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Alfredson, Håkan
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Publications (10 of 157) Show all publications
Alfredson, H. (2018). Achilles and patellar tendon operations performed in local anestesia. American journal of Anesthesiology and Pain medicine, 1(1), 001-002
Open this publication in new window or tab >>Achilles and patellar tendon operations performed in local anestesia
2018 (English)In: American journal of Anesthesiology and Pain medicine, ISSN 2640-5377, Vol. 1, no 1, p. 001-002Article in journal (Refereed) Published
Abstract [en]

From 20 years of research on innervation patterns and pain mechanisms in chronic painful Achilles and patellar tendinopathy, we have learned that the nerves are located outside the affected tendon. With this background we use local anestetics in combination with Adrenaline when these patients are surgical treated. We have now more than 15 years of experience in treating Achilles tendinopathy, and 10 years of experience in treating patellar tendinopaty, in local anesthesia alone. I will present the scientific background and practi-cal techniques to use local anesthesia for treatment of chronic painful Achilles and patellar tendinopathy.

Place, publisher, year, edition, pages
New York: ONOMY, 2018
National Category
Sport and Fitness Sciences
Research subject
Sports Medicine
Identifiers
urn:nbn:se:umu:diva-154643 (URN)
Available from: 2018-12-21 Created: 2018-12-21 Last updated: 2018-12-21Bibliographically approved
Welford, P. & Alfredson, H. (2018). Achilles insertion bone pathology not related to pain in a triathlete with cystic fibrosis. Journal of Surgical Case Reports (8), Article ID rjy182.
Open this publication in new window or tab >>Achilles insertion bone pathology not related to pain in a triathlete with cystic fibrosis
2018 (English)In: Journal of Surgical Case Reports, ISSN 2042-8812, E-ISSN 2042-8812, no 8, article id rjy182Article in journal (Refereed) Published
Abstract [en]

This report concerns the unusual case of a 48-year old, world-class triathlete who has won 11 ironman competitions. She has reached the top level of international endurance sport in spite of being diagnosed with cystic fibrosis. This patient presented with Achilles pain and severe bony pathology at her left Achilles insertion. Traditionally this condition is treated via tendon detachment and re-attachment or intra-tendinous surgery, followed by a protracted rehabilitation. These procedures were considered risky due to this patient's chronic disease with vulnerability to immobilization. Instead, she was treated by surgical removal of the superficial bursa alone, under local anaesthetic. This allowed the patient to become active and load her Achilles tendon immediately, and resulted in a significant symptomatic improvement. This case illustrates that despite the presence of severe tendon and bone pathology at the Achilles insertion, pain may originate in the superficial bursa; a structure ignored by traditional operations.

Place, publisher, year, edition, pages
Oxford University Press, 2018
National Category
Orthopaedics Surgery
Identifiers
urn:nbn:se:umu:diva-152228 (URN)10.1093/jscr/rjy182 (DOI)000443544800002 ()30151099 (PubMedID)
Available from: 2018-10-25 Created: 2018-10-25 Last updated: 2018-10-25Bibliographically approved
Gaida, J. E., Alfredson, H., Scott, A., Mousavizadeh, R. & Forsgren, S. (2018). Apolipoprotein A1 distribution pattern in the human Achilles tendon. Scandinavian Journal of Medicine and Science in Sports, 28(5), 1506-1513
Open this publication in new window or tab >>Apolipoprotein A1 distribution pattern in the human Achilles tendon
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2018 (English)In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 28, no 5, p. 1506-1513Article in journal (Refereed) Published
Abstract [en]

