Asymptomatic Achilles tendon pathology in male distance runners

NewsBot · Jul 3, 2019

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Prevalence and factors associated with asymptomatic Achilles tendon pathology in male distance runners
Kevin Lieberthal et al
Physical Therapy in Sport; Volume 39, September 2019, Pages 64-68

Highlights
•Tendon pathology is frequently observed in male runners with no history of tendon pain.
•This study evaluated experienced male distance runners between the ages of 25 and 55 years.
•Greater running years is an associated factor for tendon pathology in these male distance runners.
•When clinicians interpret ultrasound findings in male distance runners they should therefore consider running history.
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Objectives
This study investigated the prevalence of tendon pathology and associated factors in experienced, high mileage male endurance runners with no history of Achilles tendon pain.

Design
Cross-sectional study.

Setting
Achilles tendinopathy is a debilitating running injury affecting 50% of distance runners over their lifetime. It is diagnosed through a clinical examination and imaging, usually grey scale ultrasound (US) imaging. US imaging studies have shown that pathological changes can occur in asymptomatic individuals with no tendon pain.

Participants
Thirty seven male runners who had never had Achilles tendon pain.

Main outcome measures
Participants completed a running history survey, had their height, body mass, waist circumference, and ankle dorsiflexion range of movement (ROM) measured, and their tendons were assessed (normal, abnormal) using US imaging.

Results
Almost half (46%) of these asymptomatic distance runners had at least one abnormal tendon. The runners with tendon pathology had significantly (p = 0.024) more years of running training (abnormal: median 20 years, interquartile range 6–25.5) than runners with no pathology (normal: median 7 years, interquartile range 5–15). No other significant differences between the groups were identified.

Conclusions
Asymptomatic male distance runners had a high incidence of tendon pathology. Increased running years was associated with pathology in the Achilles tendon...
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NewsBot · Jul 3, 2019

Related Thread:
Prevalence of Asymptomatic Achilles Tendinosis

NewsBot · Sep 11, 2019

Using Ultrasound Measurement of the Achilles Tendon in Asymptomatic Runners to Assist in Predicting Tendinopathy
Christopher Kudron MD Morgan Jake Carlson MD Adele Meron MD Balaji Sridhar MD, PhD Rachel Brakke Holman MD
06 September 2019 https://doi.org/10.1002/jum.15125

Objectives
The Achilles tendon is the strongest tendon in the human body, and Achilles tendinopathy is common in athletes due to the stress imparted by repetitive forces. The prevalence of Achilles tendon abnormalities in asymptomatic elite runners is unknown. Since there is a substantial risk of developing symptomatic tendinopathy in those with abnormal tendons, identifying those asymptomatic athletes with abnormal tendons and characterizing baseline characteristics of elite runners using ultrasound (US) are valuable injury prevention tools.

Methods
This study used US to evaluate the Achilles tendons of 27 asymptomatic National Collegiate Athletic Association Division I cross‐country athletes and performed correlations between dominant and nondominant side tendon size (cross‐sectional area [CSA] and thickness) and athlete characteristics. Tendons were also assessed for signs of abnormalities that were suggestive of Achilles tendinopathy.

Results
The prevalence of tendon abnormalities in asymptomatic collegiate runners was 11%. Among the participants included in this study, dominant and nondominant Achilles tendons did not vary significantly in thickness or CSA (P > .05). The CSA was found to correlate with height, weight, sex, body mass index, and miles run per week (P < .05). Thickness was found to correlate best with miles run per week (P < .05).

Conclusions
A US evaluation of the Achilles tendon has potential to identify changes in tendon size in addition to abnormalities consistent with tendinopathy. As more normative values are identified among various populations, tendon size may have prognostic value for collegiate athletes in the evaluation of Achilles tendinopathy.
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NewsBot · Mar 7, 2020

Sonographic tendon abnormalities can predict symptomatic tendinopathy in marathon runners
Sarah Eby, Masaru Teramoto, Rudi Zurbuchen, Keith Cummings, Joy English, Daniel M Cushman
British Journal of Sports Medicine 2020;54:A22.

Background Tendinopathies of the patellar and Achilles tendons are common injuries among athletes and the general population. These injuries are costly, time-intensive to treat, and significantly limit activity. Predicting and eventually preventing these injuries is invaluable.

