Achilles Tendinosis Research Articles

Prolotherapy in the Treatment of Sports-Related Tendinopathies: A Systematic Review of Randomized Controlled Trials.

As sports have increased in popularity, the incidence of tendinopathy has also grown dramatically. Nonoperative techniques and treatments used to address these pathologies continue to evolve and improve. One such treatment, prolotherapy (PrT), has become increasingly popular and may provide patients with an alternative nonoperative treatment option. To review high-quality randomized controlled trials (RCTs) that analyzed PrT treatments for the most common tendinopathies. Specifically, this review aims to provide meaningful data regarding methods and outcomes for each condition treated and guide professionals who are considering PrT as a treatment option. Systematic review; Level of evidence, 2. All RCTs published in English between January 1, 1980, and July 30, 2021, and reported in Embase, Medline, and Web of Science databases were reviewed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After the initial search, a total of 3264 articles were identified. Studies analyzing sports medicine injuries and musculoskeletal pathologies using an RCT design were included, while case-reports, case-studies, reviews, and observational studies were excluded. Two independent researchers reviewed the search results, and conflicts were resolved by discussion of inclusion and exclusion criteria among all authors. The articles' quality was evaluated using the Cochrane tool for assessing the risk of bias. Statistical analysis and graphical representations were performed using SPSS Version 28.00. A total of 20 articles, including 1136 patients, met the inclusion criteria and were included in the study. Overall, in 85% of the studies, PrT was found to be effective in the treatment of tendinopathy. Specifically, PrT was superior to or as effective as the control in 83% (10/12) of the studies analyzing lateral epicondylitis (LE) and rotator cuff (RC) tendinopathies and in 88% (7/8) of the studies on plantar fasciitis (PF), Osgood-Schlatter disease (OSD), and Achilles tendinosis (AT). LE, RC, and PF tendinopathies were the most studied conditions (17/20 studies), while AT and OSD were the least studied (3/20 studies). Of the studies, 95% (19/20) used dextrose solutions, with only 1 using solutions of 2.5% phenol, 25% glycerin, and 25% dextrose in sterile water. Our systematic review suggests that PrT appears to be a promising alternative treatment for common tendinopathies. Most studies used a hypertonic dextrose solution. Even though further, larger randomized controlled trials comparing PrT with other orthobiologics would be beneficial, based on this review, sports medicine physiciansmay safely pursue PrT as an additional component of conservative treatment.

Diamondback Double-Row Reconstruction with Proximal Modification for the Treatment of Chronic Insertional Achilles Tendinosis

Diamondback Double-Row Reconstruction with Proximal Modification for the Treatment of Chronic Insertional Achilles Tendinosis

The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment.

The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Needle‑based gastrocnemius lengthening: a novel ultrasound‑guided noninvasive technique: part II—clinical results

