Achilles Tendon Insertion Research Articles

Measuring Achilles Tendon Length: A Simple and Reliable Method

BackgroundThe purpose of the study was to evaluate the inter-rater reliability of the Achilles tendon length (ATL) by use a simple US marker-based method. Methods and MaterialsBy the use of metal fine-wires placed between skin and transducer, distal Achilles tendon insertions and medial gastrocnemius myotendinous-junctions of 10 healthy subjects were detected, marked and finally, ATL was measured on the skin. Reliability was analysed between an experienced and an inexperienced examiner using Intraclass Correlation Coefficient (ICC, 2.1), Inter-Rater-Variability (IRV, %), Bland-Altman-analyses (Bias ± Limits of Agreement, [LoA]) and Standard-Error of Measurement (SEM, mm). ResultsResults revealed an ICC of 0.91, IRV of 3.1±2.5%, Bias ± LoA of -2.4±16.6mm and SEM of 5.7mm. ConclusionThe present novel method provides a reliable assessment of ATL in healthy subjects in a simple and time-efficient manner, independent of observer's experience.

Knotted Versus Knotless Suture Bridge Repair of the Achilles Tendon Insertion

Background: Surgical treatment of insertional Achilles tendinopathy often involves detachment and debridement of the Achilles tendon insertion. A recent study has shown that knotted suture bridge fixation of the Achilles to the calcaneus is biomechanically superior to single-row fixation, but there is an absence of literature on the use of different suture bridge constructs to repair the Achilles tendon. Hypothesis: There will be no significant difference in the load to failure, mode of failure, tendon strain, tendon stiffness, repair site gapping, or footprint size when comparing knotted suture bridge repair to knotless suture bridge repair of the Achilles tendon after detachment for insertional Achilles tendinopathy. Study Design: Controlled laboratory study. Methods: A single specimen from each pair of 10 cadaveric Achilles tendons was randomized to 1 of 2 Achilles insertion repair groups: knotted (n = 10) or knotless (n = 10) suture bridge repair. Repaired footprint size was measured, and then cyclic testing from 10 to 100 N for 2000 cycles was performed. This was followed by measurement of tendon strain, repair site displacement, load to failure, and tendon stiffness. Results: The knotted suture bridge repair had a significantly higher load to failure compared with the knotless suture bridge (mean ± SD, 317.8 ± 93.6 N vs 196.1 ± 12.1 N, respectively; P = .001). All constructs failed at the tendon-suture interface. Tendon strain after cyclic testing was significantly greater in the knotless (1.20 ± 1.05) compared with the knotted (0.39 ± 0.4) suture repair groups (P = .011). There was no significant difference in footprint size between the knotted (230.3 ± 63.3 mm2) and knotless (248.5 ± 48.8 mm2) groups (P = .40). There was also no significant difference in stiffness (knotted = 76.4 ± 8.0 N/mm; knotless = 69.6 ± 10.9 N/mm; P = .17) and repair site displacement after cyclic testing (knotted = 2.8 ± 1.2 mm; knotless = 3.6 ± 1.1 mm; P = .17). Conclusion: During suture bridge repair of the Achilles tendon after detachment, knots at the proximal suture anchors significantly improve the biomechanical strength of the repair. Clinical Relevance: This study demonstrated that the knotless suture bridge repair had a significantly lower load to failure than the knotted suture bridge. Surgeons should be aware of these biomechanical differences, as they influence the postoperative rehabilitation protocol and may lead to higher surgical complication rates.

Subtle cavus foot: diagnosis and management.

