Achilles tendon complications of fluoroquinolone treatment: a molecule-stratified systematic review and meta-analysis.

Purpose: The association between fluoroquinolone intake and Achilles tendinopathy (AT) or Achilles tendon rupture (ATR) is widely documented. However, it is not clear whether different molecules have the same effect on these complications. The purpose of this study was to document Achilles tendon complications for the most prescribed fluoroquinolones molecules. Methods: A literature search was performed on Pubmed, Cochrane, Embase, and Web of Science databases up to April 2023. Inclusion criteria: studies of any level of evidence, written in English, documenting the prevalence of AT/ATR after fluoroquinolone consumption and stratifying the results for each type of molecule. The Downs and Black's 'Checklist for Measuring Quality' was used to evaluate the risk of bias. Results: Twelve studies investigating 439,299 patients were included (59.7% women, 40.3% men, mean age: 53.0 ± 15.6 years). The expected risk of AT/ATR was 0.17% (95% CI: 0.15-0.19, standard error (s.e.): 0.24) for levofloxacin, 0.17% (95% CI: 0.16-0.19, s.e.: 0.20) for ciprofloxacin, 1.40% (95% CI: 0.88-2.03, s.e.: 2.51) for ofloxacin, and 0.31% (95% CI: 0.23-0.40, s.e.: 0.77) for the other molecules. The comparison between groups documented a significantly higher AT/ATR rate in the ofloxacin group (P < 0.0001 for each comparison). Levofloxacin and ciprofloxacin showed the same risk (P = n.s.). The included studies showed an overall good quality. Conclusion: Ofloxacin demonstrated a significantly higher rate of AT/ATR complications in the adult population, while levofloxacin and ciprofloxacin showed a safer profile compared to all the other molecules. More data are needed to identify other patient and treatment-related factors influencing the risk of musculoskeletal complications.

Running biomechanical and isokinetic strength differences in masters runners with and without Achilles tendinopathy.

Masters runners are an increasing proportion of the running community. The most significant musculoskeletal changes in runners occur after the age of 50 in addition to changes in injury rates and types, the most common being Achilles tendinopathy (AT). Previous evidence has suggested similarities between risk factors for AT and age-related changes that are focused at the hip and the ankle during the propulsive stage of running. The purpose of this study was to investigate biomechanical and peak torque association to AT in masters runners. Thirty-two masters runners over age 50 with AT (60.31 ± 8.37, n = 16) and without (59.94 ± 4.95 n = 16) were included. 3D motion capture and force plates were used to assess running biomechanics. A motor-driven dynamometer was used to assess isokinetic peak torque production. No significant differences in running biomechanics were found between masters runners with and without AT. Hip peak isokinetic torque production was found to be significantly less in masters runners with AT, but no significant differences in ankle plantarflexion peak isokinetic torque production were found. Masters runners with AT may be able to adapt their running biomechanics and muscular torque production during submaximal running efforts.

Masters runners with Achilles tendinopathy do not demonstrate differences in peak hip extension moments during the stance phase of running during submaximal efforts compared to healthy masters runners.Masters runners with Achilles tendinopathy do not demonstrate differences in peak ankle plantarflexion moments during the stance phase of running during submaximal efforts compared to healthy masters runners.Masters runners with Achilles tendinopathy do not demonstrate differences in peak ankle plantarflexion concentric or eccentric isokinetic torque compared to healthy masters runners.Masters runners with Achilles tendinopathy demonstrate differences in peak hip extension concentric and eccentric isokinetic torque compared to healthy masters runners.

A Comparative Study of the Graston Technique and Alfredson Protocol in the Management of Achilles Tendinopathy.

