Treatment Of Achilles Tendinopathy Research Articles

Achilles tendinopathy treatment via circadian rhythm regulation

IntroductionAchilles tendinopathy (AT) is a prevalent musculoskeletal disorder closely linked to oxidative stress. Existing evidence suggests a potential link between circadian clock rhythms and oxidative stress. However, the precise role of the circadian clock in the progression and treatment of AT remains unclear. ObjectiveThe purpose of this study was to investigate the role of the Achilles tendon circadian clock in AT pathology and explore the potential use of biomaterials for modulating the circadian clock in the treatment of AT. MethodsWe utilized in vivo and in vitro models to investigate the alterations of the circadian clock within the Achilles tendon during the progression of AT, as well as its impact on disease development. Additionally, we fabricated Nb2C@CeO2 composites featuring a Schottky heterojunction for regulating the circadian rhythm and validated its therapeutic efficacy and molecular mechanism of AT through both in vivo and in vitro experiments. ResultsThe Achilles tendon functioned as a peripheral oscillator with an independent and self-sustained time-keeping system. The rhythm of the Achilles tendon clock was disrupted during the development of AT, as indicated by the decreased amplitude of Bmal1 and Nrf2 rhythm expression. Mechanistically, the knockdown of Bmal1 disrupted the Achilles tendon clock, thereby destroying the Bmal1-Nrf2 axis dependent molecular defense mechanism, and exacerbating the inflammatory response, whereas overexpression of Bmal1 had a protective effect. Nb2C@CeO2 composites with Schottky heterojunctions enhance intercellular electrical signaling, boosting Bmal1 expression and mitigating AT’s pathological changes. Importantly, enhancing Bmal1 expression during its peak, rather than its trough, was more effective. ConclusionThis study identified the protective role of the circadian clock against oxidative stress and inflammation in the Achilles tendon. Achilles tendon circadian clock-targeted therapy represents a promising strategy for AT treatment.

Effectiveness of Kinesiotherapy in the Treatment of Achilles Tendinopathy-A Narrative Review.

This narrative review of kinesiotherapy methods in the treatment of Achilles tendinopathy (AT) encompassed a diverse range of studies, including athletes and untrained people, healthy or injured, undergoing kinesiotherapy treatments. Most experimental studies (86%) reported results related to pain perception, 27% to the range of motion, and 27% to biomechanical assessment. However, the studies showed notable heterogeneity in the outcomes associated with the interventions, and, in this review of kinesiotherapy protocols for AT, a prominent observation emerged regarding their efficacy, suggesting a more favorable impact on pain and tendon stiffness management when comparing the measured parameters between the trained and untrained groups. The importance of tailoring the treatment approach based on the individual's athletic background and conditioning status is underscored. There is a need for personalized rehabilitation strategies in athletic populations. The average duration of kinesiotherapy in the treatment of tendinopathy was 15.3 weeks. This observation underscores the potential of kinesiotherapy interventions as a viable treatment option for individuals with Achilles tendon issues. These findings underscore the urgent need for further research to provide stakeholders with more comprehensive directions for future studies. The results may be helpful for doctors, physiotherapists, trainers, and researchers interested in this topic.

Efficacy of heel lifts for mid-portion Achilles tendinopathy (the LIFT trial): study protocol for a randomised controlled trial

BackgroundMid-portion Achilles tendinopathy is a common condition, characterised by localised Achilles tendon load-related pain and dysfunction. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. Heel lifts have also been advocated as a treatment for Achilles tendinopathy, but the efficacy and mechanism of action of this intervention is unclear. This proposal describes a randomised controlled trial comparing the effectiveness of heel lifts versus sham heel lifts for reducing pain associated with mid-portion Achilles tendinopathy, with an embedded biomechanical analysis.MethodsOne hundred and eight men and women aged 18 to 65 years with mid-portion Achilles tendinopathy (who satisfy the inclusion and exclusion criteria) will be recruited. Participants will be randomised, using the website Sealed Envelope, to either a control group (sham heel lifts) or an experimental group (heel lifts). Both groups will be provided with education regarding acceptable pain levels to ensure all participants receive some form of treatment. The participants will be instructed to use their allocated intervention for at least 8 h every day for 12 weeks. The primary outcome measure will be pain intensity (numerical rating scale) at its worst over the previous week. The secondary outcome measures will be additional measures of Achilles tendon pain and disability, participant-perceived global ratings of change, function, level of physical activity and health-related quality of life. Data will be collected at baseline and the primary endpoint (week 12). Data will be analysed using the intention-to-treat principle. In addition, the acute kinetic and kinematic effects of the interventions will be examined at baseline in a subpopulation of the participants (n = 40) while walking and running using three-dimensional motion analysis.DiscussionThe LIFT trial (efficacy of heeL lIfts For mid-portion Achilles Tendinopathy) will be the first randomised trial to compare the efficacy of heel lifts to a sham intervention in reducing pain and disability in people with Achilles tendinopathy. The biomechanical analysis will provide useful insights into the mechanism of action of heel lifts.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12623000627651. Registered 7 June 2023.

