John B. King

Clinical diagnosis of Achilles tendinopathy with tendinosis.

ObjectiveTo evaluate sensitivity, specificity, reproducibility, and predictive value of palpation of the painful arc sign and of the Royal London Hospital test in 10 patients with Achilles tendinopathy and in 14 asymptomatic subjects. DesignTest-retest study. SettingUniversity teaching hospital. ParticipantsTen male athletes on the waiting list for exploration of one of their Achilles tendons for tendinopathy of the main body of the tendon attended a special clinic. Each was invited to bring at least one athlete of the same sex in the same discipline aged within 2 years of themselves with no history and no symptoms of Achilles tendinopathy. A total of 14 controls were thus recruited. Main Outcome MeasuresPain and tenderness following performance of palpation, the painful arc sign, and the Royal London Hospital test. ResultsThere were no statistically significant differences at the 5% level among the effects of investigator or between morning and afternoon measurements for any of the three measurement methods. There was no evidence of a difference of the three assessment methods (p > 0.05). When the three methods were combined, the overall sensitivity was 0.586 (confidence interval [CI], 0.469–0.741), and the overall specificity was 0.833 (CI, 0.758–0.889). ConclusionsIn patients with tendinopathy of the Achilles tendon with a tender area of intratendinous swelling that moves with the tendon and whose tenderness significantly decreases or disappears when the tendon is put under tension, a clinical diagnosis of tendinopathy can be formulated, with a high positive predictive chance that the tendon will show ultrasonographic and histologic features of tendinopathy.

Similar histopathological picture in males with Achilles and patellar tendinopathy.

PURPOSE To ascertain whether there are differences in the histopathological appearance of tendinopathic Achilles and patellar tendons. METHODS In males, we studied biopsies from tendinopathic Achilles (N = 28; average age 34.1 yr) and patellar tendons (N = 28; average age 32.1), Achilles tendons (N = 21; average age 61.8 yr) from deceased patients with no known tendon pathology, and patellar tendons (N = 15; average age 28.3) from patients undergoing anterior cruciate ligament reconstruction. Hematoxylineosin stained slides were interpreted using a semiquantitative grading scale (0: normal to 3: maximally abnormal) for fiber structure, fiber arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. All slides were assessed blindly twice, the agreement between two readings ranging from 0.170 to 0.750 (kappa statistics). RESULTS The highest mean score of tendinopathic Achilles tendons was not significantly different from that of tendinopathic patellar tendons (11.6 +/- 5 and 10.4 +/- 3, respectively). The ability to differentiate between an Achilles tendon and a patellar tendon was low. CONCLUSIONS Tendinopathic Achilles and patellar tendons show a similar histological picture. It was not possible to identify whether a specimen had been harvested from an Achilles or a patellar tendon on the basis of histological examination. The general pattern of degeneration was common to both tendinopathic Achilles and patellar tendons. A common, as yet unidentified, etiopathological mechanism may have acted on both these tendon populations.

Articular cartilage lesions in the symptomatic anterior cruciate ligament-deficient knee

PURPOSE The goal of the study was to report the prevalence of the lesions of the articular cartilage of the femoral condyles and tibial plateau in patients with a symptomatic anterior cruciate ligament (ACL)-deficient knee undergoing day-case arthroscopy. TYPE OF STUDY Case series study. METHODS We studied 378 skeletally mature patients (average age, 27.3 years; range, 16-50 years; 282 men and 84 women), part of a sample of 1,978 patients undergoing a primary knee arthroscopy between January 1986 and August 1993. The articular cartilage lesions were classified according to Outerbridge by a single observer. We assessed the relationship between time of injury and articular cartilage lesions and between meniscal lesions and articular cartilage lesions. RESULTS A complete ACL tear was found in all 378 knees. Of these, 157 showed at least one lesion of the articular cartilage. The medial femoral condyle (MFC) showed the highest frequency of articular cartilage lesions, especially in the weight-bearing portion. Patients with a bucket-handle tear of the medial meniscus had greater degeneration of the MFC than those with other meniscal tears. A meniscal tear was associated with a greater degree of articular damage. The second most common lesion was a combined lesion of the medial and lateral compartments, followed by isolated lateral compartment lesion. A time-dependent pattern of development of articular cartilage lesions was identified. CONCLUSIONS In patients with more advanced degenerative changes, the time from injury to arthroscopy was significantly longer than in patients with lesser articular surface abnormalities, and the presence of a meniscal tear was associated with a greater degree of articular cartilage damage. Patients with a symptomatic ACL-deficient knee and an associated tear of the medial meniscus are at high risk of having a lesion of the articular surface of the weight bearing area of the knee.

