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The Effect of the Plantaris Tendon on Achilles Tendinopathy
Abstract
Knowledge regarding the plantaris tendon and its involvement in midportion Achilles tendinopathy has evolved over the last decade. Various mechanisms have been proposed, including mechanical frictional syndrome, insertional variations with differential traction, and intrinsic tendon factors, as causes of midportion Achilles tendinopathy. A thorough understanding of its anatomy, function, and clinical presentation is important to manage plantaris-related pathology. Ultrasound tissue characterisation (UTC) scans can visualise and quantify the structure of the Achilles tendon and detect a plantaris tendon located close to the medial border of the Achilles. The mainstay of treatment is conservative, including relative unloading, modification of training regimes and specific exercises. Heavy slow resistance (HSR) training compared to eccentric exercises has shown higher patient satisfaction rates and compliance. Image-guided injections targeting the interface between the plantaris and the Achilles tendon are useful for recalcitrant cases with a small proportion requiring surgery. Various methods, including ultrasound-guided, endoscopic, minimal open and formal open procedures, have been described with good clinical outcomes.
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Background:
Achilles tendinopathy (AT) affects ca. 10 million recreational runners in Europe; the practice of hyaluronic acid (HA) infiltration is being increasingly adopted. The aim of this pilot study was to monitor the effects of a three-local time-spaced injections regimen of HA in the treatment of AT in middle-aged runners combining for the first time viscoelastometric, biochemical, and functional methodologies with routine clinical examinations.
Methods:
Eight male runners (Age 49.3 ± 3.9), diagnosed for unilateral AT, were given three ultrasound (US) guided peritendinous HA injections at the baseline (T0) and every fifteenth day with a follow-up on the forty-fifth day (T1, T2, and T3). At all-time points patients were assessed for viscoelastic tone and stiffness, maximal voluntary isometric contraction (MVIC), and pain level (Likert scale 0-5). The peritendinous effusions of the injured tendon were collected at T0 and T2 to quantify the volume variations and the IL-1β and MMP-3 levels.
Results:
At T0 MVIC and pain score were significantly lower and higher, respectively, in injured tendons. The volume, IL-1β and MMP-3 levels decreased in the course of treatment and the clinical endpoints ameliorated over time. Tone, stiffness, and functional performance also varied significantly at T2 and T3, as compared to T0.
Conclusions:
The sequential peritendinous injections of HA were effective in the amelioration of the clinical symptoms, as well as of the functional and viscoelastic state associated with AT. The determination of the viscoelastometric state may help to precisely evaluate the healing process in AT patients.
The aim of the present study was to compare the changes in gastrocnemius muscle thickness (MT) between conditions in which foot was pointed outward (FPO), inward (FPI), or forward (FPF). Twenty-two young men (23 ± 4 years) were selected and performed a whole-body resistance training program three times per week for nine weeks, with differences in the exercise specific for calves. Calf-raise exercise was performed unilaterally, in a pin-loaded seated horizontal leg-press machine, in 3 sets of 20-25 repetitions for training weeks 1-3, and 4 sets for weeks 4-9. Each subject's leg was randomly assigned for one of the three groups according to foot position: FPO, FPI, and FPF. Measurements with a B-mode ultrasound were performed to assess changes in MT of medial and lateral gastrocnemius heads. After training period, there were observed increases in MT of both medial (FPO = 8.4%; FPI = 3.8%; FPF = 5.8%) and lateral (FPO = 5.5%; FPI = 9.1%; FPF = 6.4%) gastrocnemius, and significant differences for magnitude of the gains were observed between FPO and FPI conditions (P < 0.05). Positioning FPO potentiated the increases in MT of medial gastrocnemius, while FPI provided greater gains for the lateral head. Our results suggest that head-specific muscle hypertrophy may be obtained selectively for gastrocnemius after nine weeks of calf training in young male adults.
Background
High Volume Injection (HVI) show promising results in the treatment of chronic midportion Achilles tendinopathy (AT). HVI consists of a large volume of saline with a small amount of corticosteroid and local anaesthetic.
Objective
To determine the effect of corticosteroid in HVI in AT.
Methods
A total of 28 men (18 to 59 years) with chronic (> 3 month) AT were included in a double‐blinded RCT and followed for 24‐wks. All performed eccentric training and randomized to either 1) HVI injection with corticosteroid or 2) HVI injection without corticosteroid. Outcomes included self‐reported function (VISA‐A score) and pain (VAS score) and ultrasound imaging (tendon thickness, Doppler flow).
Results
VISA‐A and VAS score improved in both groups at all time points (p<0.05). VISA‐A improvement was significantly greater in HVI with corticosteroid (mean ± SEM; 6‐wks=31±3 points;12‐wks=32±5 points) versus HVI without corticosteroid (6wks=14±3;12‐wks=17±3) at 6 and 12‐wks (p<0.05), but not at 24‐wks. Decrease in VAS scores were significant greater in HVI with corticosteroid (6‐wks=55±3 mm;12‐wks=53±5 mm) versus HVI without corticosteroid (6‐wks=16±3 mm;12‐wks=25±5 mm) at 6 and 12‐wks (p<0.05) but not at 24‐wks. Tendon thickness decreased significant in both groups at all time‐points (p<0.05), but more in the HVI with corticosteroid versus HVI without corticosteroid at 6 and 12‐wks (p<0.05) but not at 24‐wks.
Conclusion
HVI with or without corticosteroid in combination with eccentric training seems effective in AT. HVI with corticosteroid showed a better short term improvement than HVI without corticosteroid indicating a short term effect of corticosteroid in HVI treatment of AT.
Purpose
Open plantaris tendon excision and ventral paratendinous stripping is a recognised treatment option in selected patients with non-insertional Achilles tendinopathy. The aim of this study was to develop a minimally invasive outpatient technique of ultrasound guided plantaris tendon release (UPTR).
Methods
A 19 gauge needle, 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and a beaver blade (Arthrex, Naples, FL, USA), were used under ultrasound guidance to identify and divide the plantaris tendon in 12 cadaveric legs. Specimens were dissected to identify whether division of the plantaris tendon had been successful. UPTR was subsequently performed on patients.
Results
The 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and beaver blade (Arthrex, Naples, FL, USA) were all able to cut the plantaris tendon. However, on dissection the hook knife (Smith and Nephew, Boston MA) caused less damage to surrounding structures. Subsequently, the plantaris tendon was successfully divided in three patients using UPTR technique without complication.
Conclusion
UPTR is a viable technique for treating plantaris related non-insertional Achilles tendinopathy.
PurposeThe purpose of the present study was to compare the effects of eccentric training with different training frequencies on the blood circulation, collagen orientation, and mechanical properties of the human Achilles tendon in vivo. Methods
Ten healthy males completed 12 weeks of a unilateral eccentric training program {(15 repetitions with knee straight and 15 repetitions with knee slightly bent) × 6 sets in a single session} for the plantar flexor muscles. They performed training three times per week on one side (3TW) and six times per week on the other side (6TW). Before and after training, changes in blood volume, coefficient of variation (CV) of echogenicity (reflects collagen fiber orientation), and stiffness of the Achilles tendon were compared by two-way analysis of variance. ResultsThe tendon blood volume tended to increase after 3TW and 6TW (p = 0.064). Tendon stiffness did not change after 3TW and 6TW, whereas the elongation of tendon structures at three force levels (50, 100, and 150 N) significantly decreased with 3TW, but not 6TW. The CV of echogenicity significantly decreased after 3TW and 6TW. However, no significant differences were observed in the relative changes in these measured variables between 3TW and 6TW. Conclusion
The present results demonstrated an increase in blood volume, the alignment of collagen fibers, and unchanged stiffness of the Achilles tendon after 12 weeks of eccentric training. Furthermore, the training frequency did not influence these training-induced changes in the tendon properties.
