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Achilles tendinopathy in dancers.

Professional ballet dancers present most of the same medical problems as other high level athletes. In dance, the choreographer acts as a sculptor using the dancer as a medium of expression. This often entails placing the dancer's body in positions that require extraordinary flexibility and movement, which in turn requires controlled power and endurance. Thus, ballet and other forms of dance can be highly demanding activities, with a lifetime injury incidence of up to 90%. (1)

The Achilles tendon (AT) has been proposed to be for the dancer one of the most vulnerable parts of the body. The AT is much involved in classical ballet because the dancer spends a good deal of time in either releve (plantar flexed ankle) where the AT is tightened, or in plie (dorsiflexed ankle) where it is stretched. Almost every classical ballet movement begins or ends in demi-plie, on which, for example, the ability to jump or land steadily depends. A viable demiplie ensures that the AT will remain supple, pliant, and in working order. (2)

On the other hand, faulty technique can result all too often in Achilles tendinopathy, and studies of this injury in dancers are lacking. (3-20) Therefore, we present the best evidence in the field of diagnosis and management of patients with Achilles tendinopathy. In doing so, we hope to circumvent any thought that a dancer with Achilles tendinopathy is different from other patients, which may lead to undertaking unusual treatment modalities that are not scientifically proven and can carry an unquantifiable risk.

Achilles tendinopathy is characterized by pain, impaired performance, and swelling in and around the tendon. (21) It can be categorized as either tendinopathy of the main body or insertional tendinopathy, two distinct disorders with different underlying pathophysiology and management options. (22) Other terms used as synonyms for tendinopathy of the main body of the Achilles tendon include non-insertional tendinopathy and mid-portion Achilles tendinopathy. The terms tendinitis, tendinosis, and paratenonitis should be reserved to specific histopathological features of tendon conditions. We suggest that terms such as "partial ruptures of" a given tendon should not be used to indicate intratendinous lesions of the tendon under study. We advocate the term "tendinopathy" as a generic descriptor of clinical conditions arising from overuse in and around tendons. We challenge the common wisdom, intrinsic in the suffix "-itis," that overuse tendinopathies result from inflammation.

Epidemiology

Although scientifically sound epidemiological data are lacking, Achilles tendinopathy is common in athletes, accounting for 6% to 17% of all running injuries, (23) possibly because of the continuous, intense functional demands imposed on the AT. (24) However, it also presents in middle-aged overweight non-athletic patients without history of increased physical activity. (25,26) To date, no data are available to establish the incidence and prevalence of Achilles tendinopathy in dancers. (27)

Histology

The essence of tendinopathy is a failed healing response, with haphazard proliferation of tenocytes, some evidence of degeneration in tendon cells and disruption of collagen fibres, and subsequent increase in non-collagenous matrix. Tendinopathic lesions affect both collagen matrix and tenocytes. The parallel orientation of collagen fibres is lost, and there is a decrease in collagen fibre diameter and in the overall density of collagen. Collagen microtears may also occur and may be surrounded by erythrocytes, fibrin, and fibronectin deposits. Normally, collagen fibres in tendons are tightly bundled in a parallel fashion. In tendinopathic samples, there is unequal and irregular crimping, loosening, and increased waviness of collagen fibres, and an increase in type III (reparative) collagen. (26,28,29)

In tendinopathic tendons, tenocytes are abnormally plentiful in some areas. (30,31,32) They have rounded nuclei, and there is ultrastructural evidence of increased production of proteoglycan and protein, which gives them a chondroid appearance. Other areas may contain fewer tenocytes than normal, with small, pyknotic nuclei occasional infiltrated by lymphocytes and macrophage type cells, possibly part of a healing process associated with proliferation of capillaries and arterioles. (33)

Etiology

The aetiology of Achilles tendinopathy remains debated; it is likely caused by intrinsic or extrinsic factors, or some combination thereof. The evidence for most of these factors is limited or absent. Postulated intrinsic factors include tendon vascularity, weakness, as well as lack of flexibility of gastrocnemius soleus, (34,35) pes cavus, (34,35) and lateral ankle instability. (36,37) Excessive loading of tendons during vigorous physical training is considered the major causative factor for tendinopathy. (38) Free radical damage occurring on reperfusion after ischaemia, hypoxia, hyperthermia, and impaired tenocyte apoptosis have been linked to tendinopathy. (39) Meta-analysis of the effects of corticosteroid has shown that published data are insufficient to determine the risk of rupture following corticosteroid injections. (40) In a recent case-control study subjects with chronic painful Achilles tendinopathy had a lipid profile characteristic of a dyslipidemia. (41)

Diagnosis

The diagnosis of Achilles tendinopathy is mainly based on history and clinical examination. Pain is the pivotal symptom. A common symptom is morning stiffness or stiffness after a period of inactivity and a gradual onset of pain during activity. Athletes experience stiffness and pain at the beginning and end of a training session, with a period of diminished discomfort in between. As the condition progresses, pain may occur during exercise, and it may interfere with activities of daily living. In severe cases, pain occurs at rest. A tender, nodular swelling is usually present in chronic cases.

