跟腱断裂的MRI表现

目的 分析跟腱断裂的MRI表现.方法 回顾性分析7例跟腱断裂的MRI表现.7例均行常规MR轴面T_1WI、T_2WI,矢状面T_1WI、T_2WI和频率敏感脂肪抑制(SPIR)序列扫描.结果 完全性跟腱断裂6例,部分性跟腱断裂1例,跟腱断裂部位发生于跟腱附着于跟骨部位上方2.6～11.0 cm,平均5.4 cm.跟腱断裂的MRI表现为跟腱肿大增粗(7例)、变形,呈波浪状(2例).跟腱纤维部分或完全不连续和腱内信号强度增强(7例),完全性跟腱断裂的裂隙宽度为3.0～8.0 mm,断端水肿、充满血液,于MR T_2WI和SPIR呈高信号.7例跟腱断裂在T_1WI均呈中等信号;在T_2WI 1例呈中等信号,3例呈中-高信号,3例呈高信号;在SPIR 2例呈中-高信号,5例呈高信号.跟腱前脂肪垫模糊,见于6例完全性跟腱断裂.结论 MRI能较好显示跟腱断裂和明确诊断.     

Closed ruptures of the flexor digitorum tendons: MRI evaluation

Objective. To assess the MRI findings in cases of closed rupture of the flexor digitorum tendons (FDT). Patients and design. Ten patients with a clinical suspicion of rupture of FDT underwent MRI before surgery. None of the patients presented a skin injury. Fingers were imaged using axial T1-weighted SE sequences, three-dimensional GE images, and curved reconstructions. Results. Twelve FDT had surgical confirmation of rupture. Flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendons were more frequently ruptured (n=8) than flexor digitorum superficialis (FDS) tendons (n=4). MR images accurately depicted the level of the rupture. The gap between the tendon ends (mean 45 mm, range 21–70 mm) was assessed best with curved reconstructions and was well correlated with the surgical findings. The proximal end mainly retracted into the palm or the carpal tunnel (n=8), and less frequently into the digital canal (n=4). In two cases, the proximal end curled up in the palm, clinically simulating a rupture of a lumbrical muscle in one case. MRI also showed the appearance of the adjacent tendons. Conclusion. MRI accurately depicted the level of rupture and the gap between the tendon ends, which assisted the surgical choice between suture, graft or tendon transfer.     

跟腱损伤的MRI诊断

目的:评价跟腱损伤的MRI诊断价值。方法:回顾11例有明确踝关节损伤史、经手术证实为跟腱损伤患者的MRI表现,并与手术结果对照。结果:11例MRI均有异常表现,诊断为跟腱完全断裂5例、部分断裂6例。MRI对跟腱的形态及其内部结构显示直接、清晰、完整。跟腱损伤表现为跟腱不均匀增粗,腱内信号增高、紊乱,腱束的连续性完全中断或部分中断。结论:MRI能够直接显示外伤后跟腱的形态、内部结构及周围软组织改变,并能准确显示跟腱完全撕裂与部分撕裂的部位和程度,对临床诊治具有重要指导意义。     

Pronociceptive and antinociceptive neuromediators in patellar tendinopathy

BACKGROUND: The occurrence of nerve ingrowth and its relation to chronic tendon pain (tendinopathy) are still largely unknown. In healthy tendons, the innervation is confined to the paratenon, whereas the tendon proper is devoid of nerve fibers. In this study on the pathogenesis of tendinopathy, the authors examined sensory and sympathetic nerve fiber occurrence in the patellar tendon. HYPOTHESIS: Nerve ingrowth and altered expression of sensory and sympathetic neuromediators play a major role in the pathophysiology of pain in patellar tendinopathy. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: Biopsies from the patellar tendon in patients with patellar tendinopathy (n = 10) were compared with biopsies from a control group (n = 10) without any previous or current knee symptoms compatible with patellar tendinopathy. The biopsies were stained immunohistochemically for sensory and autonomic nerve markers. The biopsies from the 2 groups were compared using subjective and semiquantitative methods. RESULTS: Chronic painful patellar tendons exhibited increased occurrence of sprouting nonvascular sensory, substance P-positive nerve fibers and a decreased occurrence of vascular sympathetic nerve fibers, positive to tyroxin hydroxylase, a marker for noradrenaline. CONCLUSION: The altered sensory-sympathetic innervation suggests a role in the pathophysiology of tendinopathy. Ingrowth of sprouting substance P fibers presumably reflects a nociceptive and maybe a proliferative role, possibly as reactions to repeated microtraumata, whereas the decreased occurrence of tyroxin hydroxylase may represent a reduced antinociceptive role. These findings could be used to develop targeted pharmacotherapy for the specific treatment of tendinopathy.     

