Achilles Tendonopathy Research Articles

Outcomes of Gastrocnemius Recession in Patients with Plantar Fasciitis and Achilles Tendinosis: A Retrospective Study of 160 Patients

Category:HindfootIntroduction/Purpose:Plantar fasciitis and achilles tendonopathy are two of the most common foot and ankle overuse conditions encountered in clinical practice. Several recent studies have shown isolated gastrocnemius recession to be a viable treatment option for these conditions when conservative management has failed. Patient outcomes have primarily been assessed through pain and functionality scores. While pain improvement and motion restoration are of utmost importance, plantar flexion power and endurance are also key to patients’ ability to return to everyday activities. Here, we assess patient outcome scores of individuals that underwent gastrocnemius recession for plantar fascitis and achilles tendonopathy to see if surgery was beneficial.Methods:We reviewed 160 patients who underwent isolated gastrocnemius recession for chronic plantar fasciitis and achilles tendinopathy by a single surgeon from June 2011 to August 2018. Data was collected regarding patient pre-operative and post- operative pain scores at 3 months, 1 year, and final follow-up, and post-operative PROMIS physical function (PF), pain interference (PI), and depression (D) t-scores at final follow-up. We also collected data regarding time to full weight bearing, time to 50% and 100% pain relief, time to return to work, time to return to ADL, and time for patient to be out of boot. The patient population was then stratified by preoperative diagnosis and if patients received formal physical therapy. The cohorts consisted of patients that had plantar fasciitis, Achilles tendinosis, or a combination of both. The other cohorts were patients that received formal physical therapy and those that did not receive physical therapy.Results:The average preopeartive VAS score fot plantar fasciitis Achilles tendinosis and a combination of both was 4.27 4.10 and 4.93 respectively. For patients that had 3 month follow up (96) all three cohorts saw a decrease in VAS scores at 3 months (1.98, 1.50, and 1.80 respectively). Patients who received physical therapy saw a larger decrease in VAS scores (2.05 vs 1.03 respectively). Patients in all three groups were able to be fully weight baring within 30 days. 20.27 days in the plantar fasciitis, 19.25 for Achilles tendinopathy, and 28.3 days in the combination cohort. Patients with Achillis tendinosis had were able to get out of their boot the fastest (29.75 days). PROMIS scores were similar across all cohorts.Conclusion:This study is the first to complete a through evaluation of patient outcomes after gastrocnemius recession. Additionally, the study is one of the largest cohorts. This study helps to confirm that the surgery is beneficial for both plantar fasciitis and achilles tendinosis. In all cohorts patients pain improved with surgical intervention despite preoperative diagnosis and physical therapy status. Additionally, PROMIS scores across all of the patients were similar and did not indicate any signifcant decreases in physical function or increases in pain.

Long-term Outcomes of Immediate Weightbearing with Anchorless Achilles Debridement and Secondary Reconstruction for Insertional Achilles Tendonopathy

Category:Hindfoot; SportsIntroduction/Purpose:Achilles debridement and secondary reconstruction is a widely accepted procedure for treatment of insertional Achilles tendonopathy with or without Haglund resection, calcaneus exostectomy, retrocalcaneal bursectomy, and possible flexor hallucis longus tendon transfer. When less than 50% of the tendon is pathologic and elevated from the calcaneus, primary reconstruction with or without bony fixation (bone tunnels or anchors) has been advocated. Postoperative protocols demonstrate wide variability in the orthopaedic literature. This study is the first to evaluate clinical and radiographic outcomes in patients with insertional Achilles tendonopathy who underwent soft tissue only Achilles debridement and secondary reconstruction with immediate plantigrade weightbearing in plantigrade foot ankle stabilizer (FAS) high walking boot.Methods:All patients with symptomatic insertional Achilles tendonopathy who failed conservative management underwent Achilles debridement and secondary reconstruction with or without Haglund resection, calcaneus exostectomy, and retrocalcaneal bursectomy by a single senior foot and ankle surgeon at a single tertiary center between January 2006 to December 2013 were included in our retrospective case series. Patients with greater than 50% involvement of the tendon requiring flexor hallucis longus transfer were excluded. Demographics, clinical outcomes, patient comorbidity information, and Coughlin satisfaction scores were collected. The primary outcome was change in visual analog scale (VAS) pain score. Secondary outcomes were reoperation, minor complications (local wound care, use of antibiotics, and skin dehiscence).Results:From 2006 to 2013, 66 patients (40.9% male, 59.1% female) at an average age of 53.6 years (range 19 to 78) underwent Achilles debridement and secondary reconstruction. At final average follow up of 4.3 years, average VAS score improved from 5.9 to 2.3 preoperatively to postoperatively. There were a total of 10 reoperations in 9.1% of patients (n=6). Minor complications were present in 12.1% of patients (n=8; 3 local wound care, 8 use of antibiotics, and 5 skin dehiscence). Physical therapy desensitization was utilized in 25.8% of patients (n=17).Conclusion:The present study demonstrates a significant improvement in VAS pain scores following Achilles debridement and secondary reconstruction for treatment of insertional Achilles tendonopathy with immediate plantigrade weightbearing in plantigrade FAS high walking boot. This technique appears to be safe and effective.

