Imaging and Treatment of Chronic Midportion Achilles Tendinopathy

Introduction: It is estimated that 30-50% of sports injuries are caused by tendon disorders. Chronic midportion Achilles tendinopathy is a frequent problem, particularly occurring in athletes but also affecting inactive people. Diagnosis is made based on clinical findings and currently the term Achilles tendinopathy is preferred. Until know, we assumed that a reduced tissue repair mechanism with tendon tissue degeneration is the cause of the persistence of symptoms. Ultrasonographic appearance of tendinopathy is characterised by a reduced tendon fibre structure and increased blood flow to the tendon (neovascularisation). Until recently, the prognostic value of ultrasound disorders was in this patient group. Ultrasonography has no added value: Chronic Achilles tendinopathy frequently leads to a reduction of sports activities and can even be career-threatening for an athlete. Currently, a standardised exercise program of 12 weeks is the first choice of treatment. The current conservative and surgical treatments often lead to an unsatisfactory result. This dissertation shows that the ultrasonographic tendon structure can be measured with a high reliability, using a novel innovative technique which was already validated in veterinary medicine. We also found that determining the degree of neovascularisation could be measured with an excellent reliability. There was a clear difference in ultrasonographic tendon structure and neovascularisation between healthy subjects and patients with tendinopathy. However, in follow-up studies the degree of tendon structure disorganisation and neovascularisation could not predict outcome after treatment. This means that ultrasound examination has no added value. A PRP injection is not effective for chronic Achilles tendon injuries: Injections with autologous growth factors, derived from autologous blood, are widely used in the United States. An increased concentration of blood platelets can be obtained, also known as Platelet-rich plasma (PRP). The promising results of PRP gained worldwide attention in the treatment of tendon injuries. In a systematic review of the literature, however, we found only limited evidence for the effect of PRP injections in the treatment of chronic tendinopathies. Therefore we conducted a prospective double-blind placebo-controlled randomised trial. This study showed that there is no added value of a PRP injection to the current usual care. The results of this study are published in JAMA, one of the leading scientific journals. This has led to major global debates about the usefulness of these injections.

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