BackgroundIsolated gastrocnemius contracture has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flatfoot, and metatarsalgia. Although many techniques are available for gastrocnemius recession, potential anesthetic, cosmetic, and wound-related complications can lead to patient dissatisfaction. Open and endoscopic recession techniques usually require epidural or general anesthesia, exsanguination of the lower extremities and stitches and can damage the sural nerve, which is not under the complete control of the surgeon at all stages of the procedure. The purpose of this study is to evaluate the clinical results of a surgical technique for gastrocnemius lengthening with a needle, as previously described in cadaver specimens.Methods and resultsWe performed a prospective study of ultrasound-guided gastrocnemius tendon lengthening in level II using a needle in 24 cases (19 patients) of gastrocnemius contracture. The study population comprised 12 males and 7 females. Mean age was 41 years (18–64). All but 5 recessions were bilateral and occurred simultaneously. The indication for the procedure was gastrocnemius contracture; although the patients also presented other conditions such as non-insertional Achilles tendinopathy in 6 patients (2 were bilateral), insertional Achilles calcifying enthesitis in 4 (1 was bilateral), metatarsalgia in 4, flexible flat foot in 1 and plantar fasciitis in 5 (2 were bilateral). The inclusion criteria were the failure of a previous conservative protocol, that the Silfverskiöld test was positive, and that the pathology suffered by the patient was within the indications for surgical lengthening of the patients and were described in the scientific literature. The exclusion criteria were that the inclusion criteria were not met, and patients with surgical risk ASA 3 or more and children. In these patients, although possible, it is preferable to perform the procedure in the operating room with monitoring, as well as in children since they could be agitated during the procedure at the office. We used the beveled tip of an Abbocath needle as a surgical scalpel. All patients underwent recession of the gastrocnemius tendon, as in an incomplete Strayer release. We evaluated pre- and postoperative dorsiflexion, outcomes, and procedural pain (based on a visual analog scale and the American Orthopedic Foot and Ankle Society scores), as well as potential complications. No damage was done to the sural bundle.ResultsAnkle dorsiflexion increased on average by 17.89°. The average postoperative visual analog score for pain before surgery was 5.78, 5.53 in the first week, 1.89 at 1 month, and 0.26 at 3 months, decreasing to 0.11 at 9 months. The mean postoperative American Orthopedic Foot and Ankle Society Ankle-Hindfoot score the average was 50.52 before surgery, 43.42 at 1 week, 72.37 at 1 month, 87.37 at 3 months, and 90.79 at 9 months.ConclusionUltrasound-guided needle lengthening of the gastrocnemius tendon is a novel, safe, and effective technique that enables the surgeon to check all the structures clearly, thus minimizing the risk of neurovascular damage. The results are encouraging, and the advantages of this approach include absence of a wound and no need for stitches. Recovery is fast and relatively painless. A specific advantage of ultrasound-guided needle lengthening of the gastrocnemius tendon is the fact that it can be performed in a specialist's office, with a very basic instrument set and local anesthesia, thus reducing expenses.

EFFECTIVENESS OF ULTRASOUND GUIDED DEXTROSE PROLOTHERAPY INJECTION IN COMPARISON WITH EXTRACORPOREAL SHOCK WAVE THERAPY ON IMPROVING PAIN AND FUNCTION AMONG ATHLETES WITH ACHILLES TENDINOPATHY: A RANDOMIZED CONTROLLED TRIAL

Background: Achilles tendinosis is a chronic, degenerative condition affecting both sedentary individuals and athletes of all abilities, with prevalence in running-based sports particularly high. Pain is considered to be the primary symptom of Achilles tendinosis, to the extent that it is suggested that a patients symptoms can reflect the severity of the condition. Several treatment modalities such as activity modification, heel lifts, arch supports, stretching exercises, nonsteroidal anti-inflammatories, and eccentric loading are known as standard treatment mostly without proven evidence. Objectives: To determine the effectiveness of ultrasound guided Dextrose prolotherapy injection in comparison with extracorporeal wave therapy on improving pain and function among athletes with Achilles tendinopathy Study Design: A Randomized controlled trial Methods: Fifty eight athletes with achilles tendinopathy meeting the inclusion and exclusion criteria were selected for this study and randomized into 2 treatment groups: dextrose prolotherapy injection under ultrasound guidance (prolotherapy group n = 29), and 3 sessions of focused extracorporeal shock wave therapy (ESWT group n = 29). The outcome measures were Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire and pain visual analog scale (VAS). Both the groups underwent rehabilitation programs. For descriptive statistics mean, standard deviation and frequency were used. Continuous variables were analysed by students t-test. Categorical variables were analysed using Chi-square test. Within the group comparison (baseline and follow-up data of each group) was done by Repeated measures ANOVA. Between the groups comparison was analysed using students t-test. A p-value < 0.05 was taken as significant. Results: The 2 groups were homogeneous in terms of their baseline characteristics like age, gender, duration of symptoms and side of affection (p > 0.05). Within the group comparison showed significant improvement in outcome measures in both the groups at all follow ups (p = 0.00). Between the groups analysis found improvement in the VAS and VISA-A scores at all follow ups but the improvement was significantly more in the Prolotherapy group in comparison with the ESWT group (p = 0.00). Conclusion: Ultrasound guided injection of dextrose prolotherapy in combination with eccentric strengthening exercises lead to significant improvement in pain and function over the long term in comparison with focused ESWT among athletes with Achilles tendinosis and thereby enabling faster return to sports.

