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

Håkan Alfredson,1 Lorenzo Masci,2,3 Christoph Spang4,5 1Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umeå, Sweden; 2Institute of Sports Exercise and Health, University College Hospital London, London, UK; 3Sports & Exercise Medicine, Queen Mary University of London, London, UK; 4Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden; 5Private Orthopaedic Spine Center, Würzburg, GermanyCorrespondence: Håkan Alfredson, Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umeå, 90187, Sweden, Tel +46 702288441, Email hakan.alfredson@umu.sePurpose: Chronic painful quadriceps tendinopathy is a relatively rare condition known to be difficult to manage. Conservative management is first-line treatment and if that fails open intra-tendinous revision surgery followed by a long rehabilitation period is used. There is sparse research on etiology and new treatment methods. This observational study aimed to evaluate the intra-articular findings in patients with chronic painful quadriceps tendinopathy resistant to conservative management.Patients and Methods: Seven male athletes (mean age 33 years, range 22– 40) suffering from chronic painful quadriceps tendinopathy in altogether 10 tendons, not responding to conservative management including heavy strength training, were included. Clinical examination and ultrasound scanning were used for diagnosis. Arthroscopy was used for evaluation of the inside of the knee.Results: In all 10 knees, there were obliterating major plica formations in the suprapatellar pouch.Conclusion: Obliterating plica formations in the suprapatellar pouch may be involved in the aetiology and pathology in quadriceps tendinopathy.Keywords: quadriceps, tendinopathy, suprapatellar, plica, surgery

Background: Studies have demonstrated that a sub-group of patients with medial Achilles pain exhibit Achilles tendinopathy with plantaris tendon involvement. This clinical condition is characterised by structural relationships and functional interference between the two tendons, resulting in compressive or shearing forces. Surgical plantaris tendon removal together with an Achilles scraping procedure has demonstrated positive short-term clinical results. The aim of this case series was to determine the long-term outcomes on pain and Achilles tendon structure. Methods: 18 consecutive patients (13 males; 5 females; mean age 39 years; mean symptom duration 28 months), of which three were elites, were included. Clinical examination, b-mode ultrasound (US) and Ultrasound Tissue Characterisation (UTC) confirmed medial Achilles tendon pain and tenderness, medial Achilles tendinopathy plus a plantaris tendon located close to the medial side of the Achilles tendon. Patients underwent US-guided local Achilles scraping and plantaris tendon removal followed by a structured rehabilitation program. Outcomes were VISA-A score for pain and function and UTC for Achilles structure. Results: 16 of 18 patients completed the 24 months follow-up. Mean VISA-A scores increased from 58.2 (±15.9) to 92.0 (±9.2) (mean difference = 33.8, 95% CI 25.2, 42.8, p < 0.01). There was an improvement in Achilles structure with mean organised echo pixels (UTC type I+II, in %) increasing from 79.9 (±11.5) to 86.4 (±10.0) (mean difference = 6.5%, 95% CI 0.80, 13.80, p =0.01), exceeding the 3.4% minimum detectable change. All 16 patients reported satisfaction with the procedure and 14 returned to pre-injury activity levels. There were no reported complications. Conclusions: Improved pain, function and tendon structure were observed 24 months after treatment with Achilles scraping and plantaris excision. The improvement in structure on the medial side of the Achilles after plantaris removal indicates tha

Objectives: Chronic painful insertional Achilles tendinopathy is known to be difficult to manage. The diagnosis is not always easy because multiple different tissues can be involved. The plantaris tendon has recently been described to frequently be involved in chronic painful mid-portion Achilles tendinopathy. This study aimed to evaluate possible plantaris tendon involvement in patients with chronic painful insertional Achilles tendinopathy. Methods: Ninety-nine consecutive patients (74 males, 25 females) with a mean age of 40 years (range 24-64) who were surgically treated for insertional Achilles tendinopathy, were included. Clinical examination, ultrasound (US)+Doppler examination, and surgical findings were used to evaluate plantaris tendon involvement. Results: In 48/99 patients, there were clinical symptoms of plantaris tendon involvement with pain and tenderness located medially at the Achilles tendon insertion. In all these cases, surgical findings showed a thick and wide plantaris tendon together with a richly vascularised fatty infiltration between the plantaris and Achilles tendon. US examination suspected plantaris involvement in 32/48 patients. Conclusion: Plantaris tendon involvement can potentially be part of the pathology in chronic painful insertional Achilles tendinopathy and should be considered for diagnosis and treatment when there is distinct and focal medial pain and tenderness. Level of evidence: IV case series.

