Do physical tests have a prognostic value in chronic midportion Achilles tendinopathy?

OBJECTIVES: To determine whether baseline physical tests have a prognostic value on patient-reported outcomes in Achilles tendinopathy. DESIGN: Prospective cohort study, secondary analysis of data from a randomized trial. METHODS: Patients with chronic midportion Achilles tendinopathy performed a progressive calf muscle exercise program. At baseline and after 2, 6, 12 and 24 weeks, patients completed the Victorian Institute of Sports Assessment-Achilles questionnaire and performed the following physical tests: ankle dorsiflexion range of motion with a bent knee or an extended knee, calf muscle strength, jumping height and pain on palpation (Visual Analogue Scale; 0-100) and after 10 hops (Visual Analogue Scale-10-hops). Associations between baseline test results and improvement (Victorian Institute of Sports Assessment-Achilles scores) were determined using a Mixed Linear Model. RESULTS: 80 patients were included. The mean Victorian Institute of Sports Assessment-Achilles score improved 20 points (95 % confidence interval, 16-25, P < .001) after 24 weeks. There were significant associations between the baseline ankle dorsiflexion range of motion with a bent knee (ß 0.2, 95 % confidence interval 0.001 to 0.3, P = .049), the baseline pain provocation tests (Visual Analogue Scale palpation: ß -0.2; 95 % confidence interval: -0.4 to -0.1; P < .001, Visual Analogue Scale-10-hops: ß -0.3; 95 % confidence interval: -0.4 to -0.2; P < .001) and the change in the Victorian Institute of Sports Assessment-Achilles score. CONCLUSIONS: In patients with chronic midportion Achilles tendinopathy, easy-to-perform pain provocation tests have a clinically relevant prognostic value on patient-reported improvement. Patients with less pain during pain provocation tests at baseline have a better improvement in pain, function and activities after 24 weeks than patients with high baseline pain scores.

Do High-Volume Injections Affect the Ultrasonographic Neovascularization in Chronic Achilles Tendinopathy? A Randomized Placebo-Controlled Clinical Trial.

OBJECTIVE: High-volume injections (HVIs) are thought to target neovascularization in chronic midportion Achilles tendinopathy (AT), yet the mechanism has not been clarified. Therefore, we aim to evaluate whether a HVI decreases ultrasonographic Doppler flow in patients with chronic midportion AT. DESIGN: A double-blind, randomized, placebo-controlled clinical trial. SETTING: Sports medicine department at a district general hospital. PATIENTS: Sixty-two patients with clinically diagnosed chronic midportion AT were included and randomized into the intervention group (HVI-group, n = 30) and placebo group (n = 32). INTERVENTION: A daily calf-muscle exercise program combined with either (1) a HVI (HVI-group: 50 mL) or (2) a placebo-injection (placebo-group: 2 mL) with a mixture of saline and lidocaine. MAIN OUTCOME MEASURES: Primary outcome was the surface area quantification (SAQ) score (%) of the Doppler flow during a 24-week follow-up period. Secondary outcome was the association between SAQ scores and symptoms [Victorian Institute of Sports Assessment-Achilles (VISA-A)]. Outcomes were measured before, directly after, and 1 hour after the injection and at 2, 6, 12, and 24 weeks of follow-up. RESULTS: There was no significant between-group difference at 24 weeks [-0.1%; 95% confidence interval (CI), -4.9 to 4.7] or at any of the other time points. Change in SAQ score did not correlate with the change in VISA-A score (P = 0.93). CONCLUSION: A HVI does not affect Doppler flow in patients with chronic midportion AT. Also, changes in Doppler flow were not associated with the clinical outcome. These findings challenge the theoretical basis of a HVI. TRIAL REGISTRATION: NCT02996409.

Victorian Institute of Sport Assessment-Achilles (VISA-A) Questionnaire-Minimal Clinically Important Difference for Active People With Midportion Achilles Tendinopathy: A Prospective Cohort Study.

