DOCSLIB.ORG

Achilles Tendinopathy: Some Aspects of Basic Science and Clinical Management

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Achilles Tendinopathy: Some Aspects of Basic Science and Clinical Management 239 REVIEW Br J Sports Med: first published as 10.1136/bjsm.36.4.239 on 1 August 2002. Downloaded from Achilles tendinopathy: some aspects of basic science and clinical management D Kader, A Saxena, T Movin, N Maffulli ............................................................................................................................. Br J Sports Med 2002;36:239–249 Achilles tendinopathy is prevalent and potentially and the outcomes of management protocols were incapacitating in athletes involved in running sports. It is carefully scrutinised. Case reports were excluded, unless they mentioned a specific association with a degenerative, not an inflammatory, condition. Most the condition that was thought to be relevant to patients respond to conservative measures if the the discussion. Only papers that made a signifi- condition is recognised early. Surgery usually involves cant contribution to the understanding of this condition were included in the review. This left a removal of adhesions and degenerated areas and total of 347 publications, of which 135 were decompression of the tendon by tenotomy or measures directly related to the topic of this review. that influence the local circulation. .......................................................................... ANATOMY OF THE ACHILLES TENDON The gastrocnemius muscle merges with the In the past three decades, the incidence of over- soleus to form the Achilles tendon in two use injury in sports has risen enormously,1 not different ways. In the more common type 1 junc- Ionly because of the greater participation in rec- tion, the two aponeuroses join 12 cm proximal to reational and competitive sporting activities, but their calcaneal insertion. In type 2, the gastrocne- mius aponeurosis inserts directly into the also as a result of the increased duration and 9 intensity of training.23 Excessive repetitive over- aponeurosis of the soleus. The Achilles tendon has a round upper part and is relatively flat in its load of the Achilles tendon is regarded as the 10 main pathological stimulus that leads to distal 4 cm. The fibres of the Achilles tendon are tendinopathy.4 Kvist2 reviewed 455 athletes with not vertical, but spiral 90°. This arrangement Achilles tendon problems. He found that 53% of increases the tendon elongation and helps the release during locomotion of the energy stored them were involved in running sports and 11% 11 12 were soccer players, emphasising the aetiological within the tendon. role of running. The rest of the patients were Unlike other tendons around the ankle, which have a synovial sheath, the Achilles tendon is involved in other sports in which running was an http://bjsm.bmj.com/ important training means. enveloped by a paratenon, a membrane consisting Achilles tendinopathy is not always associated of two layers: a deeper layer surrounding and in direct contact with the epitenon, and a superficial with excessive physical activity, and in a series of 13 14 58 Achilles tendinopathy patients, 31% did not layer, the peritenon, which is connected with participate in sports or vigorous physical the underlying layer through the mesotenon. The activity.5 Also, the use of quinolone antibiotics is paratenon originates from the deep fascia of the associated with Achilles tendinopathy and leg, the fascia cruris, covering the tendon posteri- 6–8 orly. Recently an organised thickening of the rupture. on October 5, 2021 by guest. Protected copyright. In this review, we concentrate on tendinopathy paratenon has been described as the “watershed of the main body of the Achilles tendon. We shall band”, consisting of a thickened portion of the not deal with Haglund’s condition, insertional paratenon from the deep fascia of the posterior aspect of the leg to envelope the watershed region tendinopathy, or lesions of the myotendinous 15 junction. in the Achilles tendon. A microvascular perfusion study in the human Achilles tendon assessed by laser Doppler flow- metry showed that the blood flow was consider- See end of article for METHOD authors’ affiliations ably lower near the calcaneal insertion but other- A computerised literature search of the entire ....................... wise was distributed evenly in the tendon.16 Medline database, covering the years 1966 to the Further, blood flow in the symptomatic Achilles Correspondence to: present, was conducted for this review. Table 1 tendinopathy was considerably elevated com- Professor Maffulli, lists the keywords used in the search. All articles Department of Trauma and pared with the control tendons.17 relevant to the subject were retrieved, either Orthopaedic Surgery, Langberg et al18 measured blood flow in the locally or by interlibrary loan. The search was not Keele University School of peritendinous space of the human Achilles Medicine, North limited to the English literature, and articles in all tendon at rest and after 40 minutes of dynamic Staffordshire Hospital, journals were considered. The authors’ own Thornburrow Drive, contraction of the triceps surae. Blood flow in the personal collections of papers and any relevant Hartshill, Stoke on Trent, peritendinous space 5 cm proximal to its insertion Staffordshire ST4 7QB, UK; personal correspondence were also included. The [email protected] references selected were reviewed by the authors, Accepted and judged on their contribution to the body of ................................................. 18 January 2002 knowledge of this topic. The conduct and validity Abbreviations: MRI, magnetic resonance imaging; US, ....................... of any clinical studies was carefully considered, ultrasonography www.bjsportmed.com 240 Kader, Saxena, Movin, et al Br J Sports Med: first published as 10.1136/bjsm.36.4.239 on 1 August 2002. Downloaded from Table 1 Keywords used to search the Medline Table 2 Possible causes of Achilles tendinopathy database Possible causes of Achilles tendon rupture • Corticosteroids (intra-, peri-tendinous, oral) Keywords for main Medline literature search • Fluoroquinolone antibiotics Achilles tendon Extracellular matrix • Hyperthermia Athletic injuries Incidence Tendon • Mechanical Biomechanics Postoperative Tendon injuries complications Collagen Subheadings used for Medline literature search Abnormalities Physiopathology Tendinitis Magnetic resonance Tendinopathy Tendinosis the tendon is regained if the strain placed on it remains at less imaging Anatomy & histology Injuries Surgery than 4%. At strain levels greater than 8%, macroscopic rupture 25 34 35 Blood supply Innervation Transplantation will occur. Chemistry Metabolism Ultrasonography Cytology Pathology Ultrastructure CAUSES OF ACHILLES TENDINOPATHY Drug effects Physiology The causes of Achilles tendinopathy remain unclear.24Various theories link tendinopathies to overuse stresses, poor vascular- ity, lack of flexibility, genetic make up, sex, and endocrine or metabolic factors (table 2).36 Excessive loading of the tendon during vigorous training increased fourfold with exercise, while it increased only 2437 18 activities is regarded as the main pathological stimulus. 2.5-fold when measured 2 cm proximal to the insertion. The The Achilles tendon may respond to repetitive overload increase in blood flow during exercise probably results from beyond physiological threshold by either inflammation of its the considerable rise in the negative tissue pressure in the 19 sheath or degeneration of its body, or by a combination of the peritendinous space. two.38 Damage to the tendon can occur even if it is stressed within its physiological limits when the frequent cumulative 1 HISTOLOGY OF NORMAL ACHILLES TENDON microtrauma applied do not leave enough time for repair. Tenocytes and tenoblasts comprise 90–95% of the cellular ele- Microtrauma can result from non-uniform stress within the ments of the tendon. Chondrocytes, vascular cells, synovial Achilles tendon from different individual force contributions cells, and smooth muscle cells form the remaining cellular of the gastrocnemius and soleus, producing abnormal load elements. The extracellular tendon matrix is composed of col- concentrations within the tendon and frictional forces 39 lagen and elastin fibres, ground substance such as proteo- between the fibrils, with localised fibre damage. glycans, and organic components such as calcium.20 21 Tendinopathy has been attributed to a variety of intrinsic Collagen fibrils are bundled into fascicles containing blood, and extrinsic factors. Tendon vascularity, gastrocnemius- lymphatic vessels, and nerves,22 and have been shown to soleus dysfunction, age, sex, body weight and height, pes interchange between fascicles.23 The fascicles, which are cavus deformity, and lateral ankle instability are common surrounded by the endotenon, group together to form the intrinsic factors. Excessive motion of the hindfoot in the fron- gross structure of the tendon. The tendon is enveloped by a tal plane, especially a lateral heel strike with excessive well defined layer of connective tissue, the epitenon. This, in compensatory pronation, is thought to cause a “whipping its turn, is surrounded by the paratenon, with a thin layer of action” on the Achilles tendon, and predispose it to http://bjsm.bmj.com/ 40 fluid in between to reduce friction during tendon motion. The tendinopathy. Also, an appreciable forefoot varus has often 41 innermost layer of the epitenon is in direct contact with the been found in patients with Achilles tendon problems. endotenon. Perhaps for these reasons foot orthoses are advocated to con- trol
