The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy

Platelet-rich plasma-derived exosomes have the novel ability to alleviate insertional Achilles tendinopathy by promoting tenogenesis in tendon stem/progenitor cells

Insertional Achilles tendinopathy (IAT) is a highly prevalent overuse injury affecting the foot and ankle in clinical settings. Currently, the primary management approach is conservative treatment. Platelet-rich plasma-derived exosomes (PRP-Exos) effectively preserve essential growth factors and other vital components inherent in PRP, thereby optimizing overall treatment outcomes. Furthermore, the standardized microinjection technique for PRP-Exos significantly enhances the treatment experience for patients. In this study, PRP-Exos were isolated from SD rats, and their effects on proliferation, migration, differentiation, apoptosis and other physiological processes in tendon-derived stem cells (TDSCs) in an IL-1β-induced inflammatory state were investigated in vitro. In this context, we conducted a thorough investigation of the impact of PRP-Exos on the tendinogenic differentiation of TDSCs under inflammatory conditions and explored the underlying mechanisms through cellular RNA sequencing. In vivo, the therapeutic effects of PRP-Exos on IAT at different times after treatment were evaluated comprehensively via histological analysis, behavioral tests and biomechanical tests. The results showed that PRP-Exos significantly increased the proliferation and migration of TDSCs in an inflammatory state in vitro and promoted their differentiation into tendon cells. Animal experiments confirmed that the histology, biomechanical performance and behavior of the animals in the PRP-Exos group were significantly normalized. This work demonstrated that the topical use of PRP-Exos at the insertion site of the Achilles tendon is an effective strategy for regulating proliferation and tendinogenic differentiation and represents a novel treatment approach for IAT.

Radial Extracorporeal Shockwave Therapy (rESWT) Is Not Superior to "Minimal-Dose" rESWT for Patients With Chronic Noninsertional Achilles Tendinopathy: A Double-Anonymized Randomized Controlled Trial

BACKGROUND

Outcomes following radial extracorporeal shockwave therapy (rESWT) in patients with chronic noninsertional Achilles tendinopathy are investigated.

METHODS

Patients with chronic noninsertional Achilles tendinopathy were recruited from a single National Health Services clinic, randomized equally to either "therapeutic" or "minimal-dose" ("presumed sham") rESWT (3 sessions at weekly intervals). Both groups had an identical structured home rehabilitation program of progressive loading, balance, and stretching exercises.

RESULTS

Fifty-seven patients were recruited; mean age 49.7±7.2 years, 60% female, symptom duration: 22.2±19.5 months. No between-group differences were identified at the final or any interim time points. Clinically and statistically significant within-group improvements were identified in pain/local function patient-reported outcome measures for both groups, with "average pain" improving by 34% at 6 months. No consistent benefits were seen in global function, activity levels, or mood.

CONCLUSION

"Recommended-dose" rESWT is not superior to "minimal-dose" rESWT and may be ineffective for patients with chronic noninsertional Achilles tendinopathy.

One-Year Follow-Up of Clinical and Morphological Outcomes in Elite Athletes With Early-Stage Lower Extremity Tendinopathy

Little is known about early tendinopathy in elite athletes. This study aimed to investigate changes in clinical and ultrasonography outcomes over 1 year and assess the prognostic values of these outcomes at baseline with respect to tendinopathy progression. Sixty-two elite athletes (24 ± 5 years) with early phase (symptom duration < three months) Achilles or patellar tendinopathy (AT and PT) were examined at baseline and after one year. Pain-guided activity modification was the only intervention. Clinical outcomes were assessed using Victorian Institute of Sports Assessment questionnaires (VISA) for function and symptoms, pain scores (1-10 numerical rating scale (NRS)) and ultrasound tendon morphology (thickness, echogenicity and power Doppler (PD) flow area). A linear mixed-effects model analysed changes from baseline to 1 year. Athletes showed clinical improvements in VISA-Achilles (baseline: 66 ± 5 vs. one-year: 87 ± 2, 95% CI: 13-30, p < 0.0001 and effect size d = 3.8), VISA-Patella (baseline: 69 ± 3 vs. one-year: 86 ± 1, 95% CI: 10-26, p < 0.0001 and effect size d = 3.6) scores and most NRS pain scores (≥ 2 points). Tendinopathic Achilles tendons' peritendinous thickness was reduced (-0.79 mm, p = 0.0188 and effect size d = 0.5), whereas patellar tendons remained enlarged. For both AT and PT, lower baseline PD was associated with a greater reduction in thickness over time (p < 0.001) and higher baseline VISA scores were linked to greater increases in echo intensity over time (p = 0.0363). In conclusion, elite athletes with early phase AT and PT showed clinical improvement over 1 year, with morphological changes in tendinopathic Achilles tendons only. Lower baseline PD and better initial VISA scores represent a better prognosis for tendinopathy morphology and symptoms.

Symptom Duration is not Related to Central Sensitization Inventory in Midportion Achilles Tendinopathy

Background

There is concern that the prolonged symptom duration commonly observed in Achilles tendinopathy may alter pain processing and lead to development of central sensitization. If true, presence of altered pain processing could explain why nearly one third of individuals with Achilles tendinopathy do not respond to gold standard treatment. Currently, the relationship between symptom duration, symptom severity, pain, and central sensitization in Achilles tendinopathy is unclear.

Purpose

The purpose of this study was assess the proportion of individuals with midportion Achilles tendinopathy who may have central sensitization, as defined by the Central Sensitization Inventory (CSI) part A questionnaire. A secondary aim was to assess the relationship between symptom duration, pain intensity, symptom severity and CSI scores.

Study Design

Cross-Sectional Study.

Methods

Individuals diagnosed with midportion Achilles tendinopathy were included (n=182, 57% female (47.3±12.7 years). Bivariate correlations were used to evaluate relationships between symptom duration (time between date of symptom onset and date of study enrollment), symptom severity (assessed by Victorian Institute of Sport Assessment-Achilles, VISA-A), and pain intensity (assessed by Patient-Reported Outcomes Measurement Information System 29, PROMIS-29) with CSI scores.

Results

Nine of 182 individuals (4.9%, 9 females) scored above the clinical cut off for CSI, indicating likely presence of central sensitization. Duration of symptoms did not correlate with CSI score (r = 0.037, 95% CI [-.109, .181] p=0.622). VISA-A had a significant negative correlation with CSI score (r=-0.293, [-.420, -.154] p<0.001), and pain intensity had a significant positive correlation with CSI score (r=0.195, [.051, .331] p=0.008).

Conclusion

Less than five percent of individuals with midportion Achilles tendinopathy met criteria for likely presence of central sensitization as defined by the CSI screening questionnaire. The study findings suggest prolonged symptom duration among those with midportion Achilles tendinopathy is unlikely to increase the occurrence of symptoms associated with central sensitization.

Level of Evidence

Level 4.

The Victorian Institute of Sport Assessment - Achilles is fundamentally flawed and unfit for clinical practice or research: A Rasch Measurement Theory Analysis using COSMIN recommendations

OBJECTIVES

Evaluate structural validity, hypothesis testing and measurement invariance of the Victorian Institute of Sport Assessment-Achilles (VISA-A) using Rasch analysis to determine if it can be recommended to measure Achilles tendinopathy severity.

METHODS

We performed an evaluation of the VISA-A measurement properties using Rasch Measurement Theory by pooling individual participant data from previously conducted studies (n = 217). Structural validity was assessed via threshold/category mean order; adequate item fit; unidimensionality; local dependence; internal consistency. Hypothesis testing was assessed via divergent validity. Measurement invariance assessed via differential item functioning.

RESULTS

The VISA-A has inadequate construct validity. This is evident from issues with item 8 and insufficient threshold order, item fit, borderline internal consistency and measurement invariance, with item response being influenced by both age and BMI.

CONCLUSION

The VISA-A has inadequate structural validity, borderline internal consistency and poor measurement invariance. Thus, the VISA-A does not meet with COSMIN criteria for construct validity due to issues with structural validity and measurement invariance. Thus, the VISA-A cannot be recommended for use, and should not be used in clinical practice or research. However, if the VISA-A has been used, analysis using only items 1-6, with responses collapsed into a 4-point scale provides the best structural validity.

Normative values for calf muscle strength-endurance in the general population assessed with the Calf Raise Application: A large international cross-sectional study

BACKGROUND

Calf muscle strength-endurance can be reliably assessed with the Heel Rise Endurance Test (HRET), but normative values are lacking.

OBJECTIVES

To establish normative values for calf muscle strength-endurance, adjusted for personal characteristics.

METHODS

500 individuals without current/previous symptoms of Achilles tendinopathy or recent lower limb immobilization were included. Primary outcome measures were the number of repetitions, total work (J), total vertical displacement (cm), and peak height (cm) upon the single-leg HRET, assessed using the validated Calf Raise Application. A multiple quantile regression model was developed, incorporating covariates (personal characteristics) which significantly impacted HRET metrics. Median (50.0th percentile) and 95 % reference intervals (2.5th-97.5th percentiles) were derived.

RESULTS

55 % of the participants were female and 88 % participated in physical activities. Median (dominant/non-dominant leg) number of repetitions was 25/24, total work was 1374/1325 J, vertical displacement was 192/186 cm, and peak height was 9.3/9.6 cm. There was no significant difference between the dominant and non-dominant leg for any HRET metric. Lower physical activity levels, female sex, and higher body mass index (BMI) were associated with lower HRET metrics.

CONCLUSIONS

Normative calf muscle strength-endurance metrics (number of repetitions, total work, total displacement, and peak height) were developed. Personal characteristics influence HRET outcomes, with female sex, higher BMI, and lower physical activity levels being associated with lower HRET metrics. An openly accessible calculator for estimating normative HRET metrics was developed to help healthcare providers monitor personalized recovery trajectories and provide well-informed rehabilitation guidance. Documenting HRET metrics beyond repetition count may aid in assessing impairment severity and evaluating calf muscle function.

Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial

OBJECTIVE

To assess the effectiveness of low tendon compression rehabilitation (LTCR) versus high tendon compression rehabilitation (HTCR) for treating patients with insertional Achilles tendinopathy.

METHODS

In an investigator-blinded, stratified randomised trial, 42 sport-active patients (30 males and 12 females; age 45.8±8.2 years) with chronic (> 3 months) insertional Achilles tendinopathy were allocated in a 1:1 ratio to receive LTCR or HTCR. Both rehabilitation protocols consisted of a progressive 4-stage tendon-loading programme, including isometric, isotonic, energy-storage and release and sport-specific exercises. The LTCR programme was designed to control Achilles tendon compression by limiting ankle dorsiflexion during exercise, eliminating calf stretching and incorporating heel lifts. The primary outcome was the Victorian Institute of Sports Assessment-Achilles (VISA-A) score at 12 and 24 weeks, which measures tendon pain and function and was analysed on an intention-to-treat basis using a linear mixed model. Significance was accepted when p<0.05.

