All right, we'll go ahead and get started. I want to welcome everybody to AAP Virtual Didactics today. We're excited to have Dr. Steve Schaaf with us today, who is a sports medicine doctor. And just so everybody's aware, we also have a second lecture after this with Dr. Tim Dillingham, who is the chair of PM&R at the University of Pennsylvania. So we encourage everybody to stick around for both lectures today. I'm sure they will both be excellent. Again, first thing we want to do is recognize and appreciate people who have been most impacted by the COVID-19 pandemic, recognize that for some folks, this has been more personal than others. So for those of you who have been personally or professionally more affected by this than others, we appreciate and support you. So the goals of these didactics are to augment didactic curricula that are already ongoing at your home institutions to offload overstretched faculty due to some of the logistical challenges associated with this pandemic, provide additional learning opportunities for off-schedule residents, again, due to some of the logistical challenges and scheduling difficulties associated with this. We recognize that things have been kind of up in the air. And to develop additional learning resources and support physiatrists in general during the COVID-19 outbreak. A couple of housekeeping points. As always, we're going to keep everybody video and audio muted. Again, this isn't personal. It's just about keeping up bandwidth and trying to keep distractions and noise to a minimum. If you have any questions, you should be able to see me. If you look at the participants button on your control bar, you should see a list of individuals. And my name, Sterling Herring, should be up near the top somewhere. Send me a message if you have any questions. And I will ask Dr. Schaaf or Dr. Dillingham later as appropriate and as time allows. If you have any bigger questions, suggestions, concerns, or just kind of general things to ask or communicate, our email and Twitter is right there. So find us. So without further ado, here's Dr. Steve Schaaf. Thank you, Dr. Schaaf, for joining us today. Yep, I appreciate it. Let me see if I can get the screen pulled up. All right, well hopefully everyone can hear and see me now. So the topic we're gonna be discussing today is Achilles tendinopathy from basic tendon concepts to novel treatments. And really the reason I wanted to bring this topic up and I thought it'd be worthwhile is the fact number one, it's a board relevant topic for all the trainees. It'll show up both on the written and oral boards. But beyond that, the fact is that tendinopathy for Achilles has a lot of general concepts that can be applied to other tendons throughout the different body regions. And a lot of these concepts kind of hold up and you'll see that they start to become repetitive as far as what you'll be taking for the history physical exam. And a lot of the treatment concepts. So whether it's a common extensor tendon at the elbow, hamstring and the hip, a lot of these same tendon concepts that we'll discuss today for the Achilles can be also applied to these structures. And then lastly, we're gonna discuss some novel treatments for Achilles tendinopathy that has been based on a lot of basic science research and now has been applied clinically. And one of the important things about this is that a lot of the physicians that are bringing these treatments are from PM&R. And so really PM&R is at the forefront for pushing a lot of these new novel treatments, which I think is a credit to our field. Today, I have no financial or other conflicts of interest to report. And the objectives from the talk today is, first, we're gonna discuss the pathophysiology of Achilles tendinopathy. Secondly, we're gonna then discuss risk factors for Achilles tendinopathy, things that you should look out for from both intrinsically and extrinsically. Then we'll discuss the typical presentation for Achilles tendinopathy, both from a history and physical exam standpoint. Then we will discuss the utility of different imaging modalities from Achilles tendinopathy, from X-ray, MRI, to ultrasound. And then lastly, as we had mentioned, we'll review some of the traditional conservative and then some more newer novel interventional treatment options for Achilles tendinopathy. So we'll just start first with a clinical vignette. And so our case will be about a 42-year-old male marathon runner who presented with left heel pain. And so this will be for some of the younger level residents and also for some of the medical students. But to kind of give a little bit of a framework of a basic MSK history that you should be taking, I think as long as you hit most of these questions, I think in general, you're gonna get the majority of a pertinent history for these patients. And so for this, a good mnemonic that I like to follow so you don't forget anything is O-P-Q-R-S-T-A. And so the O portion of it stands for onset. And so this really is gonna be discussing the mechanism of injury, which is extremely important for a lot of MSK injuries. Is this something that has been traumatic? And is there a specific moment that the athlete can remember that they were injured or is this something that's more chronic? Cause that will definitely help to guide your differential. Next is gonna be P, which is provocation and palliation. So what are the things that help to relieve or what are things that end up provoking the patient's pain? Is it certain movements and then specific to their sport? Q is gonna be for quality. And so exactly how do they describe this? Is it typically with tendon issues, it's gonna be described as an ache, a stiffness, sometimes a throbbing type of pain. And then some other times, for example, if it's a nerve type pain, it may be described as burning. So that may help guide you a little bit as well too. R stands for region and radiation. So exactly where is the pain? So sometimes these patients may say heel pain, but that sometimes can mean a lot of different things. So is it specific