Ultrasound- and Doppler-Guided WALANT Arthroscopic Surgery for Patellar Tendinopathy with Partial Rupture in Elite Athletes-A 2-Year Follow-Up of a Prospective Case Series.

Background and Objectives: Patellar tendinopathy is difficult to treat, and when combined with partial rupture, there are additional challenges. The aim of this study was to evaluate the subjective outcome and return-to-sport status after ultrasound (US)- and colour doppler (CD)-guided wide awake local anaesthetic no tourniquet (WALANT) arthroscopic shaving in elite athletes. Material and Methods: Thirty Swedish and international elite athletes (27 males) with a long duration (>1 year) of persistent painful patellar tendinopathy in 35 patellar tendons, not responding to non-surgical treatment, were included. All patients were treated with the same protocol of arthroscopic shaving, including bone removal and debridement of partial rupture, followed by at least 3 months of structured rehabilitation. The VISA-P score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation. Results: At the 2-year follow-up (mean 23, range 8-38 months), 25/30 patients (29/35 tendons) were satisfied with the treatment result and had returned to their pre-injury sport. The mean VISA-P score increased from 37 (range 7-69) before surgery to 80 (range 44-100) after surgery (p < 0.05). There was one drop-out (one tendon). There were no complications. Conclusions: US- and CD-guided WALANT arthroscopic shaving for persistent painful patellar tendinopathy, including bone removal and debridement of partial rupture, followed by structured rehabilitation showed good clinical results in the majority of the elite-level athletes.

Combined Midportion Achilles and Plantaris Tendinopathy: A 1-Year Follow-Up Study after Ultrasound and Color-Doppler-Guided WALANT Surgery in a Private Setting in Southern Sweden.

Background and Objectives: Chronic painful midportion Achilles combined with plantaris tendinopathy can be a troublesome condition to treat. The objective was to prospectively follow patients subjected to ultrasound (US)- and color doppler (CD)-guided wide awake, local anesthetic, no-tourniquet (WALANT) surgery in a private setting. Material and Methods: Twenty-six Swedish patients (17 men and 9 women, mean age 50 years (range 29-62)) and eight international male patients (mean age of 38 years (range 25-71)) with combined midportion Achilles and plantaris tendinopathy in 45 tendons altogether were included. All patients had had >6 months of pain and had tried non-surgical treatment with eccentric training, without effect. US + CD-guided surgical scraping of the ventral Achilles tendon and plantaris removal under local anesthesia was performed on all patients. A 4-6-week rehabilitation protocol with an immediate full-weight-bearing tendon loading regime was used. The VISA-A score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation. Results: At the 1-year follow-up, 32/34 patients (43 tendons) were satisfied with the treatment result and had returned to their pre-injury Achilles tendon loading activity. There were two dropouts (two tendons). For the Swedish patients, the mean VISA-A score increased from 34 (0-64) before surgery to 93 (61-100) after surgery (p < 0.001). There were two complications, one wound rupture and one superficial skin infection. Conclusions: For patients suffering from painful midportion Achilles tendinopathy and plantaris tendinopathy, US + CD-guided surgical Achilles tendon scraping and plantaris tendon removal showed a high satisfaction rate and good functional results 1 year after surgery.

Is the Superficial Peritendinous Tissue an Additional Pain Driver in Patellar Tendinopathy?-Studies on Morphology and Innervation in a Case Series.

Background and Objectives: Ultrasound (US) and Doppler (DP) guided arthroscopic shaving targeting the area with neovessels and nerves on the dorsal side of the tendon has shown good clinical results. Recently, we observed that in a sub-group of patients there is also local tenderness on the superficial side of the proximal patellar tendon; Material and Methods: The aim was to examine morphology and innervation patterns of the superficial peritendinous tissue from patients (four men and two women; mean age 23 years, range 17-31 years) that on US+DP examination showed a locally thickened paratenon including high blood flow. Tissue sections were stained for morphology (hematoxylin and eosin, H&E) and immunohistochemically for nerve markers (ß-tubulin; tyrosine hydroxylase, TH; calcitonin related gene peptide, CRGP); Results: All tissue specimens contained high levels of blood vessels and nerves (fascicles, sprouting nerve fibers, perivascular innervation) as evidenced by evaluation for H&E and ß-tubulin reactions. Nerve fascicles mainly contained sensory but also sympathetic axons. Nerves related to blood vessels were sympathetic fibers; Conclusions: There was a marked innervation in the superficial peritendinous tissue in a sub-group of patients with patellar tendinopathy and severe tenderness in the proximal patellar tendon. The results indicate that this tissue might be an additional pain driver in some patients and should be considered in further studies.