BACKGROUND AND OBJECTIVES: The Achilles tendon, the largest and strongest tendon in the human body, is frequently injured by overuse; this condition is known as Achilles tendinopathy (AT). It serves as a link between the heel bone and the calf muscles and is necessary for motions, such as walking, sprinting, and jumping. Evidence is presented to support the efficacy of the Graston technique and Alfredson protocol for pain reduction and improvement of function and calf muscle strength. The objective of this study is to compare the efficacy of the Graston technique versus the Alfredson protocol in patients with AT. Methods and data collection: After obtaining approval from the ethical review board of the Rawalpindi Medical University, all patients fulfilling the inclusion criteria are divided into two groups, A and B, by generating random identity numbers using Microsoft Excel for allocation. Group A comprises patients who undergo treatment with the Graston technique as conventional therapy with Alfredson protocol (12-week calf muscle eccentric exercises), while those in group B follow a Graston technique with sole heel lift. Individuals in the eccentric exercises group follow an Alfredson method-based 12-week eccentric exercise plan for their leg muscles. The workouts need to be done twice a day, seven days a week for 12 weeks. The plan includes two exercises: the first done with the knee straightened to work the gastrocnemius and the second done with the knee bent to work the soleus. Three sets of 15 repetitions with no rest interval for each exercise are completed twice a day on the affected limb to yield functional improvement. RESULTS: The results showed that both the Alfredson protocol and the Graston technique were effective in managing AT symptoms. The study involved dividing 32 participants into two groups who received either treatment for four weeks. The main way to measure improvement was a score called the Villalta-Scanlon Achilles Tendonitis Index score. In both groups, these scores showed significant improvement (with a p-value less than 0.001, which means that the results are very statistically significant). For Group A (who received the Alfredson protocol), the average Villalta-Scanlon Achilles Tendonitis Index score before treatment was 29.25. This score increased to 31.25 at mid-treatment and 34.38 after the full four weeks of treatment. Group B (who received the Graston technique) started with an average Villalta-Scanlon Achilles Tendonitis Index score of 22.94. Their scores also increased throughout the treatment, reaching 34.94 at mid-treatment and 42.88 after four weeks. These findings provide evidence that both treatments can improve AT symptoms, with some suggestions that the Graston technique might be even more effective based on the higher average Villalta-Scanlon Achilles Tendonitis Index scores after treatment. CONCLUSIONS: The Graston technique shows promising results, particularly in the mid- and post-treatment phases, indicating its potential efficacy in comparison to the Alfredson protocol in the treatment of AT.

Endoscopic calcaneal SpeedBridge technique: Decreased postoperative complication rate in insertional achilles tendinopathy.

BACKGROUND: An endoscopic calcaneal SpeedBridge technique was described recently. The primary objective of this study was to report the postoperative complications seen with calcaneal SpeedBridge repair. The secondary objective was to report short- and medium-term functional outcomes. HYPOTHESIS: Postoperative complications are less common with endoscopic vs. open SpeedBridge suturing. MATERIAL AND METHODS: The endoscopic SpeedBridge technique was used in 9 patients who had insertional Achilles tendinopathy refractory to conservative management. The patients were evaluated at least 24 months after the procedure. Infectious and wound-healing complications were recorded. Visual analogue scale (VAS) scores for pain and patient satisfaction, shoeing difficulties, the European Foot and Ankle Society (EFAS) score, and the Victorian Institute of Sport Assessment-Achilles (VISA-A) score were assessed. RESULTS: During the mean follow-up of 25.3 months, no complications were recorded. The EFAS and VISA-A scores were 37/40 and 91/100, respectively. The mean VAS scores for pain and satisfaction were 1.7/10 and 9.3/10, respectively. No patients reported shoeing difficulties. CONCLUSION: Endoscopic calcaneal SpeedBridge suturing is associated with a lower complication rate compared to the open variant. Clinical outcomes are highly satisfactory in the short and middle terms. LEVEL OF EVIDENCE: IV; retrospective observational cohort study.

Reduced Intratendinous Sliding in Achilles Tendinopathy During Active Plantarflexion Regardless of Horizontal Foot Position.

