Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study

Background

High resolution colour Doppler ultrasound shows intratendinous Doppler activity in patients with chronic Achilles tendinopathy. Treatment of this neovascularisation with sclerosing therapy seems to relieve the pain. However, the procedure often has to be repeated.

Objective

To investigate the effect of electrocoagulation of the neovessels on tendon pain and tendon vascularity in patients with chronic Achilles tendinopathy.

Methods

Colour Doppler ultrasound guided electrocoagulation was used on vessels in the ventral portion of the Achilles tendon in 11 patients (seven men, four women, mean age 41 years) with painful chronic mid‐portion Achilles tendinosis. A unipolar coagulation device was used.

Results

One patient dropped out after two months (dissatisfied with the results). The remaining 10 patients (91%) were satisfied. These 10 patients were still satisfied at six months of follow up and had returned to their previous level of activity. All 10 patients were “cured” after one treatment. The patient who dropped out received two treatments because of lack of progress. There was significantly reduced pain (Likert pain scale, 0–10) during activity, from a median of 7 (range 4 to 10) at baseline to 0 (0 to 8) at six months'' follow up (p<0.005); and at rest, from 1.5 (1 to 5) to 0 (0 to 8) (p = 0.005). In all patients, vascularisation was unchanged at the six months follow up, with no significant change in semiquantitative or quantitative colour scoring.

Conclusions

Coagulation in the area with vessels entering the tendon appears to be effective treatment for painful chronic mid‐tendinous Achilles tendinopathy. No effect on the intratendinous Doppler activity could be detected, suggesting that the effect is independent of changes in blood flow. Localisation of hyperaemia appears to be the key to the pathology and for targeting the treatment. One explanation could be that the effect is obtained by destruction of nerves accompanying the vessels.     

Investigating Achilles and patellar tendinopathy prevalence in elite athletics

Although injury surveillance in athletics is routinely conducted, discipline-specific Achilles and patellar tendinopathy prevalence remains unknown. The purpose of this study was to explore discipline-specific tendinopathy prevalence and identify whether injury-specific risk factors differed in athletes. Elite athletes were recruited and provided information on their sport training including Achilles and patellar tendon pain history. In order to ascertain whether between-discipline differences existed, data were categorized into discipline groups. Middle-distance athletes reported the highest prevalence of Achilles tendinopathy and the combined athletes reported the highest patellar tendinopathy prevalence. Greater calf stiffness was reported in athletes who experienced Achilles tendinopathy compared to those who did not. A substantial portion of athletes believed their performance decreased as a result of their tendon pain. In order to develop discipline-specific evidence-based injury prevention programmes, further discipline-specific research is required to quantify the mechanism for Achilles and patellar tendinopathy development in elite athletics.     

Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes

Achilles (AT) and patellar tendons (PT) are commonly affected by tendinopathy in adult athletes but prevalence of symptoms and morphological changes in adolescents is unclear. The study aimed to determine prevalence of tendinopathy and intratendinous changes in ATs and PTs of adolescent athletes. A total of 760 adolescent athletes (13.0 ± 1.9 years; 160 ± 13 cm; 50 ± 14 kg) were examined. History, local clinical examination, and longitudinal Doppler ultrasound analysis for both ATs and PTs were performed including identification of intratendinous echoic changes and vascularization. Diagnosis of tendinopathy was complied clinically in case of positive history of tendon pain and tendon pain on palpation. Achilles tendinopathy was diagnosed in 1.8% and patellar tendinopathy in 5.8%. Vascularizations were visible in 3.0% of ATs and 11.4% of PTs, hypoechogenicities in 0.7% and 3.2% as well as hyperechogenicities in 0% and 0.3%, respectively. Vascularizations and hypoechogenicities were statistically significantly more often in males than in females (P ≤ 0.02). Subjects with patellar tendinopathy had higher prevalence of structural intratendinous changes than those without PT symptoms (P ≤ 0.001). In adolescent athletes, patellar tendinopathy is three times more frequent compared with Achilles tendinopathy. Longitudinal studies are necessary to investigate physiological or pathological origin of vascularizations and its predictive value in development of tendinopathy.     