Load more

Recommended publications
  • Achilles Tendinitis Causes, Symptoms, Prevention & Treatment by Dr
    ACHILLES TENDINITIS CAUSES, SYMPTOMS, PREVENTION & TREATMENT BY DR. ERIK NILSSEN 855.998.FOOT Schedule Consultation ACHILLES TENDINITIS: CAUSES, SYMPTOMS, PREVENTION & TREATMENT Your Achilles tendon is your body’s largest tendon that connects your heel bone to your calf muscles. You use it to run, walk, and jump. It is prone to Achilles tendinitis, which is a condition caused by degeneration and overuse, and is quite common. Achilles tendinitis causes you to suffer with pain down the back of your leg close to the heel. / 2 NILSSENORTHOPEDICS.COM | 855-998-FOOT ACHILLES TENDINITIS: CAUSES, SYMPTOMS, PREVENTION & TREATMENT Schedule Consultation ACHILLES TENDINITIS: CAUSES, SYMPTOMS, PREVENTION & TREATMENT What is Achilles Tendinitis? To put it simply, it is inflammation of your tendon. There are a couple forms of Achilles tendinitis, which are determined primarily by the area of the tendon that is experiencing inflammation. There are two common types. Noninsertional Achilles Tendinitis. Patients who are between the ages of 30 and 40 with an increased level of activity tend to suffer with Noninsertional Achilles tendinitis. Patients with noninsertional Achilles tendinitis are often treated with non-surgical therapy and are able to gradually increase activity. Insertional Achilles Tendinitis. When the area that the heel bone and Achilles tendon connects becomes painful with swelling, this is known as Insertional Achilles tendinitis. There are both non-surgical and surgical treatment options for insertional Achilles / 3 NILSSENORTHOPEDICS.COM | 855-998-FOOT Schedule Consultation ACHILLES TENDINITIS: CAUSES, SYMPTOMS, PREVENTION & TREATMENT Causes of Achilles Tendinitis Often individuals who are poorly conditioned have the higher risk of developing this condition. Other causes include: • Sudden activity increase.
    [Show full text]
  • The Painful Heel Comparative Study in Rheumatoid Arthritis, Ankylosing Spondylitis, Reiter's Syndrome, and Generalized Osteoarthrosis
    Ann Rheum Dis: first published as 10.1136/ard.36.4.343 on 1 August 1977. Downloaded from Annals of the Rheumatic Diseases, 1977, 36, 343-348 The painful heel Comparative study in rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and generalized osteoarthrosis J. C. GERSTER, T. L. VISCHER, A. BENNANI, AND G. H. FALLET From the Department of Medicine, Division of Rheumatology, University Hospital, Geneva, Switzerland SUMMARY This study presents the frequency of severe and mild talalgias in unselected, consecutive patients with rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and generalized osteoarthosis. Achilles tendinitis and plantar fasciitis caused a severe talalgia and they were observed mainly in males with Reiter's syndrome or ankylosing spondylitis. On the other hand, sub-Achilles bursitis more frequently affected women with rheumatoid arthritis and rarely gave rise to severe talalgias. The simple calcaneal spur was associated with generalized osteoarthrosis and its frequency increased with age. This condition was not related to talalgias. Finally, clinical and radiological involvement of the subtalar and midtarsal joints were observed mainly in rheumatoid arthritis and occasionally caused apes valgoplanus. copyright. A 'painful heel' syndrome occurs at times in patients psoriasis, urethritis, conjunctivitis, or enterocolitis. with inflammatory rheumatic disease or osteo- The antigen HLA B27 was present in 29 patients arthrosis, causing significant clinical problems. Very (80%O). few studies have investigated the frequency and characteristics of this syndrome. Therefore we have RS 16 PATIENTS studied unselected groups of patients with rheuma- All of our patients had the complete triad (non- toid arthritis (RA), ankylosing spondylitis (AS), gonococcal urethritis, arthritis, and conjunctivitis).
