Mid-portion Achilles Tendon Research Articles

Poor association between tendon structure and self-reported symptoms following conservative management in active soldiers with mid-portion Achilles tendinopathy

IntroductionMid-portion Achilles tendinopathy (mid-AT) is currently the preferred term for persistent Achilles tendon pain, defined as located 2–7 cm proximal to the calcaneus, and with loss of function related to...

Significant functional impairment and disability in individuals with psoriatic arthritis and Achilles tendon pain: a cross-sectional observational study

The Achilles tendon (AT) insertion is the most common site of enthesitis in psoriatic arthritis (PsA). The structure and function of the AT in PsA, and the prevalence of mid-portion pathology, is unknown. To compare the structure and function of the AT in people with PsA with self-reported AT pain (PsA + AT), PsA without self-reported AT pain (PsA-AT) and healthy controls. A cross-sectional, observational study was conducted. The ATs were assessed by clinical and US examination (B-mode and Power Doppler), performance-based testing (bilateral heel raise test (HRT) and 10 m walk test), and patient-reported outcome measures (PROMs) (including the Victorian Institute of Sport Assessment-Achilles [VISA-A]). Between-group differences were described using descriptive statistics, Chi-squared testing, parametric (1-way ANOVA) and non-parametric (Mann-Whitney or Kruskal-Wallis) testing. 22 PsA (11 per group) and 11 healthy control participants who were comparable in terms of sex, age, and BMI (PsA-AT = longer PsA disease duration) were recruited. VISA-A scores were significantly worse in the PsA + AT group compared to the PsA-AT group and healthy controls (p < 0.001). Inflammatory US features were significantly more prevalent in the PsA + AT group (p < 0.001). Mid-portion AT pathology was observed in the PsA + AT group, irrespective of entheseal disease. Clinical examination alone missed 5/7 cases of ‘active’ US-confirmed AT enthesitis. AT functional deficits were significant in the PsA + AT group and both PsA groups had lower HRT repetition rates and walked slower compared to healthy controls. Less than 1/3 of the PsA + AT group had received podiatry or physiotherapy care. Significant differences in the structure and function of the AT in PsA were noted. Despite management in line with current guidance, AT pain appears to persist and can result in severe functional impairment.

Autologous bone marrow derived mesenchymal stem cells are safe for the treatment of Achilles tendinopathy

Achilles tendinopathy is a disabling condition that affects more than 50% of runners. Pre-clinical studies in a large animal model of naturally-occurring tendinopathy similar to human Achilles tendinopathy has shown benefits of autologous bone marrow-derived mesenchymal stem cell (MSC) implantation. However, MSCs are advanced therapies medicinal products (ATMPs), with strict regulatory requirements. Guided by the regulator we carried out a first in man study to assess the safety and efficacy of autologous MSC injection in human patients with non-insertional Achilles tendinopathy. Ten patients, mean age 47 with mid-portion Achilles tendon pain and swelling for more than 6 months, underwent autologous cultured cell injections (median 12.2 × 106, range 5–19 × 106 cells) into their Achilles tendon. At 24 weeks follow-up, no serious adverse reactions or important medical events were observed. MOXFQ, EQ-5D-5L, and VISA-A scores improved clinically at 12 and 24 weeks. VAS pain improved increasingly at 6, 12 and 24 weeks. MOXFQ Pain and VISA-A Scores improved > 12 points from baseline to 24 weeks in 8 patients. Maximum anteroposterior tendon thickness as measured by greyscale US decreased by mean 0.8 mm at 24 weeks. This phase IIa study demonstrated the safety of autologous MSC injection for non-insertional Achilles tendinopathy and provides proof-of-concept of the technique in patients, all of whom had previously failed conservative treatments for chronic disease and leads the way for a larger randomised controlled trial.

Tendinopathic Plantaris but Normal Achilles Tendon Found in About One-Fifth of Patients Not Responding to Conservative Achilles Tendon Management - Results from a Prospective WALANT Surgical Case Series on 105 Tendons.

