Cholesterol level in non-insertional Achilles tendonopathy

NewsBot · Jun 9, 2015

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Cholesterol level in non-insertional Achilles tendonopathy
Dishan Singh
The Foot; Article in Press

Highlights
•What is already known.
•Familial hypercholesterolaemis is a treatable disorder if diagnosed early.
•Patients with familial hypercholesterolaemia may present with Achilles tendon pain.
•It has therefore been suggested that all patients presenting with Achilles tendon pain should be screened for hypercholesterolaemia.
•What this article adds.
•Only 1 out of 83 patients with Achilles tendon pain to an orthopaedic surgeon was found to have a high cholesterol.
•Screening for high cholesterol in patients presenting with Achilles tendon pain to an orthopaedic clinic is not justified.
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Familial hypercholesterolaemia is an autosomal dominant disease, with a prevalence of 1 in 500, where lipid deposits occur in the skin, tendons (particularly Achilles tendon) and arteries. It has a high risk of early coronary artery disease and mortality but is treatable with cholesterol lowering strategies if patients are diagnosed early. Studies in patients attending lipid clinics have shown that half the patients may have suffered from Achilles tendon symptoms 20 years earlier and it has been proposed that all patients presenting with Achilles tendon pain should have a serum cholesterol test.

All consecutive patients seen in an adult foot and ankle clinic with non-insertional Achilles tendonopathy between April 2012 and March 2014 had their serum cholesterol measured. Only one patient in 83 (p = 0.19) was diagnosed with heterozygous familial hypercholesterolaemia but 3 relatives of the proband patient were also diagnosed by cascade testing.

Measurement of cholesterol in all patients presenting with achillodynia does not seem to be justified but the literature suggests that it should probably be considered in patients with bilateral extensive disease or those who give a history of intermittent episodes of severe pain lasting a few days.
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Admin2 · Jun 9, 2015

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NewsBot · Dec 5, 2016

Achilles Tendon Rupture and Abnormal Lipid Profile: A Descriptive Clinical Laboratory and Histology Study
Loisel François, Hugo Kielwasser1, Grégoire Faivre, Kantelip Bernadette and Obert Laurent
Clin Res Foot Ankle 4:214. doi:10.4172/2329-910X.1000214

Introduction: Several human and animal studies have revealed a link between abnormal serum lipid levels and Achilles tendon rupture. However, clinicians have not detected macroscopic amounts of fatty tissue during the repair of ruptured tendons.

Material and Methods: A lipid profile and evaluation of tendon lipomatosis were performed in a group of 65 patients with Achilles tendon rupture recruited over a two-year period at two French hospitals. Cardiovascular and tendon rupture risk factors were inventoried.

Results: Ten patients had a history of hypercholesterolemia, seven of whom were undergoing statin treatment (15%). Two patients had known risk factors for tendon rupture (3%): one was taking inhaled corticosteroids and the other suffered from hyperuricemia. Total cholesterol was normal in 63% of cases; triglycerides were normal in 67% of cases and HDL cholesterol was normal in 54% of cases. If cardiovascular risk factors were taken into account, the portion of high-LDL cholesterol went from 17% to 23%, but this was not significant. Pathology analysis found four cases of tendon lipomatosis among the 36 collected samples (11%).

Discussion: Since this study did not include a control group, we cannot make any conclusions about the lack of relationship between abnormal lipid profile and tendon rupture. The prevalence of hypercholesterolemia in our study population was similar to that of the general population. Although high cholesterol levels have been implicated by some authors, cholesterol accumulation within the tendon is probably not directly responsible for weakening it; however, an increase in atheromatous plaque in tendon blood vessels may lead to hypoxia.
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NewsBot · Jun 30, 2018

Achilles tendon structure is negatively correlated with body mass index, but not influenced by statin use: A cross-sectional study using ultrasound tissue characterization
Agnetha de Sá, David A. Hart, Karim Khan, Alexander Scott
PLoS ONE 13(6) : June 21, 2018

Introduction
Statins are widely used to inhibit cholesterol production in the liver among people with hypercholesterolemia. A recent epidemiological study in the UK has shown that statin use (unlike elevated BMI) is not associated with an increased risk of Achilles tendon rupture. However, because of laboratory reports suggesting a negative influence of statins on tenocyte metabolism, we decided to directly compare the Achilles tendon structure (cross-sectional area and longitudinal collagen organization) in regular statin users compared to non-users.