Tendinopathy alters ultrasound transmission in the patellar tendon during squatting

Measurement of loading patterns of the patellar tendon during activity is important in understanding tendon injury. We used transmission‐mode ultrasonography to investigate patellar tendon loading during squatting in adults with and without tendinopathy. It was hypothesized that axial ultrasonic velocity, a surrogate measure of the elastic modulus of tendon, would be lower in tendinopathy. Ultrasound velocity was measured in both patellar tendons of adults with unilateral patellar tendinopathy (n = 9) and in healthy controls (n = 16) during a bilateral squat maneuver. Sagittal knee movement was measured simultaneously with an electrogoniometer. Statistical comparisons between healthy and injured tendons were made using two‐way mixed‐design ANOVAs. Axial ultrasound velocity in both symptomatic and asymptomatic patellar tendons in tendinopathy was approximately 15% higher than in healthy tendons at the commencement (F_1,23 = 5.2, P < 0.05) and completion (F_1,23 = 4.5, P < 0.05) of the squat. While peak velocity was ≈5% higher during both flexion (F_1,23 = 5.4, P < 0.05) and extension (F_1,23 = 5.3, P < 0.05) phases, there was no significant between‐group difference at the midpoint of the movement. There were no significant differences in the rate and magnitude of knee movement between groups. Although further research is required, these findings suggest enhanced baseline muscle activity in patellar tendinopathy and highlight fresh avenues for its clinical management.     

跟腱损伤的MRI诊断及临床分析

目的探讨跟腱损伤的MR I诊断价值及不同损伤程度的诊断标准。方法搜集经临床及手术证实的、MR I资料完整的外伤性跟腱损伤26例,总结其特征性MR I表现,并与10例正常跟腱进行回顾性对比观察。结果(1)正常跟腱10例表现为走行规则、边缘光滑,在T1W I、T2W I上呈均匀低信号;(2)部分性跟腱损伤17例,MR I表现为肌腱增粗、宽径/前后径比例变小,在T1W I、T2W I上肌腱内局限性高信号,肌腱束部分毛糙、不规则,但在矢状位至少有1个层面是连续的;(3)完全性跟腱损伤9例,MR I特征性表现为肌腱增粗、形态不规则,肌腱束连续性完全中断,肌腱断端交错呈“毛刷”状或回缩呈“杵”状改变,在T1W I、T2W I上其内呈混杂高信号;(4)7例合并骨挫伤及软组织损伤,2例合并韧带损伤,2例合并骨软骨损伤,11例合并腱周积液。结论MR I能够准确判断跟腱损伤的性质、范围、程度及合并症,对术前制订治疗方案及术后疗效分析具有重要价值。     

Apolipoprotein A1 distribution pattern in the human Achilles tendon

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.     

高频超声快速诊断急性闭合跟腱断裂临床价值

目的探讨高频超声在快速诊断急性闭合跟腱断裂中的应用价值。方法对急诊收治急性闭合跟腱断裂的100例患者进行高频超声检查,观察损伤跟腱的形态、内部结构及回声改变,判断跟腱损伤程度并将超声诊断结果与急诊手术结果相比较。结果急诊手术结果显示,跟腱完全性断裂85例,高频超声快速诊断均检出,诊断符合率为100%。不完全断裂14例,高频超声漏诊3例,诊断符合率80%。漏诊3例均为微小部分断裂,后被MRI确诊。误诊1例,疑似为跟腱微小囊肿,误诊率1%。结论高频超声可快速诊断急性闭合跟腱断裂,是一种便捷、经济、可靠、无创的诊断方法,为断裂跟腱快速急诊手术提供临床依据。     

Concordance of US and MRI for diagnosis of ligamentous and tendinous injuries around the ankle

Purpose

To estimate the accuracy of ultrasonography in detection of tendinous and ligamentous injuries around the ankle in comparison to MRI.

Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy

Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented.     

Lesions of the Achilles tendon: Evaluation with ultrasonography and magnetic resonance imaging

Purpose

This work aims at evaluating the role of ultrasonography and magnetic resonance imaging in the diagnosis of the lesions affecting Achilles tendon of the ankle joint.

Patients and methods

The study is a prospective study of 28 patients. Some of them are complaining of a posterior heel pain, stiffness & a limitation of movements, soft tissue thickness and swollen and ecchymotic ankle. Plain X-ray (anteroposterior and lateral views), ultrasound examination were performed for both ankles of all patients with the patients in a prone position, the Achilles tendon was examined from its musculotendinous junction to its calcaneal insertion in both longitudinal and transverse views. Finally, MRI was performed with the patients in supine position, the foot is dorsiflexed, axial and sagittal T1, T2-weighted images, STIR & proton density were done for all patients.

Results

Out of 28 patients that were examined, the final diagnosis included; eight cases of tendinopathy (five cases peritendinosis, and three cases tendinosis), 16 cases of partial thickness tear (as compared to arthroscope), and four cases of full thickness tear.

Conclusion

Ultrasound is an important complementary diagnostic tool in the diagnosis of lesions of Achilles tendon, it is as good as MRI in the diagnosis of tendinopathy and full thickness tear, however MRI is more superior in the diagnosis of partial thickness tear, and in the differentiation of the different types of tendinopathy.     

Magnetic resonance signal, rather than tendon volume, correlates to pain and functional impairment in chronic Achilles tendinopathy

PURPOSE: To depict abnormal tendon matrix composition using magnetic resonance imaging (MRI) in chronic Achilles tendinopathy, and correlate intratendinous signal alterations to pain and functional impairment. MATERIAL AND METHODS: MRI of the Achilles tendon was performed on 25 patients with chronic Achilles tendinopathy (median age 50, range 37-71 years). All patients suffered from pain in the mid-portion of the Achilles tendon. Intratendinous signal was calculated from five different sagittal sequences, using a computerized 3D seed-growing technique. Pain and functional impairment were evaluated using a questionnaire completed by patients. RESULTS: Severity of pain and functional impairment correlated to increased mean intratendinous signal in the painful tendon in all MR sequences (P < 0.05, median r = 0.38, range 0.28-0.43 for pain; P < 0.05, median r = 0.48, range 0.29-0.49 for functional impairment). However, tendon volume did not correlate to pain or functional impairment (P > 0.05). Difference in mean intratendinous signal between symptomatic and contralateral asymptomatic tendons was highly significant in all sequences (P < 0.05) except on T2-weighted images (P = 0.6). CONCLUSION: Severity of pain and disability correlated to increased MR signal rather than to tendon volume in patients with unilateral mid-portion chronic Achilles tendinopathy.     

Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy

PURPOSE: To report the middle to long-term results of ultrasound-guided percutaneous longitudinal tenotomy of the Achilles tendon METHOD: Seventy-five athletes with unilateral Achilles tendinopathy underwent ultrasound-guided percutaneous longitudinal tenotomy under local anesthetic infiltration after failure of conservative management. Sixty-three patients were reviewed at least 36 months after the operation (51 +/- 18.2 months). RESULTS: Thirty-five patients were rated excellent, 12 good, 9 fair, and 7 poor. Nine of the 16 patients with a fair or poor result underwent a formal exploration of the Achilles tendon 7-12 months after the index procedure. The operated tendons remained thickened and the ultrasonographic appearance of operated tendons remained abnormal even 8 yr after the operation, without interfering with physical training. Isometric maximal muscle strength and isometric endurance gradually returned to values similar to their contralateral unoperated tendon. CONCLUSIONS: Percutaneous longitudinal ultrasound-guided internal tenotomy is simple, can be performed on an outpatient basis, requires minimal follow-up care, does not hinder further surgery should it be unsuccessful, and, in our experience, has produced no significant complications. It should be considered in the management of chronic Achilles tendinopathy after failure of conservative management. However, patients should be advised that, if they suffer from diffuse or multinodular tendinopathy or from pantendinopathy, a formal surgical exploration with stripping of the paratenon and multiple longitudinal tenotomies may be preferable.     