Midportion Achilles tendinopathy is a relatively common condition. This study aimed to investigate the presence of a normal Achilles tendon, but a tendinopathic plantaris tendon, in a large and consecutive prospective sample of patients referred to a specialised tendon clinic for midportion Achilles tendon pain not responding to non-surgical treatment. A total of 105 consecutive tendons were operated on in 81 patients (62 males) suffering from painful midportion Achilles tendon pain. Clinical examination, ultrasound (US) and colour Doppler (CD) examination, and wide awake local anaesthetic no tourniquet (WALANT) surgery were performed in all patients. For 19/105 (18%) tendons from 14 patients, clinical examination suspected plantaris tendinopathy alone as there was a distinct tenderness on the medial side, but no thickening of the Achilles tendon. US examination followed by surgery confirmed the diagnosis. Midportion Achilles tendon pain is not always related to Achilles tendinopathy since pain related to the plantaris tendon alone was found in almost every fifth patient. Consequently, there is an obvious need for proper examination to identify the pain source and establish a correct diagnosis before treatment.

P072 Significant functional impairment and disability in individuals with psoriatic arthritis and Achilles tendon pain

Abstract Background/Aims Enthesitis is a hallmark clinical feature of psoriatic arthritis (PsA) with the most commonly affected site being the Achilles tendon (AT) insertion into the posterior calcaneum. There is overlap in the clinical and ultrasound (US) pathological presentation of Achilles enthesitis and Achilles tendinopathy, however their treatment guidelines differ significantly. AT pain in PsA is complex, with the potential interplay of mechanobiology and inflammation. The aim of this study was to assess the structure and function of the AT in individuals with PsA to inform the future development of a non-pharmacological intervention. Methods A single-centre, cross-sectional observational study was conducted. People with PsA with (PsA+AT) and without (PsA-AT) AT pain were age and sex-matched with healthy controls (n = 11 per group). AT structure and function were assessed by clinical examination (Leeds Enthesitis Index and AT tendinopathy tests), B-mode and Power Doppler (PD) US, the Victorian Institute of Sports Assessment - Achilles (VISA-A) questionnaire, the bilateral heel raise test and 10-metre walk test (10MWT). Patient-reported outcome measures were used to evaluate local and global disease activity, impact, and quality of life. Group membership associations and between-group differences for domains of interest were evaluated using Pearson’s Chi-squared, one-way ANOVA, Mann-Whitney or Kruskal-Wallis tests. Results All groups were comparable in terms of sex, age and BMI. PsA disease duration was longer in the PsA-AT group (mean [SD], 20.1 years [13.1]) compared to the PsA+AT group (7.4 [6.3]). Structural changes at the enthesis on US were detected in all groups; however inflammatory features were significantly more prevalent in the PsA+AT group (p&amp;lt;0.001). PD signal was only detected in the PsA+AT group. Mid-portion and myotendinous AT pathology, including diffuse thickening, altered echogenicity and partial tears were also present, irrespective of the presence of enthesitis. PsAID-12 and HAQ-DI scores were significantly worse in the PsA+AT compared to the PsA-AT group (p=0.018 and p=0.001, respectively). The PsA+AT group walked slower (mean=17.89 seconds for 10MWT) compared to the PsA-AT group (12.23) and controls (11.55), could perform significantly less heel raises until the point of fatigue (PsA+AT mean=19.45, PsA-AT=39.18, controls=51.55, p=0.007) and had significantly worse VISA-A scores (PsA+AT mean=33, PsA-AT=71, controls=92, p&amp;lt;0.001), indicative of impaired AT function. In the PsA+AT group, AT pain was persistent and disabling despite pharmacological management in line with current guidelines and &amp;lt;30% had received treatment from podiatry or physiotherapy services. Conclusion People with PsA and AT pain exhibit severe functional limitations as demonstrated by the bilateral heel raise test, 10MWT and VISA-A scores. The diversity of US imaging features detected, and the inconsistencies in treatment provided, highlights an opportunity to develop individualised non-pharmacological management strategies stratified by US features and performance-based testing. Disclosure A. Patience: None. M.P. Steultjens: None. S. Siebert: None. G.J. Hendry: None.

Intra- and Inter-Rater Reliability of Processing Ultrasound Tissue Characterization Scans in Midportion Achilles Tendinopathy.

