatment of tendinopathy: what works, what does not, and what is on the horizon

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

LEVEL OF EVIDENCE

Level II, systematic review.

High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional Achilles tendinopathy

BACKGROUND

High-energy extracorporeal shock wave therapy has been shown to be an effective treatment for chronic insertional Achilles tendinopathy. The results of high-energy shock wave therapy for chronic noninsertional Achilles tendinopathy have not been determined.

HYPOTHESIS

Shock wave therapy is an effective treatment for noninsertional Achilles tendinopathy.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated with a single dose of high-energy shock wave therapy (shock wave therapy group; 3000 shocks; 0.21 mJ/mm(2); total energy flux density, 604 mJ/mm(2)). Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated not with shock wave therapy but with additional forms of nonoperative therapy (control group). All shock wave therapy procedures were performed using regional anesthesia. Evaluation was by change in visual analog score and by Roles and Maudsley score.

RESULTS

One month, 3 months, and 12 months after treatment, the mean visual analog scores for the control and shock wave therapy groups were 8.4 and 4.4 (P < .001), 6.5 and 2.9 (P < .001), and 5.6 and 2.2 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 12 and 0 (P < .001), 17 and 9 (P < .001), 5 and 17 (P < .001), and 0 and 8 (P < .001), respectively. A chi(2) analysis revealed that the percentage of patients with excellent ("1") or good ("2") Roles and Maudsley scores, that is, successful results, 12 months after treatment was statistically greater in the shock wave therapy group than in the control group (P < .001).

CONCLUSION

Shock wave therapy is an effective treatment for chronic noninsertional Achilles tendinopathy.

A preliminary study on the effects of acellular tissue graft augmentation in acute Achilles tendon ruptures

Acute Achilles tendon rupture injuries present surgical challenges because of the mechanical forces placed on this tendon. The purpose of this study was to evaluate the effectiveness of an acellular human dermal tissue matrix, GraftJacket Matrix (Wright Medical Technology, Inc., Arlington, TN), as an augmentation material in acute Achilles tendon repair. Eleven consecutive patients with acute tendon ruptures were evaluated and followed up (20-31 months). Primary repair was followed by augmentation with the graft sutured circumferentially around the tendon. Patients were placed in an early functional rehabilitation program with postoperative evaluation at 3, 6, and 12 months. Outcome scores were calculated based on the American Orthopaedic Foot and Ankle Society ankle-hindfoot scoring system. At 20-month postoperative follow-up, there have been no cases of rerupture or recurrent pain. The average return-to-activity time was 11.8 +/- 0.75 weeks. These retrospective clinical results suggest that with an acellular human dermal tissue matrix to augment acute Achilles tendon, primary repair offers a desirable return-to-activity time without any rerupture or complications. ACFAS Level of Clinical Evidence: 2c.

Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial

BACKGROUND

Few randomized controlled trials compare different methods of management in chronic tendinopathy of the main body of tendo Achillis.

PURPOSE

To compare the effectiveness of 3 management strategies-group 1, eccentric loading; group 2, repetitive low-energy shock-wave therapy (SWT); and group 3, wait and see-in patients with chronic tendinopathy of the main body of tendo Achillis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Seventy-five patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on intention-to-treat basis.

RESULTS

At 4 months from baseline, the Victorian Institute of Sport Assessment (VISA)-A score increased in all groups, from 51 to 76 points in group 1 (eccentric loading), from 50 to 70 points in group 2 (repetitive low-energy SWT), and from 48 to 55 points in group 3 (wait and see). Pain rating decreased in all groups, from 7 to 4 points in group 1, from 7 to 4 points in group 2, and from 8 to 6 points in group 3. Fifteen of 25 patients in group 1 (60%), 13 of 25 patients in group 2 (52%), and 6 of 25 patients in Group 3 (24%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 did not differ significantly. For all outcome measures, groups 1 and 2 showed significantly better results than group 3.

CONCLUSION

At 4-month follow-up, eccentric loading and low-energy SWT showed comparable results. The wait-and-see strategy was ineffective for the management of chronic recalcitrant tendinopathy of the main body of the Achilles tendon.