Prospective study of change in patellar tendon abnormality on imaging and pain over a volleyball season

Objective

Patellar tendon injury, defined by tendon abnormality (TA) on imaging and by pain, is common among volleyball players, but little is known about change in this injury over a volleyball season. Increased activity in the season compared with the off season may result in the development of TA and/or pain. This study investigated the behaviour of TA and pain over a competitive volleyball season.

Methods

Tendon abnormality and pain were measured in 101 volleyball players at the beginning and end of a season. Pain was measured with the single leg decline squat test, which loads the patellar tendon, and TA was detected with ultrasound imaging. Hours of weekly activity were measured and compared during the season and the off season. The proportion of tendons that underwent development and resolution in TA and/or pain over the season was investigated.

Results

Hours of weekly activity was greater during the season than in the off season. Most of the tendons investigated (66.3%) did not undergo a change in TA or pain over the season. Tendon abnormality and/or pain developed in 16.6% of tendons and resolved in 11.2%.

Conclusions

The tendons of volleyball players respond variably to the increased load over the season. Change in TA and pain does not appear to be entirely dependent upon load.     

Patellar tendinopathy outcome predictors in jumping athletes: feasibility of measures for a cohort study

ObjectivesThe main aim was to assess feasibility by testing data collection procedures for a cohort study. Measurements validity and reliability were secondary objectives.DesignFeasibility study.SettingCombination of remote contact, assessment in clinic and biomechanical evaluation.Participants36 jumping athletes (female:17, male:19) equally spread between those with patellar tendinopathy, other knee problems and controls.Main outcome measuresMeasurements validity, reliability and feasibility.ResultsThere was no systematic difference between administration methods for patient reported outcome measures and miscellaneous questions (range of d = −0.32 to 0.26) without any order effect (all p > 0.05) except KOOS-PF (p = 0.02). Questionnaires’ inter-session reliability was moderate to excellent (ICCs = 0.68–0.93). Pain maps were 94% matched between methods. Training load recall percentage decreased until week-3 with only 20% maintaining a training diary completing the full 6 weeks. The graded loaded challenge was clinically applicable, biomechanically valid with increasing load through progression and reliable (ICCs = 0.63–0.98).ConclusionThe tested questionnaires were valid and reliable for online use, therefore being suitable for clinical and research purposes. A shorter survey to reduce burden and collecting training load using shorter recall duration should improve feasibility. Biomechanical measures were valid and reliable, and a graded loaded challenge, suitable for further testing, has been defined.     

Achilles tendon structure improves on UTC imaging over a 5‐month pre‐season in elite Australian football players

Pre‐season injuries are common and may be due to a reintroduction of training loads. Tendons are sensitive to changes in load, making them vulnerable to injury in the pre‐season. This study investigated changes in Achilles tendon structure on ultrasound tissue characterization (UTC) over the course of a 5‐month pre‐season in elite male Australian football players. Eighteen elite male Australian football players with no history of Achilles tendinopathy and normal Achilles tendons were recruited. The left Achilles tendon was scanned with UTC to quantify the stability of the echopattern. Participants were scanned at the start and completion of a 5‐month pre‐season. Fifteen players remained asymptomatic over the course of the pre‐season. All four echo‐types were significantly different at the end of the pre‐season, with the overall echopattern suggesting an improvement in Achilles tendon structure. Three of the 18 participants developed Achilles tendon pain that coincided with a change in the UTC echopattern. This study demonstrates that the UTC echopattern of the Achilles tendon improves over a 5‐month pre‐season training period, representing increased fibrillar alignment. However, further investigation is needed to elucidate with this alteration in the UTC echopattern results in improved tendon resilience and load capacity.     

