Overload and neovascularization of Achilles tendon

NewsBot · Jun 4, 2013

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Overload and neovascularization of Achilles tendons in young artistic and rhythmic gymnasts compared with controls: an observational study
A. Notarnicola, G. Maccagnano, M. Di Leo, S. Tafuri, B. Moretti
MUSCULOSKELETAL SURGERY; May 2013

The incidence of Achilles tendinopathy is very high in young female gymnasts (17.5 %). According to literature, ecography screenings show the tendons thickening, but at the same time it does not reveal a direct link to the clinical picture. The neovessels are involved in the pathophysiological process of Achilles tendinopathy. For this reason, we wanted to verify there between perfusion tendon values and the type of sport activity. We performed a clinical observational study monitoring the oximetry of the Achilles tendon and the epidemiological data of 52 elite female (artistic and rhythmic) gymnasts versus 21 age-matched controls. Analyzing the main limb, we revealed statistically higher oximetry values in the artistic gymnasts group (69.5 %) compared to the rhythmic gymnasts group (67.1 %) (t = 2.13; p = 0.01) and the sedentary group (66.2 %) (t = 2.70; p = 0.004), but we did not find any differences between rhythmic gymnasts group and the sedentary group (t = 0.68; p = 0.24). The multiple logistic regression model highlighted that the oximetry value of the main limb is not influenced by age, knowledge of the main limb, years of general and gymnastic sports activity (p > 0.05). We discovered an increase of Achilles tendon perfusion in the main limb in the artistic gymnast group. We hypothesize that specific figures of artistic sports activity are responsible for muscle overload and gastrocnemius-soleus group and, at the same time, these figures cause hyperperfusion of the tendon. Prospective longitudinal studies could explain if this could become a predictive sign of the next Achilles tendinopathy onset.
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Admin2 · Jun 5, 2013

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NewsBot · Sep 27, 2013

The Microvascular Volume of the Achilles Tendon Is Increased in Patients With Tendinopathy at Rest and After a 1-Hour Treadmill Run
Jessica Pingel, Adrian Harrison, Lene Simonsen, Charlotte Suetta, Jens Bülow and Henning Langberg
Am J Sports Med October 2013 vol. 41 no. 10 2400-2408

Background: Achilles tendinopathy (AT) is initiated asymptomatically and is therefore often discovered at a very late stage.
Purpose: To elucidate whether the microvascular volume (MV) of the Achilles tendon is elevated in patients with AT compared with healthy controls during pre-exercise rest, after acute exercise, and 24 hours after exercise. Additionally, this study investigated the muscle activation pattern of the gastrocnemius muscle and the relative elasticity of the Achilles tendon during a 1-hour treadmill run in healthy patients and in patients with AT.
Study Design: Controlled laboratory study.
Methods: Real-time harmonic contrast-enhanced ultrasound (CEU) measurements of the MV of the Achilles tendon were taken in 18 volunteers (9 patients with AT, 9 healthy controls). The CEU analyses were conducted before exercise, immediately after a 1-hour treadmill run, and 24 hours after exercise. Surface electromyography (EMG) signals of the gastrocnemius were recorded continuously during the 1-hour treadmill run.
Results: In both the controls and the patients with AT, the MV of the Achilles tendon was increased after exercise as compared with before exercise (P < .005). Additionally, the MV signal was significantly larger in the patients with AT before, immediately after, and 24 hours after the running exercise compared with values in healthy controls (P < .0001). The muscle activation pattern differed in patients with AT compared with controls in that controls had increased EMG amplitudes at the end of the 1-hour treadmill run in the medial and lateral gastrocnemius (P < .0001). Moreover, patients with AT had approximately 15% less elastic Achilles tendons at the beginning of the 1-hour treadmill run, a condition that did not change because of exercise.
Conclusion: Acute exercise increases the MV of the Achilles tendon in healthy patients and patients with AT in a similar manner. However, patients with AT have a significantly larger MV at all time points compared with healthy patients, supporting the hypothesis that microvascular changes may be involved in the pathogenesis of tendinopathy.
Clinical Relevance: This study underlines that tendon flexibility is altered in patients with AT and that CEU is a promising tool to establish the early diagnosis of this condition.
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NewsBot · Nov 18, 2013

Biomechanical and structural response of healing Achilles tendon to fatigue loading following acute injury
Benjamin R. Freedman, et al
Journal of Biomechanics; Available online 11 November 2013