to their Achilles? Is it higher up at the gastrocnemius muscle? Things like that, that you wanna be a little bit more specific on. And then does it radiate anywhere? Next S is for severity. How bad is this? Is this something that is just a minor problem right now that maybe more conservative interventions might help out with? Or is it something severe? You might start having to think about interventional options from the get-go. T stands for time. So when exactly did this start? And then over that timeframe, are things then starting to get worse? And then A stands for associated symptoms. And so this can be kind of a grab bag for a lot of different things. For example, you can ask about weakness, any type of numbness that they're having, and then also kind of sports specific risk factors that might put the patient at risk. So for example, sometimes for Achilles issues, you can discuss, have they had any recent training errors, increase in their mileage, change in shoes, kind of specific things to the pathology that you're concerned about. So for this case, the onset, as mentioned, it started gradual while the person was training for a marathon. The symptoms were continuing to be provoked with running, but seemed to be relieved with rest. It was described as sharp. The patient had, once again, it was to the left heel, but they denied any radiation. It was six out of 10 with activity, but one out of 10 at rest. And then this initially had started eight months prior, but was really worse the last six weeks. And the patient had denied any weakness, numbness, or skin changes. So now moving on to the physical exam. Once again, I wanna try to give a little bit of a framework for the younger level residents and medical students on something that they can follow. And so for the MSK physical exam, I like to use the mnemonic I-PASS. And so I think as long as you hit kind of these five different areas, this should give you a pertinent physical exam that will be worthwhile. So I stands for inspection. So definitely you wanna look at the area that you're concerned about. Is there any deformity? Is there any type of abnormality? And then especially any differences compared to the contralateral side. P stands for palpation. So specific for tendon issues, you wanna make sure that you palpate through the length of the whole tendon and then kind of specify exactly where it hurts for that patient. A stands for active and passive. Active and passive range of motion. So you wanna make sure that you perform both of these with the patient because different limitations and passive and active range of motion can lead you down to different pathologies for the patient. S stands for strength and sensation. So your normal myotomal and dermatomal screening during this section. And then lastly, will be special testing. And so you'll kind of refine this to the pertinent region that you're concerned about. So for this patient on inspection, the minute Achilles was noted to be thickened, but specifically there was no swelling or erythema. On palpation, specifically the patient was tender along the mid portion of the Achilles tendon. He did have full active and passive range of motion, but had subjective pain within range of dorsiflexion. On strength testing, he was noted to be five out of five and had intact sensation of light touch. But, and that was throughout the lower extremity of the left leg. And then on special testing, things to be noted was the Thompson test, which was negative. Single heel raise was positive and the hop test for this patient was negative. And so now at this point, coming up with a differential diagnosis, kind of a systematic way to view this for most MSK conditions, can be broken down into these different areas just so that you don't miss anything. So B is for bone, and this will also include any joint issues. T for tendon, L for ligament, N for nerve, and then kind of other is a grab bag. And so I think as long as you systematically think about your differential diagnosis for most MSK conditions, and this will help make sure that you don't miss anything. And so for this patient coming in with the heel pain, coming up with a broad differential diagnosis, B for bone can be due to ankle joint osteoarthritis, could be due to such things as a Hagelin's deformity, which we'll also discuss a little bit later on, osteochondritis of the talus, osteogonum, also stress fractures, which always can be a concern for runners, and then Severs disease, which is more common in pediatric patients. For tendon, obviously the biggest concern is gonna be Achilles tendinopathy. Once again, you can break this down by location, such as the mid portion or insertional, and then plantarus tendinopathy. L, this could be a recalcitrant high ankle sprain, which sometimes take a lot longer to heal. And especially for your older patients, you always wanna think about back pathology as well too. So could this be an S1 radiculopathy? Other things as far as peripheral neuropathy would be a sural neuropathy, and then complex regional pain syndrome. And then lastly, kind of other as a retrocranial bursitis, accessory soleus muscle and plantar fasciopathy. So I think this is a good way to kind of show about going away a differential diagnosis, whether you're kind of presenting in clinic or for the oral board examination. So ultimately the diagnosis in this case was mid portion Achilles tendinopathy. And so defining exactly what this is. And so really the term tendinopathy is really an umbrella term for both tendinitis and tendinosis. And so the clearest definition for it is that it's a clinical syndrome of tendon related pain and impaired performance. And so that's kind of the two big things that you always have to focus on, is that it causes pain. And then ultimately for these patients, it leads to performance impairments. And then further from this kind of umbrella term, then it can go further down into tendinitis and then the tendinosis, which get a little bit more specific. And so regarding these two terms, and tendinitis was traditionally