Increased versican content is associated with tendinosis pathology in the patellar tendon of athletes with jumper's knee

Expansion of the extracellular matrix is a prominent but poorly characterized feature of tendinosis. The present study aimed to characterize the extent and distribution of the large aggregating proteoglycan versican in patients with patellar tendinosis. We obtained tendon from tendinopathy patients undergoing debridement of the patellar tendon and from controls undergoing intramedullary tibial nailing. Versican content was investigated by Western blotting and immunohistochemistry. Microvessel thickness and density were determined using computer-assisted image analysis. Markers for smooth muscle actin, endothelial cells (CD31) and proliferating cells (Ki67) were examined immunohistochemically. Western blot analysis and immunohistochemical staining revealed elevated versican content in the proximal patellar tendon of tendinosis patients ( P =0.042). Versican content was enriched in regions of fibrocartilage metaplasia and fibroblast proliferation, as well as in the perivascular matrix of proliferating microvessels and within the media and intima of arterioles. Microvessel density was higher in tendinosis tissue compared with control tissue. Versican deposition is a prominent feature of patellar tendinosis. Because this molecule is not only a component of normal fibrocartilagenous matrices but also implicated in a variety of soft tissue pathologies, future studies should further detail both pathological and adaptive roles of versican in tendons.     

Comparison of anterior cruciate ligament reconstruction in male and female athletes using the patellar tendon and hamstring autografts

Despite the higher incidence of anterior cruciate ligament (ACL) injuries in female than in male athletes few authors have studied the effects of gender on the outcome of ACL reconstruction. This prospective study compared the results of ACL reconstruction using the patellar tendon and hamstring techniques in men and women. We prospectively followed 80 comparable athletes (46 males, 32 females) from a population of 287 patients operated on at our institution for ACL reconstruction using either patellar tendon or hamstring graft. There were 26 males and 14 females in the patellar tendon group, and 22 males and 18 females in the hamstring group. All patients were operated on by the same surgeon within 6 months from injury and underwent the same rehabilitation program at the same center. After an average of 36 months the patients were assessed by clinical evaluation, computerized knee laxity analysis, and isokinetic and functional strength tests; standard knee scores were also used. Among patellar tendon patients there were no significant differences between males and females regarding knee evaluation form, laxity, or isokinetic and functional tests. Females in the hamstring group had significantly greater laxity, and isokinetic tests at 1 year revealed a significantly higher deficit of peak torque at 60°/s in flexion and extension. We suggest further studies on the clinical significance of these findings particularly on their possible ramifications in the areas of return to sports and rehabilitation of female athletes     

Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes

Anterior cruciate ligament (ACL) reconstruction in double-bundle technique is advocated to more closely restore the anatomy and function of the native ligament than conventional single-bundle technique. But up to now there are only a few clinical investigations comparing both techniques in a prospective manner. We hypothesized that double-bundle ACL reconstruction reveals superior clinical and subjective results compared to single-bundle technique in a high-demand collective. A total of 50 male patients (mean age 29.4 years) were prospectively randomized consecutively into one of the two reconstruction techniques. Group 1 (SB) underwent a 4-stranded single-bundle reconstruction with a ST graft in femoral position at 10:00 and 02:00 o’clock, respectively. In group 2 (DB), reconstruction was performed by using a 2-stranded ST graft with double-bundle, four tunnel technique. Before surgery and at a 2 year follow-up (range 23–25 months) patients were evaluated by the same blinded observer. There was no significant difference in the side-to-side anterior laxity-measurement with the KT-1000 between both groups. As evaluated by the pivot shift, no significant correlation could be noted (Fisher exact test P = 0.098) between rotational stability and any of the both reconstruction techniques. However, the anterior and rotational stability improved significantly at 2-year follow-up compared to preoperatively (P = 0.003) in both groups. The statistical analysis showed a significant increase for the IKDC (subjective, objective) and the Lysholm Score at final follow-up among each single technique, while we found no significant difference between the two reconstruction methods. On the basis of our investigation, we conclude that reconstruction of the ACL by a double-bundle ST graft with an extracortical anchorage can achieve excellent clinical results. But in contrast to our initial hypothesis, we could not quote any significant advantages by creating two independent bundles. Reconstruction of the anterior cruciate ligament in conventional single-bundle technique with a more horizontal femoral tunnel placement obtains comparable clinical results in the present high-demand collective.     

Diagnostic value of tendon thickness and structure in the sonographic diagnosis of supraspinatus tendinopathy: room for a two-step approach

Objective

The aim of our study was to systematically compare different methodologies to establish an evidence-based approach based on tendon thickness and structure for sonographic diagnosis of supraspinatus tendinopathy when compared to MRI.

