This document summarizes Achilles tendinopathy (AT), including its characteristics, diagnosis, and management. AT is a failed healing response in the Achilles tendon characterized by disrupted collagen fibers and increased non-collagenous matrix. The diagnosis is clinical based on symptoms like pain and swelling. Imaging like ultrasound and MRI can help with diagnosis and differentiate between insertional and non-insertional AT. Conservative management is usually first-line for 3-6 months and includes eccentric exercises, shockwave therapy, and injections. If conservative measures fail, surgery may be considered after 6 months of non-operative management. However, outcomes are variable with both conservative and surgical approaches and symptoms may recur.
This document provides guidelines for the diagnosis and management of syncope published by the European Society of Cardiology in 2009. It was developed in collaboration with several other cardiac societies. The guidelines cover definitions of syncope, classification of causes, epidemiology, risk stratification, diagnostic testing including tilt testing and electrocardiographic monitoring, treatment of reflex syncope, cardiac arrhythmias, and other structural cardiac issues that can cause syncope. The task force that created the guidelines consisted of experts from Europe and North America.
Nicola Maffulli
Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Surgery, Salerno, Italy and Queen Mary University of London, Centre for Sports and Exercise Medicine, London, England.
-
Surgical indications for muscle injuries
This document discusses several topics related to total knee arthroplasty (TKA), including:
1. Expectations for recovery after TKA are often misaligned between patients and surgeons, with over 50% of patients expecting higher levels of function than surgeons.
2. Moderate sports and physical activity after TKA do not appear to negatively impact implant durability or increase revision rates in the short or medium term. High-impact sports should still be avoided.
3. Knee rehabilitation protocols must account for numerous patient-specific variables to optimize outcomes, such as age, BMI, pre-operative activity level, type of implant, and adherence to home exercises. A one-size-fits-all approach is inadequate.
These guidelines from the European Society of Cardiology and European Association for Cardio-Thoracic Surgery provide recommendations on myocardial revascularization. The guidelines cover risk stratification, decision making processes, diagnostic imaging strategies, revascularization for stable coronary artery disease and acute coronary syndromes, and special patient populations such as those with diabetes or chronic kidney disease. The task force that developed the guidelines included experts from cardiology and cardiac surgery.
This document proposes a new classification system for muscle injuries called MLG-R. The MLG-R system classifies injuries based on their mechanism (M), location (L), relation to tendons/connective tissue (G), and whether it is a recurrent injury (R). Previous classification systems are reviewed which focused on grading or specific muscles. The new system aims to be reproducible, distinguish different injury categories, be easy to remember, and correlate to prognosis. Magnetic resonance imaging and ultrasound are important for accurately describing the location, size and tendon involvement of injuries. The MLG-R system is designed for hamstring injuries but could be expanded to other muscles.
Guias de manejo de cardiopatias en el embarazoLucelli Yanez
This document provides guidelines on the management of cardiovascular diseases during pregnancy from the European Society of Cardiology (ESC). It summarizes recommendations for treating conditions like congenital heart disease, valvular heart disease, hypertension, arrhythmias, and venous thromboembolism during pregnancy and delivery. The guidelines were developed by a task force of ESC members and endorsed by other societies. They are intended to help health professionals manage cardiovascular risks for both the mother and fetus/child. The guidelines cover topics like risk assessment, diagnostic testing, pharmacological and non-pharmacological treatment, and delivery timing and method. They aim to optimize outcomes for women with heart conditions who wish to become pregnant or are already pregnant.
Muscle tears are extremely common and are often recurrent. They are not as simple as we used to think and the advent of better imaging has proven that the site, size and location of the tear, together with the presence or otherwise of the tendon is crucial information especially for elite or professional athletes, who need accurate information about return to play. Traditional treatments of electrotherapy are simply placebos. The challenge ahead is to optimise treatments for the various diagnostic categories.
This document provides guidelines for the diagnosis and management of syncope published by the European Society of Cardiology in 2009. It was developed in collaboration with several other cardiac societies. The guidelines cover definitions of syncope, classification of causes, epidemiology, risk stratification, diagnostic testing including tilt testing and electrocardiographic monitoring, treatment of reflex syncope, cardiac arrhythmias, and other structural cardiac issues that can cause syncope. The task force that created the guidelines consisted of experts from Europe and North America.
Nicola Maffulli
Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Surgery, Salerno, Italy and Queen Mary University of London, Centre for Sports and Exercise Medicine, London, England.
-
Surgical indications for muscle injuries
This document discusses several topics related to total knee arthroplasty (TKA), including:
1. Expectations for recovery after TKA are often misaligned between patients and surgeons, with over 50% of patients expecting higher levels of function than surgeons.
2. Moderate sports and physical activity after TKA do not appear to negatively impact implant durability or increase revision rates in the short or medium term. High-impact sports should still be avoided.
3. Knee rehabilitation protocols must account for numerous patient-specific variables to optimize outcomes, such as age, BMI, pre-operative activity level, type of implant, and adherence to home exercises. A one-size-fits-all approach is inadequate.
These guidelines from the European Society of Cardiology and European Association for Cardio-Thoracic Surgery provide recommendations on myocardial revascularization. The guidelines cover risk stratification, decision making processes, diagnostic imaging strategies, revascularization for stable coronary artery disease and acute coronary syndromes, and special patient populations such as those with diabetes or chronic kidney disease. The task force that developed the guidelines included experts from cardiology and cardiac surgery.
This document proposes a new classification system for muscle injuries called MLG-R. The MLG-R system classifies injuries based on their mechanism (M), location (L), relation to tendons/connective tissue (G), and whether it is a recurrent injury (R). Previous classification systems are reviewed which focused on grading or specific muscles. The new system aims to be reproducible, distinguish different injury categories, be easy to remember, and correlate to prognosis. Magnetic resonance imaging and ultrasound are important for accurately describing the location, size and tendon involvement of injuries. The MLG-R system is designed for hamstring injuries but could be expanded to other muscles.
Guias de manejo de cardiopatias en el embarazoLucelli Yanez
This document provides guidelines on the management of cardiovascular diseases during pregnancy from the European Society of Cardiology (ESC). It summarizes recommendations for treating conditions like congenital heart disease, valvular heart disease, hypertension, arrhythmias, and venous thromboembolism during pregnancy and delivery. The guidelines were developed by a task force of ESC members and endorsed by other societies. They are intended to help health professionals manage cardiovascular risks for both the mother and fetus/child. The guidelines cover topics like risk assessment, diagnostic testing, pharmacological and non-pharmacological treatment, and delivery timing and method. They aim to optimize outcomes for women with heart conditions who wish to become pregnant or are already pregnant.
Muscle tears are extremely common and are often recurrent. They are not as simple as we used to think and the advent of better imaging has proven that the site, size and location of the tear, together with the presence or otherwise of the tendon is crucial information especially for elite or professional athletes, who need accurate information about return to play. Traditional treatments of electrotherapy are simply placebos. The challenge ahead is to optimise treatments for the various diagnostic categories.
The document provides information on common sport injuries affecting the upper and lower limbs. It discusses injuries such as impingement syndrome, frozen shoulder, tennis elbow, golfer's elbow, ACL injury, PCL injury, meniscal injury, and ankle sprain. For each injury, it describes the anatomy, mechanisms of injury, clinical features, diagnosis, and management approaches. The document is intended as part of a teaching module on sport injuries for medical students.
The Battle 2021 Castrocaro Terme (Italy). Achilles Insertional Tendinopathy a...Nicola Taddio
The aim of this presentation is to explain the background of Achilles Insertional Tendinopathy and Haglund's Triad, the rationale of conservative treatment and finally the therapeutic exercise evidence based approach.
Conventional treatment for osteoarthritis focuses on pain management and includes medications like aspirin, acetaminophen, NSAIDs, and COX-2 inhibitors. However, these drugs can have significant side effects with long-term use including damage to the digestive tract, liver, kidneys, and heart. Additionally, NSAIDs may accelerate cartilage degeneration and worsen osteoarthritis over time by inhibiting proteoglycan production in the body. Conventional treatment does not address the underlying causes of osteoarthritis or support cartilage repair.
Mayo clinic analgesic pathway peripheral nerve blockadeNorma Obaid
This document provides information about peripheral nerve blockade for major orthopedic surgery from Mayo Clinic. It discusses the Mayo Clinic total joint anesthesia and analgesic pathway, which utilizes peripheral regional techniques and oral analgesics to manage pain after total knee and hip arthroplasty. With this approach, 95% of knee replacement patients and 80% of hip replacement patients can be discharged within 48 hours, with 90% going home rather than to a rehabilitation facility. The document contains detailed descriptions of techniques for peripheral nerve blocks of the lower extremities, including the lumbar plexus, sciatic nerve, and individual nerve blocks, as well as considerations for managing peripheral nerve catheters.
This document summarizes evidence on treatments for inversion ankle sprains. A systematic review found functional treatment to be more effective than immobilization, resulting in earlier return to sports and work, less swelling and objective instability, and greater patient satisfaction. A randomized controlled trial also found that manual physical therapy combined with exercises led to greater improvements in pain and function over 6 months compared to a home exercise program alone, with a lower recurrence rate. In summary, functional treatment and manual physical therapy are more effective approaches for inversion ankle sprains than immobilization or home exercises alone.