Gastrocnemius Release in the Treatment of Achilles Tendinopathy: A Systematic Review.

The aim of this study is to evaluate the use of isolated gastrocnemius release in the treatment of Achilles tendinopathy. The primary outcome is the change in patient-reported pain outcomes. Secondary outcomes include the change in patient-reported foot and ankle function, ankle range of motion and strength, patient satisfaction and rate of surgical complications. A systematic review was undertaken of studies involving patients treated with an isolated gastrocnemius release for Achilles tendinopathy. Randomised controlled trials, cohort studies, case-control studies and case series were eligible and identified from the following databases: MEDLINE and EMBASE. Isolated gastrocnemius release results in improved patient-reported outcome scores for pain and foot and ankle function. There is an increase in ankle range of motion but a reduction in ankle strength. Patients report a high rate of overall satisfaction. The most common surgical complications are sural nerve injury and wound infection. Isolated gastrocnemius release may offer maintained and clinically meaningful improvements in pain and foot and ankle function with an associated reduction in ankle strength.

Achilles tendinopathy research has a gender data gap: A systematic review and meta-analysis.

A persisting gender bias has been recently highlighted in orthopaedics and sports medicine. The aim of this study was to evaluate the volume of gender-specific data and gender-specific results in the treatment of a common tendon disease, Achilles tendinopathy. Pubmed, Cochrane, and Web of Science were searched to identify all clinical studies focusing on Achilles tendinopathy treatment. The Visual Analogue Scale (VAS) and Victorian Institute of Sport Assessment-Achilles (VISA-A) data of women and men of the studies that disaggregated results by gender were collected, and a meta-analysis was conducted. Treatment response within and in between gender categories was evaluated, focusing on overall gender-disaggregated data, as well as within each of the three treatment categories: conservative treatment, injective treatmentand surgical treatment. A formal risk of bias analysis was conducted using Downs and Black's grading system. Out of the 8796 papers screened, 178 were included after the screening. The number of female study participants grew from 20% up to 1990 to 48% in the years 2019-2022. Only 373 out of 3423 (11%) female patients and 685 of 4352 (16%) male patients were found in sex-disaggregated studies. A meta-analysis was conducted on the 14 papers that reported sex-disaggregated data for VAS and VISA-A. The meta-analysis revealed that there was no difference in the overall treatment response between women and men and that both genders showed an overall significant treatment benefit in terms of VAS and VISA-A values. However, significant differences were documented within the treatment categories. While no differences were found in surgical studies, in conservative treatment studies, men experienced lower posttreatment VAS values (p = 0.004). The largest difference was found in injective treatments, with men experiencing a larger change in VAS values (men = -3.0, women = -1.0, p = 0.016) and higher posttreatment VISA-A values (p = 0.032). This systematic review and meta-analysis showed a lack of awareness of the importance of sex-specific data within Achilles tendinopathy treatment research. The proportion of female study subjects has grown over the years, but there is still a large data gap caused by the absence of sex-disaggregated data. The omission of sex-disaggregated data causes the loss of valuable knowledge on the true effectiveness of current Achilles tendinopathy treatment. The results of this study indicate that women profit less from available treatments, particularly injective approaches, which prompts further research for treatment adaptation by gender. Level IV.