Purpose:
Although the plantaris muscle (PM) is vestigial in humans, it has a significant clinical role in procedures such as grafting. However, recent reports suggest its potential involvement in the tendinopathy of the midportion of the Achilles tendon. The aim of the study is therefore to evaluate morphological variation of the PM with regard to its potential conflict with the Achilles tendon.
Material and methods:
Classical anatomical dissection was performed on 130 lower limbs (71 right, 59 left) fixed in 10% formalin solution. The morphology of the PM was assessed regarding the relationship between the course of the plantaris tendon and the calcaneal tendon.
Results:
The PM was present in 89.2% of cases. The findings indicate the presence of a new type of PM tendon insertion in which the tendon is inserted into the tarsal canal flexor retinaculum, potentially affecting the tendinopathy of the tibialis posterior muscle. In 26 cases (22.4%), insertion blended with the Achilles tendon (Type II), which may increase the risk of Achilles tendinopathy.
Conclusion:
The anatomical variation of PM tendon morphology may create a potential conflict with the Achilles tendon and the tibialis posterior tendon, thus increasing the possibility of tendinopathy.
By virtue of their anatomical location between muscles and bones, tendons make it possible to transform contractile force to joint rotation and locomotion. However, tendons do not behave as rigid links, but exhibit viscoelastic tensile properties, thereby affecting the length and contractile force in the in-series muscle, but also storing and releasing elastic stain energy as some tendons are stretched and recoiled in a cyclic manner during locomotion. In the late 90s, advancements were made in the application of ultrasound scanning that allowed quantifying the tensile deformability and mechanical properties of human tendons in vivo. Since then, the main principles of the ultrasound-based method have been applied by numerous research groups throughout the world and showed that tendons increase their tensile stiffness in response to exercise training and chronic mechanical loading, in general, by increasing their size and improving their intrinsic material. It is often assumed that these changes occur homogenously, in the entire body of the tendon, but recent findings indicate that the adaptations may in fact take place in some but not all tendon regions. The present review focuses on these regional adaptability features and highlights two paradigms where they are particularly evident: a) Chronic mechanical loading in healthy tendons, and b) tendinopathy. In the former loading paradigm, local tendon adaptations indicate that certain regions may “see”, and therefore adapt to, increased levels of stress. In the latter paradigm, local pathological features indicate that certain tendon regions may be “stress-shielded” and degenerate over time. Eccentric exercise protocols have successfully been used in the management of tendinopathy, without much sound understanding of the mechanisms underpinning their effectiveness. For insertional tendinopathy, in particular, it is possible that the effectiveness of a loading/rehabilitation protocol depends on the topography of the stress created by the exercise and is not only reliant upon the type of muscle contraction performed. To better understand the micromechanical behaviour and regional adaptability/mal-adaptability of tendon tissue it is important to estimate its internal stress-strain fields. Recent relevant advancements in numerical techniques related to tendon loading are discussed.
Background: It is becoming increasingly apparent that the plantaris can contribute to symptoms in at least a subset of patients with midportion Achilles tendinopathy. However, the nature of its involvement remains unclear.
Purpose: To determine whether excised plantaris tendons from patients with midportion Achilles tendinopathy display tendinopathic changes and whether the presence of such changes affect clinical outcomes.
Study Design: Case series; Level of evidence, 4.
Methods: Sixteen plantaris tendons in patients with midportion Achilles tendinopathy recalcitrant to conservative management underwent histological examination for the presence of tendinopathic changes. All patients had imaging to confirm the presence of the plantaris tendon adherent to or invaginated into the focal area of Achilles tendinosis. Visual analog scale (VAS) and Foot and Ankle Outcome Score (FAOS) results were recorded pre- and postoperatively.
Results: Sixteen patients (mean age, 26.2 years; range, 18-47 years) underwent surgery, with a mean follow-up of 14 months (range, 6-20 months). The plantaris tendon was histologically normal in 13 of 16 cases (81%). Inflammatory changes in the loose peritendinous connective tissue surrounding the plantaris tendon were evident in all cases. There was significant improvement in mean VAS scores (P < .05) and all domains of the FAOS postoperatively (P < .05).
Conclusion: The absence of any tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic.
Objectives
The plantaris tendon has recently been described as a possible important factor in midportion Achilles tendinopathy. Ultrasound tissue characterisation (UTC) is a method to study tendon structure (matrix integrity). The effect of plantaris tendon removal on Achilles tendon structure was studied using UTC.
Design and setting
Prospective case series study at one centre.
Participants
Nine tendons in eight physically active and healthy patients (mean age 39 years) with chronic painful midportion Achilles tendinopathy were included. Preoperative two-dimensional ultrasound and UTC showed midportion Achilles tendinopathy (tendinosis) with medial tendon changes and suspected plantaris tendon involvement. Patients with previous operations to the Achilles tendon were excluded.
Interventions
Operative treatment consisted of excision of the plantaris tendon and scraping of the ventromedial surface of the Achilles tendon under a local anaesthetic.
Primary and secondary outcome measures
UTC examination and clinical scoring with the VISA-A questionnaire were performed preoperatively and 6 months postoperatively.
Results
At 6 months follow-up, UTC demonstrated a statistically significant (t=5.40, p<0.001) increase in the mean organised matrix (echo-type I+II) and a decrease in the mean disorganised matrix (echo-type III+IV). Seven out of eight patients were satisfied, and the VISA-A score had increased significantly (p<0.001) from 56.8 (range 34–73) preoperatively to 93.3 (range 87–100) postoperatively.
Conclusions
Excision of the plantaris tendon and scraping of the ventromedial Achilles tendon in chronic midportion tendinopathy seem to have the potential to improve tendon structure and reduce tendon pain. Studies on a larger group of patients and with a longer follow-up period are needed.
Non-insertional Achilles tendinopathy is a degenerative condition characterised by pain on activity.
Eccentric stretching is the most effective treatment.
Surgical treatment is reserved for recalcitrant cases.
Minimally-invasive and tendinoscopic treatments are showing promising results.
Cite this article: Pearce CJ, Tan A. Non-insertional Achilles tendinopathy. EFORT Open Rev 2016;1:383-390. DOI: 10.1302/2058-5241.1.160024.
Objective:
To compare the safety and efficacy of hyaluronan (HA) injections with standard extracorporeal shock wave therapy (ESWT) in the treatment of painful midportion Achilles tendinopathy.
Design:
Multinational, prospective, randomized controlled, blinded-observer trial.
Setting:
Ambulatory care.
Participants:
Adults presenting Achilles midportion tendinopathy for at least 6 weeks and a pain score of at least 40 mm (Huskisson, visual analogue scale (VAS), 100 mm). 62 participants were randomized and 59 analyzed in the ITT-data set. No withdrawals due to adverse effects.
Interventions:
Two peritendinous HA injections versus three ESWT applications at weekly intervals.
