Symptomatic Tendon Research Articles

Sonografische Dimensionen der Patellasehne von Hochleistungssportlern

The sonographic validity of a thickened tendon as a morphological correlate of patellar tendinopathy is beyond dispute, regarding the proximal insertion at the very least. There is, however, a lack of mandatory standard values for competitive athletes and normal individuals. In addition, research findings concerning the clinical relevance of qualitative changes such as hypoechogenic regions are still inconclusive. 202 national squad athletes from the German track and field federation and 199 age-matched normal individuals were examined sonographically. 404 patellar tendons of athletes were compared as to tendon diameter at the (i) proximal insertion, (ii) waist, and (iii) distal insertion with 398 patellar tendons of normal individuals using the portable ultrasound scanner "Just Vision". Furthermore, qualitative pathologies and clinical symptoms were assessed. Athletes reported more clinical symptoms and their tendons were thicker than normal tendons at all three positions (all p's < 0.01). In athletes, proximal diameters above 6.0 mm were very likely to go along with clinical symptoms. There was an association between tendon diameter and symptoms at all three positions among the athletes, whereas in controls, this was only true for the proximal insertion. Only few consistent qualitative differences were found between athletes and normal individuals. The pattern of results confirms the clinical relevance of the proximal tendon diameter for patellar tendinopathy and provides standard values which should be evaluated in future research with regard to their prognostic utility in competitive sports. The importance of qualitative pathologies such as hypoechogenic regions could not be firmly asserted.

The prevalence and clinical significance of sonographic tendon abnormalities in asymptomatic ballet dancers: a 24-month longitudinal study

IntroductionSonographic abnormalities of the achilles and patellar tendons are common findings in athletes, and tendinopathy is a common cause of pain and disability in athletes. However, it is unclear whether...

Ultrasound-guided corticosteroid injection therapy for juvenile idiopathic arthritis: 12-year care experience

Intra-articular corticosteroid injections are a safe and effective treatment for patients with juvenile idiopathic arthritis. The potential scope of care in ultrasound-guided corticosteroid therapy in children and a joint-based corticosteroid dose protocol designed to optimize interdisciplinary care are not found in the current literature. The purpose of this study was to report the spectrum of care, technique and safety of ultrasound-guided corticosteroid injection therapy in patients with juvenile idiopathic arthritis and to propose an age-weight-joint-based corticosteroid dose protocol. A retrospective analysis was performed of 198 patients (ages 21 months to 28 years) referred for treatment of juvenile idiopathic arthritis with corticosteroid therapy. Symptomatic joints and tendon sheaths were treated as prescribed by the referring rheumatologist. An age-weight-joint-based dose protocol was developed and utilized for corticosteroid dose prescription. A total of 1,444 corticosteroid injections (1,340 joints, 104 tendon sheaths) were performed under US guidance. Injection sites included small, medium and large appendicular skeletal joints (upper extremity 497, lower extremity 837) and six temporomandibular joints. For patients with recurrent symptoms, 414 repeat injections were performed, with an average time interval of 17.7 months (range, 0.5-101.5 months) between injections. Complications occurred in 2.6% of injections and included subcutaneous tissue atrophy, skin hypopigmentation, erythema and pruritis. US-guided corticosteroid injection therapy provides dynamic, precise and safe treatment of a broad spectrum of joints and tendon sheaths throughout the entire pediatric musculoskeletal system. An age-weight-joint-based corticosteroid dose protocol is effective and integral to interdisciplinary care of patients with juvenile idiopathic arthritis.

Achilles Tendinopathy Has an Aberrant Strain Response to Eccentric Exercise

Eccentric exercise has become the treatment of choice for Achilles tendinopathy. However, little is known about the acute response of tendons to eccentric exercise or the mechanisms underlying its clinical benefit. This research evaluated the sonographic characteristics and acute anteroposterior (AP) strain response of control (healthy), asymptomatic, and symptomatic Achilles tendons to eccentric exercise. Eleven male adults with unilateral midportion Achilles tendinopathy and nine control male adults without tendinopathy participated in the research. Sagittal sonograms of the Achilles tendon were acquired immediately before and after completion of a common eccentric rehabilitation exercise protocol and again 24 h later. Tendon thickness, echogenicity, and AP strain were determined 40 mm proximal to the calcaneal insertion. Compared with the control tendon, both the asymptomatic and symptomatic tendons were thicker (P < 0.05) and hypoechoic (P < 0.05) at baseline. All tendons decreased in thickness immediately after eccentric exercise (P < 0.05). The symptomatic tendon was characterized by a significantly lower AP strain response to eccentric exercise compared with both the asymptomatic and control tendons (P < 0.05). AP strains did not differ in the control and asymptomatic tendons. For all tendons, preexercise thickness was restored 24 h after exercise completion. These observations support the concept that Achilles tendinopathy is a bilateral or systemic process and structural changes associated with symptomatic tendinopathy alter fluid movement within the tendon matrix. Altered fluid movement may disrupt remodeling and homeostatic processes and represents a plausible mechanism underlying the progression of tendinopathy.

