Intratendinous Tears Research Articles

Clinical Efficacy and Safety of Ultrasound-Guided Injection with Low-Molecular-Weight Peptides from Hydrolyzed Collagen in Patients with Partial Supraspinatus Tendon Tears: A Pilot Study

Background: This study evaluates the clinical efficacy and safety of two ultrasound (US)-guided injections of a 5 mg/1 mL low-molecular-weight peptide (LWP) solution derived from hydrolyzed bovine collagen in patients with supraspinatus partial tendon tears. Methods: A total of 21 patients with symptomatic partial tears of the supraspinatus tendon, detected by US, were consecutively enrolled and received one injection at a baseline visit (T0) and one after two weeks (T1). The primary outcome measure was the visual analogue scale (VAS) for pain. Secondary outcomes were the shoulder pain and disability index (SPADI) total score and the safety of LWP injections. Patients were examined at baseline (T0), at a week 2 follow-up visit (T1), and at a week 12 follow-up visit (T2). Results: A statistically significant improvement was found for both VAS pain and SPADI total scores, between T0 and T2 visits. US-guided injections were well tolerated and, apart from one patient with a progression of a tendon tear, no adverse events were recorded. Conclusions: Intratendinous tear US-guided injection therapy with an LWP solution was found to be safe and effective in improving both pain and shoulder function at a 12-week follow-up visit. The present pilot study should be considered the first step justifying a larger confirmatory investigation.

High-resolution ultrasound and MRI in the evaluation of pectoralis major injuries.

The pectoralis major muscle is the largest muscle of the anterior chest wall. The primary function of the muscle is to adduct and internally rotate the arm at the shoulder. The pectoralis major muscle is broken down into two main components or "heads" based upon muscle fiber origin: clavicular and sternal. Pectoralis major muscle injury results from direct trauma or indirect force overload. The inferior sternal head fibers are the most commonly torn. The pectoralis major tendon most commonly is torn at the humeral insertion. Magnetic resonance imaging and high-resolution ultrasound have value in diagnosing pectoralis major muscle injury and help guide clinical and surgical management. Non-operative versus operative management of pectoralis major tears is dependent upon accurate diagnosis of tear location and severity on imaging. Operative management is recommended for tears at the humeral insertion and for musculotendinous junction tears with severe cosmetic/functional deformity. The indications for surgical intervention have been further expanded to complete intra-tendinous tears, defined as the mid-tendon substance between the myotendinous junction and humeral insertion, and those located at the sternal head/posterior lamina. This paper reviews normal pectoralis major anatomy and the spectrum of injury on magnetic resonance imaging and ultrasound. The importance of regional anatomical landmarks in assessing for pectoralis major muscle injury will be described. Other pathologies, such as tumor and infection, can also affect the pectoralis major muscle and key imaging features will be discussed to help differentiate these entities. Operative and non-operative management of pectoralis major muscle injury is described with examples of pectoralis major repair on post-operative imaging.

The Arthroscopic “Bellows” Sign Identifies Hidden Rotator Cuff Tears

The intraoperative recognition of rotator cuff tears continues to be a challenge in some cases, despite clinical suspicion, a physical examination suggesting a rotator cuff tear, and detection on preoperative imaging studies. Intraoperative identification can be elusive in partial tears including intratendinous tears and obscured full-thickness tears. The purpose of this Technical Note, and the associated technique video, is to discuss a visual sign for the detection of various rotator cuff tear pathologies. Derived from the dynamic fluid expansion and contraction of the affected tissues, this indicator is termed the arthroscopic “bellows” sign.

Midterm outcomes after arthroscopic repair of partial rotator cuff tears: A retrospective study of correlation between partial tear types and surgical technique.