The patellar tendinopathy in athletes: a sonographic grading correlated to prognosis and therapy

The purpose of this study is to determine in the athletes a sonographic grading of the patellar tendinopathy correlated to prognosis and therapy. The 298 patellar overuse tendinopathies were divided in four grades according to the extension of the injured area of the tendon in the axial sonograms. Grades 1, 2, and 3 were managed with medical and physical therapy. A surgical treatment was performed in grade 4 and in grades 1, 2, and 3 tendinopathies not responding to our conservative therapy. There were 21.8% injuries in grade 1 (100% responding; prognosis 20 days), 61.2% injuries in grade 2 (94.5% responding; prognosis 40 days), 16.4% injuries in grade 3 (85.7% responding; prognosis 90 days), and 0.6% injuries in grade 4. The sonographic study is fundamental to characterize adequately the patellar tendinopathy. The conservative therapy is the first option for grades 1, 2, and 3 as it determines a complete healing in most of cases.     

Relationship between neovascularization and clinical severity in Achilles tendinopathy in 556 paired measurements

Neovascularization is frequently observed in tendinopathy. Previous studies have focused on the role of neovascularization in Achilles tendinopathy, but have been conducted in small series. It is still unclear whether the degree of neovascularization is related to severity of symptoms. The purpose was to study the relationship between ultrasonographic neovascularization and clinical severity in patients with Achilles tendinopathy. In this prospective cohort study, data on 127 patients (141 tendons) were assembled from databases of three clinical trials. All patients followed an eccentric exercise program. The Öhberg neovascularization score (0–4+) and Victorian Institute of Sports Assessment‐Achilles (VISA‐A) score (split into domains: pain, function and activity) were collected during baseline and follow‐up. The relationship between neovascularization and VISA‐A score was calculated. At baseline, 107 tendons (76%) showed some degree of neovascularization. In 556 coupled measurements, neovascularization was weakly related to the VISA‐A score [Exp (B) 1.017, 95% confidence interval (CI), 1.007–1.026]. No significant relationship was found between neovascularization and the pain domain (P = 0.277) and the activity domain (P = 0.283), but there was between neovascularization and the function domain of the VISA‐A score [Exp (B) = 1.067, 95% CI 1.018–1.119]. In conclusion, neovascularization in Achilles tendinopathy is weakly related to clinical severity, mainly based on the function domain of the VISA‐A score.     

The role of eccentric training in the management of Achilles tendinopathy: A pilot study

ObjectiveTo investigate the effect of different types of treatment on Achilles tendinopathy, one proposed to increase tensile strength of the tendon, the other a more traditional treatment used in a clinical setting.DesignRepeated measures trial comparing two interventions.SettingSports injury clinic.ParticipantsTwenty-five participants were randomly allocated to the eccentric group (n=13) or the control group (n=12).Main outcome measuresThe VISA-A questionnaire was used to determine outcomes and was administered to all participants at 0, 4, 8, and 12 weeks.ResultsAll subjects significantly improved over the 12-week period (p=0.0001), but the eccentric group demonstrated significantly higher (p=0.014) VISA-A scores at 12 weeks.ConclusionThe study suggests that the addition of a 12-week eccentric exercise programme to conventional treatment of ultrasound and deep transverse frictions is more effective in treating Achilles tendinopathy than conventional treatment alone.     

Recreational runners with Achilles tendinopathy have clinically detectable impairments: A case-control study

ObjectivesTo confirm what impairments are present in runners with Achilles tendinopathy (AT) and explore the variance of AT severity in an adequately powered study.DesignCase-control study.SettingTwo private physiotherapy clinics in Australia and Spain.ParticipantsForty-four recreational male runners with AT and 44 healthy controls matched by age, height, and weight.Main outcome measuresDemographics, activity (IPAQ-SF), pain and function (VISA-A), pain during hopping (Hop pain VAS), hopping duration, psychological factors (TSK-11, PASS20), and physical tests regarding lower-limb maximal strength and endurance.ResultsBody mass index (BMI), activity, VISA-A, pain, and duration of hopping, TSK-11, PASS20, standing heel raise to failure, seated heel raise and leg extension 6RM, hip extension and abduction isometric torque were significantly different between groups (P < 0.05) with varied effect sizes (V = 0.22, d range = 0.05–4.18). 46% of AT severity variance was explained by higher BMI (β = −0.41; p = 0.001), weaker leg curl 6RM (β = 0.32; p = 0.009), and higher pain during hopping (β = −0.43; p = 0.001).ConclusionRunners with AT had lower activity levels, lower soleus strength, and were less tall. BMI, pain during hopping, and leg curl strength explained condition severity. This information, identified with clinically applicable tools, may guide clinical assessment, and inform intervention development.     