Metabolic factors such as cholesterol appear to play an important role in the development of Achilles tendinopathy. There is, however, no morphologic proof explaining the link between high cholesterol and tendinopathy. As apolipoprotein A1 (Apo-A1) is essential for reverse cholesterol transport, it may be related to cholesterol overload in tendon. Nothing is known about Apo-A1 expression in tendon tissue. We examined the distribution of Apo-A1 protein in biopsies from normal and tendinopathy-affected human Achilles tendons, and APOA1 mRNA production from cultured human hamstring tenocytes. Specific immunoreactions for Apo-A1 were detected. The tenocytes showed specific Apo-A1 immunoreactions. These reactions were usually distinct in the tendinopathy specimens. While the tendinopathy specimens often showed granular/small deposit reactions, the slender tenocytes of control specimens did not show this pattern. The magnitude of Apo-A1 immunoreactivity was especially marked in the tendinopathy specimens, as there is a high number of tenocytes. Reactions were also seen in the walls of blood vessels located within the tendon tissue proper of both the normal and tendinopathy tendons and within the peritendinous/fatty tissue of the tendinopathy tendons. The reactions were predominantly in the form of deposit reactions within the smooth muscle layer of the vessel walls. Cultured hamstring tenocytes produced APOA1 mRNA. We demonstrated the presence of Apo-A1 in human tendon tissue. This suggests there may be a link between Achilles tendinopathy and cholesterol metabolism. We hypothesize that Apo-A1 may be important for tenocyte and blood vessel function within tendons.

Place, publisher, year, edition, pages
WILEY, 2018
Keywords
Apo-A1, HDL-C, immunohistochemistry, reverse cholesterol transport, tendinopathy, tendon
National Category
Medical Biotechnology
Identifiers
urn:nbn:se:umu:diva-150705 (URN)10.1111/sms.13051 (DOI)000430471900003 ()29315811 (PubMedID)2-s2.0-85041679099 (Scopus ID)
Available from: 2018-09-05 Created: 2018-09-05 Last updated: 2018-12-21Bibliographically approved
Alfredson, H. & Spang, C. (2018). Clinical presentation and surgical management of chronic Achilles tendon disorders: a retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon. Foot and Ankle Surgery, 24(6), 490-494
Open this publication in new window or tab >>Clinical presentation and surgical management of chronic Achilles tendon disorders: a retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon
2018 (English)In: Foot and Ankle Surgery, ISSN 1268-7731, E-ISSN 1460-9584, Vol. 24, no 6, p. 490-494Article in journal (Refereed) Published
Abstract [en]

Background: Non-invasive treatment is not always successful in patients with Achilles tendon disorders, and surgical treatment is instituted as the next step. There is sparse knowledge about the diagnoses, pain levels before surgery, surgically confirmed pathologies and postoperative complications in large patient groups.

Aims: To study the diagnoses, pain scores before surgery, macroscopic surgical findings and postoperative complications in a series of patients treated for Achilles disorders.

Material and methods: One surgeon operated on 771 Achilles tendons of 481 men and 290 women during a 10-year period. The clinically and ultrasound confirmed diagnoses, pre-operative pain and functional scores (Visual Analogue Scale, VAS, range 0-100; Victorian Institute Sports Tendon Assessment - Achilles questionnaire, VISA-A), macroscopic findings during surgery and postoperative complications, were retrospectively collected from a database.

Results: Clinically, by ultrasound and during surgery midportion Achilles tendinopathy was confirmed in 519 (67%) patients, 41% of them had a thickened plantaris tendon located close the Achilles tendon. Partial midportion rupture was found in 31 (4%) patients, chronic midportion rupture in 12 (2%) patients and insertional Achilles tendinopathy, including superficial and retro-calcaneal bursitis, Haglund deformity, distal Achilles tendinopathy, plantaris tendon pathology, and bone spurs, in 209 (27%) patients. The mean pre-operative pain scores for midportion Achilles tendinopathy were 73 (VAS) and 45 (VISA-A), and for insertional Achilles tendinopathy 77 (VAS) and 39 (VISA-A). For midportion Achilles tendinopathy there were 14 (3%), and for insertional Achilles tendinopathy 10 (5%), postoperative complications.

Conclusions: Patients presenting high pain scores from midportion Achilles tendinopathy were the most common. Plantaris tendon involvement is a frequent observation. For insertional Achilles tendinopathy the combination of pathology in the subcutaneous and retrocalcaneal bursa, a Haglund deformity and distal Achilles tendinopathy/tendinosis was most frequent. 

