Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy

Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented

Novel metallic implantation technique for osteochondral defects of the medial talar dome: A cadaver study

BACKGROUND AND PURPOSE: A metallic inlay implant (HemiCAP) with 15 offset sizes has been developed for the treatment of localized osteochondral defects of the medial talar dome. The aim of this study was to test the following hypotheses: (1) a matching offset size is available for each talus, (2) the prosthetic device can be reproducibly implanted slightly recessed in relation to the talar cartilage level, and (3) with this implantation level, excessive contact pressures on the opposite tibial cartilage are avoided. METHODS: The prosthetic device was implanted in 11 intact fresh-frozen human cadaver ankles, aiming its surface 0.5 mm below cartilage level. The implantation level was measured at 4 margins of each implant. Intraarticular contact pressures were measured before and after implantation, with compressive forces of 1,000-2,000 N and the ankle joint in plantigrade position, 10 dorsiflexion, and 14 plantar flexion. RESULTS: There was a matching offset size available for each specimen. The mean implantation level was 0.45 (SD 0.18) mm below the cartilage surface. The defect area accounted for a median of 3% (0.02-18) of the total ankle contact pressure before implantation. This was reduced to 0.1% (0.02-13) after prosthetic implantation. INTERPRETATION: These results suggest that the implant can be applied clinically in a safe way, with appropriate offset sizes for various talar domes and without excessive pressure on the opposite cartilag

‘Race’ Talk! Tensions and Contradictions in Sport and PE

Background: The universal sport discourses of inclusion, belonging, meritocracy, agency, and equality are so widespread that few challenge them. It is clear from the most cursory interest in sport, PE and society that the lived reality is quite different and ambiguous. Racial disparities in the leadership and administration of sport are commonplace world wide; yet from research into ‘race’ in sport and PE the public awareness of these issues is widespread, where many know that racism takes place it is always elsewhere For many this racism is part of the game and something that enables an advantage to be stolen, for others it is trivial and not worthy of deeper thought. This paper explores the contradictions and tensions of the author’s experience of how sport and PE students talk about ‘race’. ‘Race’ talk is considered here in the context of passive everyday ‘race’ talk, dominant discourses in sporting cultures, and colour-blindness. This paper focuses on the pernicious yet persistent nature of ‘race’ talk while demystifying its multifarious, spurious, and more persuasive daily iterations. Theoretical framework: Drawing on Guinier and Torres’ (2003) ideas of resistance through political race consciousness and Bonilla-Silva’s (2010) notion of colour-blindness the semantics of ‘race’ and racialisation in sport and PE are interrogated through the prism of Critical Race Theory (CRT). Critical race scholarship has been used in sport and PE to articulate a political application of ‘race’ as a starting point for critical activism, to disrupt whiteness, and to explore the implications of ‘race’ and racism. CRT is used here to centre ‘race’ and racialised relations where disciplines have consciously or otherwise excluded them. Importantly, the centreing of ‘race’ by critical race scholars has advanced a strategic and pragmatic engagement with this slippery concept that recognises its paradoxical but symbolic location in social relations. Discussion: Before exploring ‘race’ talk in the classroom, using images from the sport media as a pedagogical tool, the paper considers how effortlessly ‘race’ is recreated and renewed. The paper then turns to explore how the effortless turn to everyday ‘race’ talk in the classroom can be viewed as an opportunity to disrupt common racialised assumptions with the potential to implicate those that passively engage in it. Further the diagnostic, aspirational and activist goals of political race consciousness are established as vehicles for a positive sociological experience in the classroom. Conclusion: The work concludes with a pragmatic consideration of the uses and dangers of passive everyday ‘race’ talk and the value of a political race consciousness in sport and PE. Part of the explanation for the perpetuation of ‘race’ talk and the relative lack of concern with its impact in education and wider society is focused on how the sovereignty of sport and PE trumps wider social concerns of ‘race’ and racism because of at least four factors 1) the liberal left discourses of sporting utopianism 2) the ‘race’ logic that pervades sport, based upon the perceived equal access and fairness of sport as it coalesces with the, 3) 'incontrovertible facts' of black and white superiority [and inferiority] in certain sports, ergo the racial justifications for patterns of activity in sport and PE 4) the racist logic of the Right perpetuated through a biological reductionism in sport and PE discourses. Keywords: ‘Race’ Talk; Critical Race Theory; Political Race Consciousnes

Terminology for Achilles tendon related disorders

The terminology of Achilles tendon pathology has become inconsistent and confusing throughout the years. For proper research, assessment and treatment, a uniform and clear terminology is necessary. A new terminology is proposed; the definitions hereof encompass the anatomic location, symptoms, clinical findings and histopathology. It comprises the following definitions: Mid-portion Achilles tendinopathy: a clinical syndrome characterized by a combination of pain, swelling and impaired performance. It includes, but is not limited to, the histopathological diagnosis of tendinosis. Achilles paratendinopathy: an acute or chronic inflammation and/or degeneration of the thin membrane around the Achilles tendon. There are clear distinctions between acute paratendinopathy and chronic paratendinopathy, both in symptoms as in histopathology. Insertional Achilles tendinopathy: located at the insertion of the Achilles tendon onto the calcaneus, bone spurs and calcifications in the tendon proper at the insertion site may exist. Retrocalcaneal bursitis: an inflammation of the bursa in the recess between the anterior inferior side of the Achilles tendon and the posterosuperior aspect of the calcaneus (retrocalcaneal recess). Superficial calcaneal bursitis: inflammation of the bursa located between a calcaneal prominence or the Achilles tendon and the skin. Finally, it is suggested that previous terms as Haglund’s disease; Haglund’s syndrome; Haglund’s deformity; pump bump (calcaneus altus; high prow heels; knobbly heels; cucumber heel), are no longer used

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Meta-Analysis of Genome-Wide Association Studies for Abdominal Aortic Aneurysm Identifies Four New Disease-Specific Risk Loci

Rationale: Abdominal aortic aneurysm (AAA) is a complex disease with both genetic and environmental risk factors. Together, 6 previously identified risk loci only explain a small proportion of the heritability of AAA. Objective: To identify additional AAA risk loci using data from all available genome-wide association studies (GWAS). Methods and Results: Through a meta-analysis of 6 GWAS datasets and a validation study totalling 10,204 cases and 107,766 controls we identified 4 new AAA risk loci: 1q32.3 (SMYD2), 13q12.11 (LINC00540), 20q13.12 (near PCIF1/MMP9/ZNF335), and 21q22.2 (ERG). In various database searches we observed no new associations between the lead AAA SNPs and coronary artery disease, blood pressure, lipids or diabetes. Network analyses identified ERG, IL6R and LDLR as modifiers of MMP9, with a direct interaction between ERG and MMP9. Conclusions: The 4 new risk loci for AAA appear to be specific for AAA compared with other cardiovascular diseases and related traits suggesting that traditional cardiovascular risk factor management may only have limited value in preventing the progression of aneurysmal disease

A posterior tibial tendon skipping rope

This report presents an athletic patient with swelling and progressive pain on the posteromedial side of his right ankle on weight bearing. MRI demonstrated tenosynovitis and suspicion of a length rupture. On posterior tibial tendoscopy, there was no rupture, but medial from the tendon a tissue cord came into view, causing impingement on the tendon at the level of maximum pain. The cord was released and 2 weeks and 1 year after the procedure the patient reported no complaint