Do PROMIS Scores Show That Nonoperative Treatment of Achilles Tendonopathy Works?

Category: Ankle, Sports Introduction/Purpose: Achilles tendonopathy (AT), whether insertional (IAT) or non-insertional (NIAT), is a common clinical disorder. Operative and nonoperative care have been evaluated, although often employing non-validated measures. In addition, it is common for AT response to be reported without separating IAT versus NIAT. This adds to uncertainty regarding expected improvement in patients presenting for treatment with AT. There is a paucity of literature analyzing nonoperative treatment of IAT and NIAT as distinct entities using patient-reported outcomes. We utilize Patient-Reported Outcomes Measurement Information System (PROMIS) Physical-Function (PF), Pain-Interference (PI) and Depression (D) domains to determine clinical response to nonoperative treatment in all AT patients. We further compared clinical response in patients with IAT to patients with NIAT. Methods: Patient visits to an academic orthopaedic foot and ankle center over an 18 month period (March 2015 to October 2016) were prospectively collected. All patients with AT were determined using ICD-9 codes, and they were stratified between IAT and NIAT. Only patients with complete PROMIS scores (PF, PI and D) at both presentation as well as following a course of nonoperative care, including heel lifts and an achilles/gastrocnemius stretching and strengthening program, were included for analysis. A total of 102 patients fit our inclusion criteria, with an average follow up of 68 days. Based on a distribution-based method, the minimum clinically important difference (MCID) was set at one-half standard deviation. Overall descriptive statistics were determined for all patients. Bivariate analysis was conducted to compare NIAT and IAT patients across a wide range of variables. Significance was set at 0.05 for all analyses. Results: Fifteen (46%), 12 (36%) and 9 (27%) patients with NIAT reached MCID for PF, PI and D, respectively. Eleven (33%) patients with NIAT reached MCID in both PF and PI. Seventeen (25%), 20 (29%) and 22 (32%) patients with IAT reached MCID for PF, PI and D, respectively. Six (9%) patients with IAT reached MCID in both PF and PI. A larger percentage of men had NIAT (63.6% vs. 36.2%; p = 0.009), while a larger percentage of women had IAT (63.8% vs. 36.4%; p = 0.009). Changes in PROMIS PF scores were higher in patients with NIAT (4.0 vs. -0.046; p = 0.035). A higher percentage of patients with NIAT reached MCID in PF (45.5% vs. 24.6%; p = 0.034). Conclusion: A considerable portion of patients with AT respond favorably to nonoperative care. PROMIS scores did not vary at presentation between IAT and NIAT, yet between 25% and 46% of patients in each subgroup reached MCID in at least one domain. Although a higher percentage of patients with NIAT reached MCID, patients with IAT also demonstrated MCID improvement. Using PROMIS for disease specific pathologies and nonoperative treatment in foot and ankle care provides clinical value previously uncaptured. Our results demonstrate nonoperative treatment for AT has clinical utility and economic value in a time of increased scrutiny on healthcare spending.

Do PROMIS scores show that nonoperative treatment of Achilles tendonopathy works?

Category:Ankle, SportsIntroduction/Purpose:Achilles tendonopathy (AT), whether insertional (IAT) or non-insertional (NIAT), is a common clinical disorder. Operative and nonoperative care have been ...

