ArticlePDF Available

The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States

Authors:

Abstract and Figures

Introduction . Disorders of the Achilles tendon can be broadly classified into acute and chronic entities. Few studies have established chronic Achilles tendinopathy as a precursor to acute Achilles ruptures. In this study, we assessed the relationship between Achilles tendinopathy and rupture, clarifying the incidence of rupture in the setting of underlying tendinopathy.Methods. The United Healthcare Orthopedic Dataset from the PearlDiver Patient Record Database was used to identify patients with ICD-9 codes for Achilles rupture and/or Achilles tendinopathy. The number of patients with acute rupture, chronic tendinopathy, and rupture following a prior diagnosis of tendinopathy was assessed.Results.Four percent of patients with an underlying diagnosis of Achilles tendinopathy went on to sustain a rupture (7,232 patients). Older patients with tendinopathy were most vulnerable to subsequent rupture.Conclusions. The current study demonstrates that 4.0% of patients who were previously diagnosed with Achilles tendinopathy sustained an Achilles tendon rupture. Additionally, older patients with Achilles tendinopathy were most vulnerable. These findings are important as they can help clinicians more objectively council patients with Achilles tendinopathy.
This content is subject to copyright.
Research Article
The Risk of Achilles Tendon Rupture in the Patients
with Achilles Tendinopathy: Healthcare Database Analysis
in the United States
Youichi Yasui,1,2 Ichiro Tonogai,2,3 Andrew J. Rosenbaum,2,4 Yoshiharu Shimozono,2
Hirotaka Kawano,1and John G. Kennedy2
1Department of Orthopedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
2Hospital for Special Surgery, New York, NY, USA
3De partm ent of O r th opedic Surg ery, Tokushima Unive rsity, Tok ushima, Japan
4Albany Medical Center, Albany, NY, USA
Correspondence should be addressed to John G. Kennedy; kennedyj@hss.edu
Received 13 October 2016; Revised 18 January 2017; Accepted 9 February 2017; Published 30 April 2017
Academic Editor: Haining Zhang
Copyright ©  Youichi Yasui et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction. Disorders of the Achilles tendon can be broadly classied into acute and chronic entities. Few studies have established
chronic Achilles tendinopathy as a precursor to acute Achilles ruptures. In this study, we assessed the relationship between
Achilles tendinopathy and rupture, clarifying the incidence of rupture in the setting of underlying tendinopathy. Methods.e
United Healthcare Orthopedic Dataset from the PearlDiver Patient Record Database was used to identify patients with ICD-
codes for Achilles rupture and/or Achilles tendinopathy. e number of patients with acute rupture, chronic tendinopathy, and
rupture following a prior diagnosis of tendinopathy was assessed. Results. Four percent of patients with an underlying diagnosis
of Achilles tendinopathy went on to sustain a rupture (, patients). Older patients with tendinopathy were most vulnerable to
subsequent rupture. Conclusions. e current studydemonstrates that .% of patients who were previously diagnosed with Achilles
tendinopathy sustained an Achilles tendon rupture. Additionally, older patients with Achilles tendinopathy were most vulnerable.
ese ndings are important as they can help clinicians more objectively council patients with Achilles tendinopathy.
1. Introduction
Achilles tendon disorders are commonly encountered in both
the athletic and general populations []. Disorders can be
divided into two general categories: acute and more chronic
overuse injuries. Acute rupture of the Achilles tendon most
frequently occurs in males between  and  years of age
[]. Although it is considered an acute process, histological
analyses have demonstrated that, even in the setting of acute
rupture, degenerative changes are regularly found within the
tendon [–]. Achilles tendinopathy is a more indolent and
chronic process and is attributed to repetitive overuse. It is
most prevalent in individuals aged – years []. In the
setting of Achilles tendinosis, histological analysis reveals
degenerative changes within the tendon [, ].
e histological similarities between acute Achilles ten-
don ruptures and chronic tendinopathy suggest that some
individuals may sustain a presumed acute rupture in the
setting of the more chronic tendinopathy. However, little
is known about this, with studies presenting conicting
ndings. While some works suggest that rupture following
tendinopathy occurs in % to % of individuals [, ],
others have shown that most patients with tendinopathy have
favorable functional outcomes without tendon rupture [–
].
rough the use of a deidentied patient database, this
study claries the risk of Achilles tendon rupture in patients
with a formal diagnosis of Achilles tendinopathy.
2. Methods
2.1. Data Source. Data was obtained from the United Health-
care Orthopedic (UHC) dataset from the PearlDiver Patient
Record Database (PearlDiver Technologies, Inc., Fort Wayne,
Hindawi
BioMed Research International
Volume 2017, Article ID 7021862, 4 pages
https://doi.org/10.1155/2017/7021862
BioMed Research International
IN, USA). is database is comprised of deidentied patients
in a Health Insurance Portability and Accountability Act
(HIPAA) compliant fashion [, ].
e UHC database consists of reported data from hos-
pitals and/or physicians between  and  and has
information on ,, patients. Approximately % of
theUnitedStates(US)populationyoungerthanyears
of age and approximately % of the US population with
private medical insurance are represented in the database
[]. Additionally, the PearlDiver Patient Record Database
includes all patients who enrolled with the insurance carrier
during the desired time period before or aer a specied
event [].
In the database, International Classication of Disease,
Nine Codes (ICD-), or current procedural terminology
(CPT) codes are used to search for subsets of patients.
Demographic information, such as age and gender, can then
be assessed for these patients.
2.2. Cohort Selection. ree subsets of patients, all between
 and  years old, were evaluated in this study: Group
: patients with an acute Achilles tendon rupture; Group :
patients with Achilles tendinopathy; and Group : patients
with an Achilles tendon rupture following a diagnosis of
Achilles tendinopathy.
e ICD- codes used in this study were  (Achilles
tendon rupture) and  (Achilles tendinopathy). e
number of patients was determined for each of the three
cohorts. e incidence of each condition per , patients
was calculated by dividing the number of patients with each
disorder by the total number of patients aged – years
in the UHC database (,, patients). e relationship
between the disorders and demographic factors was assessed.
e incidence of Achilles tendon rupture in the setting of
Achilles tendinopathy was calculated by dividing the total
number of patients with an Achilles tendon rupture following
a diagnosis of Achilles tendinopathy (Group ) by the total
number of patients with Achilles tendinopathy (Group ).