what a lot of tendinopathy used to get labeled as, especially in the 1980s and 1990s. And it just really was because of the fact that we didn't have the basic science research to go along with this. So definition for a tendinitis is an inflammatory process that involves granulocytic infiltration of the tendon. So this is initially what we thought was going on, but now with more basic science research, we found out that really this inflammatory process wasn't taking place. And so what was going on is more of what we call a tendinosis. And so this is gonna be a degenerative process. It's marked by disorganized tendon fibers, along with eventual local necrosis, potential calcification, as well as neovascular engrowth on histological examination. And so if you can see on the histological side on the left, there's gonna be disorganization of the fibers. And then on the side of the right, you even see with the blood vessel that they're starting to be neonerves and vessels that are starting to grow near that. And so this is definitely one thing that I wanna get across for the trainees. So once again, Achilles tendinopathy is a clinical syndrome that we talk about. And this then can be further broken down by what we think is going on histopathologically as a diagnosis, which first is gonna be Achilles tendinitis. And this is more of an acute process. And this is inflammatory with granulocytic infiltration. Another process that can be labeled with under tendinopathy is tendinosis. And this is more of a chronic process and it involves degeneration, disorganized fibers, cell necrosis, as well as neovascular engrowth. And for the majority of tendinopathies now, we are finding that it kind of falls into more of this tendinosis rather than what we thought traditionally as the tendinitis. And so how does tendinopathy from a pathophysiology standpoint occur? And so I think this is a good diagram for looking at how this does occur. So naturally we have a normal tendon. And so with any type of exercise or physical movement, you have, the key is that you have some type of load that is occurring. And so naturally with a healthy tendon, you'll have adaptation. And then ultimately this will strengthen the tendon and the tendon will go back to normal. However, with certain type of activities or sometimes even with trauma, the normal tendon can start to have excessive load onto this. And then at that point, the tendon fibers do not strengthen normally anymore. And a lot of the time they first become thickened. And if this load doesn't become modified and it continues, then ultimately this can lead to collagen fiber disrepair. And then ultimately kind of the end process on this continuum is that degenerative tendinopathy, that tendinosis, which we had just talked about, where you actually start to get cell death of the collagen and tendons. And then this leads to some neovascular and growth of vessels and nerves. And so other things to also consider is that they are individual, than factors that sometimes can predispose patients that they may be more vulnerable to different loads throughout their activity. And so these excessive loads can be due to numerous things such as the training volume, frequency and those types of things. And so this is really kind of the pathophysiology that happens for any type of tendinopathy throughout the body. So defining the epidemiology for this condition, it's most frequently going to occur in runners and it has an annual incidence of nine to 11% and a lifetime risk of 52%. Unfortunately, this condition is often recurrent and chronic. And so it's had 29% of patients, the cases become recalcitrant. When trying to classify Achilles tendinopathy, there's two things to really consider. One is going to be duration. So is this an acute or chronic issue? An acute is generally considered to be around four weeks and then chronic is going to be something that's greater than 12 weeks. And then anything in between is really defined as that kind of subacute stage. And secondly, Achilles tendinopathy can be defined by the exact location. And so classically this can occur both at the insertion and the mid portion. But it should be noted that the mid portion is about two to six centimeters proximal to the insertional site. And this is the more common condition for Achilles or more common location for Achilles tendinopathy by about five fold. And we'll talk about reasons for that just in a little bit. So in looking at the anatomy of the Achilles tendon, so the tendon fibers arise from both the rostral ends of the gastrocnemius and the soleus muscle actually ends up being the strongest and thickest tendon in the body. And it can ultimately take up to 12 and a half times the body weight during certain activities such as jumping and sprinting. But one thing to note is that this structure is at anatomical risk just because of the fact that it crosses two joints, that being the knee and the ankle joint. Regarding something that's a little bit specialized to the Achilles tendon is that it's not surrounded by a true tendon sheath. It's actually surrounded by a periton, which is areolar tissue. And this really serves to lubricate the tendon and also basically allow for a greater range of motion. But it should be noted that this periton actually carries its own vascularity and nerves. And so sometimes this can become even a condition on its own that is separate then from the tendinopathy that become injured. You always think about the bursa related to the Achilles tendon. And so there's two to be noted. The retrocalcaneal bursa is depicted in this picture, which is gonna be the more deep bursa. And then you're also gonna have a retro Achilles bursa, which is gonna be more superficial. And so both of these can become inflamed just depending on certain friction, most often by the type of shoes or type of activity that the patients are doing. And then lastly, there's this Kegers fat pad, which is gonna be deep to the Achilles tendon. And really the anatomical significance of the Kegers fat pad really still is relatively