Effects of acupuncture and acupressure of the acupoint compared to the tendon on the blood circulation of human tendon in vivo.

PURPOSE: The purpose of this study was to compare the effects of acupuncture and acupressure of acupoints on tendon blood circulation with those of both types of stimulation of tendon itself. METHODS: Before, during (except for acupressure), and after acupuncture and acupressure of the tendon and acupoint, blood circulation of the Achilles tendon was measured using red laser lights. RESULTS: The blood volume of the treated and non-treated tendons increased after acupuncture of the tendon (effect of time p = 0.030), whereas that tended to increase after acupuncture of the acupoint (effect of time p = 0.063). In addition, no significant difference in the increases in blood volume was found among the four conditions, i.e., after acupuncture stimulation of the tendon and acupoint for the treated and non-treated tendons (p = 0.492). The blood volume of the treated tendon significantly increased after acupressure of the tendon (effect of time p < 0.001), but not of the acupoint (effect of time p = 0.260), whereas that of the non-treated tendon did not change after acupressure of both the tendon and acupoint. CONCLUSION: These results suggested that acupuncture of the tendon and acupoint acted centrally to enhance blood circulation of both the treated and non-treated tendons during the recovery period, whereas acupressure of the tendon locally increased blood circulation of the treated tendon only, but not the non-treated tendon and both the treated and non-treated tendons after acupressure of acupoint.

Functional anatomy, histology and biomechanics of the human Achilles tendon - A comprehensive review.

OBJECTIVES: The aim of this study was to provide a comprehensive overview of the anatomical, histological, and biomechanical aspects of the Achilles tendon. METHODS: A comprehensive search on the relevant aspects of the Achilles tendon was performed through the main electronic databases up to October 2019. Data from relevant articles was gathered, analyzed, and included in this review. RESULTS: This review outlines crucial topics on the anatomy, histology, and biomechanics of the Achilles tendon. The first part, focusing on clinically relevant anatomy, describes the tendon as well as its surrounding structures. Particular focus is made on anatomical divisions. The second part discusses histologic features, contrasting normal morphology with pathologic changes. The third part summarizes various biomechanical aspects of the Achilles tendon, especially those crucial to understanding the key functionality of the tendon. These components make up this review aimed to aggregate relevant information regarding the Achilles tendon to provide an up to date assessment of current knowledge, as well as visions for future directions of Achilles tendon research. CONCLUSIONS: Comprehensive knowledge regarding the Achilles tendon is crucial whilst rates of injury continue to be relevant. A proper understanding of the anatomy, histology, and biomechanics is vital for clinical perception as well as establishing the direction of further research in new therapies.

Acupuncture- and Intermittent Compression-Induced Changes in Blood Circulation of Tendon.

Objective: The purpose of this study was to compare changes in blood circulation (blood volume and oxygen saturation [StO2]) of tendon by acupuncture (insertion depth of the needle was 4 mm) and intermittent compression. Subjects: Thirteen healthy volunteers (12 males and 1 female; age: 26.9 ± 9.8 years) participated in this study. Methods: Before the treatments (10 min for acupuncture, 3 min for intermittent compression, and 10 min for control condition) and the recovery period (40 min), the blood volume (total hemoglobin [THb]) and StO2 of treated and nontreated Achilles tendons were measured using red laser lights. Results: Regarding the acupuncture-induced changes in blood circulation of tendons, THb and StO2 of the treated tendon suddenly increased during acupuncture with up-and-down manipulation, and those of the treated and nontreated tendons gradually increased after removal of the needle. The authors were not able to present the measured variables during intermittent compression, since obvious noises were observed. After acupuncture and intermittent compression, THb and StO2 of the treated tendon remained high during the recovery period and those of the nontreated tendon gradually increased during the latter half of the recovery period. There were no differences in the mean changes of THb or StO2 of the treated and nontreated tendons during the recovery period between acupuncture and intermittent compression. Under the control condition, no significant changes were noted in the measured variables. Conclusion: These results suggest that intermittent compression to the tendon brought about increases in tendon blood circulation similar to those induced by acupuncture.

