Magnetic resonance and ultrasound in achilles tendinopathy: Predictive role and response assessment to platelet-rich plasma and adipose-derived stromal vascular fraction injection

ObjectiveTo assess the correlation between magnetic resonance and ultrasound findings and clinical outcome after intratendinous injection of leucocyte-rich platelet-rich plasma or adipose-derived stromal vascular fraction in patients with non-insertional Achilles tendinopathy.Materials and methodsForty-three patients (age: 47.8 ± 5.1, range 29–55) with unilateral or bilateral non-insertional Achilles tendinopathy (58 tendons overall) were randomly assigned to platelet-rich plasma (22 patients, 28 tendons) or adipose-derived stromal vascular fraction (21 patients, 30 tendons) injection group. All patients underwent magnetic resonance (tendon cross-sectional area, signal intensity, maximum anteroposterior thickness were measured), ultrasound (maximum anteroposterior thickness, power Doppler signal, ultrasound gray scale echotexture were measured), and visual analogue scale (VAS) pain evaluation at baseline and at six months from treatment. Wilcoxon, intraclass correlation coefficient, repeated measure ANOVA tests were used.ResultsThere was a significant (P < 0.001) decrease of mean VAS from pre-treatment (6.4 ± 1.4) to six-month evaluation (1.8 ± 1.7). Significant increase of tendon thickness measured using magnetic resonance (P = 0.013) and ultrasound (P = 0.012) and power Doppler signal (P = 0.027) was seen. There was no significant difference between pre- and post-treatment cross sectional area, signal intensity, and echotexture (P > 0.217). None of the pre-treatment parameters was a predictor of treatment outcome (P > 0.104). There was an excellent agreement between tendon thickness measurement between magnetic resonance and ultrasound (intraclass correlation coefficient = 0.986)ConclusionsBoth treatments seem to allow for clinical benefit, associated to early slight increase of tendon size and power Doppler signal. Imaging cannot be used as a predictor of clinical outcome.     

Cross-cultural adaptation of the Victorian institute of sports assessment - Hamstrings (VISA-H) questionnaire for Spanish speaking athletes with proximal hamstring tendinopathy

ObjectiveTo cross-culturally adapt and validate the Victorian Institute of Sports Assessment – Hamstrings (VISA-H) scale into Spanish.DesignClinical measurement study (psychometric analysis).SettingSports clubs and physiotherapy clinics.ParticipantsThe Spanish version of the VISA-H (VISA-H-Sp) scale was administered to 101 subjects: 50 healthy runners and 51 patients with a clinical diagnosis of PHT.Main measuresThe Victorian Institute of Sports Assessment – Hamstrings.ResultsCronbach's alpha for the VISA-H-Sp was >0.8. The ICC _2,1 was 0.993 (95%CI 0.991–0.995). In the exploratory factor analysis, a one-factor solution explained 72.1% of the total variance. Athletes with PHT scored significantly lower in the VISA-H-Sp than healthy subjects (P < 0.001). The VISA-H-Sp score results in the PHT group showed significant correlations with SF-36 physical components (Spearman r’>0.6; P < 0.001), and low or non-significant association with psychological dimensions. The standard error of measurement was 1.45 whereas the minimal detectable change was 4.02 points. The responsiveness indicators included an effect size of 2.75, and a standardised response mean of 3.1 at discharge.ConclusionThe VISA-H-Sp shows adequate psychometric properties for assessing the severity of symptoms in Spanish-speaking athletes who suffer from PHT.     

Ultrasound guided injection in patellar tendinopathy; clinical outcomes of platelet-rich plasma compared to high-volume injection

Objectives

To assess the efficacy of ultrasound guided injection of platelet rich plasma versus high volume injection in treatment of patellar tendinopathy, in patients not responding to conservative treatment.