Ultrasound-guided versus blind interventions in patellar tendon lesions: a cadaveric study.

PURPOSE: The present study aims to analyze the accuracy of injections aimed to hit the proximal and depth part of the patellar tendon "target point" in patellar tendinopathy, comparing ultrasound-guided or non-ultrasound-guided (blind) injections. METHODS: A cadaver randomized study was carried out. Injections were performed under ultrasound control, as well as blinded. There were 26 knees from fresh cadavers and injections were placed by 26 practitioners with experience in the use of musculoskeletal ultrasound and injection treatment. Each participant performed 6 ultrasound-guided and 6 blind punctures in different cadaveric specimens. This provided 312 injections that were analyzed in 2 different anatomical cuts, thus providing a database of 624 measurements for statistical analysis. RESULTS: Statistically significant differences were observed (p < 0.0001) in the distance from the target point between the ultrasound-guided and the non-guided infiltrations. The "unguided" injections were considered to have been performed on average 10 mm away from the target point compared to the "ultrasound-guided" injections. The ultrasound-guided injections obtained an accuracy of 74.36% while the "non-ultrasound-guided" injections obtained an accuracy of 11.54% (p < 0.0001). CONCLUSION: The use of ultrasound to guide the positioning of injections on the dorsal side of the proximal patellar tendon had a significantly higher accuracy compared to blind injections. The finding provides knowledge of importance for injection treatment.

ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T).

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.

ICON 2019-International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients.

BACKGROUND: The absence of any agreed-upon tendon health-related domains hampers advances in clinical tendinopathy research. This void means that researchers report a very wide range of outcome measures inconsistently. As a result, substantial synthesis/meta-analysis of tendon research findings is almost futile despite researchers publishing busily. We aimed to determine options for, and then define, core health-related domains for tendinopathy. METHODS: We conducted a Delphi study of healthcare professionals (HCP) and patients in a three-stage process. In stage 1, we extracted candidate domains from clinical trial reports and developed an online survey. Survey items took the form: 'The 'candidate domain' is important enough to be included as a core health-related domain of tendinopathy'; response options were: agree, disagree, or unsure. In stage 2, we administered the online survey and reported the findings. Stage 3 consisted of discussions of the findings of the survey at the ICON (International Scientific Tendinopathy Symposium Consensus) meeting. We set 70% participant agreement as the level required for a domain to be considered 'core'; similarly, 70% agreement was required for a domain to be relegated to 'not core' (see Results next). RESULTS: Twenty-eight HCP (92% of whom had >10 years of tendinopathy experience, 71% consulted >10 cases per month) and 32 patients completed the online survey. Fifteen HCP and two patients attended the consensus meeting. Of an original set of 24 candidate domains, the ICON group deemed nine domains to be core. These were: (1) patient rating of condition, (2) participation in life activities (day to day, work, sport), (3) pain on activity/loading, (4) function, (5) psychological factors, (6) physical function capacity, (7) disability, (8) quality of life and (9) pain over a specified time. Two of these (2, 6) were an amalgamation of five candidate domains. We agreed that seven other candidate domains were not core domains: range of motion, pain on clinician applied test, clinical examination, palpation, drop out, sensory modality pain and pain without other specification. We were undecided on the other five candidate domains of physical activity, structure, medication use, adverse effects and economic impact. CONCLUSION: Nine core domains for tendon research should guide reporting of outcomes in clinical trials. Further research should determine the best outcome measures for each specific tendinopathy (ie, core outcome sets).

Clinical presentation and surgical management of chronic Achilles tendon disorders - A retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon.

