Figure 1 - uploaded by Suzan De Jonge
Content may be subject to copyright.
Change in the mean Victorian Institute of Sports Assessment–Achilles (VISA-A) score (severity of symptoms) and mean echo type I 1 II (percentage of structure-related echoes) over time in the symptomatic group. Both the VISA-A score and echo type I 1 II increased significantly over time. Error bars denote SDs.
Source publication
Background:
Tendinopathy is characterized by alterations in the tendon structure, but there are conflicting results on the potential of tendon structure normalization and no large studies on the quantified, ultrasonographic tendon structure and its association with symptoms.
Purpose:
To determine whether the tendon structure returns to values of...
Contexts in source publication
Similar publications
Objective:
Achilles tendon pathologies occur frequently and have a significant socioeconomic impact. Currently, there is no evidence on the best treatment for these pathologies. Cell therapy has been studied in several animal models, and encouraging results have been observed with respect to tissue regeneration. This study is aimed at evaluating t...
Achilles tendinopathy produce morbidity, long-lasting disability in athletes and non-athletes and remain a challenge for clinician. Tendinopathy may lead to reduced tensile strength and a predisposition to rupture.The aim of our study was to evaluate the effects of activated and non-activated PRP on the healing process of ruptured tendinopathic ach...
Objective:
The therapeutic efficacy of platelet-rich plasma in the treatment of Achilles tendinopathy is controversial. Among the variables which can explain the discrepant results, little attention has been paid to the distribution of platelet-rich plasma inside the tendon. The aim of the present study was to evaluate whether this factor is relat...
(1) Background: Achilles tendinopathy (AT) is characterized by load-induced tendon pain, stiffness, and functional impairment that may affect the tendon midportion or insertion. Platelet-rich fibrin matrix (PRFM) is a promising adjunctive therapy for AT. We analyzed 24-month pain and functional outcomes in a cohort of patients managed by tendon deb...
Introduction
To assess outcomes of FHL transfer and V-Y plasty for chronic Achilles rupture due to insertional Achilles tendinopathy.
Materials and methods
A case series of 12 patients was conducted between 1st January 2017 and 31st December 2018. The patients had short flexor hallucis longus tendon transfer with gastrocnemius lengthening by V-Y p...
Citations
... 8,9 Imaging could aid in establishing the diagnosis of AT. 10 Currently, maximum Achilles tendon thickness is estimated at approximately 6 to 7 mm based on clinical experience and cross-sectional studies. 6,8,[11][12][13][14][15] An important knowledge gap with imaging is that current normative values for Achilles tendon thickness may not be representative of the general population and no studies differentiated between the midportion and insertional region of the tendon. [14][15][16] Previous studies also showed a considerable deviation surrounding the normative values for Achilles tendon thickness. ...
... Previous studies have described the UTC procedure in more detail. 8,11,12,23 Image analysis of all UTC scans was performed by one trained researcher (TSV). This researcher was blinded to patient characteristics while performing the analyses. ...
... pre-dominantly military recruits or elite fencers) 13,14 or relatively small samples (ranging from 6 to a maximum of 100 individuals). 8,11,12 These studies reported different mean values of tendon thickness ranging from 4.2 to 7.1 mm, without adjusting for personal characteristics. 8,[11][12][13][14][15] The relatively small and/or selected study populations in these studies may account for the variation in findings and no studies differentiated between the midportion and insertional region of the tendon, while these are considered separate clinical entities based on the current guidelines. ...
The objective of the study was to obtain adjusted ultrasonographic reference values of the Achilles tendon thickness (maximum anterior–posterior distance) in adults without (previous) Achilles tendinopathy (AT) and to compare these reference values with AT patients. Six hundred participants were consecutively included, comprising 500 asymptomatic individuals and 100 patients with clinically diagnosed chronic AT. The maximum tendon thickness was assessed using Ultrasound Tissue Characterization. A multiple quantile regression model was developed, incorporating covariates (personal characteristics) that were found to have a significant impact on the maximum anterior–posterior distance of the Achilles tendon. A 95% reference interval (RI) was derived (50th, 2.5th‐97.5th percentile). In asymptomatic participants median (95% RI) tendon thickness was 4.9 (3.8–6.9) mm for the midportion region and 3.7 (2.8–4.8) mm for the insertional region. Age, height, body mass index, and sex had a significant correlation with maximum tendon thickness. Median tendon thickness for the midportion region was calculated with the normative equation −2.1 + AGE × 0.021 + HEIGHT × 0.032+ BMI × 0.028 + SEX × 0.05. For the insertional region, the normative equation was −0.34 + AGE × 0.010+ HEIGHT × 0.018 + BMI × 0.022 + SEX × −0.05. In the equations, SEX is defined as 0 for males and 1 for females. Mean (95% CI) difference in tendon thickness compared to AT patients was 2.7 mm (2.3–3.2, p < 0.001) for the midportion and 1.4 mm (1.1–1.7, p < 0.001) for the insertional region. Compared to the asymptomatic population 73/100 (73%) AT patients exhibited increased tendon thickening, with values exceeding the 95% RI. This study presents novel reference values for the thickness of midportion and insertional region of the Achilles tendon, which were adjusted for personal characteristics. Our novel web‐based openly accessible calculator for determining normative Achilles tendon thickness (www.achillestendontool.com) will be a useful resource in the diagnostic process.