There is a need for effective therapeutic options for resistant patellar tendinopathy. Ultrasound (US)-guided arthroscopic debridement has demonstrated promising clinical results. Objectives To prospectively evaluate pain, function, tendon structure and adverse events after US and colour Doppler (CD)-guided arthroscopic debridement for persistent painful patellar tendinopathy. Materials and methods Twenty-three consecutive patients (19 males and 4 females, mean age 28 years (+/- 8), symptom duration 25 months (+/- 21)), who had failed conservative management including progressive loading, were included. US+CD and ultrasound tissue characterisation (UTC) examination verified the clinical diagnosis and quantified baseline tendon structure. Patients were treated with US+CD-guided arthroscopic debridement followed by a specific rehabilitation protocol. Outcomes were VISA-P score for pain and function and UTC for tendon structure. Adverse events were specifically elicited. Results At 6-month follow-up, mean VISA-P score increased from 40 (+/- 21.0) to 82 (+/- 15) (mean deviation (MD)=42.0, 95% CI 32 to 53, d=2.4), while organised echo pixels (combined UTC type I+II) increased from 55.0% (+/- 17.0) to 69.0% (+/- 15.0) (MD=14.0, d=0.7, 95% CI 2 to 21). Both outcomes exceeded minimum detectable change values. Twenty-one participants returned to their prediagnosis activity levels, and there were no significant adverse events. Conclusions US-guided patellar tendon debridement for persistent patellar tendinopathy improved symptoms and tendon structure without complications at 6-month follow-up. A majority (21/23) of the patients returned to their preinjury activity level. Further studies with longer follow-ups, preferably randomised and controlled, are needed.

BACKGROUND: The plantaris tendon (PT) has been implicated in the pathogenesis of symptoms in a subset of patients with Achilles region pain syndromes and traditionally has been managed via open surgical resection. Although the PT can be visualized on ultrasound, a minimally invasive technique for sonographically guided PT release has not been formally described. OBJECTIVE: To validate a technique to perform sonographically guided PT release in an unembalmed cadaveric model. DESIGN: Prospective, cadaveric laboratory investigation. SETTING: Procedural skills laboratory in a tertiary medical center. SUBJECTS: Twenty unembalmed cadaveric knee-ankle-foot specimens (10 right, 10 left) obtained from 16 donors (6 male, 10 female) ages 55-96 years (mean 82.6 years) with body mass indexes of 14.1-33.2 kg/m2 (mean 23.3 kg/m2). METHODS: After simulated local anesthesia and sonographically guided hydrodissection of the plantaris tendon-Achilles tendon interval, a single experienced operator performed sonographically guided PT release on each specimen using an in-plane, lateral-to-medial approach, a commercially available, disposable 3.0-mm hook knife, and either a 17-5 MHz or 15-7 MHz linear array transducer. Each specimen was subsequently dissected to assess for PT release and iatrogenic injury. MAIN OUTCOME: Status of the PT, Achilles tendon, and regional neurovascular structures as determined by dissection. RESULTS: All 20 PT releases were completed in a single attempt through a 3- to 5-mm incision. Dissection confirmed complete PT release in all specimens without damage to the adjacent Achilles tendon or regional neurovascular structures. CONCLUSION: Sonographically guided PT release is technically feasible and can be performed while avoiding injury to the Achilles tendon and regional neurovascular structures. Additional research is warranted to further define the role of sonographically guided PT release in patients with suspected PT-mediated Achilles region pain syndromes.

