Achilles tendinopathy is prevalent and potentially incapacitating in athletes involved in running sports. It is a degenerative, not an inflammatory, condition. Most patients respond to conservative measures if the condition is recognised early. Surgery usually involves removal of adhesions and degenerated areas and decompression of the tendon by tenotomy or measures that influence the local circulation.

https://bjsm.bmj.com/content/bjsports/36/4/239.full.pdf

Patellar tendinopathy: some aspects of basic science and clinical management.

BackgroundIdentifying factors associated with favorable or unfavorable outcomes would provide patients with accurate expectations of the arthroscopic marrow stimulation techniques.PurposeTo investigate the prognostic significance and optimal measures of defect size in osteochondral lesion of the talus as treated with arthroscopy.HypothesisA critical, or threshold, defect size may exist at which clinical outcomes become poor in the treatment of osteochondral lesion of the talus.Study DesignCohort study; Level of evidence, 3.MethodsIn sum, 120 ankles underwent arthroscopic marrow stimulation treatment for osteochondral lesion of the talus and were evaluated for prognostic factors. Clinical failure was defined as patients’ having osteochondral transplantation or an American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score less than 80. Linear regression analysis and the Kaplan-Meier method were used to identify optimal cutoff values of defect size.ResultsEight ankles (6.7%) required oste...

Osteochondral lesion of the talus: is there a critical defect size for poor outcome?

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010

Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification systems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well as to describe current approaches to diagnosis and management.

Current Concepts in the Diagnosis and Treatment of Osteochondral Lesions of the Ankle

BackgroundResults of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.PurposeTo compare the effectiveness of 2 management strategies—group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.Study DesignRandomized controlled trial; Level of evidence, 1.MethodsSixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule...

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Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy A Randomized Controlled Trial

BackgroundThe treatment options of talar osteochondral lesions are numerous. Although studies show these treatments have been used with varying success, the ability to return to activity (RTA), including sports after treatment of talar dome injuries, have not been well documented.HypothesisA treatment plan that uses microfracture for Hepple stage 2 through 4 lesions and autogenous bone grafting for Hepple stage 5 lesions for athletes with articular lesions of the talus will produce a high rate of return to athletic activity.Study DesignCase series; Level of evidence, 4.MethodsPreoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores and RTA were assessed prospectively 2 to 8 years after surgery in high-demand (athletic) patients with articular injuries to the talar dome treated according to the above protocol over a 6-year period.ResultsThere were 26 microfracture procedures and 20 bone grafts to the talus. The AOFAS scores for both microfracture (preoperative, 54.6; postop...

Articular Talar Injuries in Athletes Results of Microfracture and Autogenous Bone Graft

Twenty-two navicular stress fractures sustained during athletic activity were retrospectively reviewed for return to activity time and the appearance of fracture pattern on computerized tomography. There were 10 females and nine males, with the average patient age being 27.2 years. Three patients sustained bilateral injuries at separate times. Average follow-up was 36.5 months. Nine patients underwent open reduction, internal fixation (some with bone grafting); this group's average return to activity (RTA) was 3.1 +/- 1.2 months (range, 1.5-5 months). Thirteen patients treated conservatively had an average return to activity of 4.3 +/- 2.8 months (range, 2-13 months). The difference between the two groups' RTA was significant (p = .02). Eleven patients utilized pulsed electromagnetic fields (PEMF) and had an average RTA of 4.2 +/- 3.4 months, 27.3% of those patients with PEMF also had surgery. Two conservatively treated fractures that took 5 and 8 months to RTA, respectively, re-fractured during the treatment process. Retrospective review showed CT fracture patterns in the frontal plane that were classified as: dorsal cortical break (type I), fracture propagation into the navicular body (type II), and fracture propagation into another cortex (type III). This is a proposed classification system. It includes modifiers "A" (avascular necrosis of a portion of the navicular); "C" (cystic changes of the fracture), and "S" (sclerosis of the margins of the fracture), the latter of which was most common in our series, particularly in continually symptomatic patients. Type I fractures were more likely to receive conservative treatment (p = .02) and type III fractures took significantly longer to heal than types I and II (p values .001 and .01, respectively). Type I and II injuries had an average RTA of 3.0 and 3.6 months, respectively. Type III injuries had an average RTA of 6.8 months. Based on our findings, we recommend surgery for patients with these modifiers, particularly with type II and III injuries. Conservative treatment may be prolonged, and requires at least 6 weeks of nonweightbearing in a below-knee cast/boot to be successful.

Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system

In a retrospective review of 102 patients treated for chondromalacia patellae and patellofemoral pain syndrome/retropatellar dysplasia (PFPS/ RPD), the effectiveness of semiflexible foot orthoses was investigated. The combined disorders were diagnosed in 89.3% of the patients. Subjects were 46 women and 54 men, aged 12 to 87 years (mean, 37.9 years; SD, 15.9), who exhibited excessive forefoot varus or rearfoot varus. The initial screening and clinical diagnosis were based on an examination by an orthopedist. Particular attention was directed to patellar crepitation, patellofemoral malalignment, Q-angle measurements, limitation of range of motion, and knee effusion. Patients were evaluated for the onset and duration of patellofemoral pain and degree of knee joint disease. Semiflexible orthoses for each subject were fabricated, based on a clinical lower extremity biomechanical examination. At their follow-up visit, 76.5% were improved and 2% were asymptomatic, showing a significant decrease in the level of pain with orthoses intervention (chi-square P < .001). Although multiple treatment modalities are used for these patients, the results suggest that the use of semiflexible orthoses is significant in reducing symptoms of PFPS/RPD. (J Am Podiatr Med Assoc 93(4): 264-271, 2003)

The Effect of Foot Orthoses on Patellofemoral Pain Syndrome

Background: The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is controversial. The objective of the present study was to test whether focused extracorporeal shock wave therapy is effective in relieving chronic heel pain diagnosed as plantar fasciitis. Methods: Two hundred and fifty subjects were enrolled in a prospective, multicenter, double-blind, randomized, and placebo-controlled U.S. Food and Drug Administration trial. Subjects were randomized to focused extracorporeal shock wave therapy (0.25 mJ/mm 2 ) or placebo intervention, with three sessions of 2000 impulses in weekly intervals. Primary outcomes were both the percentage change of heel pain on the visual analog scale composite score (pain during first steps in the morning, pain with daily activities, and pain with a force meter) and the Roles and Maudsley score at twelve weeks after the last intervention compared with the scores at baseline. Results: Two hundred and forty-six patients (98.4%) were available for intention-to-treat analysis at the twelve-week follow-up. With regard to the first primary end point, the visual analog scale composite score, there was a significant difference (p = 0.0027, one-sided) in the reduction of heel pain in the extracorporeal shock wave therapy group (69.2%) compared with the placebo therapy group (34.5%). Extracorporeal shock wave therapy was also significantly superior to the placebo therapy for the Roles and Maudsley score (p = 0.0006, one-sided). Temporary pain and swelling during and after treatment were the only device-related adverse events observed. Conclusions: The results of the present study provide proof of the clinically relevant effect size of focused extracorporeal shock wave therapy without local anesthesia in the treatment of recalcitrant plantar fasciitis, with success rates between 50% and 65%. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study.

Background: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. Methods: We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation. Results: A total of 219 surgical cases were available for review (140 males and 70 females; mean ± SD age at the time of surgery, 46.5 ± 12.6 years; age range, 16–75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after th...

Amol Saxena

Papers

Articular Talar Injuries in Athletes Results of Microfracture and Autogenous Bone Graft

Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system

The Effect of Foot Orthoses on Patellofemoral Pain Syndrome

Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study.

Wound Complications from Surgeries Pertaining to the Achilles Tendon