High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up.

The aim of this study was to investigate the effectiveness of shoe inserts and plantar fascia-specific stretching vs shoe inserts and high-load strength training in patients with plantar fasciitis. Forty-eight patients with ultrasonography-verified plantar fasciitis were randomized to shoe inserts and daily plantar-specific stretching (the stretch group) or shoe inserts and high-load progressive strength training (the strength group) performed every second day. High-load strength training consisted of unilateral heel raises with a towel inserted under the toes. Primary outcome was the foot function index (FFI) at 3 months. Additional follow-ups were performed at 1, 6, and 12 months. At the primary endpoint, at 3 months, the strength group had a FFI that was 29 points lower [95% confidence interval (CI): 6-52, P = 0.016] compared with the stretch group. At 1, 6, and 12 months, there were no differences between groups (P > 0.34). At 12 months, the FFI was 22 points (95% CI: 9-36) in the strength group and 16 points (95% CI: 0-32) in the stretch group. There were no differences in any of the secondary outcomes. A simple progressive exercise protocol, performed every second day, resulted in superior self-reported outcome after 3 months compared with plantar-specific stretching. High-load strength training may aid in a quicker reduction in pain and improvements in function.

Ultrasonographic assessment of tendon thickness, Doppler activity and bony spurs of the elbow in patients with lateral epicondylitis and healthy subjects: a reliability and agreement study.

PURPOSE: Tennis elbow, also known as lateral epicondylitis (LE), is a common disorder often assessed by ultrasound. The aim of this study was to evaluate the ultrasonographic outcomes and methods used in LE research and clinical practice. MATERIALS AND METHODS: This study was designed as an intra- and interobserver reliability and agreement study. Ultrasonographic examination of the common extensor tendon of the elbow was performed. The intraobserver study examined tendon thickness twice in 20 right elbows from 20 healthy individuals at an interval of 7 to 12 days. The interobserver study examined tendon thickness, color Doppler activity, and bony spurs in 18 right elbows in 9 healthy individuals and 9 patients with LE. Two trained rheumatologists performed the interobserver examinations with the same scanner on the same day. The main outcomes were intra- and interclass correlation (ICC) and agreement. RESULTS: In the intraobserver study, the ICC with regard to tendon thickness ranged from 0.76 to 0.81, depending on the measurement techniques used. The agreement ranged from 0.06 to 0.13 mm. In the interobserver study, the tendon thickness ICC ranged from 0.45 to 0.65 and the agreement ranged from -0.17 to 0.13 mm. The ICC for color Doppler activity was 0.93, with agreement in 14/18 (78 %) of the cases. A perfect reliability was demonstrated for bony spurs, with an ICC of 1 and exact agreement in 18/18 (100 %) of the cases. CONCLUSION: Good to excellent reliability was obtained for all measurements. The ultrasonographic techniques evaluated in this trial can be recommended for use in both research and clinical practice.

Sonoelastography as a diagnostic tool in the assessment of musculoskeletal alterations: a systematic review.

UNLABELLED: Elasticity imaging is a relatively new ultrasound-based technique for investigating musculoskeletal injury. Sonoelastography (SEL), the most commonly used technique, allows determination of the elastic properties of tissue by applying pressure. PURPOSE: To critically evaluate the literature regarding the use of SEL in the diagnosis of tendon and muscle alterations. MATERIALS AND METHODS: This review includes a systematic literature search performed on major electronic databases. Eight articles were included. The GRADE approach was used to evaluate the quality of evidence presented in the included articles and the strength of their recommendations. RESULTS: The results on human tendon disorders showed that the SEL findings correlated extremely well with conventional ultrasound (US) findings as well as with magnetic resonance imaging (MRI) and clinical examination. In some articles SEL was found to be even more sensitive than conventional ultrasound and in addition capable of identifying subclinical alterations that conventional ultrasound could not. For skeletal muscle, a close correlation between SEL and US and MRI was found, although there is only one article on the topic. SEL was found to be able to distinguish between healthy and diseased muscles and was potentially more sensitive in identifying early dystrophic changes than US or MRI. CONCLUSION: Based on this critical evaluation of the literature, SEL seems to be at least as feasible as US and MRI for assessing tendon alterations and able to identify subclinical tendon alterations not visible with conventional US.  The findings in the reviewed articles suggest that SEL could become a supplementary imaging technique in the assessment of musculoskeletal alterations, potentially superior to US and MRI. Until more studies are available, SEL has to be viewed as an experimental examination without sufficient supporting evidence to be used as a routine examination equivalent to US and MRI.

