1

Describe the four cornerstones in tendon histopathology and why these changes cause pain.

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  Cellular activation and increased cell number

  
  
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  Increase in ground substance

  
  
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  Collagen disarray

  
  
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  Neovascularization

Although the pain pathways of chronic tendinopathy are not completely understood, cDNA –arrays, polymerase chain reaction (PCR), and ultrasonography have provided potentially important information in regard to the origins of chronic Achilles tendinosis. High levels of glutamate, a neurotransmitter and pain modulator, have been found in painful tendons and not in normal tendons. Chronic tendinopathy is associated with neovascularization. Biopsies taken from areas of tendinopathy have shown nerve structures in close relationship with the vascular supply. This may explain the pain associated with tendinosis.

2

How is Achilles tendonitis diagnosed?

It is important to first rule out Achilles tendon rupture, as the management for this injury is significantly different. The calf squeeze test, or Thompson test, can aid in this exclusion. The diagnosis of Achilles tendonitis can be made clinically, especially if the tendon exhibits swelling. The pain will likely be reproduced by loading the tendon (i.e., single leg heel raise). Keep in mind, some athletes may require repetitive heel raises to reproduce pain. Imaging should be reserved for those cases with concern for rupture or if the clinical diagnosis is not clear.

3

Once an Achilles tendon strain (or acute Achilles tendonitis) has been diagnosed, what are the specific treatment options?

Although scientific evidence for most treatments is limited, some treatments that have been investigated with randomized, controlled trials and demonstrated effectiveness include eccentric exercise, glyceryl trinitrate patches, electrotherapy, sclerosing injections, and nonsteroidal antiinflammatory drugs (NSAIDs). Rest, NSAIDs, changing shoes to provide more arch support, and physical therapy are the mainstays of treatment. Achilles tendonitis is often caused by overpronation of the foot and overuse. This is why rest and improving biomechanics of the foot (using orthosis and physical therapy) can be beneficial.

4

When does an Achilles tendon injury need to be referred to an orthopedic surgeon?

Patients should be referred when there is a concern for an Achilles tendon rupture. The typical presentation includes a history of a sudden “pop” at the back of the heel with subsequent pain. The examination commonly includes a positive Thompson test ( Fig. 30.1 ), which proves disruption of the musculotendinous junction (squeezing the calf muscle does not lead to foot plantarflexion, or plantarflexes weaker than the contralateral side). Not all Achilles tendon ruptures require surgical repair; however, it is important to have a specialist evaluate and discuss the best approach on an individualized basis.

Thompson test for Achilles tear.

From Stretanski MF. Achilles Tendonitis. In: Frontera WR, Silvis JK, Rizzo TD, et al. Essentials of Physical Medicine and Rehabilitation . 2nd ed. Copyright 2008. Saunders, Elsevier Inc. Reprinted in Orthopedic Secrets. 4th ed. Copyright 2015. Saunders, Elsevier Inc.

5

How should suspected Achilles tendon ruptures be diagnosed and what is considered appropriate initial management when concerned for an Achilles tendon rupture?

The diagnosis is often made clinically. Ultrasound is an emerging imaging modality that can also confirm this diagnosis by evaluating tendon continuity. Magnetic resonance imaging (MRI) is typically not needed but may be of benefit in cases where the history and physical examination are nonspecific and clinically concern persists. If there is concern for Achilles tendon rupture, the patient should be placed in a splint or boot with slight plantar flexion.

6

What is the most common mechanism for a quadriceps strain?

Acute strains commonly occur in sports that regularly require a kicking motion, such as soccer, rugby, and football. This motion is described as a sudden forceful eccentric contraction of the quadriceps during regulation of knee flexion and hip extension. Another mechanism of quadriceps strain is with excessive passive stretching of a maximally stretched muscle.

7

What is the most common quadriceps muscle to be strained?

Rectus femoris. This muscle crosses both the hip and knee joint as it originates at the anterior inferior iliac spine and inserts at the quadriceps tendon onto the patella.

8

What is the typical presentation of a quadriceps strain?

Patients will complain of pain localized to the quadriceps muscle, often at the distal aspect, and have an appropriate mechanism of injury. They may report a slightly delayed onset of pain to the end of a game or event. The physical examination may include a muscle defect or bulge, ecchymosis, and tenderness. There may also be weakness noted on strength testing. Complete weakness indicates the possibility of a complete tendon rupture and should be referred urgently to an orthopedic surgeon.

9

When is imaging indicated for a quadriceps strain?

Imaging is not necessary to diagnose a quadriceps strain but should be utilized when there is concern for associated injuries or when the diagnosis is uncertain. Radiographs are normal in a quadriceps strain. Ultrasound can be helpful in making the diagnosis by showing hematoma formation and possible muscle fiber disruption. MRI can provide detailed information on muscle injury but is typically not necessary to diagnose a quadriceps strain.

10

When a patient sustains a quadriceps strain, what is the best appropriate initial management?

Acute phase treatment: rest, ice, compression, and elevation are all recommended to minimize bleeding in the injured muscle. This should be maintained for the initial 1–3 days. In more severe strains, crutches may be necessary to allow for rest of the muscle. NSAID use can be helpful but should be limited to a 3- to 7-day course.

11

What is the best approach to continued therapy and directions on return to play?

Active phase treatment: This phase typically begins 3–5 days after the initial injury and includes stretching, strengthening, range-of-motion exercises, maintenance of aerobic fitness, proprioceptive exercises, and functional training. Strengthening exercises should be introduced gradually, depending on the level of soreness. There are no established guidelines for returning to play, but the patient should have normal hip and knee range of motion, be pain free, and demonstrate normal strength as well as perform functional sport-specific testing.

12

Name a complication of a quadriceps strain

Myositis ossificans results from proliferation of bone and cartilage in the area of a contusion injury to a muscle. This should be suspected if symptoms worsen after 2–3 weeks and is also accompanied by loss of range of motion. Radiographs are diagnostic. If athletes do not have recovery with conservative management, then surgical excision may be necessary.