Symptomatic Tendons Research Articles

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

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

Shear Wave Elastography (SWE) for Monitoring of Treatment of Tendinopathies: A Double-blinded, Longitudinal Clinical Study

We aimed to investigate the diagnostic accuracy with which shear wave elastography (SWE) can be used to monitor response to treatment of tendinopathies, and to compare it to conventional ultrasound (US)-imaging methods (B-mode US (B-US) and power Doppler US (PD-US)). A prospective Institutional Review Board-approved longitudinal study on 35 patients with 47 symptomatic tendons (17 Achilles-, 15 patellar-, and 15 humeral-epicondylar) who underwent standardized multimodal US and standardized clinical assessment before and after 6 months of treatment (tailored stretching exercise, sport break, and local Polidocanol) was carried out. All US studies were performed by radiologists blinded to the clinical symptoms on both tendon sides to avoid biased interpretations, by B-US, PD-US, and SWE, conducted in the same order, using a high-resolution linear 15 MHz probe (Aixplorer). Orthopedic surgeons who were in turn blinded to US imaging results used established orthopedic scores (Victorian Institute of Sports Assessment questionnaire for Achilles, Victorian Institute of Sports Assessment questionnaire for patellar tendons, and Disability Arm Shoulder Hand scoring system) to rate presence, degree, and possible resolution of symptoms. We analyzed the diagnostic accuracy with which the different US imaging methods were able to detect symptomatic tendons at baseline as well as treatment effects, with orthopedic scores serving as reference standard. B-US, PD-US, and SWE detected symptomatic tendons with a sensitivity of 66% (31 of 47), 72% (34 of 47), and 87.5% (41 of 47), respectively. Positive predictive value was 0.67 for B-US, 0.87 for PD-US, and 1 for SWE. After treatment, clinical scores improved in 68% (32 of 47) of tendons. Treatment effects were observable by B-US, PD-US, and SWE with a sensitivity of 3.1% (1 of 32), 28.1% (9 of 32), and 81.3% (26 of 32), respectively. B-US was false-positive in 68.8% (20 of 32), PD-US in 46.9% (15 of 32), and SWE in 12.5% (4 of 32) (SWE). Clinical scores and B-US, PD-US, and SWE findings correlated poorly (r = 0.24), moderately (r = 0.59), and strongly (r = 0.80). Unlike B-US or PD-US, SWE is able to depict processes associated with tendon healing and may be a useful tool to monitor treatment effects.

Caracterización por Ultrasound Tissue Characterization de los tendones rotulianos de jugadores de baloncesto; comparación entre profesionales versus formativos y asintomáticos versus sintomáticos

IntroductionConventional ultrasound helps to identify the macroscopic changes produced in the injured tendon. However, these changes do not correlate well with the symptoms or the response to treatment. The ‘characterization of tissues by ultrasound’ (UTC) evaluates the structure of the tendon in 3 dimensions and classifies it into 4 echo-types. The aim of this study was to investigate the structure of the patellar tendon in basketball players using the UTC technique, and to study the differences between professional and amateur players by comparing the dominant leg with the non-dominant one, and the asymptomatic with the asymptomatic ones. Material and methodsThe study included 40 patellar tendons (20 basketball players). The structure of the patellar tendon (proximal, medial, and distal) was quantified by means of UTC at the beginning of the pre-season. The within and between observer reliability was measured using the intraclass correlation coefficient (ICC). ResultsThe mean ages of the 10 professional players and 10 amateur players were 28.1 years (SD 4.5) and 17.6 years (SD 1.3), respectively. The thickness of the patellar tendon was greater in the professional players (P<.05), in the dominant leg (P<.05), and in symptomatic tendons (P<.05). There were no significant differences in the echo-types, except in the case of echo-type II in the proximal portion of the right patellar tendon, between professional and amateur players (P=.05). Similarly, there was a difference in echo-type III and IV of the proximal portion of the right tendon between symptomatic and asymptomatic players (P<.05). A good, high reliability was found with these techniques (ICC=.80-.99). ConclusionsThe ultrasound pattern of the patellar tendons of basketball players has been characterised using UTC. The thickness of the tendon is greater in professional players than in amateur players. It has also been observed that the symptomatic tendons are thicker than in asymptomatic ones. There were no significant differences in the UTC patterns between professional and amateur players, or between symptomatic and asymptomatic ones.