Trial registration number: This trial is registered in the Netherlands Trial Register (NL9010).
... In der Regel kommt es nach 12 Wochen bei den meisten Patient*innen zu Verbesserungen der Beschwerden von 70-80 % [5]. In einer Studie zu Achillessehnen-Tendinopathien ergab sich jedoch erst nach 24 Wochen eine strukturelle Angleichung an die gesunde Kontrollgruppe [27]. Da eine vollständige Heilung der Sehne bis zu 1 Jahr dauern kann, sollte Patient*innen in der Praxis eine deutlich längere (für eine konkrete Empfehlung zur Dauer fehlen aktuell noch Daten) Eigentherapiezeit bis zur Beschwerdefreiheit prognostiziert werden [5]. ...
Tendinopathien sind ein häufiges Krankheitsbild in der physiotherapeutischen Praxis, und es stellt sich die Frage, wie wirksam trotz der Schmerzsymptomatik Therapie und Training sind. Dies vor allem auch vor dem Hintergrund, dass der genaue Mechanismus für das Entstehen einer Tendinopathie nicht vollständig geklärt ist. Dieser Refresher-Artikel erklärt die aktuellen Hypothesen zur Entstehung einer Tendinopathie und zeigt Therapieansätze sowie Trainingsprinzipien für das im Wesentlichen überlastungsinduzierte Beschwerdebild.
... To our knowledge, this is the first study to comprehensively evaluate thickness measurements in the insertional region, as previous investigations have focused solely on the midportion. 9,12,14,15,23,27 The diminished reliability of thickness measurements in the insertional region may be attributed to the unique anatomical properties of this region. Specifically, the insertional part of the tendon has a less straight course compared with the midportion. ...
Introduction
Ultrasound is the preferred imaging method in the diagnostic process of Achilles tendinopathy (AT). Ultrasound tissue characterization (UTC) is a frequently used, standardized and valid method to assess tendon geometry in AT patients. It is unknown whether UTC is reliable for measuring Achilles tendon thickness.
The aim of the study was to assess intra‐ and inter‐rater reliability of Achilles tendon thickness measurements using UTC in both asymptomatic individuals and patients with AT, and to evaluate if the reliability of thickness measurements differs between the midportion and insertional area.
Methods
Exactly 50 patients with AT and 50 asymptomatic individuals were included. Using the conventional US and standardized UTC procedure maximum thickness was measured in the midportion and insertion region. To determine inter‐ and intra‐rater reliabilities, the intraclass correlation coefficient (ICC) was used.
Results
The ICC values for inter‐ and intra‐rater reliability were classified as “excellent,” for the AT group (0.93 [95% CI: 0.88–0.96] and 0.95 [0.92–0.97]) and asymptomatic participants (0.91 [0.87–0.94] and 0.94 [0.92–0.96]). The reliability of measuring tendon thickness in the midportion region was “excellent,” with both inter‐rater (0.97 [0.95–0.98]) and intra‐rater (0.98 [0.96–0.99]) ICC values indicating high levels of agreement. In the insertional region, ICC values for inter‐rater (0.79 [0.69–0.87]) and intra‐rater (0.89 [0.84–0.93]) reliability were “moderate to good.”
Conclusion
We showed excellent reliability for measuring the US thickness of the midportion and good reliability of measuring the insertional region in patients with AT. Significantly lower ICCs were observed for the reliability of thickness measurements in the insertional region when compared with the midportion.