SpeedBridge Repair in Degenerative Achilles Tear: A Novel Technique.

Retrocalcaneal pain in late adulthood and athletes has been attributed to insertional Achilles tendinosis (IAT). Another presentation of IAT is a degenerative Achilles tear, which can be partial or complete. Symptomatic patients with failed conservative management are treated by debridement and repair of the Achilles tendon. Often, they need augmentation with a tendon transfer. The flexor hallucis longus (FHL) is the most commonly used tendon for augmentation. The Speed Bridge technique to repair the degenerated tendoachilles tear gives better pullout strength and provides a larger surface area of contact between the bone and tendon. We included 12 patients with symptomatic degenerative Achilles tears repaired with the Speed Bridge technique and FHL augmentation. Post-operatively, all patients were allowed active ankle mobilization on day 1 and were allowed weight bearing as tolerated in an airwalker shoe. All patients went through an accelerated rehabilitation protocol. Pre-operative and post-operative American Orthopedic Foot and Ankle Hindfoot Score (AOFAS) and Visual Analog Scale (VAS) scores were compared for all the patients. The mean age was 58.1 (range 50-68) years. The mean follow-up period was 13.1 (range 12-15) months. The mean pre- and post-operative AOFAS score at 12 months was 59.5 (range 58-71) and 90.2 (range 87-100), respectively. The mean pre-operative VAS for pain was 6.8 (range 6-8), and the mean post-operative VAS score was 0.5 (range 0-2). The mean interval to weight bearing was 8.4 days (range 7-10) days. Our study indicates that accelerated early rehabilitation and an early return to active life are possible with the Speed Bridge technique and FHL augmentation in degenerative Achilles tears. The mean post-operative AOFAS scores were comparable to other studies, but early return to activity, minimal need for immobilization, and accelerated rehabilitation were the advantages of the Speed Bridge technique in the repair of degenerative Achilles tears.

Complications following surgical management of Haglund's triad: A retrospective, single-center analysis

BackgroundHaglund's triad consists of Haglund's deformity, insertional Achilles tendinosis, and retrocalcaneal bursitis and is most commonly managed surgically through Haglund's resection, bursectomy, and Achilles tendon detachment-reattachment using a central tendon-splitting approach stabilized with a double row suture construct. This procedure has demonstrated consistently good outcomes; however, we have anecdotally identified a higher complication rate performing this surgery compared with the published literature. Accordingly, we sought to evaluate this further. MethodsWe performed a retrospective electronic medical record review of 44 consecutive patients (10 men, 34 women) who underwent surgical correction of Haglund's triad. Patient age, gender, laterality, body mass index, follow-up duration, complications encountered, and revision surgery performed were analyzed. ResultsSignificant differences were identified for gender and incidence of complications (p = 0.01424), with women having a greater incidence of complications than men and duration of follow-up (p = 0.0432) where women endured a longer follow-up period. No other significant differences for complications were identified for age (p = 0.192), laterality (p = 0.5535), or body mass index (p = 0.9532) irrespective of gender. Complications occurred in 50 % of patients with most complications persisting at the final follow-up. ConclusionWe identified a significantly greater incidence of complications for women compared to men for operative management of Haglund's triad regardless of age, laterality, or body mass index. Further analysis of the effect gender has on operative management of Haglund's triad seems warranted so that measures to mitigate complications can be developed, especially since complications persisted for those patients who encountered them which negatively affected their outcomes. Level of EvidenceIII-Therapeutic study: Retrospective comparative analysis at a single institution CategoryRearfoot and Ankle Reconstruction

Can Achilles tendinosis be treated effectively with lidocaine and glucose infiltrations, and if so, is the effect lasting? A longitudinal, observational on 27 consecutive patients