Additionally, in each age group, the number of patients with
an Achilles tendon rupture following a diagnosis of Achilles
tendinopathy (Group ) was divided the number of patients
with Achilles tendinopathy (Group ).
2.3. Statistical Analysis. Statistical analysis was performed
using SAS . (SAS Institute, Cary, NC). Analysis of variance
and Tukey’s test were used to assess the incidence in each age
and the chi-square test was applied for gender analysis. A 𝑝
value of less than . was considered a statistically signicant
outcome.
3. Results
3.1. Group 1: Patients with an Acute Achilles Tendon Rupture.
A total of , patients ( per ,) were included.
Individuals aged – years were most oen aected,
followed by those aged – years. e incidence of Achilles
tendon rupture in these age groups was signicantly higher
than that observed in individuals aged – years and –
years (𝑝 < 0.05) (Figure ). Males sustained ruptures more
30–39 40–49 50–5920–29 60–69
(Age)
0
50
100
150
200
Population of Achilles tendon rupture
per 100,00 per year
F : Group : population distribution in each age according to
incidence of Achilles tendon rupture. Most aected age groups.
30–39 40–49 50–5920–29 60–69
(Age)
0
500
1000
1500
2000
Population of Achilles tendinopathy
per 100,00 per year
F : Group : population distribution in each age according to
incidence of Achilles tendinopathy. Most aected age groups.
frequently than females (male versus female;  per ,
versus  per ,, resp.; 𝑝 < 0.05).
3.2.Group2:PatientswithAchillesTendinopathy.Atotal
of , patients ( per ,) were diagnosed with
Achilles tendinopathy. Individuals aged – years were
most oen aected, followed by those aged – years.
e incidence of Achilles tendinopathy in those groups was
signicantly higher than that seen in those aged – years
and – years (𝑝 < 0.05) (Figure ). ere were no sta-
tistical dierences in the incidence of Achilles tendinopathy
between males and females (male versus female;  per
, versus  per ,, resp.; n.s.).
3.3. Group 3: Patients with an Achilles Tendon Rupture fol-
lowing a Diagnosis of Achilles Tendinopathy. ere were ,
patients ( per ,) who sustained an Achilles tendon
rupture following a diagnosis and treatment for Achilles
tendinopathy (Figure ). ose aged – years were most
oen aected, followed by those aged – years (.% and
.%, resp.). e incidence in these groups was signicantly
higher than that observed in those aged – and –
years (𝑝 < 0.05)(Figure).erewasnosignicant
BioMed Research International
30–39 40–49 50–5920–29 60–69
(Age)
0
20
40
60
80
Population of Achilles tendon rupture following
Achilles tendinopathy per 100,00 per year
F : Group : population distribution in each age according to
incidence of Achilles tendon rupture following Achilles tendinopa-
thy. Most aected age groups.
30–39 40–49 50–5920–29 60–69
(Age)
0
0.02
0.04
Ratio of Achilles tendon rupture following
Achilles tendinopathy/Achilles tendinopathy
F : Distribution in each age according to ratio of incidence of
Achilles tendon rupture following Achilles tendinopathy divided by
incidence of Achilles tendinopathy.
dierence in the incidence of Achilles tendinopathy between
males and females (male versus female;  per , versus
 per ,, resp.).
3.4. e Relationship between Achilles Tendon Rupture and
Achilles Tendinopathy. Approximately .% of patients with
Achilles tendinopathy subsequently sustained a rupture
(Figure ). Individuals aged – years were most suscep-
tible (.% incidence).
Admittedly, the time point between the diagnosis of
tendinopathy and subsequent rupture was not ascertainable
from current database.
4. Discussion
e present study analyzed a large, diverse population of
individuals aged – years in order to determine the rate of
Achilles tendon rupture in the setting of underlying Achilles
tendinopathy. We found that approximately .% of patients
who were previously diagnosed with Achilles tendinopathy
ultimately sustained a rupture. Additionally, older patients
with tendinopathy were most vulnerable.
Intrasubstance degeneration of the Achilles tendon has
been found in individuals with both acute rupture and
chronic tendinopathy [–, , ], suggesting that tendinopa-
thy precedes and may even predispose individuals to Achilles
tendon rupture []. However, studies have reported incon-
sistent outcomes. Maulli found that % (/) of patients
who sustained an Achilles tendon rupture had previous
symptoms over their Achilles tendon []. In a work by
Nestorson et al. [], % of patients (/) had Achilles
tendon pain before Achilles tendon rupture. ese studies
must be interpreted with caution as they are comprised of
small cohorts with uncontrolled variables.
Wefoundthat.%ofpatientspreviouslydiagnosedwith
Achilles tendinopathy suered an Achilles tendon rupture.
isisanimportantndingandelucidatestheintimate,
but complex, relationship between Achilles tendinopathy
and rupture. e small percentage of patients who went
on to rupture following a diagnosis of tendinopathy (.%)
underscores the success of the various treatment modalities
specic to Achilles tendinopathy (e.g., eccentric stretching).
Outcomes from the current study suggest that age may be
a risk factor for Achilles tendon rupture previously diagnosed
with Achilles tendinopathy. Older patients with Achilles
tendinopathy had a signicantly higher risk of rupture than
younger individuals. is nding is supported by a recent
animal study that demonstrates the relationship between
advancing age and degeneration of the Achilles tendon [].
In this study, males had a higher risk of rupture. is too is
consistent with other works, such as that by Wong et al. [].
In that study, males were found to be – times more likely
to rupture their Achilles tendon []. Although the reasons
for this nding are currently unclear, this nding should be
explored in future studies.
5. Limitations
Asadatabasestudy,thisworkhasinherentlimitations.Per-
tinent patient information, such as injury mechanism, symp-
tom severity, duration of symptoms, medical comorbidities,
the degree of tendon degeneration, use of local and systemic
corticosteroids, and uoroquinolone usage, was unavailable.