High Volume Image Guided Injections with or without Steroid for Mid-Portion Achilles Tendinopathy: A Pilot Study

Objective: High volume image guided injections of local anaesthetic and saline plus steroid plus structured rehabilitation (HVIGI and SR) have been shown to improve outcomes in Achilles tendinopathy (AT) patients. Due to concerns about steroid safety, our aim was to determine whether omitting the steroid altered the clinical effects of HVIGI and SR. Methods: 23 consecutively recruited patients with AT (26 symptomatic tendons) were treated with a HVIGI composed of 10mls of 0.5% Marcaine mixed with either 40 ml of normal saline including 25 mg of hydrocortisone or 40 ml of saline only. Treatment allocation was determined by patient selection. The VISA-A questionnaire and visual analogue scales (VAS) were administered at pre-injection; 2, 6 and 10 weeks; and 12-month follow-up. Results: VISA-A scores improved significantly in both groups, from a pre-injection mean (± SD) of 42.0 (± 20.5) to 86.9 (± 11.8) (p<0.01) in the ‘with steroid’ group, and from 42.6 (± 9.1) to 83.3 (± 12.2) (p<0.01) in the non-steroid group at final follow-up. VAS scores improved significantly in both groups. There was no statistically significance difference between the groups at baseline or any follow-up, in either VISA-A and VAS changes. A stronger effect size in favour of no steroid was seen at 10 weeks. Conclusion: Overall, HVIGI and SR without steroid yields similar effects on pain reduction and functional improvement in comparison to HVIGI and SR with steroid. These results suggest that the effects of the injection may be mechanical rather than chemical, and that the steroid can be omitted. A randomised controlled trial is required to confirm this.

Shear Wave Elastography (SWE) for the Evaluation of Patients with Tendinopathies

Shear wave elastography (SWE) has been shown to be a powerful tool to estimate tissue stiffness. The aim of this study was to compare the diagnostic accuracy of SWE to that of standard ultrasound (US) (combined use of B-mode US and power Doppler [PD] US) for diagnosing tendinopathies. This is a prospective institutional review board-approved study on 112 participants (mean age 42 ± 13.4 years) with chronic (>6 months) tendon pain in Achilles, patellar, or epicondylar tendons. Participants were systematically examined with US, PD, and SWE using a high-resolution linear 15 MHz probe (SuperSonic Imagine). A semiquantitative analysis of SWE color charts and a quantitative region of interest-based analysis of tendon elasticity were performed. SWE values of symptomatic and healthy tendons were compared by using Student t test. Clinical symptom scores served as the standard of reference. US findings were compared to clinical symptom scores by using Spearman correlation. At semiquantitative analysis of SWE color charts, symptomatic tendons were rated as "soft" in 80/140 (57.1%), as "intermediate" in 54/140 (38.6%), and as "rigid" in 6/140 (4.3%). Healthy tendons were rated as "soft" in 8/84 (10%), as "intermediate" in 31/84 (37%), and as "rigid" in 45/84 (53%). At quantitative analysis, symptomatic tendons exhibited significantly lower mean SWE values (60.3 kPa/4.48 m/s; range 15.3-201.4 kPa/2.26-14.18 m/s) than healthy tendons (185 kPa/7.85 m/s; range 56-265 kPa/4.32-9.23 m/s) (P = 0.0004). SWE values correlated closely with patients' clinical symptoms obtained by clinical scores (r = 0.81). Overall sensitivity of conventional US and PD in detecting tendinopathies could be enhanced from 67.1% (94/140) to 94.3% (132/140) when combined with SWE. SWE is a simple way to estimate tissue stiffness and, by reduced tissue rigidity, to identify tendon pathology. SWE significantly increases the diagnostic accuracy of tendon sonography and may prove to be a sensitive tool to early detect or monitor tendinopathy.

Ultrasound-guided retro-calcaneal bursa corticosteroid injection for refractory Achilles tendinitis in patients with seronegative spondyloarthropathy: efficacy and follow-up study.