A Novel 3-D Power Doppler Ultrasound Approach to the Quantification of Achilles Tendon Neovascularity

To investigate the amount of neovascularization in the symptomatic Achilles tendon, we developed a novel three-dimensional (3-D) power Doppler ultrasound scanning system to prospectively examine 10 patients with 12 symptomatic Achilles tendons, as well as 20 asymptomatic Achilles tendons as a control group. The mean volume of neovascularity (VON) in the whole Achilles tendon was calculated during the phase of the cardiac cycle displaying maximum vascularity and also during the phase of the cardiac cycle displaying the minimum. The mean VONs in the control group were found to be 0.41 mm 3 (maximum) and 0.02 mm 3 (minimum), respectively. The mean VONs in patients with painful Achilles tendon were 380 mm 3 (maximum) and 70.3 mm 3 (minimum), respectively. The initial results showed that the 3-D power Doppler ultrasound system could be used to measure the mean VON in controls and in patients with symptomatic Achilles tendinopathy. The results demonstrated a significantly greater VON in the maximum phase compared with the minimum phase as well as in the patient group compared with that in the control group. The system was therefore capable of defining the degree of vascularity in the Achilles tendon.

Clinical and radiological outcome of conservative vs. surgical treatment of atraumatic degenerative rotator cuff rupture: design of a randomized controlled trial

BackgroundSubacromial impingement syndrome is a frequently observed disorder in orthopedic practice. Lasting symptoms and impairment may occur when a subsequent atraumatic rotator cuff rupture is also present. However, degenerative ruptures of the rotator cuff can also be observed in asymptomatic elderly individuals. Treatment of these symptomatic degenerative ruptures may be conservative or surgical. Acceptable results are reported for both treatment modalities. No evidence-based level-1 studies have been conducted so far to compare these treatment modalities. The objective of this study is to determine whether there is a difference in outcome between surgical reconstruction and conservative treatment of a degenerative atraumatic rotator cuff tendon rupture.Methods/DesignA randomized controlled trial will be conducted. Patients aged between 45 and 75 with a symptomatic atraumatic rotator cuff rupture as diagnosed by MRI will be included. Exclusion criteria are traumatic rotator cuff rupture, frozen shoulder and diabetes mellitus. Patients will be randomized into two groups. Conservative treatment includes physical therapy according to a standardized protocol, NSAIDs and, if indicated, subacromial infiltration with a local anesthetic and corticosteroids. Surgical reconstruction is performed under general anesthesia in combination with an interscalenus plexus block. An acromioplasty with reconstruction of the rotator cuff tendon is performed, as described by Rockwood et al. Measurements take place preoperatively and 6 weeks, 3 months, 6 months and 1 year postoperatively. The primary outcome measure is the Constant score. Secondary measures include both disease-specific and generic outcome measures, and an economic evaluation. Additionally, one year after inclusion a second MRI will be taken of all patients in order to determine whether extent and localization of the rupture as well as the amount of fatty degeneration are prognostic factors.DiscussionBoth surgical as conservative treatment of a symptomatic atraumatic rotator cuff tendon rupture is used in current practice. There is a lack of level-1 studies comparing surgical vs. conservative treatment. This randomized controlled trial has been designed to determine whether the surgical treatment of a degenerative atraumatic rotator cuff tendon rupture may lead to a better functional and radiological outcome than conservative treatment after one year of follow-up.Trial registration numberNetherlands Trial Register (NTR): NTRTC2343

Achilles tendon thickness, ultrasound signs and symptoms in skaters, gymnasts, elite soccer players, club athletes and healthy sedentary adults - a cross-sectional study

BackgroundLittle is known about differences between various sports in terms of Achilles tendon pathology and ultrasonographic (US) findings. An improved knowledge of these differences may help to shed light on...

