M.Tech.

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Bakgrund: Besvär från akillessenan är ett vanligt problem hos såväl motionärer som elitidrottare och kan leda till båda smärta och funktionsförlust. Excentrisk träning är en vanlig behandlingsmetod i klinik, trots att evidensen är begränsad och motstridig. Syfte: Att kartlägga vilken evidens som finns för excentrisk träning som behandling av akillestendinopati. Metod: Systematisk litteraturstudie. Sökningen genomfördes i databasen PubMed. Studierna granskades med PEDro-skalan och den sammanlagda evidensen graderades enligt GRADEstud. Resultat: Litteratursökningen resulterade i att 7 studier med totalt 448 deltagare inkluderades. Studierna fick medelhög-hög kvalitet enligt PEDro. Evidensen för excentrisk träning vid 8-16 veckor var måttligt hög (+++) och vid 52 veckor mycket låg (+). Excentrisk träning hade en lägre effekt än hälinlägg och akupunktur mätt med VISA-A vid 8-16 veckor. Effekten av excentrisk träning mätt med VISA-A hade en likvärdig effekt som passiv stretch och tung långsam styrketräning vid 8-16 veckor. Vid 52 veckor var effekten mätt med VISA-A densamma av excentrisk träning som proloterapiinjektioner och tung långsam styrketräning. Konklusion: Excentrisk träning kan ha en effekt vid achillestendinopati. Effekten är densamma som eller lägre sett till poäng på VISA-A än andra behandlingsmetoder och skulle kunna bero på naturlig läkning över tid eller deltagandet i en studie. Evidensen för excentrisk träning graderades vid 8-16 respektive 52 veckor till måttligt hög (+++) och mycket låg (+). Detta grundar sig på studier av medelgod till hög kvalitet. / Background: Achilles tendon issues is a common problem among athletes on all levels. The problem can cause pain and loss of function. Eccentric exercise is a somewhat gold standard and often used in the clinical setting although the level of evidence is limited and conflicting. Objective: Map the evidence of eccentric exercise as a treatment for achilles tendinopathy. Method: A systematic review. The search was conducted in the Pubmed database. The included studies were analyzed using the PEDro scale and the evidence was graded using the GRADEstud. Results: The literature search identified 7 studies that were included with a total of 448 participants. The studies received a moderate-high quality on PEDro. The level of evidence at 8-16 weeks was moderate (+++) and at 52 weeks very low (+). Eccentric exercise had a lower effect than heel lifts and acupuncture measured with VISA-A. Eccentric exercise had a similar effect on VISA-A as passive stretch and heavy slow resistance. At 52 weeks the effect of eccentric exercise was the same as prolotherapy injections and heavy slow resistance. Conclusion: Eccentric exercise might have an effect as treatment for achilles tendinopathy, but the effect is the same or lower than other treatment options measured with VISA-A and might depend on the natural healing process or the participation in a study. The level of evidence for eccentric exercise was graded at 8-16 and 52 weeks respectively, as moderate (+++) and very low (+). This is based on studies of moderate to high quality.

Treatment of acute Achilles tendon ruptures has long been controversial. Several treatment options exist for patient with variable harms and benefits to each. Recognizing that decision of treatment option is preference-sensitive, this thesis focused on updating the current literature on Achilles tendon rupture management to facilitate the creation of a patient decision aid. A network meta-analysis of all treatment options for acute Achilles tendon ruptures was performed. Results demonstrated that minimally invasive surgery options were associated with lower complications and lower complications requiring surgery. Return to sport was similar amongst all treatment groups. With guidance from the Ottawa Decision Support Framework and the International Patient Decision Aid Standards, a three-tiered protocol for development, alpha testing and field-testing a novel patient decision aid is outlined next. The patient decision aid will be reviewed and revised iteratively by multi-disciplinary steering group. This protocol will act as a framework for further orthopaedic patient decision aid development.