Main outcome measures:
Primary efficacy criterion was changed from VISA-A score to percent change in pain (VAS) at 3 months post-treatment, compared to baseline values. Main secondary parameters were VISA-A, Clinical Global Impression (CGI) and clinical parameters.
Results:
HA treatment provided a clinically relevant improvement in Achilles midportion tendinopathy. A large superiority of the HA-group, compared to ESWT application, was observed for percent change in pain (VAS) and this superiority was proven to be statistically significant (Mann-Whitney statistic (MW) = 0.7507 with p = 0.0030 lower than required alpha = 0.025 significance level one-sided; Mann-Whitney-U test) at 3 months post-treatment. Similar findings for HA were also observed at 4 weeks (MW = 0.6425, p = 0.0304) and 6 months (MW = 0.7172, p = 0.0018). Advantage of HA treatment was confirmed by VISA-A, CGI and clinical parameters. Ten adverse events, 4 in HA-group and 6 in ESWT-group were reported, but none were classified as serious.
Conclusions:
Two peritendinous HA injections showed greater treatment success in Achilles midportion tendinopathy compared to standard ESWT.
Background
The purpose of this investigation was to evaluate if clinical assessment, Ultrasound + Colour Doppler (US + CD) and Ultrasound Tissue Characterisation (UTC) can be useful in detecting plantaris tendon involvement in patients with midportion Achilles tendinopathy.
Methods
Twenty-three tendons in 18 patients (14 men, mean age: 37 years and 4 women: 44 years) (5 patients with bilateral tendons) with midportion Achilles tendinopathy were surgically treated with a scraping procedure and plantaris tendon removal. For all tendons, clinical assessment, Ultrasound + Colour Doppler (US + CD) examination and Ultrasound Tissue Characterisation (UTC) were performed.
Results
At surgery, all 23 cases had a plantaris tendon located close to the medial side of the Achilles tendon. There was vascularised fat tissue in the interface between the Achilles and plantaris tendons. Clinical assessment revealed localised medial activity-related pain in 20/23 tendons and focal medial tendon tenderness in 20/23 tendons. For US + CD, 20/23 tendons had a tendon-like structure interpreted to be the plantaris tendon and localised high blood flow in close relation to the medial side of the Achilles. For UTC, 19/23 tendons had disorganised (type 3 and 4) echopixels located only in the medial part of the Achilles tendon indicating possible plantaris tendon involvement.
Conclusions
US + CD directly, and clinical assessment indirectly, can detect a close by located plantaris tendon in a high proportion of patients with midportion Achilles tendinopathy. UTC could complement US + CD and clinical assessment by demonstrating disorganised focal medial Achilles tendon structure indicative of possible plantaris involvement.
The present article systematically reviews recent literature on the in vivo adaptation of asymptomatic human tendons following increased chronic mechanical loading, and meta-analyzes the loading conditions, intervention outcomes, as well as methodological aspects.
The search was performed in the databases PubMed, Web of Knowledge, and Scopus as well as in the reference lists of the eligible articles. A study was included if it conducted (a) a longitudinal exercise intervention (≥8 weeks) on (b) healthy humans (18 to 50 years), (c) investigating the effects on mechanical (i.e., stiffness), material (i.e., Young’s modulus) and/or morphological properties (i.e., cross-sectional area (CSA)) of tendons in vivo, and was reported (d) in English language. Weighted average effect sizes (SMD, random-effects) and heterogeneity (Q and I
2
statistics) of the intervention-induced changes of tendon stiffness, Young’s modulus, and CSA were calculated. A subgroup analysis was conducted regarding the applied loading intensity, muscle contraction type, and intervention duration. Further, the methodological study quality and the risk of bias were assessed.
The review process yielded 27 studies with 37 separate interventions on either the Achilles or patellar tendon (264 participants). SMD was 0.70 (confidence interval: 0.51, 0.88) for tendon stiffness (N=37), 0.69 (0.36, 1.03) for Young’s modulus (N=17), and 0.24 (0.07, 0.42) for CSA (N=33), with significant overall intervention effects (p<0.05). The heterogeneity analysis (stiffness: I
2
=30%; Young’s modulus: I
2
=57%; CSA: I
2
=21%) indicated that differences in the loading conditions may affect the adaptive responses. The subgroup analysis confirmed that stiffness adaptation significantly (p<0.05) depends on loading intensity (I
2
=0%), but not on muscle contraction type. Although not significantly different, SMD was higher for interventions with longer duration (≥12 weeks). The average score of 71±9% in methodological quality assessment indicated an appropriate quality of most studies.
The present meta-analysis provides elaborate statistical evidence that tendons are highly responsive to diverse loading regimens. However, the data strongly suggests that loading magnitude in particular plays a key role for tendon adaptation in contrast to muscle contraction type. Furthermore, intervention-induced changes in tendon stiffness seem to be more attributed to adaptations of the material rather than morphological properties.
Previous studies have shown that eccentric training has a positive effect on Achilles tendinopathy, but few randomized controlled trials have compared it with other loading-based treatment regimens.
To evaluate the effectiveness of eccentric training (ECC) and heavy slow resistance training (HSR) among patients with midportion Achilles tendinopathy.
Randomized controlled trial; Level of evidence, 1.
A total of 58 patients with chronic (>3 months) midportion Achilles tendinopathy were randomized to ECC or HSR for 12 weeks. Function and symptoms (Victorian Institute of Sports Assessment-Achilles), tendon pain during activity (visual analog scale), tendon swelling, tendon neovascularization, and treatment satisfaction were assessed at 0 and 12 weeks and at the 52-week follow-up. Analyses were performed on an intention-to-treat basis.
Both groups showed significant (P < .0001) improvements in Victorian Institute of Sports Assessment-Achilles and visual analog scale from 0 to 12 weeks, and these improvements were maintained at the 52-week follow-up. Concomitant with the clinical improvement, there was a significant reduction in tendon thickness and neovascularization. None of these robust clinical and structural improvements differed between the ECC and HSR groups. However, patient satisfaction tended to be greater after 12 weeks with HSR (100%) than with ECC (80%; P = .052) but not after 52 weeks (HSR, 96%; ECC, 76%; P = .10), and the mean training session compliance rate was 78% in the ECC group and 92% in the HSR group, with a significant difference between groups (P < .005).
The results of this study show that both traditional ECC and HSR yield positive, equally good, lasting clinical results in patients with Achilles tendinopathy and that the latter tends to be associated with greater patient satisfaction after 12 weeks but not after 52 weeks.
© 2015 The Author(s).
Achilles tendinopathy (AT) is a prevalent condition among runners and military personnel. Although ankle dorsiflexion (DF) range of motion (ROM) as measured with the knee bent has not been previously associated with AT, the literature concerning its role is limited. In addition, the role of lower extremity movement pattern in the pathogenesis of AT has not been studied prospectively. The purpose of this study was to further explore the role of ankle DF ROM as measured with the knee bent and that of lower extremity movement pattern as risk factors for mid-portion AT.
Seventy healthy male military recruits (mean ± SD age, height and body mass of 19.6 ± 1.0 years, 176.0 ± 10.0 cm, and 71.5 ± 7.4 kg) participated in this study. Ankle DF ROM as measured with the knee bent in weight-bearing (WB) and non-weight-bearing (NWB), as well as lower extremity quality of movement during a lateral step down (LSD) test were measured at baseline. Participants were then followed for a 6-month period of army basic training with recording of the development of AT.