Although we found that .% of patients with tendinopathy
go on to rupture, our data can be presented dierently, as
it also suggests that .% of patients who sustained a rup-
ture were previously diagnosed with Achilles tendinopathy
(Group /Group ). In other words, .% of patients who
sustained an Achilles tendon rupture were not previously
diagnosed with Achilles tendinopathy. While this can be
interpreted as suggesting that Achilles tendon rupture is more
common in the absence of tendinopathy, we do not believe
that this is accurate. It is likely that some rupture patients
may have had undiagnosed tendinopathy. Furthermore, we
fail to account for the mechanism of injury in our analysis. In
other words, patients rupturing in the absence of a tendinosis
diagnosis may have been more likely to do so because of their
given activities []. As previously mentioned, the database
BioMed Research International
does not provide this information. e time between each
diagnosis was also unknown. Another potential source of
erroristhepossibilityofanydocumentationorcoding
mistakes. We also do not know how tendinopathy patients
were treated. is is important, as certain modalities (e.g.,
steroid injection) may have predisposed patients to rupture.
Despite these limitations, we believe that the results from
our large cohort of patients provide valuable insight into the
relationship between Achilles tendinopathy and rupture.
6. Conclusions
In this large cohort database study, we found that approxi-
mately .% of patients who were previously diagnosed with
Achilles tendinopathy sustained an Achilles tendon rupture.
Additionally, older patients with Achilles tendinopathy were
most susceptible to rupture. ese ndings are important
as they can help clinicians more objectively council patients
following a diagnosis of Achilles tendinopathy.
Disclosure
An earlier version of this work was presented as a poster at
the th AFFAS Triennial Scientic Meeting, .
Conflicts of Interest
John G. Kennedy is a consultant for Arteriocyte, Inc.; has
received research support from the Ohnell Family Foun-
dation,Mr.andMrs.MichaelJ.Levitt,andArteriocyte
Inc.; and is a board member for the European Society
of Sports Traumatology, Knee Surgery, and Arthroscopy,
International Society for Cartilage Repair of the Ankle,
American Orthopedic Foot and Ankle Society Awards and
Scholarships Committee, and International Cartilage Repair
Society nance board.
References
[] N. Levi, “e incidence of Achilles tendon rupture in Copen-
hagen,Injury,vol.,no.,pp.,.
[] S. Houshian, T. Tscherning, and P. Riegels-Nielsen, “e epi-
demiology of achilles tendon rupture in a Danish county,
Injur y, vol. , no. , pp. –, .
[] C.Tallon,N.Maulli,andS.W.B.Ewen,“RupturedAchilles
tendons are signicantly more degenerated than tendinopathic
tendons,Medicine and Science in Sports and Exercise,vol.,
no. , pp. –, .
[]N.Maulli,S.W.Waterston,andS.W.B.Ewen,“Ruptured
Achilles tendons show increased lectin stainability,Medicine
and Science in Sports and Exercise,vol.,no.,pp.,
.
[] N.Maulli,S.W.B.Ewen,S.W.Waterston,J.Reaper,andV.
Barrass, “Tenocytes from ruptured and tendinopathic achilles
tendons produce greater quantities of type III collagen than
tenocytes from normal achilles tendons: an in vitro model of
humantendonhealing,American Journal of Sports Medicine,
vol. , no. , pp. –, .
[] O. Arner, A. Lindholm, and S. R. Orell, “Histologic changes
in subcutaneous rupture of the Achilles tendon; a study of 
cases,Acta chirurgica Scandinavica,vol.,no.-,pp.
, .
[] L. J´
ozsa and P. Kannus, “Histopathological ndings in sponta-
neous tendon ruptures,Scandinavian Journal of Medicine and
Science in Sports,vol.,no.,pp.,.
[] P. Kannus and L. Jozsa, “Histopathological changes preceding
spontaneous rupture of a tendon: a controlled study of 
patients,Journal of Bone and Joint Surgery. Series A,vol.,no.
, pp. –, .
[] S.DeJonge,C.VanDenBerg,R.J.DeVosetal.,“Incidenceof
midportion Achilles tendinopathy in the general population,
British Journal of Sports Medicine, vol. , no. , pp. –,
.
[] U. G. Longo, M. Ronga, and N. Maulli, “Achilles tendinopathy,
Sports Medicine and Arthroscopy Review,vol.,no.,pp.
, .
[] N. Maulli, P. M. Bineld, and J. B. King, “Tendon prob-
lems in athletic individuals,e Journal of Bone & Joint
Surgery—American Volume, vol. , no. , pp. –, .
[] N. Maulli, “Rupture of the Achilles tendon,Journal of Bone
and Joint Surgery. Series A,vol.,no.,pp.,.
[] J. Nestorson, T. Movin, M. M¨
oller, and J. Karlsson, “Function
aer Achilles tendon rupture in the elderly:  patients older
than  years followed for  years,Acta Orthopaedica Scandi-
navica,vol.,no.,pp.,.
[] H. Alfredson, T. Pietil¨
a, P. Jonsson, and R. Lorentzon, “Heavy-
load eccentric calf muscle training for the treatment of chronic
achilles tendinosis,AmericanJournalofSportsMedicine,vol.
,no.,pp.,.
[] G. Nelen, M. Martens, and A. Burssens, “Surgical treatment
of chronic Achilles tendinitis,e American Journal of Sports
Medicine,vol.,no.,pp.,.
[] A. Coutts, A. MacGregor, J. Gibson et al., “Clinical and
functional results of open operative repair for Achilles tendon
rupture in a nonspecialist surgical unit,JournaloftheRoyal
CollegeofSurgeonsofEdinburgh,vol.,no.,pp.,
.
[]Y.Yasui,C.D.Murawski,A.Wollstein,andJ.G.Kennedy,
“Reoperation rates following ankle ligament procedures per-
formed with and without concomitant arthroscopic proce-
dures,Knee Surgery, Sports Traumatology, Arthroscopy,pp.,
.
[] Y. Yasui, K. S. Vig, C. D. Murawski, P. Desai, I. Savage-Elliott,
andJ.G.Kennedy,“Openversusarthroscopicanklearthrodesis:
a comparison of subsequent procedures in a large database,
Journal of Foot and Ankle Surgery,vol.,no.,pp.,
.