BACKGROUND: Non-invasive treatment is not always successful in patients with Achilles tendon disorders, and surgical treatment is instituted as the next step. There is sparse knowledge about the diagnoses, pain levels before surgery, surgically confirmed pathologies and postoperative complications in large patient groups. AIMS: To study the diagnoses, pain scores before surgery, macroscopic surgical findings and postoperative complications in a series of patients treated for Achilles disorders. MATERIAL AND METHODS: One surgeon operated on 771 Achilles tendons of 481 men and 290 women during a 10-year period. The clinically and ultrasound confirmed diagnoses, pre-operative pain and functional scores (Visual Analogue Scale, VAS, range 0-100; Victorian Institute Sports Tendon Assessment - Achilles questionnaire, VISA-A), macroscopic findings during surgery and postoperative complications, were retrospectively collected from a database. RESULTS: Clinically, by ultrasound and during surgery midportion Achilles tendinopathy was confirmed in 519 (67%) patients, 41% of them had a thickened plantaris tendon located close the Achilles tendon. Partial midportion rupture was found in 31 (4%) patients, chronic midportion rupture in 12 (2%) patients and insertional Achilles tendinopathy, including superficial and retro-calcaneal bursitis, Haglund deformity, distal Achilles tendinopathy, plantaris tendon pathology, and bone spurs, in 209 (27%) patients. The mean pre-operative pain scores for midportion Achilles tendinopathy were 73 (VAS) and 45 (VISA-A), and for insertional Achilles tendinopathy 77 (VAS) and 39 (VISA-A). For midportion Achilles tendinopathy there were 14 (3%), and for insertional Achilles tendinopathy 10 (5%), postoperative complications. CONCLUSIONS: Patients presenting high pain scores from midportion Achilles tendinopathy were the most common. Plantaris tendon involvement is a frequent observation. For insertional Achilles tendinopathy the combination of pathology in the subcutaneous and retrocalcaneal bursa, a Haglund deformity and distal Achilles tendinopathy/tendinosis was most frequent. SERIES STUDY, LEVEL OF EVIDENCE: 4.

How to diagnose plantaris tendon involvement in midportion Achilles tendinopathy - clinical and imaging findings.

BACKGROUND: The purpose of this investigation was to evaluate if clinical assessment, Ultrasound + Colour Doppler (US + CD) and Ultrasound Tissue Characterisation (UTC) can be useful in detecting plantaris tendon involvement in patients with midportion Achilles tendinopathy. METHODS: Twenty-three tendons in 18 patients (14 men, mean age: 37 years and 4 women: 44 years) (5 patients with bilateral tendons) with midportion Achilles tendinopathy were surgically treated with a scraping procedure and plantaris tendon removal. For all tendons, clinical assessment, Ultrasound + Colour Doppler (US + CD) examination and Ultrasound Tissue Characterisation (UTC) were performed. RESULTS: At surgery, all 23 cases had a plantaris tendon located close to the medial side of the Achilles tendon. There was vascularised fat tissue in the interface between the Achilles and plantaris tendons. Clinical assessment revealed localised medial activity-related pain in 20/23 tendons and focal medial tendon tenderness in 20/23 tendons. For US + CD, 20/23 tendons had a tendon-like structure interpreted to be the plantaris tendon and localised high blood flow in close relation to the medial side of the Achilles. For UTC, 19/23 tendons had disorganised (type 3 and 4) echopixels located only in the medial part of the Achilles tendon indicating possible plantaris tendon involvement. CONCLUSIONS: US + CD directly, and clinical assessment indirectly, can detect a close by located plantaris tendon in a high proportion of patients with midportion Achilles tendinopathy. UTC could complement US + CD and clinical assessment by demonstrating disorganised focal medial Achilles tendon structure indicative of possible plantaris involvement.

Protease-activated receptors in the Achilles tendon-a potential explanation for the excessive pain signalling in tendinopathy.

BACKGROUND/AIM: Tendinopathies are pathological conditions of tissue remodelling occurring in the major tendons of the body, accompanied by excessive nociceptive signalling. Tendinopathies have been shown to exhibit an increase in the number of mast cells, which are capable of releasing histamine, tryptase and other substances upon activation, which may play a role in the development of tendinopathies. This study set out to describe the distribution patterns of a family of receptors called protease-activated receptors (PARs) within the Achilles tendon. These four receptors (PAR1, PAR2, PAR3, PAR4) are activated by proteases, including tryptase released from mast cells, and are involved in fibrosis, hyperalgesia and neovascularisation, which are changes seen in tendinopathies. METHOD: In order to study which structures involved in tendinopathy that these proteases can affect, biopsies from patients suffering of mid-portion Achilles tendinosis and healthy controls were collected and examined using immunohistochemistry. Tendon cells were cultured to study in vitro expression patterns. RESULTS: The findings showed a distribution of PARs inside the tendon tissue proper, and in the paratendinous tissue, with all four being expressed on nerves and vascular structures. Double staining showed co-localisation of PARs with nociceptive fibres expressing substance P. Concerning tenocytes, PAR2, PAR3, and PAR4, were found in both biopsies of tendon tissue and cultured tendon cells. CONCLUSIONS: This study describes the expression patterns of PARs in the mid-portion of the Achilles tendon, which can help explain the tissue changes and increased pain signalling seen in tendinopathies. These findings also show that in-vitro studies of the effects of these receptors are plausible and that PARs are a possible therapeutic target in the future treatment strategies of tendinopathy.