... 11 12 The exact pathophysiology and source of nociception of mid-AT are currently unknown. 2 10 12 Ultrasound tissue characterisation (UTC) is an imaging modality that can quantify the AT structure into four echo types (I-IV), discriminating aligned fibrillar structure (echo types I+II) from disorganised tendon structure (echo types III+IV). 13 Growing evidence indicates that AT structure is poorly associated with self-reported symptoms, [14][15][16] as measured with the Victorian Institute of Sports Assessment-Achilles (VISA-A) Questionnaire. 17 Yet, UTC has been found to be able to discriminate symptomatic from asymptomatic ATs, using a threshold for aligned fibrillar structure. ...
Introduction
Tendon structure in mid-portion Achilles tendinopathy (mid-AT) appears poorly associated with symptoms. Yet, degenerative tendon changes on imaging have been associated with an increased risk of mid-AT. We aimed to investigate the prognostic value of ultrasound tissue characterisation (UTC) for a mid-AT recurrence in service members reporting to be recovered following standard care.
Methods
Mid-portion aligned fibrillar structure was quantified post-treatment in 37 participants. Recurrences were determined after 1 year of follow-up, based on self-perceived recurrence (yes/no) combined with a decrease in post-treatment Victorian Institute of Sports Assessment–Achilles score of at least the minimal important change of 7 points. Receiver operating characteristic curve analyses were used to determine a threshold for dichotomisation of outcomes for aligned fibrillar structure (normal representation/under-representation). Using multivariable logistic regression, the association between a mid-AT recurrence (yes/no) and the dichotomised aligned fibrillar structure was determined.
Results
Eight participants (22%) experienced a recurrence. The threshold for aligned fibrillar structure was set at 73.2% (95% CI: 69.4% to 77.8%) according to Youden’s index. Values below this threshold were significantly associated with a mid-AT recurrence (odds ratio (OR) 9.7, 95% CI: 1.007 to 93.185). The OR for a mid-AT recurrence was 1.1 (95% CI: 1.002 to 1.150) for each additional month of symptom duration. The explained variance of our multivariable logistic regression model was 0.423; symptom duration appeared to be a better predictor than aligned fibrillar structure.
Conclusions
This study identified mid-portion aligned fibrillar structure and symptom duration as potential prognostic factors for a mid-AT recurrence in military service members. The threshold for aligned fibrillar structure of 73.2% can guide preventative interventions (eg, training load adjustments or additional tendon load programmes) aiming to improve tendon structure to minimise the future recurrence risk.
Trial registration number
https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm , file number ToetsingOnline NL69527.028.19
... Traditional clinical signs for tendinopathy such as localised pressure pain associated with tendon loading were seen as suggestive for nociceptive pain (Rio et al., 2014;Smart et al., 2010). However, imaging showed that noticeable alterations in tendon tissue morphology is not consistently related to clinical symptoms (Corrigan et al., 2018); tendon changes can be present in absence of pain and pain can be present in absence of tendon changes (Corrigan et al., 2018(Corrigan et al., , 2020de Jonge et al., 2015;Gisslèn et al., 2005;Rio et al., 2014). Additionally, even though some potential nociceptive mediators have been identified in tendinopathy (Millar et al., 2021), the nociceptive driver and the pathways involved in pain perception are not fully understood (Cardoso et al., 2019). ...
Objective:
to conduct and report a scoping review of the available evidence of the effects and content of pain neuroscience education for patients with persistent painful tendinopathies.
Methods:
PubMed, Embase, Web of Science, CINAHL, SPORTDiscus, and grey literature databases were searched from database inception to May 2022. Randomised and non-randomised controlled trials, non-controlled clinical trials, cohort studies, case series, case studies including people with persistent painful tendinopathy aged ≥18 years, a pain education intervention, and in English were included. Studies were excluded if they were cross-sectional studies, reviews, editorials, abstracts, or full-text not available or if included heterogeneous study cohorts, patients with tendon rupture, or patients with systemic diseases.
Results:
five studies (n = 164) were included. Pain neuroscience education entailed face-to-face discussion sessions or educational materials including videos, brochures, paper drawings, and review questions. All studies used pain neuroscience education in conjunction with other interventions, obtaining significant benefits in outcomes related to pain, physical performance, or self-reported function, among others.
Conclusions:
The application of pain neuroscience education in conjunction with other interventions seemed to improve several outcomes. However, considering the current knowledge about tendon pain and the scarcity of well-designed trials studying pain neuroscience education in tendinopathy, additional research is needed.
... In der Regel kommt es nach 12 Wochen bei den meisten Patient*innen zu Verbesserungen der Beschwerden von 70-80 % [5]. In einer Studie zu Achillessehnen-Tendinopathien ergab sich jedoch erst nach 24 Wochen eine strukturelle Angleichung an die gesunde Kontrollgruppe [27]. Da eine vollständige Heilung der Sehne bis zu 1 Jahr dauern kann, sollte Patient*innen in der Praxis eine deutlich längere (für eine konkrete Empfehlung zur Dauer fehlen aktuell noch Daten) Eigentherapiezeit bis zur Beschwerdefreiheit prognostiziert werden [5]. ...
