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Patellar and Achilles tendinopathy: sclerosing injections and ultrasound guided arthroscopic shaving
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine. (idrottsmedicin)ORCID iD: 0003-1225-2099
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Chronic painful tendinopathy is a common cause for elite- and recreational athletes to stop or decrease the level of their sports activity. Recent research on innervation patterns, histopathology and possible pain mechanisms in tendons has led to an increased knowledge about the chronic painful tendon. Ultrasound (US) and colourDoppler (CD) examination showing localized high blood flow, inside and outside regions with structural tendon abnormalities, has been shown to be of importance for tendon pain. Immuno-histochemical analyses of biopsies have shown sensory and sympathetic nerves in close relation to the high blood flow outside the tendon. These findings have led to new ideas about development of new treatment methods for chronic painful tendinopathy. In study I, we evaluated the already in use, US-guided sclerosing polidocanol injection treatment of midportion Achilles tendinopathy, using two different concentrations of the substance. This study aimed to find out if there was a faster return to pain-free activity by using the concentration 10 mg/ml compared to the formerly used 5 mg/ml. There were no significant differences in the clinical results between the groups. In study II - Technical note, we aimed to develop a new one-stage surgical treatment method for patellar tendinopathy. This method was based on research concerning the innervation patterns and US and CD findings in patellar tendinopathy/ “jumper’s knee”. Technically we added ultrasound guidance to knee arthroscopy to identify and visualize the region of interest during a surgical shaving procedure. In study III, we tested the newly invented US and CD-guided arthroscopic shaving technique in a pilot study. The short-term clinical results were promising and the majority of the patients returned to pain-free activity after a short rehabilitation period. In study IV, we compared the US and CD-guided artrhroscopic shaving method with the already in use sclerosing polidocanol injection treatment in a randomized study. At short-term follow-up, the patients treated with US and CD-guided arthroscopic shaving had significantly less pain during rest and activity, were significantly more satisfied with the treatment, and had a faster return to sports, compared to the patients in the sclerosing injection group. There were no complications. In study V, at longer-term followup (endpoint 46 months) there was a significant decrease in pain during activity in both groups. There were no remaining significant differences in the pain levels during activity between the groups. The tendon structure had improved significantly in both groups. There was a significant decrease in the antero-posterior thickness of the proximal patellar tendon in patients treated with US and CD-guided arthroscopic shaving, but not in the sclerosing injection group. The CD flow had diminished significantly in both groups, and there was a correlation between low CD flow and high patient satisfaction in both groups, The CD flow decreased faster in the surgical group than in the injection group. In conclusion, this newly invented US and CD-guided arthroscopic shaving treatment, focusing on treatment outside the tendon, has shown good clinical results with pain relief and a fast return to sports activity, in patients with patellar tendinopathy.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2013. , 128 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1585
Keyword [en]
arthroscopy, jumper’s knee, sclerosing injection, tendinopathy, ultrasound
National Category
Orthopedics
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:umu:diva-80194ISBN: 978-91-7459-696-0 (print)OAI: oai:DiVA.org:umu-80194DiVA: diva2:647344
Public defence
2013-10-04, Ejnarsalen, Capio Artro Clinic, Sophiahemmet, hus O, plan 3, Valhallavägen 91, Stockholm, 10:30 (Swedish)
Opponent
Supervisors
Available from: 2013-09-13 Created: 2013-09-11 Last updated: 2013-09-13Bibliographically approved
List of papers
1. Sclerosing polidocanol injections or arthroscopic shaving to treat patellar tendinopathy/jumper's knee?: a randomised controlled study
Open this publication in new window or tab >>Sclerosing polidocanol injections or arthroscopic shaving to treat patellar tendinopathy/jumper's knee?: a randomised controlled study
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2011 (English)In: British Journal of Sports Medicine, ISSN 0306-3674, E-ISSN 1473-0480, Vol. 45, no 5, 411-415 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Proximal patellar tendinopathy/jumper's knee (PT/JK) is well known to be difficult to treat. Recent studies using an ultrasound and colour Doppler-based treatment approach on the dorsal side of the tendon, sclerosing polidocanol injections and ultrasound-guided arthroscopic shaving, have shown promising clinical results.

OBJECTIVES: To compare the clinical effects after treatment with sclerosing polidocanol injections and arthroscopic shaving.

MATERIAL AND METHODS: 52 patellar tendons (43 men and two women) with ultrasound and colour Doppler-verified diagnosis of PT/JK were randomly assigned to treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections (group A) or ultrasound and colour Doppler-guided arthroscopic shaving (group B). All patients were involved in patellar tendon loading sports or recreational activities, and had had a long duration of pain symptoms from the proximal patellar tendon. Pain during patellar tendon loading activity, and at rest, before and after treatment (visual analogue scale; VAS), and patient satisfaction with the result of the treatment, was registered.

RESULTS: After treatment, the patients treated with arthroscopic shaving had a significantly lower VAS score at rest and during activity, and were significantly more satisfied compared with the patients in the sclerosing injection group.