The subtle cavovarus foot (SCF) is a mild malalignment caused by either primary hindfoot varus or a plantarflexed first ray, resulting in a typical constellation of symptoms because of altered foot mechanics. Key clinical signs are a peek-a-boo heel and a positive Coleman block test. The cavovarus position places lateral ankle soft-tissue structures, such as the anterior talofibular ligament and the peroneal tendons, on stretch during normal gait. This can lead to common conditions such as lateral ankle instability, peroneal tendon tears, and stress fractures of the lateral metatarsals and cuboid. The gait cycle is altered because a greater proportion of time is spent with the transverse tarsal joints locked due to the overall varus foot position. In contradistinction to physiologic valgus at heel strike, which maintains the transverse tarsal joints unlocked and affords approximately 50% force dissipation, the increased rigidity of the foot causes a maldistribution of forces that leads to accelerated wear of the midfoot joints and increased stresses along the plantar fascia and the Achilles tendon insertion. Successful nonsurgical management requires correction of the biomechanical anomaly; surgical management of a subtle cavovarus foot typically is part of a comprehensive plan for correcting the symptoms and the malalignment.

AB0975 Power and Colour Doppler Findings in Lower Extremity Entheses of Healthy Children – Effect of Measurement Distance from Bone and Joint Position

BackgroundMusculoskeletal ultrasound has significant potential in the assessment of the pediatric entheses. Doppler signals at the site of tendon insertions are often considered as signs of pathology for enthesitis as...

AB0708 Differences in Localization and Activity of the Entheseal Involvement between Non-Radiographic and Radiographic Axial Spondyloarthritis by the Ultrasound Assessment

BackgroundPeripheral entheseal involvement seems to be an important sign of spondyloarthritis (SpA). It may occur in patients with long-term as well as newly diagnosed disease and in those with definite...

SAT0387 Ultrasonographic and Clinical Assessment of Peripheral Enthesitis in Italian Patients with Psoriatic Arthritis, Psoriasis and Fibromyalgia –The ULISSE Study

BackgroundEnthesitis in Spondylarthropathy (SpA) is underestimated and often misdiagnosed. A recent paper suggests that tenderness at entheseal sites by itself is not useful in distinguishing between psoriatic arthritis (PsA) and...

An anatomical and cadaveric study examining the risk of sural nerve injury in percutaneous Achilles tendon repair using the Achillon device.

Percutaneous Achilles tendon repairs are gaining in popularity. This study aims to quantify the risk of sural nerve injury when using the Achillon device. The Achillon device was instrumented into 15 cadaveric specimens and through dissection the rate of sural nerve puncture and the position of the sural nerve in relation to the Achilles tendon was documented. The sural nerve was found lateral to the Achilles tendon insertion point over a range of 14.3mm and crossed the lateral border of the Achilles tendon over a range of 57.7mm. The sural nerve was punctured a total of 6 times and in 4 out of 15 cadaveric specimens (27%). Four out of the 6 punctures occurred when the Achillon device was instrumented distally. The sural nerve displays a highly variable anatomical course and there is a risk of puncture during percutaneous Achilles tendon repair using the Achillon device.

Endoscopic-Assisted Achilles Tendon Reconstruction With Free Hamstring Tendon Autograft for Chronic Rupture of Achilles Tendon: Clinical and Isokinetic Evaluation

To evaluate the clinical and functional outcome of endoscopic-assisted reconstruction of chronic ruptures of the Achilles tendon using free hamstring tendon autograft. We present a case series of 15 patients who had chronic ruptures of the Achilles tendon (>6 weeks earlier) and underwent endoscopic-assisted reconstruction with a free hamstring autograft. The graft loop was passed through and fixed to the proximal stump of the tendon. The graft was then passed through suture to the distal stump and finally inserted into a tunnel in the anterior calcaneus to the Achilles tendon insertion and fixed with an bioabsorbable interference screw. The mean follow-up period was 27 months (SD, 3 months; range, 24 to 33 months). All patients underwent magnetic resonance imaging preoperatively, immediately postoperatively, and at follow-up 2 years postoperatively. All patients were functionally evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score for the hindfoot preoperatively and postoperatively. Calf muscle power was evaluated by isokinetic strength testing at 2 years' follow-up. The mean size of the gap on preoperative magnetic resonance imaging was 49 mm (SD, 9 mm). The mean preoperative AOFAS score was 32.6 (SD, 7.5). There was a statistically significant improvement in the postoperative AOFAS score after 2 years to 90.8 (SD, 3.54) (P < .05). The mean time of return to all daily activities (except running and other sports) was 12.6 weeks (SD, 1.39 weeks). Isokinetic testing showed a nonsignificant deficit (<10%) between the involved and uninvolved plantar flexors and dorsiflexors with regard to peak torque, average power, and total work. Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon autograft for chronic ruptures of the Achilles tendon showed good to excellent results in all patients. Isokinetic testing showed a nonsignificant deficit between the involved and uninvolved sides at 2 years' follow-up. Level IV, therapeutic cases series.