Background: Achilles tendinopathy is a common debilitating running related injury. Achilles tendon loading force has been hypothesized as a contributor to Achilles tendinopathy. Loading force through the Achilles tendon during running is impacted by many factors such as footwear and foot strike pattern. Achilles tendon biomechanical (Achilles tendon cross-sectional area, thickness, echogenicity, stiffness, and T2*) responses to loading forces are variable and measurable in vivo. These responses impact the physiologic function of the tendon. Aims: 1) To evaluate baseline Achilles tendon biomechanical characteristics associated with a runner's habitual foot strike pattern. 2) To evaluate single running bout Achilles tendon biomechanical changes to varied forces in runners while maintaining their habitual foot strike pattern. This will be accomplished using minimalist and cushioned running shoes. Methods: 29 recreational runners were recruited. Runners completed two separate 5.3 km running sessions wearing alternating shoe types (cushioned and minimalist) at a pace of 3.15 m/s. Prior to running each day, participants had 32 retroreflective markers placed upon them for motion analysis collection. Additionally, participants had their Achilles tendon imaged via ultrasound pre and post run. On a separate day 24 of the participants underwent an ultrashort echo time (UTE) MRI imaging session of their Achilles tendon. Results: Achilles tendon stiffness was 20% greater in non-rear foot strike runners when compared with rear foot strike runners (p = 0.0166). Achilles tendon CSA, thickness, echogenicity, and T2* were not different between running groups (p > 0.05). Both foot strike pattern groups experienced significant Achilles tendon CSA and thickness decreases from pre to post run in minimalist and cushioned shoes (p < 0.05). Both running groups in cushioned shoes and the non-heel strike runners in minimalist shoes experienced significant increases in Achilles tendon echogenicity from pre to post run. Only non-rear foot strike runners had a significant increase in Achilles tendon stiffness while running in cushioned shoes (p = 0.03). Conclusions: The Achilles tendons of non-rear foot strike runners were significantly stiffer than those of rear foot strike runners. This Achilles tendon characteristic may be attributable to differences in Achilles tendon loading force while running but needs further research. Both groups of runners experienced multiple single running bout Achilles tendon changes as measured via ultrasound. Although loading forces varied within groups in different shoes and between foot strike pattern groups, all Achilles tendon changes were similar regardless of loading forces from pre to post run.

Background: Achilles tendinopathy is a common and debilitating condition among female ballet dancers due to the large repetitive loading forces placed on their Achilles tendons during rehearsals and performances. Tendon health problems in females are exacerbated by a lack of understanding about how energy availability influences tendons. Ballet dancers, as aesthetic athletes, are vulnerable to low energy availability and can enter a spectrum disorder, relative energy deficiency in sport, that consists of low energy availability (with or without disordered eating), menstrual cycle dysfunction, and low bone mineral density (BMD). Aims: 1) To investigate the relationship between insufficient caloric intake and Achilles tendon health in pre-professional ballet dancers. 2) To evaluate if symptoms of relative energy deficiency in sport such as low BMD and menstrual irregularity can be matched with Achilles tendon structural damage in pre-professional ballet dancers. 3) To analyze if there is a relationship between BMD and nutrition in pre-professional ballet dancers. Methods: 30 pre-professional ballet dancers were recruited. Over the course of a 16-week training and performance period, the dancers underwent four ultrasound imaging sessions and two MRI sessions investigating their Achilles tendons. They also underwent one full body DXA scan and completed four ASA24 dietary recall surveys. The dancers additionally filled out questionnaires describing their menstrual history and current Achilles tendon health. At the end of the study, dancers were organized into calorie sufficiency groups (sufficient or insufficient). Results: Within both calorie groups, the Achilles tendon was significantly thicker at the end of the study as compared to the start of the study (p=.046). Within both calorie groups, echogenicity was significantly higher at the first two ultrasound imaging sessions than it was at the last two (p<.05). Additionally, the calorie sufficient group's tendons had a significantly higher echogenicity than the calorie insufficient group at the first two ultrasound imaging sessions (p<.05). There were significantly more dancers in the calorie insufficient group that experienced changes to their menstrual cycle (p=.007). Conclusion: Participants in the calorie sufficient group had significantly more hyperechoic tendons than those in the calorie insufficient group at the start of the study, and all participants saw a significant drop in tendon echogenicity halfway through the study. The results of this study suggest that a better understanding of how average caloric intake affects tendon health in dancers is necessary in order to help treat and prevent AT injuries in this dance population.