Patients who underwent arthroscopic repair for partial rotator cuff tears were evaluated retrospectively. This study purposed to assess the postoperative clinical results of arthroscopic treatment of intratendinous rotator cuff tears and to investigate the effect of the tear type on the postoperative clinical outcomes. Overall, 60 patients [36 women and 24 men; mean age: 48.6±12.2 years (range 33-67 years)] who underwent arthroscopic repair of Ellman stage 3 partial rotator cuff tear were evaluated retrospectively. These patients were grouped into the following three groups: articular-sided tears, bursal-sided tears, and intratendinous tears, with 20 patients included in each group. Subacromial decompression, acromioplasty, and tear repair without transforming to full-thickness tear were applied to the bursal-sided tears. The same technique was performed for intratendinous ruptures, with the only technical difference was that the capsular tissue was preserved during debridement of intratendinous tears. The articular-sided tears were transformed to complete tears and repaired arthroscopically. The preoperative and postoperative ASES scores and range of motion improvements were evaluated in all patients. The mean follow-up time was 44±6.5 months (range: 36-62 months). No significant intergroup differences were observed concerning the age and the mean follow-up duration (p=0.524, p=0.665). A similar increase in ASES scores was observed for all three types of tears (bursal-sided tears: 31.09-82.65; articular-sided tears: 35.50--84.00; intratendinous tears: 34.01-83.49). Statistically, no significant intergroup difference was observed concerning ASES score improvement (p=0.585). An increase in mean forward flexion, abduction, and external rotation were observed, especially, a statistically significant increase in flexion (p=0.001) and abduction (p=0.001) in all three types of tears. No patient experienced any intraoperative or postoperative complications. The results of arthroscopic treatment of intratendinous tears were similar to the other types of partial tears, and the results of arthroscopic treatment of grade 3 partial rotator cuff tears revealed satisfactory outcomes, regardless of the type of the tear. Level III, Therapeutic study.

Intratendinous tears of the Achilles tendon - a new pathology? Analysis of a large 4-year cohort

Intratendinous tears of the Achilles tendon - a new pathology? Analysis of a large 4-year cohort

Arthroscopic treatment for intratendinous rotator cuff tear results in satisfactory clinical outcomes and structural integrity

This study aimed to evaluate the clinical outcomes and structural integrity of arthroscopic repair of intratendinous rotator cuff tear. Patients who were diagnosed with an intratendinous tear but in whom conservative treatment failed were selected and underwent arthroscopic repair. Between 2008 and 2014, a total of 30 patients (6 men, 24 women; mean age, 59 ± 3.7years) met the inclusion criteria and were followed up. The mean follow-up period was 26.3 ± 0.7months. The results were evaluated using the University of California at Los Angeles (UCLA) score, the Society of the American Shoulder and Elbow Surgeons rating scale (ASES) questionnaire, and the visual analog scale (VAS) and range of motion (ROM) were measured preoperatively and at final follow-up. Magnetic resonance imaging (MRI) was performed preoperatively and at 6.7 ± 0.2months postoperatively. Postoperative MRI was performed on 27 out of 30 patients and analysed using the Sugaya classification. Corresponding to the preoperative MRI findings, arthroscopic findings of intratendinous tears were observed in all 30 patients. The mean active forward elevation ROM was 137.3° ± 15.4° before surgery and 168.8° ± 15.2° at the final follow-up. The internal and external rotations at abduction were 31.7° ± 5.1° and 63.0° ± 11.6° before surgery, respectively, and 60.5° ± 8.0° and 75.2° ± 10.8° after surgery, respectively. The UCLA score improved from of 20.1 ± 7.4 points preoperative to 28.4 ± 5.5 points at the final follow-up. The ASES score improved from 55.7 ± 15.3 points preoperative to 82.6 ± 9.7 points postoperatively. The VAS for pain score decreased from 6.4 ± 1.2 points preoperative to 1.6 ± 0.9 points postoperative. Satisfactory outcomes (excellent/good) in terms of UCLA and ASES scores were observed in 29 of 30 patients. Based on Sugaya classification, grades I, II, and III structural integrities were observed in 9, 14, and 4 patients, respectively. Successful clinical outcomes and structural integrity can be achieved with arthroscopic repair of intratendinous rotator cuff tears involving more than half thickness (> 50%). Therefore, arthroscopic repair is a practical next treatment option for patients with intratendinous rotator cuff tears in whom conservative treatment fails. IV.

Intratendinous tears of the Achilles tendon - a new pathology? Analysis of a large 4-year cohort.