Association Between Clinical and Imaging Outcomes After Therapeutic Loading Exercise in Patients Diagnosed With Achilles or Patellar Tendinopathy at Short- and Long-Term Follow-up: A Systematic Review.

OBJECTIVE: To determine the association between clinical and imaging outcomes after therapeutic loading exercise in Achilles tendinopathy (AT) and patellar tendinopathy (PT) populations at both short- and long-term follow-up. DATA SOURCES: The PUBMED and EMBASE databases were searched (up to June 2017) to identify articles that meet the inclusion criteria: (1) patients diagnosed with AT (insertional or midportion) or PT; (2) rehabilitation based on therapeutic loading exercise; and (3) assessment of clinical outcomes and tendon structure using an imaging modality. MAIN RESULTS: Two independent reviewers screened 2894 search results, identifying 21 suitable studies. According to the studies included in this review, clinical results showed significant improvements for patients with AT and PT after eccentric exercise (ECC) and heavy slow resistance (HSR) at short- and long-term follow-up. Imaging outcomes were not consistent. Moderate-to-strong evidence for patients with AT suggested an association between clinical outcomes and imaging outcomes (tendon thickness and tendon neovascularization) after ECC at long-term follow-up. For patients with PT, there was moderate evidence supporting an association between clinical outcomes (questionnaire score and pain) and imaging (tendon thickness and tendon neovascularization) after ECC at short-term follow-up. For both the AT and PT groups, there was moderate evidence for an association between clinical outcomes and tendon thickness and neovascularization after HSR exercise. Results related to the HSR exercise should be interpreted with caution because of the small number of studies. CONCLUSIONS: Based on the findings of the present review, the use of imaging outcomes as a complementary examination to the clinical assessment was confirmed. Overall, an improvement in clinical outcomes seems to be associated with a reduction in tendon thickness and tendon neovascularization. Clinicians should be aware that during the interpretation of the imaging outcomes, factors such as tendinopathy location, exercise modality performed, and a follow-up period should be considered.

Ultrasound Evaluation of Anti-Vascular Endothelial Growth Factor-Induced Changes in Vascular Response Following Tendon Injury.

While vascular ingrowth is necessary for tendon healing, hypervascularization following tendon injury is not always believed to be beneficial, and there is now evidence showing beneficial results of anti-angiogenic treatments in the context of tendon healing. However, the dose-dependency of anti-angiogenic-altered vascular response, as well as methods for evaluating these changes in vivo, has not been fully investigated. Therefore, the objective of this study was to evaluate if in vivo ultrasound imaging can detect dose-dependent, anti-angiogenic treatment-induced changes in vascularity in rat Achilles tendon after injury. Color Doppler ultrasound revealed an increase in vascularity in a low-dosage group, while photoacoustic imaging demonstrated a decrease in vascularity in mid- and high-dosage groups. Histologic staining supported the decrease in vascularity observed in the mid-dosage group. This study demonstrates dose-dependent vascular alterations from the delivery of an anti-angiogenic factor after tendon injury that can be detected through ultrasound imaging methods.

Acute and Long-Term Effects of Mechanotherapy on the Outcome After an Achilles Repair: A Prospective Cohort Study With Historical Controls.

