Achilles Tendinopathy: risk factors, imaging, and treatment

Achilles tendinopathy, or an overuse injury to the Achilles tendon, is a common injury in the population as a whole. Especially among runners it is a major problem with 10% of this group having complaints of his or her Achilles tendon. Complaints are often limiting both in sports activities and in daily life. Recovery often takes a long time and is often frustrating for both the patient and the healthcare provider. This is partly due to the fact that it is unknown which treatment works best, which often means that several treatments are performed consecutively by patients. This dissertation has led to more knowledge about risk factors for the development of Achilles tendinopathy, the role of imaging with a focus on vascular renewal and the treatment options in patients with Achilles tendinopathy

The association between patellar tendon stiffness measured with shear-wave elastography and patellar tendinopathy

Objectives: (1) To determine the association between patellar tendon stiffness and the presence of patellar tendinopathy (PT). (2) To evaluate the reliability of shear-wave elastography (SWE). Methods: Participants were consecutively enrolled between January 2017 and June 2019. PT was diagnosed clinically and confirmed by either grayscale US or power Doppler US, or both. Controls had no history of anterior knee pain and no clinical signs of PT. Patellar tendon stiffness (kilopascal, kPa) was assessed using SWE. Logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Reliability analyses included coefficients-of-variation (CV), coefficients-of-repeatability (CR), intraclass correlation coefficient (ICC) for intraobserver and interobserver reliability, and Bland-Altman analysis. Results: In total, 76 participants with PT (58 men, mean age 24.4 ± 3.8 years) and 35 asymptomatic controls (16 men, mean age 21.5 ± 3.8 years) were included. Univariate analyses (OR 1.094, 95% CI 1.061–1.128, p <.001) and adjusted multivariate analyses (OR 1.294, 95% CI 1.044–1.605, p =.018) showed that athletes with PT had significantly increased patellar tendon stiffness. ICC for intraobserver reliability was 0.95 (95% CI 0.92–0.97), CR (CV) 12 kPa (10%) and 0.79 (95% CI 0.65–0.88), CR (CV) 18 kPa (21%) for interobserver reliability. Mean differences from Bland-Altman analysis were 5.6 kPa (95% CI 3.1–8.1, p <.001) for intraobserver reliability and 4.6 kPa (95% CI 1.9–7.2, p <.001) for interobserver reli

Ultrasound Doppler Flow in Patients With Chronic Midportion Achilles Tendinopathy

OBJECTIVES: Ultrasound assessments of patients with chronic midportion Achilles tendinopathy include determining the degree of neovascularization using Doppler flow. A frequently used measure to quantify neovascularization is the modified Öhberg score. It is unknown whether the semiquantitative modified Öhberg score (0-4+) has higher reliability than a quantified measure of Doppler flow (0-100%). The purpose of this cross-sectional study was to evaluate the interobserver reliability of the modified Öhberg score and a surface area quantification (SAQ) method for Doppler flow in patients with chronic midportion Achilles tendinopathy. METHODS: Two observers examined the degree of Doppler flow independently using SAQ and the modified Öhberg score during a single consultation. The intraclass correlation coefficient, standard error of measurement, and minimal detectable difference were determined to evaluate the reliability and measurement properties of the SAQ method and the modified Öhberg score. RESULTS: In total, 28 consecutive patients with chronic midportion Achilles tendinopathy participated. The intraclass correlation coefficient for interobserver reliability of the SAQ method was 0.81 (95% confidence interval, 0.58-0.91), compared to 0.64 (95% confidence interval, 0.45-0.81) for the modified Öhberg score. The standard error of measurement and minimal detectable difference values for the SAQ method were 2.9% and 8.0%, respectively, and for the modified Öhberg score, they were 0.55 and 1.53 points. CONCLUSIONS: The SAQ method shows good reliability to evaluate the degree of Doppler flow in patients with chronic midportion Achilles tendinopathy, and it overcome

Clinical risk factors for Achilles tendinopathy

Background Achilles tendinopathy is a common problem, but its exact aetiology remains unclear. Objective To evaluate the association between potential clinical risk factors and Achilles tendinopathy. Design Systematic review. Data sources The databases Embase, MEDLINE Ovid, Web of Science, Cochrane Library and Google Scholar were searched up to February 2018. Eligibility criteria To answer our research question, cohort studies investigating risk factors for Achilles tendinopathy in humans were included. We restricted our search to potential clinical risk factors (imaging studies were excluded). Results We included 10 cohort studies, all with a high risk of bias, from 5111 publications identified. There is limited evidence for nine risk factors: (1) prior lower limb tendinopathy or fracture, (2) use of ofloxacin (quinolone) antibiotics, (3) an increased time between heart transplantation and initiation of quinolone treatment for infectious disease, (4) moderate alcohol use, (5) training during cold weather, (6) decreased isokinetic plantar flexor strength, (7) abnormal gait pattern with decreased forward progression of propulsion, (8) more lateral foot roll-over at the forefoot flat phase and (9) creatinine clearance of <60mL/min in heart transplant patients. Twenty-six other putative risk factors were not associated with Achilles tendinopathy, including being overweight, static foot posture and physical activity level. Conclusion From an ocean of studies with high levels of bias, we extracted nine clinical risk factors that may increase a person’s risk of Achilles tendinopathy. Clinicians may consider ofloxacin use, alcohol consumption and a reduced plantar flexor strength as modifiable risk factors when treating patients with Achilles tendinopath

