Nat Padhiar

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.

The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy

We investigated neovascularisation, tendon thickness and clinical function in chronic resistant Achilles tendinopathy following high volume image guided injections (HVIGI). The subjects involved 11 athletes (mean age 43.5 years+/-11.6, range 22-59) with resistant tendinopathy of the main body of the Achilles tendon for a mean of 51.4 months (+/-55.56, range 4-144) who failed to improve with an eccentric loading program (mean 11.8 months+/-2.6, range 8-16). The morphological features, neovascularisation and maximal tendon thickness were assessed with power Doppler ultrasound. Clinical function was measured with the Victorian Institute of Sports Assessment-Achilles tendon (VISA-A) questionnaire. All the tendinopathic Achilles tendons were injected with 10 mL of 0.5% bupivacaine hydrochloride, 25 mg of hydrocortisone acetate, and 40 mL of 0.9% NaCl saline solution under real time ultrasound guidance. All outcome measures were recorded at baseline and after a short-term follow-up (mean 2.9 weeks, range 2-4). The results showed a statistically significant difference between baseline and 3-week follow-up in all the outcome measures after HVIGI. The grade of neovascularisation reduced (3-1.1, p=0.003), the maximal tendon diameter decreased (8.7-7.6 mm, p<0.001), and the VISA-A scores improved (46.3-84.1, p<0.001). In conclusion, HVIGI for resistant tendinopathy of the main body of the Achilles tendon is effective to improve symptoms, reduce neovascularisation, and decrease maximal tendon thickness at short-term follow-up.

High volume ultrasound guided injections at the interface between the patellar tendon and Hoffa's body are effective in chronic patellar tendinopathy: A pilot study

Purpose. To evaluate a novel conservative management modality for patellar tendinopathy. Methods. We recruited nine patients with patellar tendinopathy who had failed conservative management and showed evidence of neovascularisation on power Doppler scanning. A high volume ultrasound guided injection at the interface between the patellar tendon and Hoffas body. The injection contained 10 ml 0.5% Bupivacaine, 25 mg Hydrocortisone, and between 12 and 40 ml normosaline. 100 mm visual analogue scales (VAS) for pain and for function, and Victorian Institute of Sport Assessment – Patellar tendon (VISA-P) questionnaires at an average of 9 months from the injection. Results. All but one patient (whose pain was unchanged) improved (p = 0.028). The mean improvement in function 2 weeks after injection was 58 mm on VAS (interquartile range 27 – 88, p = 0.018). The mean improvement in pain 2 weeks after injection was 56 mm on a VAS scale (interquartile range 32 – 80, p = 0.018). At a mean follow up of 9 months, an improvement of 22 points from a baseline score of 46 on the VISA-P questionnaire (100 being normal) was established. Conclusion. High volume injections to mechanically disrupt the neovascularisation in patellar tendinopathy are helpful in the management of this condition. Controlled trials would be warranted to investigate in a more conclusive fashion this management modality.

Diagnosis and management of bone stress injuries of the lower limb in athletes

#### Summary points The annual incidence of overuse injuries in track and field athletes is estimated to be 3.9 per 1000 training hours, with a prevalence of 76%,w1 and 10-20% of consultations in sports medicine practice are for stress fractures.1 Stress fractures are also common among army recruits. With the advent of magnetic resonance imaging, stress fractures are diagnosed earlier and more readily than they were in the past, and early surgical treatment is increasingly considered as a management option for patients who are at high risk of fracture non-union. Rapid and accurate diagnosis of stress fractures is important to prevent propagation of the fracture, and early effective treatment may reduce time away from training and participation in sport. Experts think that overtreatment of low risk stress injuries and undertreatment of high risk injuries both occur and lead to unnecessary time away from training.2 In addition, increasing participation of non-athletes in endurance sports such as marathon running has led to an increase in stress injuries among non-professional sportspeople. We review the diagnosis and management of stress injuries of the lower limb, drawing on evidence from randomised trials, non-randomised intervention studies, observational studies, …

Site of maximum neovascularisation correlates with the site of pain in recalcitrant mid-tendon Achilles tendinopathy

BACKGROUND Neovascularisation is associated with pain in Achilles tendinopathy (AT). The anatomical relationship between ultrasound (US)-defined indicators of tendinopathy and clinically determined pain sites has not been investigated. PURPOSE To measure the spatial correlation between the sites of maximum palpated tenderness, site of patient-indicated pain, maximum US-determined neovascularisation and maximum antero-posterior tendon thickness in patients with chronic recalcitrant AT (CRAT). METHODS A custom-designed measuring apparatus and clinical examination were used to measure the sites of maximum tenderness and subjectively defined pain on 29 tendons from patients diagnosed with mid-tendon CRAT. All tendons had been previously non-responsive to eccentric loading. Maximal neovascularisation and tendon thickness were measured by US scanning in conjunction with the measuring device. RESULTS A significant association exists between clinically determined pain and neovascularisation (r = 0.85, p < 0.001), patient reported pain (r = 0.91, p < 0.001), maximal tendon thickness (r = 0.91, p < 0.001), maximal thickness and maximal neovascularisation (r = 0.86, p < 0.001). CONCLUSION Sites of subjectively defined pain, clinically palpated tenderness, tendon thickness and neovascularisation are anatomically associated. Palpation can be reliably used as a clinical guide when planning interventions in patients with CRAT.