OBJECTIVES: To evaluate the effects of vibration on Achilles' tendon microcirculation and characteristics following surgical repair of Achilles' tendon rupture. DESIGN: Cohort study with historical controls. SETTING: A university institute. PARTICIPANTS: Participants (N=32), including 19 (16 men, 3 women; median [range] age: 43.0 [25.0-57.0] years) and 13 (10 men, 3 women; 44.00 [29.0-60.0] years) in the vibration (application to the ball of the foot, 30Hz, 2mm amplitude, 4kg pressure, and self-administration) and control groups, respectively, who underwent unilateral Achilles' tendon repairs were recruited. INTERVENTION: A 4-week vibration intervention in the vibration group. MAIN OUTCOME MEASUREMENTS: The tendon microcirculation was measured after the first session of vibration. The participants were evaluated repeatedly with bilateral follow-up measurements of tendon stiffness, 3 functional outcome tests, and a questionnaire survey. RESULTS: Acute effects of the vibration were observed immediately after the 5-minute vibration (P≤.001). Lower total hemoglobin and oxygen saturation were respectively observed (P=.043) in the repaired legs 3 and 6 months postsurgery in the vibration group as compared with the control group. The vibration group also showed greater tendon stiffness, heel raising height and hopping distance 3 or 6 months postoperation in both the repaired and noninjured legs (all P<.05). The microcirculatory characteristics 2 months postoperation were correlated with the outcomes at 6 months postoperation. CONCLUSIONS: Differences in microcirculatory characteristics and better rehabilitation outcomes were observed in the legs with an Achilles repair that underwent the early vibration intervention.

Acute effects of capacitive and resistive electric transfer (CRet) on the Achilles tendon.

This study aimed to investigate the acute effects of capacitive and resistive electric transfer (CRet) on Achilles tendon elongation during muscle contraction, as well as the circulation in the peritendinous region. Sixteen healthy men participated in this study. All 16 participants underwent 2 interventions: (1) CRet trial and (2) CRet without power (sham trial). Tendon elongation was measured four times. Using near-infrared spectroscopy, the blood circulation (volume of total-hemoglobin (Hb), oxygenated hemoglobin (oxy-Hb), and deoxygenated hemoglobin (deoxy-Hb)) was measured for 5 min before the intervention and for 30 min after the intervention. The differences between the measurements obtained before and after intervention were compared between the two interventions. The changes in tendon elongation and deoxy-Hb were not significantly different between the interventions. Total- and oxy-Hb were significantly increased in the CRet trial compared with the sham trial. In addition, the increases in total-Hb and oxy-Hb lasted for 30 min after the CRet intervention (CRet vs. sham: oxy-Hb: F = 8.063, p = 0.001, total-Hb: F = 4.564, p = 0.011). In conclusion, CRet significantly improved blood circulation in the peritendinous region.

Effects of eccentric training with different training frequencies on blood circulation, collagen fiber orientation, and mechanical properties of human Achilles tendons in vivo.

PURPOSE: The purpose of the present study was to compare the effects of eccentric training with different training frequencies on the blood circulation, collagen orientation, and mechanical properties of the human Achilles tendon in vivo. METHODS: Ten healthy males completed 12 weeks of a unilateral eccentric training program {(15 repetitions with knee straight and 15 repetitions with knee slightly bent) × 6 sets in a single session} for the plantar flexor muscles. They performed training three times per week on one side (3TW) and six times per week on the other side (6TW). Before and after training, changes in blood volume, coefficient of variation (CV) of echogenicity (reflects collagen fiber orientation), and stiffness of the Achilles tendon were compared by two-way analysis of variance. RESULTS: The tendon blood volume tended to increase after 3TW and 6TW (p = 0.064). Tendon stiffness did not change after 3TW and 6TW, whereas the elongation of tendon structures at three force levels (50, 100, and 150 N) significantly decreased with 3TW, but not 6TW. The CV of echogenicity significantly decreased after 3TW and 6TW. However, no significant differences were observed in the relative changes in these measured variables between 3TW and 6TW. CONCLUSION: The present results demonstrated an increase in blood volume, the alignment of collagen fibers, and unchanged stiffness of the Achilles tendon after 12 weeks of eccentric training. Furthermore, the training frequency did not influence these training-induced changes in the tendon properties.

Activity-Induced Increase in Achilles Tendon Blood Flow Is Age and Sex Dependent.