Achilles tendon injuries affect both athletes and the general population, and their incidence is rising. In particular, the Achilles tendon is subject to dynamic loading at or near failure loads during activity, and fatigue induced damage is likely a contributing factor to ultimate tendon failure. Unfortunately, little is known about how injured Achilles tendons respond mechanically and structurally to fatigue loading during healing. Knowledge of these properties remains critical to best evaluate tendon damage induction and the ability of the tendon to maintain mechanical properties with repeated loading. Thus, this study investigated the mechanical and structural changes in healing mouse Achilles tendons during fatigue loading. Twenty four mice received bilateral full thickness, partial width excisional injuries to their Achilles tendons (IACUC approved) and twelve tendons from six mice were used as controls. Tendons were fatigue loaded to assess mechanical and structural properties simultaneously after 0, 1, 3, and 6 weeks of healing using an integrated polarized light system. Results showed that the number of cycles to failure decreased dramatically (37-fold, p<0.005) due to injury, but increased throughout healing, ultimately recovering after 6 weeks. The tangent stiffness, hysteresis, and dynamic modulus did not improve with healing (p<0.005). Linear regression analysis was used to determine relationships between mechanical and structural properties. Of tendon structural properties, the apparent birefringence was able to best predict dynamic modulus (=0.88–0.92) throughout healing and fatigue life. This study reinforces the concept that fatigue loading is a sensitive metric to assess tendon healing and demonstrates potential structural metrics to predict mechanical properties.
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NewsBot · Nov 22, 2013

The influence of physical activity during youth on structural and functional properties of the Achilles tendon
A. Lenskjold et al
Scandinavian Journal of Medicine & Science in Sports; Early View

Achilles tendinopathy is a highly prevalent sports injury. Animal studies show a growth response in tendons in response to loading in the immature phase but not after puberty maturation. The aim of this investigation was to examine the structural and material properties in long distance runners who were either physically active (HAY) or inactive (LAY) in young age. Twelve men in HAY group and eight men in LAY group participated. Structural, functional, and biochemical properties of Achilles tendon were estimated from magnetic resonance imaging, ultrasound video recordings, mechanical tests, and tendon biopsies, respectively. There was no difference between the groups with respect to tendon cross-sectional area or tendon free length. There was no difference between the groups with respect to maximal force or mechanical properties. The collagen content, enzymatic and nonenzymatic cross-link density did not differ between the groups, nor did collagen fibril density, diameter, and area. There was a correlation between age and pentosidine/collagen within the groups [(HAY: P < 0.05 and r2 = 0.47) and (LAY: P < 0.05 and r2 = 0.52)]. The data suggest that high or low activity during youth did not appreciably influence the mechanical, structural, or biochemical properties of the Achilles tendon in adult long distance runners.
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NewsBot · Dec 7, 2017

Achilles Tendon Cross Sectional Area Changes Over a Division I NCAA Cross Country Season.
SPONBECK, JOSHUA K.; PERKINS, CANDACE L.; BERG, MATTHEW J.; RIGBY, JUSTIN H.
International Journal of Exercise Science . 2017, Vol. 10 Issue 8, p1226-1234. 9p.

Tracking Achilles tendon cross sectional area (CSA) changes may help clinicians understand exercise adaptations and Achilles tendon injury mechanisms. To track adaptations in the Achilles tendon in response to a cross country season. Design: Longitudinal study. Musculoskeletal (MSK) ultrasound images were obtained in a research laboratory. Cross country athletes ran with no restrictions outdoors and indoors. Participants were Division I NCAA cross country athletes (N = 24, age = 19.9 ± 2.1 years, mass = 61.32 ± 20.16 kg, height = 168.92 ± 17.16 cm, sex = 8 males and 16 females). Achilles tendon CSA was obtained through MSK ultrasound imaging at a pre-season baseline measurement, every 3 weeks throughout the season, and at post-season for a total of 4 measurements. Participants followed their normal running regimen outlined by their cross country coach. The dependent variable was Achilles tendon CSA measured by ultrasound imaging. We used a repeated measures ANCOVA to determine differences in CSA over the cross country season. CSA increased from baseline (0.439 ± .081 cm), to 0.466 ± 0.096 cm at 3-weeks, to 0.471 ± 0.092 cm 6-weeks, and decreased to 0.451 ± 0.104 cm at the post-season measurement. The 3-week and 6-week measures significantly increased from baseline (F<sub>3,72</sub> = 8.575, p < .001). Achilles tendon CSA increased during the cross country season, but returned to baseline values at the end of a cross country season. Clinicians should be aware of the changing nature of the Achilles tendon CSA when treating cross country runners.
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NewsBot · Dec 9, 2017

Three-dimensional morphology and volume of the free Achilles tendon at rest and under load in people with unilateral mid-portion Achilles tendinopathy
Leila Nuri et al
Exp Physiol: 3 December 2017