急性跟腱撕裂的低场MRI诊断

目的探讨低场MRI在急性跟腱损伤中的诊断价值和表现。方法分析29例有踝关节外伤病史、经临床或手术证实且MRI资料完整的跟腱完全撕裂或部分撕裂患者,总结其特征性MRI表现。结果 MRI诊断跟腱完全撕裂10例,MRI特征性表现为肌腱增粗、形态不规则,肌腱束连续性完全中断,肌腱断端回缩呈"杵"状或交错呈"毛刷"状改变,在T₁WI、T₂WI上其内呈混杂高信号。部分性撕裂19例,MRI表现为跟腱增粗,前后径与宽径的比例变大,在T₁WI、T₂WI上肌腱内局限性高信号,肌腱束部分毛糙、不规则,但在矢状位至少有1层面连续。结论低场MRI能清晰显示跟腱形态及内部结构,可以准确诊断撕裂的部位和程度,为临床手术治疗提供准确的依据。     

Coexistence of up‐regulated NMDA receptor 1 and glutamate on nerves,vessels and transformed tenocytes in tendinopathy

Elevated levels of the neurotransmitter glutamate and the presence of its receptor, N‐methyl‐d ‐aspartate receptor type 1 (NMDAR1), have been established in patients with tendinopathy, i.e. chronic tendon pain and degeneration. However, whether NMDAR1 is up‐ or down‐regulated in tendinopathy and co‐localized with glutamate is still unexplored. We hypothesize that an alteration in tissue expression and in the coexistence of NMDAR1 and glutamate occurs in tendinopathy and might play a role in nociception and possibly also progression of tendon degeneration (tendinosis). We therefore examined the tissue distribution and levels of NMDAR1 and glutamate in biopsies from patients with patellar tendinopathy (n=10) and from controls (n=8). The biopsies were single‐ and double‐stained immunohistochemically for glutamate and NMDAR1 and assessed subjectively and semi‐quantitatively. The chronic painful tendons exhibited a significant elevation of NMDAR1 (ninefold), which was independent of the observed increase in glutamate (10‐fold). This up‐regulation of NMDAR1 and glutamate was found to be co‐localized on nerve fibers as well as on morphologically altered tenocytes and blood vessels. None of the controls exhibited neuronal coexistence of glutamate and NMDAR1. The neuronal coexistence of glutamate and NMDAR1, observed in painful tendinosis but not in controls, suggests a regulatory role in intensified pain signalling.     

Differences in tendon properties in elite badminton players with or without patellar tendinopathy

The aim of this study was to examine the structural and mechanical properties of the patellar tendon in elite male badminton players with and without patellar tendinopathy. Seven players with unilateral patellar tendinopathy (PT group) on the lead extremity (used for forward lunge) and nine players with no current or previous patellar tendinopathy (CT group) were included. Magnetic resonance imaging was used to assess distal patellar tendon dimensions. Patellar tendon mechanical properties were assessed using simultaneous tendon force and deformation measurements. Distal tendon cross‐sectional area (CSA) normalized for body weight (mm²/kg^2/3) was lower in the PT group compared with the CT group on both the non‐lead extremity (6.1 ± 0.3 vs 7.4 ± 0.2, P < 0.05) and the lead extremity (6.5 ± 0.6 vs 8.4 ± 0.3, P < 0.05). Distal tendon stress was higher in the PT group compared with the CT group for both the non‐lead extremity (31 ± 1 vs 27 ± 1 MPa, P < 0.05) and the lead extremity (32 ± 3 vs 21 ± 3 MPa, P < 0.01). Conclusively, the PT group had smaller distal patellar tendon CSA on both the injured (lead extremity) and the uninjured side (non‐lead extremity) compared with the CT group. Subsequently, the smaller CSA yielded a greater distal patellar tendon stress in the PT group. Therefore, a small tendon CSA may predispose to the development of tendinopathy.     