Ultrasound tissue characterization (UTC) is used to visualize and quantify the Achilles tendon structure. We investigated the intra-rater and inter-rater reliability of UTC for quantifying the midportion tendon structure and the area of maximum degeneration (AoMD) in military personnel with midportion Achilles tendinopathy. UTC scans of 50 patients (16-60 years) were processed twice by rater 1 and once by rater 2. First, the midportion tendon structure was quantified and subsequently the AoMD. The intraclass correlation coefficient (ICC) was calculated for echo-types I, II, III, IV, aligned fibrillar structure (echo-types I + II), and disorganized tendon structure (echo-types III + IV). For midportion tendon structure, all ICC values were excellent for intra-rater reliability (range: 0.97 to 0.99) and inter-rater reliability (range: 0.98 to 0.99). Regarding the AoMD, intra-rater reliability showed excellent ICC values for all echo-types (range: 0.94 to 0.98) except for echo-type II (0.85). Inter-rater reliability showed excellent ICC values for all echo-types (range: 0.92 to 0.98). Processing of UTC scans is highly reliable in quantifying the midportion Achilles tendon structure and the AoMD.

Sharp pain in a normal Achilles tendon of a professional female football player was related to a plantaris tendon in a rare position: a case report

BackgroundPlantaris tendinopathy and plantaris-associated Achilles tendinopathy can be responsible for chronic pain in the Achilles tendon midportion, often accompanied by medial tenderness. As conservative treatments are less successful for this patient group, proper diagnosis is important for decision making. This report presents a case with plantaris tendinopathy in a rare (superficial) location.Case presentationThis article describes a pain history and treatment timeline of a professional Swedish female soccer player (32 years old, Northern European ethnicity, white) who suffered from sharp pain in the Achilles tendon midportion and tenderness on the medial and superficial side for about 2 years. Conservative treatments, including eccentric exercises, were not successful and, to some extent, even caused additional irritation in that region. Ultrasound showed a wide and thick plantaris tendon located on the superficial side of the Achilles tendon midportion. The patient was surgically treated with local removal of the plantaris tendon. After surgery there was a relatively quick (4–6 weeks) rehabilitation, with immediate weight bearing, gradual increased loading, and return to running activities after 4 weeks. At follow-up at 8 weeks, the patient was running and had not experienced any further episodes of sharp pain during change of direction or sprinting.ConclusionsThe plantaris tendon should be considered as a possible source of Achilles tendon pain. This case study demonstrates that the plantaris tendon can be found in unexpected (superficial) positions and needs to be carefully visualized during clinical and imaging examinations.

Arthroscopic Flexor Halluces Longus Transfer and Percutaneous Achilles Tendon Repair for Distal Traumatic Ruptures

The Achilles tendon is the largest and strongest tendon in the human body. It is the tendon that most often suffers injury and accounts for 20% of all tendon ruptures. These types of ruptures often occur 2 to 6 cm proximal to the stumps in an area of reduced vascularity. One such injury, the distal acute Achilles tendon rupture, is quite uncommon. For distal repairs, there have been studies that used a pullout technique, a button technique, and the use of local tendons for open-fashion augmentation. Although percutaneous repair and endoscopic flexor hallucis longus (FHL) tendon transfer techniques have been described for both acute midportion and chronic Achilles tendon rupture repair, there are no studies that describe the use of percutaneous sutures and biological augmentation with FHL transfer as a treatment option for acute distal injuries. The purpose of this Technical Note is to describe a novel approach to repair. It combines arthroscopic FHL tendon transfer with a percutaneous Achilles tendon repair technique for traumatic distal ruptures.

Repair of acute Achilles tears with plantaris augmentation.

To determine the benefits associated with using the fanned out plantaris tendon as a membrane to cover and augment the acute Achilles tendon midportion end-to-end suture repair. Between 2014 and 2018, 31 (67.4%) patients had plantaris augmented reconstruction and 15 simple end-to-end suture. The clinician filled out the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale and the patient the Achilles tendon total rupture score (ATRS). Examination included clinical examination, limb symmetry index (LSI) using the heel rise test, and ultrasound determination of cross-sectional area (CSA). 80.4% were males, mean age 41 (SD 6.7, range 29-57), of which 82.6% were sports accidents. 39/46 were operated in less than two weeks from injury. 82.6% were available at the two year follow-up. Duration of surgery (62.3min vs 58, p = 0.45), AOFAS (89.6 vs 88.4, p = 0.61 and 97.2 vs 96.8, p = 0.72), ATRS (86.3 vs 83.8, p = 0.33 and 95.6 vs 93.6, p = 0.12), LSI (60.8% vs 58.75, p = 0.24 and 80.5 vs 79, p = 0.29), CSA (3.39cm2 vs 3.36, p = 0.82 and 2.57 vs 2.59, p = 0.87), return to sport (80% vs 57, p = 0.15 and 84.6 vs 85.7, p = 1.00), and complications at sixmonths and twoyears were comparable between the two techniques. Fanned out plantaris augmentation of acute Achilles tendon tears yields excellent and comparable clinical and ultrasonographic results to end-to-end suture at mid-term follow-up.

