Am J Sports Med. 2008 Jan;36(1):104-9. Epub 2007 Nov 30.
Folsom GJ, Larson CM.Minnesota Sports Medicine Orthopaedic Sports Medicine Fellowship Program, Twin Cities Orthopaedics, Eden Prairie, Minnesota 55344, USA.BACKGROUND: Acute surgical repair of proximal hamstring ruptures has been shown to result in a high return to preinjury activity level. HYPOTHESIS: Achilles allograft reconstruction of chronic complete proximal hamstring ruptures results in improved function and strength that approaches that of acute surgical repairs. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2002 and 2005, 26 patients underwent surgical treatment for complete proximal hamstring ruptures. Twenty-one were acute primary repairs. Five chronic ruptures were treated with Achilles allograft reconstruction with (n = 2) or without (n = 2) interference screw fixation or mobilization and primary repair (n = 1). Isokinetic strength testing was conducted postoperatively in 11 acute and 3 chronic cases, and a functional questionnaire was given at most recent follow-up.
RESULTS: Subjective results for all patients at a mean follow-up of 20 months revealed good leg control in 96%, no pain in 80%, and return to sporting activities in 76%. Ninety-six percent of patients said they would have the procedure done again. With the isokinetic testing available at most recent follow-up, there was no significant difference in the mean hamstring strength deficits for the acute versus chronic groups tested at 60 deg/s (8% vs 21%, P =.295) and 180 deg/s (12% vs 2%, P = .294). Overall, there were 3 major adverse events and 5 patients with superficial wound drainage treated with antibiotics. CONCLUSION: Surgical treatment of acute and chronic complete proximal hamstring ruptures can result in a high return to full activity. Reconstruction of chronic ruptures with Achilles allograft appears to restore function and strength comparable to acute repairs.
Wednesday, 6 February 2008
Friday, 27 April 2007
Topical glyceryl trinitrate for chronic Achilles tendinopathy.
Hunte G,
Lloyd-Smith R.
University of British Columbia, Vancouver, British Columbia, Canada.
OBJECTIVE: To determine whether continuous application of topical glyceryl trinitrate decreases pain and symptoms in chronic noninsertional Achilles tendinopathy. DESIGN: Randomized double-blind placebo-controlled study of 6-months' duration. SETTING: Community and referral study at an Australian University Hospital. PARTICIPANTS: Recruitment was through newspaper advertisements and private consulting rooms. Eligibility criteria were age >18 years, a history of insidious onset of Achilles tendon pain, a tender nodule localized to the region of the calcaneal insertion, and an ultrasound examination that excluded a tendon tear. Exclusion criteria were Achilles tendinopathy of <3 months' duration, a previous operation on, or dislocation of, the affected ankle or leg, distal neurologic signs, a local corticosteroid injection in the previous 3 months, and current pregnancy. The 65 participants (84 affected tendons; 62% men) had a median age of 49 years (range, 24-79 years), with a median duration of symptoms of 16 months (range, 4-147 months). INTERVENTION: Participants were assigned an active transdermal patch (1/4 of a Nitro-Dur 5 [Schering-Plough] glyceryl trinitrate patch), which delivered 1.25 mg of glyceryl trinitrate over 24 hours, or a placebo patch. Patients were required to cut the patches into quarters and apply 1/d to the site of maximal tenderness for the 24-week duration of the study. All patients were also given 500-mg paracetamol tablets for use with headaches, and instructed in a rehabilitation program that comprised rest from aggravating activities, the use of heel-raise wedges, prolonged daily stretching of the gastrocnemius and soleus musculature, and an eccentric calf muscle-strengthening program. MAIN OUTCOME MEASURES: At the baseline, 2, 6, 12, and 24-week examinations the patient completed a symptom assessment sheet to rate the severity of Achilles pain with activity, at rest, and at night (0 = no pain, 4 = very severe pain). The single assessor used the same scale to measure local tenderness; an 11-point scale for the patient to report pain after the single-leg 10-hop test; and also measured the ankle plantar flexor mean peak force and ankle plantar flexor work. Follow-up was 89% complete. MAIN RESULTS: The groups did not differ in pain with activity, night pain, or local tenderness until the 12-week assessment when participants in the glyceryl trinitrate group reported less pain on each measure (mean scores, 0.9 vs. 1.6 [P = 0.02]; 0.2 vs. 0.7 [P = 0.04]; and 