Methods

US was obtained from 164 symptomatic patients with supraspinatus tendinopathy detected at MRI and 42 asymptomatic controls with normal MRI. Diagnostic yield was calculated for either maximal supraspinatus tendon thickness (MSTT) and tendon structure as isolated criteria and using different combinations of parallel and sequential testing at US. Chi-squared tests were performed to assess sensitivity, specificity, and accuracy of different diagnostic approaches.

Results

Mean MSTT was 6.68 mm in symptomatic patients and 5.61 mm in asymptomatic controls (P < .05). When used as an isolated criterion, MSTT > 6.0 mm provided best results for accuracy (93.7%) when compared to other measurements of tendon thickness. Also as an isolated criterion, abnormal tendon structure (ATS) yielded 93.2% accuracy for diagnosis. The best overall yield was obtained by both parallel and sequential testing using either MSTT > 6.0 mm or ATS as diagnostic criteria at no particular order, which provided 99.0% accuracy, 100% sensitivity, and 95.2% specificity. Among these parallel and sequential tests that provided best overall yield, additional analysis revealed that sequential testing first evaluating tendon structure required assessment of 258 criteria (vs. 261 for sequential testing first evaluating tendon thickness and 412 for parallel testing) and demanded a mean of 16.1 s to assess diagnostic criteria and reach the diagnosis (vs. 43.3 s for sequential testing first evaluating tendon thickness and 47.4 s for parallel testing).

Conclusions

We found that using either MSTT > 6.0 mm or ATS as diagnostic criteria for both parallel and sequential testing provides the best overall yield for sonographic diagnosis of supraspinatus tendinopathy when compared to MRI. Among these strategies, a two-step sequential approach first assessing tendon structure was advantageous because it required a lower number of criteria to be assessed and demanded less time to assess diagnostic criteria and reach the diagnosis.     

The influence of sleep and training load on illness in nationally competitive male Australian Football athletes: A cohort study over one season

Objectives

To determine the incidence of illness, and identify the relationship between sleep, training load and illness in nationally competitive Australian football athletes. Second, to assess multivariate effect between training load and/or sleep variables.

The course of the patellar tendon after reharvesting its central third for ACL revision surgery: a long-term clinical and radiographic study

The choice of the optimal graft for anterior cruciate ligament (ACL) revision surgery is still controversial. Reharvesting the patellar tendon has been suggested as one graft alternative. Our hypothesis was that in the long-term, ACL revision surgery using reharvested patellar tendon autografts would render a good clinical outcome and a normal patellar tendon at the donor site as seen on magnetic resonance imaging (MRI). Fourteen consecutive patients (five women, nine men), who underwent ACL revision surgery using reharvested ipsilateral patellar tendon grafts, were included in the study. They underwent bilateral MRI evaluations of the patellar tendon and were tested for clinical outcome 26 (20–35) and 115 months (102–127) after the revision procedure. On the second occasion, they also underwent standard weight-bearing X-ray examinations.The serial MRI evaluations revealed that the thickness of the patellar tendon at the donor site was significantly increased compared with the non-harvested, normal contralateral side and that the donor-site gap was still visible after 10 years. No significant differences were seen between the 2- and 10-year MRI evaluations. Standard weight-bearing X-ray examinations revealed signs of mild degenerative changes in all patients. Clinical results in terms of the Lysholm score, IKDC evaluation system, one-leg-hop test, KT-1000 laxity test and the knee-walking test revealed no significant differences between the 2- and 10-year assessments. In overall terms, the clinical results were considered to be poor on both occasions. The patellar tendon at the donor site had not normalised 10 years after the reharvesting procedure, as seen on MRI. Furthermore, the clinical results were poor after ACL revision surgery using reharvested patellar tendon autograft.     

Effect of position,time in the season,and playing surface on Achilles tendon ruptures in NFL games: a 2009-10 to 2016-17 review

Objectives: Achilles tendon (AT) ruptures are a potentially career-altering and ending injury. Achilles tendon ruptures have a below average return-to-play rate compared to other common orthopaedic procedures for National Football League (NFL) players. The objective of this study was to monitor the incidence and injury rates (IR) of AT ruptures that occurred during the regular season in order to evaluate the influence of player position, time of injury, and playing surface on rupture rates.