OBJECTIVE: To determine the minimal clinically important difference (MCID) for the Victorian Institute of Sport Assessment-Achilles (VISA-A) score in patients with midportion Achilles tendinopathy (AT). DESIGN: Prospective cohort study. METHODS: We included physically active patients with midportion AT who received exercises and an injection. We measured the VISA-A score (ranging from 0 to 100 points, where 100 points represents a healthy tendon) at baseline and at 12 weeks and 24 weeks after treatment, and the 7-point Global Assessment Scale (ranging from "worse than ever" to "completely recovered") at 12 weeks and 24 weeks after treatment. We dichotomized the Global Assessment Scale to not improved ("worse than ever" to "unchanged") or improved ("moderately improved" to "completely recovered"). The area under the curve and the Youden's index value closest to 1 were determined for both MCIDs (12 and 24 weeks), with corresponding sensitivity and specificity. RESULTS: Sixty-four patients were included, and 61 patients (95%) completed the 24-week follow-up. The MCID was 14 points (95% confidence interval [CI]: 3, 19) over a 12-week period, corresponding to 57% sensitivity and 88% specificity. The MCID was 7 points (95% CI: -10, 28) over a 24-week period, with 85% sensitivity and 62% specificity. CONCLUSION: A change in VISA-A score of at least 14 points after 12 weeks or at least 7 points after 24 weeks of exercise therapy and an injection reflects a meaningful change for physically active patients with midportion AT. J Orthop Sports Phys Ther 2021;51(10):510-516. doi:10.2519/jospt.2021.10040.

Are pain coping strategies and neuropathic pain associated with a worse outcome after conservative treatment for Achilles tendinopathy? A prospective cohort study.

OBJECTIVES: To analyse whether (1) passive or active pain coping strategies and (2) presence of neuropathic pain component influences the change of Achilles tendinopathy (AT) symptoms over a course of 24 weeks in conservatively-treated patients. DESIGN: Prospective cohort study. METHODS: Patients with clinically-diagnosed chronic midportion AT were conservatively treated. At baseline, the Pain Coping Inventory (PCI) was used to determine scores of coping, which consisted of two domains, active and passive (score ranging from 0 to 1; the higher, the more active or passive). Presence of neuropathic pain (PainDETECT questionnaire, -1 to 38 points) was categorized as (a) unlikely (≤12 points), (b) unclear (13-18 points) and (c) likely (≥19 points). The symptom severity was determined with the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire (0-100) at baseline, 6, 12 and 24 weeks. We analysed the correlation between (1) PCI and (2) PainDETECT baseline scores with change in VISA-A score using an adjusted Generalized Estimating Equations model. RESULTS: Of 80 included patients, 76 (95%) completed the 24-weeks follow-up. The mean VISA-A score (standard deviation) increased from 43 (16) points at baseline to 63 (23) points at 24 weeks. Patients had a mean (standard deviation) active coping score of 0.53 (0.13) and a passive score of 0.43 (0.10). Twelve patients (15%) had a likely neuropathic pain component. Active and passive coping mechanisms and presence of neuropathic pain did not influence the change in AT symptoms (p=0.459, p=0.478 and p=0.420, respectively). CONCLUSIONS: Contrary to widespread belief, coping strategy and presence of neuropathic pain are not associated with a worse clinical outcome in this homogeneous group of patients with clinically diagnosed AT.

Impact of chronic Achilles tendinopathy on health-related quality of life, work performance, healthcare utilisation and costs.