[] D.Wang,N.B.Joshi,F.A.Petriglianoetal.,“Trendsassociated
with distal biceps tendon repair in the United States,  to
,Journal of Shoulder and Elbow Surgery,vol.,no.,pp.
–, .
[] N. Maulli, A. G. Via, and F. Oliva, “Chronic achilles tendon
disorders: tendinopathy and chronic rupture,Clinics in Sports
Medicine,vol.,no.,pp.,.
[] T. Y. Kostrominova and S. V. Brooks, “Age-related changes in
structure and extracellular matrix protein expression levels in
rat tendons,Age, vol. , no. , pp. –, .
[] J.Wong,V.Barrass,andN.Maulli,“Quantitativereviewof
operative and nonoperative management of Achilles tendon
ruptures,American Journal of Sports Medicine,vol.,no.,
pp. –, .
... One study examined the risk of ATR in patients with Achilles tendinopathy. They found that 4.0% of patients that sustained ATR were previously diagnosed with Achilles tendinopathy [28]. The evidence was low. ...
... The majority of the evidence indicates a positive association between Achilles tendinopathy and ATR risk. It is suggested that Achilles tendinopathy precedes and may predispose patients to ATR [28]. The risk of ATR was higher in older patients with tendinopathy [28], and this could be explained by the fact that older people may display more severe tendinosis and thus, less eccentric contracture required to rupture [30]. ...
... It is suggested that Achilles tendinopathy precedes and may predispose patients to ATR [28]. The risk of ATR was higher in older patients with tendinopathy [28], and this could be explained by the fact that older people may display more severe tendinosis and thus, less eccentric contracture required to rupture [30]. Biopsies in ruptured and tendinopathic Achilles tendons confirmed the presence of non-resolved chronic inflammation [24] and thus, targeting the chronic inflammation may benefit the prevention of ATR. ...
Article
Objective Identifying risk factors for Achilles Tendon Rupture (ATR) is one of the first necessary steps for its prevention. This systematic review aimed to update the systematic review published in 2014 in ATR etiology. Methodology A systematic review was carried out using PubMed, EBSCO, and ScienceDirect databases. All types of research studies (Randomized Control Trials – RCTs, Cohort studies, Case-control studies and Cross-sectional studies) that considered ATR, were eligible. The inclusion criteria for eligibility of the studies were to be written in the English language, and to include populations of men and/or women, both athletes, and non-athletes, healthy individuals, and patients. Two independent reviewers used the assessment instrument Newcastle-Ottawa Scale independently, to evaluate the quality of each selected study. Further, two reviewers worked independently to extract the study characteristics, and the GRADE methodology was used to assess the level of certainty of each risk factor. Results From 9526 studies initially identified, 19 studies were eligible for further analysis to identify risk factors for ATR. Seventeen studies were considered good quality, and two studies fair quality. Low to very low certainty of evidence was found for the following medications: steroids, quinolones, and oral bisphosphonate, as well as for other factors such as chronic tendon inflammation and Achilles’ tendinopathy, spring season, diabetes, previous musculoskeletal injury, regular participation in athletic activity, hyperparathyroidism, renal failure, and genetic factors. Conclusions The risk factors found prove that ATR is a multifactorial injury. Appropriate methodologies and well-designed studies are needed to determine the factors and their significance in ATR risk. Finally, the role of biomechanical and psychological aspects in the ATR etiology may be of interest in future studies, as we could not extract relative data in our review.
... GAGs contain highly hydrophilic side chains and therefore increase the water content within the tendon. These degenerative adaptations deteriorate the mechanical properties of the pathologic tendons (Seo et al., 2015;Ooi et al., 2016;Finnamore et al., 2019) and favor traumatic tendon injuries (Cook and Purdam, 2009;Yasui et al., 2017). From a screening and injury prevention perspective, however, both physiological and pathological processes are crucial since tendon pathologies move along a partially reversible continuum (Cook and Purdam, 2009). ...
... In this context, lower tendon hysteresis has been reported in ski jumpers and runners compared to control subjects (Wiesinger et al., 2017). Pathological adaptations, on the other hand, lead to deterioration of the tendon structure, limiting the capacity for physical performance and increasing the risk of tendon rupture (Cook and Purdam, 2009;Ooi et al., 2016;Yasui et al., 2017). Competitive alpine skiers are exposed to tremendous loads both during off-season training and in the competition season (Supej and Holmberg, 2010;Hydren et al., 2013; Gilgien et al., 2018). ...
Article
Full-text available
Competitive alpine skiers are exposed to enormous forces acting on their bodies-particularly on the knee joint and hence the patellar tendon-during both the off-season preparation and in-season competition phases. However, factors influencing patellar tendon adaptation and regional pattern differences between alpine skiers and healthy controls are not yet fully understood, but are essential for deriving effective screening approaches and preventative countermeasures. Thirty elite competitive alpine skiers, all members of the Swiss Alpine Ski Team, and 38 healthy age-matched controls were recruited. A set of two-dimensional shear wave elastography measurements of the PT was acquired and projected into three-dimensional space yielding a volumetric representation of the shear wave velocity profile of the patellar tendon. Multivariate linear models served to quantify differences between the two cohorts and effects of other confounding variables with respect to regional shear wave velocity. A significant (p < 0.001) intergroup difference was found between skiers (mean ± SD = 10.4 ± 1.32 m/s) and controls (mean ± SD = 8.9 ± 1.59 m/s). A significant sex difference was found within skiers (p = 0.024), but no such difference was found in the control group (p = 0.842). Regional SWV pattern alterations between skiers and controls were found for the distal region when compared to the mid-portion (p = 0.023). Competitive alpine skiers exhibit higher SWV in all PT regions than healthy controls, potentially caused by long-term adaptations to heavy tendon loading. The presence of sex-specific differences in PT SWV in skiers but not in controls indicates that sex effects have load-dependent dimensions. Alterations in regional SWV patterns between skiers and controls suggest that patellar tendon adaptation is region specific. In addition to the implementation of 3D SWE, deeper insights into long-term tendon adaptation and normative values for the purpose of preventative screening are provided.
