The objectives of this thesis are to study aetiology and pathoanatomy,
and toevaluate diagnostic methods in patients with long-standing pain and
tenderness localisedto the mid portion of the Achilles tendon. Treatment
had failed to relieve symptomsprior to referral to our clinic, where some
of these patients underwent surgicaltreatment.
Fifty eight patients, derived from 60 consecutive operations, were
analysed regardinghistory, clinical assessment, ultrasound,
histopathology and outcome of surgery.One third of the patients were not
used to any form of vigorous physical activity.Ultrasonographic pathology
was observed in 54 out of 59 examinations. Macroscopicallydiseased tendon
tissue showed marked histopathological changes. At the follow-upto
surgery, after in median 25 months (range 12-50), there was an overall
satisfactoryresult in 75% of the patients.
Topical applications of ketoprofen, a hydrophilic non-steroidal
anti-inflammatorydrug, in patients in surgery for chronic tendon
disorders revealed high concentrationsof ketoprofen in fat, paratenon and
tendon, while plasma levels were found to below. The results indicated a
direct penetration and that tissues act as a reservoirfor ketoprofen. No
attempt was made to study clinical effects.
Tendon biopsies from 40 surgically treated patients revealed abnormal
fibre structureand arrangement, focal variations in cellularity, rounded
nuclei, decreased collagenstainability and increased non-collagenous
matrix. Increased vascularity was seenin 26 out of the 40 subjects.
Inflammatory cell infiltration was not found. A semi-quantitativegrading,
using a total tendon score, had a median of 21 (6-24) compared to 0
(0-13)in control biopsies (p<0.001). The volume-density estimation of
glycosaminoglycan-richareas had a median of 0.47 (0-0.86) in patients and
0 (0-0.07) in controls (p<0.001).
A percutaneous core biopsy technique, guided by ultrasound and performed
underlocal anaesthesia, turned out to be a reliable and valid tool, which
can be usedin clinical and experimental in vivo studies of Achilles
tendon disorders.
Gadolinium contrast enhancement improved the imaging of intra-tendinous
signalabnormality on Tl-weighted magnetic resonance images. The increased
amount of extracellular glycosaminoglycans, highly fixed negativly
charged macromolecules with waterretaining capacity, may contribute to
explain this finding.
Intra-tendinous alterations were imaged with contrast medium enhanced
magneticresonance and with ultrasound in 20 patients with achillodynia.
Core biopsies wereobtained from ultrasound hypoechoic and normoechoic
regions. The increased signalabnormality in gadolinium contrast enhanced
Tl-weighted images revealed a largervolume of the lesion compared with
ultrasound. Hypoechoic areas showed a markedlyabnormal tendon structure.
However, moderate pathology was found also in the
neighbouringnormoechogenous areas within the same tendon, indicating a
more generalised disorderthan imaged by echogenic properties.
In conclusion, the data and the new tools presented in this thesis
encourage furtherstudies including treatment on the Achilles and other
tendon disorders.
Key words: Achilles tendon, achillodynia, pathology, MR-imaging,
ultrasonography,gadolinium, contrast enhancement, glycosaminoglycan,
aetiology, core biopsy.
ISBN 91-628-2817-