Isometric exercises do not provide immediate pain relief in Achilles tendinopathy

Background: Isometric exercises may provide an immediate analgesic effect in patients with lower-limb tendinopathy and have been proposed as initial treatment and for immediate pain relief. Current evidence is conflicting, and previous studies were small. Objective: To study whether isometric exercises result in an immediate analgesic effect in patients with chronic midportion Achilles tendinopathy. Methods: Patients with clinically diagnosed chronic midportion Achilles tendinopathy were quasi-randomized to one of four arms: isometric calf-muscle exercises (tiptoes), isometric calf-muscle exercises (dorsiflexed ankle position), isotonic calf-muscle exercises, or rest. The primary outcome was pain measured on a visual analogue scale (VAS) score (0-100) during a functional task (10 unilateral hops) both before and after the intervention. Between-group differences were analyzed using a generalized estimation equations model. Results: We included 91 patients. There was no significant reduction in pain on the 10 hop test after performing any of the four interventions: isometric (tiptoes) group 0.2, 95%CI −11.2 to 11.5; isometric (dorsiflexed) group −1.9, 95%CI −13.6 to 9.7; isotonic group 1.4, 95%CI −8.3 to 11.1; and rest group 7.2, 95%CI −2.4 to 16.7. There were also no between-group differences after the interventions. Conclusion: The isometric exercises investigated in this study did not result in immediate analgesic benefit in patients with chronic midportion Achilles tendinopathy. We do not recommend isometric exercises if the aim is providing immediate pain relief. Future research should focus on the use of isometric or isotonic exercise therapy as initial treatment as all exercise protocols used in this study were well-tolerated

Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy

Objective To study whether a high volume injection without corticosteroids improves clinical outcome in addition to usual care for adults with chronic midportion Achilles tendinopathy. Design Patient and assessor blinded, placebo controlled randomised clinical trial. Setting Sports medicine department of a large district general hospital, the Netherlands. Participants 80 adults (aged 18-70 years) with clinically diagnosed chronic midportion Achilles tendinopathy and neovascula

Which treatment is most effective for patients with Achilles tendinopathy?:A living systematic review with network meta-analysis of 29 randomised controlled trials

Objective: To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy. Design: Living systematic review and network meta-analysis. Data sources: Multiple databases including grey literature sources were searched up to February 2019. Study eligibility criteria: Randomised controlled trials examining the effectiveness of any treatment in patients wit

Which treatment is most effective for adults with Achilles tendinopathy?

__Introduction__ Achilles tendinopathy is a condition that affects both active and sedentary individuals. It is characterized by localized pain in relation to tendon-loading activities. As chronic Achilles tendinopathy results in substantial disease burden, it is vital to treat it effectively. There are many different conservative and surgical treatments available, but the comparative effectiveness of these treatments has never been evalu

Are pain coping strategies and neuropathic pain associated with a worse outcome after conservative treatment for Achilles tendinopathy?

ObjectivesTo analyse whether (1) passive or active pain coping strategies and (2) presence of neuropathic pain component influences the change of Achilles tendinopathy (AT) symptoms over a course of 24 weeks in conservatively-treated patients.DesignProspective cohort study.MethodsPatients with clinically-diagnosed chronic midportion AT were conservatively treated. At baseline, the Pain Coping Inventory (PCI) was used to determine scores of coping, which consisted of two domains, active and passive (score ranging from 0 to 1; the higher, the more active or passive). Presence of neuropathic pain (PainDETECT questionnaire, −1 to 38 points) was categorized as (a) unlikely (≤12 points), (b) unclear (13–18 points) and (c) likely (≥19 points). The symptom severity was determined with the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire (0–100) at baseline, 6, 12 and 24 weeks. We analysed the correlation between (1) PCI and (2) PainDETECT baseline scores with change in VISA-A score using an adjusted Generalized Estimating Equations model.ResultsOf 80 included patients, 76 (95%) completed the 24-weeks follow-up. The mean VISA-A score (standard deviation) increased from 43 (16) points at baseline to 63 (23) points at 24 weeks. Patients had a mean (standard deviation) active coping score of 0.53 (0.13) and a passive score of 0.43 (0.10). Twelve patients (15%) had a likely neuropathic pain component. Active and passive coping mechanisms and presence of neuropathic pain did not influence the change in AT symptoms (p = 0.459, p = 0.478 and p = 0.420, respectively).ConclusionsContrary to widespread belief, coping strategy and presence of neuropathic pain are not associated with a worse clinical outcome in this homogeneous group of patients with clinically diagnosed AT