Sclerosing injections and ultrasound-guided arthroscopic shaving for patellar tendinopathy: good clinical results and decreased tendon thickness after surgery-a medium-term follow-up study.

PURPOSE: Treatment of patellar tendinopathy/jumper's knee with ultrasound-guided sclerosing injections or ultrasound-guided arthroscopic shaving has shown good clinical short-term results. Former studies indicate that the tendon thickness and structure stays unaffected after successful treatment. The aim of this study was to evaluate the sonographic findings and clinical outcome 3-5 years after treatment of patellar tendinopathy with ultrasound-guided sclerosing injections or arthroscopic shaving. METHODS: Fifty-seven patellar tendons (43 patients) with chronic patellar tendinopathy were evaluated, with ultrasound, colour Doppler (CD) and visual analogue scale (VAS) for pain and satisfaction with treatment, 3-5 years after treatment. Functional status was evaluated with a single question-"Back in full loading activity?" yes or no. RESULTS: At endpoint (mean 46 months), there was a significant decrease in anteroposterior thickness of the proximal patellar tendon in patients treated with ultrasound-guided arthroscopic shaving but not after sclerosing injections. Tendon structure had improved, and CD local blood flow had diminished significantly in both groups. There were good clinical results with a significant decrease in VAS for pain after sclerosing injections (VAS 64 ± 18 â†’ 17 ± 23) with 74 % satisfied patients and also after arthroscopic shaving (VAS 77 ± 16 â†’ 13 ± 23) with 80 % satisfied patients. There were no significant differences in VAS between groups. A significant correlation between low local blood flow and high patient satisfaction was found. CONCLUSIONS: Tendon thickness decreased over time after ultrasound-guided arthroscopic shaving, and tendon structure and local blood flow decreased after both treatments. There were good, and similar, clinical results with both methods. LEVEL OF EVIDENCE: III.

Unilateral surgical treatment for patients with midportion Achilles tendinopathy may result in bilateral recovery.

BACKGROUND: Bilateral midportion Achilles tendinopathy/tendinosis is not unusual, and treatment of both sides is often carried out. Experiments in animals suggest of the potential involvement of central neuronal mechanisms in Achilles tendinosis. OBJECTIVES: To evaluate the outcome of surgery for Achilles tendinopathy. METHODS: This observational study included 13 patients (7 men and 6 women, mean age 53 years) with a long duration (6-120 months) of chronic painful bilateral midportion Achilles tendinopathy. The most painful side at the time for investigation was selected to be operated on first. Treatment was ultrasound-guided and Doppler-guided scraping procedure outside the ventral part of the tendon under local anaesthetic. The patients started walking on the first day after surgery. Follow-ups were conducted and the primary outcome was pain by visual analogue scale. In an additional part of the study, specimens from Achilles and plantaris tendons in three patients with bilateral Achilles tendinosis were examined. RESULTS: Short-term follow-ups showed postoperative improvement on the non-operated side as well as the operated side in 11 of 13 patients. Final follow-up after 37 (mean) months showed significant pain relief and patient satisfaction on both sides for these 11 patients. In 2 of 13 patients operation on the other, initially non-operated side, was instituted due to persisting pain. Morphologically, it was found that there were similar morphological effects, and immunohistochemical patterns of enzyme involved in signal substance production, bilaterally. CONCLUSION: Unilateral treatment with a scraping operation can have benefits contralaterally; the clinical implication is that unilateral surgery may be a logical first treatment in cases of bilateral Achilles tendinopathy.

Tendinopathic Plantaris but Normal Achilles Tendon Found in About One-Fifth of Patients Not Responding to Conservative Achilles Tendon Management - Results from a Prospective WALANT Surgical Case Series on 105 Tendons.

