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

Divani, Kiran; Chan, Otto; Padhiar, Nat; Twycross-Lewis, Richard; Maffulli, Nicola; Crisp, Tom; Morrissey, Dylan

doi:10.1016/j.math.2010.03.011

Cited by 52 publications

(43 citation statements)

References 24 publications

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“…The presence of neovascularization and its association with symptoms within the musculoskeletal system is a topic of much debate. Although several studies have reported a correlation between neovascularization and tendon pain, 21,23,24,26 other studies have not found such a relationship. 22,25,29 No prior studies have systematically evaluated the plantar heel pad for vascularization in an asymptomatic population of distance runners.…”

Section: Discussionmentioning

confidence: 96%

“…Although asymptomatic structural changes have been reported in a variety of body regions, to our knowledge, no prior investigation has systematically evaluated the plantar heel region in asymptomatic runners, a group at risk for developing heel abnormalities. [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] Consequently, the primary purpose of this investigation was to determine the prevalence and spectrum of asymptomatic sonographically determined structural changes in the plantar fascia and plantar heel pad among experienced runners without a history of heel pain. On the basis of our preliminary observations, we hypothesized that more than 50% of asymptomatic runners would have at least 1 structural abnormality in 1 heel, as defined by the following: (1) presence of vascularization on power Doppler sonography, (2) nonuniform heterogeneous echo texture of the plantar heel pad, (3) abnormal plantar heel pad thickness (uncompressed heel pad thickness <12 or > 28 mm), 15,36 (4) abnormal plantar heel pad compressibility (heel pad compressibility index <0.45 or >0.75), 15 (5) abnormal plantar fascia thickness (>4 mm), 1 and (6) abnormal plantar fascia echo texture.…”

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confidence: 99%

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Sonographic Evaluation of the Plantar Heel in Asymptomatic Endurance Runners

Hall

Finnoff

Sayeed

et al. 2015

J of Ultrasound Medicine

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lantar heel pain is a common condition affecting endurance runners and accounts for approximately 8% of all runningrelated injuries. 1 Although plantar fasciitis is the most common cause of heel pain in the athletic population, 2,3 the differential diagnosis of heel pain is broad and includes plantar heel pad syndrome (also referred to as fat pad syndrome), calcaneal fractures, regional nerve entrapments (eg, Baxter nerve), and referred pain syndromes. 2 The role of musculoskeletal sonography in the evaluation of plantar heel pain has been well established with respect to the plantar fascia. [3][4][5][6][7][8][9][10][11][12][13][14][15] More specifically, plantar fascia thickening (>4 mm), hypoecho genicity, heterogeneity, and neovascularization are considered reliable markers of symptomatic plantar fasciitis, whereas a normalappearing plantar fascia warrants consideration of alternative causes of heel pain. 1,3,4,9,[12][13][14] On the contrary, the role of sonography Mederic M. Hall, MD, Jonathan T. Finnoff, DO, Yusef A. Sayeed, MD, MPH, MEng, Jay Smith, MD Received December 31, 2014, ORIGINAL RESEARCHObjectives-The primary purpose of this investigation was to determine the prevalence and spectrum of asymptomatic sonographically determined structural changes in the plantar fascia and plantar heel pad among experienced runners without a history of heel pain.Methods-Thirty-nine asymptomatic runners without a history of plantar heel pain were recruited. The following sonographic measures were recorded: power Doppler sonography in the plantar heel pad and plantar fascia, echo texture of the plantar heel pad, uncompressed heel pad thickness, compressed heel pad thickness, heel pad compressibility index, plantar fascia thickness, and plantar fascia echo texture. Conclusions-At least 1 potentially abnormal sonographic finding was present in each heel of all asymptomatic runners in this study. Consequently, sonographic abnormalities in the plantar heel should be interpreted within the clinical context when evaluating runners. Results-Doppler

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Section: Discussionmentioning

confidence: 96%

mentioning

confidence: 99%

Sonographic Evaluation of the Plantar Heel in Asymptomatic Endurance Runners

Hall

Finnoff

Sayeed

et al. 2015

J of Ultrasound Medicine

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“…Recent evidences show that the transition to symptomatic tendinopathy is marked by nerve and vascular proliferation, arising from the ventral/anterior side of the paratenon. Vascular ingrowth, as already said, has the aim to repair tendon's defects, but it has been found to correlate with the location of pain in patients with symptomatic tendinopathy [127] . Neovascularization with thick walls, a tortuous appearance and small lumen ventral from the Achilles tendon and in the paratenon is found in 50-88% of symptomatic tendons but not in pain-free tendons [128,129] ; these blood vessels are accompanied by sensory neonerves [130,131] causing an increase in pain signaling by producing nociceptive substances such as glutamate, substance P, calcitonin gene-related peptide (CGRP) past the critical threshold [132,133] .…”