High volume image guided injections in chronic Achilles tendinopathy.

Purpose. To determine the effectiveness of high volume image guided injections (HVIGI) for chronic Achilles tendinopathy. Methods. We included in the study 30 consecutive patients (mean age 37.2 years, range 24 – 58 years) with Achilles tendinopathy for a mean of 35.8 months (range 2 – 276 months) who had failed to improve after a three-month programme of eccentric loading of the gastro-soleus complex. Patients were injected with 10 ml of 0.5% Bupivacaine Hydrochloride, 25 mg Hydrocortisone acetate, and up to 40 ml of injectable normal saline. A study-specific questionnaire and the Victorian Institute of Sport Assessment – Achilles tendon (VISA-A) were retrospectively administered to assess short- and long-term pain and functional improvement. Results. Some 21 patients (70%) responded. Patients reported significant short-term improvement at 4 weeks of both pain (mean change 50 mm, [SD 28, p < 0.0001], from a mean of 76 mm [SD 18.2], to a mean of 25 mm [SD 23.3]), and function scores (mean change 51 mm, [SD 31.2, p < 0.0001], from a mean of 78 mm [SD 20.8], to a mean of 27 mm [SD 28.4]). Patients also reported significant long-term improvement in symptoms using the VISA-A questionnaire (mean change 31.2 points, [SD = 28, p < 0.0001], from a mean of 44.8 points [SD 17.7], to a mean of 76.2 points [SD 24.6]) at a mean of 30.3 weeks from the injection. Conclusions. HVIGI significantly reduces pain and improves function in patients with resistant Achilles tendinopathy in the short- and long-term.

Surgical Decompression of Chronic Central Core Lesions of the Achilles Tendon

We report the outcome of 14 athletes with chronic recalcitrant achillodynia and central core degeneration of the Achilles tendon. The patients underwent surgery after an average time from onset of symptoms to surgery of 87 months. All patients had undergone conservative management, including physical therapy treatment, orthoses, nonsteroidal antiinflammatory drugs, and steroid injections. At an average follow-up of 35 months (range, 27 to 52), only 5 patients had an excellent or good result, despite reexploration in 6 of the 14 patients. In athletes with long-standing pain and central core degeneration of the Achilles tendon, prognosis is poor, and even reexploration is not successful. If the referral pattern allows, surgery should probably be undertaken earlier.

Effects of open versus closed kinetic chain training on knee laxity in the early period after anterior cruciate ligament reconstruction

Abstract. Knee extensor resistance training using open kinetic chain (OKC) exercise for patients recovering from anterior cruciate ligament reconstruction (ACLR) surgery has lost favour mainly because of research indicating that OKC exercise causes greater ACL strain than closed kinetic chain (CKC) exercise. In this prospective, randomized clinical trial the effects of these two regimes on knee laxity were compared in the early period after ACLR surgery. Thirty-six patients recovering from ACLR surgery (29 males, 7 females; age mean=30) were tested at 2 and 6 weeks after ACLR with knee laxity measured using the Knee Signature System arthrometer. Between tests subjects trained using either OKC or CKC resistance of their knee and hip extensors in formal physical therapy sessions three times per week. Following adjustment for site of treatment, pretraining injured knee laxity, and untreated knee laxity at post-training, the use of OKC exercise, when compared to CKC exercise, was found to lead to a 9% increase in looseness with a 95% confidence interval of –8% to +29%. These results indicate that the great concern about the safety of OKC knee extensor training in the early period after ACLR surgery may not be well founded.