BACKGROUND: Previous research of a young adult population identified a lower increase in Achilles tendon blood flow immediately after a running activity as a significant predictor for the development of Achilles tendinopathy (AT). Furthermore, advancing age is often mentioned as a risk factor for the development of AT, and the highest incidence for AT is reported to occur in middle-aged recreational male athletes. PURPOSE: To investigate the effect of age, sex, and type of physical activity on the increase in Achilles tendon blood flow. STUDY DESIGN: Controlled laboratory study. METHODS: Blood flow measurements of 33 subjects aged 18 to 25 years and 30 subjects aged 40 to 55 years were obtained before and after 4 physical activities performed in randomized order: running, cycling, dynamic stretching, and rope skipping. Blood flow measurements of the Achilles tendon were performed before, immediately after, 5 minutes after, and 10 minutes after the physical activities. The effect of age, sex, and physical activities on the increase in blood flow was investigated with linear mixed models. RESULTS: The results of this study identified that running, rope skipping, and cycling resulted in a significant increase in tendon blood flow ( P ≤ .001), whereas stretching did not. Prominent was the finding that the increase in blood flow after activity was significantly lower in the older population as compared with the younger population ( P < .001). Furthermore, male participants in the older group showed a significantly lower increase in tendon blood flow than did their female counterparts ( P = .019). CONCLUSION: This study identified that sex and age significantly influence the increase in blood flow after activity, possibly explaining the increased risk for AT among middle-aged recreational athletes. CLINICAL RELEVANCE: This study possibly identified one of the mechanisms explaining why an older male population is at increased risk for developing AT. Given that the lower increase in blood flow is an identified risk factor according to previous research, preventative measures should focus on improving this blood flow during physical activity in the physically active older male population. Registration: NCT03218605 ( ClinicalTrials.gov identifier).

Soft tissue microcirculation around the healthy Achilles tendon: a cross-sectional study focusing on the Achilles tendon and dorsal surgical approaches to the hindfoot.

BACKGROUND: Dorsal approaches to the hindfoot are frequently used. Furthermore, the vascular supply is discussed as a possible cause for ruptures and degeneration of the Achilles tendon. The aim of this study was to evaluate the microperfusion of three possible posterior approaches to the hindfoot and different areas of the Achilles tendon. METHODS: In 111 subjects, a laser Doppler/white light spectroscopy was used to measure microperfusion in terms of blood flow (Flow) and capillary venous oxygen saturation (SO2) in the hindfoot and Achilles tendon. Measurements were performed at two measurement points (MP, proximal and distal) of three dorsal approaches (medial, lateral and central) and inside the Achilles tendon. RESULTS: Microperfusion differed partially between the surgical approaches. The medial and the lateral approaches were significantly superior to the central approach with regard to Flow in both MP (p <  0.001), while SO2 was significantly higher at the proximal measurement point (MP 1; p <  0.001). In this area, the lateral approach was significantly superior to the medial approach regarding Flow (MP 1; p = 0.012). The Achilles tendon exhibited a significantly reduced microperfusion 5 cm proximal to the calcaneal tubercle (SO2 p = 0.001; Flow p = 0.048). Demographic factors, such as body mass index and age, had different effects. Microcirculation was partially superior in men and negatively affected by smoking. CONCLUSIONS: Soft tissue microcirculation on the lateral and medial side of the healthy Achilles tendon was better than centrally on the tendon. Proximally, the lateral approach was better than the medial approach. These circumstances could provide advantages regarding the surgical approach. The Achilles tendon exhibited significantly reduced microperfusion at the typical side of degeneration and rupture. This circumstance could be a possible cause of degenerative processes.

The acute effects of exercise on tendon dimensions and vascularity. An exploratory study using diagnostic ultrasound of the male Achilles tendon.

