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

April 2017
BioMed Research International 2017(4):1-4

DOI:10.1155/2017/7021862

Authors:

Youichi Yasui

Teikyo University

Andrew J Rosenbaum

Albany Medical College

Yoshiharu Shimozono

Kyoto University

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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.

Group 1: population distribution in each age according to incidence of Achilles tendon rupture. ∗Most affected age groups.

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Group 2: population distribution in each age according to incidence of Achilles tendinopathy. ∗Most affected age groups.

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Group 3: population distribution in each age according to incidence of Achilles tendon rupture following Achilles tendinopathy. ∗Most affected age groups.

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Distribution in each age according to ratio of incidence of Achilles tendon rupture following Achilles tendinopathy divided by incidence of Achilles tendinopathy.

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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

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)

∗

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)

∗

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).erewasnosignicant

BioMed Research International 

30–39 40–49 50–5920–29 60–69

(Age)

∗

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)

0.02

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.

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Risk factors for Achilles Tendon Rupture: an updated systematic review

Article

Jun 2022

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.

Patellar Tendon Shear Wave Velocity Is Higher and has Different Regional Patterns in Elite Competitive Alpine Skiers than in Healthy Controls

Article

Full-text available

Jun 2022

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.

Advances in Stem Cell Therapies for Rotator Cuff Injuries

Article

Full-text available

May 2022

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.

Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials

Article

Full-text available

Dec 2022

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.

Adjusted Landing Technique Reduces the Load on the Achilles Tendon in Badminton Players

Article

Apr 2022
J SPORT SCI MED

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.

Epidemiology of Achilles Tendon Rupture in South Korea: Claims Data of the National Health Insurance Service from 2009 to 2017

Article

Dec 2021

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.

Fluoroquinolone antibiotics and adverse events

Article

Oct 2021

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.

Original paper Intra- and Inter-Rater Reliability of Processing Ultrasound Tissue Characterization Scans in Midportion Achilles Tendinopathy

Article

Full-text available

Jun 2022

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.

The Achilles Tendon: Imaging Diagnoses and Image-Guided Interventions— AJR Expert Panel Narrative Review

Article

May 2022

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.

Gene Electrotransfer of FGF2 Enhances Collagen Scaffold Biocompatibility

Article

Oct 2021
BIOELECTROCHEMISTRY

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.

Reoperation rates following ankle ligament procedures performed with and without concomitant arthroscopic procedures

Article

Full-text available

Jun 2016

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.

Open Versus Arthroscopic Ankle Arthrodesis: A Comparison of Subsequent Procedures in a Large Database

Article

Full-text available

Apr 2016

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.

Incidence of midportion Achilles tendinopathy in the general population

Article

Full-text available

Oct 2011
BRIT J SPORT MED

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.

Achilles Tendinopathy

Article

Full-text available

Jul 2009

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.

Rupture of the Achilles Tendon*

Article

Jul 1999

Nicola Maffulli

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 …

Trends associated with distal biceps tendon repair in the United States, 2007 to 2011

Article

Feb 2016

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.

Chronic Achilles Tendon Disorders: Tendinopathy and Chronic Rupture

Article

Sep 2015

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

Jan 2013
AGE

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.

Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients

Article

Jan 1992

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.

Surgical treatment of chronic Achilles tendinitis

Article

Dec 1989
AM J SPORT MED

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.