Evaluation of sonoelastography in Achilles tendon of healthy volunteers and patients with symptomatic Achilles tendon

Aim and objectives: To assess the role of SEL in evaluation of Achilles tendon. Methodology: This study included 40 healthy volunteers and 40 patients with symptomatic Achilles tendon. All patients were examined by conventional B-mode ultrasound, sonoelastography and MRI. Results: Achilles tendons of the volunteers were characterized by hard texture with higher strain ratios than those of the patients with Achilles tendinopathy. No significant differences could be detected between SR of male and female volunteers yet significant differences could be detected in the volunteer group above and below forty being lower with softer tendon properties in the group above forty with a cut-off value of ≤1.84 between healthy and diseased group. Sonoelastography had the sensitivity of 89.1% and specificity of 96.1% for diagnosis of tendinopathy with results superior to those of conventional B-mode ultrasonography. Conclusion: SEL is a reliable tool in the evaluation of Achilles tendinopathy with sensitivity and specificity superior to B-mode US. Strain ratio provides excellent non-invasive diagnostic data adds strongly in more objective evaluation of Achilles tendon properties.     

急性跟腱撕裂的影像学诊断

目的探讨跟腱撕裂的X线平片和MRI诊断价值。方法分析21例有急性踝关节损伤病史、经手术证实为跟腱完全撕裂或部分撕裂患者的X线平片和MRI表现，并与手术结果对照。结果21例MRI均有异常表现，诊断跟腱完全撕裂7例，部分撕裂14例，MRI表现为跟腱增粗，腱内信号增高，腱束连续性完全中断或部分中断。X线片5例诊断跟腱撕裂，12例疑似撕裂，4例正常。手术结果完全撕裂9例，部分撕裂12例。结论MRI能准确显示跟腱撕裂的程度和部位，对临床治疗具有重要的指导意义；X线可作为跟腱撕裂初诊的辅助检查，但明确诊断还有赖于MRI。     

3D-FIESTA和3D-FSE对于跟腱损伤的诊断价值

目的：研究闭合性跟腱撕裂患者的MRI影像特点,比较其在不同MRI序列上的表现,探讨新序列在跟腱撕裂中的诊断价值。方法分析2011年6月-2013年6月间在我院就诊的41例跟腱损伤患者的MRI表现。将41例患者分为A、B两组。A组25例,行常规序列扫描（T1WI＋T2WI＋STIR）,B组16例,行常规序列（T1WI＋T2WI＋STIR）及新序列（3D-FIESTA＋3D-FSE）扫描。MRI检查后,A组11例、B组8例行手术治疗,并将其影像资料与手术结果进行比较,比较A、B组的诊断效能。结果跟腱部分撕裂的MRI表现为跟腱增粗,跟腱内条状或片状高信号。完全撕裂的MRI表现为跟腱损伤处完全分离,断端回缩或完全交错。A组诊断完全撕裂10例均行手术治疗,手术结果9例为完全撕裂。B组诊断完全撕裂7例均与手术证实符合。结论MRI对于诊断跟腱撕裂具有重要价值,新序列（3D-FIESTA,3D-FSE）能提高诊断跟腱完全撕裂的正确率及部分撕裂的检出率。     

“Tenomalacia”: a new sonographic sign of tendinopathy?

The purpose of this study was to assess tendon compressibility with sonography in extensor tendinopathy and in asymptomatic extensor tendons of the elbow. Sonography of both elbows was performed in eight patients with a clinical diagnosis of unilateral lateral epicondylitis. Tendons were assessed for compressibility by measuring their thickness before and after compression with the transducer. The same manoeuvre was performed while tendon vascularity was assessed with colour Doppler. All eight cases showed increased compressibility of the common extensor tendon on the painful side compared to the asymptomatic side, as well as increased vascularity with compressible vessels on colour Doppler. Other signs of tendinopathy were hypoechogenicity (n = 8), loss of fibrillar pattern (n = 8), intratendinous calcifications (n = 1), partial tears (n = 3), and enthesophytes (n = 5). Increased tendon compressibility indicative of tendon softening or “tenomalacia” is a new sonographic sign of common extensor tendinopathy. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.