Changes in the symptoms and ultrasound signs of achilles tendinopathy during a twelve week course of loaded eccentric training: a pilot study

Background12 weeks of eccentric exercise has been shown to be a useful therapy for Achilles tendinopathy, but little is known of the time-course of recovery, or the nature of any...

Arthroscopic rotator cuff repair: Clinical outcome of 606 patients

During the last decade arthroscopic repair has evolved to become common practice in the surgical treatment of symptomatic rotator cuff tendon tears. This paper reports the results of a consecutive series of patients who underwent arthroscopic rotator cuff repair surgery. All patients were independently assessed pre and post operatively utilizing the UCLA scoring system. All procedures were performed by a single surgeon, with a minimum of one year follow-up. Operative details were noted, including patient age, tear size, type of repair performed and concomitant procedures performed. Overall, 87% of patients had a good-excellent result. The results were found to be independent of tear size, tear configuration and concomitant procedures performed. This prospective study is one of the largest series of arthroscopic rotator cuff repairs reported. According to our results, 87% of patients who underwent arthroscopic rotator cuff repair have maintained good clinical outcomes up to 8 years after surgery.

Fibromatosis of the flexor pollicus longus tendon.

An unusual case of fibromatosis of the dominant left flexor pollicus longus (FPL) in a thirteen year old schoolboy. Initially presenting with pain in the thenar eminence and difficulty flexing the metacarpal phalangeal joint (MPJ), other symptoms include locking, triggering and difficulty writing. MRI showed a 4cm segment of thickened abnormal tendon. Intra-operatively three 1cm nodules were excised from the FPL while preserving the tendon. Histopathology reported the nodules as fibromatosis.A literature search revealed that this has not previously been reported although symptomatic tendon sheath fibromas have. Our patient achieved a good result following surgical intervention and the two year review has shown no complications.

Work-related lesions of the supraspinatus tendon: a case–control study

To examine the dose-response relationship between cumulative duration of work with highly elevated arms (work above shoulder level) as well as of manual material handling and ruptures of the supraspinatus tendon in a population-based case-control study. In 14 radiologic practices, we recruited 483 male patients aged 25-65 with radiographically confirmed partial (n=385) or total (n=98) supraspinatus tears associated with shoulder pain. A total of 300 male control subjects were recruited. Data were gathered in a structured personal interview. To calculate cumulative exposure, the self-reported duration of lifting/carrying of heavy loads (>20kg) as well as the duration of work with highly elevated arms was added up over the entire working life. The results of our study support a dose-response relationship between cumulative duration of work with highly elevated arms and symptomatic supraspinatus tendon tears. For a cumulative duration of >3,195h work above shoulder level, the risk of a supraspinatus tendon rupture is elevated to 2.0 (95% CI 1.1-3.5), adjusted for age, region, lifting/carrying of heavy loads, handheld vibration, apparatus gymnastics/shot put/javelin/hammer throwing/wrestling, and tennis. The cumulative duration of carrying/lifting of heavy loads also yields a positive dose-response relation with disease (independent from work above shoulder level and from handheld vibration), with an adjusted odds ratio of 1.8 (95% CI 1.0-3.2) in the highest exposure category (>77h). We find an increased risk for subjects exposed to handheld vibration with an adjusted OR of 3.2 (95% CI 1.7-5.9) in the highest exposure category (16years or more in the job with exposure), but a clear dose-response relationship is lacking. This study points to a potential etiologic role of long-term cumulative effects of work with highly elevated arms and heavy lifting/carrying on shoulder tendon disorders.

Troubles du comportement : les maladies métaboliques par intoxication

Lesions of the long head of the biceps tendon have been recognized to be a common source of anterior shoulder pain and dysfunction. Common syndromes include primary biceps tendinitis, symptomatic biceps tendon subluxation, traumatic biceps tearing, coracoid impingement, and biceps tendinitis associated with either superior labrum anterior-to-posterior lesions or rotator cuff tears. The diagnosis is made on history of anterior shoulder pain, tenderness in the bicipital groove, and symptomatic relief of the pain with an injection of local anesthetic into the bicipital groove. MRI is not reliable in the diagnosis of biceps tendon disorders. When nonoperative treatment fails to relieve the symptoms of painful biceps tendinitis, biceps tenotomy or biceps tenodesis are often considered. In this chapter, we will review the pathology and anatomy of biceps tendon lesions, and the advantages of arthroscopic-assisted subpectoral biceps tenodesis. Excellent outcomes have been reported with this technique.