Purpose: Midportion Achilles tendinopathy is a relatively common condition. This study aimed to investigate the presence of a normal Achilles tendon, but a tendinopathic plantaris tendon, in a large and consecutive prospective sample of patients referred to a specialised tendon clinic for midportion Achilles tendon pain not responding to non-surgical treatment. Patients and Methods: A total of 105 consecutive tendons were operated on in 81 patients (62 males) suffering from painful midportion Achilles tendon pain. Clinical examination, ultrasound (US) and colour Doppler (CD) examination, and wide awake local anaesthetic no tourniquet (WALANT) surgery were performed in all patients. Results: For 19/105 (18%) tendons from 14 patients, clinical examination suspected plantaris tendinopathy alone as there was a distinct tenderness on the medial side, but no thickening of the Achilles tendon. US examination followed by surgery confirmed the diagnosis. Conclusion: Midportion Achilles tendon pain is not always related to Achilles tendinopathy since pain related to the plantaris tendon alone was found in almost every fifth patient. Consequently, there is an obvious need for proper examination to identify the pain source and establish a correct diagnosis before treatment.

Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012.

In September 2010, the first International Scientific Tendinopathy Symposium (ISTS) was held in Umeå, Sweden, to establish a forum for original scientific and clinical insights in this growing field of clinical research and practice. The second ISTS was organised by the same group and held in Vancouver, Canada, in September 2012. This symposium was preceded by a round-table meeting in which the participants engaged in focused discussions, resulting in the following overview of tendinopathy clinical and research issues. This paper is a narrative review and summary developed during and after the second ISTS. The document is designed to highlight some key issues raised at ISTS 2012, and to integrate them into a shared conceptual framework. It should be considered an update and a signposting document rather than a comprehensive review. The document is developed for use by physiotherapists, physicians, athletic trainers, massage therapists and other health professionals as well as team coaches and strength/conditioning managers involved in care of sportspeople or workers with tendinopathy.

Ultrasonography- and Doppler-Guided Surgical Treatment for Insertional Achilles Tendinopathy: Results From a Case Series in a Southern Sweden County Hospital.

Background: Treatment with ultrasonography (US)- and color Doppler (CD)-guided mini surgery for insertional Achilles tendinopathy has shown good clinical results in a sports medicine setting. The aim in this study was to introduce this new methodology at a county hospital and study the clinical results on a traditional orthopaedic population. Methods: Twenty-six consecutive patients (12 men, mean age 61 years; 14 women, mean age 56 years) with a long duration (>12 months) of pain symptoms from insertional Achilles tendinopathy (a combination of bursae, bone, and tendon pathology) were included. US- and CD-guided surgical removal of bursae, bone, and tendon pathology, performed with local anaesthesia, was used. After surgery, there was immediate weightbearing loading without immobilization, followed by a structured rehabilitation protocol for 12 weeks. The VISA-A and SEFAS scores plus a questionnaire evaluating satisfaction with treatment and activity level was used for evaluation. Results: At the 1-year follow-up, there were 3 dropouts. Twenty-one patients were satisfied. Their VISA-A score had increased significantly from 26 to 81 (P < .001), and the SEFAS score from 17 to 38 (P < .001). Two patients were not satisfied. There were 3 complications, 2 superficial skin infections, and 1 wound rupture. Conclusion: For patients with chronic painful insertional Achilles tendinopathy, the US- and CD-guided surgical treatment method followed by immediate weightbearing loading showed a high satisfaction rate and improved functional scores at the 1-year follow-up in a majority of the patients. There are advantages using this method compared to other more tendon invasive surgical methods in use for this condition. Level of Evidence: Level IV, case series.

High-impact loading on the skeleton is associated with a decrease in glucose levels in young men.

OBJECTIVE: The skeleton has been suggested to be involved in energy metabolism through osteocalcin (OC), an osteoblast-specific molecule. The objective of this study was to investigate whether high-impact (HI) exercise stimulating bone formation would lead to changes in glucose and lipid metabolism independent of cardiorespiratory effects and whether OC mediates this association. DESIGN: Prospective intervention study. METHODS: Fifty men aged 20-32 years were allocated to an intervention group or a control group. The intervention group completed six different types of jumps in sets of five, with the frequency of these exercises gradually increasing over 8 weeks. At baseline and after 8 weeks, glycerol concentrations were measured in fat tissue as a marker of lipolysis using microdialysis. Blood samples were assayed for OC and markers of glucose and lipid metabolism. Physical activity was measured using an accelerometer. RESULTS: After adjustment for confounders at baseline and changes in physical activity during the intervention period, the intervention was associated with a decrease in levels of glucose (P = 0·04), adrenalin (P = 0·03) and OC (P = 0·04) after adjusting for baseline levels and changes in physical activity. No other differences between the groups were significant, although the trends of the metabolic variables favoured the intervention group. CONCLUSIONS: The results of this study suggest that HI loading on the skeleton may affect glucose metabolism independent of the level of aerobic exercise.