Tendinopathies are common, painful, and debilitating injuries that can be challenging to treat. Current treatment methods are limited to surgery, nonsteroidal anti-inflammatory drugs, dry needling, and injectable therapeutics, platelet rich plasma and corticosteroids. Unfortunately, these existing treatments display poor long-term outcomes and have an increased risk of reinjury. Additionally, the healing mechanism for injured tendons forms scar tissue which is characterized by disrupted extracellular matrix rather than complete injury resolution. These structural changes impact the mechanical properties of tendon, reducing their capacity to transfer and store energy, making them inferior to uninjured tendons. The reduced mechanical properties increase the risk of rupture, exacerbating this debilitating disease and decreasing quality of life. Physical therapy (eccentric loading) decreases the symptoms of tendinopathy and restores Achilles tendon functionality. However, the mechanism by which these mechanical stimulations induce healing is poorly understood. There is a clinically relevant motivation to better understand the healing cascade in response to eccentric exercises. We aim to identify and characterize the effects of eccentric rehabilitative muscle loading on the Achilles tendon and gastrocnemius muscle complex using our preclinical TGF-ß1-induced murine model of Achilles tendinopathy. To accomplish our objective, we tested three muscle loading magnitudes (50%, 75%, and 100% body weight), over three treatment durations (1, 2, and 4 weeks) to determine their effects on tendon healing. Age-matched injured/untreated and naïve groups accompanied each loading magnitude and duration period. The functional biomechanical properties, morphological adaptations, transcriptomic response, and muscle strength of the Achilles tendon were assessed. Injured/untreated tendons had a significantly increased cross-sectional area compared to naïve and all loading groups at 2 and 4 weeks. Maximum stress and elastic modulus of injured/untreated tendons were significantly lower compared to naïve and all loading groups after 4 weeks. Gastrocnemius muscle strength was maintained over time as loading magnitude increased. Force output was lower after 2 weeks at 100% body weight loading compared to the naïve group, then recovered to naïve levels after 4 weeks. Histological findings included increased cross-sectional area, matrix disorganization, and increased cellular density of injured/untreated tendons. The transcriptomic evaluation revealed several patterns of expression among exercised groups. Biological processes associated with exercised groups revealed genes responsible for inflammation, extracellular matrix organization, and cell to cell signaling. Overall, eccentric muscle loading improved tendon geometry and material properties compared to naïve levels and improved muscle strength over time. Morphological evaluation also showed improvements in cross-sectional area, and collagen orientation, and cell appearance after 2 and 4 weeks of eccentric loading. Similarly, the transcriptomic changes showed an effect from exercise and upregulation of genes essential for extracellular matrix organization, inflammatory regulation, and cell to cell signaling. / Doctor of Philosophy / Tendons are connective tissues that join muscle to bone to facilitate movement. Tendons are prone to injury because of their consistent use for daily activities. The Achilles tendon is particularly at risk for injury since it is responsible for walking, running, and jumping, making it susceptible to overuse. Current treatment methods such as surgery and pain relief medication can provide immediate symptomatic relief, but have limited long-term success. Physical therapy provides relief of symptoms of chronic Achilles tendinopathy and improves the tendon healing response. Eccentric-based exercises (lengthening of the muscle while it contracts) are known as 'heel drops' and have been the most successful physical therapy technique to improve Achilles tendon healing. However, the way these rehabilitative exercises facilitate healing is poorly understood. It is difficult to determine the exact methods of healing because the required frequency and amount of exercise varies between patients, and recovery times can take weeks or months. In this research, we aim to better characterize how different 'heel drop' routines improve tendon healing, providing a foundation for determining the intensity and duration of rehabilitative exercises that can be applied for better clinical outcomes. To examine the effects of different eccentric-based loading profiles, we used a previously developed mouse model of chronic Achilles tendinopathy and customizable muscle stimulation device to simulate human physical therapy exercises at different intensity levels: full body weight (100%), assisted body weight (75%), and half body weight (50%). Prior to beginning treatments, we induced a tendon injury that mimics human injury and measured muscle strength before any exercise was performed. Mice were then introduced to muscle loading treatments that mimic clinical exercise routines: 3 sets of 10 heel drops, performed twice a week for 1-, 2- or 4-weeks. After the final day of exercise, muscle strength was measured again to see how the heel drop exercises impacted the muscle tissue. Tendons were collected and the mechanical properties, histologic changes, and transcriptomic adaptations were evaluated. Eccentric-based exercises improved the mechanical properties injured tendons and improved the architecture compared to injured/untreated controls. Injured tendons without treatment had inferior tendon mechanical properties and inferior structural changes. We also saw improved tissue changes and upregulation of genes responsible for tendon healing after exercise compared to naïve or injured/untreated mice. Our research demonstrates that performing consistent eccentric-based exercises for 2 or more weeks positively impacts tendon healing.