Effect of ultrasound-guided, peritendinous injections of adalimumab and anakinra in chronic Achilles tendinopathy: a pilot study.

A new review suggested that an inflammatory process may be related to the development of tendinopathy and that the inflammation may also play a role in chronic tendinopathy. Hitherto, peritendinous injections of glucocorticosteroids have been used to reduce the inflammation. In an attempt to reduce the possible side effects and the high frequency of relapse of symptoms after local treatments with glucocorticosteroids, new anti-inflammatory treatments were tested. Ultrasound-guided, peritendinous injections of adalimumab (tumor necrosis factor -alpha blocker) and anakinra (interleukin-1 receptor antagonist) were evaluated with regard to reducing pain, tendon thickness, and the blood flow in chronic Achilles tendinopathy. We found in this small pilot study that peritendinous injections of adalimumab had a significant effect on pain sensation at rest in chronic Achilles tendinopathy. Adalimumab had no effect on tendon thickness and contrary to all expectation, the tendon thickness in the anakinra-treated patients increased significantly after 12 weeks. Adalimumab showed a significant tendency to reduce the blood flow in the tendon over 12 weeks, whereas anakinra had no effect on the blood flow.

Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation.

Continuing progress in research in molecular biology and biomechanics has provided considerable new information and has given rise to new hypotheses in chronic tendinopathy. Overloading is still, however, crucial in the development of tendinopathy. Most of the histologic findings in tendinopathy represent chronic degeneration, regeneration, and microtears of the tendinous tissue. The prevailing opinion is that no histological evidence of acute inflammation has been documented, but in newer studies using immunohistochemistry and flow cytometry inflammatory cells have been detected. The existing data indicate that the initiators of the tendinopathic pathway include many proinflammatory agents (e.g. cytokines, prostaglandins, different growth factors, and neuropetides). Because of the complex interaction between the classic proinflammatory agents and the neuropeptides, it seems impossible and somewhat irrelevant to distinguish sharply between chemical and neurogenic inflammation. Furthermore, glucocorticoids are, at the moment, the most effective treatment in tendinopathy with regard to reduction of pain, tendon thickness, and neovascularization. This review indicates - despite a great deal of uncertainty regarding the concepts - that an inflammatory process may be related not only to the development of tendinopathy but also chronic tendinopathy. More attention should be directed towards the "tendinitis myth" in the future.

Ultrasonography in evaluation of Achilles and patella tendon thickness.

UNLABELLED: Despite the general acknowledgement that measurement of tendon thickness by ultrasonography (US) is an integral part of clinical examination of tendons in both symptomatic and asymptomatic athletes, there is no consensus on where and how the tendons should be measured. PURPOSE: This study aims to evaluate the Achilles and patellar tendons by ultrasonography with the intention of establishing a consensus for measuring the thickness of Achilles and patellar tendons in future studies. MATERIALS AND METHODS: This study includes three sub-studies, evaluating: 1. Achilles and patellar tendon thickness in relation to the distance from the attachment at the calcaneus or patella, 2. longitudinal versus transversal US scan for measurement of the tendon thickness by examining the tendons in both longitudinal and transversal scan planes twice by the same observer, and 3. differences in tendon thickness using three different US measurement methods, when measuring both the sagittal AP thickness and the "true" thickness (measured perpendicular to the greatest width) twice by the same observer. A total of 209 tendons were included. RESULTS: Normal Achilles tendons have the same thickness in the distal 5 cm-long section. Patellar tendons are more cone-shaped proximally. There is no significant difference between the longitudinal and transversal scan except when applied on abnormal patellar tendons. The tendon thickness and coefficient of variation is smaller when measuring the true thickness compared to the AP thickness. CONCLUSION: The true tendon thickness is less than the AP thickness, because the AP-thickness is dependent upon the rotation of the tendon. Moreover, the true thickness is a more precise measurement. In future measurements, the true thickness of tendons could be measured in either transversal or longitudinal scan. When measuring abnormal patellar tendons, however, it is necessary to apply a longitudinal scan as this is the only method allowing the examiner to record the distance from the point where the thickness is measured to the bony attachment. The measurement can thereby be repeated at exactly the same point during subsequent controls.