CONCLUSIONS: Both treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections and arthroscopic shaving showed good clinical results, but patients treated with arthroscopic shaving had less pain and were more satisfied with the treatment result. Because surgical treatment is a one-stage treatment return to sports was faster in this group.

National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:umu:diva-53449 (URN)10.1136/bjsm.2010.082446 (DOI)21393261 (PubMedID)
Available from: 2012-03-27 Created: 2012-03-27 Last updated: 2017-12-07Bibliographically approved
2. Ultrasound- and Doppler-guided arthroscopic shaving to treat Jumper's knee: a technical note.
Open this publication in new window or tab >>Ultrasound- and Doppler-guided arthroscopic shaving to treat Jumper's knee: a technical note.
2007 (English)In: Knee Surg Sports Traumatol Arthrosc, ISSN 0942-2056, Vol. 15, no 11, 1400-3 p.Article in journal (Refereed) Published
Identifiers
urn:nbn:se:umu:diva-8336 (URN)17721702 (PubMedID)
Available from: 2008-01-17 Created: 2008-01-17 Last updated: 2013-09-13Bibliographically approved
3. Treatment of Jumper's knee: promising short-term results in a pilot study using a new arthroscopic approach based on imaging findings.
Open this publication in new window or tab >>Treatment of Jumper's knee: promising short-term results in a pilot study using a new arthroscopic approach based on imaging findings.
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2007 (English)In: Knee Surg Sports Traumatol Arthrosc, ISSN 0942-2056, Vol. 15, no 5, 676-81 p.Article in journal (Refereed) Published
Keyword
Adult, Arthroscopy, Female, Follow-Up Studies, Humans, Knee Joint/surgery/ultrasonography, Male, Neovascularization; Physiologic, Pain Measurement, Patellar Ligament/blood supply/innervation/*surgery/ultrasonography, Patient Satisfaction, Pilot Projects, Recovery of Function, Tendinopathy/*surgery/ultrasonography, Ultrasonography; Doppler; Color
Identifiers
urn:nbn:se:umu:diva-8337 (URN)17151848 (PubMedID)
Available from: 2008-01-17 Created: 2008-01-17 Last updated: 2013-09-13Bibliographically approved
4. Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol.
Open this publication in new window or tab >>Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol.
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2008 (English)In: Knee Surgery, Sports Traumatology, Arthroscopy, ISSN 0942-2056, E-ISSN 1433-7347, Vol. 16, no 9, 859-864 p.Article in journal (Refereed) Published
Abstract [en]

Two to three ultrasound (US) and colour Doppler (CD)-guided injections of the sclerosing substance Polidocanol (5 mg/ml) have been demonstrated to give good clinical results in patients with chronic midportion Achilles tendinopathy. This study aimed to investigate if a higher concentration of Polidocanol (10 mg/ml) would lead to a less number of treatments, and lower volumes, needed for good clinical results. Fifty-two consecutive Achilles tendons (48 patients, mean age 49.6 years) with chronic painful midportion Achilles tendinopathy, were randomised to treatment with Polidocanol 5 mg/ml (group A) or 10 mg/ml (group B). The patients and treating physician were blinded to the concentration of Polidocanol injected. All patients had structural tendon changes and neovascularisation in the Achilles midportion. Treatment was US + CD-guided injections targeting the region with neovascularisation (outside ventral tendon). A maximum of three treatments (6-8 weeks in between) were given before evaluation. Patients not satisfied after three treatments were given additional treatment with Polidocanol 10 mg/ml, up to five treatments. For evaluation, the patients recorded the severity of Achilles tendon pain during activity on a visual analogue scale (VAS), before and after treatment. Patient satisfaction with treatment was also assessed. At follow-up (mean 14 months) after three treatments, 18/26 patients in group A and 19/26 patients in group B were satisfied with the treatment and had a significantly reduced level of tendon pain (P < 0.05). After completion of the study, additional treatments with Polidocanol 10 mg/ml in the not satisfied patients resulted in 26/26 satisfied patients in both groups A and B. In summary, we found no significant differences in the number of satisfied patients, number of injections or volumes given, between patients treated with 5 or 10 mg/ml Polidocanol.

Place, publisher, year, edition, pages
Springer, 2008
Keyword
Achilles tendon, chronic pain, injections, polidocanol, randomized, controlled trial
National Category
Orthopedics Sport and Fitness Sciences Surgery
Identifiers
urn:nbn:se:umu:diva-22760 (URN)10.1007/s00167-008-0579-x (DOI)18633599 (PubMedID)
Funder
Swedish Research Council
Available from: 2009-05-18 Created: 2009-05-18 Last updated: 2017-12-13Bibliographically approved
5. Treatment of patellar tendinopathy with sclerosing injections or ultrasound-guided arthroscopic shaving: a long term follow-up of ultrasound findings and clinical results
Open this publication in new window or tab >>Treatment of patellar tendinopathy with sclerosing injections or ultrasound-guided arthroscopic shaving: a long term follow-up of ultrasound findings and clinical results
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(English)Manuscript (preprint) (Other academic)
National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:umu:diva-80268 (URN)
Available from: 2013-09-13 Created: 2013-09-13 Last updated: 2013-09-13Bibliographically approved

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