Effect of eccentric exercise and shock wave therapy in patients with Achilles tendinopathy – a review of the literature

Aim of study. The purpose of this study was to evaluate the effectiveness of training using eccentric exercises and shock wave therapy in people with Achilles tendinopathy. Material and methods. The available literature was analyzed based on English-language databases PubMed, Scopus, ScienceDirect, Medline and others, using the Google Scholar search engine. Twenty articles were analyzed out of 120 retrieved by the above method. Publications published up to 24/09/2023 were used, using the following keywords: Achilles tendinopathy, physiotherapy, shock wave, Alfredson protocol, eccentric exercises. Results: After analyzing the papers, it was noted that eccentric exercises based on the Alfredson protocol are effective in the treatment of Achilles tendinopathy. Shock wave therapy appears to be a mostly safe and effective form of treatment. Conclusions. Contemporary research indicates that conservative treatment methods in the form of eccentric exercises and shock wave therapy appear to be effective in the treatment of Achilles tendinopathy. Although studies on the effectiveness of using shock wave therapy are of low quality for the most part, it appears to be a safe and effective form of treatment for Achilles tendinopathy.

Combined extract (Curcuma longa-Glycyrrhiza glabra) alleviates the inflammations of Achilles tendinopathy in Wistar rats.

Achilles tendinopathy is a frequent pathological condition in adults with overused ankles, causing microtrauma, inducing tenocyte apoptosis and inflammatory response. Common treatment involves oral prescription or injection of anti-inflammatory agents, surgery, or shock-wave therapy. However, prolonged administration is not advisable due to adverse effects. Therefore, a novel and safe regimen is needed. Curcuma longa and Glycyrrhiza glabra extracts are known for their anti-inflammatory effects owing to their active compounds (curcumin and glycyrrhizin, respectively). This study aimed to determine the effect of combined extracts of Curcuma longa and Glycyrrhiza glabra on tendon healing in an animal model of Achilles tendinopathy (Wistar rats). This study took place from February to May 2022 and compared the regimens administered to 32 animal models of Wistar rats with 4 healthy rats as a control group to determine the most effective therapeutic regimen: immobilization, immobilization with ibuprofen, or immobilization with the combined extract. The outcomes were measured to find which intervention provided the lowest inflammatory markers [High Mobility Group Box-1 (HMGB-1), Tumor Necrosis Factor-α (TNF-α), Chemokin motif ligand 12 (CXCL-12)], and improved tissue morphology represented by the BONAR score, decreased cross-sectional area (CSA), and increased Macrophage 2 (M2) differentiation. After Achilles tendinopathy was induced, total immobilization (I1) was proven to be the most effective with the lowest CSA, whereas immobilization+175 mg/kg Curcuma longa+110 mg/kg Glycyrrhiza glabra extract (I5) was the most effective with the lowest HMGB-1 levels and the lowest CXCL-12 levels. Immobilization+131 mg/kg Curcuma longa+82.5 mg/kg Glycyrrhiza glabra extract (I6) was the most effective with the lowest Bonar score, while immobilization+87.5 mg/kg Curcuma longa+55 mg/kg Glycyrrhiza glabra extract (I7) was proven to be the most effective with the highest M2 coverage area and the lowest TNF-α levels. We found that combined extract therapy was the most effective intervention for treating Achilles tendinopathy due to its ability to provide the lowest inflammatory markers.

Comparability of the Effectiveness of Different Types of Exercise in the Treatment of Achilles Tendinopathy: A Systematic Review.

Achilles tendinopathy (AT) is a common condition both in athletes and the general population. The purpose of this study is to highlight the most effective form of exercise in managing pain-related symptoms and functional capacity as well as in a return to life activities, ensuring the quality of life of patients with AT, and creating a protocol to be used in rehabilitation. We conducted a systematic review of the published literature in Pubmed, Scopus, Science Direct, and PEDro for Randomised Controlled Trials concerning interventions that were based exclusively on exercise and delivered in patients 18-65 years old, athletes and non-athletes. An amount of 5235 research articles generated from our search. Five met our inclusion criteria and were included in the review. Research evidence supports the effectiveness of a progressive loading eccentric exercise program based on Alfredson's protocol, which could be modified in intensity and pace to fit the needs of each patient with AT. Future research may focus on the optimal dosage and load of exercise in eccentric training and confirm the effectiveness of other type of exercise, such as a combination of eccentric-concentric training or heavy slow resistance exercise. Pilates could be applied as an alternative, useful, and friendly tool in the rehabilitation of AT.

Platelet-rich plasma injections as a treatment for Achilles tendinopathy and plantar fasciitis in athletes.

