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Gaida JE, Alfredson H, Scott A, Mousavizadeh R, Forsgren S. Apolipoprotein A1 distribution pattern in the human Achilles tendon. Scand J Med Sci Sports 2018; 28:1506-1513. [PMID: 29315811 DOI: 10.1111/sms.13051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2018] [Indexed: 11/27/2022]
Abstract
Metabolic factors such as cholesterol appear to play an important role in the development of Achilles tendinopathy. There is, however, no morphologic proof explaining the link between high cholesterol and tendinopathy. As apolipoprotein A1 (Apo-A1) is essential for reverse cholesterol transport, it may be related to cholesterol overload in tendon. Nothing is known about Apo-A1 expression in tendon tissue. We examined the distribution of Apo-A1 protein in biopsies from normal and tendinopathy-affected human Achilles tendons, and APOA1 mRNA production from cultured human hamstring tenocytes. Specific immunoreactions for Apo-A1 were detected. The tenocytes showed specific Apo-A1 immunoreactions. These reactions were usually distinct in the tendinopathy specimens. While the tendinopathy specimens often showed granular/small deposit reactions, the slender tenocytes of control specimens did not show this pattern. The magnitude of Apo-A1 immunoreactivity was especially marked in the tendinopathy specimens, as there is a high number of tenocytes. Reactions were also seen in the walls of blood vessels located within the tendon tissue proper of both the normal and tendinopathy tendons and within the peritendinous/fatty tissue of the tendinopathy tendons. The reactions were predominantly in the form of deposit reactions within the smooth muscle layer of the vessel walls. Cultured hamstring tenocytes produced APOA1 mRNA. We demonstrated the presence of Apo-A1 in human tendon tissue. This suggests there may be a link between Achilles tendinopathy and cholesterol metabolism. We hypothesize that Apo-A1 may be important for tenocyte and blood vessel function within tendons.
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Affiliation(s)
- J E Gaida
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, ACT, Australia.,Discipline of Physiotherapy, University of Canberra, Canberra, ACT, Australia.,Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Sports Medicine, Umeå University, Umeå, Sweden
| | - H Alfredson
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden.,Institute of Sport Exercise and Health, University College Hospital London, London, UK
| | - A Scott
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - R Mousavizadeh
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - S Forsgren
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden
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Spang C, Renström L, Alfredson H, Forsgren S. Marked expression of TNF receptors in human peritendinous tissues including in nerve fascicles with axonal damage - Studies on tendinopathy and tennis elbow. J Musculoskelet Neuronal Interact 2017; 17:226-236. [PMID: 28860425 PMCID: PMC5601268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The peritendinous connective tissues can have importance in chronic tendon pain. Recently cytokine TNF-α has been suggested to be involved in tendinopathic processes. It is not known how TNF-α and its receptors TNFR1 and TNFR2 are expressed in peritendinous tissues. METHODS The objective for this study was to immunohistochemically evaluate the expression patterns of these in the peritendinous tissue located between the plantaris and Achilles tendons and the one located superficially to the extensor origin at the elbow region for patients with tendinopathy/tennis elbow. RESULTS The nerve fascicles were of two types, one type being homogenously stained for the nerve markers βIII-tubulin and neurofilament and the other showing deficits for these suggesting features of axonal damage. Much more distinct TNFR1/TNFR2 immunoreactions were seen for the latter nerve fascicles. TNFR1 was seen in axons, TNFR2 mainly in Schwann cells. TNFR1 and particularly TNFR2 were seen in walls of parts of blood vessels. The dispersed cells showed frequently TNFR1 and TNFR2 immunoreactivity. DISCUSSION These findings suggest that TNF-α can be related to degenerative events but also attempts for healing concerning the nerve structures. The marked expression of the TNF-α system in the peritendinous tissue suggests an impact of TNF-α in tendinopathy/tennis elbow.
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Affiliation(s)
- C. Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden,Dr. Alfen Orthopaedic Spine Center, Würzburg, Germany,Corresponding author: Christoph Spang, Department of Integrative Medical Biology, Anatomy Section, Umeå University, SE-901 87 Umeå, Sweden E-mail:
| | - L. Renström
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden
| | - H. Alfredson
- Department of Community Medicine and Rehabilitation, Sports Medicine Unit, Umeå University, Umeå, Sweden,Pure Sports Medicine Clinic, London, UK,ISEH, UCLH, London, UK
| | - S. Forsgren
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden
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Spang C, Alfredson H. Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow - Implication for treatment? J Musculoskelet Neuronal Interact 2017; 17:97-103. [PMID: 28574416 PMCID: PMC5492324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Tennis elbow is difficult to treat. The results of surgical treatments are not convincing. Treatment studies on Achilles and patellar tendinopathy targeting the richly innervated and vascularized soft tissues outside the tendon have shown promising outcomes. The innervation patterns in the fibrous/fatty tissues superficially to the elbow extensor origin have not been clarified. METHODS Nine tissue specimens from the fibrous/fatty tissue covering the extensor origin was taken from seven patients (mean age: 45 years) undergoing surgical treatment for chronic painful tennis elbow. The specimens were stained for morphology (haematoxylin and eosin, H and E) and immunohistochemically for general nerve marker protein gene product 9.5 (PGP 9.5) and markers for sympathetic (tyrosine hydroxylase, TH) and sensory nerve fibres (calcitonin gene-related peptide, CGRP). RESULTS All specimens contained multiple blood vessels and nerve structures indicated by morphology and immunoreactions. There was a frequent occurrence of TH reactions, especially peri-vascularly, but also in nerve fascicles. Immunoreactions for CGRP were seen in nerve fascicles and isolated nerve fibres. CONCLUSION The results provide new information on the innervation patterns of the superficial tissues of the extensor origin and their potential as source of tennis elbow pain. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- C. Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Sweden,Dr. Alfen, Orthopaedic Spine Center, Wuerzburg, Germany,Corresponding author: Christoph Spang, Department of Integrative Medical Biology, Anatomy Section, Umeå University, 90187 Umeå, Sweden E-mail:
| | - H. Alfredson
- Department of Community Medicine and Rehabilitation, Sports Medicine Unit, Umeå University, Sweden,ISEH, University College London Hospitals, UK,Pure Sports Medicine Clinic, London, UK
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Abat F, Alfredson H, Cucchiarini M, Madry H, Marmotti A, Mouton C, Oliveira JM, Pereira H, Peretti GM, Romero-Rodriguez D, Spang C, Stephen J, van Bergen CJA, de Girolamo L. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach. J Exp Orthop 2017; 4:18. [PMID: 28560707 PMCID: PMC5449348 DOI: 10.1186/s40634-017-0092-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/12/2017] [Indexed: 12/05/2022] Open
Abstract
Chronic tendinopathies represent a major problem in the clinical practice of sports orthopaedic surgeons, sports doctors and other health professionals involved in the treatment of athletes and patients that perform repetitive actions. The lack of consensus relative to the diagnostic tools and treatment modalities represents a management dilemma for these professionals. With this review, the purpose of the ESSKA Basic Science Committee is to establish guidelines for understanding, diagnosing and treating this complex pathology.