Ultrasonography as a tool for diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the treatment of athletes with chronic jumper's knee and Achilles tendinitis: a randomized, double-blind, placebo-controlled study.

BACKGROUND: The diagnosis of Achilles and patella tendinitis has until recently been based on clinical examination, and treatment with local steroid injection has been given blindly. This is the first randomized, double blind, placebo-controlled study of local steroid injection in athletes with chronic tendinitis, which used ultrasonography to increase diagnostic accuracy, to guide the correct placement of local steroid and, conjunctively with pressure algometry, to objectify and monitor the results of treatment. METHOD: Forty-eight athletes each with severe symptomatic tendinitis of a patellar (24) or Achilles tendon (24) for more than 6 months, whose conditions were confirmed ultrasonographically, and who all failed conservative treatment (rehabilitation) were included in this double-blind, placebo-controlled study and treated with three ultrasonographically guided peritendinous injections of steroid or placebo. RESULTS: The conditions of only one-third of the referred athletes with clinically suspected tendinitis were confirmed by ultrasonographic examination. The ultrasonographically guided peritendinous injection of steroid had a significant effect in reducing pain and thickening of tendons. CONCLUSION: Ultrasonography should be used in the future to assure precise diagnosis and to guide the peritendinous injection of steroid in chronic Achilles and patella tendinitis. Ultrasonography and pressure algometry are recommended as objective methods for monitoring the effect of treatment. Ultrasonographically guided injection of long-acting steroid can normalize the ultrasonographic pathological lesions in the Achilles and patellar tendons, and has a dramatic clinical effect but when combined with aggressive rehabilitation with running after a few days, many will have relapse of symptoms within 6 months.

Traumatic arthritis in sport.

After the introduction of ultrasonography in sports medicine, traumatic arthritis is recognized relatively frequently among athletes. In this case study, the ultrasonographic findings and the prompt effect of ultrasonographically guided intra-articular injection of long-acting steroid are demonstrated in two patients.

Jumper's knee. Review of the literature.

Jumper's knee is an overuse disease. The initial subjective complaints are well-localized pain, usually occurring after physical activities and often at the lower pole of the patella. The diagnosis of jumper's knee is usually easily established after acquiring a detailed history and a carefully performed physical examination, but the lesion can be mistaken for other disorders or injuries, such as bursitis, meniscal injuries or chondromalacia (1) or other causes of the patellofemoral pain syndrome. Today ultrasonography is the method of choice for the evaluation of jumper's knee as it is both time and cost saving, non-invasive, repeatable, accurate and allows a dynamic image of the tendon, guided injections and control of treatment. Conservative therapy is the treatment of choice in the early stages and includes adequate warm-up, stretching of the quadriceps muscle and physical activity with respect to the pain, and ice pack application after activity. When the pain disappears, the training intensity can be increased. NSAID (Non-Steroidal Anti-Inflammatory Drugs) and local peritendinous injections with long-acting steroids can be a helpful and safe adjuvant to the conservative treatment and should be tried before surgery. Surgical treatment is indicated only if a prolonged and well-supervised conservative treatment program fails in chronic jumper's knee (including local injection with steroid) or in acute total rupture. Review papers concerning jumper's knee are already published (2-5), but in this review the importance of ultrasonography to make the diagnosis, to plan therapy and control the treatment and the safety of peritendinous injection with steroid is pointed out. The scientific documentation for the recommanded treatment (conservative, steroid injection and operation) is, however, insufficient. Many more controlled studies are needed. Ultrasonography and placebo-controlled, double-blinded, cross-over studies for treatment with local injection of steroid are ongoing (6, 7).

