Calcific insertional Achilles tendinopathy: reattachment with bone anchors

BACKGROUND: Recalcitrant calcific insertional Achilles tendinopathy is difficult to treat. HYPOTHESIS: Bursectomy, excision of the distal paratenon, disinsertion of the tendon, removal of the calcific deposit, and reinsertion of the Achilles tendon with bone anchors is safe and effective. STUDY DESIGN: Longitudinal study. METHODS: Twenty-one patients (six women) (21 feet) (average age 46.9 +/- 6.4 years) with recalcitrant calcific insertional Achilles tendinopathy were treated surgically with removal of the calcific deposit; the Achilles tendon was reinserted with bone anchors. RESULTS: At an average follow-up of 48.4 months, one patient necessitated a further operation. Eleven patients reported an excellent result, and five a good result. The remaining five patients could not return to their normal levels of sporting activity and kept fit by alternative means. The results of the VISA-A questionnaire were markedly improved in all patients, from an average of 62.4% to 88.1%. CONCLUSIONS: We recommend disinsertion of the Achilles tendon to excise the calcific deposit fully and reinsertion of the Achilles tendon in the calcaneus with suture anchors. No patient experienced a traumatic disinsertion of the reattached tendon. However, five patients were not able to return to their original level of physical activity.     

Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes

BACKGROUND: Neovascularisation can be detected qualitatively by Power Doppler in Achilles tendinopathy. Quantitative data regarding tendon microcirculation have not been established and may be substantial. PURPOSE: To assess the microcirculation of the Achilles tendon and the paratendon in healthy volunteers as well as in athletes with either midportion or insertional tendinopathy. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In 66 physically active volunteers, parameters of Achilles tendon and paratendon microcirculation, such as tissue oxygen saturation, relative postcapillary venous filling pressures, and microcirculatory blood flow, were determined at rest at 2-mm and 8-mm tissue depths. Forty-one patients never had Achilles pain (25 men, 27 +/- 8 years), 14 patients had insertional pain (7 men, 29 +/- 8 years), and 11 patients had midportion tendinopathy (7 men, 38 +/- 13 years, not significant). RESULTS: Achilles tendon diameter 2 cm and 6 cm proximal to the insertion was increased in symptomatic tendons. Compared with the uninvolved opposite tendon, deep microcirculatory blood flow was significantly elevated at insertional (160 +/- 79 vs 132 +/- 42, P < .05) as well as in midportion tendinopathy (150 +/- 74 vs 119 +/- 34, P < .05). The microcirculation in the uninvolved opposite tendon and the normal athlete controls were not significantly different from each other (132 +/- 42 insertional asymptomatic vs 119 +/- 34 mid-portion vs 120 +/- 48 healthy tendon). Insertional paratendon deep microcirculatory flow was elevated in all groups, whereas tissue oxygen saturation and relative postcapillary venous filling pressures were not significantly different. CONCLUSION: Microcirculatory blood flow is significantly elevated at the point of pain in insertional and midportion tendinopathy. Postcapillary venous filling pressures are increased at both the midportion Achilles tendon and the midportion paratendon, whereas tissue oxygen saturation is not different among the studied groups. We found no evidence of an abnormal microcirculation of the asymptomatic limb in Achilles tendinopathy.     

Similar histopathological picture in males with Achilles and patellar tendinopathy

PURPOSE: To ascertain whether there are differences in the histopathological appearance of tendinopathic Achilles and patellar tendons. METHODS: In males, we studied biopsies from tendinopathic Achilles (N = 28; average age 34.1 yr) and patellar tendons (N = 28; average age 32.1), Achilles tendons (N = 21; average age 61.8 yr) from deceased patients with no known tendon pathology, and patellar tendons (N = 15; average age 28.3) from patients undergoing anterior cruciate ligament reconstruction. Hematoxylineosin stained slides were interpreted using a semiquantitative grading scale (0: normal to 3: maximally abnormal) for fiber structure, fiber arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. All slides were assessed blindly twice, the agreement between two readings ranging from 0.170 to 0.750 (kappa statistics). RESULTS: The highest mean score of tendinopathic Achilles tendons was not significantly different from that of tendinopathic patellar tendons (11.6 +/- 5 and 10.4 +/- 3, respectively). The ability to differentiate between an Achilles tendon and a patellar tendon was low. CONCLUSIONS: Tendinopathic Achilles and patellar tendons show a similar histological picture. It was not possible to identify whether a specimen had been harvested from an Achilles or a patellar tendon on the basis of histological examination. The general pattern of degeneration was common to both tendinopathic Achilles and patellar tendons. A common, as yet unidentified, etiopathological mechanism may have acted on both these tendon populations.     