Efficacy of platelet-rich plasma injections in pain associated with chronic tendinopathy: A systematic review

Background: Chronic tendinopathy has often been a management dilemma for general practitioners. With our understanding of the pathophysiology of tendinopathy evolving, so has our management, with the advent of newer strategies such as topical glycerol trinitrate, extracorporeal shock-wave therapy, as well as platelet-rich plasma (PRP). Aim: To systematically review the literature regarding PRP therapy in chronic tendinopathy. Design and setting: The databases used in our search include the Elton B. Stephens Co. (EBSCO) database, Medline, the Cochrane library, Ovid, and Embase (the Excerpta Medica database). A total of 389 articles were reviewed from Feb 2010 to April 2014, for possible inclusion. Of these articles, a total of 9 randomized controlled trials (RCTs) met our inclusion criteria. Only 1 RCT was excluded due to previous surgery in both the trial and control groups. Methods: Each article was reviewed independently by 2 authors. Each article was analyzed using the Cochrane Criteria checklist. Where any discrepancy occurred in results, a third independent reviewer was consulted. Results: Our review found that PRP was most effective in patellar and lateral epicondylar tendinopathy, with both RCTs in the patellar section of our study supporting the use of PRP in pain reduction at 3 and 12 months, whereas 2 of 4 studies in the lateral epicondylar section showed improvements in pain and disability at 6 and 12 months. There was a lack of evidence to support the use of PRP in Achilles and rotator cuff tendinopathy. Conclusions: Although the results of this review show promise for the use of PRP in chronic tendinopathy, the analysis highlighted the need for more controlled clinical trials comparing PRP with placebo.     

The clinical impact of platelet-rich plasma on tendinopathy compared to placebo or dry needling injections: A meta-analysis

ObjectiveThe purpose of this meta-analysis was to compare the impact of platelet-rich plasma with that of placebo or dry needling injections on tendinopathy.MethodsThe databases of PubMed, CENTRAL, Scopus, Web of Science, and trial registries, reference lists, and conference abstract books were searched up to December 2014. Adults with tendinopathy in randomized controlled trials were enrolled. The trials compared effect of platelet-rich plasma with that of placebo or dry needling. We used subgroup analysis linked to the anatomical location of the tendinopathy. The primary outcome was pain intensity at two or three and six months after intervention. The secondary outcome was functional disability at three months after treatment.ResultsFive trials were included. There was a statistically significant difference in favor of the platelet-rich plasma intervention at the second primary outcome time point (SMD −0.48, 95%CIs −0.86 to −0.10, I² = 0%, p = 0.01) and at the secondary outcome time point (SMD −0.47, 95%CIs −0.85 to −0.09, I² = 0%, p=0.01).ConclusionsPlatelet-rich plasma did not provide significantly greater clinical benefit versus placebo or dry needling for the treatment of tendinopathy at a six-month follow-up. However, there was a marginal clinical difference in favor of platelet-rich plasma injections on rotator cuff tendinopathy.     

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Greater trochanteric pain syndrome is commonly due to gluteus minimus or medius injury rather than trochanteric bursitis. Gluteal tendinopathy most frequently occurs in late-middle aged females. In this pictorial review the pertinent MRI and US anatomy of the gluteal tendon insertions on the greater trochanter and the adjacent bursae are reviewed. The direct (peritendinitis, tendinosis, partial and complete tear) and indirect (bursal fluid, bony changes and fatty atrophy) MRI signs of gluteal tendon injury are illustrated. The key sonographic findings of gluteal tendinopathy are also discussed.     

Practice patterns for the treatment of acute proximal hamstring ruptures

ABSTRACT

Objective: Proximal ischial hamstring avulsion injuries are relatively uncommon. As such, the management of these injuries is often highly variable. Consensus agreement is lacking for the indications for repair, along with the operative technique, and post-operative rehabilitation. The purpose of this study was to survey surgeons who treat proximal hamstring avulsion injuries to identify current trends in the management of this injury.