CPTE-Fortbildung CPTE (Continuing Physiotherapy Education) fördert selbstständiges lebenslanges Lernen und wird von der Forschungsgruppe CPTE (Bundesverband selbstständiger Physiotherapeuten-IFK e.V., Hochschule Osnabrück, Thieme) wissenschaftlich begleitet: www.thieme.de/lesen-punktet.
... Somit können Therapeut*innen die Übungsform an Vorlieben der Patient*innen und vorhandene Trainingsgeräte anpassen, ohne negative Auswirkungen auf die Therapie befürchten zu müssen [5].In der Regel kommt es nach 12 Wochen bei den meisten Patient*innen zu Verbesserungen der Beschwerden von 70-80 % [5]. In einer Studie zu AchillessehnenTendinopathien ergab sich jedoch erst nach 24 Wochen eine strukturelle Angleichung an die gesunde Kontrollgruppe[27]. Da eine vollständige Heilung der Sehne bis zu 1 Jahr dauern kann, sollte Patient*innen in der Praxis eine deutlich längere (für eine konkrete Empfehlung zur Dauer fehlen aktuell noch Daten) Eigentherapiezeit bis zur Beschwerdefreiheit prognostiziert werden [5].Effiziente Trainingsformen berücksichtigen die Prin zipien von High Load und HighTime under Tension.isometrische, ...
Tendinopathien sind ein häufiges Krankheitsbild in der physiotherapeutischen Praxis, und es stellt sich die Frage, wie wirksam trotz der Schmerzsymptomatik Therapie und Training sind. Dies vor allem auch vor dem Hintergrund, dass der genaue Mechanismus für das Entstehen einer Tendinopathie nicht vollständig geklärt ist. Dieser Refresher-Artikel erklärt die aktuellen Hypothesen zur Entstehung einer Tendinopathie und zeigt Therapieansätze sowie Trainingsprinzipien für das im Wesentlichen überlastungsinduzierte Beschwerdebild.
... 12 In the second study, de Jonge et al 11 evaluated eccentric loading combined with either a platelet-rich plasma injection or a saline injection, 11 also reporting no associations between VISA and UTC. 11 Both studies concluded that tendon structure was not related to disease severity or prognosis in mid-AT. 11 12 In tendinopathy, the exact pathophysiology and the source of nociception are currently unknown. 2 6 19 The fact that recovery of tendon structure and improvement in pain and function do not follow the same pace may partly explain the poor associations. ...
... Our findings contradict the results of an in vivo study 24 and an in vitro study 25 that suggest ESWT-induced tendon structure improvements, but are in line with a study by de Vos et al, 12 who reported no increase of aligned fibrillar structure following an eccentric loading programme after 24 weeks. Contrastingly, de Jonge et al 11 reported a mean improvement in aligned fibrillar structure of 11% following an eccentric loading programme. It should be acknowledged that in the latter study, patients additionally received either a platelet-rich plasma injection or a saline injection. ...
Introduction
Mid-portion Achilles tendinopathy (mid-AT) is currently the preferred term for persistent Achilles tendon pain, defined as located 2–7 cm proximal to the calcaneus, and with loss of function related to mechanical loading. Histologically, mid-AT is considered to represent a degenerative condition. Therefore, monitoring of tendon structure additional to pain and function may be warranted, to prevent progression of degeneration or even tendon rupture. The aim of this study was to determine the association between pain and function, relative to the Achilles tendon structure, in soldiers treated with a conservative programme for mid-AT.
Methods
A total of 40 soldiers (40 unilateral symptomatic tendons) were included in this study. Pain and function were evaluated with the Victorian Institute of Sports Assessment -Achilles (VISA-A) questionnaire. Tendon structure was quantified using ultrasound tissue characterisation (UTC). We quantified both the Achilles tendon mid-portion (2–7 cm) and the area of maximum degeneration (AoMD) within the tendon mid-portion. VISA-A and UTC measurements were taken at baseline and after 26 weeks of follow-up. Spearman’s rho was used to determine the correlation between VISA-A and UTC. Correlations were calculated for baseline, follow-up and change score values.