RESULTS

20 patients were randomised to the LTCR group and 22 to the HTCR group. Improvement in VISA-A score was significantly greater for LTCR compared with HTCR after 12 weeks (LTCR=24.4; HTCR=12.2; mean between-group difference=12.9 (95% CI: 6.2 to 19.6); p<0.001) and after 24 weeks (LTCR=29.0; HTCR=19.3; mean between-group difference=10.4 (95% CI: 3.7 to 17.1); p<0.001). These differences exceeded the minimal clinically important difference of 10.

CONCLUSIONS

In sport-active patients with insertional Achilles tendinopathy, LTCR was more effective than HTCR in improving tendon pain and function at 12 and 24 weeks. Consequently, LTCR should be considered in the treatment of insertional Achilles tendinopathy.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (ID: NCT05456620).

A Prospective Randomized Pilot Study on the Efficacy of a Dietary Supplementation Regimen of Vitamin E and Selenium for the Prevention of Fluoroquinolone-Induced Tendinopathy

Background: Fluoroquinolone-induced tendinopathy is a clinically significant adverse effect associated with this class of antibiotics, particularly affecting the Achilles tendon. Despite its growing recognition, the precise pathophysiological mechanisms remain incompletely understood, with hypotheses referencing increased matrix metalloproteinase activity, collagen degradation, and oxidative stress. Methods: This prospective randomized pilot study evaluates the potential protective effectiveness of vitamin E and selenium supplementation in mitigating fluoroquinolone-induced tendinopathy. The study was conducted on 25 patients receiving 500 mg/day levofloxacin antibiotherapy, randomly divided into a control group and an experimental group-vitamin E (400 IU/day) and selenium (200 µg/day), oral supplementation for 28 days. Clinical assessment of the pain level through the VAS score and of functionality through the VISA-A score was performed, alongside ultrasound imaging of the Achilles tendon. To assess potential toxicity and ensure adherence to the supplementation protocol, serial biochemical analyses of serum vitamin E and selenium were performed at predetermined intervals. Results: A significant improvement was observed in pain scores (p = 0.0120) and functional outcomes (p = 0.0340) when comparing the control and experimental groups at the three-month follow-up. Ultrasound analysis revealed reduced tendon thickness and neovascularization, supporting structural recovery. Although the incidence of tendinopathy was lower in the interventional group (13.3% vs. 40%), statistical significance was not reached, possibly due to the small sample size. Conclusions: These findings suggest that antioxidant supplementation with vitamin E and selenium may provide a protective effect against fluoroquinolone-induced tendinopathy, warranting further investigation in larger randomized clinical trials.

Reduced Achilles tendinopathy symptoms (e.g. stiffness), but not pain, relate to patient-perceived resolution of Achilles tendinopathy: a cross-sectional study

We aimed to determine whether pain, symptoms and/or physical function are associated with perceived recovery in people with current or resolved Achilles tendinopathy. We performed a cross-sectional cohort study, including people who reported having either "current" or "resolved" Achilles tendinopathy. Participants completed an online survey, including the Tendinopathy Severity Assessment- Achilles (TENDINS-A). We used multivariable binary logistic regression and reported odds ratio (OR) to quantify the strength of the association. We included 100 cases (n = 63 current, n = 37 resolved). There were no associations of age, sex, BMI, TENDINS-A (Pain) or TENDINS-A (Physical Function) with whether participants reported having current or resolved Achilles tendinopathy. However, for every 1% greater the TENDINS-A (Symptoms) there was 0.28 lower odds of a participant reporting their tendinopathy has resolved (OR = 0.972, 95% CI = 0.953 to 0.992, p = 0.007). We demonstrated a lower "symptom" severity but not "pain" severity was associated with greater patient-reported resolution of Achilles tendinopathy.

Metabolic Risk Factors Relate to Worse Tendon Health in Individuals With Achilles Tendinopathy

A high proportion of individuals with Achilles tendinopathy continue to demonstrate long-term symptoms and functional impairments after exercise treatment. Thus, there is a need to delineate patient presentations that may require alternative treatment. The objective of this study was to evaluate if the presence of metabolic risk factors relates to tendon symptoms, psychological factors, triceps surae structure, and lower limb function in individuals with Achilles tendinopathy. One hundred and fifty-eight individuals (88 female) with diagnosed midportion Achilles tendinopathy were divided into three groups based on the number of metabolic risk factors linked to cardiovascular disease present at baseline: two or more factors, one factor, no factors. Metabolic risk factors were determined by clinical evaluation and past medical history. Achilles tendinopathy symptoms (Victorian Institute of Sport Assessment-Achilles, Patient Reported Outcome Measurement Information System, movement-evoked pain ratings), psychological factors (Tampa Scale for Kinesiophobia), triceps surae structure (B-mode ultrasound of tendon and muscle morphology, continuous shear wave elastography of tendon mechanical properties), and lower limb function (test battery) were compared among groups. Individuals with two or more metabolic risk factors had worse symptoms with loading (p = 0.011), smaller Achilles tendon size relative to body mass (p = 0.002), and worse lower limb function compared to individuals without metabolic risk factors (p < 0.02). No differences were observed between individuals with one metabolic risk factor and those without metabolic risk factors. Future consideration of multiple metabolic risk factors for individuals with Achilles tendinopathy could facilitate understanding the underlying impairments of tendon pathology and recovery that may be addressed with treatment.

Achilles Tendon Mechanical but Not Morphological Properties Change with Rehabilitation in Patients with Chronic Midportion Achilles Tendinopathy

PURPOSE

Achilles tendinopathy is associated with altered tendon's morphological and mechanical properties, yet it is unclear whether these properties are reversed upon mechanical loading to promote tendon healing. This study aims to determine the extent to which pathological tendon's morphological and mechanical properties adapt throughout a 12-wk eccentric rehabilitation protocol.

METHODS

Forty participants with midportion Achilles tendinopathy were recruited and participated in a 12-wk eccentric rehabilitation program. Function and symptoms were recorded through the Victorian Institute of Sports Assessment-Achilles (VISA-A) and hopping. The tendon's morphological (i.e., volume, midportion cross-sectional area (CSA) and anteroposterior (AP) diameter) and mechanical (i.e., stiffness, Young's modulus, and tendon nonuniform displacement) properties were measured at baseline and at 6 and 12-wk of the intervention.

RESULTS

Significant functional improvements were observed, with VISA-A scores and hopping results showing marked improvements ( P < 0.001). Morphologically, no significant changes in volume, midportion CSA, or AP diameter were found, although a trend toward decreased CSA between 30% and 70% of tendon length was noted. Mechanically, significant increases in Achilles tendon stiffness ( P = 0.001) and Young's modulus ( P < 0.001) were observed over the course of the rehabilitation program. No differences in tendon nonuniform displacement were found after a 12-wk rehabilitation program.

CONCLUSIONS

These findings suggest that tendon adaptation in response to mechanical loading primarily involves changes in mechanical properties rather than morphology, highlighting the complexity and variability in tendon adaptation. Clinically, these mechanical properties could be considered in the load progression throughout rehabilitation as potentially higher strains will be induced when clinical improvements precede mechanical adaptations.

Achilles tendinopathy

Achilles tendon pathologies are prevalent, impacting ~6% of the general population and up to 50% of elite endurance runners over their lifetimes. These conditions substantially affect quality of life and work productivity, leading to substantial societal costs. Achilles tendinopathy (AT) is a condition marked by localized pain and functional impairment related to mechanical loading. AT can considerably impair participation and potentially also performance in sports and daily activities. The aetiology of AT is multifactorial and repetitive overloading of the tendon is often observed as the inciting factor by health professionals. However, AT can also be associated with adverse effects of certain medication, ageing and various comorbidities. Characteristic tendon changes include proteoglycan accumulation, fluid accumulation with swelling and hypervascularization. Tissue disorganization advances as pathological changes in matrix structure are driven by altered cellular function and makeup, often accompanied by persistent inflammation. Treatment strategies include various interventions, although these can be protracted and challenging for both patients and health-care providers, often with high failure rates. Current research focuses on understanding the pathological processes at the cellular and molecular levels to distinguish between disease categories and to investigate the role of inflammation, metabolic maladaptation and mechanical stress. Emerging therapeutic approaches need to be developed to address these underlying mechanisms. These approaches focus on optimizing rehabilitation protocols and advancing the development of adjunct therapies, such as advanced therapy medicinal products, alongside the integration of precision medicine to improve treatment outcomes.

Factors Explaining the Severity of Acute Achilles Tendinopathy Among Runners: A Comprehensive Cross-Sectional Analysis

BACKGROUND

Achilles tendinopathy (AT) is a prevalent musculoskeletal injury among runners, accounting for approximately 10% of all running-related injuries. AT can result in persistent symptoms and impact the quality of life of runners. The Victorian Institute of Sport Assessment questionnaire (VISA-A) is a widely used self-reported tool for assessing severity of AT. However, the anatomic, biomechanical, psychological, and social factors that influence its score are still poorly understood. The aim of this study is to identify the factors that explain the severity of AT based on the VISA-A score in runners experiencing acute AT.

HYPOTHESIS

The VISA-A score will be explained by both biological and psychosocial factors.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Runners with AT were assessed within 3 months of symptoms onset. The potential explanatory factors assessed included sociodemographic characteristics and medical history, as well as psychosocial, physical, and anatomic (ultrasound imaging) variables.

RESULTS

Participants with AT (n = 84) demonstrated moderate impairments, with a mean VISA-A score of 62.8 (SD, 15.1). Three variables emerged as significant factors explaining AT severity: higher level of kinesiophobia and pain catastrophizing, pain during single-leg jumps, and increased cross-sectional Achilles tendon area on ultrasound imaging. These 3 variables had a moderate capacity (R2 = 0.47) to explain the VISA-A score.

CONCLUSION

Pain during single-leg jumps, an increased cross-sectional tendon area assessed by ultrasound, and a high score on kinesiophobia and pain catastrophizing questions are associated with higher VISA scores.

CLINICAL RELEVANCE

These findings provide the basis for the development of more tailored interventions to improve the quality of life and function of runners with acute AT.

The Effects of Noxious Electrical Stimulation and Eccentric Exercise on Mechanical and Thermal Pain Sensitivity in Recreational Runners with Achilles Tendinopathy

Background

Achilles tendinopathy is a common overuse condition that can become persistent despite conservative treatment. Sensitization of both the peripheral and central nervous systems may contribute to the persistent pain. Both exercise and electrical stimulation have the potential to modulate the nervous system's sensitivity to painful stimuli.