PURPOSE: The Achilles tendon consists of three subtendons with the ability to slide relative to each other. As optimal intratendinous sliding is thought to reduce the overall stress in the tendon, alterations in sliding behavior could potentially play a role in the development of Achilles tendinopathy. The aims of this study were to investigate the difference in intratendinous sliding within the Achilles tendon during isometric contractions between asymptomatic controls and patients with Achilles tendinopathy and the effect of changing the horizontal foot position on intratendinous sliding in both groups. METHODS: Twenty-nine participants (13 Achilles tendinopathy and 16 controls) performed isometric plantarflexion contractions at 60% of their maximal voluntary contraction (MVC), in toes-neutral, and at 30% MVC in toes-neutral, toes-in, and toes-out positions during which ultrasound images were recorded. Intratendinous sliding was estimated as the superficial-to-middle and middle-to-deep relative displacement. RESULTS: Patients with Achilles tendinopathy present lower intratendinous sliding than asymptomatic controls. Regarding the horizontal foot position in both groups, the toes-out foot position resulted in increased sliding compared with both toes-neutral and toes-out foot position. CONCLUSION: We provided evidence that patients with Achilles tendinopathy show lower intratendinous sliding than asymptomatic controls. Since intratendinous sliding is a physiological feature of the Achilles tendon, the external foot position holds promise to increase sliding in patients with Achilles tendinopathy and promote healthy tendon behavior. Future research should investigate if implementing this external foot position in rehabilitation programs stimulates sliding within the Achilles tendon and improves clinical outcome.

Biomechanical consequences of Zadek osteotomy in insertional achilles tendinopathy: A virtual surgical simulation study.

BACKGROUND: The Zadek osteotomy modified by Taylor (ZO) is a surgical technique used to treat insertional Achilles tendinopathy (IAT) by reducing the heel's prominence and elevating the Achilles tendon insertion. This study aims to analyze the biomechanical consequences of IAT after ZO using a virtual surgical simulation with a specific software. METHODS: A retrospective analysis of 20 wtbearing computed tomography (WBCT) scans of IAT patients was conducted. Using Disior's BonelogicTM software, 3D models were created from WBCT images. Virtual ZO was performed on these models, and various biomechanical parameters were measured before and after the virtual osteotomy. RESULTS: The virtual ZO showed significant statistical differences in the average of the calcaneal length (p < 0.001), Fowler Philips angle (p < 0.001), calcaneal pitch (p < 0.001), and the sagittal talocalcaneal angle (p < 0.001). CONCLUSIONS: The virtual ZO analysis suggests that this procedure can decrease the Fowler Philips angle, shorten the calcaneus, modifying specifically the sagittal alignment. LEVEL OF EVIDENCE: IV; case series.

The surgical learning curve for percutaneous Zadek osteotomy for treatment of insertional achilles tendinopathy.

INTRODUCTION: The Zadek Osteotomy has been described as an effective technique for the treatment of insertional Achilles tendinopathy. Recently, this strategy has been modified using minimally invasive techniques. A learning curve has been observed in many minimally invasive procedures in foot and ankle surgery. This retrospective study first intended to evaluate if there is a learning curve associated with the percutaneous Zadek Osteotomy. Further, if a learning curve was observed, we planned to assess the data for associated changes in complications and postoperative outcomes. METHODS: A retrospective analysis of 98 patients who underwent percutaneous Zadek Osteotomy was performed. Patient charts were reviewed for operative times, complications, union rates, and Foot Function Index (FFI) and Visual Analogue Scale (VAS) scores. Analysis of variance was utilized to assess for differences between groups of cases. RESULTS: Patients included 61 females and 37 males. Mean age was 51.28 ± 11.12 (range 28-81) years. Mean follow-up time was 42.07 ± 12.99 (range 24-65) months. Significant increases in operative times were observed in cases 1-14 when compared to cases 15-98 (p < 0.001). Improvements in FFI and VAS scores were observed at final follow-up within each case group (p < 0.001); there were no differences detected in FFI or VAS scores between groups of cases. There was no difference detected in number of complications between intervals of cases. CONCLUSION: A learning curve was observed for the percutaneous Zadek Osteotomy, which was overcome around case 14. This learning curve was only observed in terms of procedure length. A surgeon's level of inexperience with the technique does not appear to affect functional outcomes, nonunion, or need for revision. LEVEL OF EVIDENCE IV: Data will not be deposited in a repository.

Gastrocnemius Release in the Treatment of Achilles Tendinopathy: A Systematic Review.