Home treatment with recombinant activated factor VII: results from one centre.

Haemophilia patients developing an inhibitor against factor VIII (FVIII) or FIX require alternative treatment for the management of their bleeding, rather than standard procedures. In patients with low titre inhibitors, increased doses of FVIII or FIX may improve haemostasis. If a higher titre is present, a porcine FVIII concentrate may be efficacious in selected cases. 'Bypassing' agents, such as low purity FIX concentrates, or activated or unactivated concentrates of prothrombin complex may also be useful in inhibitor patients. An activated factor VII molecule (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark), has been produced by recombinant DNA cell technology. In June 1994, we established a home treatment programme with rFVIIa for five inhibitor patients to study its efficacy in the early intervention of bleeding episodes; our results from the first 3 years are presented. Self-treatment in the home took place in 50 instances of acute minor bleeding. A mean of 2.02 doses of rFVIIa (each dose of about 90 microg/kg bodyweight) was required to arrest bleeding (range 1-4 doses). Four bleeding episodes required in-hospital management either because the acute condition was caused by severe trauma, or because treatment had not been instituted in the early phase of bleeding. Here, the range of rFVIIa doses was 4-37. For comparison, we also report 36 minor bleeding episodes managed in-hospital in three of these five patients who participated in the Compassionate Use Study where home treatment was not permitted. These bleeding episodes required considerably more administrations of rFVIIa with a mean consumption of 8 doses in joint bleeds and 9.5 doses in muscle and soft tissue bleeds. In conclusion, we feel that our home treatment results strongly suggest that early intervention by home treatment with rFVIIa in acute minor bleeding is efficacious and cost effective.

Local corticosteroid injection in sport: review of literature and guidelines for treatment.

The risks and benefits of local injection therapy of overuse sports injuries with corticosteroids are reviewed here. Injection of corticosteroid inside the tendon has a deleterious effect on the tendon tissue and should be unanimously condemned. No reliable proof exists of the deleterious effects of peritendinous injections. Too many conclusions in the literature are based on poor scientific evidence and it is just the reiteration of a dogma if all steroid injections are abandoned. The corticosteroids represent an adjuvant treatment in the overall management of sports injuries: basic treatment is 'active' rest and graduated rehabilitation within the limits of pain. With proper indications there are only few and trivial complications that may occur with corticosteroid injections. Guidelines for proper local injection therapy with corticosteroids are given.

[Injury pattern in a sports club with its own sports physician]. / Skademønsteret i en idraetsklub med egen idraetslaegeordning.

As the first Danish athletic association, TST-79 in 1995 appointed a permanent sports doctor for use by all its members. We publish the results of the first year. Seventeen percent of all handball players and 11% of all football players were seen in the consultation. The athletes were between 10 and 69 years old. Seventy-eight percent of the injured athletes could be diagnosed, instructed and, if necessary, treated after one consultation. Eight percent were sent for further examination at a hospital. Ultrasound examinations were necessary for establishing the diagnosis in 10% of the injured athletes. Some of the injuries were serious, and would probably not have been seen if the athletes did not have the possibility of consulting a sports doctor. This would increase the risk of chronic injury. It is suggested that a permanent arrangement with a sports doctor is an economically reasonable investment.

Use of recombinant factor VIIa in surgery in factor-VII-deficient patients.