Ultrasound (US)-guided corticosteroid injection has been shown to be safe and effective for varied causes of plantar fasciitis; however, its use for Achilles tendinitis is controversial. We studied the efficacy and changes in US findings at Achilles enthesitis after corticosteroid injection in patients with spondyloarthropathy (SpA). Patients with SpA with symptomatic Achilles enthesitis, refractory to 6weeks of full-dose NSAIDs, were offered US-guided local corticosteroid injection. Injected entheses were examined by US (both B mode and power Doppler) at baseline and 6weeks after injection. Standard OMERACT definitions were used to define enthesitis. Achilles tendon thickness >5.29mm, 2cm proximal to insertion in long axis, was considered thickened. Twenty-seven symptomatic Achilles tendons (in 18 patients) were injected with 20mg methylprednisolone under US guidance baseline, and 6-week follow-up US features were compared. All patients reported improvement in pain (VAS) in the affected tendon after injection (p<0.0001). Simultaneously, improvement in local inflammatory changes were noted, in the form of significant reduction in tendon thickness (p<0.0001), vascularity (p<0.0001), peritendinous oedema (p=0.001), bursitis and bursal vascularity (p<0.001 and<0.0001, respectively). There was no change in bone erosions and enthesophyte. None of the patients had tendon rupture or other injection-related complications at 6weeks of follow-up. US-guided local corticosteroid injection is an effective and safe modality for refractory Achilles enthesitis in patients with SpA and leads to reversion of acute changes at entheseal site.

Role of ultrasonography in the evaluation of Achilles tendon disorders

Background This study was conducted to highlight the role of ultrasonography as an initial imaging modality for evaluation of symptomatic Achilles tendon disorders. Patient and Methods 60 patients (33 men and 27 women) had symptomatic Achilles tendons disorders and confirmed clinically as all patients were referred from orthopedic surgery department. 20 patients had history of blunt trauma followed by pain which may be associated with lost plantar flexion. 40 patients had chronic pain either associated or not associated with swelling at the site of Achilles tendon. US examination (13 MHz probe, GE logic P5 machine) using real time with color and power Doppler examination was performed while the patient in prone position. Results US depicted full-thickness tears in 11 (18.5%) tendons where tendon gaps were not significant (less than 5 mm) in 6 tendons and significant (more than 5 mm) in 5 tendons. De novo partial tears were detected in 15 (25%) tendons. Tendinopathy were seen in 18 (30%) tendons. US depicted paratenonopathy in 3 tendons (5%). 13 (21.7%) tendons appeared normal by ultrasonography. Conclusion Ultrasonography is an initial imaging of choice for evaluation of symptomatic Achilles tendon disorders. Diagnostic accuracy reaches 85%. However, Tendons that appeared normal by US should be followed by MRI for more diagnostic accuracy, detailed regional evaluation and subsequently can exclude other etiologies giving similar clinical manifestations.

Tendinopathy alters ultrasound transmission in the patellar tendon during squatting.

Measurement of loading patterns of the patellar tendon during activity is important in understanding tendon injury. We used transmission-mode ultrasonography to investigate patellar tendon loading during squatting in adults with and without tendinopathy. It was hypothesized that axial ultrasonic velocity, a surrogate measure of the elastic modulus of tendon, would be lower in tendinopathy. Ultrasound velocity was measured in both patellar tendons of adults with unilateral patellar tendinopathy (n=9) and in healthy controls (n=16) during a bilateral squat maneuver. Sagittal knee movement was measured simultaneously with an electrogoniometer. Statistical comparisons between healthy and injured tendons were made using two-way mixed-design ANOVAs. Axial ultrasound velocity in both symptomatic and asymptomatic patellar tendons in tendinopathy was approximately 15% higher than in healthy tendons at the commencement (F1,23 =5.2, P<0.05) and completion (F1,23 =4.5, P<0.05) of the squat. While peak velocity was ≈5% higher during both flexion (F1,23 =5.4, P<0.05) and extension (F1,23 =5.3, P<0.05) phases, there was no significant between-group difference at the midpoint of the movement. There were no significant differences in the rateand magnitude of knee movement between groups. Although further research is required, these findings suggestenhanced baseline muscle activity in patellar tendinopathy and highlight fresh avenues for its clinical management.