unknown. Some physicians think that this can be separately impinged in a separate source of pain, but really no studies up to this point has really borne that out. So really the Kegers fat pad remains relatively unknown how it might contribute to Achilles tendinopathy, just besides from the fact that there might be some ingrowth from vessels from that region. All right. For the blood supply, which is an important factor to consider for Achilles tendon, it is derived from both the posterior tibial artery and the peroneal artery. And kind of one of the key takeaways is that mid portion area is a watershed area. So it receives less blood supply than both the insertional and more proximal area. And so this is one of the major reasons why mid portion Achilles tendinopathy is more frequent than that insertional location. And then lastly, the sensation to the Achilles tendon is primarily derived from the sural nerve, which you can see in this picture is at that more lateral location. So sometimes that can be a peripheral neuropathy that might mimic Achilles tendon issues, but it also has smaller contributions from the tibial nerve as well too. And lastly, kind of a newer concept regarding anatomy is the plantarus tendon. So for several decades, this tendon was kind of just ignored. It was known that it descended along the medial aspect of the Achilles tendon, but now with more sensitive and specific imaging modalities, we now know that the plantarus tendon has a variable insertion into the Achilles tendon, or sometimes can actually separately insert onto the calcaneus. And this can contribute to mid portion Achilles tendinopathy often due to abnormal contact. And this sometimes can result in adhesions and tendon pain. But this also can occur on its own in several cases. So just something to be aware of that both can contribute to Achilles tendinopathy that you might have to address or something that can mimic it to be aware of if traditional treatments for Achilles tendon are successful for the patient. So when looking at risk factors, I think for a majority of MSK conditions, the best way to look at these is breaking them down into intrinsic and extrinsic risk factors. And really this is helpful because the intrinsic risk factors, most of the time the factors that we can modify and make a difference as clinicians. These intrinsic risk factors are obviously things that we're gonna have to be aware about and things that we can educate our patient on. But it's really being aware of the two differences and things that we can do about each. So for Achilles tendon, athletes that are gonna be at risk generally have a male gender, advanced age, which is generally defined as around 60 years old. And then there's also several biomechanical malalignments that predispose these patients to Achilles tendon issues. First of which is a forefoot hyperpigmentation. And so this ultimately causes excess stress generally on the medial portion of the Achilles tendon, but also the opposite, cavus foot can lead to issues within the Achilles tendon as well too, generally on the more lateral side. But kind of really the big things to be aware of are extrinsic issues. So really these training errors are the number one risk factor for patients with Achilles tendinopathy. And common training errors to be aware of to counsel our patients that may need to be modified or changed is a sudden increase in running mileage or intensity. So in general, patients should only increase their mileage or this intensity by about 10% each week. It can also be due to a change in terrain. Did they go from a treadmill then to kind of out on the road, on cement or on trail running? Or are they running also on slope surfaces? And so these are all things that you can kind of counsel the patients to avoid or things that you make sure that you discuss during the history. And then other things extrinsically to be aware of that are risk factors is improper footwear. So this can be due to insufficient heel height, rigid soles and inadequate shock absorption, wedging from uneven wear. And so making sure that your runners are kind of changing out their shoes about every 300 miles, making sure that they're getting out kind of properly fitted at their local running shoe store. And then one other kind of thing that always comes up too, that's been more of a hot topic is the fact that these minimalistic running shoes and a lot of these times they'll cause a little bit more of a forefoot strike pattern which may predispose patients as well to these Achilles tendon issues. So just something to be aware of. On clinical presentation, kind of the hallmark for Achilles tendon issues is gonna be pain in the Achilles tendon area that's worse with loading of the tendon. And so initially this may just be at the start of running, but a lot of the time this can also progress to occur throughout the entire run. And then may even start to begin with initial loading as well too in the morning. On physical exam, on inspection, most often the Achilles tendon is gonna be thickened in those focal areas. So for example, whether it's at the mid portion or insertional area, and this is most often gonna suggest that tendinosis if you see swelling in erythema, this might be more consistent with the concept of tendinitis that we had discussed. On palpation, the area of pathology is gonna be focally tender. And generally with range of motion, they will have full and active, but generally towards the end range of dorsiflexion due to the fact that you're causing maximum stress on that Achilles tendon, patients will often have pain as well too on strength. They'll often have a five out of five strength throughout, but generally repetitive calf raises may elicit further issues for these patients. And then lastly, you wanna make sure that you always do special testing. And one of the pertinent things to do for this is a Thompson test, which has a positive predictive value of around 96 to 98% for Achilles tendon rupture. And so really the proper way to do this is have your patients lie prone and then