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Affiliation(s)
- F Abat
- Department of Orthopaedic Sports Medicine, ReSport Clinic, Passeig Fabra i Puig 47, 08030, Barcelona, Spain.
| | - H Alfredson
- Sports Medicine Unit, University of Umeå, Umeå, Sweden.,Alfredson Tendon Clinic Inc, Umeå, Sweden.,Pure Sports Medicine Clinic, ISEH, UCLH, London, UK
| | - M Cucchiarini
- Molecular Biology, Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr Bldg 37, 66421, Homburg/Saar, Germany
| | - H Madry
- Lehrstuhl für Experimentelle Orthopädie und Arthroseforschung, Universität des Saarlandes, Gebäude 37, Kirrbergerstr 1, 66421, Homburg, Germany
| | - A Marmotti
- Department of Orthopaedics and Traumatology, San Luigi Gonzaga Hospital, Orbassano, University of Turin, Turin, Italy
| | - C Mouton
- Department of Orthopedic Surgery, Clinique d'Eich-Centre Hospitalier de Luxembourg, 76, rue d'Eich, L-1460, Luxembourg, Luxembourg
| | - J M Oliveira
- 3B's Research Group - Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark, Zona Industrial da Gandra, 4805-017, Barco, GMR, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal
| | - H Pereira
- 3B's Research Group University of Minho, ICVS/3B's-PT Government Associate Laboratory, Braga, Guimarães, Portugal.,Orthopedic Department Centro Hospitalar Póvoa de Varzim, Vila do Conde, Portugal.,Ripoll y De Prado Sports Clinic - FIFA Medical Centre of Excellence, Murcia, Madrid, Spain
| | - G M Peretti
- IRCCS Istituto Ortopedico Galeazzi, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - D Romero-Rodriguez
- Department of Physical Therapy and Sports Rehabilitation, ReSport Clinic Barcelona, Barcelona, Spain.,EUSES Sports Science, University of Girona, Girona, Spain
| | - C Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden
| | - J Stephen
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.,The Biomechanics Group, Department of Mechanical Engineering, Imperial College, London, UK
| | - C J A van Bergen
- Department of Orthopedic Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - L de Girolamo
- Orthopaedic Biotechnology Laboratory, Galeazzi Orthopaedic Institute, Milan, Italy
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Spang C, Alfredson H, Docking SI, Masci L, Andersson G. The plantaris tendon: a narrative review focusing on anatomical features and clinical importance. Bone Joint J 2017; 98-B:1312-1319. [PMID: 27694583 DOI: 10.1302/0301-620x.98b10.37939] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/24/2016] [Indexed: 11/05/2022]
Abstract
In recent years, the plantaris tendon has been implicated in the development of chronic painful mid-portion Achilles tendinopathy. In some cases, a thickened plantaris tendon is closely associated with the Achilles tendon, and surgical excision of the plantaris tendon has been reported to be curative in patients who have not derived benefit following conservative treatment and surgical interventions. The aim of this review is to outline the basic aspects of, and the recent research findings, related to the plantaris tendon, covering anatomical and clinical studies including those dealing with histology, imaging and treatment. Cite this article: Bone Joint J 2016;98-B:1312-19.
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Affiliation(s)
- C Spang
- Umeå University, 901 87 Umeå, Sweden
| | - H Alfredson
- University College London Hospitals, 170 Tottenham Court Road, London W1T 7HA, UK
| | - S I Docking
- Federation University, Lydiard Street South, Ballarat VIC 3350, Australia
| | - L Masci
- Pure Sports Medicine Clinic, Cabot Place West, London E14 4QS, UK
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Spang C, Harandi V, Alfredson H, Forsgren S. Marked innervation but also signs of nerve degeneration in between the Achilles and plantaris tendons and presence of innervation within the plantaris tendon in midportion Achilles tendinopathy. J Musculoskelet Neuronal Interact 2015; 15:197-206. [PMID: 26032213 PMCID: PMC5133724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The plantaris tendon is increasingly recognised as an important factor in midportion Achilles tendinopathy. Its innervation pattern is completely unknown. METHODS Plantaris tendons (n=56) and associated peritendinous tissue from 46 patients with midportion Achilles tendinopathy and where the plantaris tendon was closely related to the Achilles tendon were evaluated. Morphological evaluations and stainings for nerve markers [general (PGP9.5), sensory (CGRP), sympathetic (TH)], glutamate NMDA receptor and Schwann cells (S-100β) were made. RESULTS A marked innervation, as evidenced by evaluation for PGP9.5 reactions, occurred in the peritendinous tissue located between the plantaris and Achilles tendons. It contained sensory and to some extent sympathetic and NMDAR1-positive axons. There was also an innervation in the zones of connective tissue within the plantaris tendons. Interestingly, some of the nerve fascicles showed a partial lack of axonal reactions. CONCLUSION New information on the innervation patterns for the plantaris tendon in situations with midportion Achilles tendinopathy has here been obtained. The peritendinous tissue was found to be markedly innervated and there was also innervation within the plantaris tendon. Furthermore, axonal degeneration is likely to occur. Both features should be further taken into account when considering the relationship between the nervous system and tendinopathy.
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Affiliation(s)
- C. Spang
- Department of Integrative Medical Biology (IMB), Anatomy Section, Umeå University, Sweden,Corresponding author: Christoph Spang, Department of Integrative Medical Biology, Section for Anatomy, Umeå University, SE- 901 87 Umeå, Sweden E-mail:
| | - V.M. Harandi
- Department of Integrative Medical Biology (IMB), Anatomy Section, Umeå University, Sweden
| | - H. Alfredson
- Department of Community Medicine and Rehabilitation, Umeå University, Sweden,Pure Sports Medicine Clinic, London, UK,ISEH, UCLH, London, UK
| | - S. Forsgren
- Department of Integrative Medical Biology (IMB), Anatomy Section, Umeå University, Sweden
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Gaida J, Alfredson H, Forsgren S, Cook J. DECREASED TUMOUR NECROSIS FACTOR ALPHA (TNF-Α) IN SERUM OF PATIENTS WITH ACHILLES TENDINOPATHY: FURTHER EVIDENCE AGAINST THE ROLE OF INFLAMMATION IN THE CHRONIC STAGE. Br J Sports Med 2014. [DOI: 10.1136/bjsports-2014-093494.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Andersson G, Alfredson H. PROTEASE-ACTIVATED RECEPTORS ARE EXPRESSED IN HUMAN TENDON TISSUE AND MAY EXPLAIN EXCESSIVE PAIN-SIGNALLING IN TENDINOPATHY. Br J Sports Med 2013. [DOI: 10.1136/bjsports-2013-092459.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Alfredson H, Spang C, Forsgren S. STUDIES ON ACHILLES TENDINOSIS: BILATERAL RECOVERY AFTER UNILATERAL SURGERY, AND SIMILAR HISTOPATHOLOGICAL APPEARANCES BILATERALLY. Br J Sports Med 2013. [DOI: 10.1136/bjsports-2013-092459.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Alfredson H, Andersson G, Backman L, Bagge J, Danielson P, Forsgren S. US AND DOPPLER-GUIDED SURGICAL TREATMENT BASED ON IMMUNOHISTOCHEMICAL FINDINGS IN MIDPORTION ACHILLES TENDINOPATHY SHOWS GOOD CLINICAL RESULTS AND FAST RETURN TO ACTIVITY. Br J Sports Med 2013. [DOI: 10.1136/bjsports-2013-092459.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Backman LJ, Andersson G, Fong G, Alfredson H, Scott A, Danielson P. Alpha-2 adrenergic stimulation triggers Achilles tenocyte hypercellularity: Comparison between two model systems. Scand J Med Sci Sports 2012; 23:687-96. [PMID: 22292987 PMCID: PMC3933766 DOI: 10.1111/j.1600-0838.2011.01442.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2011] [Indexed: 11/29/2022]
Abstract
The histopathology of tendons with painful tendinopathy is often tendinosis, a fibrosis-like condition of unclear pathogenesis characterized by tissue changes including hypercellularity. The primary tendon cells (tenocytes) have been shown to express adrenoreceptors (mainly alpha-2A) as well as markers of catecholamine production, particularly in tendinosis. It is known that adrenergic stimulation can induce proliferation in other cells. The present study investigated the effects of an exogenously administered alpha-2 adrenergic agonist in an established in vivo Achilles tendinosis model (rabbit) and also in an in vitro human tendon cell culture model. The catecholamine producing enzyme tyrosine hydroxylase and the alpha-2A-adrenoreceptor (α2A AR) were expressed by tenocytes, and alpha-2 adrenergic stimulation had a proliferative effect on these cells, in both models. The proliferation was inhibited by administration of an α2A AR antagonist, and the in vitro model further showed that the proliferative alpha-2A effect was mediated via a mitogenic cell signaling pathway involving phosphorylation of extracellular-signal-regulated kinases 1 and 2. The results indicate that catecholamines produced by tenocytes in tendinosis might contribute to the proliferative nature of the pathology through stimulation of the α2A AR, pointing to a novel target for future therapies. The study furthermore shows that animal models are not necessarily required for all aspects of this research.