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Tendinopathy, Midportion, Tendinosis, Partial rupture, Plantaris, Insertional
National Category
Sport and Fitness Sciences Surgery
Identifiers
urn:nbn:se:umu:diva-154030 (URN)10.1016/j.fas.2017.05.011 (DOI)000451098700005 ()29409190 (PubMedID)
Available from: 2018-12-20 Created: 2018-12-20 Last updated: 2018-12-20Bibliographically approved
Abat, F., Alfredson, H., Cucchiarini, M., Madry, H., Marmotti, A., Mouton, C., . . . de Girolamo, L. (2018). Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II. Journal of experimental orthopaedics, 5(38)
Open this publication in new window or tab >>Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II
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2018 (English)In: Journal of experimental orthopaedics, ISSN 2197-1153, Vol. 5, no 38Article in journal (Refereed) Published
Abstract [en]

The treatment of painful chronic tendinopathy is challenging. Multiple non-invasive and tendon-invasive methods are used. When traditional non-invasive treatments fail, the injections of platelet-rich plasma autologous blood or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment. As the last resort, intra- or peritendinous open or endoscopic surgery are employed even though these also show varying results. This ESSKA basic science committee current concepts review follows the first part on the biology, biomechanics and anatomy of tendinopathies, to provide a comprehensive overview of the latest treatment options for tendinopathy as reported in the literature.

Place, publisher, year, edition, pages
Springer, 2018
National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:umu:diva-154642 (URN)10.1186/s40634-018-0145-5 (DOI)30251203 (PubMedID)
Available from: 2018-12-21 Created: 2018-12-21 Last updated: 2019-01-14Bibliographically approved
Alfredson, H., Masci, L. & Spang, C. (2018). Surgical plantaris tendon removal for patients with plantaris tendon-related pain only and a normal Achilles tendon: a case series. BMJ Open Sport & Exercise Medicine, 4(1), Article ID e000462.
Open this publication in new window or tab >>Surgical plantaris tendon removal for patients with plantaris tendon-related pain only and a normal Achilles tendon: a case series
2018 (English)In: BMJ Open Sport & Exercise Medicine, ISSN 2055-7647, Vol. 4, no 1, article id e000462Article in journal (Refereed) Published
Abstract [en]

Objectives: Surgical removal of the plantaris tendon can cure plantaris-associated Achilles tendinopathy, a condition in which Achilles and plantaris tendinopathy coexist. However, rare cases with plantaris tendinopathy alone are often misdiagnosed due to a normal Achilles tendon.

Design and setting: Prospective case series study at one centre.

Participants: Ten consecutive patients (9 men and one woman, mean age 35 years, range 19–67) with plantaris tendon-related pain alone in altogether 13 tendons were included. All had had a long duration (median 10 months, range 3 months to 10 years) of pain symptoms on the medial side of the Achilles tendon mid-portion. Preoperative ultrasound showed thickened plantaris tendon but a normal Achilles tendon.

Interventions: Operative treatment consisting of ultrasound-guided excision of the plantaris tendon.

Primary and secondary outcome measures: Scores from Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A)were taken preoperatively and postoperatively (median duration 10 months). Patient satisfaction and time until full return to sports activity level was asked by a questionnaire.

Results: The VISA-A scores increased from 61 (range 45–81) preoperatively to 97 (range 94–100) postoperatively (p<0.01). Follow-up results at 10 months (range 7–72 months) on 9/10 patients showed full satisfaction and return to their preinjury sports or recreational activity

Conclusion: The plantaris tendon should be kept in mind when evaluating painful conditions in the Achilles tendon region, especially when no Achilles tendinopathy is present. Excision of the plantaris tendon via a minor surgical procedure in local anaesthesia results in a good outcome.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2018
National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:umu:diva-154645 (URN)10.1136/bmjsem-2018-000462 (DOI)
Available from: 2018-12-21 Created: 2018-12-21 Last updated: 2018-12-21Bibliographically approved
Smith, J., Alfredson, H., Masci, L., Sellon, J. L. & Woods, C. D. (2017). Differential Plantaris-Achilles Tendon Motion: A Sonographic and Cadaveric Investigation. PM&R, 9(7), 691-698
Open this publication in new window or tab >>Differential Plantaris-Achilles Tendon Motion: A Sonographic and Cadaveric Investigation
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2017 (English)In: PM&R, ISSN 1934-1482, E-ISSN 1934-1563, Vol. 9, no 7, p. 691-698Article in journal (Refereed) Published
Abstract [en]