Mid-portion Achilles tendinopathy (MAT) adversely affects free Achilles tendon (AT) structure and composition. However, it is not known how these pathological alterations associated with MAT change the normal three-dimensional (3D) morphology of free AT at rest and under load throughout the entire free tendon length. Here, we used 3D ultrasound to examine the effect of unilateral MAT on free tendon 3D morphology [length, cross-sectional area (CSA), antero-posterior (AP) diameter, and medio-lateral (ML) diameter] and volume at rest and during a sub-maximal (50%) voluntary isometric plantarflexion contraction bilaterally in individuals with unilateral MAT (n = 10) compared to a matched healthy control group (n = 10). The tendinopathic free AT had a greater CSA relative to the control tendons along the entire tendon length which was mainly driven by a greater tendon AP diameter. Under load, the tendinopathic tendon experienced greater longitudinal and transverse strains than the control tendons. In contrast to the control tendons, which experienced a reduction in tendon CSA and ML diameter and bulged along the AP axis and behaved iso-volumetrically under load, the tendinopathic tendon experienced a reduction in tendon CSA, AP diameter, ML diameter, and an overall volume reduction. Overall, these findings suggest that the magnitude of longitudinal strain and volume change and the corresponding magnitude and direction of transverse strain under load are altered in MAT compared to normal tendon. These findings are indicative of a fundamental reorganization of the tendon matrix and alterations in tendon fluid content and distribution under load in tendinopathic tendon.
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NewsBot · Mar 19, 2020

Ultrasound imaging features of the Achilles tendon in dancers. Is there a correlation between the imaging and clinical findings? A cross-sectional study
Blancade-la-Cruz-TorresaIreneBarrera-García-MartínaMónica de laCueva-ReguerabMariaBravo-AguilarbVanesaAbuin-PorrasbCarlosRomero-Moralesb
Physical Therapy in Sport; 18 March 2020

Highlights
•Dancers are clearly athletes in the degree to which sophisticated physical capacities are required to perform at a high level. For this reason, they are particularly susceptible to a wide variety of musculoskeletal injuries.
•Ultrasound imaging is an important tool for the clinicians to control training load, to improve performance and to prevent injuries.
•Asymptomatic classic dancers had a high incidence of tendon pathology.
•Dancing years were moderately correlated with achilles tendon thickness.
•These abnormalities may not affect dance performance.
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Objectives
To analyze the prevalence of tendon pathology and performance associated in pre-professional classic dancers with no history of Achilles tendon (AT) pain. Design: A cross-sectional study was conducted.

Participants
Twenty-nine classic ballet dancers without AT pain (58 tendons) were recruited. The tendons were classified (normal, abnormal) using ultrasound imaging (USI). Cross-sectional area (CSA) and thickness of flexor hallucis longus (FHL) muscle were measured using USI. Range of movement (ROM) of the first metatarsophalangeal join, balance test, endurance test and vertical jump were measured (bilaterally) as performance variables.

Results
More than a half (62%) of the participants had at least one abnormal tendon, with 45% of the dancers in the abnormal group having bilateral abnormalities. Dancers with AT pathology had significantly more years of dancing and number of weekly pointe hours than those with no pathology on US imaging. No significant differences between the groups were identified for the rest of the variables. Dancing years were moderately correlated with AT thickness.

Conclusions
Asymptomatic classic dancers had a high incidence of tendon pathology. Increased dancing years was associated with pathology in the AT. Nevertheless, these abnormalities may not affect dance performance.
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NewsBot · Aug 21, 2021

Six-weeks of intensive rehearsals for the Swan Lake ballet shows ultrasound tissue characterization changes of the Achilles tendons in dancers
Charlotte Anker-Petersen, Birgit Juul-Kristensen, Jarrod Antflick, Henrik Aagaard, Christopher Myers, Anders Ploug Boesen, Eleanor Boyle, Per Hölmich, Kristian Thorborg
18 August 2021 https://doi.org/10.1111/sms.14034

The objective was to investigate, first, whether six weeks of intensive ballet dance exposure is associated with structural and clinical changes in the Achilles tendon; second, the importance of demographics, self-reported Achilles pain, and generalized joint hypermobility (GJH).

Data were collected at baseline and at six weeks’ follow-up, using Achilles tendon ultrasound tissue characteristics (UTC) as primary outcome (percentage distribution of echo-type I-IV; type I=intact and aligned bundles, type II=discontinuous/wavy bundles, type III=fibrillar, type IV=amorphous cells/fluid). Secondary outcomes included clinical signs of Achilles tendinopathy, Achilles tendon pain during single-leg heel raise, self-reported symptoms (VISA-A questionnaire) and GJH. Sixty-three ballet dancers (aged 18-41) participated. From baseline to follow-up, UTC echo-type I decreased significantly (β=-3.6, p=0.001; 95% CI: -5.8;-1.4), whereas echo-type II increased significantly (β=3.2, p<0.0001, 95% CI: 1.6;4.8). Furthermore, a significant effect of limb (left limb showed decreased echo-type I and increased echo-type III+IV) and sex (women showed decreased echo-type I and increased in type II) was found. No significant changes in the remaining secondary outcomes were found.

Ballet dancers showed structural changes in UTC, corresponding to a decreased echo-type I distribution after six weeks of rehearsing for Swan Lake ballet. No changes in self-reported symptoms, clinical signs of Achilles tendinopathy and single-leg heel raise test were seen from pre- to post-rehearsal. Thus, UTC changes in the Achilles tendon seem to appear earlier than clinical signs of tendinopathy.
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