... Generally, tendinopathy does not cause substantial problems; therefore, patients with tendinopathy are initially recommended for a course of conservative management, such as physiotherapy and analgesia (Seida et al., 2010). In some cases, patients with tendinopathy may have an increased risk of tendon rupture, especially among those in the older population (Yasui et al., 2017). Nevertheless, acute shoulder trauma may cause partial or complete tendon tears, which require surgical treatment to repair the continuity of the structure or surgery to reattach the tendon back to its bony insertion. ...
Article
Full-text available
Rotator cuff injury is a common upper extremity musculoskeletal disease that may lead to persistent pain and functional impairment. Despite the clinical outcomes of the surgical procedures being satisfactory, the repair of the rotator cuff remains problematic, such as through failure of healing, adhesion formation, and fatty infiltration. Stem cells have high proliferation, strong paracrine action, and multiple differentiation potential, which promote tendon remodeling and fibrocartilage formation and increase biomechanical strength. Additionally, stem cell-derived extracellular vesicles (EVs) can increase collagen synthesis and inhibit inflammation and adhesion formation by carrying regulatory proteins and microRNAs. Therefore, stem cell-based therapy is a promising therapeutic strategy that has great potential for rotator cuff healing. In this review, we summarize the advances of stem cells and stem cell-derived EVs in rotator cuff repair and highlight the underlying mechanism of stem cells and stem cell-derived EVs and biomaterial delivery systems. Future studies need to explore stem cell therapy in combination with cellular factors, gene therapy, and novel biomaterial delivery systems.
... Mid-AT is more common (55-65%) than ins-AT (20-25%) [2]. AT occurs most frequently between the ages of 40-59 years [3] and is particularly prevalent in athletes, especially in runners [4]. ...
Article
Full-text available
Background Extracorporeal shockwave therapy (ESWT) is used commonly to treat pain and function in Achilles tendinopathy (AT). The aim of this study was to synthesize the evidence from (non-) randomized controlled trials, to determine the clinical effectiveness of ESWT for mid-portion Achilles tendinopathy (mid-AT) and insertional Achilles tendinopathy (ins-AT) separately. Methods We searched PubMed/Medline, Embase (Ovid), and Cochrane Central, up to January 2021. Unpublished studies and gray literature were searched in trial registers (ACTRN, ChiCTR, ChiCtr, CTRI, DRKS, EUCTR, IRCT, ISRCTN, JPRN UMIN, ClinicalTrials.gov, NTR, TCTR) and databases (OpenGrey.eu, NARCIS.nl, DART-Europe.org, OATD.org). Randomized controlled trials (RCTs) and non-randomized controlled clinical trials (CCTs) were eligible when investigating the clinical effectiveness of ESWT for chronic mid-AT or chronic ins-AT. We excluded studies that focused on treating individuals with systemic conditions, and studies investigating mixed cohorts of mid-AT and ins-AT, when it was not possible to perform a subgroup analysis for both clinical entities separately. Two reviewers independently performed the study selection, quality assessment, data extraction, and grading of the evidence levels. Discrepancies were resolved through discussion or by consulting a third reviewer when necessary. Results We included three RCTs on mid-AT and four RCTs on ins-AT. For mid-AT, moderate quality of evidence was found for the overall effectiveness of ESWT compared to standard care, with a pooled mean difference (MD) on the VISA-A of 9.08 points (95% CI 6.35–11.81). Subgroup analysis on the effects of ESWT additional to standard care for mid-AT resulted in a pooled MD on the VISA-A of 10.28 points (95% CI 7.43–13.12). For ins-AT, we found very low quality of evidence, indicating that, overall, ESWT has no additional value over standard care, with a standardized mean difference (SMD) of − 0.02 (95% CI − 0.27 to 0.23). Subgroup analysis to determine the effect of ESWT additional to standard care for ins-AT showed a negative effect (SMD − 0.29; 95% CI − 0.56 to − 0.01) compared to standard care alone. Conclusions There is moderate evidence supporting the effectiveness of ESWT additional to a tendon loading program in mid-AT. Evidence supporting the effectiveness of ESWT for ins-AT is lacking. Trial Registration : PROSPERO Database; No. CRD42021236107.
... Pre-existing conditions like tendinopathy may also lower the threshold of rupture due to changes in stiffness and strength of the tendon fibers (Yasui et al., 2017;Dakin et al., 2018). As in running, discomfort related to Achilles tendinopathy may alter badminton players movement pattern and increase the load on the AT, yet the association between landing technique and Achilles tendinopathy among badminton players is still unknown (Sancho et al., 2019). ...
Article
Achilles tendon (AT) rupture is common among recreational male badminton players. We hypothesize that a landing technique following forehand jump strokes with the landing foot in a neutral position often performed by recreational players and occasionally by elite players may expose the AT to higher loads than a scissor kick jump (SKJ) technique with the leg/foot externally rotated. The study aimed to investigate if recreational players could reduce the load in the AT when adopting the SKJ technique compared to their habitual landing technique with the foot in a neutral position and secondarily to compare the AT force between recreational players and elite players. Ten recreational male players performed simulated jump strokes in a biomechanical laboratory using both their original technique and the SKJ technique traditionally used by elite players. For comparison reasons ten elite players performed SKJs. Landing kinematics and AT forces were captured and calculated using 3D movement analysis. The landing leg was more externally rotated in the recreational players' adjusted technique (78 ± 10 degrees, p < 0.001) compared to 22 ± 21 degrees in recreational players' original technique. The peak AT force of the recreational players was significantly higher for the original technique compared to the adjusted technique (68 ± 19 N/kg vs. 50 ± 14 N/kg, p = 0.005). Additionally, the peak AT forces observed during the recreational players’ original technique was higher, though not significantly, than those observed for elite players (55 ± 11 N/kg, p = 0.017). / = 0.016 due to a Bonferroni correction. These findings indicate that recreational badminton players that normally land with the foot in a neutral position, may reduce their AT load by 25% when adopting the SKJ technique of elite players and land with the leg/foot in an externally rotated position.
... At this stage, additional stress could result in increased susceptibility to injuries. Yasui et al. 18) further explained that older patients with Achilles tendinopathy were most susceptible to rup- ture. Based on the results of our study, the highest increasing trend of incidence, as observed in patients between 41 and 50 years of age from 2009 to 2017, may continue in the future. ...