Background: Differential motion between the plantaris and Achilles tendons has been hypothesized to contribute to pain in some patients presenting with Achilles tendinopathy. However, objective evidence of differential Achilles-plantaris motion is currently lacking from the literature. Objective: To determine whether differential, multidirectional motion exists between the plantaris tendon (PT) and Achilles tendon (AT) as documented by dynamic ultrasound (US) and postdissection examination in an unembalmed cadaveric model. Design: Prospective, cadaveric laboratory investigation. Setting: Procedural skills laboratory in a tertiary medical center. Subjects: Twenty unembalmed knee-ankle-foot specimens (9 right, 11 left) obtained from 6 male and 10 female donors ages 55-96 years (mean 80 years) with body mass indices of 14.1-33.2 kg/m(2) (mean 22.5 kg/m(2)). Methods: A single, experienced operator used high -resolution dynamic US to qualitatively document differential PT-AT motion during passive ankle dorsifiexion-plantarflexion. Specimens were then dissected and passive dorsiflexion-plantarfiexion was repeated while differential PT-AT motion was visualized directly. Main Outcome Measurements: Presence or absence of multidirectional differential PT-AT motion. Results: All 20 specimens exhibited smooth but variable amplitude multidirectional differential PT-AT motion. Whereas US readily demonstrated medial-lateral and anterior-posterior PT motion relative to the AT, differential longitudinal motion was only appreciated on dissection and direct inspection. Many specimens exhibited partial or complete encasement of the PT between the gastrocnemius portion of the AT and the soleus aponeurosis. Conclusion: Some degree of multidirectional differential PT-AT motion appears to be a normal phenomenon, and PT motion can be evaluated sonographically in both the medial -lateral and anterior-posterior directions. The existence of normal differential PT-AT motion suggests that alterations in PT motion or repetitive stress within the PT-AT interval may produce symptoms in some patients presenting with Achilles region pain syndromes. The PT should be evaluated in all patients presenting with Achilles, plantaris, or calf pain syndromes. Future research would benefit from the development of a sonographic classification system for PT anatomy and motion with the goal of differentiating normal versus pathologic states and identifying risk factors for symptom development.

Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2017
National Category
Orthopaedics Physiotherapy
Identifiers
urn:nbn:se:umu:diva-138606 (URN)10.1016/j.pmrj.2016.10.013 (DOI)000406575300007 ()27789336 (PubMedID)
Available from: 2017-09-08 Created: 2017-09-08 Last updated: 2018-06-09Bibliographically approved
Spang, C., Renström, L., Alfredson, H. & Forsgren, S. (2017). Marked expression of TNF receptors in human peritendinous tissues including in nerve fascicles with axonal damage: Studies on tendinopathy and tennis elbow. Journal of Musculoskeletal and Neuronal Interactions - JMNI, 17(3), 226-236
Open this publication in new window or tab >>Marked expression of TNF receptors in human peritendinous tissues including in nerve fascicles with axonal damage: Studies on tendinopathy and tennis elbow
2017 (English)In: Journal of Musculoskeletal and Neuronal Interactions - JMNI, ISSN 1108-7161, Vol. 17, no 3, p. 226-236Article in journal (Refereed) Published
Abstract [en]

Background: The peritendinous connective tissues can have importance in chronic tendon pain. Recently cytokine TNF-alpha has been suggested to be involved in tendinopathic processes. It is not known how TNF-alpha and its receptors TNFR1 and TNFR2 are expressed in peritendinous tissues.

Methods: The objective for this study was to immunohistochemically evaluate the expression patterns of these in the peritendinous tissue located between the plantaris and Achilles tendons and the one located superficially to the extensor origin at the elbow region for patients with tendinopathy/tennis elbow.