OBJECTIVES: This study examines the acute morphological changes (up to three days) in the normal, asymptomatic Achilles tendon (AT) in response to a single bout of exercise in relation to tendon dimensions and vascularity. DESIGN: Within-subject pre-post design. METHODS: Participants conducted a 7.7km pack march on a sealed road in a time of 1h 16min (approximately 6kmh-1). The longitudinal image of the sagittal diameter, transverse image of the area and vascularity at 20mm proximal to the superior aspect of the calcaneus and longitudinal image of the sagittal diameter at the insertion was measured the day before the pack march, immediately afterwards and then three days later. RESULTS: The tendon showed no significant change in sagittal diameter and cross-sectional area at 20mm proximal to the calcaneus and at the insertion immediately post-exercise. Tendon vascularity increased significantly in 91% of the left ATs and 87% of the right ATs in response to the pack march. Three days after the pack march an increase in sagittal diameter at the insertion and 20mm proximal to the calcaneus was observed and increased vascularity was still present in 22% of the ATs. CONCLUSIONS: This study highlighted the tendon's response to exercise and has shown that at three days post-exercise that the tendon had not recovered to pre-exercise levels with respect to tendon dimensions and vascularity.

Intravoxel incoherent motion (IVIM) imaging in human achilles tendon.

BACKGROUND: Limited microcirculation has been implicated in Achilles tendinopathy and may affect healing and disease progression. Existing invasive and noninvasive approaches to evaluate tendon microcirculation lack sensitivity and spatial coverage. PURPOSE: To develop a novel Achilles tendon intravoxel incoherent motion (IVIM) MRI protocol to overcome the limitations from low tendon T2 /T2 * value and low intratendinous blood volume and blood velocity to evaluate tendon microcirculation. STUDY TYPE: Prospective. SUBJECTS: Sixteen healthy male participants (age 31.0 ± 2.1) were recruited. FIELD STRENGTH/SEQUENCE: A stimulated echo readout-segmented echo planar imaging (ste-RS-EPI) IVIM sequence at 3.0T. ASSESSMENT: The feasibility of the proposed ste-RS-EPI IVIM protocol combined with Achilles tendon magic angle effect was evaluated. The sensitivity of the protocol was assessed by an exercise-induced intratendinous hemodynamic response in healthy participants. The vascular origin of the observed IVIM signal was validated by varying the diffusion mixing time and echo time. STATISTICAL TESTS: Two-tailed t-tests were used to evaluate differences (P < 0.05 was considered significant). RESULTS: Consistent with known tendon hypovascularity, the midportion Achilles tendon at baseline showed significantly lower IVIM-derived perfusion fraction (fp ) (3.1 ± 0.9%) compared to the proximal and distal Achilles tendon (6.0 ± 1.8% and 6.1 ± 2.0%, respectively; P < 0.01). Similarly, the midportion Achilles tendon exhibited significantly lower baseline blood flow index (D*×fp ) (40.9 ± 19.2, 18.3 ± 5.3, and 32.0 ± 9.4 in proximal, midportion, and distal Achilles tendon, respectively; P < 0.01). Eccentric heel-raise exercise led to ∼2 times increase of Achilles tendon blood flow in healthy participants. Consistent with its vascular origin, the estimated fp demonstrated a high dependency to IVIM protocol parameters, while the T1 /T2 -corrected absolute intratendinous microvascular blood volume fraction (Vb ) did not vary. DATA CONCLUSION: Achilles tendon ste-RS-EPI IVIM noninvasively assessed baseline values and exercise-induced changes to tendon microcirculation in healthy tendon. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1690-1699.

Microvascular volume in symptomatic Achilles tendons is associated with VISA-A score.