    [Show full text]
  • Management of Rotator Cuff Tendinopathy
    Management of rotator cuff tendinopathy Jeremy Lewis PhD FCSP MMACP Consultant Physiotherapist, Central London Community Healthcare NHS Trust, London, UK; Professor of Musculoskeletal Research, Faculty of Education and Health Sciences, University of Limerick, Ireland; Reader in Physiotherapy, School of Health and Social Work, University of Hertfordshire, Hatfield, UK; Sonographer Rotator cuff (RC) tendinopathy is characterised by shoulder pain and weakness most commonly experienced during shoulder external rotation and elevation. Assessment is complicated by the lack of diagnostic accuracy of the special orthopaedic tests and the poor correlation between structural changes identified on imaging and symptoms. Clinicians and people suffering with the symptoms of RC tendinopathy should derive considerable confidence that the outcomes achieved with an appropriately graduated exercise programme are equal to those achieved with surgery for RC tendinopathy, as well as atraumatic partial and full thickness RC tears. Education is an essential component of rehabilitation. Outcomes may also be enhanced by clinically sub-grouping RC tendinopathy presentations and directing treatment strategies according to the clinical presentation as against a generic “one size fits all” approach. There are substantial deficits in our knowledge regarding RC tendinopathy that need to be addressed to further improve clinical outcomes. Learning outcomes has at least equivalent outcome to surgical intervention, with the added generalised benefits of exercise http://www.youtube. 1 Review a presented model for the assessment and com/watch?v=aUaInS6HIGo , a faster return to work and at a management of rotator cuff tendinopathy. lower cost than surgery. This evidence relates to those diagnosed 2 Consider consistent evidence supporting an with subacromial pain syndrome (Lewis 2011), rotator cuff exercise based approach for management that is tendinopathy (Holmgren et al 2012) and atraumatic partial and equivalent to surgical outcomes.
    [Show full text]
  • Rotator Cuff and Subacromial Impingement Syndrome: Anatomy, Etiology, Screening, and Treatment
    Rotator Cuff and Subacromial Impingement Syndrome: Anatomy, Etiology, Screening, and Treatment The glenohumeral joint is the most mobile joint in the human body, but this same characteristic also makes it the least stable joint.1-3 The rotator cuff is a group of muscles that are important in supporting the glenohumeral joint, essential in almost every type of shoulder movement.4 These muscles maintain dynamic joint stability which not only avoids mechanical obstruction but also increases the functional range of motion at the joint.1,2 However, dysfunction of these stabilizers often leads to a complex pattern of degeneration, rotator cuff tear arthropathy that often involves subacromial impingement.2,22 Rotator cuff tear arthropathy is strikingly prevalent and is the most common cause of shoulder pain and dysfunction.3,4 It appears to be age-dependent, affecting 9.7% of patients aged 20 years and younger and increasing to 62% of patients of 80 years and older ( P < .001); odds ratio, 15; 95% CI, 9.6-24; P < .001.4 Etiology for rotator cuff pathology varies but rotator cuff tears and tendinopathy are most common in athletes and the elderly.12 It can be the result of a traumatic event or activity-based deterioration such as from excessive use of arms overhead, but some argue that deterioration of these stabilizers is part of the natural aging process given the trend of increased deterioration even in individuals who do not regularly perform overhead activities.2,4 The factors affecting the rotator cuff and subsequent treatment are wide-ranging. The major objectives of this exposition are to describe rotator cuff anatomy, biomechanics, and subacromial impingement; expound upon diagnosis and assessment; and discuss surgical and conservative interventions.