Background: The aim of this study is to evaluate the use of isolated gastrocnemius release in the treatment of Achilles tendinopathy. The primary outcome is the change in patient-reported pain outcomes. Secondary outcomes include the change in patient-reported foot and ankle function, ankle range of motion and strength, patient satisfaction and rate of surgical complications. Methods: A systematic review was undertaken of studies involving patients treated with an isolated gastrocnemius release for Achilles tendinopathy. Randomised controlled trials, cohort studies, case-control studies and case series were eligible and identified from the following databases: MEDLINE and EMBASE. Results: Isolated gastrocnemius release results in improved patient-reported outcome scores for pain and foot and ankle function. There is an increase in ankle range of motion but a reduction in ankle strength. Patients report a high rate of overall satisfaction. The most common surgical complications are sural nerve injury and wound infection. Conclusions: Isolated gastrocnemius release may offer maintained and clinically meaningful improvements in pain and foot and ankle function with an associated reduction in ankle strength.

Dorsal calcaneal wedge removal in zadek osteotomy: A cadaveric study.

BACKGROUND: Insertional Achilles tendinopathy (IAT) is a common pathology with multiple surgical interventions available for treatment. The Zadek, dorsal closing wedge calcaneal osteotomy (ZO) has been demonstrated to be effective treatment of IAT. There have been various recommendations in the literature as to what measurement of wedge removal should be considered ideal to produce greatest postoperative range of motion (ROM), thus postoperative biomechanical potential. Accordingly, the purpose of this cadaveric study was to assess the range of motion achieved after various measurements of wedge removal by ZO. METHODS: The ZO was performed on six cadaveric specimens. A 7.5 mm and 15 mm wedge osteotomy was marked and sequentially completed on each specimen. Lateral fluoroscopic imaging was utilized to take preoperative and postoperative ROM measurements for each osteotomy. Dorsiflexion (DF) and plantarflexion (PF) ROM arcs were measured for each wedge size and compared by t-test. Effect sizes were calculated by Cohen's d analysis. RESULTS: Maximal DF was 110.87 ± 12.97 deg in the pre-osteotomy state. Removal of a 7.5 mm wedge improved DF by 8 deg to a mean 102.93 ± 13.81 deg (p = 0.08). Removal of a 15 mm wedge improved DF by 16 deg to a mean 95.96 ± 11.41 deg (p = 0.003). Cohen's d and effect size calculation demonstrated a 7.5 mm wedge to have a small effect on DF, while a 15 mm wedge had a medium effect (0.29, 0.52 respectively). Maximal PF did not change significantly amongst the pre-osteotomy, 7.5 mm wedge, or 15 mm wedge positions. ICC was 0.96. CONCLUSION: Based on the results presented in this study, removal of a 15 mm wedge with ZO yields significant and greater improvement in ROM than a 7.5 mm wedge. We hope the current study will better inform preoperative planning for ZO. STUDY TYPE: Prospective Cadaver Study. LEVEL OF EVIDENCE: V.

Tran slation , cultural adap tation an d psycho metric anal ysis of U rd u ver sion of Vic torian; institu te of sp or ts ass es sme nt: Achill es quest i onnaire fo r athletes with achilles tendinopathy.

OBJECTIVE: To translate, culturally adapt and psychometrically analyse the Urdu version of the Victorian Institute of Spor t Assessment-Achilles questionnaire. METHODS: The cross-sec tional study was conducted at the Pak istan Sports Board, Lahore, Pakistan, from June 17, 2021, to February 15, 2022, and comprised patients with Achilles tendinopathy in group A and healthy controls in group B. Beaton's guidelines for cultural adaptation and validation for self-repor ted measures were followed to translate and validate the Victorian Institute of Sport Assessment-Achilles questionnaire in Urdu language. Data was analysed using SPSS 23. RESULTS: Of the 180 subjects with mean age 28.06±5.95 years, 125(69.6%) were males. There were 130(72.2%) patients in group A and 50(27.8%) controls in group B. The overall mean score of the Victorian Institute of Sport Assessment- Achille s questionnaire was 55.99±25.43; group A 41.14±9.54 and group B 94.60±4.22. The Urdu version exhibited excellent internal consistency with Cronbach's alpha values 0.95, and excellent test-retest reliability (p<0.001). Absolute reliability was expressed by standard error of measurement 5.317 and minimal detectable change (6.38). Convergent validity demonstrated strong correlation with the physical domain (r=0.81) of the Urdu version of the World Health Organisation Quality of Life Brief Version. CONCLUSIONS: The Victorian Institute of Sport Assessment-Achilles questionnaire could be utilised for assessing severity of Achilles tendinopathy among Urdu-speaking population for clinical as well as research purposes.