OBJECTIVES: The role of neovascularisation in tendinopathy is still poorly understood, potentially due to technical limitations of conventional power Doppler ultrasound. This study aimed to investigate the association between contrast-enhanced ultrasound (CEUS) microvascular volume (MV), Victorian Institute of Sports Assessment-Achilles (VISA-A) scores and intrinsic Achilles tendon tenderness, as well as two different Power Doppler modes. DESIGN: Cross-sectional study. METHODS: 20 individuals with uni- or bilateral Achilles tendinopathy completed a VISA-A questionnaire, and underwent microvascular volume measurements of the Achilles tendon mid-portion using both conventional, ultrasensitive (SMI™) power Doppler ultrasound and CEUS. Intrinsic tendon tenderness was assessed with sensation detection threshold to extracorporeal shock waves (ESW). Linear Mixed Model analysis was used to determine the association between microvascular volume (MV), VISA-A, and ESW-detection threshold for both symptomatic and asymptomatic Achilles tendons. RESULTS: There was a significant association between VISA-A and MV (B=-5.3, 95%CI=[-8.5; -2.0], P=0.0004), and between MV and symptom duration (B=-1.7, 95%CI=[-3.2; -5.0], P=0.023). No significant associations were found between power Doppler ultrasound and CEUS-based MV or between CEUS-based MV and ESW-detection threshold. In comparison with conventional power Doppler ultrasound, SMI™ showed on average similar detection capacity for neovessels in the mid-portion of the Achilles tendon, whilst being superior for detecting neovessels within Kager's fat pad (t=3.46, 95%CI=[0.27; 1.03], P<0.005). CONCLUSIONS: Our results indicate that CEUS-based MV of the Achilles tendon is moderately associated with Achilles tendon symptoms. In accordance, CEUS-detected MV could be a novel target for treatment as it seems to be more sensitive than PDU and is correlated with symptoms.

Acute effect of running exercise on physiological Achilles tendon blood flow.

Sonographically detectable intratendinous blood flow (IBF) is found in 50%-88% of Achilles tendinopathy patients as well as in up to 35% of asymptomatic Achilles tendons (AT). Although IBF is frequently associated with tendon pathology, it may also represent a physiological regulation, for example, due to increased blood flow in response to exercise. Therefore, this study aimed to investigate the acute effects of a standardized running exercise protocol on IBF assessed with Doppler ultrasound (DU) "Advanced dynamic flow" in healthy ATs. 10 recreationally active adults (5 f, 5 m; 29±3 years, 1.72±0.12 m, 68±16 kg, physical activity 206±145 minute/wk) with no history of AT pain and inconspicious tendon structure performed 3 treadmill running tasks on separate days (M1-3) with DU examinations directly before and 5, 30, 60, and 120 minutes after exercise. At M1, an incremental exercise test was used to determine the individual anaerobic threshold (IAT). At M2 and M3, participants performed 30- minute submaximal constant load tests (CL1 /CL2 ) with an intensity 5% below IAT. IBF in each tendon was quantified by counting the number of vessels. IBF increased in five ATs from no vessels at baseline to one to four vessels solely detectable 5 minutes after CL1 or CL2 . One AT had persisting IBF (three vessels) throughout all examinations. Fourteen ATs revealed no IBF at all. Prolonged running led to a physiological, temporary appearance of IBF in 25% of asymptomatic ATs. To avoid exercise-induced IBF in clinical practice, DU examinations should be performed after 30 minutes of rest.

Microcirculation after Achilles tendon rupture correlates with functional and patient-reported outcomes.

Patients with acute Achilles tendon rupture (ATR) display an extended healing process with varying clinical outcome. Poor microcirculatory blood flow has been suggested to be a significant factor for the healing process. However, whether microcirculation may predict healing outcome has been mostly unknown. Therefore, we investigated whether blood flow in the Achilles tendon may be associated with patient-reported and functional outcomes after ATR. In vivo laser-Doppler flowmetry was used to assess microvascular blood flow bilateral in the Achilles tendons, during post-occlusive reactive hyperemia, of nine patients with acute total ATR at 2 weeks post-operatively. At 3 months post-operatively, patient-reported outcome was assessed using Achilles tendon Total Rupture Score (ATRS). At 1 year a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining validated, independent, patient-reported (ATRS), and functional outcome (heel-rise test) measures. An improved combined patient-reported and functional outcome, ACOS, at 1 year was significantly correlated with higher maximum blood flow (r=.777, P=.040) in the injured limb. Furthermore, enhanced patient-reported outcome, ATRS, at 3 months, was associated with an elevated ratio of maximum to resting blood flow (r=.809, P=.015) in the uninjured limb. Blood flow in early tendon healing is associated with long-term patient-reported and functional outcomes after ATR. The microcirculatory blood flow of both the healing and contralateral Achilles tendon seems to determine the healing potential after injury.