0.9 vs. 1.6 [P = 0.02], respectively). The difference was maintained at 24 weeks for pain with activity (mean scores, 0.4 vs. 1.0 [P = 0.03]). At 24 weeks the glyceryl trinitrate group reported less pain on the 10-hop test than the placebo group (mean scores, 0.5 vs. 1.6 [P = 0.005]). Although the intervention group showed a greater increase in plantar flexor mean total work at 24 weeks than the placebo group, the baseline scores were significantly different. The groups did not differ in pain at rest or in ankle plantar flexor peak force. Combining all the measures showed an estimated 14% (95% CI, 9%-19%) excess of asymptomatic tendons in the intervention group at 6 months. Reported main side effects were headaches (glyceryl trinitrate group, 53%; placebo group, 45%) and rashes (glyceryl trinitrate group, 16%%; placebo group, 12%). CONCLUSION: A topical glyceryl trinitrate patch was more effective than placebo for reducing pain from chronic noninsertional Achilles tendonitis in the first 12 and 24 weeks of use.
Lloyd-Smith R.
University of British Columbia, Vancouver, British Columbia, Canada.
OBJECTIVE: To determine whether continuous application of topical glyceryl trinitrate decreases pain and symptoms in chronic noninsertional Achilles tendinopathy. DESIGN: Randomized double-blind placebo-controlled study of 6-months' duration. SETTING: Community and referral study at an Australian University Hospital. PARTICIPANTS: Recruitment was through newspaper advertisements and private consulting rooms. Eligibility criteria were age >18 years, a history of insidious onset of Achilles tendon pain, a tender nodule localized to the region of the calcaneal insertion, and an ultrasound examination that excluded a tendon tear. Exclusion criteria were Achilles tendinopathy of <3 months' duration, a previous operation on, or dislocation of, the affected ankle or leg, distal neurologic signs, a local corticosteroid injection in the previous 3 months, and current pregnancy. The 65 participants (84 affected tendons; 62% men) had a median age of 49 years (range, 24-79 years), with a median duration of symptoms of 16 months (range, 4-147 months). INTERVENTION: Participants were assigned an active transdermal patch (1/4 of a Nitro-Dur 5 [Schering-Plough] glyceryl trinitrate patch), which delivered 1.25 mg of glyceryl trinitrate over 24 hours, or a placebo patch. Patients were required to cut the patches into quarters and apply 1/d to the site of maximal tenderness for the 24-week duration of the study. All patients were also given 500-mg paracetamol tablets for use with headaches, and instructed in a rehabilitation program that comprised rest from aggravating activities, the use of heel-raise wedges, prolonged daily stretching of the gastrocnemius and soleus musculature, and an eccentric calf muscle-strengthening program. MAIN OUTCOME MEASURES: At the baseline, 2, 6, 12, and 24-week examinations the patient completed a symptom assessment sheet to rate the severity of Achilles pain with activity, at rest, and at night (0 = no pain, 4 = very severe pain). The single assessor used the same scale to measure local tenderness; an 11-point scale for the patient to report pain after the single-leg 10-hop test; and also measured the ankle plantar flexor mean peak force and ankle plantar flexor work. Follow-up was 89% complete. MAIN RESULTS: The groups did not differ in pain with activity, night pain, or local tenderness until the 12-week assessment when participants in the glyceryl trinitrate group reported less pain on each measure (mean scores, 0.9 vs. 1.6 [P = 0.02]; 0.2 vs. 0.7 [P = 0.04]; and 0.9 vs. 1.6 [P = 0.02], respectively). The difference was maintained at 24 weeks for pain with activity (mean scores, 0.4 vs. 1.0 [P = 0.03]). At 24 weeks the glyceryl trinitrate group reported less pain on the 10-hop test than the placebo group (mean scores, 0.5 vs. 1.6 [P = 0.005]). Although the intervention group showed a greater increase in plantar flexor mean total work at 24 weeks than the placebo group, the baseline scores were significantly different. The groups did not differ in pain at rest or in ankle plantar flexor peak force. Combining all the measures showed an estimated 14% (95% CI, 9%-19%) excess of asymptomatic tendons in the intervention group at 6 months. Reported main side effects were headaches (glyceryl trinitrate group, 53%; placebo group, 45%) and rashes (glyceryl trinitrate group, 16%%; placebo group, 12%). CONCLUSION: A topical glyceryl trinitrate patch was more effective than placebo for reducing pain from chronic noninsertional Achilles tendonitis in the first 12 and 24 weeks of use.