OBJECTIVES: To evaluate the impact of Achilles tendinopathy (AT) on quality of life (QoL), work performance, healthcare utilisation and costs in adults with conservatively treated chronic midportion AT. METHODS: This cross-sectional survey-based study included 80 patients and took place in a sports medicine department of a large regional hospital in the Netherlands. Data were collected before any intervention was given. Primary outcome was the EuroQol questionnaire (EQ-5D). The EQ-5D expresses the percentage of moderate/major problems on the domains self-care, anxiety/depression, mobility, usual activities and pain/discomfort. Secondary outcomes were the number of previous healthcare visits, work performance during the period of symptoms and estimated annual direct medical and indirect costs per patient as a result of AT. RESULTS: All 80 patients completed the questionnaires. The EQ-5D scores were low for the domains self-care (1%) and anxiety/depression (20%), and high for the domains mobility (66%), usual activities (50%) and pain/discomfort (89%). Patients with AT mainly reported an impact on work productivity (38%). Work absenteeism due to AT was present in 9%. The total median (IQR) number of annual healthcare visits was 9 (3-11). The total mean (SD) estimated annual costs were €840 (1420) per patient with AT (mean (SD) US$991 (1675)). CONCLUSIONS: This study shows the large impact of AT on QoL and work productivity. This study also provides new information about the socioeconomic impact of AT, which emphasises that this common and longstanding disease causes substantial costs. These findings stress the need for optimised treatment and improved preventive interventions for AT. TRIAL REGISTRATION NUMBER: NCT02996409.

Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial.

OBJECTIVE: To study whether a high volume injection without corticosteroids improves clinical outcome in addition to usual care for adults with chronic midportion Achilles tendinopathy. DESIGN: Patient and assessor blinded, placebo controlled randomised clinical trial. SETTING: Sports medicine department of a large district general hospital, the Netherlands. PARTICIPANTS: 80 adults (aged 18-70 years) with clinically diagnosed chronic midportion Achilles tendinopathy and neovascularisation on ultrasonography. 39 were randomised to a high volume injection without corticosteroids and 41 to placebo. INTERVENTIONS: Participants were instructed to perform an exercise programme for 24 weeks (usual care) combined with one 50 mL high volume injection of saline and lidocaine (intervention group) or one 2 mL placebo injection of saline and lidocaine (placebo group) at baseline. MAIN OUTCOME MEASURES: Primary outcome was pain and function assessed using the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire at 24 weeks (analysed using a generalised estimation equations model). Secondary outcomes were patient satisfaction, return to sport, degree of ultrasonographic Doppler flow, visual analogue scale on 10 hop test, power and flexibility of the gastrocnemius and soleus muscles, pain detect questionnaire for neuropathic pain, and pain coping inventory. Participants were evaluated at baseline and at 2, 6, 12, and 24 weeks. RESULTS: Only one participant (1%) was lost to follow-up. The estimated mean VISA-A score improved significantly, from 40.4 (95% confidence interval 32.0 to 48.7) at baseline to 59.1 (50.4 to 67.8) at 24 weeks in the high volume injection group and from 36.9 (27.1 to 46.8) to 58.5 (47.9 to 69.1) in the placebo group. The VISA-A score over time did not differ between the groups (adjusted between group difference at 24 weeks 0.5 points, 95% confidence interval -17.8 to 18.8). No significant between group differences were found for patient satisfaction (21/37 (57%) v 19/39 (49%) patients, P=0.50) and return to desired sport (15/29 (52%) v 19/31 (61%) patients active in sports, P=0.65) at 24 weeks. None of the other secondary outcomes differed between the two groups. CONCLUSIONS: A high volume injection without corticosteroids in addition to usual care is not effective for symptom reduction in patients with chronic midportion Achilles tendinopathy. On the basis of our findings, we cannot recommend the use of a high volume injection in this patient group. TRIAL REGISTRATION: ClinicalTrials.gov NCT02996409.

Rare case of a traumatic myositis ossificans in the tibialis anterior muscle.