Platelet-rich plasma (PRP) injections represent a growing interest in the use of biologic therapies for treatment of musculoskeletal injuries. One possible application of PRP is in the management of overuse injuries commonly experienced by athletes. The aim of this review is to evaluate and summarize existing evidence regarding the efficacy of PRP in the treatment of Achilles tendinopathy and plantar fasciitis in athletes. Although many lower quality single-armed studies have demonstrated clinical improvement in athletes treated for Achilles tendinopathy with PRP, higher quality randomized controlled trials (RCTs) have shown no clear benefit in athletes. Existing data suggest PRP significantly improves clinical outcomes for plantar fasciitis in the general population, but very few studies and no RCTs are available that specifically analyze outcomes in athletic populations. More research is needed to evaluate how platelet concentration, leukocyte and erythrocyte presence, and sport type may interact to affect clinical outcomes in athletes.

Prolotherapy Injection with Hyperosmolar Dextrose Solution in the Treatment of Achilles Tendinopathy: A Pilot Study

Prolotherapy Injection with Hyperosmolar Dextrose Solution in the Treatment of Achilles Tendinopathy: A Pilot Study

Adding Corticosteroid Injection to Exercise Therapy Beneficial in Treating Achilles Tendinopathy

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The Statistical Fragility of Platelet-Rich Plasma as Treatment for Achilles Tendinopathy: A Systematic Review and Meta-Analysis

Category: Basic Sciences/Biologics; Hindfoot; Sports Introduction/Purpose: Randomized controlled trial (RCT) outcomes reaching statistical significance, frequently determined by p<0.05, are often used to guide decision-making. Noted lack of reproducibility of some RCTs has brought special attention to the limitations of this approach. In this meta-analysis, we assessed the robustness of RCTs evaluating platelet-rich plasma (PRP) for the treatment of Achilles tendinopathy (AT) by using fragility indices. Methods: RCTs comparing outcomes after PRP injection versus alternative treatment in patients with chronic AT were evaluated. Representative datasets were generated for each reported continuous outcome event using summary statistics. The fragility index (FI) and continuous FI (CFI) were determined for dichotomous and continuous outcomes, respectively, by manipulating each dataset until reversal of significance (a=0.05) was achieved. The corresponding fragility quotient (FQ) and continuous FQ (CFQ) were calculated by dividing FI/CFI by sample size. Results: Of 432 studies screened, 8 studies (52 outcome events) were included in the present analysis. The 12 dichotomous outcomes had a median FI of 4.5 (FQ: 0.111), and the 40 continuous outcomes had a median CFI of 5 (CFQ: 0.154). All 52 outcome events included lost-to-follow-up data, and 12 (23.1%) indicated a greater number of patients lost to follow-up than the FI or CFI. Conclusion: Our findings suggest that RCTs evaluating PRP for AT therapy lack statistical robustness, since changing only a small number of events may alter outcome significance. Given the importance of RCTs in clinical decision-making, fragility indices should be reported alongside p-values to indicate the strength of statistical findings. It is paramount that future RCTs be designed with consideration of sample size from both recruitment and retention perspectives to maximize protocol robustness and determine the true therapeutic effect of PRP in AT.

Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol

Calcaneal apophysitis and Achilles tendinopathy are common overuse injuries characterised by insidious posterior heel pain with activity. Calcaneal apophysitis is commonly diagnosed in adolescents, although Achilles tendinopathy is understudied in...

Evaluating daily physical activity and biomechanical measures using wearable technology in people with Achilles tendinopathy: A descriptive exploratory study

BackgroundLoad management is considered an important factor for prevention and treatment of Achilles tendinopathy. However, little attention has been given to monitoring daily load objectively in this population. ObjectivesWe aimed to explore patterns in proxies of daily load derived from a six-axis inertial measurement unit (IMU) over a one-week period and the concordance between day-to-day fluctuation in pain intensity and IMU measures. DesignDescriptive exploratory study. MethodTen participants with Achilles tendinopathy (age: 53.00 ± 12.37) wore an IMU on the affected ankle for one week. Participants were contacted via text message three times daily to rate their worst pain intensity. Physical activity and biomechanical measures derived from the IMU signals including daily number of steps, peak stride rate, peak shank acceleration, and peak shank angular velocity were calculated. ResultsThe relationship between weekly worst pain and physical activity levels appeared modest; with increased steps not seeming to be linked to increased or reduced pain levels. According to the daily pain and daily IMU measures, a concordant pattern was evident in younger, highly active participants. However, in the middle-aged/older less active participants, there was either a fluctuation in pain intensity without fluctuation in the IMU measures, or a stable pattern of both pain and IMU measures. ConclusionsOur exploratory study results suggest that continuous monitoring of proxies of daily load measures in parallel with pain may provide information about load management strategies in people with Achilles tendinopathy. Monitoring of these proxies may ultimately have a role in improving Achilles tendinopathy management.