Objective Evaluate the relationship between sonographic tendon abnormalities and development of future injury in community marathon runners.

Design Prospective longitudinal cohort study. A blinded reviewer rated pre-race ultrasound images for tendon abnormalities, including thickening, hypoechogenicity, intratendinous delamination, or calcifications.

Setting 2019 Salt Lake City Marathon

Participants Marathon or half-marathon runners with no knee or ankle symptoms. 166 were screened; 138 completed the study (36.2±12.0 years of age, male: n=68).

Assessment of risk factors Ultrasound evaluation of bilateral Achilles and patellar tendons immediately prior to the race and longitudinal surveys of subsequent injury development immediately following the race, and 1 and 3 months post-race.

Main outcome measurements Patellar or Achilles injury development. Statistical analyses included calculating relative risk (RR) with a 95% confidence interval (CI) and hazard ratio (HR) with a 95% CI from the Cox proportional hazards (PH) model.

Results Sonographic abnormalities were found among 12.3% (left Achilles) and 26.8% (right patellar) of runners. Runners with sonographic abnormalities were 2 times (RR=2.20, 95% CI=1.15, 4.22, p=0.040) more likely to develop pain in the Achilles tendon within three months compared to those with normal ultrasounds. The Cox PH model indicated that sonographic abnormalities were associated with 2 times (HR=2.35, 95% CI=1.10, 4.99, p=0.027) higher risk of developing post-race pain in the Achilles tendon after adjusting for runners’ demographics and training regimens. No significant findings were observed between sonographic abnormality and post-race pain in the patellar tendon for the current observation period.

Conclusions Pre-race sonographic Achilles tendon abnormalities are associated with development of Achilles tendon pain within 3 months. Subsequent injury development, including at 6, 9, and 12-months post-race is pending.
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NewsBot · May 20, 2020

Ultrasound imaging evaluation of structural and textural features in asymptomatic achilles tendons in pre-professional dancers: A cross-sectional study
Blancade-la-Cruz-Torres et al
Physical Therapy in Sport; 19 May 2020

Highlights
•A lower echointensity in asymptomatic AT was observed for the heterogeneous group.
•A higher echovariation in asymptomatic AT was observed for the heterogeneous group.
•Tendon echogenicity did not interact with performance variables.
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Objective
To evaluate performance descriptors, sociodemographics variables and tendon echogenicity of asymptomatic Achilles tendons and to compare the echotexture from different classification subgroups.

Design
A prospective, randomized cross-sectional study was carried out.

Setting: laboratory of university.

Participants
Forty-two Achilles tendons (AT) were recruited from pre-professional dancers. Based on the echogenicity pattern, the sample was divided into two groups (n = 21, Heterogeneous group; n = 21, Homogeneous group).

Main outocome measures
Ultrasound images and ImageJ measurements were performed to evaluate thickness (AT-TH), echointensity (EI) and echovariation (EV), in addition to a balance and endurance test were measured as performance parameter.

Results
EI (p = 0.001) and EV (p = 0.001) reported statistically significant differences between groups. AT-TH, endurance test, balance test, years of dance, training hours per week and average pointe hours per week did not showed differences between groups. A multivariate prediction model between groups and the echotexture variables (EI (R2 = 0.569; EV (R2 = 0.341)) were determined.

Conclusion
Asymptomatic AT of heterogeneous group showed a lower EI and a higher EV compared to homogeneous group. Tendon echogenicity did not interact with performance variables.
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NewsBot · Jun 24, 2020

Prevalence of Abnormal Ultrasound Findings in Asymptomatic Posterior Tibial Tendons
F. Baker Mills, IV, MS, Kevin Williams, MD, Christopher H. Chu, MD, ...
Foot & Ankle International June 21, 2020

Background:
Posterior tibial tendon dysfunction (PTTD) is a pathological condition that can cause failure of the posterior tibial tendon (PTT). Initially, patients with PTTD are often asymptomatic, making early identification and treatment challenging. Certain ultrasound (US) characteristics have been implicated in the presence of tendinopathy, but their frequency has yet to be assessed in the PTT. The purpose of this study was to identify and report on the frequency of incidental, or potentially early subclinical, tendinopathic US characteristics in asymptomatic PTTs.