Cellular and Structural Changes in Achilles and Patellar Tendinopathies: A Pilot In Vivo Study.

Tendinopathies continue to be a challenge for both patients and the medical teams providing care as no universal clinical practice guidelines have been established. In general, tendinopathies are typically characterized by prolonged, localized, activity-related pain with abnormalities in tissue composition, cellularity, and microstructure that may be observed on imaging or histology. In the lower limb, tendinopathies affecting the Achilles and the patellar tendons are the most common, showing a high incidence in athletic populations. Consistent diagnosis and management have been challenged by a lack of universal consensus on the pathophysiology and clinical presentation. Current management is primarily based on symptom relief and often consists of medications such as non-steroidal anti-inflammatories, injectable therapies, and exercise regimens that typically emphasize progressive eccentric loading of the affected structures. Implementing the knowledge of tendon stem/progenitor cells (TSPCs) and assessing their potential in enhancing tendon repair could fill an important gap in this regard. In the present pilot in vivo study, we have characterized the structural and cellular alterations that occur soon after tendon insult in models of both Achilles and patellar tendinopathy. Upon injury, CD146+ TSPCs are recruited from the interfascicular tendon matrix to the vicinity of the paratenon, whereas the observed reduction in M1 macrophage polarization is related to a greater abundance of reparative CD146+ TSPCs in situ. The robust TSPCs' immunomodulatory effects on macrophages were also demonstrated in in vitro settings where TSPCs can effectively polarize M1 macrophages towards an anti-inflammatory therapeutic M2 phenotype. Although preliminary, our findings suggest CD146+ TSPCs as a key phenotype that could be explored in the development of targeted regenerative therapies for tendinopathies.

Whipping or tearing? The biomechanics of Achilles tendinopathy in rearfoot strike runners.

BACKGROUND: Two biomechanical mechanisms for the development of Achilles tendinopathy in runners have been proposed: A whipping mechanism characterized by prolonged and excessive rearfoot eversion, and a tearing mechanism characterized by high eccentric plantar flexor forces. The purpose of this pilot study was to determine if runners with and without a history of Achilles tendinopathy exhibited gait biomechanics consistent with either of these mechanisms. METHODS: Seven male runners with previous or current Achilles tendinopathy and seven healthy male control runners were evaluated by three-dimensional gait analysis. Peak rearfoot eversion angle, rearfoot eversion excursion, duration of rearfoot eversion, and peak rearfoot inversion angle were compared between groups to evaluate the whipping mechanism of injury. Peak dorsiflexion angle, peak dorsiflexion velocity, and peak ankle power absorption were compared between groups to evaluate the tearing mechanism. Additionally, rearfoot eversion angle and sagittal plane ankle power waveforms were compared between groups using statistical parametric mapping. FINDINGS: There were no differences in any rearfoot eversion, inversion, or dorsiflexion variables or waveforms during running in the Achilles tendinopathy group compared to controls. INTERPRETATION: Rearfoot strike runners with Achilles tendinopathy do not exhibit running biomechanics consistent with either the whipping or tearing mechanisms of injury.

Novel Insights Into the Intratendinous Pressure Behavior of the Achilles Tendon in Athletes.