flex their knee to about 90 degrees. And then you're gonna squeeze the mid portion of the gastrocnemius muscle, and then you should see plantar flexion that occurs. And if this doesn't, then this is a sign that they potentially have Achilles tendon tear or rupture, which is obviously gonna guide you down a different treatment path than if they just have tendinopathy alone. Discussing imaging. So first things that people initially will order will be x-rays. Unfortunately, these actually have very low utility, but in certain conditions may reveal bone issues associated with posterior heel pain. So one of these can be a Hagelin's deformity, which is just really a posterior superior outgrowth arising from the calcaneal tuberosity. And often this is usually asymptomatic, but it can occur due to friction often from certain types of shoes, but sometimes can be associated with insertional tendinopathy. And lastly, you can also see calcification of the tendon as well too in certain areas if this is more of a chronic issue. MRI is definitely gonna be of more value and is gonna be the preferred imaging technique when tendon ruptures are suspected if you have a positive Thompson test. And then ultimately too, if high quality ultrasound is not available at your practice. And so these are examples of what you'll find on the MRI. So tendinosis generally is gonna result in an increased T2 signal within the tendon as well too, you'll see a increased tendon thickening and then a fusiform tendon shape. So these pictures on the right of the MRI kind of depict this. So you have a sagittal image here, which shows the fusiform thickening along the Achilles tendon at the mid portion location. And then you'll have an axial image here where you'll see the increased T2 signal. But really kind of the modality of choice nowadays is gonna be ultrasound. It's been shown to be a cost effective, readily available, reliable imaging modality to locate tendon abnormalities and estimate severity. I won't really discuss too much about the ultrasound just because I know Dr. Visco has a talk coming up tomorrow that he'll probably discuss this a lot more detail, but kind of just in brief, common findings that you're gonna have on tendinosis are gonna be the tendon will turn hypocoic, you'll have fusiform thickening, and then you may have possible neovascularization or hyperemia. And so for the Achilles tendon, here's an ultrasound image measuring the thickness. So general thickness for the Achilles tendon is gonna be about four to seven millimeters. And so one thing that you can always do for these patients, as long as they have asymmetric complaints, is just compare side to side. So this is a comparison where you look on the left as a normal Achilles tendon, and then we look on the right side and the patient obviously has increased thickening in tendon as well as it's become hypocoic. And now we'll discuss a little bit more about this concept of the neovascularization. So what is this? So this is gonna be the development of new blood vessels within the tendon, and this can be visualized when you turn on the color doppler. And so we have found out that from the basic science that this does occur with tendinosis, but now clinically it's also been shown that this is a sign of chronic tendon irritation that we can view on ultrasound. And then in clinical studies, it's been associated with greater pain for these patients as well too, and then worse functional outcomes when identified. And so this is just another kind of live. Looks like we're having some technical difficulties. Hopefully he'll come back online here in a second. Are there any, again, if there are any questions that come up through this, you can pull up your participant list and find me on there, Sterling Herring, and shoot me those questions, and then I can ask Dr. Schaff as time allows. Internet connection just went out for a minute. So regarding the treatments then, so first and foremost, you'll think about activity modifications for these patients. So as far as we had talked about risk factors, as far as their training regimen, so this can be adjusting their volume or frequency. And then other things, if it is so severe, you may need to just do a period of relative rest for these patients. And then other things you can think about are gonna be stretching, particularly for Achilles tendinopathy, you wanna make sure that you're stretching, obviously the Achilles as well as the plantar fascia. And then sometimes heel lifts or taping. Medications that you can think about are gonna be classically NSAIDs, but as we had talked about, majority of these conditions are no longer tendonitis. So there really isn't too much rationale to use NSAIDs for these patients. Otherwise, newer treatments are topical nitroglycerin patches. Physical therapy is gonna be this eccentric heavy load training, which we'll discuss a little bit in more detail. And then a modality that you can use is gonna be the extracorporeal shockwave therapy. So in general, conservative treatments should be employed for about six months before you consider advancing to alternative or more invasive treatments. So really the best treatment for Achilles tendinopathy is the traditional treatment of eccentric heavy loading physical therapy. And so this is really the standard of care and was developed by Alfredson in the 1990s. And really the mechanism of action for this is that by doing more eccentric and heavy loading exercises this encourages healing by improving tendon fiber orientation and then restoring muscle strength. So what exactly is this Alfredson protocol that they created? So this is gonna be three sets of 15 slow repetitions of eccentric unilateral loading. And then this is usually performed on a step on a staircase. And then one exercise is performed initially with a straight knee and then one with a bent knee. And you can do this twice a day for seven days a week. And then ultimately you'll do this for about three months. And then you can increase the load on the tendon gradually by using a weighted backpack. And