The reliability of ultrasound imaging in measuring tendon size: systematic review and clinical implications

Background: Pathological tendons are known to increase their diameter, which can be viewed using ultrasound (US) and MRI. Although systematic reviews have confirmed the reliability of US for the measurement of muscle thickness, no such reviews exist to examine the reliability of US measures of tendon size. Purpose: To systematically review the literature on the reliability of US to assess tendon dimensions including thickness and cross-sectional area in human limbs. Methods: A comprehensive review of electronic databases was performed by two reviewers using an agreed range of keywords. Clinical trials which investigated inter or intra rater reliability of real time ultrasound was included in this review. The Quality Appraisal of Reliability Studies (QAREL) checklist was used to assess risk of bias. Included studies performed ultrasound analysis in a range of clinical settings. Variations existed between studies in terms of rater training, tendons studied, and participant pain status. Inter and Intra rater reliability of tendon thickness and cross sectional area were analysed using estimates of both reliability and precision using intraclass correlation coefficients (ICC’s) and coefficients of variation (CVs), percentage coefficient of variation (CV%), percentage standard error of the mean (SEM%), limits of agreement (LOA), pearsons correlation coefficient (r2) and 95% confidence intervals (95% CI). Results: A total number of 615 were included in the review. Of this 136 were Symptomatic and 479 were asymptomatic participants, with an age range: 17.5–73 years. Assessment of the risks of bias indicated 15/16 chosen studies was of high quality. ICC values for inter and intra rater reliability indicate good to excellent reliability for all tendon sites with values ranging from (0.55–0.99). Percentage coefficent of variation (CV%) ranged from 0-16% across all tendon sites. The most commonly studied tendons achilles and supraspinatus, the average measurement error from the included studies on Achilles tendons was 9.5% %CV and 5.39% SEM%, these figures equate to errors of 0.67mm and 0.32mm respectively which is well below the observed differences between symptomatic and asymptomatic tendons. The average measurement error from the included studies on supraspinatus tendons was 11.24% %CV and 5.72% SEM%, which equate to errors of 0.77mm and 0.39mm respectivelywhich is similar to, or below, the proposed differences between symptomatic and asymptomatic tendons.LOA ranged from (0.35–3.50mm), r2 ranged from (0.43–0.92), 95% CI ranged from (0.43–0.98) for all tendons. Conclusion(s): Findings of the current review appear to indicate that real time ultrasound is a clinically reliable method inmeasuring tendondimensions.However thesefindings must be considered in light of the limitations identified in the studies with a wide array of statistical methodology and wide range of measurement protocols and assessors. Implications: The findings of this current review may have important clinical implications as regards indicating future direction for possible injury prevention strategies. An understanding of the relationship between sonographic abnormalities and the likelihood of the development of symptoms in asymptomatic individuals, may allow ultrasound to be used as a screening tool to identify athletes at risk and guide prophylactic treatments or training modifications.

Evaluation of Achilles and patellar tendinopathy with greyscale ultrasound and colour Doppler: using a four-grade scale.

In tendon research, using ultrasound (US), studies often refer to tendon thickness, structural abnormalities and neovascularisation. The reliability concerning these measurements and evaluations is seldom reported. The aim of this study was to assess the intra- and inter-observer reliability for quantitative measures (thickness) and qualitative evaluations (structure and neovascularisation) of symptomatic and asymptomatic Achilles and patellar tendons with US and colour Doppler using a modified Öhberg score. Twenty-eight consecutive patients with symptomatic and asymptomatic Achilles (n=27) and patellar tendons (n=26) were included. Tendon anteroposterior thickness was measured. Tendon structure and neovascularisation were evaluated using a modified Öhberg score. US-images were evaluated twice by four independent observers. Mean thickness for Achilles and patellar tendons was 8.4mm (±2.0) and 5.5mm (±1.7), respectively. The reliability for measures of distance was high all over (ICC=0.963-0.999). A moderate-strong correlation was found between observers concerning evaluation of neovascularisation (r=0.767-0.992) and poor-moderate correlation concerning evaluation of structural changes (r=0.379-0.837). Intra-observer reliability was moderate strong for evaluations of both tendon structure (k=0.537-0.873) and neovascularisation (k=0.639-0.864). With a strict method for how to measure tendon thickness and set criteria for evaluating structural changes and amount and distribution of neovascularisation, US and colour Doppler is a reliable method for evaluating Achilles and patellar tendons. The modified, 4-graded, Öhberg score was found to be a reproducible instrument for assessment of tendon structure and neovascularisation.

