Lars Öhberg

Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up

Objective: To prospectively investigate tendon thickness and tendon structure by ultrasonography in patients treated with eccentric calf muscle training for painful chronic Achilles tendinosis located at the 2–6 cm level in the tendon. Methods: The patients were examined with grey scale ultrasonography before and 3.8 years (mean) after the 12 week eccentric training regimen. At follow up, a questionnaire assessed present activity level and satisfaction with treatment. Results: Twenty six tendons in twenty five patients (19 men and six women) with a mean age of 50 years were followed for a mean of 3.8 years (range 1.6–7.75). All patients had a long duration of painful symptoms (mean 17.1 months) from chronic Achilles tendinosis before treatment. At follow up, 22 of 25 patients were satisfied with treatment and active in Achilles tendon loading activities at the desired level. Ultrasonography showed that tendon thickness (at the widest part) had decreased significantly (p<0.005) after treatment (7.6 (2.3) v 8.8 (3) mm; mean (SD)). In untreated normal tendons, there was no significant difference in thickness after treatment (5.3 (1.3) mm before and 5.9 (0.8) mm after). All tendons with tendinosis had structural abnormalities (hypoechoic areas and irregular structure) before the start of treatment. After treatment, the structure was normal in 19 of the 26 tendons. Six of the seven patients with remaining structural abnormalities experienced pain in the tendon during loading. Conclusions: Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon.

Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment

Background: The mechanism that causes pain in chronic Achilles tendinosis is not known. However, high resolution colour Doppler ultrasound has shown that neovascularisation may be involved. Objective: To investigate if sclerosing the neovessels would affect the level of tendon pain. Methods: The effect of colour Doppler ultrasound guided injection of a sclerosing agent, polidocanol, against neovessels was studied in 10 patients (seven men and three women, mean age 55 years) with painful chronic mid-portion Achilles tendinosis. Results: Eight patients were satisfied with the results of treatment. There was significantly reduced pain during activity (reported on a visual analogue scale (VAS)) and no remaining neovascularisation after an average of two injections. Two patients were not satisfied, and neovascularisation remained. At the six month follow up, the same eight patients remained satisfied and could perform Achilles tendon loading activities as desired. Their VAS score had decreased from 74 before treatment to 8 (p<0.01). Conclusions: Sclerosing neovessels appears to be an effective treatment for painful chronic Achilles tendinosis, suggesting that neovessels play a key part in causing chronic tendon pain.

Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?

The background to the good clinical results reported using painful eccentric calf-muscle training as treatment for chronic painful mid-portion Achilles tendinosis is not known. Recently, using ultrasound and colour Doppler technique, we showed that painful tendinosis was associated with a local neovascularisation. Furthermore, in a pilot study, destroying these neovessels by sclerosing therapy cured the pain in most patients. Dynamic ultrasound and colour Doppler examination has shown that the flow in the neovessels stops during dorsiflexion in the ankle joint. Therefore, it was of interest to study the occurrence of neovascularisation before and after eccentric training. Forty-one tendons in 30 patients (22 men and 8 women, mean age 48 years) with chronic painful mid-portion Achilles tendinosis were examined with ultrasonography and colour Doppler, before and after 12 weeks of eccentric calf-muscle training. Before treatment, there was a local neovascularisation in the area with tendon changes (hypo-echoic areas, irregular fibre structure) in all tendons. At follow-up after treatment (mean 28 months), there was a good clinical result (no tendon pain during activity) in 36/41 tendons, and a poor result in 5/41 tendons. In 34/36 tendons with a good clinical result of treatment there was a more normal tendon structure, and in 32/36 tendons there was no remaining neovascularisation. In 5/5 tendons with a poor clinical result there was a remaining neovascularisation in the tendon, and in 2/5 tendons there were remaining structural abnormalities. In conclusion, in patients with chronic painful mid-portion Achilles tendinosis, a good clinical result after eccentric training seems to be associated with a more normal tendon structure and no remaining neovascularisation. Action on the area with neovessels during the eccentric training regimen might possibly be responsible for the good clinical results.