    [Show full text]
  • Gluteal Tendinopathy
    Gluteal Tendinopathy What is a Gluteal Tendinopathy? In lying Up until recently hip bursitis was diagnosed as the main Either on your bad hip or with bad cause of lateral hip pain but recent studies suggest that an hip hanging across body like so irritation of the gluteus muscle tendon is the likeliest cause. The tendon attaches onto a bony prominence (greater trochanter) and it is here that the tendon is subject to All these positions lead to increase friction of the tendon, compressive forces leading to irritation. can cause pain and slow the healing process. This can result in pain over the lateral hip which can refer down the outside For sleeping you might like to try these positions: of the thigh and into the knee. How common is it? Gluteal tendinopathy is relatively common affecting 10-25% of the population. It is 3 times more prevalent in women than men and is most common in women between the ages of 40 and 60. One of the reasons for this is women It is also important to modify your activity. Avoid or reduce tend to have a greater angle at their hip joint increasing things that flare up your pain, this could be climbing stairs compressive forces on the tendon. or hills or those longer walks/runs. Signs and Symptoms Exercise Therapy • Pain on the outside of your hip, can refer down outside of the thigh to the knee This is best administered by a Physiotherapist to suit the • Worse when going up and/or down stairs individual but below is a rough guide to exercises which • Worse lying on affected side (and sometimes on the can help a gluteal tendinopathy.
    [Show full text]
  • Current Trends in Tendinopathy Management
    Best Practice & Research Clinical Rheumatology 33 (2019) 122e140 Contents lists available at ScienceDirect Best Practice & Research Clinical Rheumatology journal homepage: www.elsevierhealth.com/berh 8 Current trends in tendinopathy management * Tanusha B. Cardoso a, , Tania Pizzari b, Rita Kinsella b, Danielle Hope c, Jill L. Cook b a The Alphington Sports Medicine Clinic, 339 Heidelberg Road, Northcote, Victoria, 3070, Australia b La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Corner of Plenty Road and Kingsbury Drive, Bundoora, Victoria, 3083, Australia c MP Sports Physicians, Frankston Clinic, Suite 1, 20 Clarendon Street, Frankston, Victoria, 3199, Australia abstract Keywords: Tendinopathy Tendinopathy (pain and dysfunction in a tendon) is a prevalent Management clinical musculoskeletal presentation across the age spectrum, Rehabilitation mostly in active and sporting people. Excess load above the ten- Achilles tendinopathy don's usual capacity is the primary cause of clinical presentation. Rotator cuff tendinopathy The propensity towards chronicity and the extended times for recovery and optimal function and the challenge of managing tendinopathy in a sporting competition season make this a difficult condition to treat. Tendinopathy is a heterogeneous condition in terms of its pathology and clinical presentation. Despite ongoing research, there is no consensus on tendon pathoetiology and the complex relationship between tendon pathology, pain and func- tion is incompletely understood. The diagnosis of tendinopathy is primarily clinical, with imaging only useful in special circum- stances. There has been a surge of tendinopathy treatments, most of which are poorly supported and warrant further exploration. The evidence supports a slowly progressive loading program, rather than complete rest, with other treatment modalities used as adjuncts mainly targeted at achieving pain relief.