Belastungsabhängige Prävalenz von Patellasehnen-Tendinopathie und sonographischen Veränderungen junger Nachwuchsathleten

BackgroundPrevalence of Patella tendinopathy (PT) in athletes was shown to be present in up to 45%. However, representative data of PT and morphological tendon alterations in adolescent athletes at the beginning of their systematic training are not known, yet. Material und MethodsA total of 536 adolescent athletes (12.6±1.5 years) out 16 different sports, categorized into 6 types of sports, were included in the study. Tendinopathy was diagnosed in case of pain in history and tendon pain on palpation. Structural tendon irregularities (neovascularization, hypo- und hyperechogenicities) were detected sonographically. ResultsIn 4.5% of the adolescent athletes PT was diagnosed. No statistically significant differences were detected in prevalence of PT between different categories. Sonographically 11.8% of tendons presented neovascularizations, 1.6% hypo- and 0.2% hyperechogenicities. Symptomatic tendons had significantly more neovascularizations and hypoechogenicities. ConclusionsPT is present already at the start of systematic training in adolescent athletes. It correlates with a higher amount of intratendinous structural changes. Level of evidenceII (Cohort study – Cross-sectional survey)

Dynamic contrast enhanced magnetic resonance imaging in chronic Achilles tendinosis

BackgroundChronic Achilles tendinosis is a common problem. When evaluating and comparing different therapies there is a need for reliable imaging methods. Our aim was to evaluate if chronic Achilles tendinosis affects the dynamic contrast-enhancement in the tendon and its surroundings and if short-term eccentric calf-muscle training normalizes the dynamic contrast-enhancement.Methods20 patients with chronic Achilles tendinopathy were included. Median duration of symptoms was 31 months (range 6 to 120 months). Both Achilles tendons were examined with dynamic contrast enhanced MRI before and after a 12- week exercise programme of eccentric calf-muscle training. The dynamic MRI was evaluated in tendon, vessel and in fat ventrally of tendon. Area under the curve (AUC), time to peak of signal, signal increase per second (SI/s) and increase in signal between start and peak as a percentage (SI%) was calculated. Pain and performance were evaluated using a questionnaire.ResultsIn the fat ventrally of the tendon, dynamic contrast enhancement was significantly higher in the symptomatic leg compared to the contralateral non-symptomatic leg before but not after treatment. Despite decreased pain and improved performance there was no significant change of dynamic contrast enhancement in symptomatic tendons after treatment.ConclusionIn Achilles tendinosis there is an increased contrast enhancement in the fat ventrally of the tendon. The lack of correlation with symptoms and the lack of significant changes in tendon contrast enhancement parameters do however indicate that dynamic enhanced MRI is currently not a useful method to evaluate chronic Achilles tendinosis.

Mechanical properties of the patellar tendon in elite volleyball players with and without patellar tendinopathy

BackgroundAlthough differences in mechanical properties between symptomatic and healthy tendons have been observed for the Achilles tendon, the impact of tendinopathy on patellar tendon mechanics is not fully documented. The...

The Volume of the Neovascularity and Its Clinical Implications in Achilles Tendinopathy

Thirty-seven pathologic Achilles tendons from 27 patients were investigated by a three-dimensional (3-D) power Doppler ultrasound system. Both the volume of the neovascularity (VON) and the volume of Achilles tendon (VOAT) were investigated. VON-VOAT index (VVI), as the normalization of the neovascularization, was accordingly calculated. Patient's clinical indications were assessed using the visual analog scale for pain (VAS) and Victorian Institute of Sport Assessment Achilles (VISA-A). Relationships between VAS and VON, VISA-A and VON, VAS and VOAT, VISA-A and VOAT, VAS and VVI, and VISA-A and VVI, were statistically analyzed. The vascular mapping within and surrounding the symptomatic Achilles tendons was investigated. 97.3% of the Achilles tendons were found to have neovascularization. In 55.6% of these Achilles, the neovascularity was associated with the location of thickening. The VAS was found to be positively correlated with the VON and the VVI, the VON was found to be independent from the VOAT.