Evidence of the TNF-α system in the human Achilles tendon: expression of TNF-α and TNF receptor at both protein and mRNA levels in the tenocytes.

UNLABELLED: Understanding adaption to load is essential for prevention and treatment of tendinopathy/tendinosis. Cytokine release in response to load is one mechanism involved in mechanotransduction. The cytokine tumor necrosis factor alpha (TNF-α) is implicated in tendinosis and can induce apoptotic effects via tumor necrosis factor receptor 1 (TNFR1). The complete absence of information concerning the TNF-α system in Achilles tendon is a limitation as mid-portion Achilles tendinosis is very frequent. PURPOSE: To examine expression patterns of TNF-α and its two receptors (TNFR1 and TNFR2) in human Achilles tendinosis and control tissue and to biochemically confirm the presence of TNF-α in tendinosis tissue. METHODS: TNF-α and TNFR1 mRNA were detected via in situ hybridization. TNF-α, TNFR1, and TNFR2 were demonstrated immunohistochemically. Apoptosis markers were utilized. ELISA was used to detect TNF-α. RESULTS: TNF-α and TNFR1 mRNA was detected in tenocytes of both tendinosis and control tendons. Tenocytes from both groups displayed specific immunoreactions for TNF-α, TNFR1, and TNFR2. The widened/rounded tenocytes of tendinosis samples exhibited the most intense immunoreactions. Apoptosis was detected in only a subpopulation of the tenocytes in tendinosis tissue. TNF-α was measurable in tendinosis tissue. Inflammatory cells were not seen. CONCLUSION: This is the first evidence of the existence of the TNF-α system in the human Achilles tendon. Findings are confirmed at mRNA and protein levels as well as biochemically. The TNF-α system was in principle confined to the tenocytes. The connection between tenocyte morphology and the expression pattern of TNF-α, TNFR1, and TNFR2 suggests that the TNF-α system may be involved in tenocyte activation in Achilles tendinosis.

A Regenerated Achilles Tendon with Good Function One Year After Total Extirpation Due to Infection - A Case Report.

Background: Delayed Achilles tendon ruptures leaving large defects are difficult to treat, and the potential for tendon regeneration is thought to be limited. Furthermore, post-operative wound healing problems, sometimes including infections, can be challenging to treat and negatively affect rehabilitation. Case Presentation: This 74-year-old lady suffered from insertional Achilles tendinopathy. After treatment with a local cortisone injection, she sustained a total insertional Achilles tendon rupture. This rupture was treated conservatively, and after treatment the Achilles re-ruptured in the insertional area. The rupture was then treated with re-insertion into the calcaneal insertion. Early in the post-operative period the patient sustained a deep surgical wound infection and sepsis. Because of poor effect of treatment with antibiotics, and total tendon destruction, the whole Achilles was extirpated. After extirpation there was immobilization in a cast followed by mobilization and gradually increased loading. At a one-year follow-up, the patient was walking without a limp, could do heel-raise halfway up standing on one leg, there was a palpable Achilles tendon and ultrasound scanning showed a structure very similar to a slightly thickened and tendinopathic Achilles tendon. There was an obvious regeneration of the whole Achilles tendon, and the tendon function was surprisingly good. Conclusion: This case study clearly shows the regeneration potential in the Achilles tendon and provides significant knowledge of importance for clinicians dealing with Achilles tendon injuries.

Is There a Relationship Between Quadriceps Tendinopathy and Suprapatellar Plica? An Observational Case Series.

Purpose: Chronic painful quadriceps tendinopathy is a relatively rare condition known to be difficult to manage. Conservative management is first-line treatment and if that fails open intra-tendinous revision surgery followed by a long rehabilitation period is used. There is sparse research on etiology and new treatment methods. This observational study aimed to evaluate the intra-articular findings in patients with chronic painful quadriceps tendinopathy resistant to conservative management. Patients and Methods: Seven male athletes (mean age 33 years, range 22-40) suffering from chronic painful quadriceps tendinopathy in altogether 10 tendons, not responding to conservative management including heavy strength training, were included. Clinical examination and ultrasound scanning were used for diagnosis. Arthroscopy was used for evaluation of the inside of the knee. Results: In all 10 knees, there were obliterating major plica formations in the suprapatellar pouch. Conclusion: Obliterating plica formations in the suprapatellar pouch may be involved in the aetiology and pathology in quadriceps tendinopathy.