Methods:
Following institutional review board approval, 150 participants underwent a bilateral-comprehensive US assessment. The resulting images were reviewed and assessed to identify the presence of abnormalities demonstrated to represent tendinopathy.

Results:
Overall, 266 tendons were assessed and 128 (48.1%) were determined to have at least one tendinopathic trait. Specifically, 51 (19.2%) had circumferential fluid, 69 (25.9%) had noncircumferential fluid, 22 (8.3%) had thickening, 31 (11.7%) had heterogenicity, 19 (7.1%) had hyperemia, and 2 (0.8%) had calcification. Additionally, Caucasian participants were found to be nearly 3 times more likely to have tendinopathic findings when compared with African American participants.

Conclusion:
Sixty-seven percent of participants and 48.1% of PTTs evaluated had at least one tendinopathic feature identified on US. The prevalence rates of these findings, observed in participants, were as follows: noncircumferential fluid, circumferential fluid, heterogenicity, and thickening. Knowing the frequency of these traits may help clinicians to identify subclinical tendinopathy in the PTT before it progresses to PTTD.
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NewsBot · Jul 30, 2020

MRI features of and factors related to ankle injuries in asymptomatic amateur marathon runners
Wanzhen Yao, Yanjing Zhang, Li Zhang, Jing Zhou, Yi Zhang, Xiaozhong Zheng & Jianping Ding
Skeletal Radiology (2020)

Objective
To analyze the MRI manifestations of and factors related to ankle injuries in asymptomatic amateur marathon runners.

Materials and methods
A total of 113 amateur marathon runners without any ankle joint symptoms were recruited. Each participant was asked to complete a questionnaire at the beginning of the study and underwent MRI of the ankle. The MRI manifestations of ankle injuries were summarized, and binary logistic regression analysis was applied to analyze the factors related to ankle injuries.

Results
The main MRI features were bone marrow edema-like signal intensity, peritendinous effusion, and partial lateral collateral ligament injury. Others included Achilles tendinopathy, cyst-like lesions, osteochondral lesions, and subcutaneous soft tissue edema. The risk factor for bone marrow edema-like signal intensity in amateur marathon runners was a rearfoot strike pattern (p = 0.028, OR = 1.172); the risk factors for peritendinous effusion were a higher weekly running distance (p = 0.013, OR = 1.685) and increased running years (p = 0.039, OR = 1.113), whereas a rearfoot strike pattern (p = 0.005, OR = 0.831) was a protective factor for peritendinous effusion; the risk factor for Achilles tendinopathy was increased age (p = 0.008, OR = 1.412); the risk factors for anterior talofibular ligament injury were a rearfoot strike pattern (p = 0.017, OR = 1.346) and higher weekly running distance (p = 0.022, OR = 1.171); and the factors for calcaneofibular ligament injury were a higher weekly running distance (p = 0.029, OR = 1.570) and rearfoot strike pattern (p = 0.035, OR = 1.463).

Conclusion
The main MRI features of asymptomatic amateur marathon runners are bone marrow edema-like signal intensity, peritendinous effusion, and partial lateral collateral ligament injury. In addition, increased age, increased running years, higher weekly running distance, and different foot strike patterns are risk factors for ankle injuries
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NewsBot · Aug 19, 2020

Ultrasound findings are not associated with tendon pain in recreational athletes with chronic Achilles tendinopathy
Nonhlanhla S. Mkumbuzi Oscar H. Jørgensen Trevor S. Mafu Alison V. September Michael Posthumus Malcolm Collins
15 July 2020