GEMC- Injuries of the Lower Extremity: Knee, Ankle and Foot- Resident TrainingOpen.Michigan
This is a lecture by Dr. John Burkhardt from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Root Cause Orthopedics - Minimally Invasive SolutionGraMedica
There are many healthcare professionals addressing the symptoms of musculoskeletal disease to the few who are reducing or eliminating the underlying cause. View this slideshow to find out about the most powerful minimally invasive orthopedic solution.
Facet disease occurs when a facet joint in the spine degenerates, most commonly affecting the lumbar region. As the cartilage in the facet joints wears away with age, bone spurs can develop, causing pain, swelling, and stiffness. Non-surgical treatments include rest, physical therapy, and facet joint blocks to diagnose and treat pain. Surgical options include facet rhizotomy to disable sensory nerves, fusion to stop disc and joint problems, or facetectomy to remove bone spurs and decompress nerves. A case study describes a man with left neck and shoulder pain from a septic arthritis infection in his C5-C6 facet joint that was treated with IV antibiotics.
Osteoarthritis is a common form of arthritis that affects cartilage in the joints. It occurs most often in weight-bearing joints like the knees, hips, and spine. Risk factors include older age, obesity, joint injuries, and genetics. Symptoms include joint pain, stiffness, and loss of flexibility. Diagnosis involves physical exams, imaging tests like x-rays, and blood tests. Treatment focuses on pain management through medications, physical therapy, braces, and in severe cases surgery like joint replacement.
Facet joint syndrome refers to pain that occurs in the facet joints of the spine, which connect vertebrae and allow bending and twisting. The facet joints are synovial joints surrounded by cartilage and fluid. Facet joint syndrome is most common in the elderly and causes pain in the lower back or neck that increases with twisting or bending and can radiate to the buttocks or thighs. It is diagnosed through medical history, exams, and sometimes imaging tests or facet joint blocks. Treatments include medications, exercises, massage, and in severe cases, nerve ablation surgery. Merely treating symptoms often fails, so a combined approach addressing causes like inflammation and muscle imbalances works best to relieve pain.
SPORTS INJURIES HAMSTRING ACL OVERHEAD ATHELTE I Dr.RAJAT JANGIR JAIPUR
#aclsurgeryjaipur #aclsurgeryhindia #aclsurgerytaekwondo
Acl reconstruction in jaipur | Acl reconstruction in taekwondo | Acl injury in football player surgery | Acl reconstruction surgery in football | acl surgery | Acl surgery ke baad physiotherapy | Acl surgery in jaipur | acl surgery recovery | Best acl surgeon in jaipur | Best ligament doctor in hindi | Best acl surgeon in india | Meniscus repair surgery in jaipur | Sports injury doctor | Acl injury in football players | Acl injury in taekwondo | acl tear | Best knee surgeon in jaipur
#allinsideacl #internalbrace #drrajatjangir #bestaclsurgeon #aclexpert #bestkneesurgeon
To Know more about ACL Injury, Click the links below:
1. ACL surgery 7 different Techniques we do at our center - "Not single technique best for all"
https://youtu.be/oWkIr8IXvr8
2. Everything about ACL Injury tear surgery in Hindi I
https://youtu.be/bqpjkAkwZ14
3. Best Screw for ACL tear surgery in Hindi
https://youtu.be/1LGpU1NHiIs
4. ACL Injury Tear Surgery Recovery : All your questions & queries solved by Dr.Rajat Jangir
https://youtu.be/SIAPWiMbOqs
5. Partial ACL Tear Surgery or not ! ACL आधा टूटा हो तो क्या करें ?
https://youtu.be/NEJRPKskJTI
6. 5 Symptoms of ACL Injury tear इंजरी के पांच लक्षण ?
https://youtu.be/EXpgy19Jxzw
7. PRP injection therapy in Partial ACL TEARs
https://youtu.be/qyG1EYgS87E
Dr.RAJAT JANGIR(Asso Prof.)
Senior Consultant Arthroscopy and Joint Replacement
(Specialist in Shoulder Knee Hip Surgery)
Ligament and Joints Clinic
67/34 Mansarovar Jaipur
Whatsapp: shorturl.at/gnAEP
Appointment: +91 8104855900
Email: ligamentsurgeon@gmail.com
Google Page: https://g.page/KNEE-Shoulder-SURGERY?...
Facebook: https://www.facebook.com/Ligamentandj...
* Vast experience and specialisation in the field of Arthroscopy and sports surgery.
* M.S. orthopaedics from BJ Medical College, Civil hospital, Ahmedabad
* Fellowship in Arthroscopy and Sports injury with Prof Joon Ho Wang at Samsung Medical Center, South Korea
* Diploma in Sports Medicine from InternationaI Olympic Committee
* Invited as Athlete Medical Doctor at Rio Olympic 2016
* Done Rajasthan's first "All Inside Physeal Preserving ACL reconstruction" in 13 year old Athlete
Dr.Rajat is rated as one of the best orthopedic surgeon with with excellence in Knee Shoulder Arthroscopy surgeries as replacements'
Ergonomic health implications as it relates to dental health professionals. This presentation reviews common causes of ergonomic injuries including carpal tunnel syndrome and tendinitis, ways to manage these conditions, and how to prevent them.
1) The presentation discussed return to play in gastrocnemius and soleus muscle injuries, focusing on how doctors think and make decisions. It covered common cognitive traps and emphasized evaluating the healing response before clearing an athlete to return.
2) The gastrocnemius and soleus muscles were described as "non-identical twins" with different fiber types, fatigue resistance, and injury patterns. Soleus strains often involve the tendon and are underdiagnosed.
3) Special considerations for these injuries include fluid collections or hematomas in the gastrocnemius that may delay healing, and accurate diagnosis of soleus strains involving the tendon. Aspiration and platelet-rich plasma treatments were presented as options
Bruce Hamilton - Classification and Grading of Muscle InjuriesMuscleTech Network
Bruce Hamilton
Sports medicine physician, High Performance Center, Oakland, New Zeeland,
-
Classification and Grading of Muscle Injuries: A Review of the Literature
(6th MuscleTech Network Workshop)
14th October, Barcelona
Fatigue Analysis of a Bone Implant ConstructMert G
This document discusses a graduation project report on fatigue analysis of a bone implant construct. It provides background on limb lengthening procedures using intramedullary devices and discusses reliability issues with the distal locking screw. The aim of the project is to apply a sample fatigue analysis calculation to the distal interlocking screw of an intramedullary nail placed in the femur bone of a 1.90m tall patient weighing 80kg. The analysis will involve load, stress, and fatigue calculations to evaluate the reliability of the implant construct.
Bryan English - classification of muscle injuries in sportMuscleTech Network
Bryan English
Medical Director Middlesbrough Football Club. Member of Technical Advisory Group in Sports Science. The English Institute of Sport
-
Terminology and classification of muscle injuries in sport: a Munich consensus statement
(6th MuscleTech Network Workshop)
14th October, Barcelona
George Kouloris: MR Imaging of the Quadricepc Muscle ComplexMuscleTech Network
This document discusses MRI imaging of injuries to the quadriceps muscle complex (QMC). It reviews 66 vastus muscle injuries over 7 years. Injuries were most common in the vastus lateralis, medialis, and intermedius muscles. Most injuries were grade 1 or 2 strains located in the proximal or distal thirds of the muscles. Injuries often involved multiple vastus muscles. MRI findings correlated with return to play time, with grade 1 injuries returning around 17 days on average. Differential diagnoses for quadriceps injuries include contusions, hematomas, and soft tissue masses. Prognosis is generally excellent, though complications like myositis ossificans may occur.
Suffering from knee pain? It is important to know you what is the cause of your knee pain and their physiotherapy treatment also. To know your types of pain and their various pain management treatment my slide will help you.
This document provides an overview of musculoskeletal and connective tissue disorders, including assessment factors, potential complications of fractures, and nursing care for conditions like sprains, strains, dislocations, and fractures. Key points covered include the signs and symptoms of common injuries; stages of bone healing; reduction, stabilization, and fixation methods for fractures; and inflammatory disorders like osteoarthritis, rheumatoid arthritis, and osteoporosis.
This document provides a review of the use of mesenchymal stem cells for the treatment of canine osteoarthritis. It begins with an overview of canine osteoarthritis, including its prevalence, pathophysiology, and current treatment options. Current treatments discussed include NSAIDs, steroidal drugs, and nutraceuticals. The document then reviews the potential of mesenchymal stem cells as a novel treatment for canine osteoarthritis, discussing both autologous and heterologous sources of adipose-derived mesenchymal stem cells. Several studies are summarized that show stem cell therapy can improve signs of osteoarthritis in dogs without significant side effects by aiding cartilage repair and modulating the immune system. The review concludes
This document discusses elbow pain, its causes, and treatments. It defines the elbow joint and describes common injuries like tendinitis, fractures, and nerve entrapment that can cause elbow pain. It explains that tendinitis is usually treated with ice, rest, and anti-inflammatory medication, while more severe issues like infections or tumors may require surgery. The summary concludes by noting the elbow can be rehabilitated through conservative treatments like exercises and activity modifications prescribed by an occupational therapist.
The document provides information on common sport injuries affecting the upper and lower limbs. It discusses injuries such as impingement syndrome, frozen shoulder, tennis elbow, golfer's elbow, ACL injury, PCL injury, meniscal injury, and ankle sprain. For each injury, it describes the anatomy, mechanisms of injury, clinical features, diagnosis, and management approaches. The document is intended as part of a teaching module on sport injuries for medical students.