Achillodynia is common and includes Achilles tendinopathy, partial Achilles tears and Achilles tendon ruptures. However, we believe an additional pathology should be considered for Achillodynia differentials - the intratendinous tear (ITT). Examinations of 740 achillodynic patients in one specialist centre were reviewed. ITTs were defined as a clearly visualised echopoor area situated centrally and extending to, but not through the tendon periphery, with pain on palpation and no clinical findings consistent with Achilles rupture. Descriptive statistics were used to analyse differences between pathological sub-groups, and images described qualitatively. 5% (29 males, 8 females) of 740 patients had an ITT. Patients typically presented with a history of sudden onset localised pain and the ability to train but not reach maximal loading. Average age was 36.3 years (range 20-64), significantly lower than mid-tendon tendinopathy (8.48 years; p<0.01). 92% had concurrent Achilles tendinopathy. Elite sportspeople were more highly represented in the ITT than mid-tendon tendi nopathy groups (86.2% ITT group vs 13.8% mid-tendon AT group; p<0.01). ITTs should be actively searched for in patients with Achilles pathology, especially in elite male athletes with a history of high-impact pain. Prospective research is warranted concerning diagnosis and management. IV.

Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series.

The intra-tendinous tear is a new pathology that is defined as a discontinuity of fibres situated entirely within the tendon. Prolotherapy involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain. 43 consecutive patients diagnosed with an intra-tendinous tear were included (27 males: 16 females, mean (SD) age 41 (11.3). Patients were injected with 0.4ml-1.5ml (mean 0.8ml) of 50% dextrose and 0.5% marcaine mixed in a 1:1 ratio. A 4-6 week period of walking boot immobilisation was followed by progressive rehabilitation (6-8 weeks). Outcomes were assessed with a VISA-A questionnaire at baseline, 3 months and a mean 12.6 (7.0) months post-treatment. Ultrasound scans were conducted before treatment and 5.2 (2.3) weeks later to assess sonographic changes. 30 patients (70%) responded with VISA-A scores increasing by 31 (30.5) points after 3 months (f=0.62, p<0.05) and by 40 (29.3) points after 12.60 (7.0) months (f=0.87, p<0.05). After 5.2 (2.3) weeks, echogenicity was significantly reduced (p<0.05) and 27% of tears were no longer detectable. No significant differences were observed in remaining tears with respect to tear size, tendon thickness or neovascularisation. Treatment resulted in clinically significant improvements and controlled trials are warranted. IV.

Intratendinous rupture of the supraspinatus: anatomical and functional results of 24 operative cases.

The aim was to describe the natural history of intratendinous partial rotator cuff tears as well as the anatomical and clinical results of surgical treatment of a cohort of 24 patients. There were 14 men and 10 women with a mean age of 50 years. The right shoulder was involved in 17 cases. For 16 cases, a progressive history of shoulder pain was reported. Pre-operatively, a painful and positive Jobe's sign was observed in only 13 cases. Pre-operative mean absolute constant score was 63.52 points. Based on standard MRI, intratendinous lesions were diagnosed on the coronal view with hyper-signal within the tendon in the T2 FatSat sequence. No fatty infiltration was noted. Fourteen open and 10 arthroscopic repairs were performed. Patients were reviewed with clinical assessment and MRI. The final Constant score was 81.3 points with a mean gain of 18.5 points. Patients were back to work after a mean of 5.8 months and to sports after 6 months. The mean subjective result was of 8.9/10. Three cases of reflex sympathetic dystrophy were observed. Intratendinous tears of the supraspinatus tendon are rare and difficult to diagnose. Diagnosis relies on MRI (T2 FatSat). Trauma is not usually described. Chronic calcifying tendonitis may also contribute to the development of such tears. There is no associated fatty infiltration of the muscle. The Jobe's test is frequently painful or positive. Arthroscopic resection of the tendon insertion with reinsertion to the greater tuberosity seems to be the optimal treatment. Retrospective study, IV.

Clinical and Magnetic Resonance Imaging Results of Arthroscopic Repair of Intratendinous Partial-thickness Rotator Cuff Tears.