really your kind of guide to do this is as the pain diminishes. And so these are some pictures depicting how this is done. So the patient in A is gonna initially start like we had discussed in that maximum planar flexion. And then with a straight knee then they're gonna gradually slow down into a dorsiflexion. And then they can also perform this with a bent knee as well too. And so why is this the standard of care? Well, it was shown in clinical studies that it has around a 90% success rate. So this is gonna be something that you're gonna have to recommend. And then even during these times of using telehealth this is something that you can even demonstrate to your patients as well too if they're having issues. But just let them know that once again this is gonna be kind of a slow and steady progress. A lot of the time the benefits will kind of take up to 12 weeks to see. But one kind of caveat is to this is that it was seen with insertional tendinopathy cases. Unfortunately, it's had only around a 32% success rate. And so some of the modifications that Alfredson and his group recommended for this is that the patient should instead slowly lower the foot to a flat surface rather than a step. And this really eliminated that dorsiflexion component which they thought was causing more insertional issues. Next, we had talked a little bit about topical nitroglycerin or glycerol trinitrate patches. And the mechanism of the action is that it's a pro-drug for nitric oxide. And in theory stimulates collagen synthesis by wound fibroblasts and thus promotes tendon healing by improving blood supply. So the general prescription that you'll think about this for Achilles tendon patients is 1.25 milligrams every 24 hours. But one thing to be aware of and counsel your patients that common side effects are gonna be headaches and orthostasis. And a lot of the time these are gonna be even be things that you look out for to make sure that the medication is properly working as whether they are getting these. But generally these are gonna be very immediate within the first 24 hours that the patients start taking these medications. And also it should be avoided in any patients taking nitrate containing compounds for vascular conditions, because obviously this can lead to cardiac issues. But ultimately for this treatment, it's really been equivocal in reducing pain and increasing activity levels, unfortunately for Achilles tendinopathy. So something that you can potentially think about but it hasn't shown really too great of results to this point. Next is gonna be the extracorporeal shockwave therapy. And so this involves the delivery of acoustic energy waves to the pathological condition. So this can either be done at the mid portion or the insertion for the Achilles. And the mechanism of action to this point still remains relatively unknown, but it is thought to create an inflammatory response around the pathological tissue, triggering healthy remodeling within the damaged tendon. And results so far have shown at least improved outcomes insertional Achilles tendinopathy without that Haglund's deformity. Up to this point, there hasn't been too much data for the mid portion Achilles tendinopathy. Then we can move on to more, some of the more novel interventional treatments. And so once again, these are kind of reserved for those patients that have at least undergone six months of that kind of traditional care, or if these are patients that their pain is so severe that it's gonna be difficult for them to tolerate the therapy. So different interventional options that have now been developed are PRP or platelet-rich plasma pro-therapy, which is kind of an older regenerative therapy that you can use, chemical ablation injections, and then percutaneous stenographically guided tendon scraping, high volume image guided injections, and then percutaneous ultrasonic tenotomy. So these are kind of all mostly new novel treatments that have started to be investigated for Achilles tendon. But it should be noted that the traditional corticosteroid injections are not recommended for this condition due to the fact that there's a high risk of Achilles tendon rupture. And then there just really wasn't any improvement long-term for these tendon conditions. So regarding just briefly platelet-rich plasma, so the mechanism of action is thought to trigger a release of anti-inflammatory and growth factors, which should establish cell functions for cell perforation, collagen synthesis, and vascularity. But really for the Achilles tendon so far, there's been mixed results in the clinical studies. So initially there's some promising case series, but ultimately with a double-blind randomized placebo control trial by DeBose at all around 2010, there was really no differences in outcomes or pain comparing PRP to placebo lidocaine injection plus this eccentric exercise. But there was definitely limitations with this study. So really potentially some promising results, but once again, there kind of needs to be further investigation about the different concentration, repeat injections, variable activation techniques, and then kind of long-term outcomes with PRP that might show better results. Next kind of the one treatment that I really wanted to highlight is those percutaneous sonographically guided tendon scraping. And so the mechanism of action for this treatment is to cause mechanical disruption of neobessels and accompanying neonerves, which will provide pain relief and then really set the healing process. So this is a procedure that can be done in office under ultrasound. So generally what you're gonna do first is anesthetize the area with local anesthetic. After this is performed, then you can make a small incision with a number 11 blade needle. And then this can then be followed by inserting a 18 gauge needle. And then once kind of at that tendon fat pad interface where the Kager's fat pad and the undersurface of the tendon is, then you can start to create basically a scraping motion. And then ultimately what you're looking for is ease of swiping and