Methods: After IRB approval, a 46-question cross-sectional survey was distributed using a secure electronic survey portal. The survey sought to determine surgeon experience, diagnostic preferences, treatment patterns, surgical indications/technique, perceived patient outcomes, surgical complications, as well as post-operative management and rehab protocols. Surveys were completed electronically and anonymously, with invitations distributed to members of the American Orthopedic Society for Sports Medicine (AOSSM) and Arthroscopy Association of Canada (AAC).

Results: A total of 108 surgeons who manage proximal hamstring injuries completed the survey. Most respondents (77%) treat one to five of these injuries per year. MRI was the preferred imaging modality to confirm diagnosis. Despite 98% of respondents indicating that there was a role for surgical management of proximal hamstring avulsions, operative treatment was reportedly undertaken in only 50% of cases seen by each respondent. The top three reported surgical indications were: number of tendons involved (most important factor = 42%, second most = 26%, third most = 13%), amount of tendon retraction (28%, 41%, 16%), and patient activity level (16%, 18%, 24%).

Conclusion: Based on the practice patterns of the surgeons who completed the survey, there is continued disparity in the management of proximal hamstring avulsions. A lack of agreement exists with regards to surgical indications, operative technique, and post-operative protocols. Most striking is the rate of non-operative treatment and perceived rate of poor outcomes within this cohort. Future research should focus on objective evaluation of non-operative management, and additional variables involved in surgical treatment and post-operative rehabilitation.     

Platelet rich plasma compared to dry needling in the treatment of non-insertional Achilles tendinopathy

Objectives: The efficacy of platelet rich plasma in the treatment of Achilles tendinopathy is controversial. Despite positive results observed in open studies, randomized controlled trials failed to show difference against saline or rehabilitation. Aims of this retrospective observational study were to compare the efficacy of platelet-rich plasma and dry needling and to assess possible differences age and sex-related.

Methods: Groups of 46 and 38 patients with non-insertional Achilles tendinopathy were treated with platelet-rich plasma and dry needling (once a week for 3 weeks), respectively. At baseline, 3 and 6 months, pain and function scores and the percentage of satisfactory outcomes were evaluated. Sub-group analyses were performed according to age and sex.

Results: At 3 and 6 months no differences in terms of pain and function between groups were observed, but the percentage of subjects reporting satisfactory results, at 6 months, was higher in platelet rich plasma group. Better results were observed in younger subjects, with a greater reduction of pain, improvement of function, and accordingly of the percentage of positive outcomes. A trend toward better results was also observed in males.

Conclusion: Beneficial effects of platelet rich plasma and dry needling in non-insertional Achilles tendinopathy have been observed only in some subjects, but not in others; platelet rich plasma shows a slight superiority against dry needling, mainly in younger persons; finally, a gender difference in the therapeutic response can be hypothesized.     

高频超声对轻中度腕管综合征注射富血小板血浆疗效的动态评估价值

目的:探讨高频超声动态观察轻中度腕管综合征(CTS)注射富血小板血浆(PRP)疗效的评估价值.方法:选择36例(44腕)轻中度CTS为PRP组注射PRP,同时选择38例(46腕)轻中度CTS作为对照组进行激素治疗,随访1、3、6个月时分别行CTS功能评分及高频超声检查,统计分析轻中度CTS正中神经形态参数与CTS功能评...     

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.     

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.     

Surgical treatment of partial tears of the proximal origin of the hamstring muscles

Background

Hamstring injuries are common especially in athletes. Partial and complete tears of the proximal origin may cause pain and functional loss.

Objective

To evaluate the results of surgical treatment for partial proximal hamstring tears.

Methods

Between 1994 and 2005, 47 athletes (48 cases, 1 bilateral) with partial proximal hamstring tears were operated on. The cases were retrospectively analysed. Before surgery, 42 of the patients had undergone conservative treatment with unsatisfactory results, whereas in five patients the operation was performed within four weeks of the injury.

Results

The mean length of the follow up was 36 months (range 6–72). The result of the operation was rated excellent in 33 cases, good in nine, fair in four, and poor in two. Forty one patients were able to return to their former level of sport after an average of five months (range 1–12).

