Left Achilles Tendon Research Articles

Ultrasonographic Achilles Tendon Measurements and Static and Dynamic Balance in Prediabetes.

Background and Objectives: There is a lack of studies examining balance problems and Achilles tendon thickness in prediabetes despite their common occurrence in diabetes mellitus. The aim of this study was to evaluate Achilles tendon size and static and dynamic balance, as well as the role of the Achilles tendon in balance, in prediabetic patients. Materials and Methods: A total of 96 participants were divided into three groups: (1) the control group, consisting of participants without diabetes mellitus; (2) the prediabetes group; and (3) the diabetes mellitus group. Ultrasonographic measurements of Achilles tendon sizes (thickness, width and area) were performed. Dynamic balance was assessed using the Berg Balance Scale, and static balance (the Fall and Stability Indices) was assessed using a Tetrax device. The Self-Leeds Assessment of Neuropathic Symptoms and Signs was utilized to identify neuropathic pain. Results: In the prediabetes group, the median dynamic balance scores [54.0 (51.0-56.0)] were lower than those of the control group [55.0 (54.0-56.0)] but higher than those of the patients with diabetes mellitus [52.50 (49.0-54.25)]; however, this difference did not reach statistical significance. The ultrasonographic measurements of the Achilles tendon size were similar among the three groups. On the other hand, in the prediabetes group, a positive correlation was observed between the bilateral Achilles tendon anterior-posterior thickness and Fall Index score (p = 0.045), while a negative correlation was found between the left Achilles tendon anterior-posterior thickness and the Berg Balance Score (p = 0.045). Conclusions: In prediabetes, neither Achilles tendon size nor static or dynamic balance appears to be significantly affected. However, in prediabetic patients, increased Achilles tendon thickness appears to be associated with increased risk of falls and decreased balance.

Effect of Electroacupuncture on the Treatment of Chronic Achilles Tendinopathy: A Case Report

Background and Objective: Chronic Achilles tendinopathy is among the most prevalent musculoskeletal disorders, especially among athletes. Despite numerous non-surgical procedures performed for this disorder, the treatment of these patients is still challenging. Given that electroacupuncture is a novel technique for the treatment of tendinopathy, a few studies have addressed it. This case report aimed to present the electroacupuncture technique for the treatment of chronic Achilles tendinopathy. Case Presentation: A 53-year-old male patient with a 6-month history of left Achilles tendon pain and limited daily activities was referred to Mobasher Physiotherapy Clinic in January 2024. For this purpose, 3-mm needles were inserted into the distal part of Achilles tendon at points BL 60, BL 61, KI 3, and KI 4. The patient received ten 20-min sessions of electroacupuncture treatment (three times per week at the frequency of 5 Hz and current intensity of 5 mA). Pain intensity and ankle range of motion were evaluated at first and last sessions. Conclusion: As evidenced by the results of this study, applying electroacupuncture for Achilles tendinopathy, especially chronic tendinitis that has not been treated with other conservative procedures, could improve the patient’s symptoms and ankle function, enhancing the patient’s functional activities and life quality.

Four hours of normobaric hypoxia reduces Achilles tendon reflex inhibition.