Bilateral Symptomatic Snapping Biceps Femoris Tendon due to Fibular Exostosis

We present an unusual case of an athletic 17-year-old male cyclist with bilateral chronic dislocating biceps femoris tendons. On flexion of the knee, the biceps tendon subluxed over a large exostosis, creating a snapping sound. Snapping of tendons is common around the hip, ankles, shoulder, and elbow, but rare at the knee. When it does occur, snapping about the knee can be due to discoid meniscus, rheumatoid nodules, synovial plicae, iliotibial band syndrome, congenital snapping knee, and snapping tendons. Research revealed only 5 previous cases due to subluxation of the biceps femoris tendon. The case we present is the only one due to an exostosis, as well as the only one that required bilateral surgical repair. The patient presented when his pain became significant enough to interfere with his ability to continue competitive cycling.

Partial Tendon Release for Treatment of a Symptomatic Snapping Biceps Femoris Tendon: A Case Report

Snapping of the biceps femoris tendon over the fibular head is an uncommon condition. Reported causes include an anomalous insertion of the tendon, trauma at the insertion site of the tendon, and an abnormality of the fibular head. This article reports a case of a painful snapping biceps femoris tendon in a patient without an anomalous tendon insertion or an abnormality of the fibular head. Partial release of the superior aspect of the tendon resulted in resolution of symptoms.

Real-Time Sonoelastography of Lateral Epicondylitis: Comparison of Findings Between Patients and Healthy Volunteers

The purpose of this study was to evaluate real-time sonoelastography in the assessment of the origins the common extensor tendon in healthy volunteers and in patients with symptoms of lateral epicondylitis. The findings were compared with those obtained at clinical examination, ultrasonography, and power Doppler sonography. Thirty-eight elbows of 32 consecutively registered patients with symptoms of lateral epicondylitis and 44 asymptomatic elbows of 28 healthy volunteers were assessed with ultrasound and real-time sonoelastography. A clinical examination was performed, and pain was classified with a visual analog scale. In healthy volunteers, real-time sonoelastographic images showed hard tendon structures in 96% of tendon thirds and mild alterations in 4%. Real-time sonoelastography of patients showed hard structures in 33% of tendon thirds but softening of different grades in 67%, a statistically significant difference in relation to the findings in healthy volunteers (p < 0.001). Lateral collateral ligament involvement and overlying fascial involvement were more commonly detected with real-time sonoelastography. The sensitivity of real-time sonoelastography was 100%, the specificity 89%, and the accuracy 94% with clinical examination as the reference standard. Good correlation with ultrasound findings was found (r > or = 0.900). No correlation was observed between ultrasound or real-time sonoelastographic findings and power Doppler sonographic findings, but power Doppler sonographic findings had a strong correlation with the visual analog scale score. Real-time sonoelastography is valuable in the detection of the intratendinous and peritendinous alterations of lateral epicondylitis and facilitates differentiation between healthy and symptomatic extensor tendon origins with excellent sensitivity and excellent correlation with ultrasound findings.

Is the central portal a safe approach for arthroscopy of the knee?

Dear Editor, I read with interest the report by Bayar et al. [1]. Recently, my colleagues and I submitted a similar study to Current Orthopedic Practice (in review), stimulated by the concerns regarding with the transtendineal arthroscopic portal. Several papers after the original publication by Gillquist and Hagberg [6] have shown the central approach is a useful portal in knee arthroscopy [3, 8]. Eriksson [5], however, in a cadaveric study, found that this does not offer any major advantages compared with the standard lateral portal. In addition, this portal has been associated with increased postoperative pain, and decreased isokinetic quadriceps strength postoperatively. Complications, such as peritendinitis, tendinitis or tendon granuloma have been reported [2, 3]. In my practice, the central approach in arthroscopy of the knee has been a useful portal when convectional portals do not offer ample vision or good arthroscopy triangulation as in bucket-handle tears on the medial meniscus or to resection fibrous tissue around the stub in an old injury of the anterior cruciate ligament. In our study, an ultrasonographic follow-up in a series of eight patients (ten knees) who underwent arthroscopy for bucket-handle tears on the medial meniscus and utilized central portal, the procedure was well tolerated. In addition, we found no changes of the echotexture in the patellar tendon, such as an abnormal echogenecity, enlargement, or nodules 4–6 weeks after arthroscopy. No remarkable differences of the sagittal diameter of the patellar tendon were found when the affected and unaffected knees were compared. According to Martino et al. [7], ecographic changes in the patellar tendon are usually temporary events linked with normal cicatrisation weeks after the surgery and should not be considered a necessary complication of arthroscopy. Bayar et al. [1] found ecographic changes after several months. However, even when they found echographic thickness and focal hypoechoic areas in the patellar tendon, none of the patients had complaints and returned to their previous physical activity level. As referenced by Bayar et al. in their article [1], ultrasonographic findings such as hypoechoic areas of the patellar tendon had no significant relationship with the risk of patellar tendinitis in asymptomatic individuals [4]. Therefore, the interpretation of isolate changes as an abnormality in the tendon may be confusing, to conclude that the central approach is unsafe for arthroscopy of the knee. I agree with Bayar that the central portal should be avoided in patients with a symptomatic or previous tendon injury, and that future studies are needed to delineate indications and avoidance criteria of the central arthroscopic approach of the knee.

