Gürhan Dönmez

Functional anatomy of the Achilles tendon

The Achilles tendon is the strongest and thickest tendon in the human body. It is also the commonest tendon to rupture. It begins near the middle of the calf and is the conjoint tendon of the gastrocnemius and soleus muscles. The relative contribution of the two muscles to the tendon varies. Spiralisation of the fibres of the tendon produces an area of concentrated stress and confers a mechanical advantage. The calcaneal insertion is specialised and designed to aid the dissipation of stress from the tendon to the calcaneum. The insertion is crescent shaped and has significant medial and lateral projections. The blood supply of the tendon is from the musculotendinous junction, vessels in surrounding connective tissue and the osteotendinous junction. The vascular territories can be classified simply in three, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. This leaves a relatively hypovascular area in the mid-portion of the tendon where most problems occur. The Achilles tendon derives its innervation from the sural nerve with a smaller supply from the tibial nerve. Tenocytes produce type I collagen and form 90% of the cellular component of the normal tendon. Evidence suggests ruptured or pathological tendon produce more type III collagen, which may affect the tensile strength of the tendon. Direct measurements of forces reveal loading in the Achilles tendon as high as 9 KN during running, which is up to 12.5 times body weight.

Achilles tendon rupture: physiotherapy and endoscopy-assisted surgical treatment of a common sports injury

Although the Achilles tendon (AT) is the strongest tendon in the human body, rupture of this tendon is one of the most common sports injuries in the athletic population. Despite numerous nonoperative and operative methods that have been described, there is no universal agreement about the optimal management strategy of acute total AT ruptures. The management of AT ruptures should aim to minimize the morbidity of the injury, optimize rapid return to full function, and prevent complications. Since endoscopy-assisted percutaneous AT repair allows direct visualization of the synovia and protects the paratenon that is important in biological healing of the AT, this technique becomes a reasonable treatment option in AT ruptures. Furthermore, Achilles tendoscopy technique may decrease the complications about the sural nerve. Also, early functional postoperative physiotherapy following surgery may improve the surgical outcomes.

Paget-Schroetter Syndrome Forerunning the Diagnoses of Thoracic Outlet Syndrome and Thrombophilia:

Reported here is a 22-year-old professional wrestler who was diagnosed to have Paget-Schroetter syndrome after Greco-Roman wrestling. On substantial neuromuscular examination and laboratory testing, he was found to have also thoracic outlet syndrome and heterozygous mutations for factor V Leiden and methyltetrahydrofolate reductase genes. To the best knowledge of the authors, the concomitance of these pathologies is discussed for the first time in the literature.

Shoulder joint position sense is negatively correlated with free-throw percentage in professional basketball players

Purpose: The aim of this study was to assess the relationship between the free-throw percentage, joint position sense, and muscle torque in professional basketball players. Methods: Eleven professional basketball players participated in the study, with each subject acting as their own internal control by using the non-dominant side. Knee and shoulder joint of the players were evaluated bilaterally. Flexion and extension peak torque of the knee were evaluated isokinetically system. In addition flexion/abduction/external rotation (F/ABD/ER) and extension/adduction/internal rotation (E/ADD/IR) diagonal pattern peak torque of the shoulder were measured. The joint position sense of both knees and shoulders were evaluated using an active angle reproduction. Thirty, 45, 60 and 75 degrees target angles were used for knee and 160, 135, and 120 degrees target angles were used shoulder. The free-throw percentage of the players for 40 matches in the 2009-2010 season was taken from the Turkish Basketball League official website. The relationship between the peak torque of the muscles, joint position sense, and the free-throw percentage was evaluated. Results: There were no significant differences in the peak torques of the knee and shoulder muscles and joint position sense between the dominant and non-dominant sides (p > 0.05). There was a significant correlation between the free-throw percentage and the peak torque of the shoulder muscles during the F/ABD/ER pattern at 60 degrees/s in the dominant side of the players. There was a borderline trend to significance between the free-throw percentage and the shoulder joint position sense (eyes-closed and at 160 degrees) in the dominant side. There was a borderline significant correlation between the free-throw percentage and the knee joint position sense (eyes-open and at 75 degrees) in the dominant side. Conclusions: The effect of proprioceptive and strengthening exercises on the free-throw percentage is still unknown. Further comprehensive studies are warranted to analyze the effect of proprioceptive and strengthening exercises on the free-throw percentage in elite basketball players