Acute exposure to hypoxia increases postural sway, but the underlying neurophysiological factors are unclear. Golgi tendon organs (GTOs), located within the musculotendinous junction (MTJ), provide inhibitory signals to plantar flexor muscles that are important for balance control; however, it is uncertain if GTO function is influenced by hypoxia. The aim of this study was to determine how normobaric hypoxia influences lower limb tendon-evoked inhibitory reflexes during upright stance. We hypothesized that tendon-evoked reflex area and duration would decrease during hypoxia, indicating less inhibition of postural muscles compared with normoxia. At baseline (BL; 0.21 fraction of inspired oxygen, FIO2) and at ∼2 (H2) and 4 (H4) h of normobaric hypoxia (0.11 FIO2) in a normobaric hypoxic chamber, 16 healthy participants received electrical musculotendinous stimulation (MTstim) to the MTJ of the left Achilles tendon. The MTstim was delivered as two sets of 50 stimuli while the participant stood on a force plate with their feet together. Tendon-evoked inhibitory reflexes were recorded from the surface electromyogram of the ipsilateral medial gastrocnemius, and center of pressure (CoP) variables were recorded from the force plate. Normobaric hypoxia increased CoP velocity (P ≤ 0.002) but not CoP standard deviation (P ≥ 0.12). Compared with BL, normobaric hypoxia reduced tendon-evoked inhibitory reflex area by 45% at H2 and 53% at H4 (P ≤ 0.002). In contrast, reflex duration was unchanged during hypoxia. The reduced inhibitory feedback from the GTO pathway could likely play a role in the increased postural sway observed during acute exposure to hypoxia.NEW & NOTEWORTHY The Ib pathway arising from the Golgi tendon organ provides inhibitory signals onto motor neuron pools that modifies force and, hence, postural control. Although hypoxia influences standing balance (increases sway), the underlying mechanisms have yet to be unraveled. Our study identified that tendon-evoked inhibition onto a plantar flexor motoneuron pool is reduced by acute exposure to normobaric hypoxia. This reduction of inhibition may contribute to the hypoxia-related increase in postural sway.

RAPAMYCIN HAS A LIMITED EFFECT ON TENDON HEALING IN A RODENT MODEL

Tendon injuries occur frequently in athletes and the general population, with inferior healing leading to deposition of fibrotic scar tissue. New treatments are essential to limit fibrosis and enable tendon regeneration post-injury. In this study, we tested the hypothesis that rapamycin improves tendon repair and limits fibrosis by inhibiting the mTOR pathway.The left hindlimb of female adult Wistar rats was injured by needle puncture and animals were either given daily injections of rapamycin (2mg/kg) or vehicle. Animals were euthanized 1 week or 3 weeks post-injury (n=6/group). Left and right Achilles tendons were harvested, with the right limbs acting as controls. Tendon sections were stained with haematoxylin & eosin, and scored by 2 blinded scorers, assessing alterations in cellularity, cell morphology, vascularity, extracellular matrix (ECM) organization and peritendinous fibrosis. Immunohistochemistry was performed for the tendon pan-vascular marker CD146 and the autophagy marker LC3.Injury resulted in significantly altered ECM organization, cell morphology and cellularity in both rapamycin and vehicle-treated groups, but no alterations in vascularity compared to uninjured tendons. Rapamycin had a limited effect on tendon repair, with a significant reduction in peritendinous fibrosis 3 weeks after injury (p=0.028) but no change in cell morphology, cellularity or ECM organization compared to vehicle treated tendons at either 1 week or 3 weeks post injury. CD146 labelling was increased at the site of injury, but there was no apparent difference in CD146 or LC3 labelling in rapamycin and vehicle treated tendons.The decrease in peritendinous fibrosis post-injury observed in rapamycin treated tendons indicates rapamycin as a potential therapy for tendon adhesions. However, the lack of improvement of other morphological parameters in response to rapamycin treatment indicates that rapamycin is not an effective therapy for injuries to the tendon core.Acknowledgements: This study was funded by Versus Arthritis (22607)

Achilles tendinopathy following severe acute respiratory syndrome coronavirus 2 infection and COVID-19 vaccination

Abstract: Musculoskeletal symptoms are commonly reported following SARS-CoV-2 infection, with fatigue, arthralgia, and myalgia being the most common manifestations. Severe cases may include conditions like arthritis and rhabdomyolysis. Similarly, post-vaccination musculoskeletal symptoms have been documented. However, tendinopathy, particularly Achilles tendinopathy, remains underreported in both contexts. We present two cases of Achilles tendinopathy, one following SARS-CoV-2 infection and the other post-vaccination, to highlight potential musculoskeletal complications associated with COVID-19 and vaccination. In the first case, a 48-year-old male developed bilateral ankle pain eight weeks after a confirmed COVID-19 infection. The second case involves a 27-year-old male who experienced sudden, intense left Achilles tendon pain following SARS-CoV-2 vaccination. Case 1: The 48-year-old patient exhibited bilateral ankle pain and swelling, with MRI confirming Achilles enthesitis. Laboratory tests showed elevated ESR and CRP, with other parameters within normal ranges. Treatment with sulfasalazine led to significant improvement. Case 2: The 27-year-old patient demonstrates Achilles tendon rupture post-vaccination. Detailed findings and treatment outcomes were discussed to emphasize the rarity and significance of this condition. These two cases underscore the need for awareness and further research on the relatively serious musculoskeletal complications like Achilles tendinopathy following COVID-19 infection and vaccination. Enhanced medical understanding is crucial for optimizing patient care and addressing potential side effects effectively.

