Search Results
Background:
We sought to compare clinical efficacy among endoscopy-assisted radio-frequency ablation under local anesthesia, extracorporeal shockwaves (ESWs), and eccentric exercises in treating insertional Achilles tendinosis.
Methods:
In this retrospective study, 78 patients diagnosed as having unilateral insertional Achilles tendinosis were enrolled. These participants underwent endoscopy-assisted radio-frequency ablation, ESWs, and eccentric calf muscle exercises between March 1, 2006, and February 28, 2011. Clinical efficacy was evaluated by the visual analog scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot scale, and the Victorian Institute of Sport Assessment–Achilles (VISA-A) scale before and after treatment.
Results:
Before treatment, there were no statistically significant differences in VAS, AOFAS ankle/hindfoot scale, and VISA-A scale scores among the different groups (all P > .05). For the endoscopy and ESW groups, VAS, AOFAS ankle/hindfoot scale, and VISA-A scale scores were significantly improved after 18 months of treatment (all P < .05). The VAS, AOFAS ankle/hindfoot scale, and VISA-A scale scores in the endoscopy group were significantly higher than those in the ESW and eccentric exercise groups after 18 months of therapy (all P < .05).
Conclusions:
Combined with synovectomy and tendon debridement, endoscopy-assisted radio-frequency ablation yields better clinical efficacy compared with ESWs in treating insertional Achilles tendinosis.
Background: Human amniotic membrane contains growth factors and cytokines, which promote epithelial cell migration and proliferation, stimulate metabolic processes leading to collagen synthesis, and attract fibroblasts, while also reducing pain and inflammation. Randomized studies have shown that micronized dehydrated human amnion chorion membrane (mdHACM) allograft injection is an effective treatment for plantar fasciitis. Our objective is to present our experience with using mdHACM injection as a treatment for Achilles tendinopathy and report short term treatment outcomes. Methods: Included in this retrospective case series were patients diagnosed with Achilles tendinopathy treated with mdHACM by a single physician were identified from an electronic medical record system. Included for analysis were those with at least 2 follow up visits within 45 days of mdHACM injection. Outcomes examined included change in reported level of pain during the 45-day observation period and adverse events associated with treatment. Results: Follow-up data were available for 32 mdHACM-treated patients and abstracted from the electronic medical record. At treatment initiation 97% of patients reported severe (66%) or moderate (31%) pain. At first follow-up visit (mean 8.1 {plus minus} 2.7 days after injection), 84% (27/32) had reported improvement in pain levels, although 37% of patients continued to report severe (6%) or moderate (31%) pain. At the second follow-up visit (mean 23.1 {plus minus} 6.2 days after injection), no patients reported severe pain and one reported moderate pain. Within 45 days of mdHACM injection complete resolution of symptoms was reported by 66% of treated patients (n=21) with the remaining 34% reporting improvement but not complete resolution (n=11) of their symptoms. Two patients reported calf or quadricep pain or tightness post-injection. Conclusions: In a single practice mdHACM injection reduced or eliminated pain in all patients where follow-up data was available.
Extracorporeal Shockwave Therapy for the Treatment of Achilles Tendinopathies
A Prospective Study
Background: Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders.
Methods: Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score > 5. The mean follow-up was 20 months (range, 4–35 months).
Results: Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1.
Conclusion: High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy. (J Am Podiatr Med Assoc 98(6): 466–468, 2008)
Achilles Tendon Sports Injuries
A Review of Classification and Treatment
Achilles tendon injuries are among the three most frequent sports-related injuries of the foot and ankle. Proper function of the Achilles tendon is critical to performance in sports. A thorough knowledge of the anatomy and biomechanical function of this tendon is essential to the effective treatment of these injuries. Distinguishing among the various pathologies of the Achilles tendon is an important first step toward successful treatment and return of the athlete to sports activity. The term Achilles tendinitis is a nonspecific diagnosis that does not accurately describe an actual injury. This review is intended to provide the sports medicine physician with a means of classifying Achilles tendon injuries and, thus, arriving at an accurate diagnosis and treatment plan. (J Am Podiatr Med Assoc 97(1): 37–48, 2007)
True Pathologic Abnormality versus Artifact
Foot Position and Magic Angle Artifact in the Peroneal Tendons with 3T Imaging
Magnetic resonance imaging is a commonly ordered examination by many foot and ankle surgeons for ankle pain and suspected peroneal tendon pathologic abnormalities. Magic angle artifact is one of the complexities associated with this imaging modality. Magic angle refers to the increased signal on magnetic resonance images associated with the highly organized collagen fibers in tendons and ligaments when they are orientated at a 55° angle to the main magnetic field. We present several examples from a clinical practice setting using 3T imaging illustrating a substantial reduction in magic angle artifact of the peroneal tendon in the prone plantarflexed position compared with the standard neutral (right angle) position.
Background
Insertional Achilles tendinopathy is a common complaint among patients. Oftentimes, conservative treatment is inadequate, and surgical treatment is required. However, there is no published consensus regarding surgical intervention in reference to insertional Achilles tendinopathy.
Methods
The purpose of this systematic review was to evaluate the surgical management of insertional Achilles tendinopathy and report which surgical procedures provide the greatest pain reduction and improvement in functional outcome. A review of PubMed, OVID, Google Scholar, and Cochrane Controlled Trials Register was performed using a defined search strategy and inclusion criteria.
Results
Of 2,863 articles identified using the defined strategy, 20 met the inclusion criteria (three prospective and 17 retrospective). Operative interventions included Achilles tendon debridement, reattachment with suture anchors, reconstruction with flexor hallucis longus tendon autograft or bone-patellar tendon autograft, and gastrocnemius recession. All of the studies, regardless of intervention, showed generalized improvement after surgery. Wide variation in outcome scoring systems prevented direct comparison between studies and interventions.