Five participants developed AT during training. Participants that developed AT had a more limited NWB ankle DF ROM (27.4(0) versus 21.1(0), p = 0.025). The quality of lower extremity movement did not differ between injured and uninjured participants (p = 0.361).
A more limited ankle DF ROM as measured in NWB with the knee bent increases the risk of developing AT among military recruits taking part in intensive physical training.
Background Achilles tendinopathy is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional Achilles tendinopathy.
Aim To assess whether excising the plantaris tendon improved the symptoms of Achilles tendinopathy in elite athletes.
Methods This prospective consecutive case series study investigated 32 elite athletes who underwent plantaris tendon excision using a mini-incision technique to treat medially located pain associated with non-insertional Achilles tendinopathy. Preoperative and postoperative visual analogue scores (VAS) for pain and the foot and ankle outcome score (FAOS) as well as time to return to sport and satisfaction scores were assessed.
Results At a mean follow-up of 22.4 months (12–48), 29/32 (90%) of athletes were satisfied with the results. Thirty of the 32 athletes (94%) returned to sport at a mean of 10.3 weeks (5–27). The mean VAS score improved from 5.8 to 0.8 (p<0.01) and the mean FAOS improved in all domains (p<0.01). Few complications were seen, four athletes experienced short-term stiffness and one had a superficial wound infection.
Conclusions The plantaris tendon may be responsible for symptoms in some athletes with non-insertional Achilles tendinopathy. Excision carries a low risk of complications and may provide significant improvement in symptoms enabling an early return to elite-level sports.
Purpose:
The plantaris tendon is present in 98-100 % of people, and a potential relationship between the plantaris tendon and the development of Achilles tendinopathy has been postulated. There are no studies on the epidemiology of plantaris injuries in a sporting population. This retrospective cohort study presents the incidence, nature and outcome of plantaris injuries in elite British track and field athletes.
Method:
All 214 elite athletes supported by the British Athletics Medical team from 2009 to 2013 were included in this cohort study. An injury was recorded if a plantaris injury was diagnosed and confirmed with imaging or surgical findings. Patient demographics, injury details and return to competitive elite track and field were recorded.
Results:
There were 33 new plantaris injuries, with an annual plantaris injury incidence of 3.9-9.3 %. There were significantly more right-sided plantaris injuries in bend running sprinters (15 right-sided vs. 4 left-sided). 74 % of the athletes who had a plantaris injury also had Achilles tendinopathy at some point during the study period. Seventeen plantaris tendons were surgically removed from 13 athletes during the course of the study with 12 of the 13 athletes returning to the same level on the Tegner activity scale.
Conclusion:
This retrospective cohort study demonstrates that plantaris injuries are common in elite track and field athletes and may be underreported in the literature. There may be an association between the biomechanics bend sprinting and plantaris injury. Elite athletes may benefit from appropriate preventative and management strategies implemented by coaching and medical teams. LEVEL OF EVIDENCE: IV.
Viscosupplementation with hyaluronic acid is safe and effective in the management of osteoarthritis, but its use in the treatment of tendon disorders has received less attention. The aim of this review is to summarize the current knowledge on this topic, evaluating experimental and clinical trials. A search of English-language articles was performed using the key search terms "hyaluronic acid" or "viscosupplementation" combined with "tendon," "tendinopathy," "adhesions," or "gliding," independently. In quite all the experimental studies, performed after surgical procedures for tendon injuries or in the treatment of chronic tendinopathies, using different hyaluronic acid compounds, positive results (reduced formation of scars and granulation tissue after tendon repair, less adhesions and gliding resistance, and improved tissue healing) were observed. In a limited number of cases, hyaluronic acid has been employed in clinical practice. After flexor tendon surgery, a greater total active motion and fingers function, with an earlier return to work and daily activities, were observed. Similarly, in patients suffering from elbow, patellar, and shoulder tendons disorders, pain was reduced, and function improved. The positive effect of hyaluronic acid can be attributed to the anti-inflammatory activity, enhanced cell proliferation, and collagen deposition, besides the lubricating action on the sliding surface of the tendon.
The Achilles tendon is a tissue that responds to mechanical loads at a molecular and cellular level. In vitro and in vivo studies have shown that the expression of anabolic and/or catabolic proteins can change within hours of loading and return to baseline levels within 72 h. These biochemical changes have not been correlated with changes in whole tendon structure on imaging. We examined the nature and temporal sequence of changes in Achilles tendon structure in response to competitive game loads in elite Australian football players.
Elite male Australian football players with no history of Achilles tendinopathy were recruited. Achilles tendon structure was quantified using ultrasound tissue characterisation (UTC) imaging, a valid and reliable measure of intratendinous structure, the day prior to the match (day 0), and then reimaged on days 1, 2 and 4 postgame.
Of the 18 participants eligible for this study, 12 had no history of tendinopathy (NORM) and 6 had a history of patellar or hamstring tendinopathy (TEN). Differences in baseline UTC echopattern were observed between the NORM and TEN groups, with the Achilles of the TEN group exhibiting altered UTC echopattern, consistent with a slightly disorganised tendon structure. In the NORM group, a significant reduction in echo-type I (normal tendon structure) was seen on day 2 (p=0.012) that returned to baseline on day 4.
There was a transient change in UTC echopattern in the Achilles tendon as a result of an Australian football game in individuals without a history of lower limb tendinopathy.
The two main categories of tendo Achillis tendon disorder are broadly classified by anatomical location to include non-insertional and insertional conditions.
Non-insertional Achilles tendinopathy is often managed conservatively, and many rehabilitation protocols have been adapted and modified, with excellent clinical results. Emerging and popular alternative therapies, including a variety of injections and extracorporeal shockwave therapy, are often combined with rehabilitation protocols. Surgical approaches have developed, with minimally invasive procedures proving popular.
The management of insertional Achilles tendinopathy is improved by recognising coexisting pathologies around the insertion. Conservative rehabilitation protocols as used in non-insertional disorders are thought to prove less successful, but such methods are being modified, with improving results. Treatment such as shockwave therapy is also proving successful. Surgical approaches specific to the diagnosis are constantly evolving, and good results have been achieved.
Calf muscle trauma commonly involves the gastrocnemius and soleus muscles. Plantaris muscle is a vestigial muscle coursing through the calf. Similar clinical features may be seen with injury to the plantaris muscle. It can also mimic other conditions like deep vein thrombosis, rupture of Baker's cyst, and tumors. MRI is helpful in identifying and characterizing it. We report two cases of ruptured plantaris muscle seen on MRI.
Achilles tendinopathy is a problem that is generally difficult to treat. The pain is frequently most prominent on the medial side of the mid-portion of the tendon, where the plantaris tendon is running parallel to the Achilles tendon. The purpose of this study was to assess whether excision of the plantaris tendon would relieve symptoms.
Three patients with pain and stiffness at the mid-portion of the Achilles tendon were treated by excision of the plantaris tendon. Preoperatively, these patients experienced recognizable tenderness on palpation of the medial side of the mid-portion of the Achilles tendon with localized nodular thickening at 4-7 cm proximal to the insertion. MRI indicated Achilles tendinopathy with the involvement of the plantaris tendon.
The plantaris tendon was bluntly retrieved and excised with a tendon stripper through a 4-cm incision in the proximal calf. We report a good-to-excellent outcome of this novel procedure in three patients with chronic mid-portion Achilles tendinopathy
The medial pain might be based on the involvement of the plantaris tendon in the process.