Carrying the Load Together: The Role of the Therapeutic Alliance in a Patient With Bilateral Achilles Tendon Repair With Unilateral Failure and Subsequent Infection: A Case Report

BACKGROUND: Adverse events can complicate the rehabilitation process. In complex clinical situations, the therapeutic alliance can aid the therapist and patient in navigating clinical challenges and facilitate a successful outcome. CASE PRESENTATION: A 38-year-old male presented to physical therapy after sequential bilateral Achilles tendon repairs following a 2-year history of chronic bilateral Achilles tendinopathy that did not respond to limited conservative care. The patient subsequently experienced traumatic failure and infection of the left Achilles tendon repair, necessitating prolonged medical management and physical therapy care over 56 weeks. His goals were to return to high-level physical activity and collegiate basketball officiating. OUTCOME AND FOLLOW UP: Approximately 80 weeks following initial physical therapy evaluation, the patient had returned to collegiate basketball officiating and was fully participating in high-intensity interval-based circuit training, including strength training, plyometric training, and sprint training, 3 times per week. DISCUSSION: The primary physical therapist in this case sought to intentionally develop the therapeutic alliance with the patient through use of core components of the therapeutic alliance and components of psychologically informed practice. Specific strategies were utilized to develop the therapeutic alliance and leverage it in ways that positively influenced outcomes. This case report demonstrates the theories of the therapeutic alliance in practice and serves as an example to clinicians managing complex clinical cases. JOSPT Cases 2023;3(4):235-244. Epub 13 October 2023. doi:10.2519/josptcases.2023.11557

An immunohistochemical and biomechanical evaluation of the effect of fat graft on tendon healing.

To investigate the efficacy of fat grafting in primary tendon healing through immunohistochemical and biomechanical examinations. The study material comprised a total of 10 male Sprague-Dawley rats, each approximately 10weeks old. All 10 rats were operated on bilaterally. The right Achilles tendon in all the animals was defined as the study group. The tendon was cut and then repaired, and then fat graft was applied to the repair area. The left Achilles tendon of all the rats constituted the control group. The tendon was cut and repaired with no further application. After 4 weeks, the rats were euthanised and samples were taken from the tendons for immunohistochemical and biomechanical examinations. In the biomechanical evaluations, no statistically significant difference was determined between the groups in respect of peak load and stiffness values (p: .068, p: .089, respectively). In the histopathological evaluation, the tenocyte value of the study group was superior to that of the control group (p: .04). No statistically significant differences were determined between the groups in respect of the other histopathological parameters. In the immunohistochemical evaluations, the type I collagen and TGF values of the study group were found to be higher than those of the control group (p: .011, p: .012, respectively). Compared to stem cell applications, the use of fat grafting is clinically easy to apply, has low costs, and has been shown to contribute to tendon healing at an immunohistochemical level with increased collagen and TGF beta values.

Anaesthesia for a child with α-dystroglycan-related congenital muscular dystrophy