Minimum 3.5-year outcomes of operative treatment for Achilles tendon partial tears in the midportion and retrocalcaneal area

BackgroundAchilles tendon partial tears are not easy to diagnose and to manage. Most frequently, they are located in the midportion and insertional area. These entities result from different pathologic pathways, and different treatment strategies are applied. The outcome is rarely investigated.MethodsThis study includes patients who underwent surgery for partial tears in the midportion or retrocalcaneal Achilles tendon area between the years 2009 and 2015 by a single surgeon. Patients were prospectively assessed preoperatively and 3, 6, and 12 months postoperatively, using the VISA-A-G questionnaire. The final retrospective follow-up was performed after a minimum of 3.5 years postoperatively. Forty-eight Achilles tendon partial tears at the level of the retrocalcaneal bursa (impingement lesions) and 27 midportion Achilles tendon partial tears were identified. After applying rigorous exclusion criteria, 21 and 16 cases, respectively, remained for the final follow-up. Results were analysed by inferential and descriptive statistics.ResultsThe VISA-A-G outcome scores improved significantly from preoperative to 6 months, 12 months, and final postoperative assessment. Preoperatively, the average VISA-A-G score was 42.1 (range, 18–73) for patients operated for Achilles tendon partial tears at the level of the retrocalcaneal bursa and 44.6 (range, 10–73) for the midportion Achilles tendon partial tear group, respectively. At final follow-up 88.8 (range, 15 to 100) and 96.9 (range, 71 to 100) were scored in the respective treatment groups. A repeated measures ANOVA determined that mean performance levels showed a statistically significant difference between measurements (p < 0.001). There was no systematic effect found between groups (p = 0.836).ConclusionsIn Achilles tendon partial tears recalcitrant to conservative treatment, operative intervention is highly successful in most cases, irrespective of the level of the injury. Results were statistically equal when comparing the midportion and retrocalcaneal Achilles tendon partial tear groups.Trial registrationDRKS, DRKS00014266. Registered 06 April 2018. ‘Retrospectively registered’, https://www.drks.de/drks_web/navigate.do?navigationId=results.

Considerations for multi-centre conditioned pain modulation (CPM) research; an investigation of the inter-rater reliability, level of agreement and confounders for the Achilles tendon and Triceps Surae.

This study aimed to investigate the inter-rater reliability of the conditioned pain modulation (CPM) effect. The reliability between two examiners assessing the CPM effect via pressure pain thresholds and induced using the cold pressor test of 28 healthy volunteers at the mid-portion Achilles tendon (AT) and Triceps Surae musculotendinous junction was performed. Reliability was calculated using intraclass correlation coefficient (ICC). Confounders were assessed using multivariable generalised estimating equations (GEEs). Bias in the level of agreement was assumed if the confidence intervals (CIs) of the mean difference in Bland-Altman plots did not cross the line of equality. The inter-rater reliability of the CPM effect was poor to moderate in the AT (ICC 95% CI = 0.00-0.66) and Triceps Surae (ICC 95% CI = 0.00-0.69). However, when accounting for confounders within the GEE, there were no differences between testers and Bland-Altman plots reported good agreement between testers. Habitual completion of running-related physical activity was a confounder for both the AT parallel-paradigm (p = 0.017) and sequential-paradigm (p = 0.029). Testing order was a confounder for the AT (p = 0.023) and Triceps Surae (p = 0.014) parallel-paradigm. This study suggests the CPM effect may be site specific (i.e. differences between the AT and Triceps Surae exist). In addition, differences in the reliability between examiners are likely due to the influence of confounders and not examiner technique and therefore appropriate analysis should be used in research investigating the CPM effect.

The interrater reliability of ultrasonography for Achilles tendon structure.