Endoscopy and Percutaneous Suturing in the Achilles Tendon Ruptures

Achilles tendon ruptures commonly occur during sportive activities and there is a tendency of increasing in the incidence of ruptures because of “weekend warriors” who are over 30 years of age. These pathologies are the third most frequent major tendon ruptures after rotator cuff and quadriceps ruptures. Various modalities have been recommended as appropriate treatment options for Achilles tendon ruptures. Nevertheless, there is no consensus on the treatment method, and it is still determined by the surgeon and the patient. Open surgical repair of the Achilles tendon carries specific risks including adhesions between the tendon and the skin, infection, and particularly wound breakdown. Therefore, to avoid these complications the percutaneous repair technique has been described and has become popular. Endoscopy-assisted percutaneous suturing of the Achilles tendon under infiltration anesthesia proffers a rational alternative for the treatment of both athletic and non-athletic individuals. This technique resulted in a cosmetic wound appearance, endurable to early active mobilization and satisfactory clinical recovery without any severe complication. Furthermore, this procedure protects the paratenon and thus blood supplies of the tendon, and enhances biologic recovery. Also direct visualization and manipulation of the tendon ends provides a precise apposition of the ruptured tendon, thus diminishing the handicaps of the single percutaneous technique. In this chapter we described our Achilles tendon repair technique under local anesthesia without tourniquet and with cooperation of the patient, and the results of our clinical experiences under the lights of literature.

Thirty Minutes of Running Exercise Decreases T2 Signal Intensity but Not Thickness of the Knee Joint Cartilage: A 3.0-T Magnetic Resonance Imaging Study:

Objective Recent studies showed a potential of magnetic resonance imaging (MRI), which can be used as an additional tool for diagnosing cartilage degeneration in the early stage. We designed a cross-sectional study in order to evaluate knee joint cartilage adaptation to running, using 3.0-T MRI equipped with the 3-dimensional turbo spin echo (VISTA = Volume ISotropic Turbo spin echo Acquisition) software. By this thickness (mm) and signal intensity (mean pixel value) can be quantified, which could be closely related to the fluid content of the knee joint cartilage, before and after running. Methods A total of 22 males, aged 18 to 35 years, dominant (right) and nondominant (left) knees were assessed before and after 30 minutes of running. Cartilage thickness and signal intensity of surfaces of the patella, medial and lateral femoral and tibial condyles were measured. Results Cartilage thickness of the lateral condyle decreased at the dominant knee, while it increased at the medial tibial plateau. Signal intensity decreased at all locations, except the lateral patella in both knees. The most obvious decrease in signal intensity (10.6%) was at the medial tibial plateau from 949.8 to 849.0 of the dominant knee. Conclusion There was an increase in thickness measurements and decrease in signal intensity in medial tibial plateau of the dominant knee after 30 minutes of running. This outcome could be related to fluid outflow from the tissue. Greater reductions in the medial tibial plateau cartilage indicate greater load sharing by these areas of the joint during a 30-minute running.

Meloxicam and diclofenac do not change VEGF and PDGF-ABserum levels of platelet-rich plasma

BACKGROUND/AIM Platelet-rich plasma (PRP) application has gained widespread interest for musculoskeletal injuries. Nonsteroidal antiinflammatory drugs are frequently used in sports medicine before and/or after PRP application. Our study seeks to determine whether serum levels of platelet-derived growth factor-AB (PDGF-AB) and vascular endothelial growth factor (VEGF) levels of PRP would be affected by nonsteroidal antiinflammatory drugs. MATERIALS AND METHODS Two different final concentrations of diclofenac (0.5 μg mL-1 and 2.5 μg mL-1), meloxicam (0.8 μg mL-1 and 2.0 μg mL-1), and acetylsalicylic acid (final concentration 450 μm) were obtained in separate tubes with PRPs prepared from 20 healthy male volunteers. Medicine-free PRP was the control group. Growth factors were measured using ELISA. RESULTS PDGF-AB and VEGF serum levels did not change with diclofenac, meloxicam, or acetylsalicylic acid addition. PDGF-AB and VEGF serum levels correlated with each other. CONCLUSION Diclofenac, meloxicam, and acetylsalicylic acid did not affect PDGF-AB and VEGF serum levels.