The Battle 2021 Castrocaro Terme (Italy). Achilles Insertional Tendinopathy a...Nicola Taddio
The aim of this presentation is to explain the background of Achilles Insertional Tendinopathy and Haglund's Triad, the rationale of conservative treatment and finally the therapeutic exercise evidence based approach.
Conventional treatment for osteoarthritis focuses on pain management and includes medications like aspirin, acetaminophen, NSAIDs, and COX-2 inhibitors. However, these drugs can have significant side effects with long-term use including damage to the digestive tract, liver, kidneys, and heart. Additionally, NSAIDs may accelerate cartilage degeneration and worsen osteoarthritis over time by inhibiting proteoglycan production in the body. Conventional treatment does not address the underlying causes of osteoarthritis or support cartilage repair.
Mayo clinic analgesic pathway peripheral nerve blockadeNorma Obaid
This document provides information about peripheral nerve blockade for major orthopedic surgery from Mayo Clinic. It discusses the Mayo Clinic total joint anesthesia and analgesic pathway, which utilizes peripheral regional techniques and oral analgesics to manage pain after total knee and hip arthroplasty. With this approach, 95% of knee replacement patients and 80% of hip replacement patients can be discharged within 48 hours, with 90% going home rather than to a rehabilitation facility. The document contains detailed descriptions of techniques for peripheral nerve blocks of the lower extremities, including the lumbar plexus, sciatic nerve, and individual nerve blocks, as well as considerations for managing peripheral nerve catheters.
This document summarizes evidence on treatments for inversion ankle sprains. A systematic review found functional treatment to be more effective than immobilization, resulting in earlier return to sports and work, less swelling and objective instability, and greater patient satisfaction. A randomized controlled trial also found that manual physical therapy combined with exercises led to greater improvements in pain and function over 6 months compared to a home exercise program alone, with a lower recurrence rate. In summary, functional treatment and manual physical therapy are more effective approaches for inversion ankle sprains than immobilization or home exercises alone.
GEMC- Injuries of the Lower Extremity: Knee, Ankle and Foot- Resident TrainingOpen.Michigan
This is a lecture by Dr. John Burkhardt from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Root Cause Orthopedics - Minimally Invasive SolutionGraMedica
There are many healthcare professionals addressing the symptoms of musculoskeletal disease to the few who are reducing or eliminating the underlying cause. View this slideshow to find out about the most powerful minimally invasive orthopedic solution.
Facet disease occurs when a facet joint in the spine degenerates, most commonly affecting the lumbar region. As the cartilage in the facet joints wears away with age, bone spurs can develop, causing pain, swelling, and stiffness. Non-surgical treatments include rest, physical therapy, and facet joint blocks to diagnose and treat pain. Surgical options include facet rhizotomy to disable sensory nerves, fusion to stop disc and joint problems, or facetectomy to remove bone spurs and decompress nerves. A case study describes a man with left neck and shoulder pain from a septic arthritis infection in his C5-C6 facet joint that was treated with IV antibiotics.
Osteoarthritis is a common form of arthritis that affects cartilage in the joints. It occurs most often in weight-bearing joints like the knees, hips, and spine. Risk factors include older age, obesity, joint injuries, and genetics. Symptoms include joint pain, stiffness, and loss of flexibility. Diagnosis involves physical exams, imaging tests like x-rays, and blood tests. Treatment focuses on pain management through medications, physical therapy, braces, and in severe cases surgery like joint replacement.
Facet joint syndrome refers to pain that occurs in the facet joints of the spine, which connect vertebrae and allow bending and twisting. The facet joints are synovial joints surrounded by cartilage and fluid. Facet joint syndrome is most common in the elderly and causes pain in the lower back or neck that increases with twisting or bending and can radiate to the buttocks or thighs. It is diagnosed through medical history, exams, and sometimes imaging tests or facet joint blocks. Treatments include medications, exercises, massage, and in severe cases, nerve ablation surgery. Merely treating symptoms often fails, so a combined approach addressing causes like inflammation and muscle imbalances works best to relieve pain.
SPORTS INJURIES HAMSTRING ACL OVERHEAD ATHELTE I Dr.RAJAT JANGIR JAIPUR
#aclsurgeryjaipur #aclsurgeryhindia #aclsurgerytaekwondo
Acl reconstruction in jaipur | Acl reconstruction in taekwondo | Acl injury in football player surgery | Acl reconstruction surgery in football | acl surgery | Acl surgery ke baad physiotherapy | Acl surgery in jaipur | acl surgery recovery | Best acl surgeon in jaipur | Best ligament doctor in hindi | Best acl surgeon in india | Meniscus repair surgery in jaipur | Sports injury doctor | Acl injury in football players | Acl injury in taekwondo | acl tear | Best knee surgeon in jaipur
#allinsideacl #internalbrace #drrajatjangir #bestaclsurgeon #aclexpert #bestkneesurgeon
To Know more about ACL Injury, Click the links below:
1. ACL surgery 7 different Techniques we do at our center - "Not single technique best for all"
https://youtu.be/oWkIr8IXvr8
2. Everything about ACL Injury tear surgery in Hindi I
https://youtu.be/bqpjkAkwZ14
3. Best Screw for ACL tear surgery in Hindi
https://youtu.be/1LGpU1NHiIs
4. ACL Injury Tear Surgery Recovery : All your questions & queries solved by Dr.Rajat Jangir
https://youtu.be/SIAPWiMbOqs
5. Partial ACL Tear Surgery or not ! ACL आधा टूटा हो तो क्या करें ?
https://youtu.be/NEJRPKskJTI
6. 5 Symptoms of ACL Injury tear इंजरी के पांच लक्षण ?
https://youtu.be/EXpgy19Jxzw
7. PRP injection therapy in Partial ACL TEARs
https://youtu.be/qyG1EYgS87E
Dr.RAJAT JANGIR(Asso Prof.)
Senior Consultant Arthroscopy and Joint Replacement
(Specialist in Shoulder Knee Hip Surgery)
Ligament and Joints Clinic
67/34 Mansarovar Jaipur
Whatsapp: shorturl.at/gnAEP
Appointment: +91 8104855900
Email: ligamentsurgeon@gmail.com
Google Page: https://g.page/KNEE-Shoulder-SURGERY?...
Facebook: https://www.facebook.com/Ligamentandj...
* Vast experience and specialisation in the field of Arthroscopy and sports surgery.
* M.S. orthopaedics from BJ Medical College, Civil hospital, Ahmedabad
* Fellowship in Arthroscopy and Sports injury with Prof Joon Ho Wang at Samsung Medical Center, South Korea
* Diploma in Sports Medicine from InternationaI Olympic Committee
* Invited as Athlete Medical Doctor at Rio Olympic 2016
* Done Rajasthan's first "All Inside Physeal Preserving ACL reconstruction" in 13 year old Athlete
Dr.Rajat is rated as one of the best orthopedic surgeon with with excellence in Knee Shoulder Arthroscopy surgeries as replacements'
Ergonomic health implications as it relates to dental health professionals. This presentation reviews common causes of ergonomic injuries including carpal tunnel syndrome and tendinitis, ways to manage these conditions, and how to prevent them.
1) The presentation discussed return to play in gastrocnemius and soleus muscle injuries, focusing on how doctors think and make decisions. It covered common cognitive traps and emphasized evaluating the healing response before clearing an athlete to return.
2) The gastrocnemius and soleus muscles were described as "non-identical twins" with different fiber types, fatigue resistance, and injury patterns. Soleus strains often involve the tendon and are underdiagnosed.
3) Special considerations for these injuries include fluid collections or hematomas in the gastrocnemius that may delay healing, and accurate diagnosis of soleus strains involving the tendon. Aspiration and platelet-rich plasma treatments were presented as options
Bruce Hamilton - Classification and Grading of Muscle InjuriesMuscleTech Network
Bruce Hamilton
Sports medicine physician, High Performance Center, Oakland, New Zeeland,
-
Classification and Grading of Muscle Injuries: A Review of the Literature
(6th MuscleTech Network Workshop)
14th October, Barcelona
Fatigue Analysis of a Bone Implant ConstructMert G
This document discusses a graduation project report on fatigue analysis of a bone implant construct. It provides background on limb lengthening procedures using intramedullary devices and discusses reliability issues with the distal locking screw. The aim of the project is to apply a sample fatigue analysis calculation to the distal interlocking screw of an intramedullary nail placed in the femur bone of a 1.90m tall patient weighing 80kg. The analysis will involve load, stress, and fatigue calculations to evaluate the reliability of the implant construct.
Bryan English - classification of muscle injuries in sportMuscleTech Network
Bryan English
Medical Director Middlesbrough Football Club. Member of Technical Advisory Group in Sports Science. The English Institute of Sport
-
Terminology and classification of muscle injuries in sport: a Munich consensus statement
(6th MuscleTech Network Workshop)
14th October, Barcelona
George Kouloris: MR Imaging of the Quadricepc Muscle ComplexMuscleTech Network
This document discusses MRI imaging of injuries to the quadriceps muscle complex (QMC). It reviews 66 vastus muscle injuries over 7 years. Injuries were most common in the vastus lateralis, medialis, and intermedius muscles. Most injuries were grade 1 or 2 strains located in the proximal or distal thirds of the muscles. Injuries often involved multiple vastus muscles. MRI findings correlated with return to play time, with grade 1 injuries returning around 17 days on average. Differential diagnoses for quadriceps injuries include contusions, hematomas, and soft tissue masses. Prognosis is generally excellent, though complications like myositis ossificans may occur.
Suffering from knee pain? It is important to know you what is the cause of your knee pain and their physiotherapy treatment also. To know your types of pain and their various pain management treatment my slide will help you.