Aim of the studyReliable assessment of Achilles tendon structure (architecture and morphology) may help prevent clinical symptoms or progression of Achilles tendinopathy. The objective of this study was to determine the interrater reliability of musculoskeletal ultrasonography for the assessment of the mid-portion of the Achilles tendon: (1) structure, (2) anteroposterior diameter and (3) neovascularization, in asymptomatic military personnel.Material and methodsTwo sonographers acquired B-mode images of the Achilles tendon mid-portion in 74 volunteers (148 tendons) in short-axis and long-axis planes to assess its structure and measure the maximum anteroposterior diameter. Power Doppler ultrasound was performed to assess neovascularization. Tendon structure and neovascularization were graded using a modified four-graded Öhberg score.ResultsWeighted kappa for assessing tendon structure showed almost perfect agreement (0.87; 95% CI: 0.79, 0.95). Spearman’s rho showed: a very high positive interobserver correlation for tendon structure (0.92; 95% CI: 0.89, 0.94), a very high positive interobserver correlation for the diameter measurement in the short-axis plane (0.91; 95% CI: 0.87, 0.93) and a high positive interobserver correlation in the long-axis plane (0.87; 95% CI: 0.83, 0.91). The Wilcoxon signed-rank test showed no significant differences between observers during diameter measurements (p value >0.05). Both sonographers reported absent neovascularization in all the subjects, resulting in overall Öhberg score of 0.Conclusions(1) Interrater reliability of ultrasonography for grading the mid-portion Achilles tendon structure shows almost perfect agreement, and (2) ultrasonography is highly reliable in measuring the anteroposterior diameter. (3) In a large group of asymptomatic service members neovascularization of the Achilles tendon is consistently absent.

Achilles tendon morphology assessed using image based spatial frequency analysis is altered among healthy elite adolescent athletes compared to recreationally active controls

ObjectivesAlthough expected, tendon adaptations in adolescent elite athletes have been underreported. Morphologically, adaptations may occur by an increase in collagen fiber density and/or organization. These characteristics can be captured using spatial frequency parameters extracted from ultrasound images. This study aims to compare Achilles tendon (AT) morphology among sports-specific cohorts of elite adolescent athletes and to compare these findings to recreationally active controls by use of spatial frequency analysis. DesignCross-sectional observational study. MethodIn total, 334 healthy adolescent athletes from four sport categories (ball, combat, endurance, explosive strength) and 35 healthy controls were included. Longitudinal ultrasound scans were performed at the AT insertion and midportion. Intra-tendinous-morphology was quantified by performing spatial frequency analysis assessing eight parameters at standardized ROIs. Increased values in five parameters suggest a higher structural organization, and in two parameters higher fiber density. One parameter represents a quotient combining both organization and fiber density. ResultsAmong athletes, only ball sport athletes exhibited an increase in one summative parameter at pre-insertion site compared to athletes from other sport categories. When compared to athletes, controls had significantly higher values of four parameters at pre-insertion and three parameters at midportion site reflecting differences in both, fiber organization and density. ConclusionsIntra-tendinous-morphology was similar in all groups of adolescent athletes. Higher values found in non-athletes might suggest higher AT fiber density and organization. It is yet unclear whether the lesser structural organization in young athletes represents initial AT pathology, or a physiological adaptive response at the fiber cross-linking level.

Plantaris tendon and association with mid-portion Achilles tendinopathy. Is the plantaris tendon a contributing factor in mid-portion Achilles tendinopathy?

Plantaris tendon is implicated in some cases of load-resistant Achilles tendinopathy. The tendon courses close to the medial Achilles tendon mid-portion prior to insertion onto the medial calcaneus, although there is variation in course and insertion. Clinical suspicion of plantaris involvement includes persistent medial Achilles pain unresponsive to a rehabilitation programme and imaging revealing a thickened plantaris tendon and/or focal medial Achilles tendinosis. Potential mechanisms include compression or shearing forces between the plantaris and Achilles tendons. Initial treatment should consist of a modified loading programme avoiding end-range loading. Resistant cases may be amenable to surgical excision of the plantaris demonstrating good clinical outcomes in the short and long term, although the evidence is limited to case series. Percutaneous methods show promise but require further evaluation.