Effect of ultrasound-guided, peritendinous injections of adalimumab and anakinra in chronic Achilles tendinopathy: a pilot study

A new review suggested that an inflammatory process may be related to the development of tendinopathy and that the inflammation may also play a role in chronic tendinopathy. Hitherto, peritendinous injections of glucocorticosteroids have been used to reduce the inflammation. In an attempt to reduce the possible side effects and the high frequency of relapse of symptoms after local treatments with glucocorticosteroids, new anti-inflammatory treatments were tested. Ultrasound-guided, peritendinous injections of adalimumab (tumor necrosis factor -α blocker) and anakinra (interleukin-1 receptor antagonist) were evaluated with regard to reducing pain, tendon thickness, and the blood flow in chronic Achilles tendinopathy. We found in this small pilot study that peritendinous injections of adalimumab had a significant effect on pain sensation at rest in chronic Achilles tendinopathy. Adalimumab had no effect on tendon thickness and contrary to all expectation, the tendon thickness in the anakinra-treated patients increased significantly after 12 weeks. Adalimumab showed a significant tendency to reduce the blood flow in the tendon over 12 weeks, whereas anakinra had no effect on the blood flow.     

Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis

IntroductionBiomechanical alterations during running and hopping in people with Achilles tendinopathy (AT) may provide treatment and prevention targets. This review identifies and synthesises research evaluating biomechanical alterations among people with AT during running, jumping and hopping.MethodMEDLINE, EMBASE, CiNAHL and SPORTDiscus were searched in July 2018 for case control, cross-sectional and prospective studies investigating kinematics, kinetics, plantar pressures and neuromuscular activity in AT participants during running or hopping. Study quality was assessed with a modified version of the Downs and Black quality checklist, and evidence grading applied.Results16 studies reported 249 outcomes, of which 17% differed between groups. Reduced peroneus longus (standardized mean difference [95%CI]; −0.53 [−0.98, −0.09]) and medial gastrocnemius (−0.60 [−1.05, −0.15]) amplitude in AT runners versus control was found (limited evidence). Increased hip adduction impulse 1.62 [0.69, 2.54], hip peak external rotation moment (1.55 [0.63, 2.46] and hip external rotation impulse (1.45 [0.55, 2.35]) was found in AT runners versus control (limited evidence). Reduced anterior (−0.94 [−1.64, −0.24] and greater lateral (−0.92 [−1.61, −0.22]) displacement of plantar pressure preceded AT in runners (limited evidence). Delayed onsets of gluteus medius (1.95 [1.07, 2.83] and gluteus maximus (1.26 [0.48, 2.05] and shorter duration of gluteus maximus activation (−1.41 [−2.22, −0.61] was found during shod running in the AT group versus control (limited evidence). Earlier offset time of gluteus maximus (−1.03 [−1.79, −0.27] and shorter duration of activation of gluteus medius (−0.18 [−0.24, −0.12] during running in AT runners versus control was found (limited evidence). Reduced leg stiffness was found in the affected side during submaximal hopping (−0.39 [−0.79, −0.00]) (limited evidence).ConclusionThis review identified potential biomechanical treatment targets in people with AT. The efficacy of treatments targeting these biomechanics should be assessed.Systematic review registryPROSPERO registration number: CRD42016048636.     

Preventive effect of tailored exercises on patellar tendinopathy in elite youth athletes: A cohort study

ObjectiveTo investigate the effects of an intervention with tailored exercises on the incidence of patellar tendinopathy (PT) in elite youth jumping athletes.DesignProspective crossover cohort.SettingOne sport club facility.Participants271 elite youth basketball and volleyball player were followed in the first year of the study (Observation year) and 270 athletes were followed in the second year (intervention year).Main outcome measureIncidence rates of PT per 1,000h of exposure. Cox survival analysis was used to verify the effects of the intervention (exercises implemented according to the findings of a preseason assessment) on PT incidence.ResultsThe exercise prevention program significantly reduced the number of cases of PT, with athletes submitted to the intervention showing 51% less risk of developing PT. The overall PT incidence in the Observation year (5.9 per 1,000h of exposure) was significantly higher than that in the intervention year (2.8 per 1,000h of exposure) (P = .037). Twenty-six athletes developed PT in the observation year, whereas 13 athletes developed PT in the intervention year.ConclusionsA tailored preventive program may be able to reduce the incidence of patellar tendinopathy, especially in male youth volleyball athletes. Randomized controlled trials are encouraged to confirm these findings.     