α-Dystroglycanopathy is a newly emerging subcategory of autosomal recessive inherited muscular dystrophies which encompasses a wide spectrum of clinical severity. Mutation of at least 18 genes which are responsible for O-mannose glycosylation of α-dystroglycan has been linked to these congenital muscular dystrophy phenotypes. α-Dystroglycan-related congenital muscular dystrophy (αDG-CMD), which may be associated with multisystem involvement, poses a challenge in perioperative management. Yet, there is a dearth of resources available for reference. We report successful anaesthesia for a 6-year-old child with αDG-CMD who underwent bilateral hamstring lengthening, left Achilles tendon lengthening, and above-the-knee fibreglass for bilateral hamstring tightness. Anaesthesia was performed using total intravenous anaesthesia (TIVA) without muscle relaxant. Bilateral sciatic nerve blocks were performed for postoperative pain control, allowing opioid-free analgesia. The patient was extubated at the end of the surgery. Perioperative considerations in αDG-CMD include anticipation of difficult airway, maintenance of thermoregulation and precautions against malignant hyperthermia with the employment of TIVA, techniques that avoid opioids and neuromuscular blocking agents (particularly suxamethonium), as well as minimizing the risk of aspiration and of raised intracranial pressure.

Haglund's Disease with Clinical and Radiological Findings: 3 Case Reports

Objective: Haglund's Deformity is a variation of the posterosuperior region enlargement of the Os Calcaneus (OC) in the form of exostosis. It is associated with Haglund's Disease (HD), which encompasses Achilles tendinitis, retrocalcaneal bursitis, supra calcaneal bursitis, and inflammation of the Kager fat pad. Diagnosis is based on clinical findings and radiological methods, such as lateral ankle radiographs, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI). This study aims to present three cases of ankle pain diagnosed with HD using radiological imaging. The mean age of our cases was 44.6 years, with two females and one male. Patients commonly present with complaints of pain and swelling behind the heel. Results: Physical examination revealed pain and tenderness upon palpation over the left OC and Achilles tendon insertion. Radiological examination showed osseous protrusion in the posterosuperior part of the OC, indicating Haglund's Deformity. Edema was observed at the bony prominence of the posterosuperior OC, Kager fat pad, and heel area. The treatment plan for all three patients included leg rest splint, anti-inflammatory medication, and physical therapy. Conclusion: In cases of heel pain where traumatic events such as acute fractures are ruled out, MRI should be performed, and Haglund's Syndrome should be investigated if osseous protrusion in the posterosuperior calcaneus is observed on radiographs, along with other findings suggestive of HS.

Histological and Biomechanical Effects of Local Anesthetics and Steroids on Achilles Tendon: A Study in Rats

Background: Peritendinous injection of local anesthetics, alone or in combination with corticosteroids, is widely used in the treatment of tendinopathies. Toxicity of local anesthetics has been demonstrated in many cells, including myocytes, chondrocytes, and neurons. Bupivacaine and lidocaine are known to have time- and dose-dependent cytotoxicity in these cells. The effects of these agents on the tendon remain unknown. Purpose: To show histological and biomechanical effects after the injection of different local anesthetics and steroids, both single and combined, at different concentrations into the peritendinous sheath of rat Achilles tendon. Study Design: Controlled laboratory study. Methods: In the study, 100 rats were divided into 10 groups with equal body weights. Inflammation was induced in both Achilles tendons of each rat by means of the ball drop technique; 7 hours later, injections were made into the peritendinous sheaths of both Achilles tendons using lidocaine, bupivacaine, and dexamethasone as appropriate for the rat’s group. At the end of the first week, the right Achilles tendons of the rats were removed for histological study. Left Achilles tendons were evaluated in terms of biomechanics. Results: Histological findings demonstrated that the group with the most toxicity to the tendon was the group that received injection of dexamethasone alone. The groups with the least toxicity were those receiving dexamethasone combined with low- or high-dose bupivacaine. Biomechanical findings showed that the experimental groups had similar results to each other with the exception of the groups receiving 0.25% bupivacaine alone and dexamethasone alone, in which tendons revealed higher tensile strength. Conclusion: Local anesthetic and steroid applications have different histological and biomechanical effects on the tendon. Although the dexamethasone-injected group was the most affected in terms of histology, these changes could not be demonstrated biomechanically. Clinical Relevance: In future clinical studies, the effect of steroids on the tendon should be investigated more comprehensively. Whether biomechanical results overlap with histological results should be investigated further.

Investigation of the effects of umbilical cord-derived mesenchymal stem cells and curcumin on Achilles tendon healing - can they act synergistically?