The Use of Dry Needling and Myofascial Meridians in a Case of Plantar Fasciitis

ObjectiveThe purpose of this case report is to describe the use of dry needling based on myofascial meridians for management of plantar fasciitis. Clinical featuresA 53-year-old man presented with bilateral chronic foot pain for more than 2 years. After 2 months of conventional treatment (ultrasound, plantar fascia and Achilles tendon stretching, and intrinsic foot strengthening), symptoms eventually improved; however, symptoms returned after prolonged standing or walking. Almost all previous treatment methods were localized in the site of pain that targeted only the plantar fascia. Initial examination of this individual revealed that multiple tender points were found along the insertion of Achilles tendon, medial gastrocnemius, biceps femoris, semimembranosus, and ischial tuberosity. Intervention and outcomeDry needling of the trigger points was applied. After 4 treatments over 2 weeks, the patient felt a 60% to 70% reduction in pain. His pressure pain threshold was increased, and pain was alleviated. The patient returned to full daily activities. The rapid relief of this patient’s pain after 2 weeks of dry needling to additional locations along the superficial back line suggests that a more global view on management was beneficial to this patient. ConclusionDry needling based on myofascial meridians improved the symptoms for a patient with recurrent plantar fasciitis.

A29: Power and Colour Doppler Findings in Lower Extremity Entheses of Healthy Children—Effect of Measurement Distance from Insertion and Joint Position

Background/Purpose:Musculoskeletal ultrasound has significant potential in the assessment of the pediatric entheses. Doppler signals at the site of tendon insertions are often considered as signs of pathology for enthesitis as well as apophysitis. The normal pediatric enthesis can nevertheless exhibit Doppler signals as well and this might be especially relevant during periods of rapid growth with increased mechanical strain. Limited and partially confliciting data is available for Doppler charactistics of the normal pediatric enthesis. This may be due to technical factors, variable definitions of the anatomic location of the enthesis and variable positioning of the patient. The aim of this study was to examine relevant entheses of the knee and ankle joint in healthy children at the peak of linear growth and determine the effect of measurement distance from the insertion and position of the joint.Methods:35 males and females with an age range of 11–14 years volunteered for this study. All participants were free of musculoskeletal symptoms, medical conditions or medication affecting the MSK system, MSK injuries in the past three months and did not participate in sports more than three times per week. The Insertion of the Quadriceps tendon into the patella, the proximal and distal patella tendon insertion and the Achilles tendon insertion were examined with standardized settings in Power as well as Colour Doppler Ultrasound using an Esaote Mylab 70 XVG Gold machine with a linear probe ranging from 6 to 18 MHz. Both extremities were assessed in neutral as well as 30 degrees flexion. All images were acquired by a single examiner and read by two readers. A subset of volunteers was reassessed 2 days later. On all images the presence of Doppler signals was assessed directly at the bone/cartilage interface as well as within a distance of 2mm, 5mm and 10mm.Results:No Doppler signals were seen directly at the bone/cartilage surface in any of the enthesis. The highest prevalence of signals was found in the quadriceps tendon. Comparing neutral with 30 degrees flexion 30% vs. 40% of participants displayed Doppler signals within 10 mm of the insertion, 30% vs. 35% within 5 mm and 20% vs. 10% within 2 mm. A similar percentage of Doppler signals was seen within 2 mm of the tibial tuberosity although with 10% of volunteers displaying signals in neutral vs 20% in flexed position. At 10 mm distance these percentages were 30 % in flexed vs 20% in neutral position. In contrast no Doppler signals were seen at the insertion of the proximal Patella tendon and the Achilles tendon. No significant differences were seen between Colour and Power Doppler.Conclusion:The specificity of Doppler findings in Apophysitis or Enthesitis is expected to be much higher in the proximal Patella tendon and Achilles tendon than in other entheses. At all Entheses Doppler signals very close to the bone/cartilage surfaces are rarely observed in healthy children. In contrast, the tendon insertions at the proximal patella and the tibial tuberosity display a high prevalence of Doppler signals at a distance of more than 2 mm from the insertion possibly related to mechanical strain occurring physiologically. In order to increase sensitivity the exam should be performed in various positions of the joint.