Clinical examination is the best diagnostic tool. The legs are exposed from above the knees, and the patient is examined both while standing and prone. The AT should be palpated for tenderness, heat, thickening, nodules and crepitation. (42) The "painful arc" sign 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. (43)

Victorian Institute of Sports Assessment-Achilles

The Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire specifically measures the severity of Achilles tendinopathy. (44) 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. The VISA-A questionnaire contains eight questions that cover the three domains of pain (questions 1 to 3), function (questions 4 to 6), and activity (questions 7 and 8). Questions one through seven are scored out of 10, and question eight carries a maximum of 30 points. For question eight, participants must answer only part A, B, or C. If the patient has pain when undertaking sport, he or she automatically loses at least 10, and possibly 20, points. In clinical care, the VISA-A questionnaire provides a valid, reliable, and user-friendly index of the severity of Achilles tendinopathy. (45) It has been cross-culturally adapted to Swedish, (46) Italian, (47) Turkish, (48) and German. (49)

Imaging

Radiographs may be useful in diagnosing associated or incidental bony abnormalities. Radiographs are routinely obtained to rule out bony abnormalities and identify the possible presence of intratendinous calcific deposits and ossification.

Ultrasonography (US), though operator-dependent, correlates well with histopathology finding, (50) and, especially in Europe, it is regarded as the primary imaging method. Only if US remains unclear should MR imaging be performed. (51) A major advantage of US over other imaging modalities is its interactive capability. (52,53,54) Color or power Doppler are useful to detect neovascularity.

Magnetic resonance imaging (MRI) provides extensive information about the internal morphology of the tendon and surrounding bone and other soft tissue. It allows for differentiation between paratendinopathy and tendinopathy of the main body of the tendon. MRI is superior to US in detecting incomplete tendon ruptures. However, given the high sensitivity of MRI, the data should be interpreted with caution and correlated with the symptoms before making any recommendations. (38)

Management

The management of Achilles tendinopathy lacks evidence-based support, and patients with tendinopathy are at risk of long-term morbidity with unpredictable clinical outcome. (55) The appropriate moment to switch from conservative to operative therapy remains unknown, as no solid data exist on the natural course of recovery. Non-operative care should in general be a minimum of 3 to 6 months prior to considering surgery, as this condition usually resolves.

Conservative Management

Many common therapeutic options lack hard scientific background. (56) Rest, cryotherapy, pharmaceutical agents, such as non-steroidal anti-inflammatory drugs and various peri-tendinous injections, training modifications, splintage, taping, electrotherapy, shock wave therapy, and hyperthermia, have all been used. (56) Modalities tested using randomized controlled trials include nonsteroidal anti-inflammatory medication, eccentric exercise, glyceryl trinitrate patches, electrotherapy (microcurrent and microwave), sclerosing injections, and shock wave treatment. (57)

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Anti-inflammatory agents (nonsteroidal anti-inflammatory drugs and corticosteroids) are commonly used for the management of Achilles tendinopathy, (58) even though data from three trials (59,60,61) of NSAIDs showed, at best, a modest effect on acute symptoms in the short term, and even these findings were shown to be less than robust in a recent systematic review. (23)

Rest

Rest is considered another first-line therapy for Achilles tendinopathy, but the strength of recommendation is based only on expert opinion. (62) Data from recent randomized controlled trials showed that patients with Achilles tendinopathy can safely continue with their activity of choice, provided that the level of pain during these activities is no higher than 5 on a 0 to 10 visual analogue scale. (45,63)

Cryotherapy

Even though cryotherapy is widely used for analgesia, to reduce the metabolic rate of the tendon and to decrease the extravasation of blood and protein from new capillaries found in tendon injuries, (64) there is no evidence that this is an effective treatment for Achilles tendinopathy.