Patients suffering from severe factor VII deficiency may present with serious bleeding problems. No clear guidelines exist regarding therapy in such patients in case of a large bleeding or surgery. Indeed, it has been postulated that some patients with severe factor VII deficiency may never present with overt bleeding problems. However, in factor-VII-deficient patients who have previously demonstrated a clinical tendency to bleed, surgery is expected to cause excessive bleeding. We present two females suffering from a severe factor VII deficiency (FVII:C < 0.01 U mL(-1) ) with a distinct history of haemorrhagic diathesis. Due to recurrent bleeding in the past, or for circumstantial reasons, surgery was demanded over a 4-year period on a total of seven occasions. To assist haemostasis during and after joint surgery on five occasions and for embolization and subsequent removal of a large haemangioma of the occipital region, recombinant factor VIIa (NovoSeven) was utilized in doses approximating 20 µg kg(-1) b.w. every 6 h beginning immediately before surgery and continued until 30 h to 13 days postoperatively, depending of the size of the respective procedure. Using this approach, we observed normal haemostasis, and there were no signs of excessive postoperative bleeding or wound haematoma. No adverse reactions or side-effects were observed, and there were no complaints or clinical signs indicative of thrombotic complications. As judged from the clinical course of these seven minor and major surgeries, recombinant factor VIIa appears to be highly efficaceous and safe in the treatment patients with severe factor VII deficiency undergoing surgery.

Variability of the factor VIII response to DDAVP in a large kindred with mild haemophilia A.

Since 1977, desmopressin acetate (DDAVP) has established its important role in the clinical management of bleeding in milder cases of von Willebrand's disease and haemophilia A. We present in vivo DDAVP response data from a large kindred suffering from mild haemophilia A. Levels of FVIII: C in 22 affected family members ranged from 0.11 to 0.24 IU mL(-1) of FVIII: C (0.18 ± 0.04, mean ± SD), increasing to 0.22-0.92 IU mL(-1) after DDAVP, giving a mean response ratio of 3.5. Response rates by various routes of administration did not differ significantly, being 3.3 for subcutaneous administration (n= 17), 3.7 for intravenous administration (n= 4) and 3.2 for intranasal spray application (n= 1). No significant correlation was found between the pretreatment level and the response rate. In three individuals, the post-DDAVP level of FVIII: C was below 0.40 IU mL(-1) , the value we arbitrarily regard as the lower limit of a successful response for haemostatic efficacy suited for self-management purposes, demonstrating that the response rate in a given member of the family cannot be predicted from previous experiences with other haemophilic members of the same subset.

The sportsman's hernia--fact or fiction?

This review is based on the results of 308 operations for unexplained, chronic groin pain suspected to be caused by an imminent, but not demonstrable, inguinal hernia: the 'sportsman's hernia' (SH). No differences in perioperative findings between cured and non-cured athletes were found. However, there was a remarkable difference between the various perioperative findings in the studies. It was characteristic that further clinical investigation of the noncured, operated athletes gave an alternative and treatable diagnosis in more than 80% of cases. Herniography was used consistently in the diagnostic process in all the studies on SH. However, in 49% of cases hernias were also demonstrated on the opposite, asymptomatic groin side. In conclusion, the final diagnosis (and treatment) often reflects the speciality of the doctor and the present literature does not supply proper evidence to the theory that SH constitutes a credible explanation for chronic groin pain.

Ultrasound in the diagnosis and treatment of iliopsoas tendinitis: a case report.

Ultrasound examination is a recognized advanced tool in the diagnosis of many sport-related overuse injuries. This article illustrates a new indication for ultrasound examination: the diagnosis of iliopsoas tendinitis and its treatment by ultrasound-guided local injection of long-acting corticosteroid.

[Iliopsoas tendinitis in athletes. Diagnosis and treatment]. / Iliopsoastendinitis i sport. Diagnose og behandling.

Iliopsoas tendinitis is a common injury in sport. Despite of this there are only a few articles in the literature that deal with these injuries. The changes in the inflamed tendons and muscles have been difficult to determine objectively. The modernization of ultrasound devices has improved the methods of examination and made it possible to diagnose objective changes in the tendons and muscles. Recommendations for the treatment of acute and chronic iliopsoas tendinitis are given.