Article
Background: The incidence of Achilles tendon rupture and its trend has not been studied in Asia. The purpose of this nationwide study was to analyze the trend of incidence and surgical treatment of tendon ruptures in South Korea based on sex, age, and income level of patients, as well as seasonal variation. Methods: A descriptive epidemiologic study was performed based on the data collected retrospectively from the Korea National Health Insurance Service. Data of all outpatients and inpatients were collected from approximately 52 million residents of South Korea, primarily diagnosed with Achilles tendon rupture from 2009 to 2017. Results: A total of 112,350 patients had Achilles tendon rupture, of which 44,248 patients underwent surgical treatment during the study period. The overall, age-specific, and sex-specific incidence of Achilles tendon rupture and surgical treatment showed an increasing trend. Patients in the age group of 41 to 50 years showed the highest increase in incidence. Regarding season, higher incidence was reported during spring and summer, whereas the lowest incidence was found in winter. Higher income level was associated with increased incidence of the condition. Conclusions: The incidence of Achilles tendon rupture and surgical treatments increased rapidly in patients between 41 and 50 years of age. Patients in the higher income quintile groups experienced more Achilles tendon injury than those in lower income groups, and fewer ruptures were observed during winter.
... 3 The incidence of this adverse effect may be up to 2% in patients aged 65 years and above, compared with a background tendon rupture rate of approximately 0.9% in the general population. 4,5 The onset of tendinopathy is highest within the first month after drug exposure. 3 The Achilles tendon is most commonly affected, with severe and sudden onset pain being a characteristic clinical presentation. ...
Article
Fluoroquinolones are broad-spectrum antibiotics with good oral bioavailability. They are used for the treatment of a wide variety of infections, but there are restrictions on prescribing these drugs. Epidemiological studies have reported an increased risk of rare adverse effects. These include tendinopathy and tendon rupture, peripheral neuropathy and aortic aneurysm. Safe prescribing of fluroquinolones requires recognition of patients with risk factors for toxicity. Prompt drug discontinuation is recommended in the event of an adverse reaction. Practising antimicrobial stewardship by prescribing fluoroquinolones only when alternative drugs are unavailable is also key to limiting adverse events and antibiotic resistance.
Article
Full-text available
Purpose. Ultrasound tissue characterization (UTC) is used to visualize and quantify the Achilles tendon structure. We investigated the intra-rater and inter-rater reliability of UTC for quantifying the midportion tendon structure and the area of maximum degeneration (AoMD) in military personnel with midportion Achilles tendinopathy. Method. UTC scans of 50 patients (16-60 years) were processed twice by rater 1 and once by rater 2. First, the midportion tendon structure was quantified and subsequently the AoMD. e intraclass correlation coefficient (ICC) was calculated for echo-types I, II, III, IV, aligned fibrillar structure (echo-types I + II), and disorganized tendon structure (echo-types III + IV). Results. For midportion tendon structure, all ICC values were excellent for intra-rater reliability (range: 0.97 to 0.99) and inter-rater reliability (range: 0.98 to 0.99). Regarding the AoMD, intra-rater reliability showed excellent ICC values for all echo-types (range: 0.94 to 0.98) except for echo-type II (0.85). Inter-rater reliability showed excellent ICC values for all echo-types (range: 0.92 to 0.98). Conclusion. Processing of UTC scans is highly reliable in quantifying the midportion Achilles tendon structure and the AoMD.
Article
The Achilles tendon is commonly affected by both chronic repetitive overuse and traumatic injuries. Achilles tendon injuries can potentially affect any individual but have a particularly high incidence in professional athletes. Appropriate imaging evaluation and diagnosis are paramount to guiding appropriate management. In this AJR Expert Panel Narrative Review, we discuss the role of various imaging modalities (particularly ultrasound and MRI) in the assessment of Achilles tendon pathology, focusing on modalities' relative advantages and technical considerations. We describe the most common diagnoses affecting the Achilles tendon and adjacent structures, highlighting key imaging findings and providing representative examples. Various image-guided interventions that may be employed in the management of Achilles tendon pathology are also reviewed, including high-volume injection, tendon fenestration, prolotherapy, and corticosteroid injection. The limited evidence supporting such interventions are summarized, noting an overall paucity of large-scale studies showing benefit. Finally, a series of consensus statements by the panel on imaging and image-guided intervention for Achilles tendon pathology are provided.
Article
Tendon injuries are a common athletic injury that have been increasing in prevalence. While there are current clinical treatments for tendon injuries, they have relatively long recovery times and often do not restore native function of the tendon. In the current study, gene electrotransfer (GET) parameters for delivery to the skin were optimized with monophasic and biphasic pulses with reporter and effector genes towards optimizing underlying tendon healing. Tissue twitching and damage, as well as gene expression and distribution were evaluated. Bioprinted collagen scaffolds, mimicking healthy tendon structure were then implanted subcutaneously for biocompatibility and angiogenesis analyses when combined with GET to accelerate healing. GET of human fibroblast FGF2 significantly increased angiogenesis and biocompatibility of the bioprinted implants when compared to implant only sites. The combination of bioprinted collagen fibers and angiogenic GET therapy may lead to better graft biocompatibility in tendon repair.
Article
Full-text available
Purpose Over 50 % of the patients with chronic lateral ankle instability present with some degree of intra-articular pathology. To date, no consensus regarding the concomitant ankle arthroscopy procedures along with ankle ligament procedures has been reached. The purpose of current study was to investigate reoperation rates and postoperative complications following ankle ligament procedures with and without concomitant arthroscopic procedures. Methods Reoperations and postoperative complications following ankle ligament procedures with and without concomitant arthroscopic procedures were investigated using the PearlDiver Patient Record Database (PearlDiver Technologies, Inc.; Fort Wayne, IN, USA) between 2007 and 2011. Ankle ligament procedures, including ligament repair and reconstruction, and ankle arthroscopic procedures were investigated as primary surgery. Subsequently, the reoperation procedures, including ankle ligament procedures, arthroscopic procedures, autologous osteochondral transplantation, and ankle arthrodesis, as well as wound complications and nerve injury following primary ankle ligament procedures were identified. Results In 8014 patients receiving ligament repair, the arthroscopic group had a significantly higher reoperation rate in comparison with the non-arthroscopic group (8.8 vs. 6.5 %, odds ratio: 1.1, [p < 0.01], 95 % confidence interval (CI) 1.2–1.7). However, the non-arthroscopic group included 29 open arthrodesis procedures following the primary surgery, whereas arthroscopic group had none. Of the 8055 patients who received a ligament reconstruction, there was no significant difference in reoperation rate between the groups (5.9 vs. 5.9 %, odds ratio: 1.0, [n.s], 95 % CI 0.8–1.2). As seen in the ligament repair group, the non-arthroscopic group had a 4.9 % rate of ankle arthrodesis as a secondary procedure. Arthroscopic group had a significantly lower rate of wound dehiscence following ankle ligament procedures than non-arthroscopic group. Conclusion Concomitant ankle arthroscopy procedures performed with ankle ligament procedures did not decrease the rate of reoperation. However, there was a lower incidence of ankle arthrodesis and a lower rate of wound complications in the arthroscopic group when compared to those in non-arthroscopic group. Based on the results of the study, which analysed 16.069 patients, concomitant ankle arthroscopy is recommended. Level of evidence IV.