“Does isometric exercise improve leg stiffness and hop pain in subjects with Achilles tendinopathy? A feasibility study”

BackgroundIn Achilles tendinopathy (AT) the ability to store and recycle elastic energy during ground contact phase is often altered. A measure of this function is represented by leg stiffness (LS). Immediate responses in LS following therapeutic intervention have not been examined.ObjectiveThe aim of this paper was to examine the feasibility of the protocol in participants with AT.DesignSingle cohort feasibility study.ParticipantsAdults with persistent AT pain, symptoms on palpation and less than 80 points on the Visa-A questionnaire.Interventionheavy isometric exercise sequence in plantarflexion.Outcome measuresFeasibility was assessed by evaluating: the willingness of participants to enroll into the study, the number of eligible participants, the recruitment rate, adherence to the intervention, the drop-out rate, the tolerability of the protocol. LS, reactive strength index, pain and rate of perceived effort were secondary outcomes.Results22 AT were eligible for data collection and 19 entered the statistical analysis. The intervention was well tolerated, no withdrawals. Pain scores were low during both the intervention and the assessment. Immediate improvements in LS and pain were recorded.ConclusionsThe isometric exercise protocol was feasible. Future research should investigate its effectiveness.     

Patellar tendinopathy in junior basketball players: a controlled clinical and ultrasonographic study of 268 patellar tendons in players aged 14-18 years

Anterior knee pain is a common presenting complaint amongst adolescent athletes. We hypothesised that patellar tendinopathy may occur at a younger age than is generally recognised. Thus, we studied the patellar tendons in 134 elite 14- to 18-year-old female (n=64) and male (n=70) basketball players and 29 control swimmers (17 female, 12 male) clinically and with ultrasonography. We found that of 268 tendons, 19 (7%) had current patellar tendinopathy on clinical grounds (11% in males, 2% in females). Twenty-six percent of the basketball players' patellar tendons contained an ultrasonographic hypoechoic region. Ultrasonographic abnormality was more prevalent in the oldest tertile of players (17-18 years) than the youngest tertile (14-15.9 years). Of tendons categorised clinically as 'Never patellar tendinopathy', 22% had an ultrasonographic hypoechoic region nevertheless. This study indicates that patellar tendinopathy can occur in 14- to 18-year-old basketball players. Ultrasonographic tendon abnormality is 3 times as common as clinical symptoms.     

Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid injections in a clinical setting

In published efficacy studies on Achilles tendinopathy (AT) exercise alone results in improvement in 60–90% of the cases. However, this high success rate cannot be expected in usual clinical practice. We prospectively investigated the effectiveness of a treatment regimen consisting of home‐based exercises (concentric, eccentric, and stretching) and optional glucocorticosteroid (GCS) injections in patients with (AT) in a usual clinical setting. Patients unable to commence or progress in exercise were offered GCS, hypothesizing that the GCS would facilitate exercise. Ninety‐three consecutive patients with AT referred to two outpatient rheumatology clinics were registered, and seen at five visits over a 6‐month period. Exercises seemed to have a slow, but long‐lasting effect with GCS having a dramatic short‐term effect on symptoms. Twenty‐six percent of the patients could proceed with training alone, the remainder received one to three supplementary GCS. There were significant improvements on all outcome variables over time (P ≤ 0.001). At follow‐up, 42 had no more symptoms, 29 good result, 16 slightly improved, 4 unchanged, and 2 slightly worse. Overall, 94% of the patients had improved, and we thus recommend the use of GCS injections in AT patients if training alone does not lead to improvement.     

Self-reported pain with single leg heel raise or single leg hop offer distinct information as measures of severity in men with midportion and insertional Achilles tendinopathy: An observational cross-sectional study

ObjectivesTo investigate if self-reported pain with single leg heel raise (SLHR) or single leg hop (SLH) are concurrently valid to assess midportion (MPAT) or insertional Achilles tendinopathy (IAT) symptom severity, compared to the VISA-A. Additionally, if SLHR or SLH pain accounts for VISA-A variability, and if they are associated with psychological factors.Participants60 men with MPAT, 26 men with IAT.Main outcomesParticipants rated SLHR and SLH pain on a numerical rating scale (0 = none, 10 = worst). We investigated relationships between loading task pain, VISA-A, VISA-A constructs, and psychological outcomes (Pearson’s correlation coefficients). Linear regression determined best model accounting for VISA-A variability.ResultsIn MPAT, load tests shared fair-negative relationship with VISA-A, and VISA-A function. In IAT, SLHR had moderately strong-negative relationship with VISA-A, and pain and function constructs, and SLH shared fair-negative relationship with VISA-A, and pain and function constructs. Relationships were negligible between load tests and VISA-A activity in both conditions, and VISA-A pain in MPAT. In IAT, there was fair-positive relationship between pain catastrophising and load tests. Remaining psychological outcome relationships were negligible. Best model accounting for VISA-A included SLH in MPAT, and SLHR in IAT.ConclusionsDespite VISA-A and selected VISA-A construct associations, self-reported SLHR and SLH pain appears to provide distinct information.     