Conclusion

In most cases, excellent or good results can be expected after surgical repair of partial proximal hamstring tears even after conservative treatment has failed.     

自体富血小板凝胶换药辅助治疗难愈合创面初步探讨

目的 探讨自体富血小板血浆对难愈合创面的辅助治疗效果.方法 难愈合创面患者15例,其中男11例,女4例.糖尿病性溃疡6例,外伤手术后溃疡创面5例,压疮4例.创面清创后使用自体富血小板凝胶涂抹创面,每周换药,定期检测创面细菌培养结果,观察肉芽生长情况.待创面情况允许时,行植皮或皮瓣转移手术封闭创面.结果 15例患者中3例换药自行愈合,4例经皮瓣转移手术后愈合,8例植皮后愈合.所有患者均无复发或窦道产生.结论 自体富血小板凝胶可以有效促进创面生长,改善创面情况,提高了手术封闭创面的成功率.     

Anatomic ACL reconstruction: does the platelet-rich plasma accelerate tendon healing?

Recently, the use of hamstring tendons in anterior cruciate ligament repair has been increasing. However, tendon-to-bone healing occurs slowly, which can be a problem to an early return to sport activities. The use of growth factors from platelets seems to improve tissue healing. We enrolled 40 patients in a prospective study that were submitted to an anatomic reconstruction of the anterior cruciate ligament. Patients were sequentially enrolled into four groups: group A without platelet-rich plasma (PRP); group B with PRP in femoral tunnels at the end of surgery; group C with PRP in femoral tunnels at the end of surgery and intra-articular at 2- and 4 weeks after surgery; group D with PRP activated with thrombin in the femoral tunnels. All patients underwent magnetic resonance imaging of the knee 3 months after surgery to evaluate the signal intensity of the fibrous interzone (FIZ) in the femoral tunnels. We did not find any difference among the groups when comparing the signal intensity of the FIZ on magnetic resonance imaging.     

Effects and mechanism of platelet-rich plasma on military drill injury:A review

Military drill injury is a significant part of military medical research.The increase of training intensity and changes in training methods lead to differences in injury types.The ideal therapeutic modality should allow rapid healing at a reasonable cost and minimize impact on patients' life.Platelet-rich plasma (PRP),a platelet concentrate,is rich in a variety of growth factors and widely used clinically as a minimally invasive treatment.It plays an important role in injury repair and rehabilitation.In this article,we review the therapeutic role of PRP in military drill injury and its possible underlying mechanisms,with a focus on plantar fasciitis,stress fractures and other common injuries,in order to provide basic support for military reserve.     

超声引导关节腔内注射富血小板血浆治疗颞下颌关节紊乱的疗效分析

【摘要】　目的?评估超声引导下关节腔中注射富小板血浆（PRP）治疗颞下颌关节紊乱病的有效性。方法?2016年4月至2018年4月,门诊诊治45例确诊为颞下颌关节紊乱患者,超声引导将采集于患者自身的PRP注射于患者病变的颞下颌关节腔内。观察患者在治疗前和治疗后1、3和6个月的最大张口度,及颞下颌关节在静息、运动和咀嚼时VAS评分。结果?关节腔内注射PRP可有效改善最大口腔开放程度,颞下颌关节在静息,运动和咀嚼时VAS评分与治疗前相比显著降低。结论?超声引导下关节腔内注射PRP可显著改善颞下颌关节紊乱患者的体征和症状。     