    [Show full text]
  • Plantar Fasciitis Thomas Trojian, MD, MMB, and Alicia K
    Plantar Fasciitis Thomas Trojian, MD, MMB, and Alicia K. Tucker, MD, Drexel University College of Medicine, Philadelphia, Pennsylvania Plantar fasciitis is a common problem that one in 10 people will experience in their lifetime. Plantar fasciopathy is an appro- priate descriptor because the condition is not inflammatory. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Plantar fasciitis is common in runners but can also affect sedentary people. With proper treatment, 80% of patients with plantar fasciitis improve within 12 months. Plantar fasciitis is predominantly a clinical diagnosis. Symp- toms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. Ultrasonogra- phy is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflamma- tory drugs. Many standard treatments such as night splints and orthoses have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking. Endoscopic fasciotomy may be required in patients who continue to have pain that limits activity and function despite exhausting nonoperative treatment options. (Am Fam Physician. 2019; 99(12):744-750. Copyright © 2019 American Academy of Family Physicians.) Illustration by Todd Buck Plantar fasciitis (also called plantar fasciopathy, reflect- than 27 kg per m2 (odds ratio = 3.7), and spending most ing the absence of inflammation) is a common problem of the workday on one’s feet 4,5 (Table 1 6).
    [Show full text]
  • The Ultimate Patient's Guide to Recovering from an Achilles
    The Ultimate Patient’s Guide To Recovering from an Achilles Tendon Injury - 1 - What is an Achilles Tendon A tendon connects muscle to bone. The Achilles tendon is the largest tendon in the body. It connects your calf muscles (Soleus and Gastroncnemius) to your heel bone (calcareous) and is used when you stand, walk, run, and jump. • Information about Tendons and Ligaments Types of Injuries Although the Achilles tendon can withstand great stresses, it is also prone to injury ranging from the relatively minor tendinitis to the major complete rupture. Tendonitis: inflammation of a tendon. It is a condition associated with overuse and degeneration. Inflammation is the body's natural response to injury or disease, and often causes swelling, pain, or irritation. There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed. Tear / Rupture: When the tendon or the attaching muscle is loaded beyond its capacity fibers can tear. Much like the strains in a rope some or all may rupture leading to a PARTIAL Tear or Rupture or a COMPLET Tear or Rupture. The more complete the rupture / tear the more difficult it is to correct, heal, and recuperate. - 2 - Location of the injury Non-Insertion or Mid Substance: Fibers in the middle portion of the tendon (i.e. farther away form the heel) Insertional: Fibers in the lower portion of the heel, where the tendon attaches (inserts) to the heel bone. Insertional injuries tend to be more difficult to treat and heal. Achilles Tendon Injury (1998 American Academy of Orthopaedic Surgeons US) Diagnosis In diagnosing an Achilles tendon rupture, the foot and ankle surgeon will ask questions about how and when the injury occurred and whether the patient has previously injured the tendon or experienced similar symptoms.
    [Show full text]
  • Evaluation and Management of Elbow Tendinopathy
    vol. XX • no. X SPORTS HEALTH Evaluation and Management of Elbow Tendinopathy Samuel A. Taylor*† and Jo Hannafin† Context: Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic sur- geons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment out- comes will enable the appropriate management of patients and their expectations. Evidence Acquisitions: The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy. Results: Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments. Conclusions: Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate bene- fit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diag- nosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.
    [Show full text]
  • Everything Achilles: Knowledge Update and Current Concepts in Management AAOS Exhibit Selection
    1187 COPYRIGHT Ó 2015 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED Exhibit Selection Everything Achilles: Knowledge Update and Current Concepts in Management AAOS Exhibit Selection Carlos A. Uquillas, MD, Michael S. Guss, MD, Devon J. Ryan, BA, Laith M. Jazrawi, MD, and Eric J. Strauss, MD Investigation performed at the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY Abstract: Achilles tendon pathology is common and affects athletes and nonathletes alike. The cause is multifactorial and controversial, involving biological, anatomical, and mechanical factors. A variety of conditions characterized by Achilles tendon inflammation and/or degeneration can be clinically and histologically differentiated. These include in- sertional Achilles tendinopathy, retrocalcaneal bursitis, Achilles paratenonitis, Achilles tendinosis, and Achilles para- tenonitis with tendinosis. The mainstay of treatment for all of these diagnoses is nonoperative. There is a large body of evidence addressing treatment of acute and chronic Achilles tendon ruptures; however, controversy remains. Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors. Anatomy and Function 3.5 cm distal to the musculotendinous junction5, making it he Achilles tendon, composed of fibers from the gastrocne- vulnerable to iatrogenic injury6, particularly with minimally Tmius and soleus muscles, is the body’sstrongestandthickest invasive repair techniques5. The Achilles tendon is relatively tendon.