ObjectiveOur aim was to add to the small but growing body of evidence on the effectiveness of ultrasound-guided Achilles intratendinous hyperosmolar dextrose prolotherapy and introduce a novel, preceding step of paratenon hydrodissection with lidocaine in patients with chronic Achilles tendinosis resistant to rehabilitation therapy. MethodsWe conducted a longitudinal, observational study on 27 consecutive patients diagnosed with Achilles tendinosis, in whom conservative treatment, ie, physiotherapy or shock wave therapy, had failed. A 2% lidocaine paratenon anesthesia and hydrodissection was followed by ultrasound-guided, intratendinous injections of 25% glucose every 5 weeks. Visual analogue scales (VAS) were used for pain assessment at rest, for activities of daily living, and after moderate exercise at the begining and at the end of the treatment. Moreover, tendon thickness and vascularisation were recorded at baseline and final treatment consultation. Effectiveness was estimated from scoring and relative pain reduction using a 95% CI. The non-parametric Wilcoxon test and a general linear model for repeated measures were applied. Statistical significance was established as p < 0.05. ResultsA median of 5 (1–11) injection consultations per patient were required. Pain scores decreased significantly in all three conditions (p < 0.001). Relative reductions were 75% in pain at rest (95% CI;61–93%), 69% in pain with daily living activities (95% CI; 55–83%), and 70% in pain after moderate exercise (95% CI; 57–84%). Tendon neo-vascularisation was significantly reduced (p < 0.001). We did not observe significant changes in tendon thickness (p = 0.083). ConclusionsAchilles tendinosis treatment with paratenon lidocaine hydrodissection and subsequent prolotherapy with hyperosmolar glucose solution is safe, effective, inexpensive, and virtually painless with results maintained over time.

No Loss of Strength After Insertional Achilles Tendon Reconstruction With Single-Anchor or Double-Row Repair

Many different types of surgical repair for insertional Achilles tendinosis have been described. Strength after surgery is an essential factor for patient function and satisfaction. A retrospective series of patients that underwent surgery for insertional Achilles tendon surgery were contacted to come in for prospective strength testing, with the tester blinded to the type of surgery performed. Thirty-seven patients came in for testing, 24 with a single-anchor repair and 13 with a double-row repair. Strength of plantarflexion was tested at 60°/s and 120°/s and was compared. First each operative leg was compared to the nonoperative leg as a control. Then the percentage change, or symmetry, from the control leg to the operative leg was compared between those with a single-anchor and double-row repair. Satisfaction was also assessed with a simple questionnaire and compared the types of repair. The results demonstrated there was no statistically significant change in strength after surgery compared to the nonoperative leg, and there was no difference in limb symmetry between types of repair. Similarly, there was no difference between the groups in satisfaction. Our study showed that there is, on average, no loss of strength after insertional Achilles tendon surgery at an average follow-up of nearly 2 years, regardless of type of repair.

Poster 361: Prolotherapy in the Treatment of Sports-Related Tendinopathies: A Systematic Review

Objectives: Prolotherapy (PrT) involves the injection of a proliferant in order to irritate a microenvironment and promote healing via the inflammatory cascade. PrT has become an increasingly popular nonoperative treatment in orthopedics. However, numerous prolotherapy solutions exist and varying applications and results have been described. The purpose of this study is to review high-quality randomized controlled trials (RCTs) that analyzed efficacy and safety profiles of prolotherapy (PrT) treatments for the most common sports-related tendinopathies. Methods: All RCTs published in English between January 1st 1980 and July 30th 2021, reported in Embase, Medline, and Web of Science databases, were queried with search terms including sclerotherapy, prolotherapy, sports medicine, sports injuries, tendinopathies, and musculoskeletal pain/injuries. PRISMA guidelines were used. Studies analyzing tendinopathies using a RCT design were included, while case controls, reviews, and observational studies were excluded. Duplicates were eliminated through Endnote. The remaining articles were screened by titles, followed by abstract and then by full text analysis. The Cochrane collaboration tool was used to assess for risk of bias. Two researchers independently performed the screening and conflicts were resolved using Rayyan © software (Rayyan Systems Inc., Cambridge, MA, USA). Graphical representations were created using SPSS version 28.00. Results: Application of the inclusion and exclusion criteria yielded 20 RCTs (fig. 1): 6 studies on lateral epicondylitis (LE); 6 on rotator cuff tendinopathy (RC); 5 on plantar fasciitis (PF); 2 on Osgood-Schlatter disease (OSD); 1 on Achilles tendinosis. Most of the trials used dextrose injections over P2G or hypertonic glucose (fig. 2), and the most common studied conditions were LE and RC (fig.3). The average follow-up period was 12 weeks. No significant adverse effects were reported, and the most common outcome measures were visual analog scale (VAS), patient rated tennis elbow evaluation (PRTEE), quick- disabilities of the arm, shoulder, and hand (Q-DASH), and symptoms relief. For the treatment of LE, dextrose PrT was associated with significant improvement in VAS pain score at rest and PRTEE compared to normal saline (p&lt;0.041, p&lt;0.013 respectively). Additionally, compared to hyaluronic acid and lifestyle modifications, PrT showed significant improvement in VAS pain score with activity, Q-DASH, and PRTEE scores (p&lt;0.04, p&lt;0.04, p&lt;0.05 respectively). For the treatment of RC, dextrose PrT was found superior to physiotherapy in the shoulder disability index (p&lt;0.001). Finally, dextrose PrT demonstrated significant improvements in foot function index (p&lt;0.001) for the treatment of PF, and reduction of symptoms in OSD (p&lt;0.024) compared to physical therapy and lidocaine controls. Patients with AT had a more rapid improvement in symptoms in the combined PrT/eccentric loading exercises protocols compared to dextrose PrT alone (p&lt;0.007). A graphical representation of the results is reported in figure 4. Conclusions: This systematic review summarized high quality RCTs and found PrT injections to be overall safe and effective in the treatment of sports-related tendinopathies. Further RCTs with larger sample sizes and comparisons to orthobiologics would add to the literature. Based on the current findings, sports medicine professionals may safely pursue PrT as an additional component of conservative treatment before surgery.