Background:Partial-thickness rotator cuff tears (PTRCTs) are being diagnosed more often because of high-resolution magnetic resonance imaging (MRI). Compared with articular and bursal side tears, there have been few studies about evaluating the clinical and structural outcomes after intratendinous tear repair.Methods:From 2008 to 2012, 33 consecutive patients with intratendinous PTRCTs underwent arthroscopic repair. All of them were retrospectively evaluated. The University of California at Los Angeles (UCLA) and constant scores were evaluated before operation and at the final follow-up. Postoperative cuff integrity was determined using MRI according to Sugaya's classification.Results:At the 2-year follow-up, the average UCLA score increased from 16.7 ± 1.9 to 32.5 ± 3.5, and the constant score increased from 66.2 ± 10.5 to 92.4 ± 6.9 (P < 0.001). Twenty seven patients received follow-up MRI examinations at an average of 15.2 months after surgery. Of these 27 patients, 22 (81.5%) had a healed tendon, and five patients had partial tears. There was no association between functional and anatomic results.Conclusions:For intratendinous PTRCT, clinical outcomes and tendon healing showed good results at a minimum 2-year after arthroscopic repair.

Imaging of adductor-related groin pain.

Groin pain is a common condition in athletes and results from various causes. Osteitis pubis, adductor dysfunction, inguinal hernia, or a combination of all three entities, generally explains the onset of symptoms. Adductor longus tendinopathy is the main cause of adductor-related groin pain. It leads to a significant reduction of sports participation and can require surgical management. Diagnosis is based on ultrasonography and magnetic resonance imaging. Asymptomatic findings (tendinosis, calcifications, cortical erosions) are common in athletes and care should be taken when assessing groin pain. The most specific sign of tendinopathy is an intratendinous tear of the adductor longus.

Intratendinous Rotator Cuff Tears

Background: Intratendinous tears of the rotator cuff are rare, and little has been written about them. Purpose: To investigate the prevalence and clinical and radiological outcomes of arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair. Study Design: Case series; Level of evidence, 4. Methods: Included in the study were 33 patients (16 male, 17 female; mean age, 53.4 years) with arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair from March 2006 to July 2012. A history of trauma was found in 10 cases (30.3%). The dominant arm was involved in 26 cases (78.8%). The mean follow-up duration was 56 months. Preoperatively, a thorough physical examination was performed; at final follow-up, shoulder range of motion (ROM) in forward flexion, abduction, external rotation (ER) at the side, and internal rotation (IR) at the back was noted, and clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score; University of California, Los Angeles [UCLA] score; visual analog scale [VAS] for pain; and Simple Shoulder Test [SST]) were recorded and compared with the preoperative data. Postoperative magnetic resonance imaging (MRI) was performed at 6 months to investigate rotator cuff healing status and repair integrity. Results: The prevalence of arthroscopically confirmed intratendinous tears was 4.7% among all arthroscopically treated partial-thickness rotator cuff tears. Impingement signs were positive in most of the patients (positive Hawkins-Kennedy test result in 78.8%, positive Neer sign in 66.7%, and either positive Hawkins-Kennedy test result or Neer sign in 84.8%). At final follow-up, mean ASES, UCLA, VAS, and SST scores improved significantly from a preoperative mean of 51.4, 18.9, 6.0, and 5.4, respectively, to a postoperative mean of 90.6, 32.9, 1.4, and 10.8, respectively (P < .001). According to the UCLA rating scale, outcomes were excellent in 17, good in 13, and fair in 3 cases. Shoulder ROM in forward flexion, abduction, ER at the side, and IR at the back improved from a preoperative mean of 135°, 129°, 25°, and L2, respectively, to a postoperative mean of 161°, 160°, 29°, and T10, respectively (P < .001 for all except ER). As per the Sugaya classification, on postoperative MRI, type I healing status was found in 10 (30.3%), type II in 18 (54.5%), and type III in 2 (6.1%) cases. None of the patients showed any evidence of retears. Conclusion: Transtendon suture bridge repair yielded satisfactory clinical and radiological outcomes in patients with intratendinous rotator cuff tears.