It is known that curcumin and umbilical cord-derived mesenchymal stem cells (UC-MSCs) positively affect experi-mental tendon injury healing. This study investigated individual effects and potential synergistic effects of using curcumin and UC-MSCs alone and together. Eighty female Wistar albino rats were randomly divided into five groups: Control, curcumin, sesame oil, MSCs, and Curcumin+MSCs groups. In all rats, punch tendon defect was created in both right and left Achilles tendons. While no additional treatment was applied to the control group, curcumin, sesame oil used as a solvent for curcumin, MSCs, and MSCs and curcumin com-bination were applied locally to the injury site, respectively, in the other groups. Curcumin was solved in sesame oil before application. In each group, half of the animals were euthanized in the post-operative 2nd week while the other half were euthanized in the post-operative 4th week. The right Achilles was used for biomechanical testing, while the left Achilles was used for histological evaluation and immunohistochemical analysis of type I, Type III collagen, and tenomodulin. Histologically, significant improvement was observed in the curcumin, MSCs, and Curcumin+ MSCs groups compared to the control Group in the 2nd week. In the 2nd and 4th weeks, Type III collagen was significantly increased in the curcumin group com-pared to the control group. In week 4, tenomodulin increased significantly in the curcumin and MSCs groups compared to the control group. Tendon tensile strength increased significantly in MSCs and Curcumin+MSCs groups compared to the control group in the 4th week. No superiority was observed between the treatment groups regarding their positive effects on recovery. Locally used curcumin and UC-MSCs showed positive effects that were not superior to each other in the healing of injury caused by a punch in the Achilles tendons of rats. However, synergistic effects on healing were not observed when they were applied together.

Prevention of peritendinous adhesions with electrospun poly (lactic acid-co-glycolic acid) (PLGA) bioabsorbable nanofiber: An experimental study

In this study, we investigated the application of poly (lactic acid-co-glycolic acid) in the rat Achilles tendon injury model for the prevention or alleviation of peritendinous adhesion and guidance of Achilles tendon regeneration. In the study, 48 rats were used and the rats were randomized by closed envelope method and divided into 4 mating groups in groups of 12. Left Achilles tendons of the non-PLGA-treated control group (groups 1 and 2) were cut and repaired. In the PLGA-treated groups (groups 3 and 4) the left Achilles tendons were cut and repaired, then PLGA bioabsorbable material was wrapped around the repair line. The rats in the 1st and 3rd groups were sacrificed at the end of the 1st month, and the rats in the 2nd and 4th groups at the end of the 2nd month. The degree of tendon adhesion in the Group 3 was lower in comparison with Group 1. Similarly, compared with Group 2, the degree of tendon adhesion in the Group 4 was lower. Inflammatory density, vascularization and fibrosis were higher in the experimental group. When the Group 3 and Group 1, and Group 2 and Group 4 were compared, adhesion length (p = 0.004, p = 0.041), adhesion characteristics (p = 0.049, p = 0.039) and adhesion severity (p = 0.007, p = 0.025) were found have statistically significant tendon healing in the PLGA-treated group, respectively. Significant difference was observed in inflammatory cell density, vascular density and fibrosis for Group 1 and Group 3, (p = 0.027, p = 0.041, p = 0.002), respectively. Similarly, significant difference was observed in inflammatory cell density, vascular density and fibrosis for Group 2 and Group 4, (p = 0.002, p = 0.027, p = 0.011), respectively. As a result, it was considered that poly (lactic acid-co-glycolic acid) material significantly reduces peritendinous adhesions, and this effect could occur with the vascular density, inflammatory density and fibrosis as indicated in histopathological examination. These data suggest that PLGA membrane has good biocompatibility and alleviates tendon adhesion after injury.