Hypothesis/Purpose

The purpose of this study was to describe the changes in pain sensitivity and self-reported function in runners with chronic Achilles tendon pain following sequential treatment with noxious electrical stimulation (NxES) and eccentric plantarflexion exercise.

Study Design

Single group, repeated measures design.

Methods

Sixteen participants with chronic Achilles tendinopathy completed the Lower Extremity Functional Scale (LEFS) and the Victorian Institute of Sport Assessment-Achilles scale (VISA-A) and quantitative sensory tests (pressure pain threshold, heat temporal summation, and heat pain threshold) at baseline, one week, seven weeks, and then at a one month post intervention follow-up. The NxES was applied for one week, then followed by plantarflexion eccentric exercise for six weeks. Changes across timepoints were assessed using repeated measures ANOVA and post hoc analysis to describe differences. Hedges g effect sizes were also calculated.

Results

There was a significant improvement in LEFS (p < 0.001) and VISA-A (p < 0.001) from baseline to one month follow-up, with a mean change of 9.6 ± 7.7 and 19.4 ± 17.7 points respectively. Pressure pain threshold of the involved Achilles tendon increased over time (p < 0.001) with significant improvements after NxES application (p = 0.002) and after six weeks of eccentric exercise (p < 0.001). There were significant improvements from baseline to one month follow-up for heat temporal summation (p = 0.001) and heat pain threshold ( p < 0.001).

Conclusions

For individuals with chronic Achilles tendinopathy, a sequential treatment of NxES followed by eccentric exercise resulted in a clinically significant improvement in self-reported pain and function. During the first week of treatment there was a reduction in mechanical hyperalgesia during the NxES-only phase, while a large reduction in primary heat hyperalgesia and additional desensitization to mechanical pain occurred during the eccentric training phase of treatment.

Level of Evidence

2b.

Does shockwave therapy lead to better pain and function than sham over 12 weeks in people with insertional Achilles tendinopathy? A randomised controlled trial

OBJECTIVES

To investigate the efficacy of adding radial extracorporeal shockwave therapy or sham to exercise for people with insertional Achilles tendinopathy.

DESIGN

A two-armed, parallel-group, explanatory, single-centre, randomised controlled trial within a superiority framework.

SETTING

Private clinic.

PARTICIPANTS

People diagnosed with insertional Achilles tendinopathy who were over 18 years old with a symptom duration of greater than 3 months.

INTERVENTION

A total of 76 people were randomly assigned (one-to-one ratio) to receive three sessions of radial extracorporeal shockwave therapy or sham to the affected side (or most affected side if bilateral). All participants received identical education and exercise.

OUTCOME MEASURES

The primary outcome was the Victorian Institute of Sports Assessment - Achilles questionnaire. Measures were recorded at baseline, 6 weeks and 12 weeks.

RESULTS

At 12 weeks, the questionnaire data were available for 37 people (96%) in the radial extracorporeal shockwave therapy group and 36 people (95%) in the sham group. For the primary outcome, we found no evidence for between-group differences at 6 (3, 95% confidence interval -4.6-10.5) or 12 weeks (4.6, 95% confidence interval -2.5-11.6). There was also no evidence for a between-group difference for any secondary outcome measures at either 6 or 12 weeks (p > .05). No serious adverse events were reported.

CONCLUSION

The addition of radial extracorporeal shockwave therapy to exercise and education did not lead to improvements in pain, function or other outcomes compared to sham at 6 or 12 weeks among people with insertional Achilles tendinopathy.ANZCTR Reg No: ACTRN12620000035921.

Ultrasound tissue characterization and function of Achilles tendon in psoriatic arthritis patients: a cross-sectional study

BACKGROUND

The Achilles tendon is one of the most frequent sites of tendinopathy in both healthy and pathological subjects. An innovative approach for the quantitative assessment of the Achilles tendon structure, named Ultrasound Tissue Characterization (UTC), has recently been developed. However, no previous study performed the UTC-based assessment of the tendon structure in rheumatologic patients affected by insertional Achilles tendinopathy.

AIM

To characterize the Achilles tendon structure and function in psoriatic arthritis patients with symptomatic insertional tendinopathy.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

POPULATION

Psoriatic arthritis patients (N.=17).

METHODS

Anthropometric measurements, administration of outcome and pain questionnaires, and tendon function and structure assessments were performed in a single experimental session.

RESULTS

Pain intensity and interference and the perceived tendinopathy-related disability were moderate-severe. A relevant impairment of the strength (for both lower limbs) and walking performance was observed in all patients. In fact, the plantarflexion strength values (median values for the two sides: 10.0 and 11.5 kg) and fast walking speed (median value: 1.7 m/s) were lower than the normative values for healthy controls, respectively, in all patients for the strength values and in 14 out of 17 patients for the walking speed. The conventional ultrasound (i.e., the quantification of tendon thickness and the qualitative assessments of tendon structure and neovascularization) showed greater changes in the symptomatic (or more symptomatic) side compared with the asymptomatic (or less symptomatic) side of the insertional region of the Achilles tendon. The UTC imaging showed comparable impairment of the tendon structure between the symptomatic (or more symptomatic) side and the asymptomatic (or less symptomatic) side of the insertional region of the Achilles tendon (i.e., reduced echo-type I percentages in both tendons of all patients).

CONCLUSIONS

Psoriatic arthritis patients with symptomatic insertional Achilles tendinopathy present moderate-severe pain and perceived disability, physical function impairments, and bilateral deterioration of the tendon structure (also in case of unilateral symptoms) that can be documented through the UTC analysis.

CLINICAL REHABILITATION IMPACT

The evaluation of the insertional Achilles tendinopathy through UTC imaging can be useful for the diagnostic and prognostic assessment of psoriatic arthritis patients in combination with the assessments of pain, disability, and functional performance.

Validation and reliability of the Simple Achille Value (SAV) in Achilles tendon disorders

BACKGROUND

Achilles tendon (AT) disorders significantly impact patient life, necessitating accurate assessment tools. Current methods are often complex and time-consuming. This study aims to validate the Simple Ankle Value (SAV) for AT disorders.

METHODS

A multicenter study was conducted involving 101 participants, including a surgical, a conservative, and a control group. Participants completed the SAV, VISA-A, and EFAS scores. The study assessed correlations among scores, reliability, responsiveness to change, threshold and ceiling effect and discriminative ability of the SAV.

RESULTS

There was a significant strong correlation with the EFAS and a significant moderate to strong correlation with the VISA-A. The score showed excellent reliability (ρ = 0.95, 95 %CI: [0.913; 0.976], p < 0.001). Responsiveness to change was significant between preoperative and postoperative SAV (37.99 ± 25.73 vs 70.86 ± 21.26). The SAV discriminated between patient and controls with no threshold or ceiling effect.

CONCLUSION

The SAV provides a valid, reliable, and responsive method for assessing AT disorders. It offers a simplified and effective alternative to more complex scores.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

Prognostic value of ultrasound tissue characterisation for a recurrence of mid-portion Achilles tendinopathy in military service members: a prospective cohort study

INTRODUCTION

Tendon structure in mid-portion Achilles tendinopathy (mid-AT) appears poorly associated with symptoms. Yet, degenerative tendon changes on imaging have been associated with an increased risk of mid-AT. We aimed to investigate the prognostic value of ultrasound tissue characterisation (UTC) for a mid-AT recurrence in service members reporting to be recovered following standard care.

METHODS

Mid-portion aligned fibrillar structure was quantified post-treatment in 37 participants. Recurrences were determined after 1 year of follow-up, based on self-perceived recurrence (yes/no) combined with a decrease in post-treatment Victorian Institute of Sports Assessment-Achilles score of at least the minimal important change of 7 points. Receiver operating characteristic curve analyses were used to determine a threshold for dichotomisation of outcomes for aligned fibrillar structure (normal representation/under-representation). Using multivariable logistic regression, the association between a mid-AT recurrence (yes/no) and the dichotomised aligned fibrillar structure was determined.

RESULTS

Eight participants (22%) experienced a recurrence. The threshold for aligned fibrillar structure was set at 73.2% (95% CI: 69.4% to 77.8%) according to Youden's index. Values below this threshold were significantly associated with a mid-AT recurrence (odds ratio (OR) 9.7, 95% CI: 1.007 to 93.185). The OR for a mid-AT recurrence was 1.1 (95% CI: 1.002 to 1.150) for each additional month of symptom duration. The explained variance of our multivariable logistic regression model was 0.423; symptom duration appeared to be a better predictor than aligned fibrillar structure.

CONCLUSIONS

This study identified mid-portion aligned fibrillar structure and symptom duration as potential prognostic factors for a mid-AT recurrence in military service members. The threshold for aligned fibrillar structure of 73.2% can guide preventative interventions (eg, training load adjustments or additional tendon load programmes) aiming to improve tendon structure to minimise the future recurrence risk.

TRIAL REGISTRATION NUMBER

https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm, file number ToetsingOnline NL69527.028.19.

Surgical outcomes in patients with Achilles tendon rupture-a retrospective study

Background

There are two main methods used to treat Achilles tendon rupture (ATR): conservative treatment and surgical intervention. Surgical techniques are divided into three main categories: open surgical repair, mini-open surgical repair, and percutaneous repair (PR). We aimed to compare clinical outcomes in individuals with ATR who were treated with PR, primary repair, and flexor hallucis longus augmentation (FHL-A) with those treated with V-Y plasty and FHL-A.

Methods

The study involved 54 patients who underwent ATR surgical intervention retrospectively. Thirty-two of these were identified as acute and 22 were chronic rupture patients. PR was performed in 32 patients, primary repair and FHL-A in 14 patients, and V-Y plasty and FHL-A in eight patients.

Results

The mean forward jump was 142.69 ± 7.14 cm in individuals who received PR, 137.71 ± 4.51 cm in those who received primary repair + FHL-A, and 123.88 ± 3.09 cm in those who received V-Y plasty + FHL-A (p < 0.001). The decrease in the mean vertical jump distance on the operated side compared to the contralateral extremity was 0.97 ± 0.93, 2.07 ± 0.99, and 3.00 ± 1.69 cm in individuals who underwent PR, primary repair + FHL-A, and V-Y plasty + FHL-A, respectively (p < 0.001). The decrease in the mean dorsiflexion of the operated side ankle compared to the contralateral extremity was found to be 4.34 ± 1.18, 1.93 ± 1.07, and 2.38 ± 0.92 degrees in individuals who underwent PR, primary repair + FHL-A, and V-Y plasty + FHL-A, respectively (p < 0.001).

Conclusion

Although no surgical technique is completely superior to another, better performance tests were observed after PR repair compared to open surgery in individuals involved in sports, but rerupture, dorsiflexion restriction, and painful ankle were disadvantages. FHL-A, which has gained popularity in recent years, showed better performance in tests by contributing to more stable and stronger ankles in sporting individuals with chronic ruptures who had undergone open surgery. FHL-A can be utilized in addition to primary surgical intervention in individuals with high performance expectations before and after injury.