The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England

To investigate the prevalence of posterior tibial tendon dysfunction (PTTD) in women over the age of 40. A validated survey was posted to a random sample of 1000 women (over 40 years) from a GP group practice in Hertfordshire, England. Survey positive women were telephoned and when indicated, a detailed examination was performed. There were 582 usable responses. The majority indicated they had minor forefoot or no problems. Telephone contact was made with 116 women and of those 79 required examination. The diagnosis of symptomatic flatfeet was made in 9 patients, 7 patients had stage I PTTD, 12 patients had stage II PTTD and 9 patients had an adult acquired flatfoot deformity. This is the first report of the prevalence of stage I and II PTTD in women (over 40 years). The prevalence is 3.3% and all patients were undiagnosed despite characteristic and prolonged symptoms.

A new arthroscopic classification of articular-sided supraspinatus footprint lesions: A prospective comparison with Snyder's and Ellman's classification

The aim of this study was to find a descriptive rationale to quantify articular-sided supraspinatus tendon tears in the transverse and coronal planes, leading to a 2-dimensional description of the tear pattern. Fifty-six consecutive patients with articular-sided, symptomatic supraspinatus tendon tears diagnosed clinically and by magnetic resonance imaging underwent standardized diagnostic arthroscopy. Intra-articular findings of the rotator cuff were classified according to Ellman and Snyder. In addition, the longitudinal tear was assessed according to the length of the peeled-off bony footprint in the coronal plane. The sagittal tear extension was defined as a tear of the lateral reflection pulley on the medial border of the supraspinatus tendon and/or a tear in the area of the crescent zone. Statistically, we found a high correlation (r = 0.920, P < .0001) between the classifications of Ellman and Snyder, and we found only a slight correlation between the classifications of Snyder and Ellman with this new classification. Neither the classification of Snyder nor that of Ellman reproduced the extension of the partial-thickness rotator cuff tear in the transverse and coronal planes related to its etiologic pathomorphology.

The Proximal Biceps Tendon: Tricks and Pearls

The diagnosis and treatment of proximal biceps tendon injuries continue to be a challenge. The difficulty lies on determining if there is isolated biceps pathology versus concomitant rotator cuff tears or instability. Imaging modalities, such as magnetic resonance imaging, continue to provide us with the extra tool to help us confirm our suspicion of additional pathology. Symptomatic biceps tendon tears can undergo debridement, tenotomy, or tenodesis if nonoperative measures fail to provide relief. Reports from performing a biceps tenotomy often give similar functional outcomes compared with tenodesis. Cosmetic deformity on the lateral arm may be noted with tenodesis and initial fatigue. Tenodesis may subject the patient to a longer rehabilitation process and increased pain. The decision of which one should be performed lies between the physician and the patient's expectations.

Subpectoral Biceps Tenodesis

The long head of the biceps brachii (LHB) tendon has long been recognized as a source of shoulder pain. Surgeons have debated the merits of tenotomy versus tenodesis, open versus arthroscopic approaches, and various fixation methods. This article reviews the clinical findings associated with LHB pathology, describes the operative technique of subpectoral biceps tenodesis, and reviews the current literature related to treatment of the symptomatic LHB tendon. The miniopen subpectoral approach is technically less demanding than purely arthroscopic techniques, and offers the potential for improved pain relief without cosmetic deformity by removing most of the LHB and its associated tenosynovium. As the literature on the topic continues to grow, subpectoral biceps tenodesis has emerged as an effective treatment for pathology of the LHB.