Acoustic radiation force impulse elastography findings of achilles tendon in patients with hypothyroidism

Introduction
 The aim of our study was to investigate the effect of thyroid dysfunction on tendons and the contribution of Acoustic Radiation Force Impulse (ARFI) elastography to the diagnosis of tendinopathy.
 Methods
 Eighty Achilles tendons of 40 patients under levothyroxine treatment, who had previously known hypothyroidism but high serum thyroid stimulating hormone levels, and 80 Achilles tendons of 40 healthy individuals were evaluated with ARFI (Virtual Touch Quantification®). 19 of 40 of the patients with hypotiroidism’ Achilles tendons were re-evaluated after thyroid stimulating hormone levels reached to normal limits following the adjustments in thyroid hormone replacement therapy. The middle portion of the each Achilles tendon was chosen for the examination. Every examination consisted of three to five independent measurements (shear wave velocity- meters per second). The mean shear wave velocity value was calculated for each tendon, and used for statistical analysis.
 Results
 The stiffness values of both left and right Achilles tendons, represented as shear wave velocity, were similar in patients with hypothyroidism and control group. There was no significant difference between the Achilles tendon shear wave velocity measurements of 19 of 40 hypothyroidism patients who were re-evaluated after the adjustments in thyroid hormone replacement therapy.
 Conclusions
 The lack of significant difference in Achilles tendon stiffness between non-naive hypothyroid patients and the control group may be explained as a positive clinical effect of thyroid hormone replacement therapy.

Alkaptonuria with extensive ochronotic degeneration of the Achilles tendon and its surgical treatment: a case report and literature review.

Alkaptonuria is a rare genetic metabolic disorder due to deficiency of homogentisate 1,2-dioxygenase (HGD), an enzyme catalyzing the conversion of homogentisate to 4-maleylacetoacetate in the pathway for the catabolism of phenylalanine and tyrosine. HGD deficiency results in accumulation of homogentisic acid and its pigmented polymer. Ochronosis is a bluish-black discoloration due to the deposition of the polymer in collagenous tissues. Extensive ochronotic involvement of the Achilles tendon in alkaptonuria and its surgical treatment is rarely reported. A 43-year-old man presented to our clinic in March 2019 with sudden onset of left Achilles tendon pain with no history of prior trauma. Surgical exploration revealed a complete disruption of the tendon at its attachment to the calcaneus. Black pigmentation was extensive and reached the calcaneal tuberosity, extending about 7 cm from the insertion. Achilles reconstruction was performed using flexor hallucis longus tendon transfer. The patient experienced uncomplicated healing with satisfactory functional results. Orthopedic surgeons should be aware of the progressive nature of alkaptonuria. Extensive degenerative changes of the ruptured tendon should be suspected so that physicians can plan tendon repair and facilitate prompt surgical intervention.

Should children with psoriasis be consulted to a rheumatologist? Result from pediatric rheumatology-dermatology collaboration.

The objectives of this study were to determine the musculoskeletal (MSK) conditions associated with pediatric psoriasis (Pso) and to evaluate the thickness of Achilles tendon of children with Pso and healthy controls (HCs). Pso patients who were followed-up in dermatology outpatient clinic were referred to a pediatric rheumatology center. All patients and healthy peers were evaluated with standardized forms. Both patients and controls underwent ultrasonographic evaluation for Achilles tendon thickness. A total of 55 pediatric Pso and 46 healthy children were included in the study. Of patients with Pso 56.4% had arthralgia, 25.5% had lower back pain, 18.2% had heel pain, 12.7% had hip pain, and 10.9% described morning stiffness. Arthritis was detected in 7.3%, sacroiliac tenderness in 12.7%, and enthesitis in 9.1% of the patients. Arthralgia, lower back pain, and heel pain were significantly frequent in Pso group than healthy children median left and right Achilles tendon thicknesses of Pso patients who were significantly greater than that of HCs prevalence of psoriatic arthritis (PsA) among Pso patients was 7.3%. Evaluation of a child with Pso regularly for the MSK complaints is critical for the early recognition of PsA. Ultrasonography is a useful technique for screening Pso patients for early detection of enthesopaty.

Repair of Bone Erosion With Effective Urate‐Lowering Therapy in a Patient With Tophaceous Gout

A 61-year-old male patient with a 13-year history of untreated gout presented to our hospital with pain in the left knee. Physical examination revealed inflammatory changes in the left knee, large subcutaneous nodules in bilateral first metatarsophalangeal joints, and enlargement of the left Achilles tendon. Despite treatment for gout with allopurinol elsewhere during the last five years, the large subcutaneous nodules had progressed. His serum uric acid level was 5.9 mg/dL, and his C-reactive protein level was elevated (5.82 mg/dL).