Is conservative therapy or platelet-rich plasma therapy more effective for the treatment of Achilles tendinosis?

Teubert, Justin DO; Radcliffe, Eric MD; Patterson, Austin DO; Johnson, Michael DO Author Information

Double Row Fixation is More Costly and Does Not Have Clinical Benefit Over Single Anchor for Insertional Achilles Tendon Surgery

Surgical repair of insertional Achilles tendinosis is indicated in the face of failed conservative measures. Several methods for this repair have been described, and the optimal method is not universally agreed upon. In addition, the cost of medical care is important, and should be considered when determining the surgical repair for each patient. The purpose of this study is to compare implant costs between a single anchor or 4 anchor, double row repair, and evaluate associated outcomes. A retrospective comparative trial was performed for this purpose. The entire study encompassed 110 patients, 78 with a single anchor repair, and 32 with a double row repair. The average implant cost of the single anchor repair was $391.18 ± $272.10 and the double row repair was $1811.2 9 ± $169.47, p < .001. The groups did not have a statistically significant difference in complications (9% with single anchor vs 6.3% with double row, p=1.0) or revisions 6.4% with single anchor vs 3.1% with double row, p=.67). The only difference in demographics between the groups was that the single anchor group had a higher percentage of female patients (p=.04). While the double row repair has been shown to have favorable biomechanical results, the present study did not show a benefit in complications or revisions and was a more costly repair technique. Surgeons should take these findings in consideration when choosing the repair technique when surgery is indicated.

Dramatic Clinical and Ultrasound Outcomes Post PlateletRich Plasma for Recalcitrant Chronic Mid-Portion Achilles Tendinopathy: Case Report

Chronic Achilles tendinosis with or without tendon tear is a common form of tendon degenerative pathology that is hard to treat with traditional approaches including oral anti-inflammatory medicine, physical therapy, and shock-wave treatment. corticosteroid injection could lead to tendon rupture, thus if conservative management fails then surgery is a last resort. This article presents a middle-female, who suffered Achilles tendinopathy symptoms for over 20 years, affecting her daily activity and sports life. She had tendon nodule clinically. Ultrasound scan (USS) showed diffuse thickening of the Achilles tendon at the mid-portion of the maximal sagittal diameter of 10 mm without a tendon tear. She failed conservative management, physiotherapy, and shock wave therapy. She elected for a single trial of investigational USS-guided platelet-rich plasma (PRP) therapy. She improved gradually by returning to completely normal daily activities and running/sprinting after one year of PRP therapy. Her tendon nodule resolved clinically, and a repeat USS showed reduced diffuse thickening of the Achilles tendon at the midportion of the maximal sagittal diameter down to 7mm suggestive of the healing process. Thanks to the regenerative restoration power of the growth factors and signalling proteins in platelets that stimulate the internal mesenchymal stem cells to promote the healing process. We recommend a comprehensive randomized control trial to approve those findings and standardization of the PRP technique, trusting regenerative medicine to develop as a mainstream therapy in several musculoskeletal pathologies, particularly in degenerative conditions and resistant injuries.