Diplomová práce Účinky rázové vlny v léčbě tendinopatie Achillovy šlachy 1 Abstract This thesis focuses on the observation of the effects of low-energetic focused extracorporeal shock wave therapy (ESWT) in the treatment of Achilles tendinopathy. The theoretical part summarizes the current knowledge of anatomical, histological, kinesiological and biomechanical aspects of Achilles tendon (AT), as well as pathological processes, which can be described as Achilles tendinopathy, their differential diagnosis and treatment options. Last but not least, we present up-to-date information on the physical principles and biological effects of ESWT, not only in the treatment of AT diseases. The main goal of our research was to determine the effectiveness of low-energetic focused ESWT in the treatment of Achilles tendinopathy in comparison to the placebo group. The subject of observation was not only changes in clinical manifestations, but also possible changes in the morphology of AT using ultrasonography (USG). Methods: A total of 20 patients with symptomatic Achilles tendinopathy was included in the study, while only 18 of them completed the entire program, and therefore only the results of these patients were evaluated. They were randomly divided into two groups in 1:1 ratio. Group A was treated by ESWT with...

O desenvolvimento de novos recursos terapêuticos capazes de acelerar o processo de reparo tem proporcionado avanços significativos no tratamento de lesões tendinosas. O objetivo do presente estudo foi analisar a influência da radiação LASER HeNe em cicatrização de tendões. Foi desenvolvido um modelo experimental de lesão de tendão de Aquiles através de um procedimento minimamente invasivo em coelhos adultos. Foram utilizados 40 animais distribuídos em quatro grupos de 10 animais (I, II III IV). No grupo I a lesão do tendão foi unilateral (pata direita) e o tendão lesado não recebeu estímulos com LASER. No grupo II a lesão foi unilateral (pata direita) e o tendão lesado recebeu estímulos com LASER. No grupo III a lesão do tendão foi bilateral e apenas a pata direita foi estimulada com LASER. No grupo IV foi realizada \"Sham Operation\" bilateralmente e apenas o tendão da pata direita recebeu estímulo com LASER. Todos os animais foram tratados com dose a 5 J/cm2 de forma pontual com contato direto durante 8 dias consecutivos, diariamente. Após este período os animais foram sacrificados e os tendões de Aquiles submetidos a ensaios mecânicos de tração em máquina de ensaio mecânico. Foram ensaiados 71 tendões, sendo 09 descartados. Embora não tenhamos observado diferença estatística significante nas comparações feitas entre os grupos, podemos notar que existiu uma tendência apontando que os tendões estimulados com LASER apresentaram resistência menor que os grupos controles. Estes resultados sugerem que o LASER diminuiu a resistência dentro das condições estudadas. Relevância Clínica: O presente trabalho mostra o conceito de que a irradiação LASER pode diminuir a resistência mecânica da cicatrização tendinosa em fases precoces do processo. / The development of new therapeutic resources addressing accelerating the repairing process has proportioned a meaningful advance in the treatment of tendon lesions. The purpose of the present study was to analyse the influence of He-Ne LASER radiation on tendon healing. An experimental model of Achilles tendon lesion was developed through a minimally invasive procedure in adults rabbits. We used 40 animals divided in groups of 10 animals each. In group I the tendon lesion was unilateral (right-paw) and the injured tendon did not receive LASER stimulation. In group II the lesion was unilateral (right-paw) and only, the injured side received LASER stimulation. In group III the tendon lesion was bilateral and only the right-paw was stimulated by LASER. In group IV bilateral sham operation was performed and only the right - paw received LASER stimulation. All the animals were treated with 5 J/cm2 dosis in a punctual way with direct contact for 8 successive days. After this period the animals were killed and the Achilles tendons were submitted to mechanical tests in traction on a mechanical testing machine. Seventy-one tendons were tested and 9 were discarded. No statiscally significant difference was observed in the comparison done between groups, however we could notice a tendency suggesting that the tendons stimulated by LASER presented a lesser mechanical resistance. These results suggest that LASER probably reduces the resistance in the studied conditions. Clinic Relevance: The present study supports the concept that LASER irradiation may induce an attenuation of the mechanical properties of the healing tendon in a very early phasis of the proccess.