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Affiliation(s)
- L J Backman
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
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Bagge J, Gaida JE, Danielson P, Alfredson H, Forsgren S. Physical activity level in Achilles tendinosis is associated with blood levels of pain-related factors: a pilot study. Scand J Med Sci Sports 2011; 21:e430-8. [DOI: 10.1111/j.1600-0838.2011.01358.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Willberg L, Sunding K, Forssblad M, Fahlstrom M, Alfredson H. Sclerosing polidocanol injections or arthroscopic shaving to treat patellar tendinopathy/jumper's knee? A randomised controlled study. Br J Sports Med 2011; 45:411-5. [DOI: 10.1136/bjsm.2010.082446] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Alfredson H. Ultrasound and Doppler-guided mini-surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med 2011; 45:407-10. [DOI: 10.1136/bjsm.2010.081216] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gaida J, Bagge J, Purdam C, Cook J, Alfredson H, Forsgren S. Expression of TNF-α and TNFR1 in tenocytes in normal human Achilles tendon and tendinosis biopsies. J Sci Med Sport 2010. [DOI: 10.1016/j.jsams.2010.10.504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Andersson G, Forsgren S, Scott A, Gaida JE, Stjernfeldt JE, Lorentzon R, Alfredson H, Backman C, Danielson P. Tenocyte hypercellularity and vascular proliferation in a rabbit model of tendinopathy: contralateral effects suggest the involvement of central neuronal mechanisms. Br J Sports Med 2010; 45:399-406. [DOI: 10.1136/bjsm.2009.068122] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Gaida J, Alfredson H, Kiss Z, Bass S, Cook J. Body fat distribution differs according to the presence of asymptomatic achilles tendon pathology. J Sci Med Sport 2010. [DOI: 10.1016/j.jsams.2009.10.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bjur D, Alfredson H, Forsgren S. Presence of the neuropeptide Y1 receptor in tenocytes and blood vessel walls in the human Achilles tendon. Br J Sports Med 2009; 43:1136-42. [PMID: 19364758 DOI: 10.1136/bjsm.2008.055780] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Questions remain concerning the mechanisms of the development of chronic pain and impaired function of tendons (tendinosis). Aspects known to occur are cell proliferation, angiogenesis and altered blood flow regulation. Neuropeptide Y (NPY) is widely distributed in the body and has powerful effects in relation to these processes. NPY has its effects via the G-protein-coupled Y receptors. There is no information concerning the presence or absence of NPY receptors in Achilles tendons or other tendons. OBJECTIVE To clarify the expression patterns of the NPY receptors Y1 and Y2 in normal and tendinosis Achilles tendons of humans. METHODS Immunohistochemical methods were used. Examination on NPY was carried out in parallel. RESULTS The tenocytes showed strong immunoreactions for the Y1 receptor. The immunoreactions were more intense in the tenocytes of tendinosis tendons than in non-tendinosis tendons. The rounded/oval tenocytes typically seen in tendinosis tendons exhibited marked Y1 receptor reactions on their exterior. Pronounced Y1 reactions were seen in the smooth muscle of the arterioles of both tendinosis and non-tendinosis tendons. No reactions for the Y2 receptor were noted. NPY was detected in nerve fascicles and in perivascular innervation. CONCLUSIONS This study shows that there is a morphological correlate for the occurrence of pronounced NPY effects via the Y1 receptor in both tenocytes, especially for tendinosis tendons, and blood vessel walls in the Achilles tendon. The findings are of particular interest as NPY is known to have proliferative, angiogenic and blood vessel-regulating effects. The effects of targeting the Y1 receptor in tendinosis is an interesting task to be evaluated further.
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Affiliation(s)
- D Bjur
- Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
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Zeisig E, Ljung BO, Alfredson H, Danielson P. Immunohistochemical evidence of local production of catecholamines in cells of the muscle origins at the lateral and medial humeral epicondyles: of importance for the development of tennis and golfer's elbow? Br J Sports Med 2009; 43:269-75. [DOI: 10.1136/bjsm.2008.054619] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gaida J, Kiss J, Bass S, Alfredson H. Systemic cytokine levels among subjects with asymptomatic tendon pathology and matched controls. J Sci Med Sport 2009. [DOI: 10.1016/j.jsams.2008.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Alfredson H, Zeisig E, Fahlström M. No normalisation of the tendon structure and thickness after intratendinous surgery for chronic painful midportion Achilles tendinosis. Br J Sports Med 2008; 43:948-9. [PMID: 18927167 DOI: 10.1136/bjsm.2008.050955] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To characterise Achilles tendon structure and thickness a minimum of 8 years after intratendinous surgery. MATERIAL AND METHODS Fourteen patients (16 tendons; nine men and five women, mean age 43 years, range 27-55) surgically treated (intratendinous surgery) for chronic painful midportion Achilles tendinosis, were followed with clinical examination and grey-scale ultrasonography for a minimum of 8 years (range 8-16, mean 13). RESULTS All patients were satisfied with the result of surgery and were active in Achilles tendon loading activities without restrictions. In all operated tendons, structural abnormalities remained and tendons remained thicker than normal tendons. CONCLUSIONS Resection of tendinosis is associated with persistent structural abnormalities and thickening of the tendon 13 years after surgery, despite successful clinical outcomes.
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Affiliation(s)
- H Alfredson
- Department of Surgical and Perioperative Sciences, University of Umeå, Sweden.