Optimising physiotherapist delivery fidelity of exercise and physical activity advice for achilles tendinopathy: A prospective repeated-measures observational study

OBJECTIVES

To assess physiotherapist delivery fidelity and identify factors optimising delivery fidelity of an intervention based on recommended guidelines for Achilles tendinopathy.

DESIGN

A prospective repeated-measures observational study of physiotherapist delivery fidelity with carefully defined exercise and physical activity advice.

SETTING

An inter-disciplinary clinic in Melbourne, Australia, embedded in a randomised controlled trial.

PARTICIPANTS

Two physiotherapists delivering the intervention to five participants each, at three timepoints.

INTERVENTION

All participants were expected to receive the same intervention. Feedback at timepoint one, guided boost-training to optimise delivery fidelity.

MAIN OUTCOME MEASURES

Proportion of exercise and physical activity advice components delivered as intended (high ≥80%; moderate 51-79%; low≤50%), with relationships between variables analysed using chi-square tests.

RESULTS

Physiotherapist delivery fidelity improved significantly between timepoint one and two (χ2 = 83.3, p < 0.001), then sustained at timepoint three. At timepoint one, seven (70%) of intervention components were delivered with high fidelity, one (10%) with moderate fidelity and two (20%) with low fidelity. At timepoint two, after boost-training, nine (90%) were delivered with high fidelity and one (10%) with moderate fidelity. At timepoint three, all intervention components (100%) were delivered with high fidelity by both physiotherapists.

CONCLUSION

Physiotherapist delivery fidelity can be optimised with feedback, collaboration and boost-training.

Efficacy of a physical rehabilitation program using virtual reality in patients with chronic tendinopathy: A randomized controlled trial protocol (VirTendon-Rehab)

Objectives

To analyze the efficacy of a virtual reality (VR)-based rehabilitation program in people with chronic tendinopathy (CT) on pain, muscle activation pattern, range of motion, muscle strength, kinesiophobia, physical function, quality of life, and user satisfaction compared to a control group. In addition, the relationship between these variables and the clinical profile of this population will be analyzed.

Design

A 12-week, single-blind, low-risk, randomized controlled trial.

Methods

Sixty patients diagnosed with CT will be enrolled and randomly assigned to two groups. The control group will receive a physical exercise program without VR support (45 min), whereas the experimental group will receive an additional 15-min intervention through a physical exercise program delivered by VR. Both groups will receive three sessions per week, and the outcomes will be collected at baseline, after 12 weeks, and at the 24-week follow-up. Stratified groups will be established according to tendinopathy location (shoulder rotator cuff, elbow, patella, and Achilles tendon). Statistical analyses using SPSS v.24 will include descriptive analysis, stratified analysis by tendinopathy location, normality checks, intragroup and intergroup differences, effect sizes, and variable relationships.

Discussion

The results of this project may have a significant impact on the knowledge of using VR in tendinopathy management, understanding how the outcomes are related, and characterizing the clinical profiles of the population diagnosed with CT. If these results are confirmed, VR would be clinically useful for the treatment of these conditions.

Trial registration number

NCT06056440.

Victorian Institute of Sport Assessment-Achilles thresholds for minimal important change and return to presymptom activity level in active soldiers with mid-portion Achilles tendinopathy

INTRODUCTION

Mid-portion Achilles tendinopathy (mid-AT) is common in soldiers, significantly impacting activity levels and operational readiness. Currently, Victorian Institute of Sport Assessment-Achilles (VISA-A) represents the gold standard to evaluate pain and function in mid-AT. Our objective was to estimate VISA-A thresholds for minimal important change (MIC) and patient-acceptable symptom state for return to the presymptom activity level (PASS-RTA), in soldiers treated with a conservative programme for mid-AT.

METHODS

A total of 40 soldiers (40 unilateral symptomatic Achilles tendons) were included in this prospective cohort study. Pain and function were evaluated using VISA-A. Self-perceived recovery was assessed with the Global Perceived Effect scale. The predictive modelling method (MIC-predict) was used to estimate MIC VISA-A post-treatment (after 26 weeks) and after 1 year of follow-up. The post-treatment PASS-RTA VISA-A was estimated using receiver operating characteristic statistics. The PASS-RTA was determined by calculating Youden's index value closest to 1.

RESULTS

The adjusted MIC-predict was 6.97 points (95% CI 4.18 to 9.76) after 26 weeks and 7.37 points (95% CI 4.58 to 10.2) after 1 year of follow-up post-treatment.The post-treatment PASS-RTA was 95.5 points (95% CI 92.2 to 97.8).

CONCLUSIONS

A VISA-A change score of 7 points, post-treatment and at 1 year of follow-up, can be considered a minimal within-person change over time, above which soldiers with mid-AT perceive themselves importantly changed. Soldiers consider their symptoms to be acceptable for return to their presymptom activity level at a post-treatment VISA-A score of 96 points or higher.

TRIAL REGISTRATION NUMBER

NL69527.028.19.

Sex Differences and Extracorporeal Shockwave Therapy Outcomes in Runners with Achilles or Hamstring Tendinopathy

Background/Objectives: Achilles and hamstring tendinopathies are common injuries in runners, and extracorporeal shockwave therapy (ESWT) may be an effective treatment. Runners are at risk for lower extremity tendinopathies and the Male and Female Athlete Triad (Triad). The purpose of this study is to evaluate the association of sex, exposure to hormonal contraceptives, menopause, and Triad-related risk factors with ESWT outcomes in the treatment of Achilles and hamstring tendinopathy. Methods: This is a retrospective cohort study of runners with either Achilles or hamstring tendinopathy who received radial or combined radial and focused ESWT. Tendon function was measured using Victorian Institute of Sport Assessment (VISA) questionnaires completed before and following treatment. Treatment success was defined by a change in VISA score that met the minimal clinically important difference (MCID). Results: There were 88 runners (54.5% female, 45.5% male) with Achilles (52.3%) or hamstring (47.7%) tendinopathy. No measurable difference was found in the proportion of females and males overall that achieved the MCID (57.1% and 72.5%, p = 0.17). Similar rates of females and males met MCID for Achilles (77.8% and 75.0%, p = 0.83) and hamstring tendinopathy (46.7% and 66.7%, p = 0.24). However, females with Achilles or hamstring tendinopathy who used oral contraceptive pills (OCPs) were less likely to meet the MCID compared to females not on OCPs (p = 0.031); this finding was present in a subgroup analysis of runners with only Achilles tendinopathy (p = 0.025). No associations were found between achieving the MCID and Triad risk factors, including body mass index, energy availability, weight-related behaviors, bone health, or menstrual function (all p > 0.05). Conclusions: Female and male runners reported similar success rates for ESWT, and Triad risk factors were not found to impact outcomes. However, females who used oral contraceptive pills were less likely to achieve the MCID from ESWT.

Efficacy of heel lifts for insertional Achilles tendinopathy (LIFTIT): A randomised feasibility trial

OBJECTIVES

Insertional Achilles tendinopathy is a common and disabling condition. This trial aimed to determine the feasibility of conducting a parallel group randomised trial to evaluate the efficacy of heel lifts compared to a sham intervention for reducing pain intensity associated with insertional Achilles tendinopathy.

METHODS

Twenty-six people with insertional Achilles tendinopathy were randomised to either the heel lift group or sham intervention group. Outcome measures were obtained at baseline, 4, 8 and 12 weeks. The primary outcome was feasibility, evaluated according to demand (recruitment rate and conversion rate), acceptability, adherence, adverse events and retention. Limited efficacy testing was conducted on secondary outcome measures including pain intensity, function, physical activity, health-related quality of life, use of co-interventions and global rating of change.

RESULTS

Between August 25, 2023, and April 7, 2024, we recruited and tested 26 participants (aged 28-65 years, mean [SD] 51 [8]). The pre-determined thresholds were met for demand, acceptability, adherence, retention, pain intensity, function, quality of life and global rating of change and partly met for adverse events, physical activity and use of co-interventions. Between 47 and 241, participants will be needed for a fully powered randomised trial.

CONCLUSION

In its current form, a randomised trial of heel lifts compared to a sham intervention is feasible. However, future triallists may need to consider strategies to manage the risk of adverse events and plan to adjust the analyses to account for the use of co-interventions.

TRIAL REGISTRATION

ACTRN12623000721606.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024

The Academy of Orthopaedic Physical Therapy (AOPT) has an ongoing effort to create evidence-based clinical practice guidelines (CPG) for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The 2024 Achilles Pain, Stiffness, and Muscle Power Deficit: Midportion Achilles Tendinopathy Clinical Practice Guideline (CPG) is a revision of the 2018 CPG and represents the third CPG from AOPT on this topic. The goals of the revision were to provide a concise summary of the contemporary evidence and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers prevalence, pathoanatomical features, risk factors, clinical course, diagnosis, examination, imaging, and physical therapy interventions for the management of midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2024;54(12):CPG1-CPG32. Epub 27 November 2024. doi:10.2519/jospt.2024.0302.

Effect of Platelet-Rich Plasma Injection on the Treatment of Achilles Tendinopathy: A Systematic Review and Meta-analysis

Background

Achilles tendinopathy is a common condition without a reproducible and timely treatment modality. Platelet-rich plasma (PRP) injection has been proposed as an enticing treatment option, but there is no consensus regarding its effectiveness.

Purpose

To pool the available data and evaluate the evidence of the effect of PRP injections on Achilles tendinopathy.

Study Design

Systematic review; Level of evidence, 1.

Methods

This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. CINAHL via EBSCOhost, Cochrane Library, and PubMed databases were searched for randomized controlled trials comparing PRP injection with nonoperative treatment, with the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire score or maximal Achilles tendon (AT) thickness on ultrasound as outcome measures. Risk-of-bias assessment was performed of the included studies, and meta-analyses compared differences in outcome measures between PRP injection and control at the short-term (3-month), intermediate-term (6-month), and long-term (12-month) follow-ups.

Results

Of 409 publications, 6 publications (N = 422 patients with chronic midportion Achilles tendinopathy) were identified from the literature search. Risk-of-bias assessment revealed 2 studies were low risk, 1 was of some concern, and 3 were high risk of bias. Meta-analysis revealed no significant differences between PRP injection and control at any time point for both VISA-A score (short term: P = .29; intermediate term: P = .42; long term: P = .57) and maximal AT thickness (short term: P = .60; intermediate term: P = .20; long term: P = .55).

Conclusion

Our review demonstrated that although recent trends have shown an increasing popularity of PRP injection, no solid evidence has been established. The heterogenicity of the tendinopathy pathology and the PRP injection content and methodology should be controlled by better-designed clinical trials. Further research is needed before it should be recommended as a standard treatment.