Cholesterol level in non-insertional Achilles tendonopathy

Familial hypercholesterolaemia is an autosomal dominant disease, with a prevalence of 1 in 500, where lipid deposits occur in the skin, tendons (particularly Achilles tendon) and arteries. It has a high risk of early coronary artery disease and mortality but is treatable with cholesterol lowering strategies if patients are diagnosed early. Studies in patients attending lipid clinics have shown that half the patients may have suffered from Achilles tendon symptoms 20 years earlier and it has been proposed that all patients presenting with Achilles tendon pain should have a serum cholesterol test.All consecutive patients seen in an adult foot and ankle clinic with non-insertional Achilles tendonopathy between April 2012 and March 2014 had their serum cholesterol measured. Only one patient in 83 (p=0.19) was diagnosed with heterozygous familial hypercholesterolaemia but 3 relatives of the proband patient were also diagnosed by cascade testing.Measurement of cholesterol in all patients presenting with achillodynia does not seem to be justified but the literature suggests that it should probably be considered in patients with bilateral extensive disease or those who give a history of intermittent episodes of severe pain lasting a few days.

Viscoelasticity in Achilles tendonopathy: quantitative assessment by using real-time shear-wave elastography.

To investigate the differences in viscoelastic properties between normal and pathologic Achilles tendons (ATs) by using real-time shear-wave elastography (SWE). The institutional review board approved this study, and written informed consent was obtained from 25 symptomatic patients and 80 volunteers. One hundred eighty ultrasonographic (US) and SWE studies of ATs without tendonopathy and 30 studies of the middle portion of the AT in patients with tendonopathy were assessed prospectively. Each study included data sets acquired at B-mode US (tendon morphology and cross-sectional area) and SWE (axial and sagittal mean velocity and relative anisotropic coefficient) for two passively mobilized ankle positions. The presence of AT tears at B-mode US and signal-void areas at SWE were noted. Significantly lower mean velocity was shown in tendons with tendonopathy than in normal tendons in the relaxed position at axial SWE (P < .001) and in the stretched position at sagittal (P < .001) and axial (P = .0026) SWE. Tendon softening was a sign of tendonopathy in relaxed ATs when the mean velocity was less than or equal to 4.06 m · sec(-1) at axial SWE (sensitivity, 54.2%; 95% confidence interval [CI]: 32.8, 74.4; specificity, 91.5%; 95% CI: 86.3, 95.1) and less than or equal to 5.70 m · sec(-1) at sagittal SWE (sensitivity, 41.7%; 95% CI: 22.1, 63.3; specificity, 81.8%; 95% CI: 75.3, 87.2) and in stretched ATs, when the mean velocity was less than or equal to 4.86 m · sec(-1) at axial SWE (sensitivity, 66.7%; 95% CI: 44.7, 84.3; specificity, 75.6%; 95% CI: 68.5, 81.7) and less than or equal to 14.58 m · sec(-1) at sagittal SWE (sensitivity, 58.3%; 95% CI: 36.7, 77.9; specificity, 83.5%; 95% CI: 77.2, 88.7). Anisotropic results were not significantly different between normal and pathologic ATs. Six of six (100%) partial-thickness tears appeared as signal-void areas at SWE. Whether the AT was relaxed or stretched, SWE helped to confirm and quantify pathologic tendon softening in patients with tendonopathy in the midportion of the AT and did not reveal modifications of viscoelastic anisotropy in the tendon. Tendon softening assessed by using SWE appeared to be highly specific, but sensitivity was relatively low.

Plantar Fascia: Imaging Diagnosis and Guided Treatment

Plantar fasciopathy is a common cause of heel pain. This article covers the imaging anatomy of the hindfoot, the imaging findings on ultrasound and magnetic resonance imaging (MRI) of plantar fasciopathy, plantar fibromas, trauma, Achilles tendonopathy, neural compression, stress fractures of the os calcis and other heel pad lesions. Thickening of the plantar fascia insertion more than 5 mm either on ultrasound or MRI is suggestive of plantar fasciopathy. Ultrasound is superior to MRI for diagnosis of plantar fibroma as small low signal lesions on MRI are similar to the normal plantar fascia signal. Ultrasound demonstrates low echogenicity compared with the echogenic plantar fascia. Penetrating injuries can appear bizarre due to associated foreign body impaction and infection. Achilles tendonopathy can cause heel pain and should be considered as a possible diagnosis. Treatment options include physical therapy, ECSWT, corticosteroid injection, and dry needling. Percutaneous US guided treatment methods will be described.

Is electro-acupuncture a safe and cost-effective treatment for Achilles tendonopathy in a primary care setting?