Treatment of Achilles insertional calcific tendinosis using alongitudinal midline incision approach/central tendon splitting approach

Treatment of Achilles insertional calcific tendinosis through alongitudinal midline incision approach with optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity). Calcific Achilles tendinosis, dorsal heel spur, insertional tendinosis. General medical contraindications to surgical interventions. Fracture, infection. Longitudinal skin incision medial of the Achilles tendon. Exposure and midline incision of the Achilles tendon with plantar detachment from the insertion site preserving medial and lateral attachment. Resection of adorsal heel spur and intratendinous calcifications. Optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity). Partial weight bearing 20 kg in 30° plantar flexion in along walker boot for 2weeks. Afterwards 2weeks of progressively weight bearing in 15° plantar flexion and another 2weeks in neutral ankle joint position in along walker boot. Atotal of 26feet of 26patients with calcific Achilles tendinosis were treated with midline incision of the tendon. In all feet calcific tendon parts were resected. In10 (38%) feet, aprominent dorsal spur was resected, in 12feet (38%) retrocalcaneal bursa, and in24 (92%) feet acalcaneal tuberosity. Mean follow-up was 34.5months (range2-64months). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 58.2 (±8.1) and postoperatively the score was 22.75 (±6.0). In all, 7 (26.9%) patients stated delayed wound healing; 1suffered from deep vein thrombosis. Shoe problems were reported by 50% of patients, and 23.1% suffered from par- or dysesthesia. No revision surgery was required.

Assessing the Accuracy, Quality, and Readability of Online Patient Resources on Achilles Tendonitis

Category: Other; Hindfoot Introduction/Purpose: The internet is full of websites focused on different medical topics. With such a large accumulation of information, patients should be able to rely upon the internet as a reliable source for information on common medical conditions such as Achilles tendonitis. However, the question remains as to the accuracy, quality and readability of such online patient resources. Consumers themselves commonly evaluate online medical sites by trustworthiness, expertise, and objectivity. The purpose of this study was to investigate the top search-engine-generated online resources for Achilles tendonitis for their content and accuracy. Methods: The term 'Achilles tendonitis' was searched using the three most population search engines. The first 50 sites from each search were recorded. Duplicate sites were eliminated. Sites were categorized based on authorship type. Each website was independently evaluated by two reviewers. Quality was evaluated utilizing the DISCERN score and the Journal of the American Medical Association (JAMA) benchmark criteria. Accuracy was evaluated using a novel Achilles tendinosis-specific content rubric developed with a foot and ankle fellowship-trained orthopaedic surgeon and the AAOS OrthoInfo webpage, similar to previous studies. Readability was evaluated using the Flesch Kincaid grade level (FKGL) and Flesch Reading Ease (FRE) formulas. Higher FRE scores indicate better readability. FKGL was also compared against an 8th grade level, which represents the average US reading level. Results: The search resulted in 77 unique websites with 60 sites included for analysis. The average DISCERN score in our investigation is 42.1 which places it in the 'fair' category. Commercial websites were found to have higher DISCERN scores as compared to websites created by physicians or medical groups as well as academic websites. Our study found an average JAMA quality benchmark score of 2.2 out of 4. Our study found that on average, online patient resources on Achilles tendinosis was written at a 9th grade reading level with a FKGL score of 9.8. Academic websites were found to be written at a significantly lower reading level of 8.8. The average FRE score was 53.28 which translates to the 'fairly difficult' category. Utilizing our own content scoring system to assess the accuracy of online resources, the websites had an average accuracy of 11.5 points out of 20 possible points. Conclusion: The average online patient resource on Achilles tendinosis is too complex for the average patient, inaccurate, and is of low quality. This study found that the average website had low quality as measured by the DISCERN and JAMA benchmark scores. The average accuracy was also low as measured by our novel content specific score. The websites were also difficult to read as measured by the FRE and FKGL scores. More emphasis on improving the readability, quality, and accuracy of online patient resources on Achilles tendinosis should be undertaken in order to improve patient healthcare.