Button Fixation Technique for Achilles Tendon Reinsertion: A Biomechanical Study

Chronic insertional tendinopathy of the Achilles tendon is a frequent and disabling pathologic entity. Operative treatment is indicated for patients for whom nonoperative management has failed. The treatment can consist of the complete detachment of the tendon insertion and extensive debridement. We biomechanically tested a new operative technique that uses buttons for fixation of the Achilles tendon insertion on the posterior calcaneal tuberosity and compared it with 2 standard bone anchor techniques. A total of 40 fresh-frozen cadaver specimens were used to compare 3 fixation techniques for reinserting the Achilles tendon: single row anchors, double row anchors, and buttons. The ultimate loads and failure mechanisms were recorded. The button assembly (median load 764 N, range 713 to 888) yielded a median fixation strength equal to 202% (range 137% to 251%) of that obtained with the double row anchors (median load 412 N, range 301 to 571) and 255% (range 213% to 317%) of that obtained with the single row anchors (median load 338 N, range 241 to 433N). The most common failure mechanisms were suture breakage with the buttons (55%) and pull out of the implant with the double row (70%) and single row (85%) anchors. The results of the present biomechanical cadaver study have shown that Achilles tendon reinsertion fixation using the button technique provides superior pull out strength than the bone anchors tested.

Bilateral Kalkeneal Apofiziti Bulunan Bir Olgunun MRG Bulguları

Calcaneal apophysitis (CA) is the most common cause of heel pain in patients before the ossification of calcaneal epiphysis. We report magnetic resonance imaging (MRI) findings of a case with bilateral CA. A 9 year-old male patient with bilateral foot pain was referred to our department for MRI. On bilateral foot MRI, bilateral decreased signal intensity on T1-weighted images, increased signal intensity on fat suppressed T2-weighted images that represents edema, subchondral erosions located tuber calcanei, insertion of Achilles tendon were detected. The diagnosis was bilateral calcaneal apophysitis. Sever's disease or CA is an inflammation of the calcaneal apophysis believed to be caused by repetitive microtrauma from the traction of the Achilles tendon on the unossified apophysis. It frequently occurs before or during the peak growth spurt and often shortly after a child begins a new sport or season. It is usually seen among 8-15 age group. Patients typically have no features such as swelling, skin changes, erythema, or other local abnormalities. Osseous erosion at metaphysis of the neighboring to calcaneal apophysis is the finding of CA on MRI. Similar signal difference may be seen at the secondary apophysial ossification centers.