A maioria dos casos de pé torto congênito tratados pelo método de Ponseti requer a secção do tendão calcâneo para correção do equino residual. Evidências clínicas sugerem que há completa cicatrização entre os cotos tendíneos, mas este processo reparativo ainda não foi suficientemente estudado. Esta investigação teve como objetivo avaliar o processo de reparação que ocorre após a secção percutânea do tendão calcâneo para a correção do equino residual no pé torto congênito idiopático tratado pelo método de Ponseti. Por meio de estudo prospectivo, foram analisadas 37 tenotomias em 26 pacientes com pé torto congênito idiopático tratados pelo método de Ponseti, com seguimento mínimo de um ano após a secção. A tenotomia foi realizada percutaneamente com agulha biselada de grosso calibre, sob sedação e anestesia local. O exame ultrassonográfico foi feito logo após a secção tendínea para assegurar que ela tenha sido completa e mensurar o afastamento entre os cotos. A reparação foi estudada por meio da ultrassonografia realizada três semanas, seis meses e um ano após a tenotomia. A ultrassonografia, realizada imediatamente após o procedimento, mostrou que, em alguns casos, feixes tendíneos residuais persistiam entre os cotos, mas foram completamente seccionados, em seguida, sob controle ultrassonográfico. Houve afastamento médio de 5,65 mm ± 2,26 (2,3 a 11,0 mm) entre os cotos tendíneos logo após a secção. Em um caso ocorreu sangramento maior que o habitual, que foi controlado com pressão local e não provocou interferência no tratamento. Após três semanas, a ultrassonografia mostrou regeneração tendínea com preenchimento do espaçamento entre os cotos por tecido hipoecoico com ecotextura irregular e com restituição da continuidade entre os cotos demonstrada dinamicamente pela transmissão de movimentos do músculo tríceps sural para o calcanhar. Seis meses após a tenotomia, o exame ultrassonográfico evidenciou que o tecido de reparação apresentava ecotextura de aspecto fibrilar e, quando comparado ao tendão normal, havia leve ou moderada hipoecogenicidade e espessamento cicatricial. Um ano após a tenotomia, o exame ultrassonográfico mostrou estrutura fibrilar na região de reparação, com ecogenicidade semelhante ao tendão normal, mas ainda apresentando espessamento tendíneo cicatricial. Em termos gerais, ocorreu rápida cicatrização após a secção percutânea do tendão calcâneo, que restabeleceu a continuidade entre os cotos. Ao final do período de observação, o tecido de reparação tendínea apresentou aspecto ultrassonográfico semelhante ao lado normal, exceto por leve espessamento, o que sugere um mecanismo de reparação predominantemente intrínseco. / Most cases of congenital clubfoot treated by the Ponseti technique require percutaneous Achilles tenotomy in order to correct the residual equinus. Clinical evidences suggest that complete healing occurs between the cut tendon stumps, but there have not yet been any detailed studies investigating this reparative process. This study was performed to assess the Achilles tendon repair after percutaneous sectioning to correct the residual equinus of clubfoot treated by the Ponseti method. A prospective study analyzed 37 tenotomies in 26 patients with clubfoot treated by the Ponseti technique, with a minimum follow-up of one year after the section. The tenotomy was performed percutaneously with a large-bore needle bevel with patient sedation and local anesthesia. Ultrasonographic scanning was performed after section to ascertain that the tenotomy had been completed and to measure the stump separation. In the follow-up period, the reparative process was followed ultrasonographically at three weeks, six months and one year post-tenotomy. The ultrasonography performed immediately after the procedure showed that in some cases, residual strands between the tendon ends persisted, and these were completely sectioned under ultrasound control. A mean retraction of 5.65 mm ± 2.26 (range, 2.3 to 11.0 mm) between tendon stumps after section was observed. Unusual bleeding occurred in one case and was controlled by digital pressure, with no interference with the final treatment. After three weeks, ultrasonography showed tendon repair with the tendon gap filled with irregular hypoechoic tissue, and also with transmission of muscle motion to the heel. Six months after tenotomy, there was structural filling with a fibrillar aspect, mild or moderate hypoechogenicity, and tendon scar thickening when compared to a normal tendon. One year after tenotomy, ultrasound showed a fibrillar structure and the echogenicity at the repair site that was similar to a normal tendon, but with persistent mild tendon scarring thickness. It was observed that there was a fast reparative process after Achilles tendon percutaneous sectioning that reestablished continuity between stumps. The reparative tissue evolved to tendon tissue with a normal ultrasonographic appearance except for mild thickening, suggesting a predominantly intrinsic repair mechanism