Thursday, 5 April 2007
The Effect of Pes Cavus on Foot Pain and Plantar Pressure
Joshua Burnsa, Jack Crosbiea, Adrienne Hunta, Robert Ouvrierb
Received 19 October 2004; accepted 10 March 2005 published online 9 May 2005.
Abstract
Background. Clinical management of patients with painful pes cavus is challenging because the mechanism of foot pain is poorly understood. The purpose of this study was to explore the influence of various pes cavus aetiologies on foot pain and plantar pressure characteristics, and to identify the relationship between foot pain and plantar pressure.
Methods. Seventy subjects were recruited for this study. They included 30 subjects with pes cavus of unknown aetiology (idiopathic), 10 subjects with pes cavus of neurological aetiology (neurogenic) and 30 subjects with a normal foot type. The presence and location of foot pain was recorded and barefoot plantar pressures were measured using the EMED-SF platform for the whole foot, rearfoot, midfoot and forefoot regions.
Findings. Subjects with pes cavus of either idiopathic or neurogenic aetiology reported a higher proportion of foot pain (60%) compared to subjects with a normal foot type (23%) (P=0.009). Pressure–time integrals under the whole foot, rearfoot and forefoot regions in pes cavus, of both idiopathic and neurogenic origin, were higher than in the normal foot type (P<0.01). Pressure–time integrals in subjects reporting foot pain were higher than for pain free subjects (P<0.001). There was a significant correlation between pressure–time integral and foot pain (r=0.49, P<0.001).
Interpretation. Foot pain is a common finding among individuals with pes cavus. Regardless of aetiology, pes cavus is characterized by abnormally high pressure–time integrals which are significantly related to foot pain. An understanding of the relationship between pes cavus pressure patterns and foot pain will improve the clinical management of these patients.
Received 19 October 2004; accepted 10 March 2005 published online 9 May 2005.
Abstract
Background. Clinical management of patients with painful pes cavus is challenging because the mechanism of foot pain is poorly understood. The purpose of this study was to explore the influence of various pes cavus aetiologies on foot pain and plantar pressure characteristics, and to identify the relationship between foot pain and plantar pressure.
Methods. Seventy subjects were recruited for this study. They included 30 subjects with pes cavus of unknown aetiology (idiopathic), 10 subjects with pes cavus of neurological aetiology (neurogenic) and 30 subjects with a normal foot type. The presence and location of foot pain was recorded and barefoot plantar pressures were measured using the EMED-SF platform for the whole foot, rearfoot, midfoot and forefoot regions.
Findings. Subjects with pes cavus of either idiopathic or neurogenic aetiology reported a higher proportion of foot pain (60%) compared to subjects with a normal foot type (23%) (P=0.009). Pressure–time integrals under the whole foot, rearfoot and forefoot regions in pes cavus, of both idiopathic and neurogenic origin, were higher than in the normal foot type (P<0.01). Pressure–time integrals in subjects reporting foot pain were higher than for pain free subjects (P<0.001). There was a significant correlation between pressure–time integral and foot pain (r=0.49, P<0.001).