A Comparison of Achilles Tendon Morphological Characteristics Based Upon VISA-A Score in Active Adults Over Age 50

Morphologic Achilles tendon properties obtained via diagnostic ultrasound imaging are valuable in understanding Achilles tendon health and injury. Currently, limited information exists regarding Achilles tendon morphological properties amongst active aging adults based upon Victorian Institute of Sport Assessment (VISA-A) scores. Achilles tendon morphologic properties defined by VISA-A score groupings allow clinicians and researchers to compare data values amongst current patients. Purpose: Comparison of physically active aging adults Achilles tendon morphological properties with various VISA-A scores or a previous Achilles tendon rupture. A convenience sample of 121 participants (71 females, 50 males) at least moderately active and 50 years old, were recruited. Participants completed a VISA-A survey, and assigned groups by scores (Group 1: 90-100, Group 2: 70-89, Group 3: 45-69, Group 4: Previous Achilles tendon tear). Achilles tendon ultrasound imaging occurred at the malleolar line (The apex of the medial and lateral malleolus). Following imaging Achilles tendon cross-sectional area (CSA), thickness, and elastography were measured and analyzed. Participants with a previous Achilles tendon rupture displayed significantly larger tendon CSA and thickness compared with other groups (p<0.05). Individuals with VISA-A scores from 45-69 displayed significantly larger tendon CSA and thickness than participants with scores greater than 90 (p<0.03). No significant differences were noted for elastography between groups (p>0.05). Achilles tendon morphological differences exist based upon pain level in physically active aging adults. Diagnostic ultrasound may be used during assessment and rehabilitation of injured tendon tissue to inform about current tendon tissue properties.

Comparison of short term recovery in patients with midportion Achilles tendinopathy with varying degrees of kinesiophobia treated with the Silbernagel protocol: A prospective single cohort analysis

OBJECTIVE

To assess short term recovery between individuals with Achilles tendinopathy with varying degrees of kinesiophobia when treated with the Silbernagel protocol. Secondarily to investigate short term change in degree of kinesiophobia.

DESIGN

Prospective single cohort analysis.

SETTING

University/Clinical.

PARTICIPANTS

116 participants with midportion Achilles tendinopathy were grouped from their baseline Tampa Scale of Kinesiophobia (TSK) score: Low (≤33), Medium (34-41), and High (≥42).

MAIN OUTCOME MEASURES

Symptom severity, Achilles tendon structure, and function were assessed at baseline and 8-weeks following initiation of the Silbernagel protocol. Differences in recovery between TSK groups were analyzed.

RESULTS

No group by time interactions were observed for symptoms, structure, or function. A significant interaction of group by time was observed for TSK score. The Medium (n = 66) and High (n = 28) TSK groups significantly decreased TSK score after 8 weeks by 2.4 and 4.4 points respectively while the Low TSK group (n = 22) did not change.

CONCLUSION

There were no differences in short term recovery of symptoms, Achilles tendon structure, and function in individuals with midportion Achilles tendinopathy treated with the Silbernagel protocol regardless of baseline degree of kinesiophobia. Those with moderate and high levels of kinesiophobia at baseline decreased TSK score in the short term.

ICON 2023: International Scientific Tendinopathy Symposium Consensus - the core outcome set for Achilles tendinopathy (COS-AT) using a systematic review and a Delphi study of professional participants and patients

To develop a core outcome set for Achilles tendinopathy (COS-AT) for use in clinical trials we performed a five-step process including (1) a systematic review of available outcome measurement instruments, (2) an online survey on truth and feasibility of the available measurement instruments, (3) an assessment of the methodological quality of the selected outcome measurement instruments, (4) an online survey on the outcome measurement instruments as COS and (5) a consensus in-person meeting. Both surveys were completed by healthcare professionals and patients. The Outcome Measures in Rheumatology guidelines with a 70% threshold for consensus were followed. We identified 233 different outcome measurement instruments from 307 included studies; 177 were mapped within the International Scientific Tendinopathy Symposium Consensus core domains. 31 participants (12 patients) completed the first online survey (response rate 94%). 22/177 (12%) outcome measurement instruments were deemed truthful and feasible and their measurement properties were evaluated. 29 participants (12 patients) completed the second online survey (response rate 88%) and three outcome measurement instruments were endorsed: the Victorian Institute of Sports Assessment-Achilles questionnaire, the single-leg heel rise test and evaluating pain after activity using a Visual Analogue Scale (VAS, 0-10). 12 participants (1 patient) attended the final consensus meeting, and 1 additional outcome measurement instrument was endorsed: evaluating pain during activity/loading using a VAS (0-10). It is recommended that the identified COS-AT will be used in future clinical trials evaluating the effectiveness of an intervention. This will facilitate comparing outcomes of intervention strategies, data pooling and further progression of knowledge about AT. As COS-AT is implemented, further evidence on measurement properties of included measures and new outcome measurement instruments should lead to its review and refinement.

Ultrasonographic measurements of gastro-soleus fascia thickness in midportion Achilles tendinopathy: A case-control study

BACKGROUND

The Achilles tendon is one of the thickest, largest, and strongest tendons in the human body. Biomechanically, the AT represents the conjoint tendon of the triceps surae muscle, placed in series with the plantar fascia (PF) to ensure force transmission from the triceps surae toward the toes during walking, running, and jumping. Commonly encountered in the diagnostic evaluation of heel pain, Achilles tendinopathy (AT) refers to a combination of pathological changes affecting the tendon itself often resulting from excessive repetitive stress and overuse. Nevertheless, increasing evidence demonstrates that structural alterations due to overuse or abnormal patterns of skeletal muscle activity are not necessarily restricted to the muscles or tendons but can also affect the fascial tissue. At the same time, there has been recent discussion regarding the role of the fascial tissue as a potential contributor to the pathophysiological mechanisms of the development of several musculoskeletal disorders including tendinopathies. To the best of our knowledge, ultrasound (US) imaging studies on the fascial structures related to the triceps surae complex, as well as their possible correlation with Achillodynia have never been presented in the current literature.

METHODS

In the present study, a comparative US imaging evaluation of textural features of the suro-Achilleo-plantar complex was performed in 14 healthy controls and 14 symptomatic subjects complaining of midportion AT. The thickness of the Achilles tendon, paratenon, intermuscular fascia, and PF has been assessed with US. In addition, both groups underwent the Victorian Institute of Sport Assessment-Achilles (VISA-A), a disease-specific questionnaire that measures the severity of symptoms of AT. Correlations between quantitative ultrasound measures and VISA-A scores were determined through Pearson or Spearman's rho correlations.

RESULTS

Our ultrasonographic findings revealed statistically significant differences (p<0.05) in Achilles tendon and paratenon thicknesses between AT patients and controls. No significant differences were observed between groups in PF at the calcaneal insertion as all mean measures were within the expected range of a normal PF on US imaging. In contrast, in tendinopathic subjects, the deep intermuscular fascia between medial gastrocnemius (MG) and soleus (SOL) muscles is significantly (p<0.01) and considerably thickened compared to those of healthy subjects. Moderate correlations exist between tendon and paratenon thicknesses (r= 0.54, p= 0.04) and between MG-SOL fascia and tendon thicknesses (r= 0.58, p= 0.03). Regarding symptom severity and US morphological findings, the Spearman ρ test showed no correlation.

CONCLUSIONS

Our data demonstrate that, in symptomatic subjects, US alterations are not restricted to paratenon and intratendinous areas, but also affect upstream structures along the myofascial chain, resulting in thickening of the fascia interposed between MG and SOL muscles. Moreover, positive correlations were found between MG-SOL fascia thickening and abnormalities in AT, paratenon, and symptom severity. Thus, US alterations in the fascial system should be interpreted within the clinical context of patients with AT as they may in turn represent important predictors of subsequent clinical outcomes and could help healthcare professionals and clinicians to refine non-operative treatment strategies and rehabilitation protocols for this disease.

Clinical and Imaging Outcomes Over 12 Weeks in Elite Athletes With Early-Stage Tendinopathy

Knowledge of how to treat chronic tendinopathy has advanced in recent years, but the treatment of early tendinopathy is not well understood. The main purpose of this prospective observational study was to investigate if changes occur in clinical and imaging outcomes over 12 weeks in elite athletes with recent debut of tendinopathy. Sixty-five elite adult athletes (24 ± 5 years) with early Achilles or patellar tendinopathy (symptoms < 3 months) were examined at baseline and after 12 weeks. Patients were divided into groups based on the duration of symptoms at the time of inclusion: (T1): 0-1 month, (T2): 1-2 months, or (T3): 2-3 months. Pain-guided activity modification was the only intervention. We assessed the following clinical outcomes: Questionnaires (Victorian Institute of Sports Assessment (VISA)) and pain scores (0-10 numeric rating scale, NRS), structural outcomes from ultrasonography: Thickness, echogenicity, and Doppler flow, and from magnetic resonance imaging: Cross-sectional area (CSA), thickness and length. Tendinopathic Achilles and patellar tendons displayed no significant differences on imaging tendon structural outcomes between T1 (n = 19), T2 (n = 23), and T3 (n = 20) at baseline or after 12 weeks, with one exception: Patellar tendons in T1 were thicker than T2 and T3 at baseline. Although athletes improved clinically on VISA and most NRS scores after 12 weeks, affected tendons with greater thickness, CSA and Doppler flow than contralateral tendons at baseline remained unchanged after 12 weeks. In conclusion, these data suggest that early tendinopathy in elite athletes can improve clinically after 12 weeks while morphology remains unchanged.

Topical glyceryl trinitrate (GTN) and eccentric exercises in the treatment of mid-portion achilles tendinopathy (the NEAT trial): a randomised double-blind placebo-controlled trial

OBJECTIVES

To investigate if daily treatment with glyceryl trinitrate (GTN) ointment, over 24 weeks combined with a 12-week eccentric exercise programme is more effective for chronic mid-portion Achilles tendinopathy than placebo ointment and eccentric exercise.

METHODS

This was a single-site randomised double-blind placebo-controlled trial at an acute hospital, Dublin, Ireland. Patients with chronic mid-portion Achilles tendinopathy were randomised to either 24 weeks of daily GTN ointment or placebo ointment. Both groups received an identical 12-week eccentric exercise programme. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 24 weeks, which measures pain, function and activity. Secondary outcomes included pain severity, self-reported physical function, calf muscle function, pressure pain thresholds and ultrasound changes. Statistical analyses were performed according to intention-to-treat principles.