Ultrasound and Color Doppler-Guided Surgery for Insertional Achilles Tendinopathy-Results of a Pilot Study

Background: Treatment of insertional achilles tendinopathy is known to be difficult. Eccentric calf muscle exercises and extracorporeal shockwave therapy have been proposed as the primary treatments for this condition, but surgery is indicated after failed conservative management. There is no consensus about the most efficient surgical treatment. Objectives: To evaluate a new ultrasound and color Doppler-guided surgical treatment for insertional achilles tendinopathy. Patients and methods: 24 consecutive patients (13 men and 11 women, mean age 47 years) with a long duration of insertional achilles tendon pain (median 18 months) were included in the study. The surgical procedure consisted of extirpation of the subcutaneous and retrocalcaneal bursa, scraping of the ventral distal achilles tendon and removal of prominent bone at the upper calcaneal tuberosity (Haglund’s deformity). In 13 patients, the plantaris tendon was also cut and excised. VAS for pain during activity, satisfaction with the treatment result and the SF-36 score to measure quality of life were used for evaluation. Results: The mean VAS had decreased from 72 before surgery to 19 after surgery (p 0.001), and 20/24 (83%) patients were satisfied with the result and had returned to full tendon loading activity at the one-year follow-up. The SF-36 score had improved significantly. Conclusion: Ultrasound and color Doppler-guided surgical treatment seems to be a good method for treatment of chronic painful insertional achilles tendinopathy. Longer follow-up studies on larger materials are needed.

THE DIAGNOSTIC VALUE OF CLINICAL EXAMINATION AND ULTRASOUND STUDY OF ENTHESES FOR EARLY DETECTION OF PSORIATIC AND RHEUMATOID ARTHRITIS: REMARC STUDY

The diagnosis of enthesitis can help in differentiating early psoriatic arthritis (ePsA) from early rheumatoid arthritis (eRA). Objective. To estimate the diagnostic value of detecting enthesitis during clinical examination and ultrasound in ePsA and eRA. Subjects and methods. The trial included 36 patients with ePsA and 33 with eRA. Entheses were evaluated using the Leeds Enthesitis Index (LEI): lateral humeral epicondyle and medial femoral condyle (MFC), Achilles tendon insertion site (ATAP), and plantar fascia (PF) point on the right and on the left. Enthesitis (on ultrasound) presented with thickening, reduced echo density, and vascularization at Doppler energy imaging. DAS, DAS28, SDAI, CDAI, M±SD, Me [25th, 75th percentile], t-test, Fisher's exact test, χ2test, U test, and Spearman correlation coefficients (R) were calculated; the value p 0.05). No significant differences were found between ePsA and eRA according to LEI (0.5 [0; 2] and 1 [0; 2] and to LEI+PF (1 [0; 2] and 1 [0; 2], respectively). Enthesitis of MFC and PF was significantly more frequently detected in ePsA than in eRA – 12 (33.3%)/2 (6.1%) and 10 (27.8%)/2 (6.1%) patients, respectively. In eRA versus ePsA, enthesitis of MFC was more frequently found (16 (48.4%) and 8 (22.2%) patients), respectively. Ultrasound revealed no significant differences between the groups in enthesitis. In ePsA, there was a significant correlation between DAS, DAS28, SDAI, CDAI, LEI, and LEI+PF. Conclusion. Enthesis ultrasound cannot differentiate ePsA from eRA. Clinical examination more frequently detects enthesitis in the knee joints in eRA and in the calcaneal region in ePsA.

Correlations among enthesitis, clinical, radiographic and quality of life parameters in patients with ankylosing spondylitis