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.     

Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures

A laboratory study was performed to evaluate the histopathological features of the macroscopically intact portion of the Achilles tendon in patients undergoing surgery for an acute rupture of the Achilles tendon. Tendon samples were harvested from 29 individuals (21 men, 8 women; mean age: 46 ± 12) who underwent repair of an Achilles tendon tear tear, and from 11 male patients who died of cardiovascular events (mean age: 61). Three pieces of tendon were harvested: at the rupture site, 4 cm proximal to the site of rupture, 1 cm proximal to the insertion of the Achilles tendon on the calcaneum. Slides were assessed using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. Intra-observer reliability of the subscore readings was calculated. The pathological features were significantly more pronounced in the samples taken from the site of rupture than in the samples taken proximally and distal to it (0.008 < P < 0.01). There were no significant differences in the mean pathologic sum-scores in the samples taken proximally and distal to the site of rupture. Unruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations, with the latter demonstrating histopathological evidence of failed healing response even in areas macroscopically normal.     

Anthropometry, physical performance, and ultrasound patellar tendon abnormality in elite junior basketball players: a cross-sectional study

OBJECTIVE: Patellar tendinopathy has been reported to be associated with many intrinsic risk factors. Few have been fully investigated. This cross-sectional study examined the anthropometric and physical performance results of elite junior basketball players with normal or abnormal patellar tendons to see if any measures were associated with changes in tendon morphology. METHODS: Agility, leg strength, endurance, and flexibility were measured in 71 male and 64 female players. A blinded radiologist ultrasonographically examined their patellar tendons and athletes were grouped as having normal or abnormal tendons. One-way ANOVA was used to test for differences in anthropometric and physical performance data for athletes whose tendons were normal or abnormal (unilateral or bilateral tendinopathy) on ultrasound. RESULTS: Results show that females with abnormalities in their tendons had a significantly better vertical jump (50.9+/-6.8 cm) than those with normal tendons (46.1+/-5.4 cm) (p = 0.02). This was not found in males. In males, the mean sit and reach in those with normal tendons (13.2+/-6.7 cm) was greater (p<0.03) than in unilateral tendinopathy (10.3+/-6.2 cm) or in bilateral tendinopathy (7.8+/-8.3 cm). In females, those with normal tendons (13.3+/-4.8 cm) and bilateral tendinopathy (15.8+/-6.2 cm) were distinctly different from those with unilateral tendinopathy (7.9+/-6.6 cm). CONCLUSION: Flexibility and vertical jump ability are associated with patellar tendinopathy and the findings warrant consideration when managing young, jumping athletes.     

Ruptured Achilles tendons show increased lectin stainability

PURPOSE: To ascertain whether lectins could be a useful tool for investigation of the extracellular matrix of degenerated and normal tendons. METHODS: Hematoxylin-eosin-stained slides were assessed blindly using a semiquantitative grading scale for fiber structure, fiber arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, hyalinization, and glycosaminoglycan, with a pathology score giving up to three marks per each of the above variables, with 0 being normal and 3 being maximally abnormal. For lectin staining with Aleuria aurantia, Canavalia ensiformis, Galanthus nivalis, Phaseolus vulgaris, Arachis hypogea, Sambucus nigra, and Triticum vulgaris, assessment of staining on a scale from 0 (no staining) to 5 (strong staining) was performed blindly. RESULTS: The mean pathology sum score of ruptured tendons (N = 14; average age 46.5 yr, range 29-61) was significantly greater than the mean pathology score of the control tendons of Achilles tendons from individuals with no known tendon pathology (N = 16; average age 62.5 yr, range 49-73) (pathology score: 18.5 +/- 3.2 vs 6.1 +/- 2.3). Four of the seven lectins used exhibited significantly positive results. CONCLUSIONS: Ruptured tendons were histologically significantly more degenerated than control tendons. Ruptured tendons showed different lectin staining properties than nonruptured ones. This difference may have resulted from posttranslational changes in the extracellular matrix producing alterations in the biochemistry of the tendon, which might interfere with the interaction with the lateral sugar residues of the collagen molecules or cause steric blockade.     

Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study

OBJECTIVES: To (a) compare ultrasound (US; including grey scale and colour and power Doppler) and magnetic resonance imaging (MRI; with high resolution and fat saturation sequences) with a clinical yardstick in the evaluation of chronic Achilles tendinopathy, and (b) examine whether either imaging method predicted 12 and 24 month clinical outcome. METHODS: Forty five patients with symptoms in 57 Achilles tendons were diagnosed with tendinopathy by an experienced sports medicine doctor. All patients underwent US examination (12 MHz probe) with colour and power Doppler, and 25 consecutive patients also underwent MRI with high resolution T1 weighted and STIR sequences. RESULTS: US identified abnormal morphology in 37 of the 57 symptomatic tendons (65%) and normal morphology in 19 of 28 asymptomatic tendons (68%). Baseline US findings did not predict 12 month clinical outcome. The addition of colour and power Doppler did not improve the diagnostic performance of US. MRI identified abnormal morphology in 19 of 34 symptomatic tendons (56%) and normal morphology in 15 of 16 asymptomatic tendons (94%). Lesser grades of MR signal abnormality at baseline were associated with better clinical status at 12 month follow up. CONCLUSIONS: US and MRI show only moderate correlation with clinical assessment of chronic Achilles tendinopathy. Graded MRI appearance was associated with clinical outcome but US was not.     

Light microscopic histology of achilles tendon ruptures. A comparison with unruptured tendons

We studied biopsies from the Achilles tendons of patients undergoing open repair for a subcutaneous rupture of their Achilles tendons (27 men, 11 women; mean age, 45.3 +/- 13.8 years) and specimens of Achilles tendons from persons with no known tendon ailments (43 men, 3 women; mean age, 64.2 +/- 9.7 years). Histologic examination was performed using stained slides that were interpreted using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, hyalinization, and glycosaminoglycan. We gave up to three marks for each of these variables, with 0 being normal and 3 being maximally abnormal. All the histology slides were assessed twice in a blinded manner; the agreement between two readings ranged from 0.56 to 0.87 (kappa statistics). The score of ruptured tendons was significantly greater than the average score of control tendons (20.5 +/- 3.6 versus 6.5 +/- 2.1), and there was significantly higher degeneration in the ruptured tendons. Nonruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations. Using these staining techniques, light microscopic degeneration is not a feature of tendons from healthy, older persons.     

Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis

It has been shown that 12 weeks of eccentric heavy resistance training can reduce pain in runners suffering from chronic Achilles tendinosis, but the mechanism behind the effectiveness of this treatment is unknown. The present study investigates the local effect of an eccentric training regime on elite soccer players suffering from chronic Achilles tendinosis on the turnover of the peritendinous connective tissue. Twelve elite male soccer players, of whom six suffered from unilateral tendinosis and six were healthy controls, participated in this study. All participants performed 12 weeks of heavy-resistance eccentric training apart from their regular training and soccer activity. Before and after the training period the tissue concentration of indicators of collagen turnover was measured by the use of the microdialysis technique. After training, collagen synthesis was increased in the initially injured tendon (n=6; carboxyterminal propeptide of type I collagen (PICP): pre 3.9+/-2.5 microg/L to post 19.7+/-5.4 microg/L, P<0.05). The collagen synthesis was unchanged in healthy tendons in response to training (n=6; PICP: pre 8.3+/-5.2 microg/L to post 11.5+/-5.0 microg/L, P>0.05). Collagen degradation, measured as carboxyterminal telopeptide region of type I collagen (ICTP), was not affected by training neither in the injured nor in the healthy tendons. The clinical effect of the 12 weeks of eccentric training was determined by using a standardized loading procedure of the Achilles tendons showing a decrease in pain in all the chronic injured tendons (VAS before 44+/-9, after 13+/-9; P<0.05), and all subjects were back playing soccer following the eccentric training regime. The present study demonstrates that chronically injured Achilles tendons respond to 12 weeks of eccentric training by increasing collagen synthesis rate. In contrast, the collagen metabolism in healthy control tendons seems not to be affected by eccentric training. These findings could indicate a relation between collagen metabolism and recovery from injury in human tendons.     

