R J de Vos

Incidence of midportion Achilles tendinopathy in the general population

Background Achilles tendon disorders, like Achilles tendinopathy, are very common among athletes. In the general population, however, knowledge about the incidence of Achilles tendinopathy is lacking. Design Cross-sectional study. Methods In a cohort of 57.725 persons registered in primary care, the number of patients visiting the general practitioner (GP) with diagnosis of mid-portion Achilles tendon problems was counted using computerised registration networks of GPs in 2009. Subsequently, the authors assessed associations of these rates with demographic characteristics. Results The incidence rate of Achilles tendinopathy is 1.85 per 1,000 Dutch GP registered patients. In the adult population (21–60 years), the incidence rate is 2.35 per 1,000. In 35% of the cases, a relationship with sports activity was recorded. Conclusion This is the first report on incidence rates of mid-portion Achilles tendinopathy in general practice. With an incidence of 1.85 per 1,000 registered persons, Achilles tendinopathy is frequently seen by GPs. The actual incidence might even be higher due to study limitations. More research on the frequency of this injury is required.

No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic midportion Achilles tendinopathy

Objective To assess whether a platelet-rich plasma (PRP) injection leads to an enhanced tendon structure and neovascularisation, measured with ultrasonographic techniques, in chronic midportion Achilles tendinopathy. Design Double-blind, randomised, placebo-controlled clinical trial. Setting Sports medical department of The Hague medical centre. Patients 54 patients with chronic midportion Achilles tendinopathy were included. Interventions Patients were randomised to eccentric exercise therapy with either a PRP injection (PRP group) or a saline injection (placebo group). Main outcome measurements Tendon structure was evaluated by ultrasonographic tissue characterisation, a novel technique which quantifies tendon structure into four echo-types: echo-types I+II represent organised tendon bundles, whereas echo-types III+IV represent a disorganised tendon structure. Colour Doppler ultrasonography was used to measure the degree of neovascularisation. Follow-up was at 6, 12 and 24 weeks. Results A significant improvement in echo-types I+II was found after 24 weeks within both the PRP group (n=27) and the placebo group (n=27), but there was no significant between-group difference (95% CI −1.6 to 7.8, p=0.169). After 6 weeks, the neovascularisation score increased within the PRP group (p=0.001) and the placebo group (p=0.002), but there was no significant between-group difference in change in neovascularisation score at any point in time. Conclusion Injecting PRP for the treatment of chronic midportion Achilles tendinopathy does not contribute to an increased tendon structure or alter the degree of neovascularisation, compared with placebo. Funding Biomet Biologics LLC, Warsaw, Indiana.

Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach

Objective To assess whether three-dimensional imaging of the Achilles tendon by ultrasonographic tissue characterisation (UTC) can differentiate between symptomatic and asymptomatic tendons. Design Case-control study. Setting Sports Medical Department of the Hague Medical Centre. Patients Twenty-six tendons from patients with chronic midportion Achilles tendinopathy were included. The “matched” control group consisted of 26 asymptomatic tendons. Interventions 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. Main outcome measurements The raw ultrasonographic images were analysed with a customdesigned algorithm that quantifies the three-dimensional stability of echo patterns, qua intensity and distribution over contiguous transverse images. This threedimensional 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. Results 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. Conclusion UTC can quantitatively evaluate tendon structure and thereby discriminate symptomatic and asymptomatic tendons. As such, UTC might be useful to monitor treatment protocols.

The additional value of a night splint to eccentric exercises in chronic midportion Achilles Tendinopathy: a randomised controlled trial

Aim: To assess whether the use of a night splint is of added benefit on functional outcome in treating chronic midportion Achilles tendinopathy. Methods: This was a single-blind, prospective, single centre, randomised controlled trial set in the Sports Medical Department, The Hague Medical Centre, The Netherlands. Inclusion criteria were: age 18–70 years, active participation in sports, and tendon pain localised at 2–7 cm from distal insertion. Exclusion criteria were: insertional disorders, partial or complete ruptures, or systemic illness. 70 tendons were included and randomised into one of two treatment groups: eccentric exercises with a night splint (night splint group, n = 36) or eccentric exercises only (eccentric group, n = 34). Interventions: Both groups completed a 12-week heavy-load eccentric training programme. One group received a night splint in addition to eccentric exercises. At baseline and follow-up at 12 weeks, patient satisfaction, Victorian Institute of Sport Assessment–Achilles questionnaire (VISA-A) score and reported compliance were recorded by a single-blind trained researcher who was blinded to the treatment. Results: After 12 weeks, patient satisfaction in the eccentric group was 63% compared with 48% in the night splint group. The VISA-A score significantly improved in both groups; in the eccentric group from 50.1 to 68.8 (p = 0.001) and in the night splint group from 49.4 to 67.0 (p<0.001). There was no significant difference between the two groups in VISA-A score (p = 0.815) and patient satisfaction (p = 0.261). Conclusion: A night splint is not beneficial in addition to eccentric exercises in the treatment of chronic midportion Achilles tendinopathy.

Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain

Objective A decreased range of motion (ROM) of the hip joint is known to predispose to athletic groin injury. Femoroacetabular impingement (FAI) of the hip leads to a reduced ROM. This study examined the prevalence of radiological signs of FAI in patients presenting with long-standing adductor-related groin pain (LSARGP). Design Prospective case series. Setting Outpatient Sports Medicine Department. Patients 34 athletes with LSARGP defined as pain on palpation of the proximal insertion of adductor muscle and a painful, resisted adduction test. Assessment A clinician blinded to the results of the radiological assessment performed a physical examination: iliopsoas length, hip ROM and anterior hip impingement test. Anteroposterior pelvic radiographs were examined by a second blinded clinician for the presence of: pistol grip deformity, centrum-collum-diaphyseal angle, femoral head neck ratio, coxa profunda, protrusio acetabuli, lateral centre edge angle, acetabular index and cross-over sign. Results The prevalence of radiological signs of FAI was 94% (64/68). The mean number of radiological signs in hips with LSARGP was 1.84 (range 0–4, SD 1.05) and 1.96 (range 0–5, SD 1.12) in asymptomatic groins (p=0.95). The anterior hip impingement test was positive in nine cases. There was no relationship with the number of radiological signs (p=0.95). There was no correlation between hip ROM and the number of radiological signs (p=0.37). Conclusion Radiological signs of FAI are frequently observed in patients presenting with LSARGP. Clinicians should be aware of this fact and the possible lack of correlation when assessing athletes with groin pain.

A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy

Background Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results. Aim To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredsons heel-drop exercise programme. Study design Part of a 5-year follow-up of a previously conducted randomised controlled trial. Methods 58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded. Results In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051). Conclusion At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredsons heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.

One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy

Objective The study examined whether the addition of a night splint to eccentric exercises is beneficial for functional outcome in chronic midportion Achilles tendinopathy. Design One-year follow-up of a randomised controlled single blinded clinical trial. Setting Sports medicine department in a general hospital. Patients 58 patients (70 tendons) were included. Interventions All patients completed a 12-week heavy load eccentric training programme. One group received a night splint in addition to eccentric exercises. Main outcome measurements Outcome scores were: Victorian Institute of Sport Assessment—Achilles (VISAA) score, subjective patient satisfaction and neovascularisation score measured with power Doppler ultrasonography (PDU). Results For both groups the VISA-A score increased significantly (from 50 to 76 (p<0.01) in the eccentric group and from 49 to 78 (p<0.01) in the night splint group). No significant differences in the VISA-A score were found between the groups from baseline to one year (p = 0.32). The presence of neovessels at baseline did not predict a change in the VISA-A score after one year in the whole group (p = 0.71). Conclusion Eccentric exercises with or without a night splint improved functional outcome at one year follow-up. At follow-up there was no significant difference in clinical outcome when a night splint was used in addition to an eccentric exercise programme. Between 3 months and one year follow-up, a continuing increase in the VISA-A score was found. Assessment of the neovascularisation score with PDU at baseline has no prognostic value on long-term clinical outcome.

Platelet-rich plasma for chronic achilles tendinopathy: a double-blind randomised controlled trial with one year follow-up

Introduction Chronic Achilles tendinopathy occurs frequently and is very hard to treat. The disease involves local degeneration of tendon tissue, of which regeneration may be improved by injecting platelet-rich plasma (PRP), an increasingly used therapy for releasing growth factors into degenerative tendon. However, high-quality randomised clinical trials on this topic are lacking. The aim of this study was to evaluate the effect of a PRP injection in patients with chronic Achilles tendinopathy. Methods In this stratified, block randomised, double-blind, placebo-controlled trial at single center 54 patients aged 18–70 years were randomised in two treatment groups. Next to an eccentric training program the patients received a blinded injection containing either PRP group or saline (placebo group). Primary outcome, the objective and validated Victorian Institute of Sports Assessment-Achilles (VISA-A) score, was assessed and ultrasound examination was performed at baseline and all follow-up appointments. Results After randomisation into the PRP group (n=27) and the placebo group (n=27) there was a complete follow-up. After one year, the mean VISA-A score improved in both the PRP-group and the placebo group. There was no significant difference in increase between both groups (adjusted between-group difference, 5.5; 95% CI, −4.9 to 15.8, p=0.292). Ultrasonographic tendon structure improved significantly in both groups, but not significant different between both groups (adjusted between-group difference, 1.2 %, 95% CI, −4.1 to 6.6, p=0.647) Conclusion One-year follow-up analysis of the world’s first randomised controlled trial showed no evidence for the use of platelet-rich plasma injection in chronic Achilles tendinopathy. These findings are in line with our 6 months results (De Vos et al JAMA 2010).

Value of quantitative MRI parameters in predicting and evaluating clinical outcome in conservatively treated patients with chronic midportion Achilles tendinopathy: A prospective study

OBJECTIVES To evaluate whether baseline MRI parameters provide prognostic value for clinical outcome, and to study correlation between MRI parameters and clinical outcome. DESIGN Observational prospective cohort study. METHODS Patients with chronic midportion Achilles tendinopathy were included and performed a 16-week eccentric calf-muscle exercise program. Outcome measurements were the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire and MRI parameters at baseline and after 24 weeks. The following MRI parameters were assessed: tendon volume (Volume), tendon maximum cross-sectional area (CSA), tendon maximum anterior-posterior diameter (AP), and signal intensity (SI). Intra-class correlation coefficients (ICCs) and minimum detectable changes (MDCs) for each parameter were established in a reliability analysis. RESULTS Twenty-five patients were included and complete follow-up was achieved in 20 patients. The average VISA-A scores increased significantly with 12.3 points (27.6%). The reliability was fair-good for all MRI-parameters with ICCs>0.50. Average tendon volume and CSA decreased significantly with 0.28cm3 (5.2%) and 4.52mm2 (4.6%) respectively. Other MRI parameters did not change significantly. None of the baseline MRI parameters were univariately associated with VISA-A change after 24 weeks. MRI SI increase over 24 weeks was positively correlated with the VISA-A score improvement (B=0.7, R2=0.490, p=0.02). CONCLUSIONS Tendon volume and CSA decreased significantly after 24 weeks of conservative treatment. As these differences were within the MDC limits, they could be a result of a measurement error. Furthermore, MRI parameters at baseline did not predict the change in symptoms, and therefore have no added value in providing a prognosis in daily clinical practice.