A case of Achilles tendonopathy in a 68-year-old runner is reported. This condition continues to provide a challenge to achieve effective treatment. In this case, electro-acupuncture and attention to muscle function and gait was associated with a good outcome. A case is made for further study of this approach to treatment.

Transverse-Plane Mechanics at the Knee and Tibia in Runners With and Without a History of Achilles Tendonopathy

Retrospective cohort study. To determine if runners with a history of Achilles tendonopathy (AT) demonstrate a difference in transverse-plane motion and moments at the distal tibia and knee compared to runners without a history of AT. One of the more prevalent overuse running injuries is AT. It has been hypothesized that prolonged pronation causes contradictory rotational forces acting on the AT. Conflicting joint motions may also accentuate the rotation of the tendon. This may further affect the opposing transverse-plane moments at the knee and distal tibia. Eight runners with a history of AT and a noninjured control group consisting of 8 runners ran along a 20-m runway at a fixed speed. Biomechanical measurements were taken using a 6-camera motion analysis system and a force plate. Student t tests were employed to determine statistically significant differences (P </= .05) in transverse-plane motion and moment variables at the distal tibia and knee between groups. The AT group showed less tibial external rotation moment (P = .01) and peak knee internal rotation (P = .05) compared to the control group. There was no difference in external rotation moment at the knee (P = .34) or peak tibial internal rotation (P = .44). Runners with a previous history of AT exhibited less tibial external rotation moments during running. The lack of control in the transverse-plane at the distal tibia may be due to decreased function of the muscles primarily responsible for transverse-plane motion, resulting in greater strain on the AT in the transverse-plane. Designing an exercise program to strengthen lower leg muscles and improve distal tibial control in the transverse-plane may reduce the risk for developing AT or augment the rehabilitation of AT.

High association between accessory soleus muscle and Achilles tendonopathy

This study investigated the association between accessory soleus muscle and abnormalities of the Achilles tendon. The authors reviewed 15 consecutive cases with a diagnosis of accessory soleus muscle from a computerized database of ankle magnetic resonance (MR) examinations reported between January 1998 and January 2007. On review, two cases were eliminated because of an incorrect initial diagnosis: One patient had a low lying soleus attachment to the Achilles tendon, while the other had a prominent flexor hallucis longus tendon partially obliterating Kager's fat. The remaining 13 cases with accessory soleus muscles were evaluated for Achilles tendon abnormalities. There were 13 cases of accessory soleus muscles in 11 patients; two patients had bilateral accessory soleus muscles (the only study patients with bilateral MR examinations in our sample). There were five male and six female patients ranging from 15 to 81 years of age (mean 48). There were nine cases (69.2%) in which Achilles tendonopathy was associated with accessory soleus muscle, including tendonopathy of each Achilles tendon in the two patients with bilateral accessory muscles. In our small patient population, there was a high association between accessory soleus muscle and Achilles tendonopathy.

Effect of Eccentric Training on the Plantar Flexor Muscle-Tendon Tissue Properties

It has been shown that eccentric training can be effective in the rehabilitation of patients with Achilles tendonopathy. The mechanism behind these results is not clear. However, there is evidence that tendons are able to respond to repeated forces by altering their structure and composition, and, thus, their mechanical properties change. In this regard, the objective of the present study was to investigate whether eccentric training affects the mechanical properties of the plantar flexor's muscle-tendon tissue properties. Seventy-four healthy subjects were randomized into two groups: an eccentric training group and a control group. The eccentric training group performed a 6-wk eccentric training program for the calf muscles. Before and after this period, all subjects were evaluated for dorsiflexion range of motion using universal goniometry, passive resistive torque of the plantar flexors, and stiffness of the Achilles tendon. Passive resistive torque was measured during ankle dorsiflexion on an isokinetic dynamometer. Stiffness of the Achilles tendon was assessed using a dynamometer, in combination with ultrasonography. The results of the study reveal that the dorsiflexion range of motion was significantly increased only in the eccentric training group. The eccentric heel drop program also resulted in a significant decrease of the passive resistive torque of the plantar flexors (from 16.423 +/- 0.827 to 12.651 +/- 0.617 N.m). The stiffness of the Achilles tendon did not change significantly as a result of training. These findings provide evidence that an eccentric training program results in changes to some of the mechanical properties of the plantar flexor muscles. These changes were thought to be associated with modifications to structure rather than to stretch tolerance.