then reduced hyperemia on the collar doppler. And so here is a video example of this. And so this is gonna be looking at the needle coming once again to that undersurface of the tendon, as in you're gonna see it scraping back and forth and really kind of the key procedure is that you're not causing any damage to the tendon. And so this ultimately leads to very quick return to play. And then this is another video showing the procedure now with the needle out of plane. But once again, the key is that you're just staying at the undersurface of the tendon at that fat pad, as in you're scraping cephalocotally to disrupt those vessels. And so here's a post collar doppler flow for this patient where you're seeing no flow any longer with inside the Achilles tendon. So ultimately the results from this procedure have been great. So really there was no difference comparing it to an open surgical procedure like this and there was an 89% patient satisfaction rate. And ultimately what this ultrasound guided procedure allowed versus a more open traditional procedure was early tendon loading within one to two days. And then ultimately really over a five year period, there was only a 5% recurrence of cases. So this definitely is a very good treatment option for patients that are wanting to return to play quickly and has shown good results that it shouldn't occur long term. But definitely along with all these interventional procedures, you wanna make sure that it's followed by a proper therapy protocol as well too. And then lastly, just quickly, we'll discuss percutaneous ultrasonic tenonomy commonly known as 10X. And so this uses ultrasonic energy to emulsify and remove pathologic tissue. And so really so far there's only been case series looking at this intervention. This has really been for an insertional tendinopathy by Dr. Maderic Hall et al in 2018. So this was a retrospective case series and overall for insertional tendinopathy cases, it showed a pretty good satisfaction rate of around 70% at short term follow-up and then at long term follow-up, it had decreased the severe pain from 68% at baseline to 15%. So fairly good results at this longer term follow-up over a year. And ultimately kind of one of the keys is that there was only one minor complication. So what some of the fact is that these more interventional procedures are mimicking surgical procedures, really the major advantage is that hopefully there's gonna be less complications. So this is one study that demonstrated that this is a fairly safe procedure as well too. And really there's gonna be more coming out about this as Dr. Hall is gonna be leading a future investigation on the safety of this procedure for Achilles tendinopathy. So definitely more to come for this procedure. And then lastly, there's gonna be surgical options. So there's numerous different surgeries that you can do, more than minimally invasive options are becoming more popular due to complication risks, but definitely with a lot of these more interventional options, surgery is becoming something that hopefully is needed less by these group of patients. And the big reason is that compared to these interventional options, generally there's a long three-month return to full previous level activity, whereas with these interventional options, it's a quicker return to play, which our athletes are always trying to get. And then lastly, I'm just gonna quickly touch on Achilles tendon rupture. So the mechanism of injury as seen in this video is gonna be a sudden plantar flexion. And the location once again, is gonna be most often at that mid portion. Risk factors for this condition is gonna be obesity, classically use of fluoroquinolones. And then as we had mentioned, kind of those steroid injections can predispose you to this as well too. So clinically, the patients will classically feel that pop and they'll be unable to bear weight on the affected leg and most often have a palpable defect. And then the key test for this is gonna be that positive Thompson test, which has a 96 to 98% positive predictive value for Achilles tendon rupture. Looking at imaging, you can use either ultrasound or MRI really to confirm the diagnosis. And then for treatment wise, there's both non-operative and operative options. It should be noted that for non-operative, generally this is gonna consist of two weeks of non-weight bearing, followed by weight bearing as tolerated in a walking boot. And this is gonna be then progressively go from a 20 degree heel wedge and decrease then over kind of an eight to 12 week time period. And then at this end of the 12 week time period is the patient will reinitiate then physical therapy. Operative options are generally recommended in young active individuals. And ultimately there was really no differences in return to sports, patient satisfaction, or even Achilles tendon strength for non-operative versus operative outcomes. Really the only main difference was that operative shows that it reduces the risk of a re-rupture, which is why it might be recommended in the young athletes. But ultimately after this procedure, you should be following a post-operative rehab protocol as well too, which is gonna be early dynamic ankle motion and weight bearing in a brace. So kind of the take home points then from the lecture that I wanna make sure that we get across is number one, Achilles tendinopathy is most often associated with tendinosis, which is a degenerative process. Number two, there are numerous intrinsic and extrinsic risk factors and training errors of these are definitely the most common. Achilles tendinopathy as with most tendinopathies is gonna be characterized by a focal tendon area pain. And for the Achilles, this is at the mid portion that's gonna be worse with load being. As far as imaging, ultrasound can both help confirm the diagnosis and gauge severity. And then lastly, an eccentric strengthening protocol is really the standard of care for Achilles tendinopathy. However, there's numerous interventional techniques that have emerged with promising results, which may