    [Show full text]
  • Eccentric Training in the Treatment of Tendinopathy
    Eccentric training in the treatment of tendinopathy Per Jonsson Umeå University Department of Surgical and Perioperative Sciences Sports Medicine 901 87 Umeå, Sweden Copyright©2009 Per Jonsson ISBN: 978-91-7264-821-0 ISSN: 0346-6612 (1279) Printed in Sweden by Print & Media, Umeå University, Umeå Figures 1-3,5: Reproduced with permission from Laszlo Jòzsa and Pekka Kannus Human Tendons Figures 4,6-7: Images by Gustav Andersson Figure 8: Reproduced with permission from Sports Medicine,´The Rotator Cuff: Biological Adaption to its Environment´Malcarney et al, 2003 Figures 9-21: Photos by Peter Forsgren and Jonas Lindberg All previously published papers were reproduced with permission from the publisher Eccentric training in the treatment of tendinopathy “No pain, no gain” Benjamin Franklin (1758) Dedicated to my family – Eva, Willy and Saga Per Jonsson Contents Abstract 7 Abbreviations 8 Original papers 9 Introduction/Background 10 The normal tendon 11 Anatomy 11 Collagen fibre orientation 12 Internal architecture 12 General innervation 13 General biomechanical forces in tendons 14 Metabolism 15 Disuse/immobilisation 15 Exercise/remobilisation 15 The Achilles tendon 17 Anatomy 17 The myotendinous junction (MTJ) 18 The osteotendinous junction (OTJ) 18 Tendon structure 19 Circulation 19 Innervation 19 Biomechanics 20 Achilles tendinopathy 20 Definitions 20 Epidemiology 21 Aetiology 21 Intrinsic risk factors 21 Extrinsic risk factors 22 Pathogenesis 23 Histology 24 Pain mechanisms 24 Clinical symptoms 25 Clinical examination 25 Differential
    [Show full text]
  • Burt Klos MD Phd Stephan Konijnenberg MD Ultrasound Imaging and Conservative Treatment Follow up Presenter Disclosure Information
    Burt Klos MD PhD Stephan Konijnenberg MD Ultrasound imaging and conservative treatment follow up Presenter Disclosure Information Burt Klos disclosed no conflict of interest. Musculoskeletal Ultrasound • US Cuff /bursa • Knee Bakers Cyst • Knee Tendinitis Ultrasound positions prone , supine , hyperflexion Tendon imaging MRI vs MSU Static Dynamic Overview Focus Recognition Learning curve Less detail Interactive Relative value of MRI sports injury • KSSTA 2017 MRI is not reliable in diagnosing of concomitant anterolateral ligament and anterior cruciate ligament injuries of the knee • BM. Devitt et al AUS • KSSTA 2017 High prevalence of Segond Avulsion in MS ultrasound not found with MRI • Klos , Konijnenberg NL Courtesy C vd Hart * * Sport tendon injuries • Achilles tendon • Patella tendon • Pes anserinus Pes anserinus tendino/bursitis IA pathology (hydrops) Osteofyt impingement Endotorsion /Hyperpronation / Overload Researchgate.net femur tibia Ultrasound injection • Image-guided versus blind corticosteroid • injections in adults with shoulder pain: A systematic review • Edmund Soh 2011 BMC • statistically significant greater improvement in shoulder pain and function at 6 weeks after injection with MS Ultrasound • Sinus tarsi US guided injections Mayo Clinic 2010 • MSU 90 % accurate • Blinded injections 35 % accurate • J of Clinical ultrasound 2018 tibia • Pes anserinus bursa injection : • Blind versus US guided injection • 4/ 22 accurate placement in blind . Pes anserinus bursa injection Patella tendinopathy Patella tendinopathy • Tendon
    [Show full text]