Article
Full-text available
Arthroscopic and open ankle arthrodesis have been compared in very few studies, and no consensus has been reached regarding the incidence of postoperative revision surgery associated with each technique. The purpose of the present study was to compare these 2 approaches for the incidence of postsurgical operations. Patients who had undergone either arthroscopic or open ankle arthrodesis were identified between January 2005 to December 2011 in the PearlDiver(™) database using a predetermined algorithm and searched for the following postsurgical operations: revision ankle arthrodesis, midfoot arthrodesis, and hindfoot arthrodesis. In the current database, 7322 cases were performed with an open technique and 1152 arthroscopically. The incidence of revision arthrodesis was not significantly different statistically between the 2 techniques. However, the incidence of subsequent adjacent joint arthrodesis was greater for the open cohort (5.6% versus 2.6%; odds ratio 2.17, 95% confidence interval 1.49 to 3.16). In the open cohort, the incidence of hindfoot arthrodesis was greater than the incidence of midfoot arthrodesis (3.9% versus 1.6%, odds ratio 2.43, 95% confidence interval 1.95 to 3.01). The results showed that although open ankle arthrodesis is more commonly performed, it is associated with a greater incidence of subsequent adjacent joint arthrodesis specifically in the hindfoot.
Article
Full-text available
Achilles tendon disorders, like Achilles tendinopathy, are very common among athletes. In the general population, however, knowledge about the incidence of Achilles tendinopathy is lacking. Design Cross-sectional study. In a cohort of 57.725 persons registered in primary care, the number of patients visiting the general practitioner (GP) with diagnosis of mid-portion Achilles tendon problems was counted using computerised registration networks of GPs in 2009. Subsequently, the authors assessed associations of these rates with demographic characteristics. The incidence rate of Achilles tendinopathy is 1.85 per 1,000 Dutch GP registered patients. In the adult population (21-60 years), the incidence rate is 2.35 per 1,000. In 35% of the cases, a relationship with sports activity was recorded. This is the first report on incidence rates of mid-portion Achilles tendinopathy in general practice. With an incidence of 1.85 per 1,000 registered persons, Achilles tendinopathy is frequently seen by GPs. The actual incidence might even be higher due to study limitations. More research on the frequency of this injury is required.
Article
Full-text available
Achilles tendinopathy is a common cause of disability. Despite the economic and social relevance of the problem, the causes and mechanisms of Achilles tendinopathy remain unclear. Tendon vascularity, gastrocnemius-soleus dysfunction, age, sex, body weight and height, pes cavus, and lateral ankle instability are considered common intrinsic factors. The essence of Achilles tendinopathy is a failed healing response, with haphazard proliferation of tenocytes, some evidence of degeneration in tendon cells and disruption of collagen fibers, and subsequent increase in noncollagenous matrix. Tendinopathic tendons have an increased rate of matrix remodeling, leading to a mechanically less stable tendon which is more susceptible to damage. The diagnosis of Achilles tendinopathy is mainly based on a careful history and detailed clinical examination. The latter remains the best diagnostic tool. Over the past few years, various new therapeutic options have been proposed for the management of Achilles tendinopathy. Despite the morbidity associated with Achilles tendinopathy, many of the therapeutic options described and in common use are far from scientifically based. New minimally invasive techniques of stripping of neovessels from the Kager's triangle of the tendo Achillis have been described, and seem to allow faster recovery and accelerated return to sports, rather than open surgery. A genetic component has been implicated in tendinopathies of the Achilles tendon, but these studies are still at their infancy.
Article
Achilles, the warrior and hero of Homer's Iliad, lends his name to the Achilles tendon, the thickest and strongest tendon in the human body138. Thetis, Achilles's mother, made him invulnerable to physical harm by immersing him in the river Styx after learning of a prophecy that Achilles would die in battle. However, the heel by which he was held remained untouched by the water and thus Achilles had a vulnerable point. Achilles led the Greek military forces, which captured and destroyed Troy after killing the Trojan prince Hector. However, Hector's brother Paris killed Achilles by firing a poisoned arrow into his heel164. Hippocrates, in the first recorded description of an injury to the Achilles tendon, stated that “this tendon, if bruised or cut, causes the most acute fevers, induces choking, deranges the mind and at length brings death.”26 Ambroise Pare, in 1575, recommended that a ruptured Achilles tendon be strapped with bandages dipped in wine and spices, but advised that the result was dubious27. Operative repair of a ruptured Achilles tendon was advocated in 1888 by another Frenchman, Gustave Polaillon27, although an Arabian physician performed such procedures as early as the tenth century A.D. In the twelfth century, an Italian surgeon, Guglielmo di Faliceto, believed that nature was unable to unite divided tendons and that operative treatment was necessary27. Much research has been performed to elucidate the etiology of a rupture of the Achilles tendon, but its true nature still remains unclear190. Also, the best method of treatment is still fiercely debated. Some physicians advocate operative repair, whereas others insist that an operation is unnecessary and poses an unacceptable risk. The tendinous portions of the gastrocnemius and soleus muscles merge to form the Achilles tendon. The plantaris …
Article
Background: Current studies investigating surgical treatment of distal biceps tendon tears largely consist of small, retrospective case series. The purpose of this study was to investigate the current patient demographics, surgical trends, and postoperative complication rates associated with operative treatment of distal biceps tendon tears using a large database of privately insured, non-Medicare patients. Methods: Patients who underwent surgical intervention for distal biceps tendon tears from 2007 to 2011 were identified using the PearlDiver database. Demographic and surgical data as well as postoperative complications were reviewed. Statistical analysis was performed using linear regression analysis and χ(2) tests, with statistical significance set at P < .05. Results: A total of 1443 patients underwent surgical treatment for distal biceps tendon tears. Men and patients aged 40 to 59 years accounted for 98% and 72% of the cohort, respectively. Regarding surgical technique, reinsertion to the radial tuberosity was preferred (95%) over tenodesis to the brachialis (5%) (P < .01). In total, revision surgery for tendon rerupture occurred in 5.4% of treated patients. The incidence of revision surgery for rerupture in acute and chronic distal biceps tears was 5.1% and 7.0%, respectively (P = .36). Postoperative infection and peripheral nerve injury rates were 1.1% and 0.6%, respectively. Conclusion: Surgeons strongly preferred anatomic reinsertion to the radial tuberosity for treatment, regardless of the chronicity of the injury. Postoperative complication rates were similar to those found in prior studies, although the true rate of rerupture may be higher than previously thought.
