Sports Medicine Research: In the Lab & In the Field: Asymptomatic Achilles, Patellar, and Quadriceps Tendinopathy on Diagnostic Ultrasound (Sports Med Res)
Friday, November 11, 2011

Asymptomatic Achilles, Patellar, and Quadriceps Tendinopathy on Diagnostic Ultrasound

Asymptomatic Achilles, patellar, and quadriceps tendinopathy:  A longitudinal clinical and ultrasonographic study in elite fencers

Giombini A, Dragoni S, Di Cesare A, Di Cesare M, Del Bunono A, Maffulli N.  Scand J Med Sci Sports 2011:  doi:  10.1111/j.1600-0838.2011.01400.x

Tendinopathy is common among athletes of all shapes and sizes. Chronically tendinopathy is much more common than acute tendinopathy and is typically caused by overuse stress which causes collagen degeneration. Elite fencers perform repetitive motions during competition and therefore are prone to overuse conditions in the tendons of the lower extremity. With the advances in medical technology ultrasound has drastically improved and become more common in the sports medicine setting for diagnosing injuries. However, asymptomatic athletes commonly present with tendon abnormalities on diagnostic ultrasound due to the tissues adaptation to repetitive stress. This can make it difficult to diagnosis the source of pain or injury. Therefore, Giombini et al. examined whether ultrasound abnormalities in the Achilles, patellar, and quadriceps tendons of elite fencers changed over time and if those changes were related to the development of long-term symptoms. They examined 49 elite fencers from the Beijing Olympic Games that had no symptoms at baseline near the Achilles, patellar, or quadriceps tendon. The clinical assessment consisted of palpation and functional decline squats and single-leg drop jumps. Ultrasound examination consisted of both standard grey scale (standard imaging) and power Doppler (PD) for vascularity. The patient was positioned supine with the knee flexed to 30° to assess the quadriceps and patellar tendons. For the Achilles tendon, the patients were prone with the heels hanging over the table and the ankle was flexed to 90° (anatomical position). Anatomic landmarks were used to help increase repeatability of scans. Abnormalities were defined as the presence of at least one abnormal finding: 1) a focal hypoechoic region (dark region, indicative of swelling or the absence of collagen), 2) focal or diffuse thickening, 3) diffused hypoechogenity (possible degeneration of the tendon), and 4) abnormal vascularity within tendon). Thirty-seven athletes were reassessed clinically and with ultrasound 3 years later. The authors found that at the first assessment all three tendons (quadriceps, patellar, and Achilles) were thicker in the fencers with tendon abnormalities compared to normal tendons. At the first assessment 4 of the 74 asymptomatic Achilles tendons were abnormal. Three years later only 1 of these 4 abnormal asymptomatic patients became symptomatic and 1 of the 70 “normal” tendons became abnormal. At the first assessment, 8 of the 74 asymptomatic patellar tendons were abnormal and 3 years later 2 of the 8 abnormal tendons were symptomatic and 2 of the 66 “normal” tendons became abnormal. For the quad tendon at first assessment 3 of the 74 asymptomatic tendons were considered abnormal and 3 years later the same 3 were abnormal and still asymptomatic. No “normal” tendons developed symptoms during the 3 years.

This is an interesting longitudinal study examining if abnormal ultrasound findings are predictive of clinical symptoms. It was very impressive that the authors were able to attain such a high amount of athletes at a 3-year follow-up time point. Based on the results of the study, the development of symptoms may have several other factors other than ultrasound abnormalities, although it also seemed to be tendon specific. Fencers are commonly in a knee flexion position that may cause more patellar tendon abnormalities. The results demonstrated that a higher percentage of athletes with abnormal patellar tendon findings compared to the other tendons. Furthermore, 2 out of 8 the abnormal patellar tendons developed symptoms at the 3 year follow-up while no normal tendons became symptomatic. This study should be replicated with a larger sample size and in other overuse sports like cross country and baseball to determine if we could identify or screen athletes for ultrasound-based abnormalities that may predict future symptoms. In addition will rehabilitation cause a reversal of the abnormalities? Have you used ultrasound in this way?

Written by:  Stephen Thomas
Reviewed by: Jeffrey Driban

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Giombini, A., Dragoni, S., Di Cesare, A., Di Cesare, M., Del Buono, A., & Maffulli, N. (2011). Asymptomatic Achilles, patellar, and quadriceps tendinopathy: A longitudinal clinical and ultrasonographic study in elite fencers Scandinavian Journal of Medicine & Science in Sports DOI: 10.1111/j.1600-0838.2011.01400.x

5 comments:

Jeffrey B. Driban, PhD, ATC, CSCS said...

Steve, I think this raises an interesting question:

Is it that symptoms have several other factors other than US findings or that US shows changes that might not be pathologic but rather remodeling. Therefore, we need to figure out which types of abnormalities lead to symptoms and which are physiologic remodeling before this can be used for diagnosis. We similar issues in other fields.

Examples of physiologic remodeling being incorrectly listed as pathology:
With screening ECGs, normal exercise-induced remodeling may lead to false positives on the ECG tests. The new European recommendations were an attempt to address this issue. We also see it in osteoarthritis. One threshold for defining an incident case of knee osteoarthritis is osteophyte (bone spur) formation but in the physically active population there is evidence that peripheral osteophytes are a sign of adaptation to physical activity independent of disease.

Example of imaging findings being a risk factor for symptoms:
It has been suggested that structural changes in osteoarthritis should be considered a risk factor for osteoarthritis symptoms. This leaves it open so that structural changes don't always need to be symptomatic (which is this case).

Any thoughts on what we might be looking at in this study regarding these two scenarios (or both)?

Stephen J. Thomas, PhD, ATC said...

Jeff you bring up great points. Currently we don't know if the abnormalities in this study are in fact just remolding or actual structural injury. More research is needed to determine this and specifically basic science would be a better model to identify if abnormalities on ultrasound correlate with decreases in mechanical properties and collagen fiber alignment. Both of these variables would demonstrate if these changes are degeneration or normal remolding.

Ian Hix, ATC said...

This concept presents interesting findings; however, I think it is far from being clinically meaningful. I agree with Jeff in that the baseline findings are adaptations from the demands that the fencers have placed on the tendons over time and don’t need to be cause for symptoms of pathology. In my opinion, I consider the follow-up to be purely coincidental. Although I did not read the entire article, I wonder if the clinical assessment was thoroughly executed and if baseline measurements were similar overall. Many aspects just in looking at alignment and posture can have a considerable impact on tendinopathy, i.e. Q-angle, patellar positioning and movement, valgus and varus alignment, etc. This can also pertain to the achilles tendon with calcaneal varum and valgum. Furthermore, an injury history might pre-dispose the athlete to tendinoptathy. Again, I did not read the article, so these concerns might have already been addressed. I have seen ultrasound used in a similar manner examining the differences of anterior talofibular ligaments between individuals with healthy ankles and ones with CAI. Length and structural differences were found, which I think I could make a great correlation to chronic/overuse injuries specific to tendinopathy. Perhaps similar study designs may be used.

Stephen J. Thomas, PhD, ATC said...

Ian I agree, it is difficult to determine with any imagining tool if the changes seen are pathologic or adaptive. We see this a lot in baseball players shoulders. Often on MRI a pitcher will have what looks like is significant damage but have no symptoms. It always comes down to the "chicken or the egg." Ultimately with imagining tools we have to always treat the patient and not the image. The image is there to help support our clinical findings.

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