Pathophysiology, diagnosis and treatment of Achilles tendinopathy

El tendón de Aquiles es el tendón más grande, grueso y fuerte del cuerpo. Por ello, queremos resaltar la importancia de su patología inflamatoria, degenerativa y traumática, que representa un reto diagnóstico y terapéutico. A este respecto, cabe destacar la evolución de la ecografía como método diagnóstico comparable a la resonancia magnética (RM) en muchos aspectos. A tal efecto, la ecografía se ha integrado en los procesos terapéuticos invasivos no quirúrgicos, así como en cirugías endoscópicas, ya que les presta un soporte útil aumentando el campo de visión. En cuanto al tratamiento, sigue siendo de elección el conservador, que asocia medidas físicas y ortopédicas. El fracaso del mismo puede complementarse con terapias invasivas no quirúrgicas como la electrolisis percutánea intratisular, así como la infiltración de diferentes sustancias. El tratamiento quirúrgico solo está indicado ante la ausencia de resultados beneficiosos de los anteriores y con el único objetivo de restablecer la función del tendón. En esta línea, se han desarrollado técnicas poco invasivas con resultados similares o incluso mejores que los obtenidos con cirugía abierta, con una menor morbilidad y tiempo quirúrgico.

Comparing Effectiveness of Combination of Collagen Peptide Type-1, Low Molecular Weight Chondroitin Sulphate, Sodium Hyaluronate, and Vitamin-C Versus Oral Diclofenac Sodium in Achilles Tendinopathy: A Prospective Randomized Control Trial.

BackgroundAchilles tendinopathy, a common cause of heel pain, is primarily considered mechanical in origin, but its pathogenesis and treatment lack consensus. Molecules such as collagen peptide type-1, low molecular weight chondroitin sulphate, sodium hyaluronate and vitamin C have been shown to act as building blocks of tendon structure, and oral supplementation of these have promising results in Achilles tendinopathy.MethodsThis study was a prospective randomized control trial to compare the effectiveness of oral diclofenac sodium versus a nutraceutical combination of collagen peptide type-1, chondroitin sulphate, sodium hyaluronate, and vitamin C in the treatment of Achilles tendinopathy on pain and ultrasonographic structures. A total of 40 patients satisfying inclusion and exclusion criteria were randomly allocated into two groups and were given the nutraceutical combination in group A and diclofenac sodium in group B. The patient evaluation was done at baseline, six-week, and 12-week intervals in terms of VAS (Visual Analogue Scale) and tendo-Achilles thickness by ultrasound.ResultsBoth nutraceutical combination and diclofenac reduced pain in persons with Achilles tendinopathy. The nutraceutical combination had a statistically significant better outcome in reducing pain at the end of 12 weeks. On ultrasound, both the interventions reduced Achilles tendon anteroposterior and mediolateral thickness by the end of 12 weeks. Although there was no absolute significant intergroup difference, the percentage change was more in the nutraceutical group in the case of anteroposterior thickness.ConclusionCombining collagen peptide type-1, low molecular weight chondroitin sulphate, sodium hyaluronate, and vitamin C is more effective than oral diclofenac in controlling pain in Achilles tendinopathy.

Evaluation of Flextra® efficiency in patients with lateral elbow and Achilles tendinopathies

Background. The purpose of the study was to evaluate the efficacy and safety of the combination use of Flextra® and extracorporeal shock wave therapy (ESWT) or ESWT alone from the standpoint of clinical and structural evolution of tendinopathies (Achilles and lateral elbow tendinopathy). Materials and methods. The study was conducted at the premises of the Medical Center “European Orthopedics” in Kyiv for 2020–2021. Seventy-four patients (39 women and 35 men, mean age of 42.7 ± 5.4 years) were examined, they were randomly divided into four groups. The first group included patients with Achilles tendinopathy and the second one — those with lateral elbow tendinopathy. Both groups received two Flextra capsules a day for 90 days and underwent a course of ESWT. The third group included individuals with Achilles tendinopathy and the fourth group — patients with lateral epicondylitis, who underwent the same course of ESWT (7 procedures). Results. The study showed that taking Flextra® in combination with ESWT has a statistically significant effect on the structure and clinical symptoms of various tendinopathies. In patients with t.calcaneus tendinopathy and epicondylitis, the drug plays an important role in the healing of tendons, which is reflected in the results of ultrasound examinations. Conclusions. Flextra® is an effective and safe drug in the treatment of Achilles tendinopathy and epicondylitis, and the additional use of ESWT provides high efficiency, especially in the initial stages of the disease.