IV.
Minimally-invasive treatments for chronic Achilles tendinopathy may prevent the need for surgery when conservative methods have failed. Whilst injections have traditionally been used to manage symptoms, recently described therapies may also have disease-modifying potential. Ultrasound provides the ability to guide therapeutic interventions, ensuring that treatment is delivered to the exact site of pathology. Treatments can be broadly categorised according to their intended therapeutic targets, although some may act through several possible mechanisms. In this article, we review the ultrasound-guided techniques currently used to treat chronic Achilles tendinopathy, with reference to the available literature. There is strong pilot-level evidence supporting the use of many of these techniques, although large definitive trials are lacking. An approach towards the management of chronic Achilles tendinopathy is suggested.
To assess whether three-dimensional imaging of the Achilles tendon by ultrasonographic tissue characterisation (UTC) can differentiate between symptomatic and asymptomatic tendons.
Case-control study.
Sports Medical Department of the Hague Medical Centre.
Twenty-six tendons from patients with chronic midportion Achilles tendinopathy were included. The "matched" control group consisted of 26 asymptomatic tendons.
Symptomatic and asymptomatic tendons were scanned using the UTC procedure. One researcher performed the ultrasonographic data collection. These blinded data were randomised, and outcome measures were determined by two independent observers.
The raw ultrasonographic images were analysed with a custom-designed algorithm that quantifies the three-dimensional stability of echo patterns, qua intensity and distribution over contiguous transverse images. This three-dimensional stability was related to tendon structure in previous studies. UTC categorises four different echotypes that represent (I) highly stable; (II) medium stable; (III) highly variable and (IV) constantly low intensity and variable distribution. The percentages of echo-types were calculated, and the maximum tendon thickness was measured. Finally, the inter-observer reliability of UTC was determined.
Symptomatic tendons showed less pixels in echo-types I and II than asymptomatic tendons (51.5% vs 76.6%, p<0.001), thus less three-dimensional stability of the echo pattern. The mean maximum tendon thickness was 9.2 mm in the symptomatic group and 6.8 mm in the asymptomatic group (p<0.001). The Intraclass Correlation Coefficient (ICC) for the interobserver reliability of determining the echo-types I+II was 0.95. The ICC for tendon thickness was 0.84.
UTC can quantitatively evaluate tendon structure and thereby discriminate symptomatic and asymptomatic tendons. As such, UTC might be useful to monitor treatment protocols.
Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.
To compare the effectiveness of 2 management strategies--group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.
Randomized controlled trial; Level of evidence, 1.
Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis.
At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery.
At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.
Background
Loading interventions have become a predominant treatment strategy for tendinopathy, and positive clinical outcomes and tendon tissue responses may depend on the exercise dose and load magnitude.
Purpose/Hypothesis
The purpose was to investigate if the load magnitude influenced the effect of a 12-week loading intervention for patellar tendinopathy in the short term (12 weeks) and long term (52 weeks). We hypothesized that a greater load magnitude of 90% of 1 repetition maximum (RM) would yield a more positive clinical outcome, tendon structure, and tendon function compared with a lower load magnitude of 55% of 1 RM when the total exercise volume was kept equal in both groups.
Study Design
Randomized clinical trial; Level of evidence, 1.
Methods
A total of 44 adult participants with chronic patellar tendinopathy were included and randomized to undergo moderate slow resistance (MSR group; 55% of 1 RM) or heavy slow resistance (HSR group; 90% of 1 RM). Function and symptoms (Victorian Institute of Sport Assessment–Patella questionnaire [VISA-P]), tendon pain during activity (numeric rating scale [NRS]), and ultrasound findings (tendon vascularization and swelling) were assessed before the intervention, at 6 and 12 weeks during the intervention, and at 52 weeks from baseline. Tendon function (functional tests) and tendon structure (ultrasound and magnetic resonance imaging) were investigated before and after the intervention period.
Results
The HSR and MSR interventions both yielded significant clinical improvements in the VISA-P score (mean ± SEM) (HSR: 0 weeks, 58.8 ± 4.3; 12 weeks, 70.5 ± 4.4; 52 weeks, 79.7 ± 4.6) (MSR: 0 weeks, 59.9 ± 2.5; 12 weeks, 72.5 ± 2.9; 52 weeks, 82.6 ± 2.5), NRS score for running, NRS score for squats, NRS score for preferred sport, single-leg decline squat, and patient satisfaction after 12 weeks, and these were maintained after 52 weeks. HSR loading was not superior to MSR loading for any of the measured clinical outcomes. Similarly, there were no differences in functional (strength and jumping ability) or structural (tendon thickness, power Doppler area, and cross-sectional area) improvements between the groups undergoing HSR and MSR loading.
Conclusion
There was no superior effect of exercising with a high load magnitude (HSR) compared with a moderate load magnitude (MSR) for the clinical outcome, tendon structure, or tendon function in the treatment of patellar tendinopathy in the short term. Both HSR and MSR showed equally good, continued improvements in outcomes in the long term but did not reach normal values for healthy tendons.
Registration
NCT03096067 (ClinicalTrials.gov identifier)
Aim
The aim of this study was to evaluate the efficacy and safety of a single, peri-tendinous injection of hyaluronic acid for mid-portion, non-insertional Achilles tendinopathy.
Materials And Methods
We conducted a prospective, open labelled, single center, pilot study. All patients enrolled received a single peri-tendinous injection of Ostenil Tendon™ (40 mg/2 ml 2% HA with 0.5% mannitol). Outcome measures were Visual Analogue Scale (VAS) pain score and Manchester-Oxford Foot Questionnaire (MOxFQ) scores at 2 weeks and at final follow at 12 weeks. Any major and minor adverse effects were recorded. To assess change in VAS and MOxFQ scores, t test and Wilcoxon signed rank test were employed.
Results
Seventeen patients were enrolled in this study with a mean follow-up of 12 weeks. Mean pre-injection VAS score was 9.38 cm (9-9.8), which significantly reduced post-injection to a mean score of 4.09 cm (2-8) at week-2 stage, and further improved to 3.01 cm (2-3.9) at the final follow-up (p < 0.0001). MOxFQ score showed a significant improvement from pre-injection value of 67.77 (63.03-72.55) to 31.18 (13-60) at week-2 stage, and further improved to 24.20 (15.73-32.67) at the final follow-up (p < 0.0001). The mean improvement from pre-injection to the final follow up was 43.57 (34.25-52.90). No adverse effects for injections were recorded.
Conclusion
This small series suggests an encouraging response of a single injection of HA as an effective and safe option for non-insertional Achilles tendinopathy.
Foot orthoses and insoles are prescribed to runners, however their impact on running economy and performance is uncertain. The aim of this systematic review and meta-analysis was to determine the effect of foot orthoses and insoles on running economy and performance in distance runners. Seven electronic databases were searched from inception until June 2018. Eligible studies investigated the effect of foot orthoses or insoles on running economy (using indirect calorimetry) or running performance. Standardised mean differences (SMDs) were computed and meta-analyses were conducted using random effects models. Methodological quality was assessed using the Quality Index. Nine studies met the criteria and were included: five studies investigated the effect of foot orthoses on running economy and four investigated insoles. Foot orthoses were associated with small negative effects on running economy compared to no orthoses (SMD 0.42 [95% CI 0.17,0.72] p = 0.007). Shock absorbing insoles were also associated with negative effects on running economy, but an imprecise estimate (SMD 0.26 [95% CI −0.33,0.84] p = 0.83). Quality Index scores ranged from 4 to 15 out of 17. Foot orthoses and shock absorbing insoles may adversely affect running economy in distance runners. Future research should consider their potential effects on running performance.