Therapeutic potential of hAECs for early Achilles tendon defect repair through regeneration.

Cell-based therapy holds great promise for tendon disorders, a widespread debilitating musculoskeletal condition. Even if the cell line remains to be defined, preliminary evidences have proven that amniotic-derived cells possess in vitro and in vivo a great tenogenic potential. This study investigated the efficacy of transplanted human amniotic epithelial cells (hAECs) by testing their early regenerative properties and mechanisms involved on a validated ovine Achilles tendon partial defect performed on 29 animals. The injured tendons treated with hAECs recovered rapidly, in 28 days, structural and biomechanical properties undertaking a programmed tissue regeneration, differently from the spontaneous healing tissues. hAECs remained viable within the host tendons establishing with the endogenous progenitor cells an active dialogue. Through the secretion of modulatory factors, hAECs inhibited the inflammatory cells infiltration, activated the M2 macrophage subpopulation early recruitment, and accelerated blood vessel as well as extracellular matrix remodelling. In parallel, some in situ differentiated hAECs displayed a tenocytelike phenotype. Both paracrine and direct hAECs stimulatory effects were confirmed analysing their genome profile before and after transplantation. The 49 human up-regulated transcripts recorded in transplanted hAECs belonged to tendon lineage differentiation (epithelial-mesenchymal transition, connective specific matrix components, and skeleton or muscle system development-related transcripts), as well as the in situ activation of paracrine signalling involved in inflammatory and immunomodulatory response. Altogether, these evidences support the hypothesis that hAECs are a practicable and efficient strategy for the acute treatment of tendinopathy, reinforcing the idea of a concrete use of amniotic epithelial cells towards the clinical practice.

Reliability of Evaluating Achilles Tendon Vascularization Assessed With Doppler Ultrasound Advanced Dynamic Flow.

OBJECTIVES: The reliability of quantifying intratendinous vascularization by high-sensitivity Doppler ultrasound advanced dynamic flow has not been examined yet. Therefore, this study aimed to investigate the intraobserver and interobserver reliability of evaluating Achilles tendon vascularization by advanced dynamic flow using established scoring systems. METHODS: Three investigators evaluated vascularization in 67 recordings in a test-retest design, applying the Ohberg score, a modified Ohberg score, and a counting score. Intraobserver and interobserver agreement for the Ohberg score and modified Ohberg score was analyzed by the Cohen κ and Fleiss κ coefficients (absolute), Kendall τ b coefficient, and Kendall coefficient of concordance (W; relative). The reliability of the counting score was analyzed by intraclass correlation coefficients (ICC) 2.1 and 3.1, the standard error of measurement (SEM), and Bland-Altman analysis (bias and limits of agreement [LoA]). RESULTS: Intraobserver and interobserver agreement (absolute/relative) ranged from 0.61 to 0.87/0.87 to 0.95 and 0.11 to 0.66/0.76 to 0.89 for the Ohberg score and from 0.81 to 0.87/0.92 to 0.95 and 0.64 to 0.80/0.88 to 0.93 for the modified Ohberg score, respectively. The counting score revealed an intraobserver ICC of 0.94 to 0.97 (SEM, 1.0-1.5; bias, -1; and LoA, 3-4 vessels). The interobserver ICC for the counting score ranged from 0.91 to 0.98 (SEM, 1.0-1.9; bias, 0; and LoA, 3-5 vessels). CONCLUSIONS: The modified Ohberg score and counting score showed excellent reliability and seem convenient for research and clinical practice. The Ohberg score revealed decent intraobserver but unexpected low interobserver reliability and therefore cannot be recommended.

Anatomic, Vascular, and Mechanical Overview of the Achilles Tendon.