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Zeisig E, Fahlström M, Ohberg L, Alfredson H. A two-year sonographic follow-up after intratendinous injection therapy in patients with tennis elbow. Br J Sports Med 2008; 44:584-7. [PMID: 18664498 DOI: 10.1136/bjsm.2008.049874] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tennis elbow is a tendinopathy affecting the upper extremity. Recent studies have shown high sensitivity for ultrasound (US) examination and high specificity for colour Doppler (CD) examination. There are no mid- or long-term follow-up investigations of the tendon structure and blood flow using these techniques. OBJECTIVE To use US and CD to study structure and blood flow in the extensor origin in patients with tennis elbow treated with intratendinous injections. DESIGN Follow-up study. SETTING Sports Medicine Unit, Umeå University. PATIENTS 25 patients (28 elbows), mean age 46 years (range 27-66), treated with intratendinous injections due to chronic pain from tennis elbow. METHOD US and CD examination of the extensor origin was carried out at inclusion and at follow-up two years after intratendinous injection treatment with polidocanol and/or a local anaesthetic. MAIN OUTCOME MEASUREMENTS US (structure) and CD (blood flow) findings. RESULTS All patients had structural tendon changes and high blood flow at inclusion when given the injection treatment. At the two-year follow-up, structural tendon changes were seen in 20/28 elbows and high blood flow was seen in 4/28 elbows. The majority of patients with a good clinical result after treatment had no visible blood flow (17/20), but the structural changes showed no relation to a good result (13/20 remaining changes). CONCLUSIONS Doppler findings, but not structure, might be related to the clinical result after intratendinous injection treatment of tennis elbow.
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Affiliation(s)
- E Zeisig
- Sports Medicine Unit, Department of Surgical and Perioperative Science, University of Umeå, 901 87 Umeå, Sweden.
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Fahlström M, Alfredson H. Ultrasound and Doppler findings in the Achilles tendon among middle-aged recreational floor-ball players in direct relation to a match. Br J Sports Med 2008; 44:140-3. [PMID: 18499765 DOI: 10.1136/bjsm.2008.047316] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE In this study, structure, blood flow and thickness in the Achilles tendon related to tendon-loading activity were investigated. DESIGN Examination by ultrasound (US) and colour Doppler (CD) immediately before and after 1 h of floor-ball matchplay. SETTING Sports Medicine Unit, Umeå University, Sweden. PARTICIPANTS 36 Achilles tendons in 18 middle-aged (mean 39 years) recreational male floor-ball players. MAIN OUTCOME MEASUREMENTS Structure and high blood flow (HBF)/neovessels (NV) in the tendons were registered. Tendon thickness was measured 3 and 4.5 cm above the upper calcaneus and at the thickest part of the tendon. RESULTS The US examination showed that 11/36 tendons (30.5%) in nine individuals had structural changes before and after the floor-ball match. In 7/36 tendons (five with structural changes), there were HBF/NV before, and after, the match. In six of these seven tendons, the blood flow was higher after than before the match. In three more tendons (two with structural changes), there were HBF/NV after, but not before, the match. After the match, mean tendon thickness had decreased significantly in both normal tendons and tendons with structural changes at the 3-cm level (6.0 (1.0) mm to 5.8 (0.9) mm; p<0.019), at the 4.5-cm level (5.7 (1.1) mm to 5.5 (1.0) mm; p<0.044), and at the thickest part (6.6 (1.1) mm to 6.3 (1.2) mm; p<0.000). CONCLUSIONS In about 1/3 of the tendons, there were structural changes, about half of those tendons also had HBF/NV, which was higher after, than before, the match. Mean tendon thickness in both normal tendons and tendons with structural changes had decreased significantly after a 1-h floor-ball match.
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Affiliation(s)
- M Fahlström
- Department of Surgical and Perioperative Sciences, Umeå University, Sweden.
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Jonsson P, Alfredson H, Sunding K, Fahlstrom M, Cook J. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. Br J Sports Med 2008; 42:746-9. [DOI: 10.1136/bjsm.2007.039545] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Zeisig E, Fahlstrom M, Ohberg L, Alfredson H. Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study. Br J Sports Med 2008; 42:267-71. [DOI: 10.1136/bjsm.2007.042762] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
The chronic painful tendon (tendinopathy, tendinosis) is generally considered difficult to treat, not seldom causing long-term disability and sometimes ending the sports or work carreér. Most common sites for tendinopathy are the Achilles-, patellar-, extensor carpi radialis brevis (ERCB)-, and supraspinatus tendons. The origin of pain has for many years been unknown, but recently, by using ultrasound (US) + colour Doppler (CD), immunohistochemical analyses of tendon biopsies, and diagnostic injections of local anaestesia, we found a close relationship between areas with vasculo-neural ingrowth and tendon pain. Sensory nerves (Substance-P-SP and Calcitonin Gene Related Peptide-CGRP) were found inside and outside the vascular wall. In following clinical studies we have demonstrated good short-and mid-term clinical results using treatment with US+CD-guided sclerosing polidocanol injections, targeting the area with neovessels outside the tendon. Two-year follow ups have showed remaining good clinical results, and sonographically signs of remodelling with a significantly thinner tendon with a more normal structure. Whether the effects of polidocanol are mediated through destruction of neovessels, activity on nerves or a combination, is under evaluation.
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Affiliation(s)
- H Alfredson
- Sports Medicine Unit, University of Umeå, 901 87 Umeå, Sweden.
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Högström M, Nordström A, Alfredson H, Lorentzon R, Thorsen K, Nordström P. Current physical activity is related to bone mineral density in males but not in females. Int J Sports Med 2006; 28:431-6. [PMID: 17111323 DOI: 10.1055/s-2006-924514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The purpose of the present study was to investigate the association between high-, medium-, and low-impact physical activity in males and females at the time of peak bone mineral density in young adulthood. The cohort consisted of 62 male medical students (aged 28.1 +/- 3.9) and 62 female medical students (aged 25.1 +/- 3.9). The bone mineral density (aBMD, g/cm (2)) of the total body, femoral neck, and lumbar spine, and the bone mineral content (BMC, grams) and area (cm (2)) of the femoral neck and lumbar spine was measured using dual energy X-ray absorptiometry. Volumetric BMD (vBMD, mg/cm (3)) of the femoral neck and lumbar spine was estimated. The total amount of physical activity per week, which was recorded in a questionnaire, was divided into high-impact, medium-impact, and low-impact activity. In the male cohort, hours of high-impact physical activity per week was associated with aBMD and BMC of all sites (r=0.27 - 0.53, p<0.05) and bone area of the femoral neck (r=0.38, p<0.01). Total amount of physical activity per week was associated with aBMD of the total body and femoral neck, BMC of femoral neck and lumbar spine, femoral neck vBMD, and the lumbar spine area (p<0.05 for all). Using multiple linear regression, high-impact physical activity was independently associated with aBMD (beta=0.27, p<0.05) and BMC (beta=0.34, p<0.01) of the femoral neck. In the female cohort there was no association between amount or type of physical activity to aBMD, BMC, vBMD, or the bone area of any site. Instead body weight, lean body mass, or fat mass were significantly related to aBMD and all BMC sites in this group. The results of the present study suggest that present physical activity level has a stronger relation to different aspects of bone mass in the male compared to the female adult skeleton.