Methods
We conducted ultrasound tissue characterization (UTC) of the Achilles tendon in statin users and a comparison group of similar age and gender. Statin users and control participants were recruited from May 10 2015 to February 17 2017 through a cardiovascular health centre and from the general community. Cross-sectional area of the Achilles tendon and longitudinal collagen organization (% type I echoes) were assessed using quantitative ultrasound tissue characterization by a blinded observer at a predetermined location (2 cm proximal to the calcaneus).

Results
Sixty-six individuals who were either taking statins for at least one year (ST, n = 33) or a comparison group who had never taken statins (CG, n = 33) were included in the study. The Achilles tendon cross-sectional area (ST 59.7 (13) mm2, CG 59.9 (8.5) mm2) and proportion of echo-type I patterns [ST 70 (10)%, CG 74 (13)%] were equivalent in the two groups. In contrast, there was a negative correlation between BMI (rs = -0.25, p = 0.042) and type I echo values. Obese individuals demonstrated a significantly lower percentage of type I echoes (62 (11)%) than individuals of normal body mass index (73 (10)% p<0.05).

Conclusion
These findings demonstrate that there is no evidence of a negative statin influence on Achilles tendon structure. Given earlier reports that the risk of Achilles injury is equivalent in statin users and non-users, weightbearing exercise may be prescribed without placing the Achilles tendon at a higher risk of injury than among the general population. The results of this study are consistent with the known negative effects of elevated BMI on tendon structure, suggesting that an assessment of the Achilles tendons prior to prescribing weightbearing exercise may be prudent in obese individuals.
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NewsBot · Dec 5, 2019

The diagnosis and treatment of familial hyperlipidemia
combined with midsubstance Achilles tendinopathy
in a young woman: a clinical case report
Xuemin Li et al
Int J Clin Exp Med 2019;12(11):13018-13022

Background: Familial hyperlipidemia is primarily an inherited disorder characterized by an elevation of
plasma low-density lipoprotein cholesterol and xanthomas at various sites. Achilles tendon xanthomas usually present as a swollen tendon, caused by both intratendinous lipid infiltration and local edema and inflammation. Previous research indicates that patients with midsubstance Achilles tendinopathy might benefit from eccentric loading
exercises. However, no studies have yet evaluated the effect of eccentric exercises on patients with Achilles tendon
disease associated with familial hyperlipidemia. Case report: A 32-year old woman with familial hyperlipidemia and
midsubstance Achilles tendinopathy benefited from 12 months of therapy (including calf eccentric loading exercises
and lipid-lowering therapy). US indicated blood flow changes with her symptomatic improvement. Clinical rehabilitation Impact: Lipid-lowering therapy and exercise therapy are effective for patients with familial hyperlipidemia and
midsubstance Achilles tendinopathy.
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NewsBot · Sep 21, 2021

The effects of cholesterol accumulation on Achilles tendon biomechanics: A cross-sectional study
Kipling Squier ,Alexander Scott,Michael A. Hunt,Liam R. Brunham,David R. Wilson,Hazel Screen,Charlie M. Waugh
PLOSOne: September 16, 2021