The Achilles tendon is the strongest and thickest tendon in the body and is subjected to unique forces during the activities of living. A variety of pathologic processes have been identified causing clinical symptoms in patients of all ages. A detailed understanding of Achilles anatomy is necessary to understand the pathologic process that are seen in the tendon. As with all medical topics and conditions, our understanding is evolving as new research sheds light on pathologic processes involved with the Achilles tendon. This article reviews the anatomic, histologic, hemodynamic, and mechanical properties of the Achilles tendon and associated muscle structures.

Is Achilles tendon blood flow related to foot pronation?

In the etiology of Achilles tendinopathy (AT), it is frequently suggested that excessive pronation causes a vascular constriction of the Achilles tendon, described as the "whipping phenomenon" (Clement et al., 1984). Although previous studies focused on the association between pronation and AT, it is striking that the underlying association between foot pronation and blood flow has not been studied yet. Therefore, the aim of this study was to investigate whether the amount of pronation during running influences the Achilles tendon blood flow. Twenty-five experienced runners, aged 34.5±10.2 years, participated in this study. 2D-lower limb kinematics during barefoot and shod running in both frontal and sagittal plane were assessed. Blood flow of the Achilles tendon was measured before and after barefoot and shod running, using the oxygen-to-see device. The results of this study showed a significant effect of eversion excursion on the increase in Achilles tendon blood flow after shod running. More specifically, the more the eversion excursion observed, the lower the increase in blood flow (P=.013). We therefore suggest, in individuals with increased inversion at touchdown and increased eversion around midstance during shod running, that antipronation measures could be useful in both preventing and managing Achilles tendinopathy.

Characteristics of Intratendinous Microcirculation Shortly After an Achilles Rupture and Subsequent Treatment Outcomes.

BACKGROUND: Early microcirculatory responses after experimental tenotomy are critical to the healing of tendons and their ultimate tensile strength. The effects of changes in microcirculation on the outcomes of tendon healing, however, have not been determined. OBJECTIVES: To assess microcirculation values in injured Achilles tendons in the first 3 months after surgical repair and to correlate the inter-limb microcirculatory changes with functional outcomes at 3 and 6 months after surgery. DESIGN: Case-control study. SETTING: A university sports physiotherapy laboratory. PARTICIPANTS: Thirteen subjects (median age: 45 years; range: 34.8-51.9 years) with a repaired Achilles tendon were recruited. METHODS OR INTERVENTION: Surgical repair. MAIN OUTCOME MEASUREMENTS: Measurements were obtained at 1, 2, 3, and 6 months after surgery. Bilateral measurements of tendon microcirculation (total hemoglobin [THb] and oxygen saturation [StO2]) were recorded at the first 3 time points, whereas outcome measures of a Taiwan Chinese version of the Victorian Institute of Sport Assessment Scale-Achilles questionnaire, one-leg hopping distance, the star excursion balance test, and the heel raise index were conducted at the third and fourth time points. Correlations between the inter-limb microcirculatory changes, eg, between the measurements at 2 months and 1 month (2-1) after surgery, at 3 months and 2 months (3-2) after surgery, and at 3 months and 1 month (3-1) after surgery, and the outcome measures were investigated. RESULTS: Compared with the noninjured tendons, the repaired Achilles demonstrated greater THb (at 1, 2, and 3 months; P = .017, .008, and .012 respectively) and StO2 (at 3 months; P = .017). Furthermore, the THb2-1 and THb3-2, StO2 2-1, and StO2 3-2 showed correlations with the heel raise index, differences in the star excursion balance test and one-leg hopping distance between the noninjured leg and injured leg, and Taiwan Chinese version of the Victorian Institute of Sport Assessment Scale-Achilles questionnaire scores (rho -0.921 to 0.855). CONCLUSIONS: Changes in the inter-limb microcirculation shortly after Achilles repair were correlated with subsequent symptoms and functional symmetry. LEVEL OF EVIDENCE: III.