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Affiliation(s)
- M Högström
- Department of Surgical and Perioperative Science, Sports Medicine Unit, University Hospital of Northern Sweden, Umeå, Sweden
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Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study. Br J Sports Med 2006; 39:847-50. [PMID: 16244196 PMCID: PMC1725058 DOI: 10.1136/bjsm.2005.018630] [Citation(s) in RCA: 151] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND A recent study reported promising clinical results using eccentric quadriceps training on a decline board to treat jumper's knee (patellar tendinosis). METHODS In this prospective study, athletes (mean age 25 years) with jumper's knee were randomised to treatment with either painful eccentric or painful concentric quadriceps training on a decline board. Fifteen exercises were repeated three times, twice daily, 7 days/week, for 12 weeks. All patients ceased sporting activities for the first 6 weeks. Age, height, weight, and duration of symptoms were similar between groups. Visual analogue scales (VAS; patient estimation of pain during exercise) and Victorian Institute of Sport Assessment (VISA) scores, before and after treatment, and patient satisfaction, were used for evaluation. RESULTS In the eccentric group, for 9/10 tendons patients were satisfied with treatment, VAS decreased from 73 to 23 (p<0.005), and VISA score increased from 41 to 83 (p<0.005). In the concentric group, for 9/9 tendons patients were not satisfied, and there were no significant differences in VAS (from 74 to 68, p<0.34) and VISA score (from 41 to 37, p<0.34). At follow up (mean 32.6 months), patients in the eccentric group were still satisfied and sports active, but all patients in the concentric group had been treated surgically or by sclerosing injections. CONCLUSIONS In conclusion, eccentric, but not concentric, quadriceps training on a decline board, seems to reduce pain in jumper's knee. The study aimed to include 20 patients in each group, but was stopped at the half time control because of poor results achieved in the concentric group.
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Affiliation(s)
- P Jonsson
- Department of Surgical and Perioperative Science, Sports Medicine, Centre for Musculoskeletal Research, National Institute for Working Life, University of Umeå, 901 87 Umeå, Sweden.
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Gisslén K, Alfredson H. Neovascularisation and pain in jumper's knee: a prospective clinical and sonographic study in elite junior volleyball players. Br J Sports Med 2005; 39:423-8; discussion 423-8. [PMID: 15976162 PMCID: PMC1725252 DOI: 10.1136/bjsm.2004.013342] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The nature of tendon neovascularisation associated with pain over time has not been studied. OBJECTIVE To prospectively study the patellar tendons in elite junior volleyball players. METHODS The patellar tendons in all students at the Swedish National Centre for high school volleyball were evaluated clinically and by ultrasonography (US) and Power Doppler (PD) sonography. RESULTS Altogether 120 patellar tendons were followed for 7 months. At inclusion, jumper's knee was diagnosed clinically in 17 patellar tendons. There were structural changes on US in 14 tendons, in 13 of which PD sonography showed neovascularisation. There were 70 clinically normal tendons with normal US and PD sonography, 24 clinically normal tendons with abnormal US but normal PD sonography, and nine clinically normal tendons with abnormal US and neovascularisation on PD sonography. At 7 month follow up, jumper's knee was diagnosed clinically and by US in 19 patellar tendons, in 17 of which there was neovascularisation. Three of nine clinically normal tendons with structural changes and neovascularisation at inclusion developed jumper's knee. Two of 24 tendons clinically normal at inclusion, with abnormal US but normal PD sonography, developed jumper's knee with abnormal US and neovascularisation on PD sonography. A total of 20 clinically normal tendons with normal US and PD sonography at inclusion developed structural tendon changes and 12 of these also developed neovascularisation. CONCLUSIONS The clinical diagnosis of jumper's knee is most often associated with neovascularisation in the area with structural tendon changes. The finding of neovessels might indicate a deterioration of the condition.
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Affiliation(s)
- K Gisslén
- Department of Surgical and Perioperative Science, Sports Medicine, University of Umeå, Umeå, Sweden
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Gisslèn K, Gyulai C, Söderman K, Alfredson H. High prevalence of jumper's knee and sonographic changes in Swedish elite junior volleyball players compared to matched controls. Br J Sports Med 2005; 39:298-301. [PMID: 15849296 PMCID: PMC1725221 DOI: 10.1136/bjsm.2004.014290] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Jumper's knee is a common and troublesome condition among senior volleyball players, but its prevalence among elite junior players compared to matched non-sports active controls is not known. OBJECTIVE To clinically, and by sonography, examine the patellar tendons in elite junior volleyball players (15-19 years) at the Swedish National Centre for volleyball and in matched controls. METHODS The patellar tendons in the 57 students at the Swedish National Centre for high school volleyball and in 55 age, height, and weight matched not regularly sports active controls were evaluated clinically and by grey scale ultrasonography (US) and power Doppler (PD) sonography. RESULTS There were no significant differences in mean age, height, and weight between the volleyball players and the controls. In the volleyball group, jumper's knee was diagnosed clinically and by US in 12 patellar tendons (10 male and two female). In 12/12 tendons, PD sonography demonstrated a neovascularisation in the area with structural tendon changes. In another 10 pain free tendons, there were structural tendon changes and neovessels. In the control group, no individual had a clinical diagnosis of jumper's knee. US demonstrated structural tendon changes in 11 tendons, but there was no neovascularisation on PD sonography. CONCLUSIONS A clinical diagnosis of jumper's knee, together with structural tendon changes and neovascularisation visualised with sonography, was seen among Swedish elite junior volleyball players but not in matched not regularly sports active controls. Structural tendon change alone was seen in 10% of the control tendons.
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Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med 2005; 39:102-5. [PMID: 15665207 PMCID: PMC1725109 DOI: 10.1136/bjsm.2003.010587] [Citation(s) in RCA: 199] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Conservative treatment of patellar tendinopathy has been minimally investigated. Effective validated treatment protocols are required. OBJECTIVES To investigate the immediate (12 weeks) and long term (12 months) efficacy of two eccentric exercise programmes for the treatment of patellar tendinopathy. METHODS This was a prospective randomised controlled trial of 17 elite volleyball players with clinically diagnosed and imaging confirmed patellar tendinopathy. Participants were randomly assigned to one of two treatment groups: a decline group and a step group. The decline group were required to perform single leg squats on a 25 degrees decline board, exercising into tendon pain and progressing their exercises with load. The step group performed single leg squats on a 10 cm step, exercising without tendon pain and progressing their exercises with speed then load. All participants completed a 12 week intervention programme during their preseason. Outcome measures used were the Victorian Institute of Sport Assessment (VISA) score for knee function and 100 mm visual analogue scale (VAS) for tendon pain with activity. Measures were taken throughout the intervention period and at 12 months. RESULTS Both groups had improved significantly from baseline at 12 weeks and 12 months. Analysis of the likelihood of a 20 point improvement in VISA score at 12 months revealed a greater likelihood of clinical improvements in the decline group than the step group. VAS scores at 12 months did not differ between the groups. CONCLUSIONS Both exercise protocols improved pain and sporting function in volleyball players over 12 months. This study indicates that the decline squat protocol offers greater clinical gains during a rehabilitation programme for patellar tendinopathy in athletes who continue to train and play with pain.
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Affiliation(s)
- M A Young
- Musculoskeletal Research Centre, La Trobe University, Bundoora, Victoria 3086, Australia.
