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Masci, L., Alfredson, H. & Spang, C. (2019). Plantaris tendon and association with mid-portion Achilles tendinopathy: Is the plantaris tendon a contributing factor in mid-portion Achilles tendinopathy?. Apunts. Medicina de l'Esport, 54(201), 13-18
Open this publication in new window or tab >>Plantaris tendon and association with mid-portion Achilles tendinopathy: Is the plantaris tendon a contributing factor in mid-portion Achilles tendinopathy?
2019 (English)In: Apunts. Medicina de l'Esport, ISSN 1886-6581, Vol. 54, no 201, p. 13-18Article in journal (Refereed) Published
Abstract [en]

Plantaris tendon is implicated in some cases of load-resistant Achilles tendinopathy. The tendon courses close to the medial Achilles tendon mid-portion prior to insertion onto Mid-portion Achilles the medial calcaneus, although there is variation in course and insertion. Clinical suspicion of tendinopathy plantaris involvement includes persistent medial Achilles pain unresponsive to a rehabilitation programme and imaging revealing a thickened plantaris tendon and/or focal medial Achilles tendinosis. Potential mechanisms include compression or shearing forces between the plantaris and Achilles tendons. Initial treatment should consist of a modified loading programme avoiding end-range loading. Resistant cases may be amenable to surgical excision of the plantaris demonstrating good clinical outcomes in the short and tong term, although the evidence is limited to case series. Percutaneous methods show promise but require further evaluation.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Plantaris tendon, Midportion Achilles tendinopathy, Tendón plantar, Tendinopatía de Aquiles de media porción
National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:umu:diva-159421 (URN)10.1016/j.apunts.2018.11.003 (DOI)000465583000003 ()
Note

[Tendón plantar y asociación con la tendinopatía de Aquiles en porción media. ¿Es el tendón plantar un factor contribuyente en la tendinopatía de Aquiles de la porciín media?]

Available from: 2019-05-29 Created: 2019-05-29 Last updated: 2019-05-29Bibliographically approved
Ruergård, A., Spang, C. & Alfredson, H. (2019). Results of minimally invasive Achilles tendon scraping and plantaris tendon removal in patients with chronic midportion Achilles tendinopathy: A longer-term follow-up study. Safety, 7, Article ID UNSP 2050312118822642.
Open this publication in new window or tab >>Results of minimally invasive Achilles tendon scraping and plantaris tendon removal in patients with chronic midportion Achilles tendinopathy: A longer-term follow-up study
2019 (English)In: Safety, ISSN 0036-3375, E-ISSN 2050-3121, Vol. 7, article id UNSP 2050312118822642Article in journal (Refereed) Published
Abstract [en]

Background: Treatment with ultrasound and colour Doppler–guided minimally invasive Achilles tendon scraping and plantaris tendon removal has shown promising short-term results in patients with chronic painful midportion Achilles tendinopathy.

Methods: In a follow-up study, 182 consecutive patients (241 tendons) who had undergone Achilles tendon scraping and plantaris tendon removal were contacted on telephone by an independent investigator. The patients who answered the telephone call were included, and they answered a questionnaire on telephone and then also sent their written answers. The questionnaire included information about patient satisfaction with the result of the treatment, time to return to full Achilles tendon loading activity, and a pain score (Visual Analogue Scale-VAS).

Results: The follow-up period was 5.8 years (mean) (range of 2–13 years) after surgery. Altogether, 110 patients (136 Achilles tendons), 52 years (mean)(range 18-73) old at surgery could be reached and were included. In total, 81 tendons were operated with the Achilles scraping procedure alone, and for 55 Achilles operations also a plantaris tendon removal was performed. For 93% of the operated tendons, the patients were satisfied with the surgical outcome and the VAS had decreased from 74 preoperatively to 8 postoperatively. Nine male patients (9 tendons), five operated with scraping + plantaris removal, had remaining tendon pain during loading and were not satisfied. Their VAS score ranged from 22 to 91. For 21% of the operated tendons, some occasional mild discomfort not preventing from full tendon loading, was reported. There were no differences in pain reduction and satisfaction rates between men and women, and between Achilles scraping alone and scraping plus plantaris removal.

Conclusion: Ultrasound and colour Doppler–guided surgical Achilles tendon scraping and plantaris tendon removal in patients with chronic painful midportion Achilles tendinopathy show remaining good clinical outcomes and high satisfaction rates in this longer-term follow-up.