Athletes involved in contact sports can be diagnosed with traumatic myositis ossificans. Myositis ossificans is characterised by a benign ossifying lesion in soft tissue mass, most commonly preceded by a muscle contusion in the thigh. Despite the fact that it is often a self-limiting disease, treatment modalities are anti-inflammatory drugs, physiotherapy, shockwave therapy, radiation therapy or surgical resection. We report a 22-year-old competitive football player with severe ongoing pain in the lower leg after a direct trauma. An X-ray showed calcification between the tibia and fibula. An additional ultrasound confirmed the diagnosis: myositis ossificans of the tibialis anterior muscle. After treating him with anti-inflammatory drugs and physiotherapy, he was able to return to sports. Myositis ossificans of the lower leg is an uncommon, though if present, troublesome condition, occurring after a contusion.

Isometric exercises do not provide immediate pain relief in Achilles tendinopathy: A quasi-randomized clinical trial.

BACKGROUND: Isometric exercises may provide an immediate analgesic effect in patients with lower-limb tendinopathy and have been proposed as initial treatment and for immediate pain relief. Current evidence is conflicting, and previous studies were small. OBJECTIVE: To study whether isometric exercises result in an immediate analgesic effect in patients with chronic midportion Achilles tendinopathy. METHODS: Patients with clinically diagnosed chronic midportion Achilles tendinopathy were quasi-randomized to one of four arms: isometric calf-muscle exercises (tiptoes), isometric calf-muscle exercises (dorsiflexed ankle position), isotonic calf-muscle exercises, or rest. The primary outcome was pain measured on a visual analogue scale (VAS) score (0-100) during a functional task (10 unilateral hops) both before and after the intervention. Between-group differences were analyzed using a generalized estimation equations model. RESULTS: We included 91 patients. There was no significant reduction in pain on the 10 hop test after performing any of the four interventions: isometric (tiptoes) group 0.2, 95%CI -11.2 to 11.5; isometric (dorsiflexed) group -1.9, 95%CI -13.6 to 9.7; isotonic group 1.4, 95%CI -8.3 to 11.1; and rest group 7.2, 95%CI -2.4 to 16.7. There were also no between-group differences after the interventions. CONCLUSION: The isometric exercises investigated in this study did not result in immediate analgesic benefit in patients with chronic midportion Achilles tendinopathy. We do not recommend isometric exercises if the aim is providing immediate pain relief. Future research should focus on the use of isometric or isotonic exercise therapy as initial treatment as all exercise protocols used in this study were well-tolerated.

Ultrasound Doppler Flow in Patients With Chronic Midportion Achilles Tendinopathy: Is Surface Area Quantification a Reliable Method?

OBJECTIVES: Ultrasound assessments of patients with chronic midportion Achilles tendinopathy include determining the degree of neovascularization using Doppler flow. A frequently used measure to quantify neovascularization is the modified Öhberg score. It is unknown whether the semiquantitative modified Öhberg score (0-4+) has higher reliability than a quantified measure of Doppler flow (0-100%). The purpose of this cross-sectional study was to evaluate the interobserver reliability of the modified Öhberg score and a surface area quantification (SAQ) method for Doppler flow in patients with chronic midportion Achilles tendinopathy. METHODS: Two observers examined the degree of Doppler flow independently using SAQ and the modified Öhberg score during a single consultation. The intraclass correlation coefficient, standard error of measurement, and minimal detectable difference were determined to evaluate the reliability and measurement properties of the SAQ method and the modified Öhberg score. RESULTS: In total, 28 consecutive patients with chronic midportion Achilles tendinopathy participated. The intraclass correlation coefficient for interobserver reliability of the SAQ method was 0.81 (95% confidence interval, 0.58-0.91), compared to 0.64 (95% confidence interval, 0.45-0.81) for the modified Öhberg score. The standard error of measurement and minimal detectable difference values for the SAQ method were 2.9% and 8.0%, respectively, and for the modified Öhberg score, they were 0.55 and 1.53 points. CONCLUSIONS: The SAQ method shows good reliability to evaluate the degree of Doppler flow in patients with chronic midportion Achilles tendinopathy, and it overcomes the ceiling effect of the modified Öhberg score. Future research should focus on the relationship between the SAQ method and clinical outcomes and use this method to monitor treatment responses.