Outcomes in Open and Endoscopic Treatment for Haglund's Syndrome and Insertional Achilles Tendinopathy

Category: Arthroscopy; Ankle; Hindfoot; Sports Introduction/Purpose: Haglund's syndrome is a common cause of posterior heel pain and can be associated with retrocalcaneal bursitis and degenerative Achilles tendinosis. Open approaches for resection of the Haglund's lesion have long been employed in patients that fail to improve with conservative treatment. This often involves partial elevation of the Achilles insertion with reattachment. More recently, endoscopic surgical techniques have evolved, enabling more rapid rehabilitation with less tendon disruption. The decision on the surgical approach is influenced by the degree of insertional Achilles tendinosis with endoscopic techniques preferred in the absence of insertional pathology. The primary objective of this investigation was to report on a large series of patients treated surgically for symptomatic Haglund's lesions. Methods: We reviewed the outcomes of Haglund's syndrome surgical cases at our institution over a five-year period. We included cases with insertional Achilles tendinosis and retrocalcaneal bursitis related to the Haglund's lesion, but excluded revisions and cases involving flexor hallucis longus tendon transfers. We recorded patient demographics, sport and activity level, comorbidities, BMI, duration of symptoms, surgical technique, tourniquet time, rehabilitation protocol, postoperative complications, and duration of postoperative follow-up. We also reviewed relevant preoperative imaging and recorded the presence of Achilles insertional degenerative calcification or an insertional calcaneal enthesophyte on radiographs. We then prospectively administered questionnaires regarding return to sport and patient-reported outcome measures including the SANE, PASS, VISA-A and PROMIS (Physical Function, Pain Interference and Global Health domains). Results: In total, 17 of the 77 (22%) included cases were performed with the endoscopic surgical technique. Six patients underwent bilateral Haglund surgeries during the study period, accounting for 12 of the 77 cases. The open Haglund resection group had a higher rate of concomitant Achilles insertional degenerative calcification on radiographs and MRI (72%). In addition, the open group was older than the endoscopic group (average age 54 vs 45), had a higher rate of comorbidities, higher rate of postoperative complications, and a higher rate of return to the operating room for revision surgery (11% vs 0% for endoscopic). Seventeen patients were elite distance running athletes and were preferentially treated by endoscopic techniques (11/17, 64%). At 24-month follow-up, the majority of patients report return to baseline activity. Conclusion: Patients treated surgically for Haglund's syndrome and insertional Achilles tendinopathy generally have good outcomes. Outcomes are better for endoscopically treated patients compared to open treatment, although these patients tend to be younger, healthier, and have less Achilles tendons disease. Still, some degree of Achilles tendinopathy and limited intrasubstance calcification can be successfully addressed with the endoscopic technique. We are endeavoring to better define indications for, and limitations of, the endoscopic technique for insertional Haglund's disease.

Treatment of Insertional Achilles Tendinosis With Polyurethane Urea-Based Matrix Augmentation.

Surgical treatment for insertional Achilles tendinosis (IAT) sometimes requires tendon repair augmentation. The purpose of this study is to evaluate the efficacy of polycaprolactone-based polyurethane urea (PUUR) matrix augmentation in the treatment of IAT. A retrospective review was performed in surgically treated IAT. Repairs were augmented with a PUUR matrix. Factors evaluated included date of full weightbearing, patient satisfaction, Visual Analog Scale (VAS) pain score, strength, and ankle motion. The Wilcoxon signed-rank test was used to compare baseline and final follow-up VAS scores. A total of 18 cases were included in the study. The mean patient age was 54.61 ± 8.25 (40-75) years with a mean follow-up of 163.61 ± 57.81 (92-314) days. Patient satisfaction was obtained on 15 of 18 patients, with 14 patients satisfied with their outcome. Mean VAS for pain significantly decreased from 6.19 ± 1.97 (2.5-9) to 0.83 ± 1.54 (0-5) postoperatively, which was statistically significant (P < .01). Achilles tendon augmentation with the PUUR matrix is a viable option in the treatment of IAT. Its use in this condition has minimal morbidity and can be an alternative to other forms of augmentation. Level IV: Retrospective case series.