Section: Discussionmentioning

confidence: 99%

The Achilles Tendinopathy: Pathogenesis Review

Bondi¹,

Rossi²,

Magnan³

et al. 2015

International Journal of Orthopaedics

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Achilles tendinopathy is a degenerative disease with high prevalence in runners. For the comprehension of achilles tendinopathy we have to consider intrinsic conditions such as age, sex, BMI, tendon temperature, systemic diseases, flexibility, previous injuries and anatomical variations, genetic predisposition and blood supply and extrinsic factors such as drugs and overuse. Both categories can be responsible for development of achilles' degenerative tendinopathy. Different hypothesis were studied, those concerning the pathogenesis of tendinopathy and those concerning the etiology of complaints in patients. This review of the literature demonstrates the heterogeneity of Achilles tendinopathy pathogenesis.

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“…In addition, there were no clinical findings consistent with an Achilles rupture, for example there was a negative Simmonds squeeze test. The site of maximum tenderness has previously been shown to correspond to the site of maximum pathology in Achilles tendinopathy, and this was also reported by the radiologist (but not formally measured or statistically tested) in the patients with ITTs 22 . The ITT also differs from a partial tear in that the latter extends through the peripheral edge of the tendon but with some intact fibres, or a rupture in which there is no continuity of fibres -each of which present with commensurate clinical signs such as a positive Simmonds test.…”

Section: Ultrasound Imagingmentioning

confidence: 75%

“…It could be speculated that these isolated ITTs may reflect a particular injury mechanism or susceptibility. The use of high resolution ultrasonic diagnosis in expert hands allowed additional detail to be gained regarding the ITT in comparison to MRI, due to the dynamic evaluation and simultaneous confirmation of examination findings such as the area of maximum tenderness, as has been found in previous studies 22 . It may be that refinements of newer imaging techniques such as real-time sonoelastography or ultrasound tissue characterisation (UTC) will become useful for diagnosis in future -with anecdotal reports be- ing that UTC, due to its volumetric detail and within tendon contrast describes ITTs well 29,30 .…”

Section: @ C I C E D I Z I O N I I N T E R N a Z I O N A L Imentioning

confidence: 93%

Intratendinous tears of the Achilles tendon - a new pathology? Analysis of a large 4-year cohort

Chan

Morton

Pritchard

et al. 2017

MLTJ

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SummaryBackground: Achillodynia is common and includes Achilles tendinopathy, partial Achilles tears and Achilles tendon ruptures. However, we believe an additional pathology should be considered for Achillodynia differentials -the intratendinous tear (ITT). Methods: Examinations of 740 achillodynic patients in one specialist centre were reviewed. ITTs were defined as a clearly visualised echopoor area situated centrally and extending to, but not through the tendon periphery, with pain on palpation and no clinical findings consistent with Achilles rupture. Descriptive statistics were used to analyse differences between pathological sub-groups, and images described qualitatively. Results: 5% (29 males, 8 females) of 740 patients had an ITT. Patients typically presented with a history of sudden onset localised pain and the ability to train but not reach maximal loading. Average age was 36.3 years (range 20-64), significantly lower than mid-tendon tendinopathy (8.48 years; p<0.01). 92% had concurrent Achilles tendinopathy. Elite sportspeople were more highly represented in the ITT than mid-tendon tendi nopathy groups (86.2% ITT group vs 13.8% mid-tendon AT group; p<0.01). Conclusions: ITTs should be actively searched for in patients with Achilles pathology, especially in elite male athletes with a history of high-impact pain. Prospective research is warranted concerning diagnosis and management. Level of evidence: IV.

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

Cited by 52 publications

References 24 publications

Sonographic Evaluation of the Plantar Heel in Asymptomatic Endurance Runners

Sonographic Evaluation of the Plantar Heel in Asymptomatic Endurance Runners

The Achilles Tendinopathy: Pathogenesis Review

Intratendinous tears of the Achilles tendon - a new pathology? Analysis of a large 4-year cohort

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