Familial hypercholesterolemia, a common genetic metabolic disorder characterized by high cholesterol levels, is involved in the development of atherosclerosis and other preventable diseases. Familial hypercholesterolemia can also cause tendinous abnormalities, such as thickening and xanthoma (tendon lipid accumulation) in the Achilles, which may impede tendon biomechanics. The objective of this study was to investigate the effect of cholesterol accumulation on the biomechanical performance of Achilles tendons, in vivo. 16 participants (10 men, 6 women; 37±6 years) with familial hypercholesterolemia, diagnosed with tendon xanthoma, and 16 controls (10 men, 6 women; 36±7 years) underwent Achilles biomechanical assessment. Achilles biomechanical data was obtained during preferred pace, shod, walking by analysis of lower limb kinematics and kinetics utilizing 3D motion capture and an instrumented treadmill. Gastrocnemius medialis muscle-tendon junction displacement was imaged using ultrasonography. Achilles stiffness, hysteresis, strain and force were calculated from displacement-force data acquired during loading cycles, and tested for statistical differences using one-way ANOVA. Statistical parametric mapping was used to examine group differences in temporal data. Participants with familial hypercholesterolemia displayed lower Achilles stiffness compared to the control group (familial hypercholesterolemia group: 87±20 N/mm; controls: 111±18 N/mm; p = 0.001), which appeared to be linked to Achilles loading rate rather than an increased strain (FH: 5.27±1.2%; controls: 4.95±0.9%; p = 0.413). We found different Achilles loading patterns in the familial hypercholesterolemia group, which were traced to differences in the centre of pressure progression that affected ankle moment. This finding may indicate that individuals with familial hypercholesterolemia use different Achilles loading strategies. Participants with familial hypercholesterolemia also demonstrated significantly greater Achilles hysteresis than the control group (familial hypercholesterolemia: 57.5±7.3%; controls: 43.8±10%; p<0.001), suggesting that walking may require a greater metabolic cost. Our results indicate that cholesterol accumulation could contribute to reduced Achilles function, while potentially increasing the chance of injury.
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NewsBot · Oct 19, 2021

Dyslipidemia Is Associated With Increased
Risk of Achilles Tendon Disorders in
Underweight Individuals to a Greater Extent
Than Obese Individuals
A Nationwide, Population-Based, Longitudinal Cohort Study
Hyeong Sik Ahn et al
The Orthopaedic Journal of Sports Medicine

Background: The association between dyslipidemia and Achilles tendinopathy (AT) or Achilles tendon rupture (ATR) remains
controversial, although some studies have examined this topic.
Purpose: To evaluate the correlation of dyslipidemia and the risk of AT or ATR, and its association with body mass index (BMI), by
assessing data from a nationwide population-based cohort.
Study Design: Cohort study; Level of evidence, 3.
Methods: We used the National Health Insurance database, which includes the entire population of the Republic of Korea, to
evaluate participants in the National Health Screening Program between January 2009 and December 2010. Participants diagnosed with AT or ATR before December 31, 2017, were selected. The variables assessed were age, sex, frequency of high-intensity
exercise per week, BMI, waist circumference, systolic blood pressure, and levels of low-density lipoprotein cholesterol (LDL-C),
triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and fasting blood glucose. Multivariate Cox proportional hazards
regression was used for data analysis.
Results: A total of 16,830,532 participants were included. Of these, 125,814 and 31,424 participants developed AT and ATR,
respectively. A higher level of LDL-C was associated with an increased risk of AT (adjusted hazard ratio [HR], 1.16) and ATR
(adjusted HR, 1.18). A slightly increased risk of AT was observed in participants with higher TG levels (adjusted HR, 1.03), whereas
higher HDL-C level was associated with a slight risk reduction for AT (adjusted HR, 0.95). However, no significant association was
observed between higher TG or HDL-C levels and ATR. In the underweight group (BMI <18.5 kg/m2
), a higher LDL-C level was
associated with an increased risk of AT and ATR by 37% and 116%, respectively, compared with lower LDL-C. Higher LDL-C level
was associated with an increased risk of AT and ATR by 10% and 16%, respectively, in the obese group (BMI 25 kg/m2
).
Conclusion: Dyslipidemia was related to the development of AT and ATR. The association of higher LDL-C levels with AT and ATR
risk was more pronounced in underweight than in overweight and obese individuals.
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NewsBot · Nov 17, 2022