Place, publisher, year, edition, pages
Sage Publications, 2019
Keywords
Achilles tendinopathy, surgery, scraping, plantaris tendon, longer-term results
National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:umu:diva-156595 (URN)10.1177/2050312118822642 (DOI)000457396600001 ()30728966 (PubMedID)
Available from: 2019-02-20 Created: 2019-02-20 Last updated: 2019-02-20Bibliographically 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
Spang, C., Backman, L. J., Le Roux, S., Chen, J. & Danielson, P. (2017). Glutamate signaling through the NMDA receptor reduces the expression of scleraxis in plantaris tendon derived cells. BMC Musculoskeletal Disorders, 18, Article ID 218.
Open this publication in new window or tab >>Glutamate signaling through the NMDA receptor reduces the expression of scleraxis in plantaris tendon derived cells
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2017 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 18, article id 218Article in journal (Refereed) Published
Abstract [en]

Background: A body of evidence demonstrating changes to the glutaminergic system in tendinopathy has recently emerged. This hypothesis was further tested by studying the effects of glutamate on the tenocyte phenotype, and the impact of loading and exposure to glucocorticoids on the glutamate signaling machinery.

Methods: Plantaris tendon tissue and cultured plantaris tendon derived cells were immunohisto-/cytochemically stained for glutamate, N-Methyl-D-Aspartate receptor 1 (NMDAR1) and vesicular glutamate transporter 2 (VGluT2). Primary cells were exposed to glutamate or receptor agonist NMDA. Cell death/viability was measured via LDH/MTS assays, and Western blot for cleaved caspase 3 (c-caspase 3) and cleaved poly (ADP-ribose) polymerase (c-PARP). Scleraxis mRNA (Scx)/protein(SCX) were analyzed by qPCR and Western blot, respectively. A FlexCell system was used to apply cyclic strain. The effect of glucocorticoids was studies by adding dexamethasone (Dex). The mRNA of the glutamate synthesizing enzymes Got1 and Gls, and NMDAR1 protein were measured. Levels of free glutamate were determined by a colorimetric assay.

Results: Immunoreactions for glutamate, VGluT2, and NMDAR1 were found in tenocytes and peritendinous cells in tissue sections and in cultured cells. Cell death was induced by high concentrations of glutamate but not by NMDA. Scleraxis mRNA/protein was down-regulated in response to NMDA/glutamate stimulation. Cyclic strain increased, and Dex decreased, Gls and Got1 mRNA expression. Free glutamate levels were lower after Dex exposure.

Conclusions: In conclusion, NMDA receptor stimulation leads to a reduction of scleraxis expression that may be involved in a change of phenotype in tendon cells. Glutamate synthesis is increased in tendon cells in response to strain and decreased by glucocorticoid stimulation. This implies that locally produced glutamate could be involved in the tissue changes observed in tendinopathy.

Keywords
Glutamate, NMDAR1, Plantaris tendon, Tendinopathy, Scleraxis
National Category
Cell and Molecular Biology
Identifiers
urn:nbn:se:umu:diva-136330 (URN)10.1186/s12891-017-1575-4 (DOI)000402332800006 ()28545490 (PubMedID)
Available from: 2017-06-21 Created: 2017-06-21 Last updated: 2019-02-22Bibliographically 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
Spang, C. & Alfredson, H. (2017). Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow - Implication for treatment?. Journal of Musculoskeletal and Neuronal Interactions - JMNI, 17(2), 97-103
Open this publication in new window or tab >>Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow - Implication for treatment?
2017 (English)In: Journal of Musculoskeletal and Neuronal Interactions - JMNI, ISSN 1108-7161, Vol. 17, no 2, p. 97-103Article in journal (Refereed) Published
Abstract [en]

Background: Tennis elbow is difficult to treat. The results of surgical treatments are not convincing. Treatment studies on Achilles and patellar tendinopathy targeting the richly innervated and vascularized soft tissues outside the tendon have shown promising outcomes. The innervation patterns in the fibrous/fatty tissues superficially to the elbow extensor origin have not been clarified.

Methods: Nine tissue specimens from the fibrous/fatty tissue covering the extensor origin was taken from seven patients (mean age: 45 years) undergoing surgical treatment for chronic painful tennis elbow. The specimens were stained for morphology (haematoxylin & eosin, H&E) and immunohistochemically for general nerve marker protein gene product 9.5 (PGP 9.5) and markers for sympathetic (tyrosine hydroxylase, TH) and sensory nerve fibres (calcitonin gene-related peptide, CGRP).

Results: All specimens contained multiple blood vessels and nerve structures indicated by morphology and immunoreactions. There was a frequent occurrence of TH reactions, especially peri-vascularly, but also in nerve fascicles. Immunoreactions for CGRP were seen in nerve fascicles and isolated nerve fibres.