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Purdam CR, Jonsson P, Alfredson H, Lorentzon R, Cook JL, Khan KM. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. Br J Sports Med 2005; 38:395-7. [PMID: 15273169 PMCID: PMC1724885 DOI: 10.1136/bjsm.2003.000053] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This non-randomised pilot study investigated the effect of eccentric quadriceps training on 17 patients (22 tendons) with painful chronic patellar tendinopathy. METHODS Two different eccentric exercise regimens were used by subjects with a long duration of pain with activity (more than six months). (a) Nine consecutive patients (10 tendons; eight men, one woman; mean age 22 years) performed eccentric exercise with the ankle joint in a standard (foot flat) position. (b) Eight patients (12 tendons; five men, three women; mean age 28 years) performed eccentric training standing on a 25 degrees decline board, designed to increase load on the knee extensor mechanism. The eccentric training was performed twice daily, with three sets of 15 repetitions, for 12 weeks. Primary outcome measures were (a) 100 mm visual analogue scale (VAS), where the subject recorded the amount of pain during activity, and (b) return to previous activity. Follow up was at 12 weeks, with a further limited follow up at 15 months. RESULTS Good clinical results were obtained in the group who trained on the decline board, with six patients (nine tendons) returning to sport and showing a significantly reduced amount of pain over the 12 week period. Mean VAS scores fell from 74.2 to 28.5 (p = 0.004). At 15 months, four patients (five tendons) reported satisfactory results (mean VAS 26.2). In the standard squat group the results were poor, with only one athlete returning to previous activity. Mean VAS scores in this group were 79.0 at baseline and 72.3 at 12 weeks (p = 0.144). CONCLUSION In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced encouraging results in terms of pain reduction and return to function in the short term. Eccentric exercise using standard single leg squats in a similar sized group appeared to be a less effective form of rehabilitation in reducing pain and returning subjects to previous levels of activity.
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Affiliation(s)
- C R Purdam
- Department of Physical Therapies, Australian Institute of Sport, PO Box 176, Belconnen 2616, ACT, Australia
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Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med 2004; 38:8-11; discussion 11. [PMID: 14751936 PMCID: PMC1724744 DOI: 10.1136/bjsm.2001.000284] [Citation(s) in RCA: 294] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To prospectively investigate tendon thickness and tendon structure by ultrasonography in patients treated with eccentric calf muscle training for painful chronic Achilles tendinosis located at the 2-6 cm level in the tendon. METHODS The patients were examined with grey scale ultrasonography before and 3.8 years (mean) after the 12 week eccentric training regimen. At follow up, a questionnaire assessed present activity level and satisfaction with treatment. RESULTS Twenty six tendons in twenty five patients (19 men and six women) with a mean age of 50 years were followed for a mean of 3.8 years (range 1.6-7.75). All patients had a long duration of painful symptoms (mean 17.1 months) from chronic Achilles tendinosis before treatment. At follow up, 22 of 25 patients were satisfied with treatment and active in Achilles tendon loading activities at the desired level. Ultrasonography showed that tendon thickness (at the widest part) had decreased significantly (p<0.005) after treatment (7.6 (2.3) v 8.8 (3) mm; mean (SD)). In untreated normal tendons, there was no significant difference in thickness after treatment (5.3 (1.3) mm before and 5.9 (0.8) mm after). All tendons with tendinosis had structural abnormalities (hypoechoic areas and irregular structure) before the start of treatment. After treatment, the structure was normal in 19 of the 26 tendons. Six of the seven patients with remaining structural abnormalities experienced pain in the tendon during loading. CONCLUSIONS Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon.
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Affiliation(s)
- L Ohberg
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå,
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Pettersson U, Nordstrom P, Alfredson H, Henriksson-Larsen K, Lorentzon R. Effect of high impact activity on bone mass and size in adolescent females:
A comparative study between two different types of sports. Scand J Med Sci Sports 2003. [DOI: 10.1046/j.1524-4725.2001.110310_1.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ohberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med 2002; 36:173-5; discussion 176-7. [PMID: 12055110 PMCID: PMC1724500 DOI: 10.1136/bjsm.36.3.173] [Citation(s) in RCA: 293] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The mechanism that causes pain in chronic Achilles tendinosis is not known. However, high resolution colour Doppler ultrasound has shown that neovascularisation may be involved. OBJECTIVE To investigate if sclerosing the neovessels would affect the level of tendon pain. METHODS The effect of colour Doppler ultrasound guided injection of a sclerosing agent, polidocanol, against neovessels was studied in 10 patients (seven men and three women, mean age 55 years) with painful chronic mid-portion Achilles tendinosis. RESULTS Eight patients were satisfied with the results of treatment. There was significantly reduced pain during activity (reported on a visual analogue scale (VAS)) and no remaining neovascularisation after an average of two injections. Two patients were not satisfied, and neovascularisation remained. At the six month follow up, the same eight patients remained satisfied and could perform Achilles tendon loading activities as desired. Their VAS score had decreased from 74 before treatment to 8 (p<0.01). CONCLUSIONS Sclerosing neovessels appears to be an effective treatment for painful chronic Achilles tendinosis, suggesting that neovessels play a key part in causing chronic tendon pain.
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Affiliation(s)
- Lars Ohberg
- Department of Diagnostic Radiology, University of Umea, S-901 85 Umea, Sweden.
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Abstract
The aim of this investigation was to study the consequences of anterior cruciate ligament injuries in female soccer players. Special interest was focused on young female soccer players (< 16 years) sustaining anterior cruciate ligament injuries when playing at a senior level, which means playing together with players 19 years or older. In Sweden, all players belonging to an organized soccer club are insured by the same insurance company, the Folksam Insurance Company. Data of all soccer-related knee injuries in females reported to the Folksam Insurance Company between 1994 and 1998 were collected. A questionnaire was sent to 978 females who were registered to have sustained a knee injury before the age of 20 years. The response rate was 79%. Three hundred and ninety-eight female soccer players who had sustained an anterior cruciate ligament injury before the age of 19 years were analysed. Most of their anterior cruciate ligament injuries had been diagnosed using arthroscopy or magnetic resonance imaging (84%). Thirty-eight percent of the players had been injured before the age of 16 years. Of these, 39% were injured when playing in senior teams. When playing in senior teams 59% of the players below the age of 16 years and 44% of the players 16 years or older sustained their ACL injuries during contact situations. At the time of this investigation (2-7 years after the anterior cruciate ligament injury), altogether 78% (n = 311) reported that they had stopped playing soccer. The most common reason (80%) was symptoms from their anterior cruciate ligament-injured knee. It appears that many young female soccer players injure their anterior cruciate ligament when playing at a senior level. Therefore, we suggest that female soccer players under the age of 16 years should be allowed to participate only in practice sessions but not games at a senior level.
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Affiliation(s)
- K Söderman
- Department of Surgical and Perioperative Sciences, Sports Medicine Unit, Umeå University, Stockholm, Sweden
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Söderman K, Adolphson J, Lorentzon R, Alfredson H. Injuries in adolescent female players in European football: a prospective study over one outdoor soccer season. Scand J Med Sci Sports 2001; 11:299-304. [PMID: 11696215 DOI: 10.1034/j.1600-0838.2001.110508.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In this prospective study, injuries in 153 adolescent female soccer players were recorded during one outdoor season (April-October). The overall injury incidence rate was 6.8 per 1000 h soccer (games and practice) and the incidence rate of traumatic injury 9.1 and 1.5 per 1000 player-hours in games and practice, respectively. Sixty-three players (41%) sustained 79 injuries. Sixty-six percent of the injuries were traumatic and 34% were overuse injuries. Most of the traumatic injuries occurred during games. Eighty-nine percent of the injuries were located in the lower extremities and 42% occurred in the knee or ankle. The most frequent type of injury was ankle sprain (22.8%). Forty-one percent of the traumatic injuries and 56% of the ankle sprains were re-injuries. Most of the injuries were of moderate severity (52%), while 34% were minor and 14% were major. Most of the major injuries were traumatic such as knee ligament injuries and ankle sprains.