serve as alternatives to surgery when traditional measures fail for these patients. So these are the references. And I will admit that I'm not tech savvy, but I at least have some questions that would be kind of board relevant for some of the listeners. And we'll kind of, I guess, then see if this works. Otherwise we can potentially just run through the questions. I guess with Sterling is... We're getting some via the group chat. Okay. Yeah, this is my, I will say I'm not tech savvy, so I don't know if this is gonna potentially work. But since we have just a few minutes, I have about five questions, so we'll just start running through some of these. So question number one regarding what is true regarding Achilles tendinosis, I see at least a lot from the answers that a lot of people are answering C, which is the correct answer. So Achilles tendinosis, as we talked about, is a degenerative as opposed to an inflammatory condition. All right, question number two, what tendon location does Achilles tendinopathy most frequently occur at? All right, so I'm starting to see some of the answers roll in. So, most people seem to be saying C. So, once again, that is the correct answer. So, as we talked about, that mid-portion is going to be at highest risk for injury, just from the fact that it's a watershed vascular area. Question number three, what is the most common risk factor for Achilles tendinosis? All right, looks like most of the answers are coming in. So people are actually learning some stuff from this lecture. So the answer is B. So it's going to be training errors. So that's one of those extrinsic risk factors that we had discussed. And so just something to be aware of to counsel your patients. What test has the greatest positive predictive value for Achilles tendon rupture? All right, good. Mostly everyone's answering correctly with D. So it's going to be that Thompson test. Once again, have the patient lie prone, flex the knee to the 90 degrees, and then squeeze the gastroc, and you should see a planned heart flexion. And then lastly, there's strong evidence for first-line treatment for midsumptance achilles tendinosis includes which of the following? All right, and just so we have some time to answer some questions. So yes, it is a so as we talked about, this is really kind of the standard of care is eccentric strength program. And regarding questions, I don't know if there's anything specific from Sterling, but I at least see one question from one of my friends, Zach, who said, can you speak to the relative rest for these patients? I use boots, et cetera, really rarely and try to get them moving early, but a lot of the ortho colleagues like to boot them early with a heel up, wondering what is your approach? Yeah, I definitely agree with this. I think the biggest thing is if you can use some type of imaging modality, such as, you know, ultrasound, might make you feel a little bit better about early mobilization if you can kind of rule out a higher grade partial tear. If this is truly then just tendinopathy either and most likely tendinosis, I definitely would get these patients moving early into a functional eccentric rehab program. Only time that I might be a little bit hesitant is if it does show a higher grade tear for these patients. All right, we have a couple of other questions. We're going to need to go rapid fire because I think we're out of time. Thoughts on PT modalities for tendinosis like the Graston technique? Hasn't really shown too much evidence. Okay. Is there a maximal load that can be determined for the Alfredson protocol? If the Achilles can handle up to 12 times the body weight in jumping and sprinting, then would it be more beneficial to use a heavier weight, heavier than a loaded backpack for a simulator? Yeah, you can definitely get to the point where you're doing it like on a squat rack or like a Smith machine, those types of things. But once again, just make sure that you're guiding it by the patient's pain level. You want to make sure that you don't load it, you know, too early to the point that you might end up having a tear. But yeah, you can definitely increase the weight more than a backpack. All right. Some studies like the Young in 2014 have shown that there's a weak link between neovascularity and clinical severity of Achilles tendinopathy using the Visa A score. Recently, the questioner was listening to an AMSSM virtual lecture. And one of the people mentioned that one of the attendings mentioned that 20% of patients will have neovascularity, but no symptoms of Achilles pathology. Are there any alternate hypotheses for why scraping works? Good question. I think just in general, if you're, I mean, there's kind of two processes going on there. One is the kind of neo nerves, which is probably where the majority of the pain is coming from. Second would be if you're disrupting any of the neo vessels. And so really what potentially that could be doing is resetting the healing process where you go from kind of that degenerative continuum to kind of more of that reactive tendinopathy. And so you're kind of resetting it. So it might allow the patients then when they go into a physical therapy protocol to have better adaptations to that. That would be at least my thought process with it. Okay. I think we're out of time. We have a few questions left. If you sent me a question and we didn't get to it, please send me your email address. I'll pass these along to Dr. Schopf and we'll try to get it out. Yeah, then here's my contact information. If anyone, you can either email me or find me on Twitter. Perfect. Thank you so much. All right. Yeah, thank you. I really appreciate it. Yeah. Thanks for joining us today. Yep. So again, here's Dr. Schopf's information on Twitter, mine as well as AAP. And please stick around. We're going to have an additional lecture now. Hold on just a second. We'll get that pulled up.

Achilles tendinopathy

tendon-related pain

impaired performance

tendinitis

tendinosis

risk factors

diagnosis

imaging modalities

treatment options

surgical options