Hamstring Injury After Swimming in a Patient With Multiple Hereditary Osteochondromatosis.

Reported here is a 20-year-old male suffered a hamstring strain after a prolonged bout of swimming. After ultrasound imaging, the patients injury was considered to be the result of nearby osteochondromas. Case reports have been previously published concerning anterior cruciate ligament injury, rotator cuff tears, subacromial impingement, or femoroacetabular impingement in multiple osteochondromatosis. However, to the best of our knowledge, this is the first reported case of a hamstring injury secondary to an osteochondroma.

O-31 Two-weeks of elective sports medicine internship program in medical school education positively effects on physical activity counselling

Aim The burden of chronic diseases is rapidly increasing worldwide with estimates of trillions of dollars in annual health care cost and causing millions of deaths every year. Physical activity and exercise are now considered principal interventions for use in primary and secondary prevention of chronic diseases. Physicians are increasingly being called upon to promote physical activity among patients. While increasing physical activity and exercise prescription seems to be a very important solution in prevention of these diseases, lack of physician knowledge as a barrier in this area. In this study, knowledge and viewpoint of medical students about physical activity and exercise prescription were evaluated. Methods Of the 216 medical students underwent two weeks of elective sports medicine internship program, 65,7% (n = 142, mean age; 24.2 years) was included in the study with returned questionnaire form about sports medicine, International Physical Activity Questionnaire (IPAQ) form and Short Form Health Survey (SF-36). The internship program was consisted of theoretical and practical sessions for general issues about sports injuries, exercise physiology and exercise prescription in chronic diseases. Results They reported that 87.8% of them were not aware of sports medicine branch as a residency program. More than two-thirds (69.1%) of the students didn’t have lecture about physical activity counselling nor exercise prescription for previous 5 years of medical education. After two weeks of education program the students who felt sufficient knowledge for physical activity counselling was increased to 76.8% from one-fourth at the beginning. At the end of the internship program almost all of the students decleared to believe benefits of physical activity counselling. The percent of students perceiving that exercise prescription would be highly relevant for diabetes mellitus treatment to their future practice increase during 2 weeks of program, from 59 to 93%. Students who had higher IPAQ scores and SF-36 values as well, were significantly more prone for physical activity counselling (p < 0.05). Conclusion In conclusion, our results indicate a greater level of physical activity behaviour in medical students is important for future physicians to perform physical activity counselling as preventive medicine approach.

O-28 3.0 tesla magnetic resonance assessment for thickness and signal intensity of the knee joint cartilage after running exercise

Aim Running has become a popular physical activity, with a continuously growing number of participants in all around the world in order to maintain cardiovascular fitness and mental health. Therefore, it is a public health issue to research the short and long term effects of running over the knee joint. During the last decade, with the advancements in the quantitative magnetic resonance imaging (MRI) techniques, MRI is being widely used in the field of exercise and its effects to the joint cartilage. This study was designed to determine the effects of 30 minutes heart-rate controlled (80% of the maximal heart rate) running exercise on a treadmill to the dominant and non-dominant knees with using of 3D turbo spin echo MRI technique. Methods Twenty-two healthy subjects, aged 18–35 years, participated in the study and both knees MRI views were obtained after 24 hours of rest. Second MRI evaluation was performed for both knees immediately after running exercise at the following day. The measurements of T2 signal intensity, mean pixel values and thickness of the knee joint were taken in patellofemoral and femorotibial joints. Results Significant decrease in mean pixel values of T2 signal intensity in both dominant and non-dominant knees’ tibia and femur cartilage after running compared with the resting values was detected (p < 0.001). The most obvious decline was seen in the medial tibial plateau of the dominant knee (−10.6%). Conclusion It was speculated that decrease in T2 values suggests shifting of the cartilage water content with running activity. Greater decreases in the medial tibial plateau cartilage indicates greater load sharing by these areas of the joint during running exercise.