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Affiliation(s)
- K Söderman
- Department of Surgical and Perioperative Science, Sports Medicine Unit, Umeå University, Sweden
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Alfredson H, Forsgren S, Thorsen K, Fahlström M, Johansson H, Lorentzon R. Glutamate NMDAR1 receptors localised to nerves in human Achilles tendons. Implications for treatment? Knee Surg Sports Traumatol Arthrosc 2001; 9:123-6. [PMID: 11354854 DOI: 10.1007/s001670000188] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In this investigation, we show the presence of both free glutamate (microdialysis) and glutamate NMDAR1 receptors (immunohistochemical analyses of tendon biopsies), in tendons from patients with chronic Achilles tendon pain (Achilles tendinosis) and in controls (pain-free tendons). The NMDAR1 immunoreaction was usually confined to acetylcholinesterase-positive structures, implying that the reaction is present in nerves. Glutamate is a potent pain mediator in the human central nervous system, and in animals it has been shown that peripherally administered glutamate NMDA receptor antagonists diminish the response to formalin-induced nociception. Our present finding of glutamate NMDA receptors in human Achilles tendons might have implications for pain treatment.
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Affiliation(s)
- H Alfredson
- Sports Medicine, Department of Surgical and Perioperative Science, University of Umeå, 901 87 Umeå, Sweden.
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Alfredson H, Forsgren S, Thorsen K, Lorentzon R. In vivo microdialysis and immunohistochemical analyses of tendon tissue demonstrated high amounts of free glutamate and glutamate NMDAR1 receptors, but no signs of inflammation, in Jumper's knee. J Orthop Res 2001; 19:881-6. [PMID: 11562137 DOI: 10.1016/s0736-0266(01)00016-x] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This investigation describes, to our knowledge, the first experiment where the microdialysis technique was used to study certain metabolic events in human patellar tendons in combination with immunohistochemical analyses of tendon biopsies. In five patients (four men and one woman) with a long duration (range 12-36 months) of pain symptoms from Jumper's knee (localized tenderness in the patellar tendon verified as tendon changes with ultrasonography or MRI), and in five controls (four men and one woman) with normal patellar tendons, a standard microdialysis catheter was inserted into the patellar tendon under local anestesia. The local concentrations of glutamate (excitatory neurotransmitter) and prostaglandin E2 (PGE2) were registered under resting conditions. Samplings were done every 15 min during a 2 h period. In all individuals (patients and controls) biopsies were taken for immunohistochemical analyses. The results showed that it was possible to detect and measure the concentrations of glutamate and PGE2 in the patellar tendon with the use of microdialysis technique. There were significantly higher concentrations of free glutamate, but not PGE2, in tendons with tendinosis compared to normal tendons. In the biopsies, there were no inflammatory cell infiltrates, but, for the first time, it was shown that there was immunoreaction for the glutamate receptor NMDAR1 in association with nerve structures in human patellar tendons. These findings altogether indicate that glutamate might be involved in painful Jumper's knee, and further emphasizes that there is no chemical inflammation (normal PGE2 levels) in this chronic condition.
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Affiliation(s)
- H Alfredson
- Department of Surgical and Perioperative Sciences, University of Umeå, Sweden.
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Söderman K, Alfredson H, Pietilä T, Werner S. Risk factors for leg injuries in female soccer players: a prospective investigation during one out-door season. Knee Surg Sports Traumatol Arthrosc 2001; 9:313-21. [PMID: 11685365 DOI: 10.1007/s001670100228] [Citation(s) in RCA: 197] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2001] [Accepted: 05/14/2001] [Indexed: 11/30/2022]
Abstract
The following possible risk factors for leg injuries in female soccer players were studied: age, anatomical alignment, generalized joint laxity, thigh muscle torque, muscle flexibility, ligamentous laxity of the knee and ankle joints, recent injuries, and duration of soccer exposure. A total of 146 players from 13 teams in the second and third Swedish divisions underwent clinical examination, isokinetic measurements of quadriceps and hamstring torques, and testing of postural sway of the legs. All soccer-related leg injuries resulting in absence from at least one scheduled practice session or game were recorded during one outdoor season (April-October). In 50 players there were 61 traumatic injuries, and 17 players sustained 19 overuse injuries. The overall injury incidence rate (traumatic and overuse) was 5.49/1000 h of soccer. Variables significantly increasing the risk of traumatic leg injuries included generalized joint laxity, low postural sway of the legs, hyperextension of the knee joint, and a low hamstring-to-quadriceps ratio during concentric action. Multivariate logistic regression showed hyperextension of the knee joint, a low postural sway, reduced H/Q ratio during concentric action, and a higher exposure to soccer to significantly increase the risk of traumatic leg injury. All five players who suffered an anterior cruciate ligament injury during the study period had a lower hamstring-to-quadriceps ratio during concentric action on the injured side than on their noninjured side.
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Affiliation(s)
- K Söderman
- Department of Surgical and Perioperative Sciences, Sports Medicine Unit, Umeå University, 90187 Umeå, Sweden.
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Ohberg L, Lorentzon R, Alfredson H. Good clinical results but persisting side-to-side differences in calf muscle strength after surgical treatment of chronic Achilles tendinosis: a 5-year follow-up. Scand J Med Sci Sports 2001; 11:207-12. [PMID: 11476425 DOI: 10.1034/j.1600-0838.2001.110403.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We have prospectively studied calf muscle strength (isokinetic concentric and eccentric muscle strength at 90 degrees/s and 225 degrees/s of angular velocity in 24 patients (17 males and 7 females, mean age 43.0 years) surgically treated for chronic Achilles tendinosis (at the 2-6 cm level in the tendon). The mean follow-up time was 5 years (range 31-82 months). Surgery was followed by immobilization in a weight-bearing below the knee plaster cast for 2-6 weeks, followed by a stepwise increasing strength training programme. Strength measurements (peak torque) were done preoperatively, and 1 and 5 (mean) years postoperatively. Preoperatively, concentric plantar flexion peak torque at 90 degrees/s and 225 degrees/s and eccentric plantar flexion torque at 90 degrees/s were significantly lower (12.3%, 19.7% and 8.5% respectively) on the injured side compared to the non-injured side. Postoperatively, at the 5-year follow-up, 22 out of 24 patients (92%) were satisfied with the operation and active at their desired level (running, tennis, badminton, walking). There was no significant increase in concentric and eccentric calf muscle strength postoperatively. Concentric plantar flexion peak torque at 90 degrees/s and 225 degrees/s and eccentric plantar flexion peak torque at 90 degrees/s were still significantly lower (7.2%, 8.6% and 8.8% respectively) on the injured side compared to the non-injured side. In conclusion it seems that the calf muscle strength deficit seen on the injured side preoperatively in this group of patients remains despite 92% of the patients being pain-free and active in sports or at recreational level after the operation. However, the percentage side-to-side difference is relatively low, and might not have any clinical relevance.