Achilles tendinopathy (AT) is associated with pain and altered ultrasound (US) and color Doppler (CD) findings. However, the relationship between them is equivocal, perhaps because previous studies have only used the VISA‐A scale as the measure of tendon pain. To determine the relationship between tendon US and CD findings and self‐reported pain using the VISA‐A, Short‐form McGill Pain Questionnaire (sf‐MPQ), and Short‐form Brief Pain Inventory (sf‐BPI). Recreational athletes with AT rated their tendon pain on the VISA‐A, sf‐MPQ, and sf‐BPI. The Achilles tendons of runners with (TEN, n = 127) and without tendinopathy (CON, n = 103) were examined using conventional grayscale ultrasound and CD settings. Participants with AT had thicker tendons (mm) (median [IQR]) [TEN‐ 6.2 (5.3‐7.9) vs CON 5.5 (4.8; 6.0)] (P < 0,001); abnormal tendon ultrasound appearances (P = .001); and more neovessels than healthy controls (P < .001). No differences were noted between tendon pain scores and US or CD abnormalities (P > .05). Tendinopathy is associated with US and CD changes that may be of some prognostic value. The mismatch between patient‐reported symptoms and US and CD findings could be indicative of the need to standardize US and CD protocols in order to enhance comparisons across the studies.
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NewsBot · May 14, 2021

Shear wave elastography assessment and comparison study of the Achilles tendons in optimally conditioned asymptomatic young collegiate athletes
Felix M Gonzalez et al
Skeletal Radiol. 2021 May 8

Objective: To assess the functional parameters of the Achilles tendons among asymptomatic college level athletes using shear wave elastography (SWE) and to describe the relationship to athlete demographics and anthropometric lower extremity measurements.

Material and methods: Sixty-five athletes were included in this IRB-approved study. SWE measurements were made on two tendon positions (neutral state and active maximum dorsiflexion) with two different probe orientations (longitudinal and transverse). Associations were assessed with BMI, tibial/foot length, type of sports, and resting/maximal dorsiflexion-plantar flexion angles.

Results: Thirty-five (53.8%) males and 30 (46.2%) females with an overall mean age of 20.9 years (± 2.8), mean height of 176 cm (± 0.11), and mean weight of 74.1 kg (± 12) were studied. In the neutral state, the mean wave velocity of 7.5 m sec-1 and the mean elastic modulus of 176.8 kPa were recorded. In active maximum dorsiflexion, the mean velocity was 8.3 m sec-1 and mean elastic modulus was 199 kPa. On the transverse view, the mean velocity and elastic measurements were significantly lower (p = 0.0001). No significant differences in SWE parameters were seen between male and female athletes regardless of probe orientation (p < 0.05) with SWE values being higher in the running group vs non-running group (p < 0.05). In neutral state, longitudinal SWE measurements correlated with the tibia-foot length whereas transverse measurements correlated with the tendon diameter and ankle resting angle (ARA) (p < 0.005).

Conclusion: SWE can distinguish functional differences in Achilles tendon stiffness between athletes engaged in running-intensive sports compared with other athletes.
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NewsBot · Jul 5, 2021

Explaining Variability in the Prevalence of Achilles Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals
Journal of Orthopaedic & Sports Physical Therapy

Objective
To estimate the prevalence of, and factors associated with, Achilles tendon abnormalities observed on imaging in asymptomatic individuals.

Design
Systematic review with stratified meta-analysis and meta-regression.

Literature Search
Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science were searched from 1980 to August 2020.

Study Selection Criteria
We included studies that reported the prevalence of Achilles tendon abnormalities, observed with any imaging modality, in an asymptomatic population. We excluded studies if participant mean age was younger than 12 years or if participants had current/previous lower-limb tendon injuries/symptoms or other systemic conditions.

Data Synthesis
Random-effects proportion meta-analysis was used to estimate prevalence. We used meta-regression for continuous variables (mean age and body mass index [BMI], sample size, proportion of female participants) and stratified categorical variables (imaging modality and participation in physical activity) to explain between-study heterogeneity.

Results
We included 91 studies (10 156 limbs, 5841 participants). The prevalence of Achilles tendon abnormalities on imaging ranged from 0% to 80% per participant. Between-study heterogeneity was high (I2>90%, P<.001), precluding data pooling. Between-study heterogeneity was partly explained by participant mean BMI (slope, 2.8% per 1-unit increase in BMI; 95% confidence interval: 0.57%, 5.03%; P = .015) and participation in physical activity per limb, and mean age of 40 years old or older (P = .022) per participant.