This document provides an overview of musculoskeletal and connective tissue disorders, including assessment factors, potential complications of fractures, and nursing care for conditions like sprains, strains, dislocations, and fractures. Key points covered include the signs and symptoms of common injuries; stages of bone healing; reduction, stabilization, and fixation methods for fractures; and inflammatory disorders like osteoarthritis, rheumatoid arthritis, and osteoporosis.
This document provides a review of the use of mesenchymal stem cells for the treatment of canine osteoarthritis. It begins with an overview of canine osteoarthritis, including its prevalence, pathophysiology, and current treatment options. Current treatments discussed include NSAIDs, steroidal drugs, and nutraceuticals. The document then reviews the potential of mesenchymal stem cells as a novel treatment for canine osteoarthritis, discussing both autologous and heterologous sources of adipose-derived mesenchymal stem cells. Several studies are summarized that show stem cell therapy can improve signs of osteoarthritis in dogs without significant side effects by aiding cartilage repair and modulating the immune system. The review concludes
This document discusses elbow pain, its causes, and treatments. It defines the elbow joint and describes common injuries like tendinitis, fractures, and nerve entrapment that can cause elbow pain. It explains that tendinitis is usually treated with ice, rest, and anti-inflammatory medication, while more severe issues like infections or tumors may require surgery. The summary concludes by noting the elbow can be rehabilitated through conservative treatments like exercises and activity modifications prescribed by an occupational therapist.
This document provides information on tendinopathy and tendon repair. It defines tendons and their connection between muscle and bone. It describes the stages of tendon healing as inflammation, repair/proliferation, and remodeling. Types of tendon injuries discussed include tendonitis and tendonosis. Common sites of tendinopathy include the shoulder, elbow, wrist, hip, knee, and ankle. Suture techniques for tendon repair include Kessler, Savage, and Lee methods. The nature of sutures and suture placement is also covered, along with tendon retubularization procedures.
2017 eacts guidelines on perioperative medication in adult cardiac surgeryJimmy Wea
This document provides guidelines on perioperative medication management for adult cardiac surgery patients. It addresses recommendations for antiplatelet therapy, anticoagulation, beta-blockers, statins, antibiotics and other medications before, during and after surgery. Specific guidance is given for conditions like atrial fibrillation and different types of surgical procedures. The goal is to provide evidence-based guidance to reduce risks and optimize outcomes for cardiac surgery patients.
This document provides an overview of treatment options for knee pain, including medications, physical therapy, injections, surgery, lifestyle remedies, and alternative medicines. It discusses common causes of knee pain such as injuries, arthritis, and mechanical problems. Diagnosis may involve physical exams, imaging like x-rays, CT scans, MRIs, and lab tests. Treatment is tailored to the underlying cause but generally aims to reduce pain and inflammation, improve mobility, and resolve structural problems through conservative and surgical approaches.
CAC Protocol Impact of smoking and calorie intake on bone fracture healingRichmond Arcillas
This study aims to assess the impact of smoking and calorie intake on bone fracture healing in osteoporotic patients. It will be a prospective cohort study of 500 osteoporotic patients comparing fracture healing rates of 250 smokers to 250 non-smokers matched for other factors. The study will also assess calorie intake in non-smokers and examine outcomes like time to union, quality of life, hospital stay, and infections. Findings may help emphasize the negative effects of smoking and importance of nutrition on fracture healing to clinicians and patients.
This thesis dissertation by London College of Osteopathy graduate, Marliese Steyn, examines the role of Osteopathic Manual Therapy in combination with Pilates on the rehabilitation of disc herniation and degeneration.
This document provides an overview of the Mayo Clinic Analgesic Pathway book, which discusses the use of peripheral nerve blocks for pain management after major orthopedic surgery. The book contains 4 sections that cover the principles of peripheral nerve blocks, techniques for specific lower extremity blocks including lumbar plexus and sciatic nerve blocks, Mayo Clinic's total joint anesthesia and analgesic pathway, and the management of peripheral nerve catheters. The preface notes that peripheral nerve blocks can improve the postoperative experience for patients compared to general anesthesia alone, but that training in these techniques is still lacking in many residency programs.
Common sports-relatedshoulder injuriesShoulder pain is.docxcargillfilberto
Common sports-related
shoulder injuries
S
houlder pain is commonly treated in general practice; its causes are often
multi-factorial. The focus of this article is on sports-related shoulder injuries
likely to be seen in the community. This article aims to overview the presen-
tation, assessment and management of these conditions in general practice.
The GP curriculum and common sports-related shoulder injuries
Clinical module 3.20: Care of people with musculoskeletal problems lists the learning objectives required
for a GP to manage common sports-related shoulder injuries in the community or refer for specialist management. In
particular, GPs are expected to be able to:
. Communicate health information effectively to promote better outcomes
. Explore the perceptions, ideas or beliefs the patient has about the condition and whether these may be acting as
barriers to recovery
. Use simple techniques and consistent advice to promote activity in the presence of pain and stiffness
. Agree treatment goals and facilitate supported self-management, particularly around pain, function and physical
activity
. Assess the importance and meaning of the following presenting features:
. pain: nature, location, severity, history of trauma
. variation of symptoms over time
. loss of function – weakness, restricted movement, deformity and disability, ability to perform usual work or
occupation
. Understand that reducing pain and disability rather than achieving a complete cure could be the goal of
treatment
. Understand indications and limitations of plain radiography, ultrasound, and magnetic resonance scans
. Diagnose common, regional soft-tissue problems that can be managed in primary care
. Understand the challenge that many musculoskeletal conditions might be better and more confidently managed
by other healthcare personnel rather than GPs, because most GPs do not gain the necessary treatment skills
during their training
. Refer those conditions which may benefit from early referral to an orthopaedic surgeon
The four most common categories of shoulder pain
seen in primary care are (Mitchell, Adebajo, Hay, &
Carr, 2005):
. Rotator cuff disorders (85% tendinopathy)
. Glenohumeral disorders
. Acromioclavicular joint disease, and
. Referred neck pain.
There are many different types of sports that can cause
acute or chronic shoulder injuries. In professional English
Rugby Union, for example, the most common match
injury is of the acromioclavicular joint (32% overall) and
the most severe injury requiring the longest time off
(mean of 81 days) is shoulder dislocation (Headey,
Brooks, & Kemp, 2007).
Shoulder injuries can also occur in non-contact sports,
such as golf, tennis, swimming and weightlifting.
Although shoulder injuries may be more common in con-
tact sports, the injury may have a larger impact on the
performance of individuals playing non-contact sports.
For example, golfers require very precise manoeuvres
of their dominant.
Common sports-relatedshoulder injuriesShoulder pain is.docxdrandy1
Common sports-related
shoulder injuries
S
houlder pain is commonly treated in general practice; its causes are often
multi-factorial. The focus of this article is on sports-related shoulder injuries
likely to be seen in the community. This article aims to overview the presen-
tation, assessment and management of these conditions in general practice.
The GP curriculum and common sports-related shoulder injuries
Clinical module 3.20: Care of people with musculoskeletal problems lists the learning objectives required
for a GP to manage common sports-related shoulder injuries in the community or refer for specialist management. In
particular, GPs are expected to be able to:
. Communicate health information effectively to promote better outcomes
. Explore the perceptions, ideas or beliefs the patient has about the condition and whether these may be acting as
barriers to recovery
. Use simple techniques and consistent advice to promote activity in the presence of pain and stiffness
. Agree treatment goals and facilitate supported self-management, particularly around pain, function and physical
activity
. Assess the importance and meaning of the following presenting features:
. pain: nature, location, severity, history of trauma
. variation of symptoms over time
. loss of function – weakness, restricted movement, deformity and disability, ability to perform usual work or
occupation
. Understand that reducing pain and disability rather than achieving a complete cure could be the goal of
treatment
. Understand indications and limitations of plain radiography, ultrasound, and magnetic resonance scans
. Diagnose common, regional soft-tissue problems that can be managed in primary care
. Understand the challenge that many musculoskeletal conditions might be better and more confidently managed
by other healthcare personnel rather than GPs, because most GPs do not gain the necessary treatment skills
during their training
. Refer those conditions which may benefit from early referral to an orthopaedic surgeon
The four most common categories of shoulder pain
seen in primary care are (Mitchell, Adebajo, Hay, &
Carr, 2005):
. Rotator cuff disorders (85% tendinopathy)
. Glenohumeral disorders
. Acromioclavicular joint disease, and
. Referred neck pain.
There are many different types of sports that can cause
acute or chronic shoulder injuries. In professional English
Rugby Union, for example, the most common match
injury is of the acromioclavicular joint (32% overall) and
the most severe injury requiring the longest time off
(mean of 81 days) is shoulder dislocation (Headey,
Brooks, & Kemp, 2007).
Shoulder injuries can also occur in non-contact sports,
such as golf, tennis, swimming and weightlifting.
Although shoulder injuries may be more common in con-
tact sports, the injury may have a larger impact on the
performance of individuals playing non-contact sports.
For example, golfers require very precise manoeuvres
of their dominant.
Acl knee Protocol for Football Players Djair Garcia
This document provides information about anterior cruciate ligament (ACL) reconstruction surgery and rehabilitation. It discusses two common surgical techniques - using the hamstring tendon or bone-patellar tendon-bone graft. It also outlines the post-surgery rehabilitation process in phases from immediate post-op to returning to sports 6-12 months later. The document is intended to guide patients through ACL reconstruction and recovery.