Conclusions
This systematic review did not identify a superior treatment for insertional Achilles tendinopathy but rather found that the surgical treatment should be based on the extent of tendon injury.
Treatment Algorithm for Chronic Achilles Tendon Lesions
Review of the Literature and Proposal of a New Classification
Chronic Achilles tendon lesions (CATLs) ensue from a neglected acute rupture or a degenerated tendon. Surgical treatment is usually required. The current English literature (PubMed) about CATLs was revised, and particular emphasis was given to articles depicting CATL classification. The available treatment algorithms are based on defect size. We propose the inclusion of other parameters, such as tendon degeneration, etiology, and time from injury to surgery. Partial lesions affecting less than (I stage) or more than (II stage) half of the tendon should be treated conservatively for healthy tendons, within 12 weeks of injury. In II stage complex cases, an end-to-end anastomosis is required. Complete lesions inferior to 2 cm should be addressed by an end-to-end anastomosis, with a tendon transfer in the case of tendon degeneration. Lesions measuring 2 to 5 cm require a turndown flap and a V-Y tendinous flap in the case of a good-quality tendon; degenerated tendons may require a tendon transfer. Lesions larger than 5 cm should be treated using two tendon transfers and V-Y tendinous flaps. A proper algorithm should be introduced to calibrate the surgical procedures. In addition to tendon defect size, tendon degeneration, etiology of the lesion, and time from injury to surgery are crucial factors that should be considered in the surgical planning.
Background
Tendinopathies are common musculoskeletal disorders that often develop because of chronic loading and failed healing. Tendinopathy related to systemic inflammation has been less extensively examined. Furthermore, although the use of biological agents to treat tendinopathies continues to gain popularity, the use of amniotic fluid–derived allografts in outpatient settings to resolve tendinopathies requires further evaluation.
Methods
The focus of this case report is a 25-year-old man who presented for a second opinion, having been diagnosed with Haglund deformity and Achilles tendinopathy. At the time of presentation, he complained of 10 of 10 pain to the right Achilles tendon. He was treating the injury conservatively with intermittent use of a controlled ankle motion boot and working with physiotherapy for approximately 5 months before presentation. Diagnostic ultrasound along with magnetic resonance imaging indicated distal thickening of the Achilles tendon, substantial fluid and edema in the Kager fat pad, and retrocalcaneal erosions with bursitis. Conservative management did not resolve the symptoms. As an alternative to surgery, the patient elected to undergo an Achilles tendon injection of an amniotic fluid–derived allograft. Before and after the initial injection, a microdialysis catheter was inserted into the Achilles peritendinous space to sample local levels of extracellular matrix enzymes and growth factors important for tendon remodeling. The patient received considerable relief with the initial injection, but did not return to full strength. Over the subsequent 8 weeks, the patient was followed closely and was able to return to daily activities with minimal pain. He was not able to return to a more active lifestyle without further Achilles pain, so a second amniotic fluid–derived allograft injection was performed 8 weeks after the initial injection.
Results
Injection of the initial allograft resulted in significant improvement, but not complete resolution of pain and swelling. Microdialysis findings suggested a reduction in peritendinous levels of the cytokine interlukin-6 in addition to changes in extracellular matrix regulatory enzymes. After 8 weeks of additional conservative therapy and a second injection, no further improvement in pain was noted.
Conclusions
Based on the clinical improvement of symptoms in this individual and the changes seen with microdialysis methodology, the authors find the use of amniotic fluid–derived allograft injection for treatment of Achilles pain in this patient to be a viable treatment. Additional comorbidities of systemic inflammatory polyarthritis and possible seronegative disease were addressed after rheumatology consultation with a variety of medications that provided the patient additional relief of his symptoms. The patient ultimately moved and was lost to further follow-up.
Fasciotomy and Surgical Tenotomy for Chronic Achilles Insertional Tendinopathy
A Retrospective Study Using Ultrasound-Guided Percutaneous Microresection
Background:
Achilles insertional tendon pathology is a common condition affecting a broad range of patients. When conservative treatments are unsuccessful, the traditional open resection, debridement, and reattachment of the Achilles tendon is a variably reliable procedure with significant risk of morbidity. Fasciotomy and surgical tenotomy using ultrasound-guided percutaneous microresection is used on various tendons in the body, but the efficacy has not been examined specifically for the Achilles tendon.
Methods:
A retrospective review evaluated 26 procedures in 25 patients who underwent Achilles fasciotomy and surgical tenotomy. The Foot Function Index was used to quantify pain, disability, activity limitation, and overall scores.
Results:
Mean Foot Function Index scores were as follows: pain, 8.53%; disability, 7.91%; activity limitation, 2.50%; and overall, 6.97%. Twenty index procedures were successful, and two patients repeated the procedure successfully for an overall 84.6% success rate in patients with chronic insertional pathology with mean surveillance of 16 months. There were no infections or systemic complications.
Conclusions:
Ultrasound-guided percutaneous microresection is a safe and minimally invasive percutaneous alternative that can be used before proceeding to a more invasive open procedure.
Reported here is the case of a 55-year-old woman presenting to a podiatry clinic with a chief complaint of left heel and ankle pain, who ultimately underwent operative excision of an angioleiomyoma adjacent to the tibialis posterior artery at the level of the medial malleolus. Accompanying this case are images from three modalities through which the defining characteristics of an angioleiomyoma can be appreciated. This case advocates for the inclusion of angioleiomyoma in the preoperative differential diagnosis of a mass presenting as a pseudoaneurysm in the lower extremity, particularly among women in the fourth to sixth decades of life.