磁共振体素内不相干运动成像和扩散峰度成像在正常肾脏成像中的初步研究

目的:探讨正常人肾脏磁共振体素内不相干运动成像(IVIM)和扩散峰度成像(DKI)的定量参数指标特点.方法:对27名健康志愿者行肾脏IVIM和DKI检查,通过后处理分析,获得双肾皮髓质IVIM相关参数ADC、Dffast、Dslow、fp以及DKI相关参数MD、MK的测量值.分析同一测量者前后2次测得数据的一致性,比较正常肾脏左右侧以及同侧肾脏不同部位IVIM、DKI各参数间的差异,比较正常肾脏皮质、髓质各参数均值间的差异.结果:IVIM序列的ADC值、Dslow值、fp值和DKI序列的MD值、MK值前后两次测量总体一致性较好,Dfast值一致性一般;IVIM、DKI各参数测量值在双侧肾脏间均没有统计学差异(P值为0.058～0.954),同侧肾脏皮髓质不同部位各参数测量值间亦均没有统计学差异(P值为0.171～0.995);正常肾脏皮质ADC值、Dslow值高于髓质(t=7.072,P＜0.05;t=10.057,P＜0.05),皮髓质Dfast值、fp值差异不具有统计学意义(P＞0.05);正常肾脏皮质MD值高于髓质(t=10.268,P＜0.05),髓质MK值高于肾皮质(t=-10.228,P＜0.05).结论:正常肾脏IVIM和DKI成像能显示皮髓质间差异,反映肾脏生理功能,提示在评估肾脏疾病具有潜在应用价值,整体检查结果具有一定稳定性.     

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.     

Non-surgical treatment of patellar tendinopathy: A systematic review of randomized controlled trials

Study designSystematic review of randomized controlled trials.ObjectivesTo determine the most effective non-surgical treatment interventions for reducing pain and improving function for patients with patellar tendinopathy.MethodsStudies considered for this systematic review were from peer-reviewed journals published between January 2012 and September 2017. All included studies used a visual analogue scale (VAS) to evaluate the participant’s pain. The majority of the included studies also used the Victorian Institute of Sport Assessment Patellar Tendinopathy (VISA-P questionnaire) to assess participant’s symptoms and function.ResultsNine randomized controlled trials fit the inclusion criteria and were analyzed. The results of three studies supported the use of isometric exercise to reduce pain immediately. One study found patellar strapping and sports taping to be effective for reduction in pain during sport and immediately after. Eccentric exercise, Dry Needling (DN) (2 studies), injections with Platelet Rich Plasma (PRP), Autologous Blood Injection (ABI), and saline were found to have a more sustained effect on reducing pain and improving knee function.ConclusionIsometric exercise, patellar strapping, sports taping, eccentric exercise, injections with PRP, ABI, and saline and DN demonstrated a short-term pain relieving and functional improvement effect in subjects with patellar tendinopathy. Longer term follow up on interventions involving eccentric exercise, DN, and injections with PRP, ABI and saline showed sustained pain reduction and improvement in knee function.Level of evidenceLevel 1.     

Identification of occult breast lesions detected by magnetic resonance imaging with targeted ultrasound: A prospective study

Objective

To verify the capacity of targeted ultrasound (US) to identify additional lesions detected on breast magnetic resonance imaging (MRI), but occult to initial mammography, US and clinical examinations.

Methods

This prospective study included 68 additional relevant breast lesions identified on MRI of 49 patients. As an inclusion criterion, breast US and mammography were required and performed up to six months before MRI. These lesions were then subjected to targeted “second-look” US up to 2 weeks after MRI, performed by one or two radiologists with expertise on breast imaging. Lesions were evaluated according to the established Breast Imaging Report and Data System (BI-RADS) lexicon.

Results

Targeted US identified 46/68 (67.6%) lesions revealed by MRI. No significant associations were observed between US identification and the type of lesion, dimensions, morphological characteristics and enhancement pattern according to MRI findings. Targeted US identified 100% of BI-RADS category 5 lesions, 90% of category 4 lesions, and just over 50% of category 3 lesions (p < 0.05). There was significant agreement (p < 0.001) between MRI and US BI-RADS classification for all three categories.

Conclusion

Targeted US can identify a large proportion of the lesions detected by breast MRI, especially those at high risk of malignancy, when performed by a professional with experience in both breast US and MRI.