Eccentric Exercise

Eccentric exercises have been proposed to promote collagen fibre cross-linkage formation within the tendon, thereby facilitating tendon remodelling. (65,66,67) Although evidence of histological changes following a program of eccentric exercise is lacking, and the mechanisms by which eccentric exercises may help to resolve the pain of tendinopathy remain unclear, (68) some researchers report excellent clinical results. (65,69,70) The results of eccentric training from other study groups are less convincing, (63,71) with a 50% to 60% of good outcome after a regimen of eccentric training both in athletic and sedentary patients. In general, the overall trend suggests a positive effect of eccentric exercises, with no reported adverse effects. (45,63,69,72-76) Combining eccentric training and shock wave therapy produces higher success rates compared to eccentric loading alone or shock wave therapy alone. (77)

Orthotics

Orthotics are widely used, with heel pads being the most commonly prescribed. There is little evidence to support their use. (78) 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. (79) No differences between management with the AirHeel brace and an eccentric training program were found in patients with chronic Achilles tendon pain. (79) The combination of eccentric training with the AirHeel Brace does not exert a synergistic effect. (79-82)

Nitric Oxide

Nitric oxide is a small free radical generated by a family of enzymes, the nitric oxide synthases. (83) Recently, a prospective, randomized, 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. (84) Topical glyceryl trinitrate was effective in cases of chronic noninsertional Achilles tendinopathy, and the treatment benefits continued at 3 years. (85) However, a more recent study questioned the clinical benefit of topical glyceryl trinitrate patches. (86)

Physical Modalities

Low-energy shock wave therapy in tendinopathy has been proposed to stimulate soft tissue healing and inhibit pain receptors. (63,87) It and eccentric training produced comparable results in a randomized controlled trial, (63) and both management modalities showed outcomes superior to the wait-and-see policy. It should be kept in mind that when low energy shock wave therapy is used without the indications and modalities outlined in the above trials, the results can be disappointing. (88)

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 of toxic wastes, increase tendon extensibility, and reduce muscle and joint stiffness. (89) Randomized controlled trials seem to confirm these potential advantages. (90)

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. (91) A pilot randomized controlled trial showed similar outcomes between heavy eccentric loading and ultrasound for the management of Achilles tendinopathy in subjects with a relatively sedentary lifestyle, with no adverse effects. (92) These results need to be confirmed in wider populations.

Injections

Corticosteroid Injections

At present, there is not enough evidence from which to draw firm conclusions on the utility of local steroid treatments for Achilles tendinopathy. (40,66,93) Three randomized controlled trials (94,95,96) showed a mixed picture of the effect of local steroids on healing, with two studies reporting some benefit (94,95) and the other detecting none. (96) A meta-analysis of the effects of corticosteroid injections has shown little benefit. (40) The safety of corticosteroid injections can be enhanced with the use of imaging as a guide to enter the peritendinous space. (97)

Hyperosmolar Dextrose Injections

Sonographically guided intratendinous injection of hyperosmolar dextrose has yielded good clinical responses in patients with chronic Achilles tendinopathy in pilot studies. (98,99)

MMP-Inhibitor Aprotinin Injections

Injections of aprotinin (a broad spectrum proteinase inhibitor) have been used for the management of Achilles tendinopathy with good results. (100-103) Patients must be forewarned of the risk of allergic reaction to aprotinin injections 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. (101)

Sclerosing Injections and Neovascularization

In patients with chronic painful Achilles tendinopathy, but not in normal pain-free tendons, there is neovascularization outside and inside the ventral part of the tendinopathic area. (80,81) Local anaesthetic injected in the area of neovascularization 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 color Doppler-guidance in the area with neovessels outside the tendon. (104,105) In a randomized controlled trial, injections with the sclerosing substance Polidocanol showed the potential to reduce tendon pain during activity in patients with chronic painful mid-portion Achilles tendinopathy. (105)

High Volume Ultrasound Guided Injections

High volume ultrasound guided injections aim to produce local mechanical effects, causing neo-vessels to stretch, break, or occlude. (47) In this way, the accompanying nerve supply would also be damaged, decreasing the pain in patients with resistant Achilles tendinopathy. In a pilot study, (47) high volume image guided AT injection of normal saline in patients with resistant Achilles tendinopathy decreased the amount of perceived pain, while improving daily functional ankle and Achilles movements in the short- and long-term. (106)

Platelet Rich Plasma

Platelet-rich plasma (PRP) is a bioactive component of whole blood, which is now being widely tested in different fields of medicine for its ability to promote the regeneration of tissue with low healing potential. (107-112) The use of growth factors in PRP to help heal wounds has been under consideration since the early 1980s. (113) Its use in orthopaedic surgery, especially for augmentation of bone grafting, began during this decade, although to date there is no definitive evidence that it improves bone healing. Only recently has it been suggested that PRP might also aid in healing ten don. (114,115,116)

The specific elements of PRP have not been uniformly defined in the literature. (115) PRP, in general, has a higher concentration of platelets compared with baseline blood (117,118); clinically valuable PRP preparations typically contain one million platelets or more per microliter. (119) PRP has been defined as only platelets or as increased concentrations of white blood cells. (115) Activated platelets release the growth factors and proteins that reside within their alpha granules and dense granules. Dense granules play a role in tissue modulation and regeneration by releasing their contents of adenosine, serotonin, histamine, and calcium. The alpha granules release several cytokines, including transforming growth factor-b, platelet-derived growth factor, and vascular endothelial growth factor, with concentrations increasing linearly with increased platelet concentration. The released cytokines bind to transmembrane receptors on the surface of local or circulating cells and can start intracellular signaling, which results in the expression of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation. (115)