RESULTS

76 patients (30 women; 46 men, mean age±SD, 45.6±8.2 years) were recruited for the trial. Significant improvements in VISA-A scores occurred in both groups at 6-week, 12-week and 24-week follow-up. The increase was not significantly different between groups, adjusted mean between-group difference from baseline to week 6, -1.33 (95% CI -6.96 to 4.31); week 12, -1.25 (95% CI -8.0 to 5.49) and week 24, -3.8 (95% CI -10.6 to 3.0); negative values favour GTN. There was no significant between-group difference in any of the secondary outcome measures at 6, 12 and 24 weeks.

CONCLUSIONS

Adding daily GTN ointment over 24 weeks to a 12-week eccentric exercise programme did not improve pain, function and activity level in patients with chronic mid-portion Achilles tendinopathy when compared with placebo ointment.

Outcomes After Extracorporeal Shockwave Therapy for Chronic Noninsertional Achilles Tendinopathy Compared With Chronic Insertional Achilles Tendinopathy: A Retrospective Review

BACKGROUND

Extracorporeal shockwave therapy (ESWT) is a noninvasive treatment modality that is used in the treatment of chronic Achilles tendinopathy (AT).

PURPOSES

To (1) retrospectively assess outcomes after ESWT for both noninsertional AT (NAT) and insertional AT (IAT) at >1-year follow-up and (2) identify potential predictors of outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Chart review was conducted to identify patients who underwent ESWT for AT with a minimum of 1-year follow-up. Data collected and assessed included patient demographic characteristics, pathological characteristics including the location of AT (NAT or IAT), presence of a Haglund deformity, and severity of tendon degeneration on magnetic resonance imaging (MRI), in addition to treatment characteristics including number of sessions and intensity of ESWT. The Victorian Institute of Sports Assessment-Achilles (VISA-A) and visual analog scale (VAS) pain scores were obtained before ESWT, 6 months after ESWT, and at final follow-up. Failures were also recorded, which were defined as no improvement in VISA-A or VAS scores or need for surgical intervention. Linear regression was performed to identify potential predictors of inferior subjective clinical outcomes and failures. Survival analysis was conducted using Kaplan-Meier curves.

RESULTS

The study included 52 patients with IAT and 34 patients with NAT. The mean follow-up in the NAT cohort was 22.3 ± 10.2 months and the mean follow-up in the IAT cohort was 26.8 ± 15.8 months. Improvements in VISA-A and VAS scores were observed in the NAT cohort at 6-month follow-up and at final follow-up (P < .05). Improvements in VISA-A and VAS scores were recorded in the IAT cohort at 6-month follow-up, which subsequently deteriorated at final follow-up. In the NAT cohort, the failure rate at 6-month follow-up was 11.8%, which increased to 29.4% at final follow-up. In the IAT cohort, the failure rate at 6-month follow-up was 32.7%, which increased to 59.6% at final follow-up. Predictors of inferior subjective clinical outcomes and failures in the NAT cohort included pre-ESWT subjective clinical score, male sex, presence of a cardiovascular risk factor, and more severe MRI grading of tendinopathy. Predictors of inferior subjective clinical outcomes and failures in the IAT cohort included pre-ESWT subjective clinical score and more severe MRI grading of tendinopathy.

CONCLUSION

Superior subjective clinical outcomes together with a lower failure rate were maintained for >1 year in the NAT cohort compared with the IAT cohort, calling into question the long-term benefit of ESWT for patients with IAT.

Endoscopic calcaneal SpeedBridge technique: Decreased postoperative complication rate in insertional achilles tendinopathy

BACKGROUND

An endoscopic calcaneal SpeedBridge technique was described recently. The primary objective of this study was to report the postoperative complications seen with calcaneal SpeedBridge repair. The secondary objective was to report short- and medium-term functional outcomes.

HYPOTHESIS

Postoperative complications are less common with endoscopic vs. open SpeedBridge suturing.

MATERIAL AND METHODS

The endoscopic SpeedBridge technique was used in 9 patients who had insertional Achilles tendinopathy refractory to conservative management. The patients were evaluated at least 24 months after the procedure. Infectious and wound-healing complications were recorded. Visual analogue scale (VAS) scores for pain and patient satisfaction, shoeing difficulties, the European Foot and Ankle Society (EFAS) score, and the Victorian Institute of Sport Assessment-Achilles (VISA-A) score were assessed.

RESULTS

During the mean follow-up of 25.3 months, no complications were recorded. The EFAS and VISA-A scores were 37/40 and 91/100, respectively. The mean VAS scores for pain and satisfaction were 1.7/10 and 9.3/10, respectively. No patients reported shoeing difficulties.

CONCLUSION

Endoscopic calcaneal SpeedBridge suturing is associated with a lower complication rate compared to the open variant. Clinical outcomes are highly satisfactory in the short and middle terms.

LEVEL OF EVIDENCE

IV; retrospective observational cohort study.

Portable device for measuring isometric plantar-flexion force after open Achilles repair: Retrospective cohort of 30 recreational athletes with one-year minimum follow-up

BACKGROUND

Plantar flexion force in recreational athletes after repair of Achilles tendon tears has rarely been reported, due to the lack of a widely available and fast measurement method. Knowledge of this parameter would allow optimisation of muscular and sports recovery. The main objective of this study was to measure the isometric force of the triceps surae at least 1 year after unilateral Achilles-tendon repair, comparatively to the unaffected side, using a portable device. The secondary objectives were to compare Achilles tendon and calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test versus the normal side and to assess functional scores at last follow-up.

HYPOTHESES

(i) Plantar flexion force does not differ significantly between the operated and contralateral sides. (ii) Calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test do not differ significantly between the operated and contralateral sides.

PATIENTS AND METHODS

This single-centre retrospective study included patients aged 18 to 65 years with a history of open repair of an acute unilateral Achilles tear at least 1 year earlier. Plantar flexion force, calf-muscle trophicity, dorsiflexion, and the heel-to-floor distance were measured on both sides and compared. The ATRS, VISA-A score, and EFAS score were determined. All complications were recorded.

RESULTS

The study included 30 patients with a mean follow-up of 20.3 months (range, 12-28 months). The operated side had significantly lower values for isometric triceps surae force, calf circumference, and heel-to-floor distance compared to the contralateral side (p<0.0001). Tendon width was significantly greater on the operated side (p<0.0001). Dorsiflexion did not differ significantly between sides (p=0.106). Mean functional score values were 91.5±6 for the ATRS (maximum, 100), 85±12 for the VISA-A score (maximum, 100), and 19.5±4 for the EFAS score (maximum, 24).

DISCUSSION

Isometric triceps-surae force measured using a portable device at least 1 year after open surgical Achilles-tendon repair was significantly decreased compared to the contralateral side. Calf circumference and heel-to-floor distance were also significantly lower. These data indicate a need for improved monitoring of triceps surae recovery to optimise rehabilitation and sports resumption.

LEVEL OF EVIDENCE

IV, retrospective comparative cohort study.

Significant functional impairment and disability in individuals with psoriatic arthritis and Achilles tendon pain: a cross-sectional observational study

The Achilles tendon (AT) insertion is the most common site of enthesitis in psoriatic arthritis (PsA). The structure and function of the AT in PsA, and the prevalence of mid-portion pathology, is unknown. To compare the structure and function of the AT in people with PsA with self-reported AT pain (PsA + AT), PsA without self-reported AT pain (PsA-AT) and healthy controls. A cross-sectional, observational study was conducted. The ATs were assessed by clinical and US examination (B-mode and Power Doppler), performance-based testing (bilateral heel raise test (HRT) and 10 m walk test), and patient-reported outcome measures (PROMs) (including the Victorian Institute of Sport Assessment-Achilles [VISA-A]). Between-group differences were described using descriptive statistics, Chi-squared testing, parametric (1-way ANOVA) and non-parametric (Mann-Whitney or Kruskal-Wallis) testing. 22 PsA (11 per group) and 11 healthy control participants who were comparable in terms of sex, age, and BMI (PsA-AT = longer PsA disease duration) were recruited. VISA-A scores were significantly worse in the PsA + AT group compared to the PsA-AT group and healthy controls (p < 0.001). Inflammatory US features were significantly more prevalent in the PsA + AT group (p < 0.001). Mid-portion AT pathology was observed in the PsA + AT group, irrespective of entheseal disease. Clinical examination alone missed 5/7 cases of 'active' US-confirmed AT enthesitis. AT functional deficits were significant in the PsA + AT group and both PsA groups had lower HRT repetition rates and walked slower compared to healthy controls. Less than 1/3 of the PsA + AT group had received podiatry or physiotherapy care. Significant differences in the structure and function of the AT in PsA were noted. Despite management in line with current guidance, AT pain appears to persist and can result in severe functional impairment.

Efficacy of shock wave therapy and ultrasound therapy in non-insertional Achilles tendinopathy: a randomised clinical trial

Objective

Physiotherapists and physicians continue to seek effective conservative treatments for Achilles tendinopathy. This study aimed to subjectively and objectively determine the therapeutic efficacy of radial shock wave therapy (RSWT) and ultrasound therapy in non-insertional Achilles tendinopathy.

Materials and methods

Thirty-nine patients with non-insertional Achilles tendinopathy were randomly assigned to three experimental groups, i.e., RSWT (group A), ultrasound therapy (group B), and placebo ultrasound (group C) groups. Before the intervention and at weeks 1 and 6 after the treatment, the patients were assessed using the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire and posturographic measurements of step initiation performed on the force platforms under two different conditions (non-perturbed transit and perturbed transit).

Results

Six weeks after therapy, all groups exhibited significantly increased VISA-A scores against the measurement at week 1 after therapy. The post-therapy percentage changes in VISA-A scores were significantly greater in group A compared to group B. The three-way ANOVA demonstrated that treatment type affected sway range in the frontal plane and mean velocity of the centre of foot pressure displacements in the sagittal and frontal planes during quiet standing before step initiation. The Bonferroni post-hoc test showed that the means of all those variables were significantly smaller for group A than for group B patients. The three-way ANOVA revealed an effect of the platform arrangement on transit time and double-support period. The Bonferroni post-hoc test revealed statistically longer transit time for the perturbed vs. non-perturbed trials; a reverse relationship was observed for the double-support period.

Conclusion

The VISA-A showed that RSWT was significantly more effective than sonotherapy for alleviation of pain intensity as well as function and activity improvement in patients with non-insertional Achilles tendinopathy. Therefore, RSWT therapy can be used in clinical practice by physiotherapists to alleviate the symptoms of non-insertional Achilles tendinopathy. Objective data registered by force platforms during quiet standing before and after step initiation did not prove useful for monitoring the progress of treatment applied to patients with non-insertional Achilles tendinopathy between consecutive therapy interventions.Clinical trial registration:https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000860369, identifier (ACTRN12617000860369).