Improving the regenerative microenvironment during tendon healing by using nanostructured fibrin/agarose-based hydrogels in a rat Achilles tendon injury model.

Achilles tendon injuries are a frequent problem in orthopaedic surgery due to their limited healing capacity and the controversy surrounding surgical treatment. In recent years, tissue engineering research has focused on the development of biomaterials to improve this healing process. The aim of this study was to analyze the effect of tendon augmentation with a nanostructured fibrin-agarose hydrogel (NFAH) or genipin cross-linked nanostructured fibrin-agarose hydrogel (GP-NFAH), on the healing process of the Achilles tendon in rats. NFAH, GP-NFAH, and MatriDerm (control) scaffolds were generated (five in each group). A biomechanical and cell-biomaterial-interaction characterization of these biomaterials was then performed: Live/Dead Cell Viability Assay, water-soluble tetrazolium salt-1 (WST-1) assay, and DNA-released after 48 hours. Additionally, a complete section of the left Achilles tendon was made in 24 Wistar rats. Animals were separated into four treatment groups (six in each group): direct repair (Control), tendon repair with MatriDerm, or NFAH, or GP-NFAH. Animals were euthanized for further histological analyses after four or eight weeks post-surgery. The Achilles tendons were harvested and a histopathological analysis was performed. Tensile test revealed that NFAH and GP-NFAH had significantly higher overall biomechanical properties compared with MatriDerm. Moreover, biological studies confirmed a high cell viability in all biomaterials, especially in NFAH. In addition, in vivo evaluation of repaired tendons using biomaterials (NFAH, GP-NFAH, and MatriDerm) resulted in better organization of the collagen fibres and cell alignment without clinical complications than direct repair, with a better histological score in GP-NFAH. In this animal model we demonstrated that NFAH and GP-NFAH had the potential to improve tendon healing following a surgical repair. However, future studies are needed to determine the clinical usefulness of these engineered strategies. Cite this article: Bone Joint J 2020;102-B(8):1095-1106.

Calf And Foot Injury- Crossfit

HISTORY: A 51-year-old female presented with three-year worsening left lower leg and foot pain. No injury at time of onset but was active with CrossFit five times weekly. Pain began on bottom of forefoot with radiation through the sole of foot to posterior calf and popliteal fossa. Pain described as 7-8/10 in intensity, constant, sharp/stabbing in nature, with burning sensation on the bottom of foot. Associated with weakness of the left ankle, foot drop requiring patient to wear an ankle-foot orthotic, swelling, and color changes with her foot turning blue/red intermittently. Pain was unrelieved with oral NSAIDS, steroids, and only temporary relief with topical anti-inflammatory gel, heat/ice, deep tissue massage, and dry-needling with physical therapy. PHYSICAL EXAMINATION: Examination revealed skin color changes with blue discoloration of left foot that was cool to touch. Tender to palpation maximally over left gastrocnemius muscle, Achilles tendon, sole and ball of foot; 0/5 strength with left ankle dorsiflexion/plantar flexion, ankle inversion/eversion or great toe extension. Sensation intact to light touch in L2-S2 dermatomes. Reflexes normal and symmetric bilaterally. DIFFERENTIAL DIAGNOSIS: 1.Peripheral nerve damage secondary to entrapment/compression 2.Vascular insufficiency 3.Complex regional pain syndrome TEST AND RESULTS: MRI without IV contrast of left tibia/fibula, foot, ankle: - Mild intramuscular edema within gastrocnemius and soleus, focal fatty atrophy adjacent to medial soleus muscle. Generalized subcutaneous edema throughout ankle. EMG: -No evidence of left lumbosacral radiculopathy, left lower limb mononeuropathy, or large fiber peripheral neuropathy US lower extremity Veins: - No DVT in left lower extremity Ankle brachial index: - Normal arterial Doppler study on the left leg during rest with normal PVR waveforms. NM bone scan: - No abnormal blood flow or blood pool uptake involving the left foot or ankle. Mild radiotracer uptake in left midfoot. FINAL/WORKING DIAGNOSIS: Complex regional pain syndrome TREATMENT/OUTCOMES: 1. Physical Therapy focused on strengthening exercises and desensitization techniques 2. Diclofenac topical gel applied up to four times daily 3. Gabapentin 600mg BID 4. Referral to Pain Medicine for lumbar sympathetic nerve block