This document provides an overview of essential occupational health interventions for primary prevention of work-related diseases and injuries in low and middle income countries. It identifies the major occupational exposures that lead to diseases and injuries, including asbestos, silica, welding fumes, noise, ergonomic factors, and hazardous situations. It then categorizes interventions to reduce these exposures as environmental, behavioral, or clinical. The document conducts a literature search for systematic reviews evaluating the effectiveness of these interventions in reducing exposures and preventing diseases and injuries.
This document provides guidelines on myocardial revascularization from the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). It was developed with contributions from related organizations. The guidelines cover strategies for diagnosis and imaging, revascularization for stable coronary artery disease and acute coronary syndromes, procedural aspects of coronary artery bypass grafting and percutaneous coronary intervention, and special conditions. The task force reviewed evidence and provided recommendations to guide clinical decision making and procedures for myocardial revascularization.
This review examined evidence from randomized controlled trials on prosthetic rehabilitation for older adults with leg amputations above the knee due to poor circulation. Only one trial met the inclusion criteria, which compared preferences for three different prosthetic weights among 10 participants. Most participants preferred the lightest or middle weight, but the trial had limitations and no conclusions could be drawn on optimal rehabilitation approaches. High-quality randomized trials are still needed to inform clinical practice for this patient group.
This document provides a thorough review of evidence on best practices for telehealth in British Columbia. It is organized by clinical and educational contexts. In the clinical context section, several specialist areas are reviewed where videoconferencing has been used, including neurology, dermatology, radiology, orthopedics, and psychiatry. Several studies found videoconferencing enabled access to specialist care for remote patients. However, some studies also found lower patient satisfaction and need for follow up with telehealth compared to in-person visits. Overall, the evidence companion provides an extensive compilation of literature on telehealth applications and outcomes across many healthcare contexts.
This document discusses the treatment of hand burns. It outlines several key aims and principles of treatment, including rapid wound closure, preservation of active and passive motion, and early functional rehabilitation. The anatomy of the hand makes it vulnerable to burns, as it has a high proportion of skin surface to tissue volume and structures like blood vessels and tendons are near the skin. Proper treatment requires a multidisciplinary team approach and decisions on issues like escharotomy, wound coverage type, splinting and reconstruction of deformities. The overall goal is optimal recovery of hand function.
Osteoarthritis and total joint replacement.ppt (1)Ali Ismail
Osteoarthritis and Total Joint Replacement: Risk Factors, Prevention, and Treatment, and the Effects on Sensory Mechanisms Encountered by Osteoarthritic Total Joint Replacement Patients. This document discusses osteoarthritis, including risk factors like age and obesity, common symptoms like joint pain and stiffness, diagnostic methods like x-rays, and treatment options like physical therapy, medications, joint replacements and resurfacing. It also covers changes to sensory systems like vision and balance that can increase fall risks for osteoarthritic patients and accelerate the need for joint replacement surgery.
This document describes a project to develop a portable device to detect knee arthritis using acoustic emissions. Microphones will be attached to an elastic knee strap to collect knee sound signals, which will be filtered and analyzed using an Arduino microprocessor. Frequency and amplitude analysis of the signals will be used to determine knee health. Results will be sent via Bluetooth to an Android device for user-friendly display. The goal is to create an inexpensive, easy-to-use tool to help users assess their knee health and determine if a doctor visit is needed for arthritis diagnosis.
The document provides an overview of the spinal column, including its composition, structure, and functions. It describes how vertebrae are formed through endochondral ossification and composed of organic and inorganic matrices. The spinal column is made up of different regions including the cervical, thoracic, and lumbar vertebrae. Each vertebra has distinctive features but generally serves to protect the spinal cord and resist vertical forces. Connective tissues like ligaments between vertebrae provide stability and limit spinal motion. Common spinal issues like scoliosis are also mentioned.
total knee replacement in tobruk medical center in, libyasana I . Souliman
The aim of this study to investigate about the causes that lead to total knee joint replacement operation, especially the operation that is performed in Medical Tobruk Center where there are many reasons that cause problem in Knee joint but in tobruk . And the knee joint ,which is one of the largest and most complex joints in the human body.
ANAMOLOUS SECONDARY GROWTH IN DICOT ROOTS.pptxRASHMI M G
Abnormal or anomalous secondary growth in plants. It defines secondary growth as an increase in plant girth due to vascular cambium or cork cambium. Anomalous secondary growth does not follow the normal pattern of a single vascular cambium producing xylem internally and phloem externally.
When I was asked to give a companion lecture in support of ‘The Philosophy of Science’ (https://shorturl.at/4pUXz) I decided not to walk through the detail of the many methodologies in order of use. Instead, I chose to employ a long standing, and ongoing, scientific development as an exemplar. And so, I chose the ever evolving story of Thermodynamics as a scientific investigation at its best.
Conducted over a period of >200 years, Thermodynamics R&D, and application, benefitted from the highest levels of professionalism, collaboration, and technical thoroughness. New layers of application, methodology, and practice were made possible by the progressive advance of technology. In turn, this has seen measurement and modelling accuracy continually improved at a micro and macro level.
Perhaps most importantly, Thermodynamics rapidly became a primary tool in the advance of applied science/engineering/technology, spanning micro-tech, to aerospace and cosmology. I can think of no better a story to illustrate the breadth of scientific methodologies and applications at their best.
Nucleophilic Addition of carbonyl compounds.pptxSSR02
Nucleophilic addition is the most important reaction of carbonyls. Not just aldehydes and ketones, but also carboxylic acid derivatives in general.
Carbonyls undergo addition reactions with a large range of nucleophiles.
Comparing the relative basicity of the nucleophile and the product is extremely helpful in determining how reversible the addition reaction is. Reactions with Grignards and hydrides are irreversible. Reactions with weak bases like halides and carboxylates generally don’t happen.
Electronic effects (inductive effects, electron donation) have a large impact on reactivity.
Large groups adjacent to the carbonyl will slow the rate of reaction.
Neutral nucleophiles can also add to carbonyls, although their additions are generally slower and more reversible. Acid catalysis is sometimes employed to increase the rate of addition.
ESPP presentation to EU Waste Water Network, 4th June 2024 “EU policies driving nutrient removal and recycling
and the revised UWWTD (Urban Waste Water Treatment Directive)”
Unlocking the mysteries of reproduction: Exploring fecundity and gonadosomati...AbdullaAlAsif1
The pygmy halfbeak Dermogenys colletei, is known for its viviparous nature, this presents an intriguing case of relatively low fecundity, raising questions about potential compensatory reproductive strategies employed by this species. Our study delves into the examination of fecundity and the Gonadosomatic Index (GSI) in the Pygmy Halfbeak, D. colletei (Meisner, 2001), an intriguing viviparous fish indigenous to Sarawak, Borneo. We hypothesize that the Pygmy halfbeak, D. colletei, may exhibit unique reproductive adaptations to offset its low fecundity, thus enhancing its survival and fitness. To address this, we conducted a comprehensive study utilizing 28 mature female specimens of D. colletei, carefully measuring fecundity and GSI to shed light on the reproductive adaptations of this species. Our findings reveal that D. colletei indeed exhibits low fecundity, with a mean of 16.76 ± 2.01, and a mean GSI of 12.83 ± 1.27, providing crucial insights into the reproductive mechanisms at play in this species. These results underscore the existence of unique reproductive strategies in D. colletei, enabling its adaptation and persistence in Borneo's diverse aquatic ecosystems, and call for further ecological research to elucidate these mechanisms. This study lends to a better understanding of viviparous fish in Borneo and contributes to the broader field of aquatic ecology, enhancing our knowledge of species adaptations to unique ecological challenges.
Or: Beyond linear.
Abstract: Equivariant neural networks are neural networks that incorporate symmetries. The nonlinear activation functions in these networks result in interesting nonlinear equivariant maps between simple representations, and motivate the key player of this talk: piecewise linear representation theory.
Disclaimer: No one is perfect, so please mind that there might be mistakes and typos.
dtubbenhauer@gmail.com
Corrected slides: dtubbenhauer.com/talks.html
This presentation explores a brief idea about the structural and functional attributes of nucleotides, the structure and function of genetic materials along with the impact of UV rays and pH upon them.
2. [3]. However, it does presents in middle aged overweight non-
athletic patients without a history of increased physical activity
[3]. To date, the incidence and prevalence of AT in other
populations remain non-established, even though the conditions
has been correlated with seronegative arthropathies [4]. Most
studies include more males than females, although a definite
greater prevalence in males has not been shown. It is controversial
whether aging is a riskfactor for tendinopathy [5]. However,
evidences showed that aging also induces aberrant changes in the
expression of various genes and production of various types of
matrix proteins in the tendon, and may consequently lead to
tendon degeneration and impaired healing in aging tendons [6].
The history of a chronic tendinopathic process preceding a
rupture is also controversial, and some of the available literature
demonstrate high association of tendinopathy and rupture, since
pain symptoms represent a late finding of the process, and most
patients with AT are asymptomatic [2,7–10].
The essence of tendinopathy is a failed healing response, with
degeneration and haphazard proliferation of tenocytes, disruption
of collagen fibres, and subsequent increase in non-collagenous
matrix [1]. In tendinopathic samples, there is unequal and irregular
crimping, loosening and increased waviness of collagen fibres,
with an increase in Type III (reparative) collagen [1]. Hypoxic,
hyaline degeneration, mucoid or myxoid, fibrinoid, or lipoid
degeneration, calcification, fibrocartilaginous and bony metaplasia
can coexist [1].