上腕二頭筋長頭腱の破格を伴う棘上筋腱腱内断裂の 1 例

上腕二頭筋長頭腱の破格を伴う棘上筋腱腱内断裂の 1 例

Arthroscopic Suture Bridge Technique for Intratendinous Tear of Rotator Cuff in Chronically Painful Calcific Tendinitis of the Shoulder

Arthroscopic removal, now the main treatment option, has almost replaced open surgery for treatment of resistant calcific tendinitis. In some cases of chronic calcific tendinitis of the shoulder, the calcific materials are hard and adherent to the tendon. Removal of these materials can cause significant intratendinous tears between the superficial and deep layers of the degenerated rotator cuff. Thus far, there are no established surgical techniques for removing the calcific materials while ensuring cuff integrity. Good clinical results for rotator cuff repair were achieved by using an arthroscopic suture bridge technique in patients with long-standing calcific tendinitis. Intact rotator cuff integrity and recovery of signal change on follow-up magnetic resonance imaging scans were confirmed. This is a technical note about a surgical technique and its clinical results with a review of relevant published reports.

高校柔道選手に生じた肩腱板腱内断裂の1例

高校柔道選手に生じた肩腱板腱内断裂の1例

Thumb troubles in rheumatoid arthritis

Thumb involvement may play a relevant role in inducing a severe functional impairment in rheumatoid arthritis. The aim of this sonographic vignette is to show the value of sonography in detailing anatomic changes involving the thumb during a phase of active synovitis. The patient was a 50-year old man who presented with a 3-year history of rheumatoid arthritis. He complained of a 4-week history of a marked recrudescence inflammatory thumb involvement associated with clinical signs of carpal tunnel syndrome. Sonographic images were obtained with a real-time ultrasound system equipped with a 13 MHz linear transducer. Sonographic examination on longitudinal dorsal scan of the metacarpophalangeal joint of the thumb showed a moderate joint cavity widening with two evident bone erosions, one at the metacarpal head and the other one at the basis of the proximal phalanx. The longitudinal volar scan of the first metacarpophalangeal joint confirmed the presence of synovitis detecting a marked joint cavity widening, with aspect of synovial proliferation. The flexor pollicis longus tendon was severely involved (marked tendon sheath widening, synovial proliferation, loss of the normal homogeneous fibrillar echotexture, and a large intratendinous tear). Sonography allowed the depiction of a wide range of otherwise undetectable pathologic changes in the standard clinical setting.

Surgical treatment of confirmed intratendinous rotator cuff tears: Retrospective analysis after an average of eight years of follow-up

This study evaluated clinical features, diagnostic techniques, and summarized the results of open repair in a series of surgically confirmed cases of intratendinous rotator cuff tears. Between 1986 and 1999, 19 patients (17 men and 2 women) with intratendinous rotator cuff tears underwent surgery. Clinical findings, diagnostic results, and surgical findings were evaluated. The shoulder scores of the Japanese Orthopaedic Association (JOA) and the American Shoulder and Elbow Surgeons (ASES) were used to assess recovery at an average of 92 months (range, 31-231 months). All patients had symptoms consistent with rotator cuff tendonitis. History of overt trauma was noted in 16 (84.2%). Neither ultrasound nor magnetic resonance imaging proved reliable for preoperative diagnosis. Surgery was performed if at least 6 months of conservative treatment, such as rest, heat, and physical therapies, failed. The definitive diagnosis was established intraoperatively with a longitudinal split along the fibers of the supraspinatus tendon. None of the intratendinous lesions had communication to the subacromial bursa or the glenohumeral joint. Excision of the intratendinous tear and repair resulted in improvement in pain and total scores of both JOA (66.8 vs 94.1) and ASES (37.1 vs 91.0). Intratendinous rotator cuff tears were difficult to diagnose preoperatively. Our data suggest that conservative treatment failed, anterior acromioplasty and excision of the diseased portion of the tendon, followed by tenorrhaphy, proved effective. Satisfactory outcomes were achieved in 18 patients (94.7%) in this series.