Needle-based gastrocnemius lengthening: a novel ultrasound-guided noninvasive technique

BackgroundGastrocnemius tendon lengthening is performed to treat numerous conditions of the foot and ankle. Gastrocnemius shortening has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flat foot deformity, and metatarsalgia. Ultrasound-guided ultraminimally invasive lengthening of the gastrocnemius is a step forward in this type of surgery. It can be performed in both legs simultaneously without ischemia using only local anesthesia plus sedation and without the need for a cast or immobilization. The truly novel advantage of the procedure is that it can be performed in the office, without specific surgical instruments. The aim of our research was to prove the effectiveness and safety of a new closed needle-based ultrasound-guided surgical procedure for lengthening the gastrocnemius tendon.Methods and resultsWe performed ultrasound-guided gastrocnemius tendon lengthening using a needle in eight fresh frozen specimens (3 left and 5 right). None of the specimens had been affected by disease or undergone previous surgery that could have affected the surgical technique. We used a linear transducer with an 8- to 17-MHz linear transducer and the beveled tip of an Abbocath as a surgical blade to perform the lengthening procedure. The gastrocnemius Achilles tendon recession was entirely transected in all eight specimens, with no damage to the sural nerve or vessels. The improvement in dorsal flexion was 15°.ConclusionNeedle-based ultrasound-guided gastrocnemius tendon lengthening is safe, since the surgeon can see all structures clearly, thus minimizing the risk of damage. The absence of a wound obviates the need for stitches, and recovery seems to be faster. The procedure can be performed in a specialist's office, as no specific surgical instruments are required. This technique could be a valid option for gastrocnemius lengthening and may even be less traumatic than using a hook-knife, as in our previous description.

¿Puede tratarse la tendinosis aquílea de forma eficaz con lidocaína e infiltraciones de glucosa y, de ser así, es duradero su efecto? Estudio observacional longitudinal en 27 pacientes consecutivos

ObjectiveOur aim was to add to the small but growing body of evidence on the effectiveness of ultrasound-guided Achilles intratendinous hyperosmolar dextrose prolotherapy and introduce a novel, preceding step of paratenon hydrodissection with lidocaine in patients with chronic Achilles tendinosis resistant to rehabilitation therapy. MethodsWe conducted a longitudinal, observational study on 27 consecutive patients diagnosed with Achilles tendinosis, in whom conservative treatment, ie, physiotherapy or shock wave therapy, had failed. A 2% lidocaine paratenon anesthesia and hydrodissection was followed by ultrasound-guided, intratendinous injections of 25% glucose every 5 weeks. Visual analogue scales (VAS) were used for pain assessment at rest, for activities of daily living, and after moderate exercise at the begining and at the end of the treatment. Moreover, tendon thickness and vascularisation were recorded at baseline and final treatment consultation. Effectiveness was estimated from scoring and relative pain reduction using a 95% CI. The non-parametric Wilcoxon test and a general linear model for repeated measures were applied. Statistical significance was established as p<0.05. ResultsA median of 5 (1-11) injection consultations per patient were required. Pain scores decreased significantly in all three conditions (p<0.001). Relative reductions were 75% in pain at rest (95% CI;61-93%), 69% in pain with daily living activities (95% CI; 55-83%), and 70% in pain after moderate exercise (95% CI; 57-84%). Tendon neo-vascularisation was significantly reduced (p<0.001). We did not observe significant changes in tendon thickness (p=0.083). ConclusionsAchilles tendinosis treatment with paratenon lidocaine hydrodissection and subsequent prolotherapy with hyperosmolar glucose solution is safe, effective, inexpensive, and virtually painless with results maintained over time.

Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis.

While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT. A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups. No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund's deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012). Patients who received surgery for IAT were significantly more likely to have evidence of Haglund's deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients. Level III.