Interpretation. Foot pain is a common finding among individuals with pes cavus. Regardless of aetiology, pes cavus is characterized by abnormally high pressure–time integrals which are significantly related to foot pain. An understanding of the relationship between pes cavus pressure patterns and foot pain will improve the clinical management of these patients.
Thursday, 8 March 2007
Effects of Low-Intensity Pulsed Ultrasound on Tendon–Bone Healing in an Intra-articular Sheep Knee Model
Effects of Low-Intensity Pulsed Ultrasound on Tendon–Bone Healing in an Intra-articular Sheep Knee Model
William R. Walsh, Ph.D.a, Paul Stephens, M.D.a, Frank Vizesi, M.S.a, Warwick Bruce, M.D.a, James Huckle, Ph.D.b, Yan Yu, Ph.D.a
Purpose: This study reports the mechanical and histologic properties of intra-articular tendon–bone healing with the application of low-intensity pulsed ultrasound (LIPUS) in an ovine knee model.
Methods: A single digital extensor tendon autograft from the right hoof was used as the graft in 89 adult sheep. Femoral fixation was achieved with an EndoButton (Smith & Nephew Endoscopy, Andover, MA) and tibial fixation by tying over a bony post. LIPUS treatment was performed daily for 20 minutes over the femoral and tibial tunnels until sacrifice in all groups, apart from the 26-week group, which was treated only for the first 12 weeks. Histology was performed at 3, 6, 12, and 26 weeks. Mechanical testing was performed at 6, 12, and 26 weeks.
Results: The LIPUS-treated group showed increased cellular activity at the tendon–bone interface and general improvement in tendon–bone integration and vascularity. Stiffness and peak load were greater compared with the control group at 26 weeks after surgery (P < .05).
Conclusions: The application of LIPUS appears to improve healing at the tendon–bone interface for soft tissue grafts fixed with a suspensory fixation technique. Histology supports a benefit based on increased integration between tendon and bone and a biologically more active interface, which would account for the improved mechanical properties. Clinical Relevance: The indications of LIPUS may be expanded to include tendon–bone healing, for example, in anterior cruciate ligament reconstruction.
William R. Walsh, Ph.D.a, Paul Stephens, M.D.a, Frank Vizesi, M.S.a, Warwick Bruce, M.D.a, James Huckle, Ph.D.b, Yan Yu, Ph.D.a
Purpose: This study reports the mechanical and histologic properties of intra-articular tendon–bone healing with the application of low-intensity pulsed ultrasound (LIPUS) in an ovine knee model.
Methods: A single digital extensor tendon autograft from the right hoof was used as the graft in 89 adult sheep. Femoral fixation was achieved with an EndoButton (Smith & Nephew Endoscopy, Andover, MA) and tibial fixation by tying over a bony post. LIPUS treatment was performed daily for 20 minutes over the femoral and tibial tunnels until sacrifice in all groups, apart from the 26-week group, which was treated only for the first 12 weeks. Histology was performed at 3, 6, 12, and 26 weeks. Mechanical testing was performed at 6, 12, and 26 weeks.
Results: The LIPUS-treated group showed increased cellular activity at the tendon–bone interface and general improvement in tendon–bone integration and vascularity. Stiffness and peak load were greater compared with the control group at 26 weeks after surgery (P < .05).
Conclusions: The application of LIPUS appears to improve healing at the tendon–bone interface for soft tissue grafts fixed with a suspensory fixation technique. Histology supports a benefit based on increased integration between tendon and bone and a biologically more active interface, which would account for the improved mechanical properties. Clinical Relevance: The indications of LIPUS may be expanded to include tendon–bone healing, for example, in anterior cruciate ligament reconstruction.
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