Objectives: Surgical removal of the plantaris tendon can cure plantaris-associated Achilles tendinopathy, a condition in which Achilles and plantaris tendinopathy coexist. However, rare cases with plantaris tendinopathy alone are often misdiagnosed due to a normal Achilles tendon. Design and setting: Prospective case series study at one centre. Participants: Ten consecutive patients (9 men and one woman, mean age 35 years, range 19–67) with plantaris tendon-related pain alone in altogether 13 tendons were included. All had had a long duration (median 10 months, range 3 months to 10 years) of pain symptoms on the medial side of the Achilles tendon mid-portion. Preoperative ultrasound showed thickened plantaris tendon but a normal Achilles tendon. Interventions: Operative treatment consisting of ultrasound-guided excision of the plantaris tendon. Primary and secondary outcome measures: Scores from Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A)were taken preoperatively and postoperatively (median duration 10 months). Patient satisfaction and time until full return to sports activity level was asked by a questionnaire. Results: The VISA-A scores increased from 61 (range 45–81) preoperatively to 97 (range 94–100) postoperatively (p<0.01). Follow-up results at 10 months (range 7–72 months) on 9/10 patients showed full satisfaction and return to their preinjury sports or recreational activity Conclusion: The plantaris tendon should be kept in mind when evaluating painful conditions in the Achilles tendon region, especially when no Achilles tendinopathy is present. Excision of the plantaris tendon via a minor surgical procedure in local anaesthesia results in a good outcome.

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

Objectives The plantaris tendon has recently been described as a possible important factor in midportion Achilles tendinopathy. Ultrasound tissue characterisation (UTC) is a method to study tendon structure (matrix integrity). The effect of plantaris tendon removal on Achilles tendon structure was studied using UTC. Design and setting Prospective case series study at one centre. Participants Nine tendons in eight physically active and healthy patients (mean age 39 years) with chronic painful midportion Achilles tendinopathy were included. Preoperative two-dimensional ultrasound and UTC showed midportion Achilles tendinopathy (tendinosis) with medial tendon changes and suspected plantaris tendon involvement. Patients with previous operations to the Achilles tendon were excluded. Interventions Operative treatment consisted of excision of the plantaris tendon and scraping of the ventromedial surface of the Achilles tendon under a local anaesthetic. Primary and secondary outcome measures UTC examination and clinical scoring with the VISA-A questionnaire were performed preoperatively and 6 months postoperatively. Results At 6 months follow-up, UTC demonstrated a statistically significant (t=5.40, p<0.001) increase in the mean organised matrix (echo-type I+II) and a decrease in the mean disorganised matrix (echo-type III+IV). Seven out of eight patients were satisfied, and the VISA-A score had increased significantly (p<0.001) from 56.8 (range 34–73) preoperatively to 93.3 (range 87–100) postoperatively. Conclusions Excision of the plantaris tendon and scraping of the ventromedial Achilles tendon in chronic midportion tendinopathy seem to have the potential to improve tendon structure and reduce tendon pain. Studies on a larger group of patients and with a longer follow-up period are needed.

BACKGROUND: Partial Achilles tendon ruptures are not always easy to diagnose. A history including a sudden onset of pain, and/or relative weakness in plantar flexion force, are indicators. The most loaded side of the Achilles tendon is the dorsal side (skin side). OBJECTIVE: To evaluate the ultrasound (US) and Doppler (CD) findings in patients with a suspected partial rupture in the Achilles tendon. Material and METHODS: Seventeen patients (16 men and 1 woman) with a mean age of 36 years (range 23-71) were examined clinically and by US+CD because of midportion Achilles tendon pain. There was an acute onset in 14/17 patients, and all had painful weakness during tendon loading activity. RESULTS: In all patients the US examination showed a partial Achilles tendon rupture, presented as a disrupted dorsal (skin side) tendon line and an irregular tendon structure mainly located in the dorsal and mid-tendon. The size of the rupture varied from 1/3 to 2/3 of the tendon thickness. In the dorsal part of the tendon, corresponding to the region with disrupted tendon line and irregular structure, CD examination showed high blood flow-most often of a longitudinal character. Six of the patients were surgically treated, and macroscopical examination verified the ultrasound findings, showing disruption on the dorsal side, and a partial rupture in the dorsal and mid- tendon. CONCLUSIONS: Ultrasound and Doppler examination can be helpful tools to diagnose partial midportion Achilles tendon ruptures. The characteristic findings of a disrupted dorsal tendon line, and high blood flow in the structurally abnormal dorsal tendon, indicate a partial rupture.

Grävare Silbernagel, K., Malliaras, P., de Vos, R. J., Hanlon, S., Molenaar, M., Alfredson, H., . . . Vicenzino, B. (2021). ICON 2020—international scientific tendinopathy symposium consensus: A systematic review of outcome measures reported in clinical trials of achilles tendinopathy. Sports Medicine. Advance online publication. https://doi.org/10.1007/s40279-021-01588-6