Conclusion: The results provide new information on the innervation patterns of the superficial tissues of the extensor origin and their potential as source of tennis elbow pain. Level of Evidence: IV.

Keywords
Innervation, Tennis Elbow, Lateral Epicondylitis, Superficial, Soft Tissue
National Category
Clinical Laboratory Medicine
Identifiers
urn:nbn:se:umu:diva-138047 (URN)000405504200011 ()28574416 (PubMedID)
Available from: 2017-08-11 Created: 2017-08-11 Last updated: 2018-06-09Bibliographically approved
Spang, C., Alfredson, H., Docking, S. I., Masci, L. & Andersson, G. (2016). The plantaris tendon: a narrative review focusing on anatomical features and clinical importance. The Bone & Joint Journal, 98B(10), 1312-1319
Open this publication in new window or tab >>The plantaris tendon: a narrative review focusing on anatomical features and clinical importance
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2016 (English)In: The Bone & Joint Journal, ISSN 2049-4394, E-ISSN 2049-4408, Vol. 98B, no 10, p. 1312-1319Article, review/survey (Refereed) Published
Abstract [en]

In recent years, the plantaris tendon has been implicated in the development of chronic painful mid-portion Achilles tendinopathy. In some cases, a thickened plantaris tendon is closely associated with the Achilles tendon, and surgical excision of the plantaris tendon has been reported to be curative in patients who have not derived benefit following conservative treatment and surgical interventions. The aim of this review is to outline the basic aspects of, and the recent research findings, related to the plantaris tendon, covering anatomical and clinical studies including those dealing with histology, imaging and treatment.

National Category
Orthopaedics Surgery
Identifiers
urn:nbn:se:umu:diva-127607 (URN)10.1302/0301-620X.98B10.37939 (DOI)000385337900003 ()27694583 (PubMedID)
Available from: 2016-12-07 Created: 2016-11-16 Last updated: 2018-06-09Bibliographically approved
Spang, C., Chen, J. & Backman, L. J. (2016). The tenocyte phenotype of human primary tendon cells in vitro is reduced by glucocorticoids. BMC Musculoskeletal Disorders, 17, Article ID 467.
Open this publication in new window or tab >>The tenocyte phenotype of human primary tendon cells in vitro is reduced by glucocorticoids
2016 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 17, article id 467Article in journal (Refereed) Published
Abstract [en]

Background: The use of corticosteroids (e.g., dexamethasone) as treatment for tendinopathy has recently been questioned as higher risks for ruptures have been observed clinically. In vitro studies have reported that dexamethasone exposed tendon cells, tenocytes, show reduced cell viability and collagen production. Little is known about the effect of dexamethasone on the characteristics of tenocytes. Furthermore, there are uncertainties about the existence of apoptosis and if the reduction of collagen affects all collagen subtypes.

Methods: We evaluated these aspects by exposing primary tendon cells to dexamethasone (Dex) in concentrations ranging from 1 to 1000 nM. Gene expression of the specific tenocyte markers scleraxis (Scx) and tenomodulin (Tnmd) and markers for other mesenchymal lineages, such as bone (AlplOcn), cartilage (AcanSox9) and fat (CebpαPparg) was measured via qPCR. Cell viability and proliferation was calculated using a MTS Assay. Cell death was measured by LDH assay and cleaved caspase-3 using Western Blot. Gene expression of collagen subtypes Col1Col3 and Col14 was analyzed using qPCR.

Results: Stimulation with Dex decreased cell viability and LDH levels. Dex also induced a significant reduction of Scx gene expression and a marked loss of fibroblast like cell shape. The mRNA for all examined collagen subtypes was found to be down-regulated. Among non-tendinous genes only Pparg was significantly increased, whereas AcanAlpl and Sox9 were reduced.

Conclusions: These results indicate a Dex induced phenotype drift of the tenocytes by reducing scleraxis expression. Reduction of several collagen subtypes, but not cell death, seems to be a feature of Dex induced tissue degeneration.

Keywords
Dexamethasone, Scleraxis, Collagen, Cell viability, Phenotype, Tendinopathy
National Category
Cell and Molecular Biology
Identifiers
urn:nbn:se:umu:diva-133277 (URN)10.1186/s12891-016-1328-9 (DOI)000395053500002 ()27832770 (PubMedID)
Available from: 2017-04-06 Created: 2017-04-06 Last updated: 2019-02-22Bibliographically approved
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ORCID iD: ORCID iD iconorcid.org/0000-0002-9977-334x

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