Ultrasound-Guided Sclerosis of Neovessels in Painful Chronic Patellar Tendinopathy A Randomized Controlled Trial

Background Color Doppler ultrasound examination frequently reveals neovascularization in chronic painful Achilles and patellar tendinopathy. Sclerosing the area with vascular ingrowth using polidocanol has shown promising clinical results in patients with Achilles tendinopathy. Purpose To investigate sclerosing treatment using polidocanol on a group of elite athletes with patellar tendinopathy. tudy Design Randomized controlled trial/cross-over study; Level of evidence, 1. Methods The authors recruited 33 patients (42 tendons), mainly from the Norwegian elite divisions in basketball, team handball, and volleyball. Seventeen patients (23 knees) were randomized to the treatment group (polidocanol injections in the area of neovascularization) and 16 patients (20 knees) to the control group (similar injections with lidocaine/epinephrine). After 4 months of treatment, the control group was crossed over to active treatment. Pain and function were recorded using the Victorian Institute of Sport Assessment score before the start of treatment and 4, 8, and 12 months after the first injection. Victorian Institute of Sport Assessment scores between groups were compared using multivariate analysis of variance for repeated measures. Results The treatment group reported a significant improvement in Victorian Institute of Sport Assessment score from 51 to 62 after 4 months; there was no change for the control group (group by time interaction, P=. 052). After 8 months, when the control group had also received active treatment with polidocanol, they had a greater improvement in Victorian Institute of Sport Assessment score (58-79) than did the treatment group (54-70; group by time interaction, P=. 022; time effect, P<. 0001). There was no further time or group effect in Victorian Institute of Sport Assessment score to the 12-month follow-up (treatment, 72; control, 85). Conclusion Sclerosing injections with polidocanol resulted in a significant improvement in knee function and reduced pain in patients with patellar tendinopathy.

Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study

Background: “Tennis elbow” is a difficult condition to treat. Ultrasonography (US) and colour Doppler (CD) guided injections with polidocanol targeting the area with increased blood flow in the extensor origin have shown promising clinical results. Objective: To evaluate and compare effects of US and CD guided intratendinous injections with sclerosing polidocanol and a local anaesthetic (lidocaine + epinephrine), in patients with tennis elbow. Design: Prospective, randomised, controlled, double-blind, crossover study. Setting: Sports Medicine Unit, Umeå University. Patients: 32 patients (36 elbows), age range 27 to 66 years, with a long duration of elbow pain diagnosed as tennis elbow, were included in the study. All patients were followed up 3 and 12 months after treatment. Two patients were excluded due to other interventions during the study. Interventions: One US and CD guided injection with the sclerosing agent polidocanol (group 1) or the local anaesthetic lidocaine plus epinephrine (group 2). At the 3 month follow-up, additional injections with polidocanol were offered to both groups (crossover for group 2). Main outcome measures: Satisfaction with treatment (Yes/No), elbow pain during activity (visual analogue scale), and maximum voluntary grip strength. Results: There were no significant (p<0.05) differences in the outcome between group 1 and group 2. In both groups, there was a significantly lower VAS at the 3-month and 12-month follow-ups, and grip strength was significantly higher at the 12-month follow-up. Conclusions: US and CD guided intratendinous injections gave pain relief in patients with tennis elbow. Polidocanol and lidocaine plus epinephrine injections gave similar results.

Extensor origin vascularity related to pain in patients with Tennis elbow.

Tennis elbow, extensor carpi radialis brevis (ECRB) tendinosis, is a condition with unknown etiology and pathogenesis, known to be difficult to treat. The pain mechanisms have not been fully clarified, but involvement of a neurogenic inflammation mediated via the neuropeptide Substance-P (SP), has been suggested. In this investigation, grey-scale ultrasonography (US) and colour Doppler (CD) was used to examine the common extensor origin in 17 patients with the diagnose Tennis elbow in altogether 22 elbows, and in 11 controls with 22 pain-free elbows. In 21/22 elbows with chronic pain from the extensor origin, but only in 2/22 pain-free elbows, vascularity was demonstrated in the extensor origin. After US and CD-guided injection of a local anaesthetic, targeting the area with vessels, the patients were pain-free during extensor-loading activity. The area with vascularity found in the extensor origin seems to be related to pain. Most likely, the findings correspond with the vasculo-neural in growth that has been demonstrated in the chronic painful Achilles tendon, and possibly have implications for treatment.