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.
This book describes the current applications of arthroscopy in a very wide range of sports injuries involving, among other sites, the hip, knee, ankle, shoulder, elbow, and wrist. For each condition, mechanisms of injury are explained and the role of arthroscopy in diagnosis and treatment is described. Relevant information is also provided on the epidemiology and mechanisms of injury in specific sports and on indications for treatment and rehabilitation. The book fully reflects the recent advances that have taken place in arthroscopy, permitting more accurate assessment and more successful management of post-traumatic pathologies. Furthermore, it acknowledges that as a result of the increasing use of new technologies and biomaterials, there is now particular interest in techniques that promote biological healing of articular lesions and permit complete functional recovery. The authors are leading specialists in the field who have aimed to provide practitioners with the clear guidance that they require on the evaluation and treatment of injuries incurred during sporting activity.
Recent research has suggested a combined role of the plantaris tendon and neovascularization for Achilles tendinopathy recalcitrant to nonoperative management. The aim of our study was to determine if addressing both these issues improved symptoms of Achilles tendinopathy. We report on the results of a prospective case series involving 2 cohorts of patients between February 2011 and February 2015 undergoing this combined technique. One cohort included recreational athletes (group A), the second included patients who undertook minimal recreational activity (group B). In group A there were 19 patients (25 tendons). The mean age at surgery was 44 years (range, 20 to 55 y). The mean follow-up was 21 months (range, 7 to 38 mo). Patients were satisfied with the results in 21 of the 25 tendons (84%). The mean Victorian Institute of Sports Assessment-Achilles improved from 51 to 90 following surgery ( P <0.001). One case was revised. In group B there were 7 patients (9 tendons). Patients were satisfied in 7 of the 9 cases. These results support the use of this combined procedure in recreational athletes with failed nonoperative management. We believe surgery provides a healthier environment for conservative load-based rehabilitation. In the nonathletic population results are less consistent.
Level of Evidence
Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
Achilles tendinopathy is a frequent problem in high-level athletes. Recent research has proposed a combined etiologic role for the plantaris tendon and neovascularization. Both pathologies can be observed on ultrasound imaging.(1,13) However, little is known about the change in structure of the Achilles tendon following the surgical treatment of these issues. The purpose of the study was to assess if excising the plantaris and performing ventral paratendinous "scraping" of the neovascularization improved symptoms of Achilles tendinopathy and whether there was a change in the fibrillar structure of the tendon with ultrasound tissue characterization (UTC) following this operation.
Methods:
This prospective consecutive case series included 15 professional/semiprofessional athletes (17 Achilles tendons) who underwent plantaris excision and paratendinous scraping to treat noninsertional Achilles tendinopathy. The plantaris tendon was excised if adherent to the Achilles tendon, and the area of neovascularization for scraping was demarcated on preoperative imaging. Preoperative and postoperative Victorian Institute of Sports Assessment-Achilles (VISA-A) scores were taken. UTC was performed on 11 of 17 tendons preoperatively and postoperatively. The mean follow-up was for 25 months.
Results:
Fourteen of 15 patients had a successful outcome after the surgery. The mean VISA-A improved from 51 to 95 (p=.0001). There was a statistically significant (p=.04) improvement in the aligned fibrillar structure of the tendon confirmed with UTC scanning following surgery from 90% (±8) to 96% (±5).
Conclusion:
This group of high-level athletes derived an excellent clinical result from this operation. Furthermore, UTC scanning offered an objective method to evaluate the healing of Achilles tendons.
Level of evidence:
Level IV, case series.
Background:
Little has been reported about the biologic effect of shock waves on human normal or pathologic tendon tissue. We hypothesized that inflammatory cytokine and MMP production would be down-regulated by shock wave stimulation.
Materials and methods:
Diseased Achilles tendon tissue and healthy flexor hallucis longus tissue were used. Shock wave treatment was applied to cultured cells at 0.17 mJ/mm(2)energy 250, 500, 1000, and 2000 times.
Results:
A dose-dependent decrease in cell viability was noted in cells receiving 1000 and 2000 shocks (86.0 +/- 5.6%, p = 0.01 and 72.4 +/- 8.9%, p = 0.001) as compared with the normal control. Cell count in the 500-shock group increased by 23.4% as compared with the control (p = 0.05). The concentration of MMP 1, 2, and 13 was higher in diseased tenocytes as compared with normal cells (p = 0.04, all comparisons). IL-6 levels were higher in the diseased tenocytes as compared with normal tenocytes (44.10 +/- 16.72 versus 0.21 +/- 0.55 ng/ml, (p < 0.05). IL-1 levels in normal cells increased (2.24 +/- 5.02 ng/ml to 9.31 +/- 6.85 ng/ml) after shock wave treatment (p = 0.04). In diseased tenocytes, levels of MMP-1 (1.12 +/- 0.23 to 0.75 +/- 0.24 ng/ml; p = 0.04) and MMP-13 (1.43 +/- 0.11 to 0.80 +/- 0.15 ng/ml; p = 0.04) were significantly decreased after shock wave treatment. The IL-6 level in diseased tenocytes was decreased (44.10 +/- 16.72 to 14.66 +/- 9.49 ng/ml) after shock wave treatment (p = 0.04).
Conclusion:
Higher levels of MMPs and ILs were found in human tendinopathy-affected tenocytes as compared with normal cells. ESWT decreased the expression of several MMPs and ILs.
Clinical relevance:
This mechanism may play an important role in shock wave treatment of tendinopathy clinically.
Introduction Recent cadaveric studies have identified a plantaris tendon in 98–100% of specimens (Saxena,2000; van Sterkenberg 2007) and a number of studies have identified a potential relationship between the plantaris tendon and the development of Achilles tendinopathy (van Sterkenberg 2007; Alfredson 2011; Lintz 2011). There are a number of small published case series on the surgical removal of the plantaris tendon (Pearce, 2012; Alfredson, 2011) but no studies on the incidence, nature and management of plantaris injuries in a sporting population. This study reports plantaris injuries in an elite cohort of 214 British Track and Field athletes over a 4 year period, from 2009 – 2013.
Methods 214 athletes supported by the British Athletics Medical team between 2009 and 2013 were included in the study. An injury was recorded if a plantaris injury was diagnosed, recorded in the Electronic Medical Record and confirmed with imaging or surgical findings. Patient demographics and injury outcomes were recorded.
Results There were 33 new plantaris injuries in this cohort, representing an annual incidence of 6.4% of all athletes and 8.6% of all sprinters. All diagnoses were confirmed with imaging or surgical findings and included plantaris rupture, plantaris partial tear or plantaris tendinopathy/plantaris friction syndrome. There were 4 complete plantaris ruptures (Figure 1), 4 partial tears and 25 cases of plantaris tendinopathy/plantaris friction syndrome (Figure 2).
There was a significant difference in injured limb site with more right side only plantaris injuries in bend running sprinters (Figure 3) Of the athletes who had a plantaris presentation, 74% also had Achilles tendinopathy at some point during the study period. Seventeen plantaris tendons were surgically removed from 13 athletes. 9/13 had good or excellent outcomes with return to elite level competition without symptoms.