Blood flow of the Achilles tendon during military training

The purpose of this study was to evaluate the vascular response of the Achilles tendon as indicated by power Doppler activity during a military training program of 6 weeks. 49 male military recruits (98 tendons) volunteered for this study. Before and during the military training program, the Achilles tendons were screened with gray-scale ultrasonography and power Doppler US. Reactive tendinopathies of the Achilles tendons were registered by means of a clinical examination, VAS-scores and VISA-A scores. The US examination, the clinical examination, VAS-scores and VISA-A scores showed that 13/98 tendons developed a reactive tendinopathy. 3 of these 13 symptomatic tendons showed intratendinous Doppler activity. In these tendons, pain was always present before the vascular response of the Achilles tendon. Both pain and hypervascularisation remained visible till the end of the basic military training. In 5 asymptomatic tendons with no structural changes of the tendon, a vascular response was seen during one single measurement. It can be hypothesized that there is no relationship between the vascular response of the Achilles tendon and the pain in a reactive tendinopathy. In a reactive tendinopathy, other pain mechanisms must be investigated in future research.     

Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI

BACKGROUND: Satisfactory treatment results have been reported after eccentric calf muscle strength training in patients with chronic Achilles tendinopathy. HYPOTHESIS: Magnetic resonance imaging may be a useful adjunct in the evaluation of the effect of 3 months of eccentric calf muscle strength training. STUDY DESIGN: Prospective cohort study. METHODS: Using magnetic resonance imaging, the Achilles tendons were investigated in 25 patients (16 men and 9 women) ranging in age from 28 to 70 years (median, 51 years) before and after training. Five different magnetic resonance imaging sequences were used. Tendon volume and mean intratendinous signal were calculated using a new seed-growing technique showing 99.3% and 96.6% intraobserver reliability, respectively. The clinical outcome was categorized according to pain level and performance using a questionnaire completed by the patient. RESULTS: The eccentric training resulted in a 14% (mean) decrease of tendon volume measured on T1-weighted images, from 6.6 +/- 3.1 cm3 to 5.8 +/- 2.3 cm3 (P < .05). The intratendinous signal in the symptomatic Achilles tendon measured on proton density-weighted images decreased 23% (mean), from 227 +/- 77 signal units to 170 +/- 83 signal units (P < .05). The gadolinium contrast agent-enhanced images did not add further value compared with other sequences. CLINICAL OUTCOME: The clinical outcome was categorized as excellent in 10, good in 3, fair in 5, and poor in 8 patients. The Delta signal correlated significantly with the pain level (P < .05). CONCLUSIONS: Eccentric training resulted in decreased tendon volume and intratendinous signal and was correlated with an improved clinical outcome. Magnetic resonance imaging techniques can be used as an adjunct to clinical evaluation by monitoring morphologic effects in clinical treatment studies of Achilles tendinopathy.     

Tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type III collagen than tenocytes from normal achilles tendons. An in vitro model of human tendon healing

Type I collagen is the main collagen in tendons; type III collagen is present in small amounts. Ruptured Achilles tendons contain a significantly greater proportion of type Ill collagen, which predisposes them to rupture. We used an in vitro model to determine whether tenocytes from Achilles tendons that were ruptured (N = 22), nonruptured (N = 7), tendinopathic (N = 12), and fetal (N = 8) show different behavior. Samples of Achilles tendon were digested with collagenase and the released tenocytes were collected. Primary tenocyte cultures were established and subsequently cultured onto glass coverslips. Once a confluent monolayer was obtained, the cell populations were "wounded" by scraping a pipette tip along the surface. The cultures were further incubated for either 1, 4, 8, 12, 16, or 24 hours, and production of types I and II collagen was assessed by immunostaining. In cultures from ruptured and tendinopathic tendons, there was increased production of type Ill collagen. Athletic participation places excess stress on the Achilles tendon, which could potentially lead to areas of microtrauma within the tendon. These areas may heal by the production of type III collagen, which is an abnormal healing response. Accumulation of such episodes of microtrauma could resuit in a critical point where the resistance of the tissue to tensile forces is compromised and tendon rupture occurs.     

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.     