BACKGROUND: In contrast to other musculoskeletal tissues, the normal pressure behavior of the Achilles tendon is poorly understood. This study aimed to explore the normal intratendinous and perfusion pressures of the Achilles tendon at rest and during exercise, and investigate potential correlations with tendon load and morphology. HYPOTHESIS: Intratendinous and perfusion pressures of the Achilles tendon exhibit similarities to other musculoskeletal tissues and depend on tendon load and morphology. STUDY DESIGN: Observational study. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 22 recreational athletes were enrolled. Demographics, activity level, and blood pressures were recorded. Achilles tendon thickness and echogenicity were assessed 25 mm proximal to the posterosuperior calcaneal border. In this region, intratendinous and perfusion pressures of the Achilles tendon were measured at rest and during isometric plantarflexion up to 50 N, using the microcapillary infusion technique. Linear mixed models were used to investigate the effects of plantarflexion force, tendon thickness, and echogenicity on intratendinous and perfusion pressures. RESULTS: At rest, intratendinous and perfusion pressures of the Achilles tendon were 43.8 ± 15.2 and 48.7 ± 18.4 mmHg, respectively. Intratendinous pressure increased linearly with plantarflexion force, reaching 101.3 ± 25.5 mmHg at 50 N (P < 0.01). Perfusion pressure showed an inverse relationship, dropping below 0 mmHg at 50 N (P < 0.01). Neither intratendinous nor perfusion pressures of the Achilles tendon correlated with tendon thickness or echogenicity. CONCLUSION: The normal intratendinous resting pressure of the Achilles tendon is higher than other musculoskeletal tissues, making it more susceptible to ischemia. During exercise, intratendinous pressure increases significantly to a level that lowers perfusion pressure, thereby compromising blood supply at already low plantarflexion forces. CLINICAL RELEVANCE: Given the potential role of ischemia in Achilles tendinopathy, our findings caution against intratendinous injections, as they may exacerbate high intratendinous resting pressure, and against prolonged postexercise tendon stretching, as the associated rise in intratendinous pressure may impair the required hyperemic response.

A pilot study exploring the use of hyaluronic acid in treating insertional achilles tendinopathy.

PURPOSE: This study explores the use of ultrasound-guided Hyaluronic Acid (HA) injections for Insertional Achilles Tendinopathy (IAT). METHODS: A cohort of 15 ankles diagnosed with IAT received three weekly ultrasound-guided HA injections. The Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire scored the severity of symptoms and functional impairment before treatment, and at one and six months post-treatment. RESULTS: Significant improvement was observed in VISA-A scores post-treatment, rising from an average baseline of 34.8 ± 15.2 (11-63) to 53.6 ± 20.9 (15-77) after one month, and then to 50.7 ± 18.6 (20-75) after six months. No adverse reactions were noted, underscoring the safety of the intervention. CONCLUSION: The pilot study presents HA injections as a potentially effective treatment for IAT, while interpretation of these findings must take into account the variability in results, indicating a range of patient responses. It encourages further research to confirm these findings and to explore HA's full potential in managing IAT, despite the limitations of a small sample size and lack of control group.

Elevated fluid and glycosaminoglycan content in the Achilles tendon contribute to higher intratendinous pressures: Implications for Achilles tendinopathy.

BACKGROUND: Tendinopathy alters the compositional properties of the Achilles tendon by increasing fluid and glycosaminoglycan content. It has been speculated that these changes may affect intratendinous pressure, but the extent of this relationship remains unclear. Therefore, we aimed to investigate the impact of elevated fluid and glycosaminoglycan content on Achilles tendon intratendinous pressure and to determine whether hyaluronidase (HYAL) therapy can intervene in this potential relationship. METHODS: Twenty paired fresh-frozen cadaveric Achilles tendons were mounted in a tensile-testing machine and loaded up to 5% strain. Intratendinous resting (at 0% strain) and dynamic pressure (at 5% strain) were assessed using the microcapillary infusion technique. First, intratendinous pressure was measured under native conditions before and after infusion of 2 mL physiological saline. Next, 80 mg of glycosaminoglycans were administered bilaterally to the paired tendons. The right tendons were additionally treated with 1500 units of HYAL. Finally, both groups were retested, and the glycosaminoglycan content was analyzed. RESULTS: It was found that both elevated fluid and glycosaminoglycan content resulted in higher intratendinous resting and dynamic pressures (p < 0.001). HYAL treatment induced a 2.3-fold reduction in glycosaminoglycan content (p = 0.002) and restored intratendinous pressures. CONCLUSION: The results of this study demonstrated that elevated fluid and glycosaminoglycan content in Achilles tendinopathy contribute to increased intratendinous resting and dynamic pressures, which can be explained by the associated increased volume and reduced permeability of the tendon matrix, respectively. HYAL degrades glycosaminoglycans sufficiently to lower intratendinous pressures and may, therefore, serve as a promising treatment.