The aetiology of AT remains debated, and is likely caused by
intrinsic and extrinsic factors. Postulated intrinsic factors include
tendon vascularity, weakness as well as lack of flexibility of the
gastrocnemius-soleus complex, pes cavus, and lateral ankle
instability [11]. Excessive loading of the tendon is considered
the major causative factor for AT [12]. Free radical damage
occurring on reperfusion after ischaemia, hypoxia, hyperthermia
and impaired tenocyte apoptosis have been linked with tendin-
opathy. In a case-control study, subjects with chronic painful AT
had a lipid profile characteristic of dyslipidemia [13]. A meta-
analysis of the effects of corticosteroid has shown that published
data are insufficient to determine the risk of rupture following
corticosteroid injections [14]. Evidences from a large population-
based case-control study showed that single case of rupture would
occur for every 5958 persons treated with fluoroquinolones [15].
The corresponding number needed to harm was 979 for patients
who concomitantly use corticosteroids and 1638 for those aged
>60 years [15]. The clinical impact of fluoroquinolone use on the
onset of less severe forms of tendon disorders is actually unknown,
but it is expected to be even higher.
AT is difficult to treat, and results, even after surgery, are
variable. The few studies which reported long-term results
indicated a relatively poor outcome. Also, surgery requires
prolonged rehabilitation, and, depending on the patient's occupa-
tion, a varying period of sick leave from work.
The diagnosis of AT is mainly based on history and clinical
examination [16]. Pain is a late symptom. A common symptom is
morning stiffness or stiffness after a period of inactivity, and a
gradual onset of pain during activity. In athletes, pain typically
occurs at the beginning and end of a training session, with a period
of diminished discomfort in between. As the condition progresses,
pain may occur with even minor exertion, and may interfere with
activities of daily living. In severe cases, pain occurs at rest. In the
acute phase, the tendon is diffusely swollen and edematous, and
tenderness is usually greatest 2–6 cm proximal to the tendon
insertion. A tender, nodular swelling is usually present in chronic
cases. Clinical examination is the best diagnostic tool (Fig. 1A, B)
(Table 1).
Some simple manoeuvres during physical examination and
elements of the history can often distinguish AT from other
conditions which may cause similar symptoms (Table 2).
The Victorian Institute of Sports Assessment - Achilles (VISA-A)
questionnaire specifically measures the severity of AT [17]. It
covers the domains of pain, function, and activity. Scores are
summed to give a total out of 100. An asymptomatic person would
score 100. In clinical care, the VISA-A questionnaire provides a
valid, reliable, and user friendly index of the severity of AT.The
VISA-A-S questionnaire showed good responsiveness in a ran-
domized controlled trial (it was sensitive for clinically important
changes over time with treatment, easy for the patients to fill out,
and the data were easily handled) [18]. It has been cross-culturally
adapted to Swedish [19], Italian [20] and Turkish [21].
2. Imaging
Radiographs may be useful in diagnosing associated or
incidental bony abnormalities. Radiographs are routinely obtained
for patients with symptoms lasting longer than six weeks to rule
out bony abnormalities, and identify the possible presence of
intratendinous calcific deposits and ossification. The presence of a
posterior calcification of the calcaneus (posterior heel spur) is
diagnostic of insertional Achilles tendinopathy.
Fig. 1. Royal London Hospital Test: Once the tester has elicited local tenderness by palpating the tendon with the ankle in neutral position (Fig. 1A), the patient is asked to
actively dorsiflex the ankle and to actively plantarflex it. With the ankle in maximum dorsiflexion and in maximum plantarflexion, the portion of the tendon originally found
to be tender is palpated again (Fig. 1B).
2 N. Maffulli et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx
G Model
FAS 1285 No. of Pages 10
Please cite this article in press as: N. Maffulli, et al., Achilles tendinopathy, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.03.009
3. Ultrasonography, though operator-dependent, correlates well
with histopathologic finding, and, especially in Europe, it is
regarded as the primary imaging method (Fig. 2). A major
advantage of ultrasonography over other imaging modalities is
its interactive capability. Grey scale ultrasonography is associated
with colour or power Doppler to detect neovascularity.
Recently, ultrasound tissue characterization (UTC) has been
introduced as a reliable method to quantify tendon structure [22].
UTC can quantitatively evaluate tendon structure and thereby
discriminate symptomatic and asymptomatic tendons [23].
Structure is an important clinical marker of tendon health; current
standards use qualitative scores that are not reliable, but
quantitative assessments of tendon structure using B-mode
ultrasound could be a reliable tool to diagnose and follow up
Achilles tendinopathy [24].
Only if ultrasonography remains unclear should magnetic
resonance imaging (MRI) imaging be performed.
MRI provides extensive information about the internal mor-
phology of the tendon and surrounding bone as well as other soft
tissue. It allows the surgeon to differentiate between para-
tendinopathy and tendinopathy of the main body of the tendon
(Fig. 3). Additionally, the extent of diseased tissue present, may be
estimated valuable for pre-operative planning. MRI is superior to
ultrasound in detecting incomplete tendon ruptures. However,
given the high sensitivity of MRI, the data should be interpreted
with caution, and correlated to the patient symptoms before
making any recommendations [12].
3. Management
The management of AT lacks evidence-based support, and
tendinopathy sufferers are at risk of long-term morbidity with
unpredictable clinical outcome. The appropriate moment to switch
from conservative to operative therapy remains unknown. In a
prospective observational follow-up study, the 8 year prognosis of
patients with AT was generally favourable, even though 29% of the
patients required surgical intervention during the follow-up
period [25].
In general, non-operative care should be implemented for a
minimum of three to six months prior to considering surgery, since
AT may resolve during this period in up to three quarters of
patients. However, each patient should be evaluated on their own.
4. Conservative management
Several therapeutic options lack hard scientific background
[26]. NSAIDs are commonly used for the management of AT, even
though data from three trials of NSAIDs showed, at best, a modest
effect on acute symptoms in the short term [27].The analgesic
effect of NSAIDs allows patients to ignore early symptoms, possibly
imposing further damage to the affected tendon and delaying
definitive healing. NSAIDs can be effective, to some extent, for pain
control to allow effective eccentric strengthening as well as
gastrocnemius and soleus stretching. Potential harms of NSAIDS
(such as ulcers, hypertension, renal impairment etc, especially in
older people) need to be weighted up for each patient, balancing
potential risks and benefits.
Rest is considered another first-line therapy for AT, but the
strength of recommendation is based on expert opinion [27]. Data
from recent randomized controlled trials showed that patients
with AT can safely continue with their activity of choice [18,28].
Even though cryotherapy is widely used for analgesia, to reduce
the metabolic rate of the tendon, and decrease the extravasation of
blood and protein from new capillaries found in tendon injuries
[29], there is no evidence that this is an effective treatment for AT.
Eccentric exercises have been proposed to promote collagen
fibre cross-link formation within the tendon, thereby facilitating
tendon remodeling [30]. Evidences of histological changes
following a program of eccentric exercise are lacking, and the
mechanisms by which eccentric exercises may help to resolve the
pain of tendinopathy remain unclear. Some groups report excellent
clinical results [31,32]. The results of eccentric training from other
study groups are less convincing, with a 50–60% of good outcome
after a regime of eccentric training both in athletic and sedentary
patients [33]. In general, the overall trend suggests a positive effect
of eccentric exercises, with no reported adverse effects [30].
Combining eccentric training and shock wave therapy produces
higher success rates compared to eccentric loading alone or shock
wave therapy alone [34].
Orthotics are widely used in conservative management, with
heel pads being the most commonly prescribed. There is little
evidence to support their use [35]. An AirHeel brace, which applies
intermittent compression to minimize swelling and promote
circulation, has been proposed as a viable alternative to eccentric
exercises, especially in patient who do not tolerate training
because of pain [36]. No differences between management with
the AirHeel brace and an eccentric training program were found in
patients with chronic Achilles tendon pain [36]. The combination
of eccentric training with the AirHeel Brace does not produce a
synergistic effect [36–39].
Nitric oxide is a small free radical generated by a family of
enzymes, the nitric oxide synthases [40]. A prospective, random-
ized, double-blind, placebo controlled clinical trial in patients with
tendinopathy of the main body of the Achilles evaluated the
efficacy of nitric oxide administration via an adhesive patch [41].
Topical glyceryltrinitrate was effective in chronic noninsertionalAT,
and the treatment benefits continue at 3 years [42]. However, a
more recent study questioned the clinical benefit of topical
glyceryltrinitrate patches [43].
Low-energy shock wave therapy in tendinopathy has been
proposed to stimulate soft tissue healing and inhibit pain
receptors. Low energy shock wave therapy or eccentric training
produced comparable results in a randomized controlled trial [28],
and both management modalities showed outcomes superior to
the wait-and-see policy. The combined use of low-energy shock
wave therapy and eccentric exercises is beneficial [43]. However,
Table 1
Diagnostic tests for Achilles tendinopathy.
Test How to perform it Sensitivity Specificity
Palpation Both legs are exposed from above the knees, and the patient examined while standing and prone. The Achilles
tendon should be palpated for tenderness, heat, thickening, nodule and crepitation.
0.583 (CI 0.393,
0.752) [57]
0.845 (CI 0.745,
0.911) [57]
Painful arc It helps to distinguish between tendon and paratenon lesions. In paratendinopathy, the area of maximum
thickening and tenderness remains fixed in relation to the malleoli from full dorsi- to plantar-flexion; lesions
within the tendon move with ankle motion. There is often a discrete nodule, the tenderness of which markedly
decreases or disappears when the tendon is put under tension [57].