Results: The nerve fascicles were of two types, one type being homogenously stained for the nerve markers beta III-tubulin and neurofilament and the other showing deficits for these suggesting features of axonal damage. Much more distinct TNFR1/TNFR2 immunoreactions were seen for the latter nerve fascicles. TNFR1 was seen in axons, TNFR2 mainly in Schwann cells. TNFR1 and particularly TNFR2 were seen in walls of parts of blood vessels. The dispersed cells showed frequently TNFR1 and TNFR2 immunoreactivity.

Discussion: These findings suggest that TNF-alpha can be related to degenerative events but also attempts for healing concerning the nerve structures. The marked expression of the TNF-alpha system in the peritendinous tissue suggests an impact of TNF-alpha in tendinopathy/tennis elbow.

Place, publisher, year, edition, pages
JMNI, 2017
Keywords
TNF, Peritendinous, Tendinopathy, Tennis Elbow, Nerve Degeneration
National Category
Neurosciences Physiology
Identifiers
urn:nbn:se:umu:diva-140056 (URN)000410545600012 ()28860425 (PubMedID)
Available from: 2017-10-04 Created: 2017-10-04 Last updated: 2018-06-09Bibliographically approved
Andersson, G., Backman, L. J., Christensen, J. & Alfredson, H. (2017). Nerve distributions in insertional Achilles tendinopathy - a comparison of bone, bursae and tendon. Histology and Histopathology, 32(3), 263-270
Open this publication in new window or tab >>Nerve distributions in insertional Achilles tendinopathy - a comparison of bone, bursae and tendon
2017 (English)In: Histology and Histopathology, ISSN 0213-3911, E-ISSN 1699-5848, Vol. 32, no 3, p. 263-270Article in journal (Refereed) Published
Abstract [en]

Background/Aim. In a condition of pain in the Achilles tendon insertion there are multiple structures involved, such as the Achilles tendon itself, the retrocalcaneal bursa and a bony protrusion at the calcaneal tuberosity called Haglund's deformity. The innervation patterns of these structures are scarcely described, and the subcutaneous calcaneal bursa is traditionally not considered to be involved in the pathology. This study aimed at describing the innervation patterns of the four structures described above to provide a better understanding of possible origins of pain at the Achilles tendon insertion.

Methods. Biopsies were taken from 10 patients with insertional Achilles tendinopathy, which had pathological changes in the subcutaneous and retrocalcaneal bursae, a Haglund deformity and Achilles tendon tendinopathy as verified by ultrasound. The biopsies were stained using immunohistochemistry in order to delineate the innervation patterns in the structures involved in insertional Achilles tendinopathy.

Results. Immunohistochemical examinations found that the subcutaneous bursa scored the highest using a semi-quantitative evaluation of the degree of innervation when compared to the retrocalcaneal bursa, the Achilles tendon, and the calcaneal bone.

Conclusions. These findings suggest that the subcutaneous bursa, which is traditionally not included in surgical treatment, may be a clinically important factor in insertional Achilles tendinopathy.

Keywords
Insertional Achilles tendinopathy, Innervation, Subcutaneous bursa, Retrocalcaneal bursa
National Category
Cell and Molecular Biology
Identifiers
urn:nbn:se:umu:diva-130214 (URN)10.14670/HH-11-790 (DOI)000390220000006 ()
Available from: 2017-02-02 Created: 2017-01-14 Last updated: 2018-06-09Bibliographically approved
Alfredson, H. (2017). Persistent pain in the Achilles midportion?: Consider the plantaris tendon as a possible culprit!. British Journal of Sports Medicine, 51(10), 833-834
Open this publication in new window or tab >>Persistent pain in the Achilles midportion?: Consider the plantaris tendon as a possible culprit!
2017 (English)In: British Journal of Sports Medicine, ISSN 0306-3674, E-ISSN 1473-0480, Vol. 51, no 10, p. 833-834Article, review/survey (Refereed) Published
Place, publisher, year, edition, pages
BMJ PUBLISHING GROUP, 2017
National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:umu:diva-136197 (URN)10.1136/bjsports-2016-097360 (DOI)000400583100018 ()28235758 (PubMedID)
Available from: 2017-07-06 Created: 2017-07-06 Last updated: 2018-06-09Bibliographically approved
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