Article
Tendinopathy of the Achilles tendon involves clinical conditions in and around the tendon and it is the result of a failure of a chronic healing response. Although several conservative therapeutic options have been proposed, few of them are supported by randomized controlled trials. The management is primarily conservative and many patients respond well to conservative measures. If clinical conditions do not improve after 6 months of conservative management, surgery is recommended. The management of chronic ruptures is different from that of acute ruptures. The optimal surgical procedure is still debated. In this article chronic Achilles tendon disorders are debated and evidence-based medicine treatment strategies are discussed.
Article
The musculoskeletal system (muscle-tendon-bone) demonstrates numerous age-related changes, with modifications in tendons the least well studied, although increased predisposition to tendinopathy and rupture have been reported. In order to gain insights into the basis of age-associated increase in tendon injuries, we compared Achilles and tibialis anterior tendons and myotendinous junctions (MTJs) from 3- to 5- and 22- to 25-month-old rats for underlying structure and composition. Significant decreases were observed by qRT-PCR for collagen I, III, and V mRNA expression in tendons of old rats, but immunostaining detected no apparent differences in collagen I and V expression on the protein level. Tendons of old compared with young rats had decreased mRNA expression levels of proteoglycan 4 (PRG4) and elastin (Eln), but no differences in the mRNA expression of connective tissue growth factor, TGF-beta 1, or stromal cell-derived factor 1. For PRG4, immunostaining showed good correlation with qRT-PCR results. This is the first study to show reductions in PRG4 in tendons and MTJs of old rats. Decreased PRG4 expression in tendons could result in increased tendon stiffness and may be associated with decreased activity in the elderly. The diminished collagen mRNA expression in combination with decreased PRG4 and Eln mRNA expression may be associated with increased risk of tendon injury with aging.
Article
We evaluated specimens obtained from the biopsy of spontaneously ruptured tendons in 891 patients who were treated between 1968 and 1989. The specimens, which were removed at the time of repair, included 397 Achilles tendons, 302 biceps brachii tendons, forty extensor pollicis longus tendons, eighty-two quadriceps tendons and patellar ligaments, and seventy other tendons. Age and sex-matched control specimens, from 445 tendons taken at the time of death from the cadavera of previously healthy individuals who died accidentally, also were obtained and evaluated. The histopathological analyses of the specimens included light and polarized light microscopy and scanning and transmission electron microscopy. A healthy structure was not seen in any spontaneously ruptured tendon, but two-thirds of the control tendons were structurally healthy (p less than 0.001). There were characteristic histopathological patterns in the spontaneously ruptured tendons. Most (97 per cent) of the pathological changes were degenerative; they included hypoxic degenerative tendinopathy, mucoid degeneration, tendolipomatosis, and calcifying tendinopathy, either alone or in combination. These changes were also found in 34 per cent of the control tendons, but significantly less frequently (p less than 0.001). In the other twenty-six ruptured tendons (3 per cent), the pathological change was an intratendinous foreign body, rheumatoid tendinitis, a xanthoma, a tumor, or a tumor-like lesion such as an intratendinous ganglion. The findings clearly indicate that, at least in an urban population, degenerative changes are common in the tendons of people who are older than thirty-five years and that these changes are associated with spontaneous rupture.
Article
Between 1977 and 1985, 170 patients suffering from chronic Achilles tendinitis were treated surgically. Ninety-one patients with 143 tendons returned for fol lowup. The duration of preoperative symptoms aver aged 18 months. In all cases, conservative treatment was first attempted but failed to alleviate symptoms. Only those patients whose lesions and symptoms were confined to the Achilles tendon segment 2 to 6 cm proximal of the insertion were included in this study. All athletes who had an insertion tendinopathy or a lesion at the musculotendinous junction were excluded from this study. The surgical procedure depended on the lesion. For 93 tendons exhibiting pure peritendinitis, treatment consisted of a simple release of the fascia cruris and the peritenon. For the 50 tendons with tendinosis, a resection of diseased tendon tissue was performed. The defect could be sutured side to side in 26 cases but in the other 24 cases, reinforcement with a turned- down tendon flap was necessary because of the exten sive debridement. Of the 93 cases in which only dorsal release was performed, results were considered excellent in 54 cases, good in 28, fair in 8, and poor in 3 cases. Of the 26 cases in which side-to-side suture was performed, 15 cases were rated as having excellent results, 4 as good, 4 as fair, and 3 as poor. For the 24 cases in which a turned down tendon flap procedure was per formed, the result was excellent in 12 cases, good in 9, fair in 2, and poor in 1 case. The group of 170 patients treated surgically is part of a total number of 980 patients seen over this period in our hospital. The high percentage of operated cases for this group of 980 patients is explained by the fact that these 980 patients were a selected group of pa tients not including mild cases or patients with a tran sient Achilles tendinitis. Since the University Hospitals are mainly referral hospitals, many cases were referred because of complaints resistant to conservative treat ment.