Methods: A thorough online review was completed to identify published injury reports and public information regarding AT ruptures sustained during regular season and post-season games in the National Football League (NFL) during the 2009–10 to 2016–17 seasons. Team schedules, player position details and stadium information was used to determine period of the season of injury and playing surface. IRs were calculated per 100 team games (TG). Injury rate ratios (IRR) were utilized to compare IRs.

Results: During eight monitored seasons, there were 44 AT ruptures in NFL games. A majority of AT ruptures were sustained in the first eight games of the regular season (n = 32, 72.7%). There was a significant rate difference for the first and second four-game segments of the regular season compared to the last two four-game segments of the regular season. Defensive players suffered a majority of AT ruptures (n = 32, 72.7%). The IR on grass was 1.00 per 100 TG compared to 1.08 per 100 TG on artificial turf (IRR: 0.93, p = .80).

Conclusion: A significant increase in AT ruptures occurred in the first and second four game segments of the regular season compared to the last two-four game segments of the regular season. Defensive players suffered a majority of AT ruptures compared to offensive or specialist players. There was no difference between AT rupture rates and playing surface in games.     

Reliability in the assessment of tendon volume and intratendinous signal of the Achilles tendon on MRI: a methodological description

The purpose is to introduce a method for accurately and objectively evaluating volume and mean intratendinous signal within the Achilles tendon using MRI. We prospectively studied MRI from 33 patients with chronic Achilles tendinosis (20 males and 13 females) with a median age of 52 years (range 29-70). In all patients, both Achilles tendons were investigated with T1-WI as well as PD-WI MRI. Thus, 66 Achilles tendons were evaluated in the study. Tendon volume and mean intratendinous signal were evaluated using a computerized 3-D seed-growing technique. In general, the computerized 3-D seed-growing technique resulted in an excellent overall observer reliability of the MRI-measurements. The reliability (R) for tendon volume measurements was highest for the T1-WI sequence (R=97.9%). For the mean intratendinous signal, the PD-WI sequence showed the highest reliability (R=88.1%). The same pattern was present when we studied the coefficient of variation (CV). For the CV, lower figures indicate more reliable estimates. CV was 4.9% for tendon volume and 8.9% for mean intratendinous signal. In conclusion, it could be said that a computerized 3-D seed-growing technique to monitor and evaluate the volume of the Achilles tendon and mean intratendinous signal, using MRI, shows an overall excellent reliability regarding inter- as well as intra-observer reliability.     

Change in the cross-sectional area of a patellar tendon graft after anterior cruciate ligament reconstruction

The purpose of this study was to clarify the change in the cross-sectional area (CSA) of a patellar tendon graft after anterior cruciate ligament (ACL) reconstruction, and its relationship with postoperative knee laxity. Forty patients (25 men and 15 women) were included in this study. Intraoperative CSA measurements were performed with an instrumented areamicrometer, while a magnetic resonance imaging (MRI) evaluation was utilized for the assessment postoperatively. For intraoperative measurement, the average CSA of a 10-mm wide patellar tendon graft was 32.3 ± 7.0 mm², while the average CSA measured at follow-up (mean: 14.8 months) was 48.8 mm², showing a significant mean increase ratio of 49.4%. This value corresponded to 115% of the native ACL. The average CSA measured in 30 patients at 6 months was 49.7 mm², almost equal to the value at the final follow-up (49.8 mm²) in the same patient group. Among potentially influential factors, postoperative notch width (available space for the ACL graft) had significant correlation with the CSA of the graft at follow-up. Finally, both intra- and postoperative CSA values did not correlate with postoperative knee laxity, indicating that a bigger graft does not guarantee a better laxity.     

Spontaneous rupture of the extensor pollicis longus tendon in a young goalkeeper: a case report

We report an exceptional case of an acute spontaneous rupture of the extensor pollicis longus (EPL) tendon in a 16-year-old professional goalkeeper treated by primary surgical repair. Eight weeks after surgery, full thumb motion was regained. Four months after the surgical procedure, the patient resumed playing at the same level and he had no complaint at the 12-month follow-up. The anatomical alteration of Lister's tubercle and the consequent microinstability, associated with overuse and overloading, appeared to be the cause of the EPL tendon rupture. In the present case, an end-to-end suture appeared to be a safe surgical procedure.     

Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study

There is no agreement on the ideal type of surgical management for Achilles tendon rupture. The present randomized prospective study was performed to compare outcome data of open and percutaneous repair in the treatment of Achilles tendon rupture. Forty consecutive patients with acute rupture of Achilles tendon were recruited. Patients were randomized to receive open (group A) or percutaneous repair with Tenolig^® (group B). All patients followed the same rehabilitation protocol except for slight differences in the duration of immobilization. Follow-up included objective evaluation (at 4 and 12 months), subjective evaluation using the SF-12^® questionnaire (at 24 months), and bilateral ultrasound scanning and isokinetic testing (at 12 months). The differences in the parameters evaluated clinically were not significant except for ankle circumference, which was significantly greater in group B. There were two minor complications in the open repair group and one case of failed repair in the percutaneous group. SF-12^® questionnaire, ultrasound and isokinetic test data did not show significant differences between the groups. The present study demonstrates that the open and the percutaneous technique are both safe and effective in repairing the ruptured Achilles tendon and that both afford the same degree of restoration of clinical, ultrasound and isokinetic patterns. Medium-term results were substantially comparable. Percutaneous repair is performed on a day-surgery basis, it reduces cutaneous complications and operation times, and enables faster recovery, enhancing overall patient compliance. To us, these characteristics make it preferable to open repair in managing subcutaneous ruptures of Achilles tendon in non-professional sports practicing adults.     

Automated volumetric assessment of the Achilles tendon (AVAT) using a 3D T2 weighted SPACE sequence at 3T in healthy and pathologic cases

Purpose

Achilles tendinopathy has been reported to be frequently associated with increasing volume of the tendon. This work aims at reliable and accurate volumetric quantification of the Achilles tendon using a newly developed contour detection algorithm applied on high resolution MRI data sets recorded at 3 T.

Materials and methods

A total of 26 healthy tendons and 4 degenerated tendons were examined for this study. Automated identification (AI) of tendon boundaries was performed in transverse slices with isotropic resolution (0.8 mm) gained with a T2-weighted SPACE sequence at 3 T. For AI a snake algorithm was applied and compared to manual tracing (MT).

Results

AI was feasible in all examined tendons without further correction. AI of both tendons was performed in each participant within 2 min (2 × 37 slices) compared to MT lasting 20 min. MT and AI showed excellent agreement and correlation (R² = 0.99, p < 0.0001). AI provided a reduction of measurement error (0.4 cm³ vs. 0.5 cm³) and coefficient of variation (1% vs. 2%).

Discussion

Compared to MT the AI allows assessment of tendon volumes in highly resolved MRI data in a more accurate and reliable time-saving way. Therefore automated volume detection is seen as a helpful clinical tool for evaluation of small volumetric changes of the Achilles tendon.     

Ex vivo supplementation of TGF-beta1 enhances the fibrous tissue regeneration effect of synovium-derived fibroblast transplantation in a tendon defect: a biomechanical study

The present study was conducted to test a hypothesis that the ex vivo supplementation of TGF-beta1 into medium will significantly improve the mechanical properties of the fibrous tissue regenerated in the patellar tendon defect after transplantation of cultured autologous synovium-derived fibroblasts. Thirty rabbits were divided into the following three groups. In Group A, we applied phosphate buffered saline of 0.1 ml to the defect created in the patellar tendon. In Group B, we transplanted autologous fibroblasts, which had been cultured into the tendon defect. In Group C, we transplanted autologous fibroblasts, which had been cultured with supplementation of TGF-beta1, into the tendon defect. Animals were killed at 6 weeks, and the regenerated tissue was examined for biomechanics and histology. The tangent modulus and the tensile strength of Group C were significantly higher than that of Group B, while the tensile strength of Group C was significantly lower than that of Group A. Histologically, vascular formation was abundantly found in the regenerated tissue of Groups B and C as compared to the regenerated tissues in Group A. The present study showed that transplantation of cultured autologous synovium-derived fibroblasts enhanced vascular formation in the fibrous tissue regenerated in the patellar tendon defect, while cell transplantation deteriorated the mechanical properties of the regenerated fibrous tissue. However, the ex vivo supplementation of TGF-beta1 into the medium significantly decreased mechanical deterioration of the fibrous tissue regenerated in the tendon defect after transplantation of cultured autologous synovium-derived fibroblasts.