0.525 (CI 0.347,
0.697) [57]
0.833 (CI 0.717,
0.908) [57]
Royal London
Hospital test
The clinician elicits local tenderness by palpating the tendon with the ankle in neutral position or slightly
plantar flexed. The tenderness significantly decreases or becomes totally painless when the ankle is
dorsiflexed [57].
0.542 (CI 0.345,
0.726) [57]
0.912 (CI 0.858,
0.952) [57]
N. Maffulli et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx 3
G Model
FAS 1285 No. of Pages 10
Please cite this article in press as: N. Maffulli, et al., Achilles tendinopathy, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.03.009
4. Table 2
Differential diagnosis of Achilles tendinopathy.
Diagnosis History Findings
Physical Examination Plain-Film
Radiographic
Assessment
MRI or Ultrasonographic
Examination
Bone scan
Tendinopathy of the main
body of the Achilles
tendon
Pain, impaired function,
and swelling in and
around the Achilles
tendons.
Tender area of intratendinous
swelling that moves with the
tendon and whose tenderness
significantly decreases or
disappears when the tendon is
put under tension.
Normal findings. Focal or diffuse thickening
of the Achilles tendon, with
focal hypoechoic areas.
Normal findings.
Paratenonitis of the Achilles
tendon
Pain in the Achilles
tendon region or
posterior heel region.
The tendon is diffusely swollen
on
palpation, and is tender in the
middle third of the tendon. A
crepitus may be occasionally
palpable in the acute phase.
However, the swelling and
tenderness do not move when
the ankle is dorsiflexed. Areas of
erythema, increased local
warmth, and palpable tendon
nodules or defects
may also be present.
Normal findings. US can be useful only if
adhesions are present
around the Achilles tendon.
In acute
form, US can detect fluid
around the tendon, whereas
paratendinous adhesions
are visualized
as thickening of the
hypoechoicparatenon with
poorly defined borders in
the chronic form.
Normal findings.
Insertional Achilles
tendinopathy
Early morning stiffness,
pain at the insertion of
the Achilles tendon that
deteriorates after
exercise
or climbing stairs,
running on hard surfaces,
or heel running.
Pain, swelling, and tenderness in
the back of the calcaneus. The
pain generally emanates from
the posterior aspect of the heel
and is aggravated by active or
passive motion.
Ossification of
insertion of the Achilles
tendon or a spur
(fishhook osteophyte)
on the superior portion
of the calcaneum.
Insertional calcification.
Moderate to severe variety
in the echo structure of
tendon in the insertional
area.
Normal findings.
Retrocalcaneal bursitis Pain in the posterior heel
region.
Fluctuation at palpation
indicates an
effusion of the retrocalcaneal
bursa.
Normal findings. Hypertrophic bursa. Normal findings.
Sever's (Calcaneal traction
apophysitis)
Patients complain of
activity related pain.
Localized tenderness and
swelling at the site of insertion
of the Achilles tendon.
Avulsion of the of the
calcaneal apophysis.
Avulsion of the of the
calcaneal apophysis.
Normalfindings.
Achilles tendon ossification Pain and difficulty
walking.
May be totally silent. The Royal
London Test is negative.
Areas of ossification
within the Achilles
tendon.
Thickening of the Achilles
tendon, areas of marked
echogenicity with
no through-transmission
(consistent with
ossification). Radiographic
evidence of intratendinous
ossification.
Normalfindings.
Osteomyelitis of tibia and
calcaneus
Pain and difficulty
walking. Temperature.
The Achilles tendon itself is not
involved in the pathology.
provide an anatomic
overview of the region.
MRI: excellent soft-tissue
contrast and
its sensitivity to tissue
oedema and hyperaemia.
Increased uptake.
Neoplasms of tibia and
calcaneus
Nocturnal pain and
difficulty walking.
Temperature.
The Achilles tendon itself is not
involved in the pathology.
provide an anatomic
overview of the region.
The features change
according to the neoplasm
and its location. The Achilles
tendon shows no evident
abnormality.
Increased uptake.
Flexor
hallucislongustendinopathy
Pain on toe-off or forefoot
weigh-bearing,
maximum over the
posteromedial aspect of
the calcaneus around the
sustentaculumtali.
Pain aggravated by resisted
flexion of the first toe or stretch
into full dorsiflexion of the
hallux.
Normal findings. MRI: Abrupt fluid cut-off in
the tendon sheath,
excessive fluid loculated
around a normal-appearing
tendon proximal to the
fibro-osseous canal.
Normal findings.
Posterior tibialis
tendinopathy
Medial ankle pain behind
the medial malleolus and
extending towards the
insertion of the tendon.
Tenderness along the tendon.
Resisted inversion of the ankle
elicits pain and relative
weakness compared with the
contralateral side.
Single heel raise test viewed
from behind reveals lack of
inversion of the hind foot, and, if
severe, the patient may have
difficulty performing a heel
raise. If the pathology is
advanced, loss of the medial
arch, progressive pronation of
the foot, ‘too many toes’ sign.
Normal findings. Increased signal and tendon
thickening.
Normal findings.
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5. when low energy shock wave therapy is used outwith of the
indications and modalities outlined in the above trials, the results
can be disappointing [44].
Hyperthermia can be another option for the management of
these patients, with the potential to stimulate repair processes,
increase drug activity, allow more efficient relief from pain, help
removal toxic wastes, increase tendon extensibility and reduce
muscle and joint stiffness. Randomized controlled trials seem to
confirm these potential advantages [45].
Ultrasound therapy is widely available and frequently used.
However, systematic reviews and meta-analyses have repeatedly
concluded that there is insufficient evidence to support a beneficial
effect of ultrasound therapy at the current clinical dosages [46]. A
pilot randomized controlled trial showed similar outcome
between heavy eccentric loading and ultrasound for the manage-
ment of AT in subjects with a relatively sedentary lifestyle, with no
adverse effects [47]. These results need to be confirmed in wider
populations.
Several substances have been used for Achilles tendon
injections (Table 3). At present, studies which demonstrate the
superiority of one injection technique or of one substance over
another are few. A recent randomized control trial showed that
treatment with High Volume Injections (steroid, saline, and local
anaesthetic) or Platelet Rich Plasma in combination with eccentric
training in chronic Achilles tendinopathy seems more effective in
Table 2 (Continued)
Diagnosis History Findings
Physical Examination Plain-Film
Radiographic
Assessment
MRI or Ultrasonographic
Examination
Bone scan
Peronealtendinopathy Lateral ankle or heel pain
and swelling which is
aggravated by activity
and relieved by rest.
Local tenderness over the
peroneal tendons
Painful passive inversion and
resisted eversion.
Normal findings. Increased signal and tendon
thickening.
Normal findings.
Ostrigonum syndrome Pain with mild swelling
posterior to the ankle.
Pain is accentuated by resisted
plantar flexion or dorsiflexion
of the great toe.
Tenderness is present anterior to
the Achilles tendon and
posterior to the talus. Positive
posterior impingement sign.
There may be
hypertrophy of the
ossicle or lateral
tubercle.
MR can identify a disruption
of the cartilaginous
synchondrosis by
demonstrating fluid
between the ostrigonum
and the lateral talar process.
Increased uptake
in the region of the
os trigonum in
symptomatic os
trigonum and
ununited posterior
process fractures.
Fig. 2. Ultrasound view showing thickening of the Achilles tendon.
Fig. 3. MRI showing tendinopathy of the main body of the Achilles tendon.
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6. reducing pain, improving activity level, and reducing tendon
thickness and intratendinous vascularity than eccentric training
alone. High volume injections, also, seem to be more effective in
improving outcomes of chronic Achilles tendinopathy than Platelet
Rich Plasma in the short term [48].
4.1. Surgical management of tendinopathy of the main body of the
Achilles tendon
In 24–45.5% of patients with AT, conservative management is
unsuccessful, and surgery is recommended after at least six
months of conservative methods of management. There is a lack of
trials on surgical management of AT, and therefore the high success
rate reported by some authors needs to be interpreted with
caution. Surgical options range from simple percutaneous tenot-
omy (Fig. 4A, B, C) [49,50] (possibly ultrasound-guided [51]), to
minimally invasive stripping of the tendon (Fig. 5A, B, C) [52], to
open procedures (Fig. 6), (Table 4). During open procedures, if
more than 50% of the tendon is debrided, consideration could be
given to a tendon augmentation or transfer.
Most authorities anecdotally report excellent or good results in
up to 85% of cases. In a systematic review [53], most of the articles
on surgical success rates reported successful results in over 70% of
cases. However, this relatively high success rate is not always
observed in clinical practice. The articles that reported success
rates higher than 70% often had poorer methods scores. Surgery
appears to work better for athletes [27,54] and males [55].
Rehabilitation is focused on early motion and avoidance of
overloading the tendon in the initial healing phase. A period of
initial splinting and crutch walking is generally used to allow pain
and swelling to subside. After 14 days, patients are encouraged to
start daily active and passive ankle range of motion exercises. The
use of a removable walker boot can be helpful during this phase.
Weightbearing is not limited according to the degree of debride-
ment needed at surgery, and early weight bearing is encouraged.