High-volume injection in the management of recalcitrant mid-body Achilles tendinopathy: a prospective case series assessing the influence of neovascularity and outcome

AbstractObjectivesTo determine the effectiveness of ultrasound-guided high-volume injection (HVI) and relevance of neovascularity on outcome in Achilles tendinopathy.MethodsThis prospective clinical study at the Homerton University Hospital included 32 patients with recalcitrant unilateral mid-substance Achilles tendinopathy. Outcome measures used were Victorian Institute of Sport Assessment-Achilles tendon (VISA-A), Visual Analogue Score (VAS), modified Ohberg score and mean maximum tendon thickness.ResultsSignificant improvements in both VAS and VISA-A scores at 1 month (95% confidence interval (CI), 6.6–3.2, P < 0.001 and 37.2–63.7, P < 0.001). This improvement was maintained at 3 months (95% CI, 6.6–2.9, P < 0.001 and 37.2–65.9, P < 0.001). Symptomatic tendons were significantly thicker at baseline than the asymptomatic side (95% CI, 8.3 mm compared to 5.9 mm, P < 0.001). There was a significant decrease in maximum tendon thickness in the symptomatic tendons at baseline and at 3 months (95% CI, 8.3–7....

Ultrashort echo time MR imaging with off‐resonance saturation for characterization of pathologically altered Achilles tendons at 3 T

Off-resonance radiofrequency saturation pulses applied prior to regular excitation in MR sequences can be used to modify signal contrast based on magnetization transfer and direct saturation effects. Clinical applicability and value of ultrashort echo time sequences combined with off-resonance saturation pulses was tested in 16 healthy and 14 tendinopathic as well as paratendinopathic Achilles tendons in vivo at 3 T. A 3D ultrashort echo time sequence in combination with a gaussian off-resonance saturation pulse (frequency offset: 1000-5000 Hz) was used to modify the detectable MR signal intensity from the Achilles tendon. Off-resonance saturation ratio was calculated as the relative reduction in signal intensity under selective off-resonance saturation in relation to a reference measurement without any saturation pulse. Off-resonance saturation ratio in tendons of healthy volunteers ranged from 0.52 ± 0.06 (1000 Hz) to 0.24 ± 0.02 (5000 Hz), whereas symptomatic tendinopathic tendons (0.35 ± 0.04 to 0.17 ± 0.02) and asymptomatic tendinopathic tendons (0.41 ± 0.06 to 0.21 ± 0.02) showed significantly lower mean off-resonance saturation ratio values. Off-resonance saturation ratio values might provide a sensitive and quantitative marker for assessment of pathological microstructure alterations of the Achilles tendon.

Quantifizierte TDI-Elastosonografie der Patellarsehne bei Sportlern

TDI elastosonography allows, in contrast to conventional methods, a quantitative-numerical evaluation of the quality of a tendon on the basis of so-called strain scores. Previous studies on elastosonography were mainly based on qualitative methods, which only allow for a graduated colour and optical-visual representation. The aim of this study was to assess the strain scores of non-symptomatic compared to symptomatic patellar tendons in order to estimate reference values. Furthermore, the correlation between the neovascularisation apparent in power Doppler sonography and the magnitude of the strain scores was investigated. In total n = 75 athletes aged 33.2 ± 12.7 years were included in the study, with the ligamentum patellae diagnosed in n = 37 as being clinical non-symptomatic and in n = 38 as being symptomatic. After a detailed anamnesis and a clinical examination, all subjects underwent a conventional B-mode, a Dynaflow power Doppler and a TDI elastosonography of the ligamentum patellae using the Aplio MX (Toshiba Medical Systems, Corp.) in the longitudinal and cross-section planes, respectively. The strain scores of the non-symptomatic ligamentum patellae in the longitudinal section were on average 0.070 (± 0.039) depending on the measuring field. The symptomatic tendons showed significantly higher values in the longitudinal section with an average of 0.137 (± 0.052). Similar values were evident in the cross-section. In 58 % of the symptomatic tendons neovascularisation was detected. A correlation between the duration of the medical history and the presence of neovascularisation was thereby verified. The presented results show that TDI elastosonography in the hands of an experienced examiner is an appropriate method for quantifying the quality of the patellar tendon and gives additional information beyond that of B-mode, power Doppler sonography and MRI. To what extent the strain scores of the TDI elastosonography in addition to conventional sonography can influence the choice of the therapeutic procedure must be evaluated by conducting further studies.

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.

Blood flow of the achilles tendon during military training

BackgroundThe link between the hypervascularisation and the pain symptoms in a tendinopathy is still obscure. It can be hypothesised that it is important to take the stage of the tendinopathy...