Discussion The plantaris tendon is stiffer and stronger than the Achilles tendon demonstrating less capacity for elongation in response to load (Lintz, 2011). These different mechanical properties could result in a friction induced inflammatory reaction between the Achilles and plantaris. Continued peri-tendon inflammation may induce tendinopathic changes directly through neuro-inflammatory mediation (Andersson, 2007) or via a compressive mechanism. There appears to be a relationship with Achilles tendinopathy that requires further prospective investigation. There may be biomechanical reasons that predispose the plantaris to injury in elite track and field athletes. It has a long thin tendon which should confer elastic energy return and be of importance in sprinting athletes, who require large plantar flexor forces, throughout the full range.
The plantaris tendon has been often ignored in presentations of Achilles region pain. This study demonstrates that plantaris pathology is common and suggests that preventative and management strategies are necessary for clinicians working with athletes.
References Saxena et al. Foot Ankle Int 2000 21(7):570–2
Van Sterkenburg et al. J Anat. 2011 218(3):336–41
Alfredson et al. BrJ Sports Med 2011 45(13)1023–5
Lintz F, et al. Foot Ankle Surg. 2011 17(4):252–5
Pearce CJ, et al. Foot Ankle Surg. 2012 18(2):124–7
Alfredson, et al. BrJ Sports Med. 2011 45(5):407–10
Andersson, et al . KSSTA 2007;15(10):1272–9
Purpose:
Studies have shown that a lubricant exogenously applied on extrasynovial tendon surfaces can reduce the gliding resistance after flexor tendon repair; however, the reagents that have been tested are solely for experimental testing and are not available for clinical use. The purpose of this study was to investigate the effect of exogenously applied hylan G-F 20, a U.S. Food and Drug Administration-approved hyaluronic acid for the treatment of osteoarthritis, on extrasynovial tendon gliding resistance in an in vitro canine model.
Methods:
Twenty-four canine peroneus longus (PL) tendons and proximal pulleys of the ipsilateral paws were treated with 1 of 3 solutions: saline, carbodiimide derivatized hylan G-F 20, or unmodified hylan G-F 20. The gliding resistance of each tendon preparation was then measured over 1000 cycles in a saline bath.
Results:
After 1,000 cycles, the gliding resistance of the PL tendons treated with unmodified hylan G-F 20 decreased significantly compared with the saline-treated tendons. The gliding resistance of the PL tendons treated with modified hylan G-F 20 increased significantly compared with the saline group.
Conclusions:
The PL tendons treated with pure hylan G-F 20 showed a positive effect on the gliding resistance.
Clinical relevance:
The results of this in vitro canine study suggest that exogenously applied hylan G-F 20 improves gliding of the extrasynovial tendon graft. This material may be capable of reducing friction over flexor tendon repair sites and flexor tendon grafts.
The mainstay of treatment for non-insertional Achilles tendinopathy is non-operative, however a proportion of patients will fail conservative measures. We describe the results of Achilles tendinoscopy with plantaris tendon release in patients who have failed first line conservative treatment for at least 6 months.
A consecutive series of 11 patients with a minimum of 2 years follow up.
The mean AOFAS scores significantly improved from 68 pre-op to 92 post op (p=0.0002) as did the AOS scores for both pain (28% pre-op to 8% post op (p=0.0004)) and disability (38% pre-op to 10% post op (p=0.0005). The mean SF-36 scores also improved but were not statistically significant (pre-op 76, post op 87 (p=0.059). There were no complications. 8 of the 11 patients were satisfied, the other 3 somewhat satisfied.
The results of Achilles tendinoscopy and division of the plantaris tendon are encouraging but further studies are required to compare it to other treatments. It is minimally invasive and low risk so should not affect the ability to perform a formal open procedure if unsuccessful.
The aim of this epidemiologic study was to evaluate the incidence of the Achilles tendinopathy in non athletes and the coincidence with varus alignment of the hindfoot.
Six hundred ninety-seven patients (1394 feet) have been analysed. The tibiocalcaneal axis was goniometrically measured. The presence of a non insertional and insertional Achilles tendinopathy was clinically determined.
Achilles tendinopathy was found in 5.6% of the patients (4% insertional, 3.6% non insertional, 1.9% both forms). The average tibiocalcaneal angle was calculated with -0.76° for the tendinopathy group and -0.96° for the insertional tendinopathy whereas the control group showed an average angle of 1.77°. For the total group the average tibiocalcaneal axis was calculated with 1.62°. Out of 1394 feet 38.3% showed a varus axis of the hindfoot and 61.7% a valgus alignment.
The coincidence of varus alignment and Achilles tendinopathy could be validated.
Tendons are designed to take tensile load, but excessive load can cause overuse tendinopathy. Overuse tendinopathy results in extensive changes to the cells and extracellular matrix, resulting in activated cells, increase in large proteoglycans and a breakdown of the collagen structure. Within these pathological changes, there are areas of fibrocartilaginous metaplasia, and mechanotransduction models suggest that this response could be due to compressive load. As load management is a cornerstone of treating overuse tendinopathy, defining the effect of tensile and compressive loads is important in optimising the clinical management of tendinopathy.
This paper examines the potential role of compressive loads in the onset and perpetuation of tendinopathy, and reviews the anatomical, epidemiological and clinical evidence that supports consideration of compressive loads in overuse tendinopathy.
The Plantaris Longus Tendon (PLT) may be implicated in Achilles (AT) tendinopathy. Different mechanical characteristics may be the cause. This study is designed to measure these.
Six PLT and six AT were harvested from frozen cadavers (aged 65-88). Samples were stretched to failure using a Minimat 2000™ (Rheometric Scientific Inc.). Force and elongation were recorded. Calculated tangent stiffness, failure stress and strain were obtained. Averaged mechanical properties were compared using paired, one-tailed t-tests.
Mean stiffness was higher (p<0.001) in the PLT, measuring 5.71 N/mm (4.68-6.64), compared with 1.73 N/mm (1.40-2.22) in AT. Failure stress was also higher (p<0.01) in PLT: 1.42 N/mm(2) (0.86-2.23) AT: 0.20 N/mm(2) (0.16-0.25). Failure strain was less (p<0.05) in PLT: 14.1% (11.5-16.8) than AT: 21.8% (14.9-37.9).
The PLT is stiffer, stronger than AT, demonstrating potential for relative movement under load. The stiffer PLT could tether AT and initiate an inflammatory response.
The source of pain and the background to the pain mechanisms associated with mid-portion Achilles tendinopathy have not yet been clarified. Intratendinous degenerative changes are most often addressed when present. However, it is questionable if degeneration of the tendon itself is the main cause of pain. Pain is often most prominent on the medial side, 2-7cm from the insertion onto the calcaneus. The medial location of the pain has been explained to be caused by enhanced stress on the calcaneal tendon due to hyperpronation. However, on this medial side the plantaris tendon is also located. It has been postulated that the plantaris tendon might play a role in these medially located symptoms. To our knowledge, the exact anatomy and relationship between the plantaris- and calcaneal tendon at the level of complaints have not been anatomically assessed. This was the purpose of our study. One-hundred and seven lower extremities were dissected. After opening the superficial fascia and paratendon, the plantaris tendon was bluntly released from the calcaneal tendon moving distally. The incidence of the plantaris tendon, its course, site of insertion and possible connections were documented. When with manual force the plantaris tendon could not be released, it was defined as a 'connection' with the calcaneal tendon. In all specimens a plantaris tendon was identified. Nine different sites of insertion were found, mostly medial and fan-shaped onto the calcaneus. In 11 specimens (10%) firm connections were found at the level of the calcaneal tendon mid-portion. Clinical and histological studies are needed to confirm the role of the plantaris tendon in mid-portion Achilles tendinopathy.