Isometric exercise and pain in patellar tendinopathy: A randomized crossover trial

ObjectivesThe aim of this study was to compare the acute effects of isometric versus dynamic resistance exercise on pain during a pain-provoking activity, and exercise-induced hypoalgesia in participants with patellar tendinopathy.DesignThis study was a pre-registered randomised crossover study. Participants were blinded to the study hypothesis.MethodsParticipants (N = 21) performed a single session of high load isometric resistance exercise or dynamic resistance exercise, in a randomised order separated by a 7-day washout period. Outcomes were assessed before, immediately after, and 45 min post-exercise. The primary outcome was pain intensity scored on a numeric pain rating scale (NRS; 0–10) during a pain-provoking single leg decline squat (SLDS). Secondary outcomes were pressure pain thresholds (PPTs) locally, distally and remotely, as well as tendon thickness.ResultsThere was a significant decrease in pain NRS scores (mean reduction 0.9, NRS 95%CI 0.1–1.7; p = 0.028), and increase in PPTs at the tibialis anterior muscle (mean increase 34 kPa 95%CI 9.5–58.5; p = 0.009) immediately post-exercise. These were not sustained 45 min post-exercise for pain (NRS) or PPTs (p > 0.05). There were no differences between exercise on any outcome.ConclusionsWhile patients with patellar tendinopathy decreased pain during SLDS in response to resistance training, but the magnitude was small. Contraction mode may not be the most important factor in determining the magnitude of pain relieving effects. Similarly, there were only small increases in PPTs at the tibialis anterior which were not superior for isometric exercise.     

Pain,not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: A cross sectional study

QuestionWhat are the functional differences between people with greater trochanteric pain syndrome (GT), hip osteoarthritis (OA) or an asymptomatic population as measured by walking, Time Up and Go, single leg standing and strength?DesignCross sectional study with blinded measurers.Participants38 participants with GT, 20 with end stage hip OA and 21 asymptomatic healthy control (AS) participants. All participants were women.Outcome measuresPain (numeric rating scale), Walking speed (m/s), cadence (steps/min) and step length (m) measured via the 10 m walk test and the Timed Up and Go; balance via single leg stance (s) duration; and hip abduction, adduction, medial and lateral rotation strength, standardized to body mass (BM) via the body mass average index (BMavg), measured via a wall mounted dynamometer.ResultsThe two symptomatic groups reported similar pain levels (p = 0.226), more pain then the AS group (p < 0.000). Compared to the AS participants, participants with GT or hip OA demonstrated lower walking speed (10mwt and TUG, p < 0.001), lower cadence and shorter duration single leg stance on the affected leg (p < 0.05). Participants with GT or hip OA also demonstrated bilaterally weaker hip abduction than the AS group (p ≤ 0.005). Compared to AS and GT participants, participants with hip OA demonstrated adduction weakness on the affected side (p = 0.008 and p = 0.002 respectively).ConclusionThere is a significant level of dysfunction and impairments associated with GT and hip OA. As activity limitations do not appear to be differentiated by structural impairments, we suggest that pain, rather than the underlying pathology may be the driving impairment that leads to walking and single leg standing dysfunction.     

Effect of patellar strap and sports tape on pain in patellar tendinopathy: A randomized controlled trial

Numerous athletes with patellar tendinopathy (PT) use a patellar strap or sports tape during sports. This study's aim was to investigate the short‐term effect of these orthoses on patellar tendon pain. Participants performed the single‐leg decline squat, vertical jump test, and triple‐hop test under four different conditions (patellar strap, sports tape, placebo, and control). Subsequently, participants practiced sports as usual for 2 weeks; during 1 week, they were assigned to one of the four conditions. Pain was measured with the visual analog scale (VAS). In total, 97 athletes with PT [61% male, age 27.0 (SD8.1), VISA‐P 58.5 (SD12.7)] were analyzed. On the single‐leg decline squat, the VAS pain score reduced significantly in the patellar strap (14 mm, P = 0.04) and the sports tape condition (13 mm, P = 0.04), compared with control, but not placebo. A significant decrease in VAS pain during sports was found in the sports tape (7 mm, P = 0.04) and placebo group (6 mm, P = 0.04). The VAS pain score two hours after sports decreased significantly in the patellar strap, sports tape and placebo group (8‐mm, P < 0.001, 10 mm, P = 0.001 and 7 mm, P = 0.03, respectively). This study's findings indicate that an orthosis (including placebo tape) during sports can reduce pain in PT patients in the short term.