Ultrasound as a Primary Evaluation Tool of Bone Stress Injuries in Elite Track and Field Athletes

Background: Little is known about therapeutic ultrasound (TUS) to diagnose bone stress injuries. Hypothesis: Therapeutic ultrasound is an accurate, cost-efficient alternative to other imaging methods for primary assessment of bone stress injuries. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: One hundred thirteen elite track and field athletes (mean age, 20.1 years; range, 17-28 years) underwent TUS and magnetic resonance imaging (MRI) for clinical suspicion of a bone stress injury. A 5-stage MRI grading system was used to classify bone stress injuries. Sensitivity, specificity, accuracy, and positive and negative predictive values of TUS were calculated using MRI as the standard for diagnosis. Results: At MRI, of 113 assessed patients, 3 (2.7%) had grade 0 injuries, 12 (10.6%) had grade 1, 15 (13.3%) had grade 2, 77 (68.2%) had grade 3, and 6 (5.3%) had grade 4. At TUS, no injury was detected in 22 of 113 patients: 2 with grade 0 injury, 8 with grade 1, 8 with grade 2, and 4 with grade 3. Using MRI as the gold standard, TUS showed 81.8% sensitivity, 66.6% specificity, 99.0% positive predictive value, 13.4% negative predictive value, and 81.4% accuracy. Conclusion: Therapeutic ultrasound is a reproducible procedure that is reliable to diagnose bone stress injuries.

Chronic exertional compartment syndrome of the foot.

Chronic exertional compartment syndrome (CECS) usually refers to myoneural ischemia from a reversible increase in tissue pressure within a myofascial compartment. CECS of the leg is well documented, as its first description by Mavor in 1956. CECS of the foot remains underdiagnosed, and has been reported in the literature only on an anecdotal basis. Wood Jones proposed that there were 4 compartments in the foot, but Manoli and Weber suggest that there are 9 separate compartments. Clinical signs and symptoms of CECS of the foot remain vague, diverse, and lack the consistency of its counterpart in the leg. The most effective treatment is a fasciotomy. We present a literature review of the condition to increase the awareness and high index of suspicion among the clinicians as the symptoms are often vague and, to consider the condition as part of the differential diagnosis.

The effect of ankle position on intracompartmental pressures of the leg

OBJECTIVES We investigated differences in the intracompartmental pressures (ICP) of the leg in relation to various positions of the ankle joint in patients with chronic exertional compartment syndrome (CECS). METHODS The study included 16 patients (10 males, 6 females; mean age 30+/-9 years, range 16 to 48 years) actively involved in various sports. Intracompartmental pressures were monitored with the use of slit catheters connected to a pressure transducer in 28 anterior and 14 deep posterior compartments before and after exercise during the following positions of the ankle joint: relaxed-resting, passive plantar flexion, neutral, and passive dorsiflexion. Alterations in ICP were assessed with reference to that measured in the relaxed-resting position of the ankle. RESULTS Significant increases in ICP were observed in both anterior and deep posterior compartments during dorsiflexion of the ankle, being 9.1+/-10.6 mmHg (p=0.0001) and 8+/-10.3 mmHg (p=0.001) in the anterior compartment, and 6.4+/-4.4 mmHg (p=0.0001) and 7.2+/-4.3 mmHg (p=0.001) in the deep posterior compartment before and after exercise, respectively. No significant increases were found in other positions of the ankle (p>0.05). While the lowest values of ICP were noted in the relaxed-resting position, plantar flexion of the ankle was associated with decreased ICP pressures. CONCLUSION Dorsiflexion of the ankle increases ICP significantly in both anterior and deep posterior compartments. The results of this study may have clinical implications for the conservative management of both CECS and tibial fractures.

Pennation angle of the soleus in patients with unilateral Achilles tendinopathy.

We measured the ultrasound scans of 23 (21 males, two females) physically active subjects (mean age: 40 years; range: 20 – 58) with unilateral Achilles tendinopathy to determine the pennation angle in the soleus muscles of the affected and non-affected limb. All scans were performed by one radiologist. The pennation angle was lower on the affected side in 15 patients, and higher on the non-affected side in eight patients. There was a significant difference in the angle of pennation of the soleus muscle on the affected side (15.9°) compared with that on the non-affected one (17.3°; p = 0.01). Patients with symptomatic Achilles tendinopathy are more likely to have decreased pennation angle of the soleus muscle on the affected side. This may have implications for appropriate management of Achilles tendinopathy.

Development and validation of a questionnaire to measure the severity of functional limitations and reduction of sports ability in German-speaking patients with exercise-induced leg pain

Background Currently, there is no generally agreed measure available to quantify a subjects perceived severity of exercise-induced leg pain symptoms. The aim of this study was to develop and validate a questionnaire that measures the severity of symptoms that impact on function and sports ability in patients with exercise-induced leg pain. Methods The exercise-induced leg pain questionnaire for German-speaking patients (EILP-G) was developed in five steps: (1) initial item generation, (2) item reduction, (3) pretesting, (4) expert meeting and (5) validation. The resulting EILP-G was tested for reliability, validity and internal consistency in 20 patients with exercise-induced leg pain, 20 asymptomatic track and field athletes serving as a population at risk and 33 asymptomatic sport students. Results The patient group scored the EILP-G questionnaire significantly lower than both control groups (each p<0.001). Test–retest demonstrates an excellent reliability in all tested groups (Intraclass Correlation Coefficient, ICC=0.861–0.987). Concurrent validity of the EILP-G questionnaire showed a substantial agreement when correlated with the chronic exertional compartment syndrome classification system of Schepsis (r=−0.743; p<0.001). Internal consistency for the EILP-G questionnaire was 0.924. Conclusions EILP-G questionnaire is a valid and reliable self-administered and disease-related outcome tool to measure the severity of symptoms that impact on function and sports ability in patients with exercise-induced leg pain. It can be recommended as a robust tool for measuring the subjectively perceived severity in German-speaking patients with exercise-induced leg pain.