Objectives. To investigate the relationship between enthesitis and disease activity, functional status, fatigue, joint mobility, radiological damage, laboratory parameter and quality of life in patients with ankylosing spondylitis (AS).Methods. A total of 421 patients with AS (323 male and 98 female) who were included in the Turkish League Against Rheumatism Registry were enrolled in the study. The Bath AS Disease Activity Index (BASDAI), fatigue, the Bath AS Functional Index (BASFI), the Bath AS Metrology Index (BASMI), the Maastricht AS Enthesitis Score (MASES), AS quality of life (ASQoL), the Bath AS Radiology Index (BASRI) and erythrocyte sedimentation rate (ESR) were evaluated.Results. Enthesitis was detected in 27.3% of patients. There were positive correlations between MASES and BASDAI, BASFI and fatigue (p < 0.05). MASES was not correlated with BASRI, BASMI, ASQoL and ESR. The mean MASES score was 1.1 ± 2.4. The most frequent regions of enthesopathies were right iliac crest, spinous process of L5 and proximal to the insertion of left achilles tendon, respectively.Conclusions. Enthesitis was found to be associated with higher disease activity, higher fatigue, worse functional status and lower disease duration. As enthesitis was correlated with BASDAI, we conclude that enthesitis can reflect the disease activity in patients with AS.

Chronic Tibialis Anterior Tendon Tear Treated With an Achilles Tendon Allograft Technique

Tibialis anterior tendon tear is an uncommon injury. Nontraumatic or degenerative tears are usually seen in the avascular zone of the tendon. Treatment can be conservative or surgical. Conservative treatment is adequate for low-demand older patients. For active patients, surgical treatment can be challenging for the surgeon because after debridement of degenerative tissue, a gap may be formed that can make side-to-side suture impossible. The authors present allograft Achilles tendon insertion for reconstruction of chronic degenerative tears. Using Achilles tendon allograft has the advantage of bone-to-bone fixation, allowing rapid incorporation and earlier full weight bearing.

The Effect of the Achilles Tendon on Trabecular Structure in the Primate Calcaneus

Humans possess the longest Achilles tendon relative to total muscle length of any primate, an anatomy that is beneficial for bipedal locomotion. Reconstructing the evolutionary history of the Achilles tendon has been challenging, in part because soft tissue does not fossilize. The only skeletal evidence for Achilles tendon anatomy in extinct taxa is the insertion site on the calcaneal tuber, which is rarely preserved in the fossil record and, when present, is equivocal for reconstructing tendon morphology. In this study, we used high-resolution three-dimensional microcomputed tomography (micro-CT) to quantify the microstructure of the trabecular bone underlying the Achilles tendon insertion site in baboons, gibbons, chimpanzees, and humans to test the hypothesis that trabecular orientation differs among primates with different tendon morphologies. Surprisingly, despite their very different Achilles tendon lengths, we were unable to find differences between the trabecular properties of chimpanzee and human calcanei in this specific region. There were regional differences within the calcaneus in the degree of anisotropy (DA) in both chimpanzees and humans, though the patterns were similar between the two species (higher DA inferiorly in the calcaneal tuber). Our results suggest that while trabecular bone within the calcaneus varies, it does not respond to the variation of Achilles tendon morphology across taxa in the way we hypothesized. These results imply that internal bone architecture may not be informative for reconstructing Achilles tendon anatomy in early hominins.

AB0901 Spondyloarthritis research consortium of canada (SAPRCC) enthesitis index in turkish as patients

BackgroundEnthesitis is one of the assessment parameters of the patients with Ankylosing spondylitis (AS). Many indexes are used in the evaluation of the severity of enthesitis and there are several...

SAT0261 Correlations among enthesitis, clinical, radiographic and quality of life parameters in patients with ankylosing spondylitis

BackgroundEnthesitis is a primary clinical feature in Ankylosing spondylitis (AS). It is an inflammatory process that affects the site of insertion of ligaments and tendons into bone. Elevated enthesitis scores...

OP0165 Whole-body MRI for assessment of enthesitis in psoriatic arthritis, axial spondyloarthritis and healthy subjects – a comparison with 7 clinical enthesitis indices

BackgroundTender entheses is a common disease manifestation in patients with psoriatic arthritis (PsA) and spondyloarthritis (SpA). Whole-body MRI (WBMRI) is a new imaging modality where patients are scanned from “head...