Conclusion
There was substantial variability in the prevalence of Achilles tendon abnormalities on imaging in asymptomatic individuals. Higher prevalence of abnormalities was associated with older age (40 years old or older), higher BMI, and participation in physical activity. A large proportion of heterogeneity remains unaccounted for, likely due to variations in abnormality definitions and study design
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NewsBot · Jun 3, 2022

Self-reported foot strike patterns and sonographic evidence of Achilles tendinopathy in asymptomatic marathon runners
Scott M. Marberry,Sara E. Filmalter,George G.A. PujalteORCID Icon,James C. Presley,Kristina F. DeMatas,Daniel P. Montero
Journal of Sports Sciences: 31 May 2022

It is unknown whether ultrasound findings and symptoms of Achilles tendinopathy in runners correlate with foot strike patterns. We aimed to examine the relationships among Achilles tendon ultrasound findings in runners with or without Achilles tendinopathy, their foot strike patterns, and their training regimens. We recruited marathon runners 18 years of age or older with no history of Achilles tendon pain or surgery participating in the 2018 DONNA Marathon. Participants completed surveys and underwent Achilles tendon sonographic evaluations and were categorized by foot strike patterns. Seventy-nine runners were included; 22 (28%) with forefoot, 30 (38%) midfoot, and 27 (34%) hindfoot strike patterns. Foot strike pattern was not associated with tendon hyperaemia (P = 1.00) or hypoechogenicity (P = .97), and there was no association of cross-sectional area of the Achilles tendon with peak weekly distance while training. Sonographic characteristics of Achilles tendinopathy did not correlate with foot strike patterns or training regimens. Although not statistically significant, it is worth noting that cross-sectional area was 1 mm2 larger per every 1 kg/m2 increase in body mass index.
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NewsBot · Aug 9, 2023

Prevalence of Sonographic Achilles Tendon, Patellar Tendon, and Plantar Fascia Abnormalities in Division I Collegiate Athletes From a Variety of Sports
Cushman, Daniel et al
Clinical Journal of Sport Medicine ():10.1097/JSM.0000000000001183, August 4, 2023. | DOI: 10.1097/JSM.0000000000001183

Objective:
This study aimed to determine the prevalence of ultrasound abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among a large cohort of collegiate student-athletes.

Design:
Observational cross-sectional study.

Setting:
Three Division I institutions.

Participants:
243 student-athletes participated in this study. Exclusion criteria included those younger than 18 years or who underwent prior surgery/amputation of structures, including anterior cruciate ligament (ACL) surgeries with patellar tendon grafts.

Interventions:
Ultrasound examination of the Achilles tendon, patellar tendon, and plantar fascia of each leg was performed. An experienced sonographer reviewed each tendon video in a blinded manner, with a separate experienced sonographer separately reviewing to establish inter-rater reliability.

Main Outcome Measures:
The primary outcome measured was the presence of any sonographic abnormality including hypoechogenicity, thickening, or neovascularity.

Results:
Ultrasound abnormalities were identified in 10.1%, 37.2%, and 3.9% of all Achilles tendons, patellar tendons, and plantar fasciae, respectively. Abnormalities were significantly associated with the presence of concurrent pain for all structures (P < 0.01). Specifically, athletes with sonographic abnormalities were approximately 4 times [relative risk (RR) = 4.25; 95% confidence interval (CI), 2.05-8.84], 6 times (RR = 5.69; 95% CI, 2.31-14.00), and 5 times (RR = 5.17; 95% CI, 1.76-15.25) more likely to self-report pain in the Achilles tendon, patellar tendon, and plantar fascia, respectively.

Conclusions:
This multi-institutional study completed at 3 Division I institutions is the largest study of its kind to identify the prevalence of sonographic abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among collegiate student-athletes of various sports.
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Asymptomatic Achilles tendon pathology in male distance runners

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Asymptomatic Achilles tendon pathology in male distance runners

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Prevalence of Asymptomatic Achilles Tendinosis

MRI features in asymptomatic amateur marathon runners

Structure, Flexibility and Function Variables that Discriminate Asymptomatic Foot Types

Elevated pain threshold in patients with asymptomatic diabetic neuropathy

Asymptomatic peroneal tendon pathology

Is It Unethical to Prescribe Orthoses for Children with Asymptomatic Flatfoot Deformity?

Plantar fascia changes in asymptomatic population

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