Surgical Versus Nonsurgical Treatment for Acute Achilles Tendon Rupture A Systematic Review/Meta-Analysis

Abstract Background and Introduction Tendon Achilles injury affects 31.17 per 100000 per year, it has major impact on quality of life of affected patients, mostly active young patients. Different management options exist ranging from conservative treatment, to operative repair either open or percutaneous repair.no consensus has been reached on which treatment modality is preferred for each patient .in this study we systematically reviewed the literature for available evidence regarding management of tendon Achilles rupture. Aim of the Study to compare the two methods for treating Acute Achilles tendon rupture in a systematic review with meta-analysis and evaluate the functional outcomes of each methods. The objective is to perform a systematic review of overlapping meta-analysis regarding surgical versus non-surgical management of Acute Achilles tendon rupture to assist the decision makers in selecting their decision and provide intervention recommendations by the best available evidence. Methods This systematic review consisted of 5 studies, including a systematic search of the literature (PubMed, SCOPUS, and The Cochrane Library), selection of studies, extraction of study characteristics, assessment of methodological quality and bias. and extraction of data on clinical outcomes and their comparisons between different surgical groups. Results a total of 9 studies were included, 822 patients were extracted from the included studies. Of the 822 patients, 415 (50.4%) had undergone surgical intervention and 407 (49.6%) had received non-surgical treatment. The minimum follow-up duration was 12 months. The left Achilles tendon was relatively more prone to rupture. The interval from injury to treatment was within 2 to 14 days. Five 5 different surgical techniques were used; end to end, modified Kessler, augmented repair, Krackow type and interrupted circumferential stitch. Operative repair was found to significantly decrease rupture rate (risk ratio of 0.36, 95% CI 0.21-0.64; P = 0.0005) with higher risk of wound complications. No statistically significant difference between the two groups in functional outcome scores and range of motion. Conclusion We conclude that surgical technique lowers the risk of re-rupture rate but associated with higher complication rate which can be reduced by using the minimally invasive techniques. Multicenter randomized clinical trials are needed to obtain a high-quality level of evidence for the comparison between the different modified surgical techniques and the gap effect on making different decision of managements.

Effect of Autologous Platelet-rich Plasma on Appearance of Tenocytes at Injured Achilles Tendon Entheses in Rabbits.

To determine the effects of autologous platelet-rich plasma on appearance of tenocytes at injured Achilles tendon entheses in rabbits. Laboratory-based experimental study. Department of Anatomy and Pathology, Army Medical College, Rawalpindi, in collaboration with National Institute of Health, Islamabad, from March to May, 2018. Forty healthy male, 4-6 months old New Zealand white rabbits, weighing 2000-2500 gm, were randomly divided into four equal groups A, B, C and D. Group A served as control, while B, C and D were experimental groups. Injury was surgically induced at left Achilles tendon entheses of experimental groups, which were treated with injections of autologous platelet-rich plasma, at the time of induction of injury in group C and two weeks after injury in group D, while no treatment was given in group B. Animals were euthanised at the end of 12 weeks. Specimens were taken and processed for histological observations. Bonar's modified score was used to assess the appearance of tenocytes. SPSS version 21 was used for statistical analysis. Chi-square test was applied and p-value of <0.05 was taken as significant. Experimental group B showed marked deterioration in Bonar's score as compared to the control group A. The scores were significantly improved in treatment groups C and D as compared to group B. Injection of autologous platelet-rich plasma effectively improved the Bonar's modified score for appearance of tenocytes at injured entheses, 12 weeks after injury.