De Vos and colleagues (120) conducted a randomized controlled trial to examine whether a PRP injection would improve outcome in chronic tendinopathy of the main body of the Achilles tendon. Eccentric exercises (normal care) with either a PRP injection (PRP group) or saline injection (placebo group) were compared. After randomization into the PRP group (N = 27) or placebo group (N = 27), there was complete follow-up of all patients. The mean VISA-A score improved after 24 weeks in the PRP group by 21.7 points (95% confidence interval [CI], 13.0-30.5) and in the placebo group by 20.5 points (95% CI, 11.6-29.4). The increase was not significantly different between the groups (adjusted between-group difference from baseline to 24 weeks, -0.9; 95% CI, -12.4 to 10.6). The investigators concluded that, in patients with chronic Achilles tendinopathy who were managed with eccentric exercises, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity.

Surgery

Surgical Management of Tendinopathy of the Main Body of the Achilles Tendon

In 24% to 45.5% of patients with Achilles tendinopathy, conservative management, often tried for at least 6 months, is unsuccessful, and surgery is recommended. (121,122) Surgical options range from simple percutaneous tenotomy (123,124) (possibly ultrasound-guided (125)) to minimally invasive stripping of the tendon, (126) to open procedures. As there are no randomized controlled trials of surgical management of Achilles tendinopathy, success rates need to be interpreted with caution.

The classical aims of open surgery are to excise fibrotic adhesions, remove areas of failed healing, and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, restore vascularity, and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. (64) However, there is no level I evidence that fibrotic adhesions should be removed or that areas of failed healing should be excised, at least if the pathology does not involve the paratenon. Multiple longitudinal tenotomies trigger well ordered neoangiogenesis of the AT. (127) This hypothetically results in improved nutrition and a more favorable environment for healing.

A more recent approach targets not the tendinous lesion itself but the neo-innervation that accompanies the neovessels. New minimally invasive stripping techniques (126) of neovessels from the Kager's triangle of the AT in patients with tendinopathy allow for safe and secure disruption of neovessels and the accompanying nerve supply, producing a denervation effect. During open procedure, if more than 50% of the tendon is to be debrided, consideration could be given to a tendon augmentation or transfer.

Minimally Invasive Stripping

The current investigators have developed a novel management modality whereby a minimally invasive technique of stripping of neovessels from the Kager's triangle of the AT is performed. This achieves safe and secure breaking of neovessels and the accompanying nerve supply.

The patient is positioned prone with a calf tourniquet that is inflated to 250 mmHg after exsanguination. Four skin incisions are made. The first two 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 one cm distal to the distal end of the tendon insertion on the calcaneus.

A mosquito is inserted into the proximal incisions, and the Achilles tendon is freed of 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 through the distal incisions, over the anterior 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 anterior to the tendon, which is stripped and freed from the fat of Kager's triangle.

Our minimally invasive technique reduces the risk of infection, is technically easy to master, and inexpensive. It may provide greater potential for the management of recalcitrant Achilles tendinopathy by breaking neovessels and the accompanying nerve supply to the tendon. It can be combined with other minimally invasive procedures to optimize results.

Outcome of Surgery

Most authorities anecdotally report excellent or good results in up to 85% of cases. In a systematic review, (128) 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% had poorer methods scores. Surgery appears to work better for athletes than for the general population (62,129) and better for men than for women. (130)

Conclusion

Similar to other high caliber athletes, the professional ballet dancer experiences an array of injuries associated with physically vigorous performance requirements. Achilles tendinopathy gives rise to significant morbidity, and at present, only limited scientifically proven management modalities exist. The management of this condition remains a challenge, especially in dancers, with whom the physician often tries to be innovative. In many instances this carries with it an unquantifiable risk. (131) A better understanding of tendon function and healing will allow specific management strategies to be developed. (132,133,134) Future trials should use validated functional and clinical outcomes, adequate methodology, and be sufficiently powered. Clearly, studies with high levels of evidence, for instance large randomized trials, should be conducted to help answer many of the unsolved questions in this field.

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Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.), is at the Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London El 4DG, United Kingdom. Umile Giuseppe Longo, M.D., and Vincenzo Denaro, M.D., are in the Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Via Alvaro del Portillo, 200, 00128 Rome, Italy.

Correspondence: Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.), Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom; n.maffulli@qmul.ac.uk.
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Author:Maffulli, Nicola; Longo, Umile Giuseppe; Denaro, Vincenzo
Publication:Journal of Dance Medicine & Science
Date:Jul 1, 2012
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