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.

Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy, Calcaneus, Syndrome, Insertional, Achilles tendon, and Tendinopathy. Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Medial arch instability/internal foot overload association with non-insertional Achilles tendinopathy and the 'Zone of Conflict Theory'.

BACKGROUND: Non insertional Achilles tendinopathy [AT] is a degenerative condition that is prevalent in runners. 30% have no preceding history and many runners do not develop AT. Overuse, pronation, and compromised blood supply are hypothesised as causal. The exact precipitant is still unknown. The link between medial arch instability and AT has not been made. The purpose of this study was to investigate the association between spring ligament (SL) laxity and first ray (FRI) instability, and the presence of (AT). METHODS: Ethical approval was obtained. Patients were identified from hospital databases for unilateral AT, allowing the opposite unaffected foot to be used as an internal control. SL laxity was measured using the lateral translation score and FRI was measured using a modified digital Klauemeter. Ultrasound was used to assess the tendoachilles [TA] in affected vs unaffected legs. RESULTS: 17 patients were recruited with a mean age of 55.6 and mean body mass index (BMI) of 33.3. The average symptom duration was 3.62 years. There were 12 left feet and 5 right feet. There was no statistical difference in dorsiflexion angles for the TA or the gastrocnemius. All Beighton scores < 5. Lateral translation scores, FRI scores and TA thickness was significantly greater in AT feet [p < 0.05]. More affected feet had Tibialis posterior tendon pain (TP) [p < 0.05]. CONCLUSIONS: Feet with AT exhibit higher lateral translation scores and greater FRI compared to healthy feet, and combined with previous literature evidence, suggests alteration of the subtalar axis alters force moments that may lead to an intrinsic overload of the TA, when the foot enters a "zone of conflict". Medial arch instability, in particular SL laxity and FRI, may contribute to the development of non-insertional AT and treatment of this with early arch support may prevent progressive degeneration.

An Achilles Tendinopathy Educational Intervention for Generalist Physicians Raises Awareness and Improves Knowledge for Treating Ballet Dancers.

BACKGROUND: Achilles tendinopathy can be a devastating condition in ballet dancers. Initial medical evaluation is frequently conducted by generalist physicians, who may lack the perspective of dance and sports medicine focused training and often prescribe complete rest for chronic overuse injuries. In order to provide targeted information about Achilles tendinopathy and the unique needs of elite athletes, such as ballet dancers, we designed an educational intervention that covers relevant anatomy, physiology, biomechanics, clinical presentation and evaluation, and recommendations for initial treatment and sub-specialty referral. The objectives of this study were to determine baseline understanding of Achilles tendinopathy by generalist physicians and to evaluate the efficacy of an educational intervention on their knowledge. METHODS: This was a prospective pre- post-test study, to measure improvement in knowledge about Achilles tendinopathy. Emergency Medicine and Primary Care physicians participated in an educational intervention with didactic and hands-on components. Data were analyzed using a two-tailed t-test. RESULTS: Twenty generalist physicians participated. There was significant improvement in their knowledge of Achilles tendinopathy for all our educational objectives (Pre-test: 59% correct answers; post-test: 79% correct answers; P < .0001; 95% CI: 6.32-10.78.). CONCLUSIONS: A brief educational intervention leads to increased knowledge of Achilles tendinopathy in generalist physicians. By increasing awareness of Achilles tendinopathy through a standard educational model, we propose that our curriculum can be portable and accessible to all health care providers who encounter dancers and other athletes with Achilles tendinopathy and may serve as a model for expanded education to generalists about other conditions commonly encountered in ballet dancers.