Differences in Achilles tendon mechanical properties between professional ballet dancers and collegiate athletes utilizing shear wave elastography

PURPOSE

To report normative stiffness parameters obtained using shear wave elastography in dorsiflexion from the Achilles tendons in asymptomatic professional ballet dancers and compare them with college-level athletes.

METHODS

An Institutional Review Board (IRB)-approved study consists of 28 professional ballet dancers and 64 asymptomatic collegiate athletes. The athletes were further subdivided into runner and non-runner disciplines. Shear wave elastography (SWE) measurements were made in maximum ankle dorsiflexion position.

RESULTS AND DISCUSSION

Forty-eight (52%) males and 44 (48%) females were examined with an overall mean age of 22.2 (± 3.8 years). There were no significant SWE differences between dominant and non-dominant legs in both groups and comparing spin vs. non-spin leg of ballet dancers (p > 0.05). Ballet dancers had significantly higher short-axis velocity values than runners and non-runners (2.34 m/s increase and 2.79 m/s increase, respectively, p < 0.001). Long-axis velocity was significantly higher in ballet dancers compared to non-runners (by 0.80 m/s, p < 0.001), but was not different between ballet dancers and runners (p > 0.05). Short-axis modulus was significantly higher in dancers compared to runners and non-runners (by 135.2 kPa and 159.2 kPa, respectively, p < 0.001). Long-axis modulus (LAM) was not significantly different in ballet dancers when compared to runners.

CONCLUSION

Asymptomatic professional ballet dancers exhibit greater short-axis tendon stiffness compared to athletes and greater long-axis tendon stiffness compared to non-runners but similar to runners. The functional benefit from elevated short-axis stiffness in dancers is not clear but may be related to greater axial loading and adaptations of the tendon matrix.

Whipping or tearing? The biomechanics of Achilles tendinopathy in rearfoot strike runners

BACKGROUND

Two biomechanical mechanisms for the development of Achilles tendinopathy in runners have been proposed: A whipping mechanism characterized by prolonged and excessive rearfoot eversion, and a tearing mechanism characterized by high eccentric plantar flexor forces. The purpose of this pilot study was to determine if runners with and without a history of Achilles tendinopathy exhibited gait biomechanics consistent with either of these mechanisms.

METHODS

Seven male runners with previous or current Achilles tendinopathy and seven healthy male control runners were evaluated by three-dimensional gait analysis. Peak rearfoot eversion angle, rearfoot eversion excursion, duration of rearfoot eversion, and peak rearfoot inversion angle were compared between groups to evaluate the whipping mechanism of injury. Peak dorsiflexion angle, peak dorsiflexion velocity, and peak ankle power absorption were compared between groups to evaluate the tearing mechanism. Additionally, rearfoot eversion angle and sagittal plane ankle power waveforms were compared between groups using statistical parametric mapping.

FINDINGS

There were no differences in any rearfoot eversion, inversion, or dorsiflexion variables or waveforms during running in the Achilles tendinopathy group compared to controls.

INTERPRETATION

Rearfoot strike runners with Achilles tendinopathy do not exhibit running biomechanics consistent with either the whipping or tearing mechanisms of injury.

Cross-Cultural Adaptation, Translation, and Validation of the Victorian Institute of Sport Assessment-Achilles Questionnaire (VISA-A) for Use With Arabic-Speaking Patients With Achilles Tendinopathy

Background

The Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire is a validated instrument for assessing symptoms of Achilles tendinopathy (AT). However, there is a need to validate the Arabic version of the VISA-A (VISA-A-AR) in Arabic-speaking patients with AT.

Purpose

To validate the VISA-A-AR in Arabic patients with AT and evaluate its reliability and validity.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

The translation and cultural adaptation of the VISA-A questionnaire into Arabic followed international guidelines. A total of 81 participants were recruited, including 45 patients diagnosed with AT and 36 healthy individuals. The AT group comprised male and female native Arabic speakers aged ≥18 years who were diagnosed with and had symptoms of AT. The inclusion criteria for the healthy group were the same, except that they must not have had AT at the time of the study or previously. The exclusion criteria were individuals with a partial or complete Achilles tendon rupture or prior Achilles tendon surgery. The internal consistency of the VISA-A-AR was assessed using the Cronbach α coefficient. Test-retest reliability was evaluated using the intraclass correlation coefficient (ICC[3,1]). Construct validity was assessed through correlation analysis between VISA-A-AR scores and the Arabic versions of the Short Form-36 Health Survey (SF-36-AR) and the Numeric Pain Rating Scale (ANPRS). Differences in VISA-A-AR scores between patients with AT and healthy controls were analyzed using appropriate statistical tests.

Results

The VISA-A-AR demonstrated a high level of internal consistency (Cronbach α = 0.935) and excellent test-retest reliability (ICC[3,1] = 0.985). Significant positive correlations were observed between VISA-A-AR scores and SF-36-AR (r(43) = 0.838, P < .001), indicating good construct validity. In addition, VISA-A-AR scores showed a significant negative correlation with ANPRS (rS(43) = -0.835, P < .001). Furthermore, VISA-A-AR scores exhibited a significant difference between patients with AT (mean, 45.82 ± 16.65) and healthy controls (mean, 99.94 ± 0.33) (P < .001).

Conclusion

The findings of this study validate the VISA-A-AR as a reliable and valid tool for assessing symptoms of AT in Arabic-speaking patients.

Excellent Clinical Outcomes and Rapid Return to Activity Following In-Office Needle Tendoscopy for Chronic Achilles Tendinopathy

PURPOSE

To assess outcomes following Achilles in-office needle tendoscopy (IONT) for the treatment of chronic Achilles tendinopathy (cAT) at a minimum 12-month follow-up.

METHODS

A retrospective case series was conducted to evaluate patients who underwent Achilles IONT for cAT between January 2019 and December 2022. Inclusion criteria were patients ≥18 years of age and clinical history, physical history, and magnetic resonance imaging findings consistent with cAT who did not respond to a minimum of 3 months of conservative management for which each patient underwent Achilles IONT and had a minimum 12-month follow-up. Clinical outcomes were evaluated using the Victorian Institute of Sport Assessment-Achilles and visual analog scale scores. Patient satisfaction was measured at the final follow-up visit with a 5-point Likert scale.

RESULTS

Twelve patients (13 Achilles) with a mean age of 50.9 ± 14.6 years were included in the study. The mean follow-up time was 26.3 ± 6.3 months. The mean Victorian Institute of Sport Assessment-Achilles scores improved from a preoperative score of 35.6 ± 5.9 to a postoperative score of 83.6 ± 14.1 (P < .001). The mean visual analog scale score improved from a preoperative score of 6.6 ± 1.0 to a postoperative score of 1.3 ± 1.7 (P < .001). There were 10 patients (83.3%) who participated in sports activities before the IONT procedure. Within this group, 9 patients (90.0%) returned to play at a mean time of 5.9 ± 2.6 weeks. The mean time to return to work was 4.2 ± 1.2 days. Patients reported an overall positive IONT experience with a mean rating scale of 4.5 ± 0.9.

CONCLUSIONS

This retrospective review demonstrated that Achilles IONT for the treatment of cAT results in significant improvements in subjective clinical outcomes and a low complication rate together with high patient satisfaction scores at short-term follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Effectiveness of Low-Level Laser Therapy Combined With Eccentric Exercise in Treating Midportion Achilles Tendinopathy: A Randomized Controlled Trial

Background Achilles tendinopathy is a common overuse tendon injury, affecting athletes in running and similar sports. Repetitive overload of the Achilles tendon is the primary cause of inflammation, collagen degeneration, and tendon thickening. This study aims to investigate the efficacy of combining low-level laser therapy (LLLT) with eccentric exercises in treating midportion Achilles tendinopathy. Methods This prospective randomized controlled trial was conducted at the Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, from 2019 to 2022. Sixty clinically diagnosed patients with midportion Achilles tendinopathy, aged 18 to 60, were randomly assigned to two groups: Group A received eccentric exercises with LLLT, and Group B received eccentric exercises with placebo LLLT. The Victorian Institute of Sport Assessment-Achilles (VISA-A) score and the visual analog scale (VAS) score were used to measure treatment effectiveness at baseline and three, six, 12, and 24 weeks. Results The study included 60 participants, with no dropouts observed. The mean age was 33.9 ± 8.3 years in Group A and 33.40 ± 8.64 years in Group B, with no significant difference between the groups (p = 0.821). Both groups showed significant improvement in VISA-A and VAS scores over time (p < 0.001), but there was no statistically significant difference between the groups at any time point (p > 0.05). Conclusion Adding LLLT to eccentric exercises did not provide significant additional benefits compared to eccentric exercises alone in treating midportion Achilles tendinopathy. Practitioners should prioritize evidence-based interventions, such as eccentric exercises, as the primary treatment modality while considering alternative therapies for adjunctive purposes. Further research is needed to explore additional modalities or combination therapies that may enhance outcomes for patients with Achilles tendinopathy.

TENDINopathy Severity assessment-Achilles (TENDINS-A): evaluation of reliability and validity in accordance with COSMIN recommendations

OBJECTIVE

To evaluate the construct validity (structural validity and hypothesis testing), reliability (test-retest reliability, measurement error and internal consistency) and minimal important change (MIC) of the 13-item TENDINopathy Severity assessment-Achilles (TENDINS-A).

METHODS

Participants with Achilles pain completed an online survey including: demographics, TENDINS-A, Foot and Ankle Outcome Score (FAOS) and Victorian Institute of Sport Assessment-Achilles (VISA-A). Exploratory factor analysis (EFA) assessed dimensionality. Confirmatory factor analysis (CFA) assessed structural validity (root mean square error of approximation (RMSEA); Comparative Fit Index (CFI); Tucker-Lewis Index (TLI); standardised root measure square (SRMS)). Correlations between TENDINS-A and the FAOS or VISA-A assessed hypothesis testing. Intraclass correlation (ICC) assessed test-retest reliability. Cronbach's alpha assessed internal consistency. SE of the measurement (SEM) assessed measurement error. A distribution-based approach assessed MIC.

RESULTS

79 participants (51% female) with a mean (SD) age=42.6 (13.0) years, height=175.0 (11.7) cm and body mass=82.0 (19.1) kg were included. EFA identified three meaningful factors, proposed as pain, symptoms and function. The best model identified using CFA for TENDINS-A had structural validity (RMSEA=0.101, CFI=0.959, TLI=0.947, SRMS=0.068), which included three factors (pain, symptoms and function), but excluded three items from the original TENDINS-A. TENDINS-A exhibited moderate positive correlation with FAOS (r=0.598, p<0.001) and a moderate negative correlation with VISA-A (r=-0.639, p<0.001). Reliability of the TENDINS-A was excellent (ICC=0.930; Cronbach's α=0.808; SEM=6.54 units), with an MIC of 12 units.