Results
Negligible correlations were found for all analyses, ranging from −0.173 to 0.166 between mid-portion tendon structure and VISA-A, and from −0.137 to 0.150 between AoMD and VISA-A. While VISA-A scores improved, on average, from 59.4 points at baseline to 93.5 points at follow-up, no detectable improvement in aligned fibrillar structure was observed in our population.
Conclusion
Pain and function are poorly associated with Achilles tendon structure in soldiers treated with a conservative programme for mid-AT. Therefore, we advise clinicians to use great caution in communicating relationships between both clinical entities.
Trial registration number
NL69527.028.19.
... 12 The mechanism for why some patients do not respond to exercise programmes is unknown; explanations for treatment failure include challenges with compliance, 1 the treatment programme not continued for a sufficient duration of months to achieve tendon changes and pain limiting the tolerance to the exercise programme. [13][14][15] EXER loading programmes' success in managing AT may be enhanced through a combination of other interventions. Extracorporeal shockwave therapy (ESWT) has been studied in the management of tendinopathy and may induce healing through mechanisms of promoting tissue remodelling and modifying pain. ...
Background
Achilles tendinopathy (AT) is a common overuse injury in runners. While the mainstay of treatment for AT is tendon loading exercises (physical therapy and exercise programme (EXER)), some patients have refractory symptoms. Extracorporeal shockwave therapy (ESWT) and photobiomodulation therapy (PBMT) have each been evaluated to facilitate tendon healing; the influence of combining treatments is unknown and limited studies have been completed in runners. This randomised control study, with an elective cross-over at 3 months, will evaluate the efficacy of three forms of treatment of non-insertional AT: (1) EXER (loading programme specific to Achilles tendon combined with physical therapy); (2) EXER and ESWT; (3) EXER, ESWT and PBMT. Sixty runners will be assigned using block randomisation into one of three treatment groups (n=20). After 3 months, each participant may elect a different treatment than previously assigned and will be followed for an additional 3 months. The EXER Achilles loading programme will be standardised using the Silbernagel at-home programme. The primary outcome of interest is treatment group responses using the Victorian Institute of Sports Assessment—Achilles (VISA-A) Score. Secondary outcomes include the Patient-Reported Outcomes Measurement Information System—29 questions, the University of Wisconsin Running Injury and Recovery Index, heel raise to fatigue test, hopping test and ultrasound measurements. We will also capture patient preference and satisfaction with treatment. We hypothesise that the cohorts assigned EXER+ESWT+PBMT and EXER+ESWT will see greater improvements in VISA-A than the EXER cohort, and the largest gains are anticipated in combining ESWT+PBMT. The elective cross-over phase will be an exploratory study and will inform us whether patient preference for treatment will impact the treatment response.
Trial registration number
NCT04725513 .
... Moreover, previous studies are only based on traditional imaging features for diagnosis, and there is still a lack of ultrasonic analysis based on artificial intelligence technologies such as radiomics. [24][25][26] Therefore, in this study, we performed standard radiomics analysis based on musculoskeletal ultrasound image. The radiomics-based machine learning model showed the satisfactory diagnostic performance for the diagnosis of Achilles tendinopathy in skiers, and its AUC, predictive consistency, and clinical benefit all were excellent in the independent validation. ...
Objectives:
Our study aimed to develop and validate an efficient ultrasound image-based radiomic model for determining the Achilles tendinopathy in skiers.
Methods:
A total of 88 feet of skiers clinically diagnosed with unilateral chronic Achilles tendinopathy and 51 healthy feet were included in our study. According to the time order of enrollment, the data were divided into a training set (n = 89) and a test set (n = 50). The regions of interest (ROIs) were segmented manually, and 833 radiomic features were extracted from red, green, blue color channels and grayscale of ROIs using Pyradiomics, respectively. Three feature selection and three machine learning modeling algorithms were implemented respectively, for determining the optimal radiomics pipeline. Finally, the area under the receiver operating characteristic curve (AUC), consistency analysis, and decision analysis were used to evaluate the diagnostic performance.
Results:
By comparing nine radiomics analysis strategies of three color channels and grayscale, the radiomic model under the green channel obtained the best diagnostic performance, using the Random Forest selection and Support Vector Machine modeling, which was selected as the final machine learning model. All the selected radiomic features were significantly associated with the Achilles tendinopathy (P < .05). The radiomic model had a training AUC of 0.98, a test AUC of 0.99, a sensitivity of 0.90, and a specificity of 1, which could bring sufficient clinical net benefits.
Conclusions:
Ultrasound image-based radiomics achieved high diagnostic performance, which could be used as an intelligent auxiliary tool for the diagnosis of Achilles tendinopathy.