Favorable Outcomes After Sonographically Guided Intratendinous Injection of Hyperosmolar Dextrose for Chronic Insertional and Midportion Achilles Tendinosis

The objective of our study was to report on changes in the short-term sonographic appearance and 2-year follow-up for pain outcomes in a large patient population with chronic Achilles tendinosis who underwent sonographically guided dextrose injections. One hundred eight tendons (86 midportion and 22 insertional) from 99 patients experiencing pain for greater than 6 months at either the Achilles tendon insertion or midportion were included in the study. Gray-scale (5-12 and 7-15 MHz) and color Doppler sonography examinations preceded the injection procedure using a 27-gauge needle administering a net 25% dextrose-lidocaine solution intratendinously. Structural features of each tendon and presence of neovascularity were noted. Visual analog scale (VAS) items were recorded at baseline, posttest, and 28.6 months follow-up. A median of five (range, 1-13) injection consultations were needed for each patient, spaced 5.6 +/- 3.1 (SD) weeks apart. There was a significant improvement in pain scores for both midportion (rest: 34.1 +/- 27.7-3.3 +/- 7.4, activities of daily living (ADL): 50.2 +/- 25.6-9.5 +/- 16.2, and sport: 70.7 +/- 23.3-16.7 +/- 22.0) and insertional (rest: 33.0 +/- 26.5-2.7 +/- 6.0, ADL: 51.3 +/- 25.4-10.0 +/- 16.3, and sport: 69.6 +/- 24.5-17.7 +/- 29.1) patients from baseline to follow-up for all VAS items. There were reductions in the size and severity of hypoechoic regions and intratendinous tears and improvements in neovascularity. Dextrose injections appear to present a low-cost and safe treatment alternative with good long-term evidence for reducing pain from pathology at either the insertion or midportion of the Achilles tendon.

Structural Changes, Not Neovascularization, Accounts For The Variation In Pain With Infrapatellar Tendinopathy

The source of pain in patients experiencing chronic overuse tendinopathy is not completely understood. It has been proposed that vascular in-growth within the area of tendon degeneration is closely associated with an exaggerated nociceptive response. Changes to the sonographic appearance of the tendon are often reported with tendon disease; however, a detailed examination of the sonographic structure of tendon pathology as it relates to the onset of pain has not been performed. PURPOSE: To construct a statistical model that would account for the variation in pain scores reported by tendinopathy patients based on eight sonographic features. METHODS: Clinical and sonographic data were collected from 244 consultations of 51 patients receiving injections of hyperosmolar dextrose/lidocaine for their infrapatellar tendinopathy. Pain scores were documented using visual analog scales (VAS) for pain at rest, pain with activities of daily living, and pain during or immediately after sports. The following sonographic features were documented for all visits: hypoechogenicity, obvious intratendinous tears, occult intratendinous tears, injectant spread, neovascularity, intratendinous calcification, periostitis, and cortical irregularities. Each VAS item was entered into its own backward stepwise regression model (p ≥ 0.1 for exclusion) as the dependent variable with all eight sonographic features included as independent variables. RESULTS: The appearance of periostitis and both obvious and occult intratendinous tears explained a significant variation in the pain scores at rest (R2 =.14, F(3, 240) = 12.71, p <.001); periostitis, both obvious and occult intratendinous tears, and spread of injectant explained a significant variation of pain with activities of daily living (R2 =.08, F(4, 239) = 4.86, p <.01); and periostitis, and both obvious and occult intratendinous tears, spread of injectant and intratendinous calcification explained a significant amount of the variation of pain associated with sport (R2 =.09, F(5, 238) = 4.51, p <.01). CONCLUSIONS: The sonographic appearance of tearing within the tendon, in addition to periosteal and cortical changes at the enthesis, explains a significant portion of the pain experienced by patients with infrapatellar tendinopathy.

Arthroscopic footprint reconstruction of bursal-side delaminated rotator cuff tears using the suture-bridge technique

For a bursal-side retracted laminated rotator cuff tear, simple repair of the retracted bursal-side rotator cuff might be insufficient because the repaired tendon could remain as an intratendinous tear of the rotator cuff. We present a repair method for intratendinous rotator cuff tears using the suture-bridge technique. We believe that this method helps to preserve the remnant rotator cuff tendon without tissue damage and restores the normal rotator cuff footprint in bursal-side delaminated rotator cuff tears.