CONCLUSIONS

Our evaluation of the revised 10-item TENDINS-A determined it has construct validity and excellent reliability, compared with the VISA-A and FAOS which lack content and construct validity. The TENDINS-A is recommended as the preferred patient-reported outcome measure to assess disability in people with Achilles tendinopathy.

Low socioeconomic status is associated with worse treatment outcomes in patients with Achilles tendinopathy

OBJECTIVE

To assess whether there is a difference in symptom severity at baseline and 24 weeks follow-up between conservatively managed patients with Achilles tendinopathy (AT) with low socioeconomic status (SES) compared with those with high SES.

METHODS

In this prospective cohort study, 200 patients with AT were included and treated according to current guidelines. We linked a neighbourhood SES indicator based on income, employment and education level and divided the patient population into quintiles, with Q1 being the highest SES and Q5 the lowest. Symptom severity at baseline and follow-up was assessed using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Treatment adherence was not measured. We used a general linear model and the mean VISA-A scores at baseline and at 6, 12 and 24 weeks follow-up were compared between Q1 (n=45) and Q5 (n=39), while adjusting for age, sex, body mass index (BMI), Ankle Activity Score, symptom duration and baseline VISA-A score.

RESULTS

Patients had a median age of 51 years and median BMI of 25.4, 40% were female. 74%, 70% and 58% of the participants completed the VISA-A at 6, 12 and 24 weeks, respectively. VISA-A scores at baseline were similar for Q1 and Q5 (43.9 and 41.8, p=0.591). At 24 weeks, there was a mean (95% CI) difference of 11.2 (1.0 to 21.3, p=0.032) points in favour of Q1 on the VISA-A score.

CONCLUSION

AT patients with low SES may have worse outcomes when treated using the current guidelines. The difference in VISA-A score at 24 weeks is larger than the minimal clinically important difference and might be clinically relevant, but comes with uncertainty due to the large dispersion in the data. Clinicians need to consider the impact of social inequality when developing and implementing treatment plans.

Efficacy of heel lifts for mid-portion Achilles tendinopathy (the LIFT trial): study protocol for a randomised controlled trial

BACKGROUND

Mid-portion Achilles tendinopathy is a common condition, characterised by localised Achilles tendon load-related pain and dysfunction. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. Heel lifts have also been advocated as a treatment for Achilles tendinopathy, but the efficacy and mechanism of action of this intervention is unclear. This proposal describes a randomised controlled trial comparing the effectiveness of heel lifts versus sham heel lifts for reducing pain associated with mid-portion Achilles tendinopathy, with an embedded biomechanical analysis.

METHODS

One hundred and eight men and women aged 18 to 65 years with mid-portion Achilles tendinopathy (who satisfy the inclusion and exclusion criteria) will be recruited. Participants will be randomised, using the website Sealed Envelope, to either a control group (sham heel lifts) or an experimental group (heel lifts). Both groups will be provided with education regarding acceptable pain levels to ensure all participants receive some form of treatment. The participants will be instructed to use their allocated intervention for at least 8 h every day for 12 weeks. The primary outcome measure will be pain intensity (numerical rating scale) at its worst over the previous week. The secondary outcome measures will be additional measures of Achilles tendon pain and disability, participant-perceived global ratings of change, function, level of physical activity and health-related quality of life. Data will be collected at baseline and the primary endpoint (week 12). Data will be analysed using the intention-to-treat principle. In addition, the acute kinetic and kinematic effects of the interventions will be examined at baseline in a subpopulation of the participants (n = 40) while walking and running using three-dimensional motion analysis.

DISCUSSION

The LIFT trial (efficacy of heeL lIfts For mid-portion Achilles Tendinopathy) will be the first randomised trial to compare the efficacy of heel lifts to a sham intervention in reducing pain and disability in people with Achilles tendinopathy. The biomechanical analysis will provide useful insights into the mechanism of action of heel lifts.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12623000627651 . Registered 7 June 2023.

Autologous bone marrow derived mesenchymal stem cells are safe for the treatment of Achilles tendinopathy

Achilles tendinopathy is a disabling condition that affects more than 50% of runners. Pre-clinical studies in a large animal model of naturally-occurring tendinopathy similar to human Achilles tendinopathy has shown benefits of autologous bone marrow-derived mesenchymal stem cell (MSC) implantation. However, MSCs are advanced therapies medicinal products (ATMPs), with strict regulatory requirements. Guided by the regulator we carried out a first in man study to assess the safety and efficacy of autologous MSC injection in human patients with non-insertional Achilles tendinopathy. Ten patients, mean age 47 with mid-portion Achilles tendon pain and swelling for more than 6 months, underwent autologous cultured cell injections (median 12.2 × 106, range 5-19 × 106 cells) into their Achilles tendon. At 24 weeks follow-up, no serious adverse reactions or important medical events were observed. MOXFQ, EQ-5D-5L, and VISA-A scores improved clinically at 12 and 24 weeks. VAS pain improved increasingly at 6, 12 and 24 weeks. MOXFQ Pain and VISA-A Scores improved > 12 points from baseline to 24 weeks in 8 patients. Maximum anteroposterior tendon thickness as measured by greyscale US decreased by mean 0.8 mm at 24 weeks. This phase IIa study demonstrated the safety of autologous MSC injection for non-insertional Achilles tendinopathy and provides proof-of-concept of the technique in patients, all of whom had previously failed conservative treatments for chronic disease and leads the way for a larger randomised controlled trial.

Asymmetric running is associated with pain during outdoor running in individuals with Achilles tendinopathy in the return-to-sport phase

OBJECTIVES

To determine the relationships between (1) Achilles tendon pain and loading symmetry, and (2) number of running bouts and symptom severity, during two weeks of outdoor running in individuals with Achilles tendinopathy.

DESIGN

Prospective, observational study.

SETTING

Biomechanics laboratory and outdoors.

PARTICIPANTS

Seventeen runners with Achilles tendinopathy in the return-to-sport phase of rehabilitation.

MAIN OUTCOME MEASURES

Symptom severity was recorded with the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Running bouts and Achilles tendon pain during runs were recorded with daily training logs. Ground contact time was collected during runs with wearable sensors. Linear mixed modeling determined if the relationship between Achilles tendon pain and ground contact time symmetry during running was moderated by consecutive run days. Multiple regression determined the relationship between number of running bouts and change in VISA-A scores over two weeks, adjusted for run distance.

RESULTS

Greater ground contact time on the contralateral leg corresponded to increased ipsilateral tendon pain for each consecutive run day (b = -0.028, p < 0.001). Number of running bouts was not associated with 2-week changes in VISA-A scores (p = 0.672).

CONCLUSIONS

Pain during running is associated with injured leg off-loading patterns, and this relationship strengthened with greater number of consecutive run days. Number of running bouts was not related to short-term symptom severity.

Normative ultrasound values for Achilles tendon thickness in the general population and patients with Achilles tendinopathy: A large international cross-sectional study

The objective of the study was to obtain adjusted ultrasonographic reference values of the Achilles tendon thickness (maximum anterior-posterior distance) in adults without (previous) Achilles tendinopathy (AT) and to compare these reference values with AT patients. Six hundred participants were consecutively included, comprising 500 asymptomatic individuals and 100 patients with clinically diagnosed chronic AT. The maximum tendon thickness was assessed using Ultrasound Tissue Characterization. A multiple quantile regression model was developed, incorporating covariates (personal characteristics) that were found to have a significant impact on the maximum anterior-posterior distance of the Achilles tendon. A 95% reference interval (RI) was derived (50th, 2.5th-97.5th percentile). In asymptomatic participants median (95% RI) tendon thickness was 4.9 (3.8-6.9) mm for the midportion region and 3.7 (2.8-4.8) mm for the insertional region. Age, height, body mass index, and sex had a significant correlation with maximum tendon thickness. Median tendon thickness for the midportion region was calculated with the normative equation -2.1 + AGE × 0.021 + HEIGHT × 0.032+ BMI × 0.028 + SEX × 0.05. For the insertional region, the normative equation was -0.34 + AGE × 0.010+ HEIGHT × 0.018 + BMI × 0.022 + SEX × -0.05. In the equations, SEX is defined as 0 for males and 1 for females. Mean (95% CI) difference in tendon thickness compared to AT patients was 2.7 mm (2.3-3.2, p < 0.001) for the midportion and 1.4 mm (1.1-1.7, p < 0.001) for the insertional region. Compared to the asymptomatic population 73/100 (73%) AT patients exhibited increased tendon thickening, with values exceeding the 95% RI. This study presents novel reference values for the thickness of midportion and insertional region of the Achilles tendon, which were adjusted for personal characteristics. Our novel web-based openly accessible calculator for determining normative Achilles tendon thickness (www.achillestendontool.com) will be a useful resource in the diagnostic process. Trial registration number: This trial is registered in the Netherlands Trial Register (NL9010).

Achilles tendon assessment on quantitative MRI: Sources of variability and relationships to tendinopathy

Quantitative MRI (qMRI) measures are useful in assessing musculoskeletal tissues, but application to tendon has been limited. The purposes of this study were to optimize, identify sources of variability, and establish reproducibility of qMRI to assess Achilles tendon. Additionally, preliminarily estimates of effect of tendon pathology on qMRI metrics and structure-function relationships between qMRI measures and ankle performance were examined. T1, T1ρ, T2, and T2* maps of the Achilles tendon were obtained using a 3T MRI scanner. In participants with asymptomatic tendons (n = 21), MRI procedures were repeated twice, and region of interest selection was performed by three raters. Variance decomposition and reproducibility statistics were completed. To estimate the effect of pathology, qMRI measures from individuals with asymptomatic tendons were compared to qMRI measures from a pilot group of individuals with Achilles tendinopathy (n = 7). Relationships between qMRI and ankle performance measures were assessed. Between-participant variation accounted for the majority of variability (46.7%-64.0%) in all qMRI measures except T2*. ICCs met or exceeded 0.7 for all qMRI measures when averaged across raters or scans. Relaxation times were significantly longer in tendinopathic tendons (mean (SD) T1: 977.8 (208.6) ms, T1ρ: 35.4 (7.1) ms, T2: 42.8 (7.9) ms, T2*: 14.1 (7.6) ms, n = 7) compared to asymptomatic control tendons (T1: 691.7 (32.4) ms, T1ρ: 24.0 (3.6) ms, T2: 24.4 (7.5) ms, T2*: 9.5 (3.4) ms, n = 21) (p < 0.011 for all comparisons). T1 related to functional performance measures in symptomatic and asymptomatic groups. Study findings suggest that qMRI is reliable to assess the Achilles tendon. qMRI quantitatively assesses the presence of tendon pathology and relates to functional performance outcomes, supporting the utility of incorporating qMRI in research and clinic.