Surgical plantaris tendon removal for patients with plantaris tendon-related pain only and a normal Achilles tendon: a case series

ObjectivesSurgical removal of the plantaris tendon can cure plantaris-associated Achilles tendinopathy, a condition in which Achilles and plantaris tendinopathy coexist. However, rare cases with plantaris tendinopathy alone are often misdiagnosed...

Microvascular volume in symptomatic Achilles tendons is associated with VISA-A score

ObjectivesThe role of neovascularisation in tendinopathy is still poorly understood, potentially due to technical limitations of conventional power Doppler ultrasound. This study aimed to investigate the association between contrast-enhanced ultrasound (CEUS) microvascular volume (MV), Victorian Institute of Sports Assessment-Achilles (VISA-A) scores and intrinsic Achilles tendon tenderness, as well as two different Power Doppler modes. DesignCross-sectional study. Methods20 individuals with uni- or bilateral Achilles tendinopathy completed a VISA-A questionnaire, and underwent microvascular volume measurements of the Achilles tendon mid-portion using both conventional, ultrasensitive (SMI™) power Doppler ultrasound and CEUS. Intrinsic tendon tenderness was assessed with sensation detection threshold to extracorporeal shock waves (ESW). Linear Mixed Model analysis was used to determine the association between microvascular volume (MV), VISA-A, and ESW-detection threshold for both symptomatic and asymptomatic Achilles tendons. ResultsThere was a significant association between VISA-A and MV (B=−5.3, 95%CI=[−8.5; −2.0], P=0.0004), and between MV and symptom duration (B=−1.7, 95%CI=[−3.2; −5.0], P=0.023). No significant associations were found between power Doppler ultrasound and CEUS-based MV or between CEUS-based MV and ESW-detection threshold. In comparison with conventional power Doppler ultrasound, SMI™ showed on average similar detection capacity for neovessels in the mid-portion of the Achilles tendon, whilst being superior for detecting neovessels within Kager’s fat pad (t=3.46, 95%CI=[0.27; 1.03], P<0.005). ConclusionsOur results indicate that CEUS-based MV of the Achilles tendon is moderately associated with Achilles tendon symptoms. In accordance, CEUS-detected MV could be a novel target for treatment as it seems to be more sensitive than PDU and is correlated with symptoms.

Intravoxel incoherent motion (IVIM) imaging in human achilles tendon.

Limited microcirculation has been implicated in Achilles tendinopathy and may affect healing and disease progression. Existing invasive and noninvasive approaches to evaluate tendon microcirculation lack sensitivity and spatial coverage. To develop a novel Achilles tendon intravoxel incoherent motion (IVIM) MRI protocol to overcome the limitations from low tendon T2 /T2 * value and low intratendinous blood volume and blood velocity to evaluate tendon microcirculation. Prospective. Sixteen healthy male participants (age 31.0 ± 2.1) were recruited. A stimulated echo readout-segmented echo planar imaging (ste-RS-EPI) IVIM sequence at 3.0T. The feasibility of the proposed ste-RS-EPI IVIM protocol combined with Achilles tendon magic angle effect was evaluated. The sensitivity of the protocol was assessed by an exercise-induced intratendinous hemodynamic response in healthy participants. The vascular origin of the observed IVIM signal was validated by varying the diffusion mixing time and echo time. Two-tailed t-tests were used to evaluate differences (P < 0.05 was considered significant). Consistent with known tendon hypovascularity, the midportion Achilles tendon at baseline showed significantly lower IVIM-derived perfusion fraction (fp ) (3.1 ± 0.9%) compared to the proximal and distal Achilles tendon (6.0 ± 1.8% and 6.1 ± 2.0%, respectively; P < 0.01). Similarly, the midportion Achilles tendon exhibited significantly lower baseline blood flow index (D*×fp ) (40.9 ± 19.2, 18.3 ± 5.3, and 32.0 ± 9.4 in proximal, midportion, and distal Achilles tendon, respectively; P < 0.01). Eccentric heel-raise exercise led to ∼2 times increase of Achilles tendon blood flow in healthy participants. Consistent with its vascular origin, the estimated fp demonstrated a high dependency to IVIM protocol parameters, while the T1 /T2 -corrected absolute intratendinous microvascular blood volume fraction (Vb ) did not vary. Achilles tendon ste-RS-EPI IVIM noninvasively assessed baseline values and exercise-induced changes to tendon microcirculation in healthy tendon. 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1690-1699.