However, extensive debridement and tendon transfers may require
protected weightbearing for 4–6 weeks postoperatively. After 6–8
weeks of mostly range of motion and light resistive exercises,
initial tendon healing will have completed. More intensive
strengthening exercises are started, gradually progressing to
plyometrics and eventually running and jumping
Table 3
Injections for Achilles tendinopathy.
Injections
Corticosteroid injections At present, there is not significant evidence from which to draw firm conclusions on the utility of local steroid treatments for Achilles
tendinopathy. 3 randomized controlled trials [58–60] showed a mixed picture of the effect of local steroids on healing, with 2 studies
reporting some benefit [58,59] and the other detecting none [60]. Meta-analysis of the effects of corticosteroid injections has shown
little benefit [14]. The safety of using corticosteroid injections can be enhanced with the use of imaging as a guide to enter the
peritendinous space [61].
Hyperosmolar dextrose
injections
Sonographically guided intratendinous injection of hyperosmolar dextrose yielded good clinical responses in patients with chronic
Achilles tendinopathy in pilot studies [62,63].
MMPinhibitors Injections of aprotinin (a broad spectrum proteinase inhibitor) have been used for the management of Achilles tendinopathy with
good results [64]. Patients must be warned of the risk of allergy from aprotinin injections for tendinopathy and be prepared to remain
under medical surveillance for 30 to 60 minutes after injection. Because of this risk, aprotinin should be used as second-line therapy
only, for chronic conditions where more basic measures have failed.
Sclerosing injections In patients with chronic painful Achilles tendinopathy, but not in normal pain-free tendons, there is neovascularisation outside and
inside the ventral part of the tendinopathic area [37,38]. Local anaesthetic injected in the area of neovascularisation outside the tendon
resulted in a pain-free tendon, indicating that this area is involved in pain generation. These are the bases for the injection of sclerosing
substances under ultrasonography and colour Doppler-guidance in the area with neovessels outside the tendon.
Injections with the sclerosing substance Polidocanol showed the potential to reduce tendon pain during activity in patients with
chronic painful mid-portion Achilles tendinopathy in a randomized controlled trial [65].
High volume ultrasound guided
injections
High volume ultrasound guided injections aim to produce local mechanical effects causing neo-vessels to stretch, break or occlude
[66]. In this way, the accompanying nerve supply would also be damaged, decreasing the pain in patients with resistant Achilles
tendinopathy. In a pilot study [66], high volume image guided Achilles tendon injection of normal saline in patients with resistant
Achilles tendinopathy decreased the amount of pain perceived by patients, while improving daily functional ankle and Achilles
movements in the short- and long-term.
Fig. 4. High volume injection procedure. Using an aseptic technique, a 21gaugen-
eedleattached to a 30 cm connecting tube is inserted under real-time ultrasound
guidance between the anterior aspect of the AT and Kager’sfatpad. A mixture of
10 ml 0.5% Bupivacaine hydrochloride and 25 mg of Hydrocortisone acetate is
injected, followed by 4 Â10 mL of injectable normal saline. The position of the
needle and flow of fluid is monitored continuously by US during this phase, and the
needle moved gently across the anterior aspect of the tendon.
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7. Fig. 5. Percutaneous longitudinal tenotomy. The patient lies prone on the examination couch with the feet protruding beyond its edge, and the ankles resting on a sandbag.
The tendon is accurately palpated, and the area of maximum swelling and/or tenderness marked, and checked by US scanning. A number11surgicalscalpelblade (Swann-
Morton, London, United Kingdom) is inserted parallel to the long axis of the tendon fibres in the centre of the area of tendinopathy. The cutting edge of the blade points
caudally and penetrates the whole thickness of the tendon. While keeping the blade still, a full passive ankle flexion is produced. The scalpel blade is then retracted to the
surface of the tendon and inclined 45
on the sagittal axis, and the blade is inserted medially through the original tenotomy. While keeping the blade still, a full passive ankle
flexion is produced. The whole procedure is repeated inclining the blade 45
laterally to the original tenotomy, inserting it laterally through the original tenotomy. While
keeping the blade still, a full passive ankle flexion is produced. The blade is then partially retracted to the posterior surface of the tendo Achillis, reversed 180
, so that its
cutting edge now points caudally, and the whole procedure repeated, taking care to dorsiflex the ankle passively.
Fig. 6. Minimally invasive stripping. The patient is positioned prone with a calf tourniquet which is inflated to 250 mmHg after exsanguination. Four skin incisions are made.
The first two incisions are 0.5 cm longitudinal incisions at the proximal origin of the Achilles tendon, just medial and lateral to the origin of the tendon. The other two incisions
are also 0.5 cm long and longitudinal, but 1 cm distal to the distal end of the tendon insertion on the calcaneus.
A surgical instrument (mosquito) is inserted in the proximal incisions (Fig. 6A), and the AT is freed of the peritendinous adhesions. A Number 1 unmounted Ethibond (Ethicon,
Somerville, NJ) suture thread is inserted proximally, passing through the two proximal incisions. The Ethibond is retrieved from the distal incisions (Fig. 6A), over the posterior
aspect of the Achilles tendon. Using a gentle see-saw motion, similar to using a Gigli saw, the Ethibond suture thread is made to slide posterior to the tendon (Fig. 6C), which is
stripped and freed from the fat of Kager’striangle.
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8. 5. Discussion
The natural history and clinical course of AT are unclear, and the
condition may be self-limiting in many patients. Therefore, it is
important to establish whether the many commonly used treat-
ments, including surgery, really work. Data from randomized,
controlled trials are insufficient to assess the efficacy of
conservative and surgical interventions in the management of
AT. It is still debatable why tendinopathic tendons respond to
surgery. For example, we do not know whether surgery induces
long term re-vascularisation, denervation, healing of the failed
healing response lesion or a combination of all these, resulting in
pain reduction.
Guidelines have been published for the evaluation and
management of AT [56].However, these guidelines have not been
tested in a systematic manner, and are to be regarded at best as
expert opinion.
The clinical diagnosis of AT, even in experienced hands, is not
straightforward. If the patient presents with tendinopathy of the
Achilles tendon with a tender area of intratendinous swelling that
moves with the tendon and whose tenderness significantly
decreases or disappears when the tendon is put under tension,
a clinical diagnosis of tendinopathy can be formulated. In this
instance, further imaging is indicated only for confirmatory, not
diagnostic, purposes, as it is unlikely to change the management of
the patient. It would be reasonable to refer the patient to a physical
therapist to start a programme of eccentric exercises. If the
condition does not respond to these interventions, shock wave
therapy, or nitric oxide patches might be considered, although data
on their efficacy are limited. If the condition does not respond to
these interventions, peritendinous injections or injections at the
interface between the Achilles tendon and Kager’s triangle could
be considered (Fig. 7). The possibility of surgery should be
discussed with the patient after at least three to 6 months of non-
operative management. In well conducted studies in specialist
centres, the percentage of success of surgery is around 75%, and a
Table 4
Options for Achilles Tendon Disorders.
Less invasive More invasive
Paratendinopatghy 1. High volume image guided injection (hvigi) between the achilles
tendon and paratenon.
2. Minimally invasive paratenon stripping.
3. Tendoscopic debridement of paratenon.
1. Open debridement of paratenon.
2. Gastrocnemius recession if isolated contracture is present.
Non-insertional
tendinopathy
1. Percutaneous longitudinal tenotomy.
2. Gastrocnemius recession if isolated contracture is present.
1. Debridement with tubularization if less than 50% resection required.
consider a gastrocnemius recession if an isolated contracture is
present.
2. Debridement with tubularization and concomitant tendon transfer
(flexor hallucis longus or peroneus brevis).
3. Consider a concomitant gastrocnemius recession if an isolated
contracture is present.
Insertional
tendinopathy
1. Gastrocnemius recession if isolated contracture is present. Con-
comitant resection of prominent superior calcaneus is required to
decrease the risk of further impingement following the recession.
1. Debridement and re-attachment if less than 50% resection is required.
Concomitant resection of the postero-superior corner of the calcaneus
should be performed. Consider a gastrocnemius recession if an
isolated contracture is present.
2. Debridement and re-attachment with concomitant tendon transfer
(flexor hallucis longus or peroneus brevis) if greater than 50%
resection is required. Concomitant Haglund’s resection should be
performed.
In cases of severe tendinopathy where no viable Achilles tendon remains:
a. a. Allograft reconstruction.
b. V-Y lengthening with re-attachment.
c. Tenodesis of flexor hallucis longus /peroneus brevis to remaining
Achilles.
d. Isolated flexor hallucis longus /peroneus brevis transfer in lower
demand patients (no impact).
Fig. 7. The paratenon and the Achilles tendon are exposed. The paratenon is
identified and incised. In patients with evidence of co-existing paratendinopathy,
the scarred and thickened tissue is generally excised. A longitudinal tenotomy is
performed. The tendinopathic tissue can be identified as it generally has lost its
shiny appearance, and frequently contains disorganized fibre bundles which have
more of a “crabmeat” appearance. This tissue is sharply excised.
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9. period of around 6 months will be required before returning to
sports activities.
6. Conclusions
The clinical diagnosis and management of AT, even in
experienced hands, is not straightforward. Hence, patients should
understand that symptoms may recur with either conservative or
surgical approaches. Teaching patients to control the symptoms
may be more beneficial than leading them to believe that AT is fully
curable.
Conflict of interest
We declare that we do not have any conflict of interest by any
means.
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Please cite this article in press as: N. Maffulli, et al., Achilles tendinopathy, Foot Ankle Surg (2019), https://doi.org/10.1016/j.fas.2019.03.009