The plantaris muscle (PM) and its tendon is subject to considerable variation in both the points of origin and of insertion. The present study was carried out to fi nd the different types of origin, insertion and possible variations of the PM in the population of southern costal region of India.
52 embalmed (Formalin fixed) cadaver lower limbs of 26 males (age ranged 48-79 years, mean age 68 years) were dissected, to study the origin and insertion of PM. Various dimensions (length and width) of plantaris muscle belly and its tendon were also measured.
Three types of origin and equal number of insertion were noticed in the present study. The PM took origin from type I: Lateral Supracondylar ridge, Capsule of Knee joint and Lateral head of gastrocnemius in 73.07% cases; type II: Capsule of Knee joint and Lateral head of gastronemius in 5.76% cases; type III: Lateral Supracondylar ridge , Capsule of Knee joint , Lateral head of gastrocnemius and fibular collateral ligament in 13.46% cases. The plantaris tendon was inserted into type I: to the flexor retinaculum of foot in 28.84% cases; type II: independently to the os calcaneum in 36.53% cases; type III: to the tendocalcaneus at various levels in 26.92% cases. In four lower limbs (7.69%) the plantaris muscle was completely absent. Additionally the length and width of the plantaris muscle and its tendon were measured to know any side difference. There were no statistically significant differences between the measurements of left and right side (p>0.05).
Present study will help the surgeons while attempting various surgical procedures in and around the posterior aspect of knee involving plantaris.
Little has been reported about the biologic effect of shock waves on human normal or pathologic tendon tissue. We hypothesized that inflammatory cytokine and MMP production would be down-regulated by shock wave stimulation.
Diseased Achilles tendon tissue and healthy flexor hallucis longus tissue were used. Shock wave treatment was applied to cultured cells at 0.17 mJ/mm(2)energy 250, 500, 1000, and 2000 times.
A dose-dependent decrease in cell viability was noted in cells receiving 1000 and 2000 shocks (86.0 +/- 5.6%, p = 0.01 and 72.4 +/- 8.9%, p = 0.001) as compared with the normal control. Cell count in the 500-shock group increased by 23.4% as compared with the control (p = 0.05). The concentration of MMP 1, 2, and 13 was higher in diseased tenocytes as compared with normal cells (p = 0.04, all comparisons). IL-6 levels were higher in the diseased tenocytes as compared with normal tenocytes (44.10 +/- 16.72 versus 0.21 +/- 0.55 ng/ml, (p < 0.05). IL-1 levels in normal cells increased (2.24 +/- 5.02 ng/ml to 9.31 +/- 6.85 ng/ml) after shock wave treatment (p = 0.04). In diseased tenocytes, levels of MMP-1 (1.12 +/- 0.23 to 0.75 +/- 0.24 ng/ml; p = 0.04) and MMP-13 (1.43 +/- 0.11 to 0.80 +/- 0.15 ng/ml; p = 0.04) were significantly decreased after shock wave treatment. The IL-6 level in diseased tenocytes was decreased (44.10 +/- 16.72 to 14.66 +/- 9.49 ng/ml) after shock wave treatment (p = 0.04).
Higher levels of MMPs and ILs were found in human tendinopathy-affected tenocytes as compared with normal cells. ESWT decreased the expression of several MMPs and ILs.
This mechanism may play an important role in shock wave treatment of tendinopathy clinically.
Each of 480 extremities from 120 cadavers was dissected. Particular attention was given to potential donors for tendon grafts. Both the palmaris longus and the extensor digiti minimi had an average length of 16 cm and an average width of 3 mm. The extensor indicis tendon averaged 13 cm in length and 3 mm in width. The plantaris and second toe extensors averaged 35 cm in length and 2 to 2.5 mm in width. None of these measurements correlated well with age, sex, or hand or foot size. There was, however, a high correlation between right- and left-side measurements in each specimen, in spite of some degree of anatomic variation for all the tendons studied. The palmaris longus was missing in 25% of the upper extremities, and the plantaris in 19% of the lower extremities dissected.
Rupture of plantaris muscle is demonstrated in two patients, one with magnetic resonance imaging (MRI) and one with ultrasound. This entity, thought to be clinically common, has never before been demonstrated at surgery or with imaging. Anatomic and physiologic aspects of the diagnosis that enable radiologists to make the diagnosis, once familiar with the entity, are discussed.
Sixty runners belonging to two clubs were followed for 1 year with regard to training and injury. There were 55 injuries in 39 athletes. The injury rate per 1,000 hours of training was 2.5 in long-distance/marathon runners and 5.6 to 5.8 in sprinters and middle-distance runners. There were significant differences in the injury rate in different periods of the 12 month study, the highest rates occurring in spring and summer. In marathon runners there was a significant correlation between the injury rate during any 1 month and the distance covered during the preceding month (r = 0.59). In a retrospective analysis of the cause of injury, a training error alone or in combination with other factors was the most common injury-provoking factor (72%). The injury pattern varied among the three groups of runners: hamstring strain and tendinitis were most common in sprinters, backache and hip problems were most common in middle-distance runners, and foot problems were most common in marathon runners.
The lower limbs of five cadavers were dissected and the lengths of the muscle fibres and the weights of all the muscles below the knee were measured. From this information the relative strength and excursion of each muscle was determined. We found that the plantarflexors of the ankle were six times as strong as the dorsiflexors. We have therefore discarded the concept of "muscle balance" in tendon transfer surgery and propose that task appropriateness should be the guide. The constant relationship between muscle fibre length and muscle excursion means that contractures are accompanied by decreased excursion. Tendon lengthening improves deformity but does not improve the decreased active range of movement.
The plantaris tendon is valuable as a donor tendon in hand surgery, but its presence is difficult to predict. Dissection of 658 cadavers showed that the tendon was present in 81.8% of limbs dissected and that there was no significant difference in the availability of plantaris between the two sexes or the sides. The incidence of bilateral absence shows that when the plantaris is absent on one side, the chance of finding it on the other is 1 in 3. There is no significant relationship between the condition of palmaris longus and the presence or usefulness of plantaris.
To determine the MR imaging appearance of injury to the plantaris muscle.
Fifteen patients with sports-related injuries to the lower leg underwent magnetic resonance (MR) imaging with T1- and T2-weighted, gradient-echo T2*-weighted, short inversion time inversion-recovery, and fast spin-echo sequences. The plantaris muscle and tendon, as well as the surrounding structures, were retrospectively examined for abnormalities.
All 15 patients had rupture of the plantaris muscle or strain. An associated torn anterior cruciate ligament (ACL) was found in 10 of 15 patients. Five injuries were isolated or associated with partial tears of the gastrocnemius or popliteus muscle. At initial presentation, three patients had large, focal elongated fluid collections between the medial head of the gastrocnemius muscle and the soleus muscle.
Rupture of the plantaris muscle may occur at the myotendinous junction with or without an associated hematoma or partial tear of the medial head of the gastrocnemius muscle. A strain of the more proximal plantaris muscle may also occur as an isolated injury or in conjunction with injury to the ACL.