Is heavy eccentric calf training superior to wait-and-see, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy?

BackgroundMid-portion Achilles tendinopathy (AT) is prevalent amongst athletic and non-athletic populations with pain, stiffness and impaired function typically reported. While different management options exist, loading protocols remain the best available intervention and have been shown to be effective in the management of AT. Trials investigating loading in AT have used a variety of different protocols, and recent narrative reviews suggest that no protocol is superior to another when comparing outcomes in pain and function. However, there has been no systematic review or meta-analysis completed to determine this. Furthermore, the narrative review did not consider wait-and-see or sham interventions, thus a systematic review and met-analysis which includes wait-and-see or sham interventions is warranted.MethodsA systematic review and meta-analyses will be conducted as per the PRISMA guidelines. The databases PUBMED, CINAHL (Ovid) and CINAHL (EBSCO) will be searched for articles published from inception to 31 December 2017. Our search focuses on studies examining the improvement of pain and function when completing a loading program for mid-portion AT. Only randomised/ quasi-randomised trials will be included while case reports and case series will be excluded. The primary outcome assessing pain and function will be the Victorian Institute Sports Assessment - Achilles (VISA-A). Two reviewers will screen articles, extract data and assess the risk of bias independently with a third reviewer resolving any disagreements between the two reviewers. A meta-analysis will then be performed on the data (if appropriate) to determine if the traditional heavy load calf training protocol described by Alfredson is superior to wait-and-see, sham intervention, traditional physiotherapy, and other forms of exercise rehabilitation.DiscussionThis systematic review and meta-analysis will allow us to investigate if there are difference in pain and function when comparing wait-and-see, sham interventions, traditional physiotherapy and different exercise interventions to the traditional heavy eccentric calf training protocol for mid-portion Achilles tendon pain.Systematic review registrationPROSPERO registration number CRD42018084493.

Sonoelastography of the Achilles Tendon: Prevalence and Prognostic Value Among Asymptomatic Elite Australian Rules Football Players.

To investigate the prevalence of sonographic abnormalities at the mid-Achilles tendon among a cohort of asymptomatic professional football players and to determine whether these sonographic abnormalities predict midportion Achilles tendon symptoms. Longitudinal study. A single competitive season in the Australian Rules Football League. Forty-two elite Australian Rules football players. Using ultrasound and sonoelastography, 42 players were examined at baseline and again 9 months later (postseason) for the existence of intratendinous hypoechogenicity, delamination, softening, and neovascularization. The anterio-posterior (AP) thickness and cross-sectional area (CSA) were measured. Players reporting Achilles tendon pain or with Victorian Institute of Sports Assessment-Achilles scores below 80 at the end of the season were classified as symptomatic. At preseason, ultrasound and/or sonoelastographic abnormalities were found in 22 (22/42, 52.4%) asymptomatic players. Baseline AP thickness and CSA were significantly greater in symptomatic players at the end season than those in asymptomatic players (0.57 ± 0.05 cm vs 0.50 ± 0.03 cm; P < 0.001 and 0.67 ± 0.07 cm vs 0.57 ± 0.06 cm; P < 0.001, respectively). The presence of intratendinous softening and delaminations at baseline was associated with pain onset during the season (P = 0.046; P = 0.048, respectively). Ultrasound and sonoelastography-detected abnormalities were relatively common among the asymptomatic footballers. Greater AP thickness and CSA and also the presence of intratendinous softening and delaminations were associated with the increased risk of developing symptoms. Conventional ultrasound supplement with sonoelastography may be able to identify elite athletes at risk of Achilles tendon injury, which may, in turn, impact therapeutic decisions.

Clinical commentary of the evolution of the treatment for chronic painful mid-portion Achilles tendinopathy.

The chronic painful Achilles tendon mid-portion was for many years, and still is in many countries, treated with intratendinous revision surgery. However, by coincidence, painful eccentric calf muscle training was tried, and it showed very good clinical results. This finding was unexpected and led to research into the pain mechanisms involved in this condition. Today we know that there are very few nerves inside, but multiple nerves outside, the ventral side of the chronic painful Achilles tendon mid-portion. These research findings have resulted in new treatment methods targeting the regions with nerves outside the tendon, methods that allow for a rapid rehabilitation and fast return to sports.