High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy

BACKGROUND: Results of high-energy extracorporeal shock wave therapy for the treatment of insertional Achilles tendinopathy are not determined. It is unclear how local anesthesia alters the outcome of this procedure. HYPOTHESIS: Extracorporeal shock wave therapy is an effective treatment for insertional Achilles tendinopathy. Local anesthesia field block adversely affects outcome. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: Thirty-five patients with chronic insertional Achilles tendinopathy were treated with 1 dose of high-energy extracorporeal shock wave therapy (ESWT group; 3000 shocks; 0.21 mJ/mm2; total energy flux density, 604 mJ/mm2), and 33 were treated with nonoperative therapy (control group). All extracorporeal shock wave therapy procedures were performed using a local anesthesia field block (LA subgroup, 12 patients) or a nonlocal anesthesia (NLA subgroup, 23 patients). Evaluation was by visual analog score and by Roles and Maudsley score. RESULTS: One month, 3 months, and 12 months after treatment, the mean visual analog score for the control and ESWT groups were 8.2 and 4.2 (P < .001), 7.2 and 2.9 (P < .001), and 7.0 and 2.8 (P < .001), respectively. Twelve months after treatment, the number of patients with successful Roles and Maudsley scores was statistically greater in the ESWT group compared with the control group (P > .0002), with 83% of ESWT group patients having a successful result, and the mean improvement in visual analog score for the LA subgroup was significantly less than that in the NLA subgroup (F = 16.77 vs F = 53.95, P < .001). The percentage of patients with successful Roles and Maudsley scores did not differ among the LA and NLA subgroups. CONCLUSION: Extracorporeal shock wave therapy is an effective treatment for chronic insertional Achilles tendinopathy. Local field block anesthesia may decrease the effectiveness of this procedure.     

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.     

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.     

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.     

Standardized pain mapping for diagnosing Achilles tendinopathy

ObjectivesTo assess the level of agreement between patient-reported pain using a standardized pain map and the physician-determined clinical diagnosis of Achilles tendinopathy.DesignCross-sectional study.MethodsEligible patients were adults visiting a sports physician for symptoms in the Achilles tendon region. Patients completed a digital questionnaire and indicated one location on a pain map where they experienced their pain. The primary outcome measure was level of agreement (% and Kappa coefficient) between patient-reported pain on the pain map and the physician-determined clinical diagnosis (defined as localized pain associated with tendon-loading activities and pain on palpation with or without tendon thickening). The secondary outcome measure was the agreement between the location on the pain map (midportion/insertional region) with the clinical diagnosis of midportion/insertional Achilles tendinopathy.Results110 patients (mean (SD) age 48 (13), 61% men) with pain in the Achilles region were included. In 102 (93%, Kappa = 0.86, CI 0.78–0.95) patients who indicated pain in the Achilles tendon region on the pain map, the clinical diagnosis of Achilles tendinopathy was made by the sports physician. 82% of the patients had the clinical diagnosis of tendinopathy in the specific region of the tendon they marked on the pain map (Kappa = 0.67, CI 0.54–0.79).ConclusionsThere is almost perfect agreement between patient-reported pain on a pain map and a physician-established clinical diagnosis of Achilles tendinopathy. There was substantial agreement between the localization of the pain that was selected by the patient and the diagnosis of insertional/midportion Achilles tendinopathy by the physician. This tool could potentially aid in adequate triage for specialized care and for researchers performing large epidemiological studies.     

强化循环训练促进跟腱组织塑形改建的实验研究

目的考察耐力运动训练过程中大鼠跟腱组织结构与生化成分的变化及不同训练模式与大鼠跟腱塑形改建规律的对应关系。方法120只8周龄雄性Wistar大鼠按训练方式、训练时间两因素析因设计以体重区组进行随机分组,训练方式有自由活动、中等负荷训练、强化训练、强化循环训练4个水平,训练时间有1、2、3、4、6、8周6个水平,共24组,每组5只。训练结束后切取跟腱组织,通过扫描电镜及透射电镜观察其超微结构,并应用碱解法测定强化循环训练组大鼠跟腱中羟脯氨酸的含量,以其代表胶原蛋白总量的变化;通过免疫组织化学染色的方法对该训练组大鼠跟腱组织中Ⅲ型胶原蛋白含量的动态变化进行半定量分析。结果在训练过程中,跟腱的组织结构出现由以损伤为主到修复重建占主导的动态变化,循环训练模式下损伤表现出现早,程度轻,持续时间最短。跟腱胶原蛋白总量在训练过程中保持不变,而Ⅲ型胶原的表达呈现训练早期增强,随塑形改建的进行又逐渐减弱的规律。在运动训练下肌腱组织的塑形改建过程中,胶原的新生与破坏,合成与降解是相平衡的过程。训练早期Ⅲ型胶原的含量增加提示应力作用下胶原代谢活动加速,促进组织结构发生改建。结论肌腱在运动训练中的塑形改建是通过其内部结构的重塑而非组织肥大来完成的。训练中负荷重复的次数较之单次负荷的大小对肌腱的塑形改建更具积极意义,强化循环训练可以加速跟腱的塑形改建。