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Affiliation(s)
- L Ohberg
- Department of Surgical and Perioperative Science, National Institute for Working Life, University of Umeå, Sweden
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Ohberg L, Lorentzon R, Alfredson H. Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 2001; 9:233-8. [PMID: 11522081 DOI: 10.1007/s001670000189] [Citation(s) in RCA: 338] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Chronic Achilles tendinosis is a condition with unknown aetiology and pathogenesis, most often, but not always, associated with painful nodular thickening of the tendon. In this investigation, 28 tendons (21 patients) with a painful nodule located at the 2-6 cm level in the tendon, and 20 normal (pain-free) tendons, were examined with grey-scale ultrasonography combined with colour Doppler examination. In all tendons with a painful nodule, but not in any of the normal pain-free tendons, neovascularisation was seen in the area with tendon changes (localised widening of the tendon with focal hypo-echoic areas). In tendons with advanced changes, vessels were seen through the entire widened part of the tendons, and both arterial and venous blood flows were registered. The neovascularisation found in this investigation might have implications on the pathogenesis of chronic Achilles tendinosis.
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Affiliation(s)
- L Ohberg
- Department of Surgical and Perioperative Science, University of Umeå, Sweden
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47
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Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2001; 9:42-7. [PMID: 11269583 DOI: 10.1007/s001670000148] [Citation(s) in RCA: 311] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In a previous uncontrolled pilot study we demonstrated very good clinical results with eccentric calf muscle training on patients with painful chronic Achilles tendinosis located at the 2-6 cm level in the tendon. In the present prospective multicenter study (Sundsvall and Umeå) patients with painful chronic Achilles tendinosis at the 2-6 cm level in the tendon were randomized to treatment with either an eccentric or a concentric training regimen for the calf muscles. The study included 44 patients, with 22 patients (12 men, 10 women; mean age 48 years) in each treatment group. The amount of pain during activity (jogging or walking) was recorded by the patients on a visual analogue scale, and patient satisfaction was assessed before and after treatment. The patients were instructed to perform their eccentric or concentric training regimen on a daily basis for 12 weeks. In both types of treatment regimen the patients were told to do their exercises despite experiencing pain or discomfort in the tendon during exercise. The results showed that after the eccentric training regimen 82% of the patients (18/22) were satisfied and had resumed their previous activity level (before injury), compared to 36% of the patients (8/22) who were treated with the concentric training regimen. The results after treatment with eccentric training was significantly better (P<0.002) than after concentric training. The good clinical results previously demonstrated in the pilot study with eccentric calf muscle training on patients with chronic Achilles tendinosis, were thus reproduced in this multicenter, showing superior results to treatment with concentric training.
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Affiliation(s)
- N Mafi
- Department of Surgical and Perioperative Science, Umeå University, Sweden
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48
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Alfredson H, Lorentzon R. Autologous periosteum transplantation for the treatment of full thickness patellar cartilage defects. Ortop Traumatol Rehabil 2001; 3:216-223. [PMID: 17986988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Full-thickness patellar cartilage defects are often, but not always, associated with disabling anterior knee-pain and inability to take part in regular daily activities. There is no treatment of choice for this condition. It is well known that the cells in the cambium layer of the periosteum are pluripotent and can differentiate into hyaline (or hyaline-like) cartilage, especially if in a joint environment and under the influence of continous passive motion. In a few clinical studies autologous periosteum transplants alone have been used in the treatment of full thickness patellar cartilage defects. The results are varying. At our clinic, autologous periosteum transplantation alone, followed by continous passive motion (CPM) in the immediate postoperative period and non-weight bearing loading for 3 months, has shown promising clinical results. The best clinical results have been achieved on traumatic (fracture, contusion, dislocation) cartilage defects, where 83% of patients have been clinically graded as excellent or good at follow-up (> 2 years postoperatively). For non-traumatic patellar cartilage defects (chondromalacia NUD) the results are poor, with only 35% of patients being graded as excellent or good. Therefore, we believe that no-traumatic patellar cartilage defects (chondromalacia NUD) are less suitable for treatment with autologous periosteum transplants, and are at our clinic not any longer included for this type of treatment.
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Affiliation(s)
- H Alfredson
- Umea University, Sports Medicine Unit Department of Surgical and Perioperative Science, Centre Musculoskeletal Resarch National Insitute for Working Life, Umea, Sweden
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Söderman K, Werner S, Pietilä T, Engström B, Alfredson H. Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg Sports Traumatol Arthrosc 2001; 8:356-63. [PMID: 11147154 DOI: 10.1007/s001670000147] [Citation(s) in RCA: 259] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This prospective randomized intervention investigated whether training on a balance board could reduce the amount of traumatic injuries of the lower extremities in female soccer players. A total of 221 female soccer players from 13 different teams playing in the second and third Swedish divisions volunteered to participate in the study. Seven teams (n = 121) were randomized to an intervention group and six teams (n = 100) to a control group and were followed during one outdoor season (April-October). Before and after the season muscle flexibility and balance/postural sway of the lower extremities were measured in the players. There were no significant differences in age, height, weight, muscle flexibility and balance/postural sway of the lower extremities between the intervention and the control group. During the season the players in the intervention group performed a special training program consisting of 10-15 min of balance board training in addition to their standard soccer practice and games. After a 37% drop-out the intervention group consisted of 62 players and the control group of 78 players. The results showed no significant differences between the groups with respect either to the number, incidence, or type of traumatic injuries of the lower extremities. The incidence rate of "major" injuries was higher in the intervention group than in the control group. Four of five anterior cruciate ligament injuries occurred in the intervention group, which means that we could not prevent severe knee injuries in female soccer players with balance board training. However, among the players who had been injured during the 3-month period prior to this investigation there were significantly more players from the control group than from the intervention group who sustained new injuries during the study period.
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Affiliation(s)
- K Söderman
- Department of Surgical and Perioperative Science, Umeå University, 90187 Umeå, Sweden.
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50
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Alfredson H, Ljung BO, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique--no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand 2000; 71:475-9. [PMID: 11186404 DOI: 10.1080/000164700317381162] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We used the microdialysis technique to study concentrations of substances in the extensor carpi radialis brevis (ECRB) tendon in patients with tennis elbow. In 4 patients (mean age 41 years, 3 men) with a long duration of localized pain at the ECRB muscle origin, and in 4 controls (mean age 36 years, 2 men) with no history of elbow pain, a standard microdialysis catheter was inserted into the ECRB tendon under local anesthesia. The local concentrations of the neurotransmitter glutamate and prostaglandin E2 (PGE2) were recorded under resting conditions. Samplings were done every 15 minutes during a 2-hour period. We found higher mean concentrations of glutamate in ECRB tendons from patients with tennis elbow than in tendons from controls (215 vs. 69 micromoL/L, p < 0.001). There were no significant differences in the mean concentrations of PGE2 (74 vs. 86 pg/mL). In conclusion, in situ microdialysis can be used to study certain metabolic events in the ECRB tendon of the elbow. Our findings indicate involvement of the excitatory neurotransmitter glutamate, but no biochemical signs of inflammation (normal PGE2 levels) in ECRB tendons from patients with tennis elbow.
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Affiliation(s)
- H Alfredson
- Department of Surgical and Perioperative Science, Umeå University, Sweden.
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