The distribution of microvascular response in Achilles tendonopathy assessed by colour and power Doppler

To assess the distribution of microvascular response on colour Doppler (CD) and power Doppler (PD) ultrasound (US) of the tendo Achilles (TA) in tendonopathy, and to look for any relationship between tendon morphology and symptoms. A retrospective, observational study was carried out on consecutive ambulant US patients with suspected tendonopathy, presenting with pain or an Achilles mass. Exclusion criteria were: use of steroids, and previous or possible rupture or surgery in either tendon or arthropathy. Using a 5-12 MHz linear array probe (ATL HDI 3000) both TAs were scanned. Tendonopathy was defined as tendon swelling and/or hypoechogenicity of the TA. The site, number and distribution of microvascularity, on CD and PD, and the anteroposterior size were recorded, with the analysis masked. Fifty-two patients presented with TA pain and six also with swelling. There were 34 males and 18 females, aged from 11 to 78 years (mean 45 years). Fifty-five TAs that showed tendonopathy with hypoechogenic areas were all observed to be over 5.9 mm (mean 11.1 mm, range 5.9-20 mm), of which 45 were symptomatic with abnormal PD and 24 with abnormal CD flow. It was observed that the extent and completeness of vessel branching was more extensive on PD than CD. All TAs demonstrating tendonopathy were over 5.9 mm in adults and all TAs that showed PD flow were over 6.5 mm. All microvessels originated towards the TA from the ventral surface usually into tendonopathy, and were 16-fold more frequent around the margins. There were 49 TAs with normal spectral US, and with no PD flow, with a mean size of 4.5 mm (range 3.0-7.4 mm). For the right and left TAs independently analysed and taking the 40 patients with a paired asymptomatic and symptomatic tendon: (1) There was a highly significant difference in size (P<0.00001) using the paired t-test (parametric) between the asymptomatic tendon (mean 5.2+/-1.4 mm (1 SD)), and the contralateral morphologically abnormal and symptomatic side (mean 9.7+/-1.4 mm). (2) There was no linear Pearson correlation (0.25) between TA size and duration of symptoms (P=0.11) for symptomatic tendons. (3) There was a positive Spearman correlation (0.84) between the number of vessels and TA size (P<0.00001). (4) There was a significant difference in the number of PD vessels using the non-parametric Wilcoxon signed test (P<0.00001) between the symptomatic and asymptomatic groups. (1) PD shows more tendon microvascularity than CD in TA tendonopathy. (2) All microvessels arise on the ventral side of the TA. (3) There is a non-linear relationship between tendonopathy, TA size and the amount of microvascularity, but not between PD and duration of symptoms. (4) Morphologically abnormal adult TAs were larger than 5.9 mm, and PD flow was only seen in TAs above 6.5 mm.

Magic Angle Imaging of the Achilles Tendon in Patients with Chronic Tendonopathy

AIMS: To assess the Achilles tendon in patients with chronic tendonopathy using magnetic resonance (MR) magic angle imaging, and to compare the appearances and uptake of contrast medium in abnormal tendons with those in normal tendons. MATERIAL AND METHODS: Eight patients with chronic Achilles tendonopathy and five normal controls were examined with the long axis of the tendon placed at 55° and at 0° to the main magnetic field. Conventional two-dimensional (2D) multi-slice images were obtained and T1 values were calculated before, and for up to 1 h after the administration of intravenous gadodiamide. Both the unenhanced appearance and the pattern of enhancement in the tendon were compared. RESULTS: In the patients with tendonopathy, high signal intensity areas were evident on the short T1 inversion recovery (STIR) images obtained at 55° in all tendons. Contrast medium enhancement was seen in six tendons and was most obvious on the images obtained at the magic angle. This was initially focal and then spread more diffusely within the tendon. After contrast medium administration, T1 values were significantly reduced in the tendonopathy group compared with normal controls ( p<0.01). On the late post-contrast medium images obtained at 55°, enhancement was evident in most of the tendon and correlated well with high signal intensity seen on STIR images. CONCLUSION: The use of magic angle MR imaging improved the demonstration of signal changes in the Achilles tendon in chronic tendonopathy. The STIR images obtained at the magic angle showed more obvious signal change than those obtained at 0°. The changes due to enhancement were much more evident on images obtained at 55° than at 0°. The uptake of contrast medium was greater in the patients than in normal controls.