Backward Running on a Negative Slope as a Treatment for Achilles Tendinopathy in Runners: A Feasibility Pilot Study.

Achilles tendinopathy (AT) is a common musculoskeletal injury among runners. Eccentric exercises are considered first-line treatment. However, during the early stages of rehabilitation, patients are usually instructed to stop running. Backward running (BR) on a negative slope provides a similar eccentric load while enabling ongoing physical activity; thus, it may be suggested as an alternative treatment. To determine the feasibility of a BR program as a treatment option for AT in runners. Prospective, single-arm feasibility study. Outpatient clinic. Recreational runners diagnosed with AT and referred to the Meuhedet Health Services Physical Therapy Clinic in Jerusalem, Israel, from September 2019 to February 2020. The patients completed a 5-week (9 sessions) rehabilitation program of supervised BR on a negatively inclined treadmill. Compliance with the program was evaluated by calculating the percentage of patients who completed the full protocol with no adverse events. Personal running-related goals were set before the program and were assessed following rehabilitation using the goal attainment scaling method. Forward-running time until the onset of relevant Achilles tendon pain, and the Victorian Institute of Sports Assessment Scale-Achilles were measured at baseline (T0), before treatment session 6 (T1), and after the last session (T2). Among the 15 patients recruited, 14 (93%), average age 48.8 (10.4) years (86% males), completed the full protocol with no adverse events. Almost all participants (85.7%) achieved their running-related functional goals. Postintervention, the median forward-running time increased from 52.5 (92.5) to 900 (522.5)seconds (P = .008, effect size = .858), and the median Victorian Institute of Sports Assessment Scale-Achilles score improved by 28 points (P = .003, effect size = .881). BR on a negative slope may be a feasible treatment method for runners suffering from AT. Future randomized control trials are required to further validate the efficacy of this method.

Evaluation of cytokines in protective effect of docosahexaenoic acid in experimental achilles tendinopathy rat model induced with type-1 collagenase

ABSTRACT Background We aimed to investigate the effectiveness of docosahexaenoic acid (DHA) as a treatment for Achilles tendinopathy (AT) induced with type-I collagenase in rats and compare it with collagen. Methods The AT model was induced with type I collagenase, and animals were randomly assigned to groups. Group 1:AT, Group 2: Collagen (7.2 mg/kg/day), Group 3:DHA (300 mg/kg/day), and Group 4:DHA (100 mg/kg/day). Right tendons of Group1 were used as a healthy control (HC). Oral treatments were applied for eight weeks. Serum tumor necrosis factor-alpha(TNF-α), matrix metalloproteinase-13 (MMP-13), and interleukin-1 beta(IL-1β) concentrations were determined by ELISA. Tendon samples were taken for histopathological evaluation and examined immunohistochemically with antibodies specific for Col1A1, TNF-α, MMP-13, IL-1β, and nitric oxide synthase-2(NOS-2). The ultimate tensile force (UTF) yield force(YF) and stiffness were measured by biomechanical assessments. Results UTF,YF and stiffness values were increased in all treatment groups compared to the AT control, a significant increase was found in Group 2 (p < 0.05). There was severe degeneration of tendon cells in the AT control. The tendon cells in samples from Groups 2-3 were less degraded, and this was statistically significant (p < 0.05). TNF-α, MMP-13, IL-1β, and NOS-2 expressions were significantly higher in the AT control compared to the HC. In all treatment groups, their concentrations were lower than in the AT control. Serum TNF-α, MMP-13, and IL-1β levels were lower in all treatment groups (Especially in Group3 (p < 0.001)) compared to Group1. Conclusion The efficacy of high-dose DHA as a treatment for AT was investigated from biochemical, histopathological, and biomechanical perspectives. The results showed that DHA could be an alternative treatment compound to collagen.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)\u2014part VI, foot and ankle

ObjectivesClarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.MethodsWe report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.ResultsA list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.ConclusionAccording to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.Key Points• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.• Strong consensus was obtained for all statements.• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.