Color Doppler Ultrasound Findings in Patellar Tendinopathy (Jumper's Knee)

BACKGROUND Recent studies have revealed structural changes with neovessels in patients with jumpers knee and Achilles tendinopathy, and treatment with sclerosing injections has shown promising clinical results. PURPOSE To study the prevalence of neovascularization and structural tendon changes on color Doppler ultrasound examination in elite athletes with clinical symptoms of jumpers knee and to examine the ultrasound characteristics of the tendon after sclerosing injection treatment with polidocanol. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The authors recruited patients among elite athletes with a clinical diagnosis of jumpers knee who participated in a previous randomized clinical trial. The patients recorded knee function using the Victorian Institute of Sport Assessment score. Patients were examined by color Doppler ultrasound at baseline and, for patients with structural changes and neovascularization who received sclerosing treatment, after treatment. RESULTS Sixty-three patients (11 women and 52 men) with 79 symptomatic tendons were studied. The ultrasound examination revealed that neovascularization was present in 48 of the 79 tendons (60%). Of 33 patients (43 tendons) who received sclerosing injections, 29 patients (37 tendons, 86%) were examined 37 (19 to 53) weeks after their final sclerosing injections. Of these, 7 tendons (18.9%) had no change in neovascularization after treatment, 21 tendons (56.8%) had less neovascularization, and 9 tendons (24.3%) had more visible neovascularization. There were no significant differences in the change in Victorian Institute of Sport Assessment score between patients who had less, more, or unchanged neovascularization after treatment (analysis of variance, P = .9). CONCLUSION About two thirds of patients with jumpers knee can be expected to have structural tendon changes with neovascularization. There was no relationship between changes in ultrasound characteristic and knee function after sclerosing treatment.

Achilles Tendinosis and Calf Muscle Strength The Effect of Short-Term Immobilization after Surgical Treatment

We prospectively studied calf muscle strength in 7 men and 4 women (mean age, 40.9 +/- 10.1 years) who had surgical treatment for chronic Achilles tendinosis. Surgery was followed by immobilization in a weightbearing below-the-knee plaster cast for 2 weeks followed by a stepwise increasing strength training program. Strength measurements (peak torque and total work) were done preoperatively (Week 0) and at 16, 26, and 52 weeks postoperatively. We measured isokinetic concentric plantar flexion strength at 90 and 225 deg/sec and eccentric flexion strength at 90 deg/sec on both the injured and noninjured sides. Preoperatively, concentric and eccentric strength were significantly lower on the injured side at 90 and 225 deg/sec. Postoperatively, concentric peak torque on the injured side decreased significantly between Weeks 0 and 16 and increased significantly between Weeks 26 and 52 at 90 deg/sec but was significantly lower than that on the noninjured side at all periods and at both velocities. The eccentric strength was significantly lower on the injured side at Week 26 but increased significantly until at Week 52 no significant differences between the sides could be demonstrated. It seems, therefore, that the recovery in concentric and eccentric calf muscle strength after surgery for Achilles tendinosis is slow. We saw no obvious advantages in recovery of muscle strength with a short immobilization time (2 weeks) versus a longer (6 weeks) period used in a previous study.

A two-year sonographic follow-up after intratendinous injection therapy in patients with tennis elbow

Background Tennis elbow is a tendinopathy affecting the upper extremity. Recent studies have shown high sensitivity for ultrasound (US) examination and high specificity for colour Doppler (CD) examination. There are no mid- or long-term follow-up investigations of the tendon structure and blood flow using these techniques. Objective To use US and CD to study structure and blood flow in the extensor origin in patients with tennis elbow treated with intratendinous injections. Design Follow-up study Setting Sports Medicine Unit, Umeå University. Patients 25 patients (28 elbows), mean age 46 years (range 27–66), treated with intratendinous injections due to chronic pain from tennis elbow. Method US and CD examination of the extensor origin was carried out at inclusion and at follow-up two years after intratendinous injection treatment with polidocanol and/or a local anaesthetic. Main outcome measurements US (structure) and CD (blood flow) findings. Results All patients had structural tendon changes and high blood flow at inclusion when given the injection treatment. At the two-year follow-up, structural tendon changes were seen in 20/28 elbows and high blood flow was seen in 4/28 elbows. The majority of patients with a good clinical result after treatment had no visible blood flow (17/20), but the structural changes showed no relation to a good result (13/20 remaining changes). Conclusions Doppler findings, but not structure, might be related to the clinical result after intratendinous injection treatment of tennis elbow.

Increased intratendinous vascularity in the early period after sclerosing injection treatment in Achilles tendinosis : a healing response?

Increased intratendinous vascularity in the early period after sclerosing injection treatment in Achilles tendinosis : a healing response?