Dyslipidemia is Associated with an Increased Risk of Achilles Tendinopathy and Tendon Rupture to a Greater Extent in Underweight Than in Obese Subjects
Jun Young Choi et al
Source

Introduction/Purpose:
The association between dyslipidemia and Achilles tendinopathy (AT) or Achilles tendon rupture (ATR) remains controversial, although some studies have been reported on the subject. This study aimed to evaluate the correlation of dyslipidemia and the risk of AT or ATR, and its association with body mass index (BMI), by assessing data from a nationwide population-based cohort.
Methods:
We used the National Health Insurance database, which includes the entire South Korean population to follow-up subjects who participated in the National Health Screening Program (NHSP) from January 2009 to December 2010. Participants diagnosed with AT or ATR before December 31, 2017, were selected. The variables were age, sex, frequency of high-intensity exercise per week, BMI, waist circumference, low-density lipoprotein cholesterol (LDL-C) levels, triglyceride (TG) levels, high- density lipoprotein cholesterol (HDL-C) levels, fasting blood glucose levels, and systolic blood pressure. Multivariate Cox proportional hazards regression was used for data analysis.
Results:
A total of 16,830,532 subjects were included. Of these, 125,814 and 31,424 subjects developed AT and ATR, respectively. A higher level of LDL-C was associated with an increased risk of both AT (adjusted hazard ratio [HR], 1.16) and ATR (adjusted HR, 1.18). A slightly increased risk of AT was observed in subjects with higher TG levels (adjusted HR, 1.03), whereas higher HDL-C level was associated with a slight risk reduction for AT (adjusted HR, 0.95). However, no significant association was observed between higher TG or HDL-C levels and ATR. In the underweight group (BMI < 18.5 kg/m2), a higher LDL-C level was associated with an increased risk of AT and ATR by 37 and 116%, respectively, compared with lower LDL-C. Higher LDL-C levels was associated with an increased risk of AT and ATR by 10 and 16%, respectively, in the obese group (BMI >= 25 kg/m2).
Conclusion:
Our results support the hypothesis that dyslipidemia was related to the development of AT and ATR. The association of higher LDL-C levels with AT and ATR risk was more pronounced in underweight than in overweight and obese subjects.
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NewsBot · Apr 11, 2024

Mild untreated hypercholesterolaemia affects mechanical properties of the Achilles tendon but not gastrocnemius muscle
Brooke K Coombes et al
Journal of Biomechanics March 2024,

Tendon xanthoma and altered mechanical properties have been demonstrated in people with familial hypercholesterolaemia. However, it is unclear whether mild, untreated hypercholesterolaemia alters musculotendinous mechanical properties and muscle architecture. We conducted a case-control study of adults aged 50 years and over, without lower limb injury or history of statin medication. Based on fasting low-density lipoprotein (LDL) cholesterol levels, 6 participants had borderline high LDL (>3.33 mmol/L) and 6 had optimal LDL cholesterol (<2.56 mmol/L). Using shear wave elastography, shear wave velocity (SWV) of the Achilles tendon and gastrocnemius medialis muscle (a proxy for stiffness), along with muscle fascicle length and pennation angle were measured under four passive tensile loads (0, 0.5, 1.0, 1.5 kg) applied via a pulley system. Differences between groups were found for tendon SWV but not muscle SWV, fascicle length or pennation angle. Participants with hypercholesterolaemia showed greater SWV (mean difference, 95 % CI: 2.4 m/s, 0.9 to 4.0, P = 0.024) compared to the control group across all loads. These findings suggest that adults with mild hypercholesterolaemia have increased tendon stiffness under low passive loads, while muscle was not affected. Future research is needed to confirm findings in a larger cohort and explore the impact of hypercholesterolaemia on tendon fatigue injury and tendinopathy.
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