Open and Closed Kinetic Chain Exercises in the Early Period after Anterior Cruciate Ligament Reconstruction: Improvements in Level Walking, Stair Ascent, and Stair Descent

Thirty-seven patients who had undergone anterior cruciate ligament reconstruction were tested in a gait analysis laboratory at 2 and 6 weeks after surgery. Between test sessions, patients were randomly assigned to a course of either closed or open kinetic chain resistance exercises (3 sessions per week for 4 weeks). Gait analysis consisted of bilateral calculations of knee joint angle, moment, and power during level walking, stair ascent, and stair descent. An analysis of variance on the effects of training group and test session indicated that the only variable to be significantly affected by the type of exercise program was the amount of knee flexion at the beginning of step-up (P<0.05). All other measures of knee angle, moment, and power (16 total variables) showed no significant difference between the exercise groups. All variables measured on the injured side showed significant improvement from test 1 to test 2 (P<0.05), but the injured leg remained functionally deficient when compared with the uninjured leg. These data suggest that there are no clinically significant differences in the functional improvement resulting from the choice of open or closed kinetic chain exercises in the early period after this surgery.

Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases

We made a prospective arthroscopic study of 106 skeletally mature male sportsmen with an average age of 28.35 years (16.8 to 44) who presented with an acute haemarthrosis of the knee due to sporting activities. We excluded those with patellar dislocations, radiographic bone injuries, extra-articular ligamentous lesions or a previous injury to the same joint. The anterior cruciate ligament (ACL) was intact in 35 patients, partially disrupted in 28 and completely ruptured in 43. In the patients with an ACL lesion, associated injuries included meniscal tears (17 patients), cartilaginous loose bodies (6), and minimal osteochondral fractures of the patella (2), the tibial plateau (3) or the femoral condyle (9). We found no age-related trend in the pattern of ACL injuries. Isolated injuries included one small osteochondral fracture of the patella, and one partial and one total disruption of the posterior cruciate ligament. Three patients had cartilaginous loose bodies, and no injury was detected in five. Acute traumatic haemarthrosis indicates a serious ligament injury until proved otherwise, and arthroscopy is needed to complement careful history and clinical examination. All cases with a tense effusion developing within 12 hours of injury should have an aspiration. If haemarthrosis is confirmed, urgent admission and arthroscopy are indicated.

Surgery for chronic achilles tendinopathy yields worse results in nonathletic patients

ObjectiveTo report the outcome of surgery for chronic recalcitrant Achilles tendinopathy in nonathletic and athletic subjects. DesignCase-control study. SettingUniversity teaching hospitals. PatientsWe matched each of the 61 nonathletic patients with a diagnosis of tendinopathy of the Achilles tendon with an athletic patient with tendinopathy of the main body of the Achilles tendon of the same sex and age (±2 years). A match was possible for 56 patients (23 males and 33 females). Forty-eight nonathletic subjects and 45 athletic subjects agreed to participate. InterventionsOpen surgery for Achilles tendinopathy. Main Outcome MeasureOutcome of surgery, return to sport, complication rate. ResultsNonathletic patients were shorter and heavier than athletic patients. They had greater body mass index, calf circumference, side-to-side calf circumference differences, and subcutaneous body fat than athletic patients. Of the 48 nonathletic patients, 9 underwent further surgery during the study period, and only 25 reported an excellent or good result. Of the 45 athletic subjects, 4 underwent further surgery during the study period, and 36 reported an excellent or good result. The remaining patients could not return to their normal levels of activity. In all of them, pain significantly interfered with daily activities. ConclusionsNonathletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy.

Double-bundle arthroscopic reconstruction of the anterior cruciate ligament DOES THE EVIDENCE ADD UP?

There is a trend towards the use of double-bundle techniques for the reconstruction of the anterior cruciate ligament. This has not been substantiated scientifically. The functional outcome of these techniques is equivalent to that of single-bundle methods. The main advantage of a double-bundle rather than a single-bundle reconstruction should be a better rotational stability, but the validity and accuracy of systems for the measurement of rotational stability have not been confirmed. Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with a single-bundle should remain the standard method for managing deficiency of the anterior cruciate ligament until strong evidence in favour of the use of the double-bundle method is available.