La Tendinopatia dell’ Achilleo SITODAgostino Achilleo.pdf · • Stretching ed esercizi eccentrici • FANS (short term) • Terapiafiltrativa in con Acido Ialuronico • Fattori

M. Cristina d’Agostino, MD

Vicepresidente SITODISMST Senator & Membership Secretary

International ISMST Instructor

Responsabile Centro Terapia e Ricerca Onde d’Urto HUMANITAS Research Hospital

Adjunct Professor – HUMANITAS UNIVERSITYRozzano (Milano)

La Tendinopatia dell’ Achilleo

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Dr. MC d’AgostinoHumanitas Research HospitalHumanitas University - Milano

The twisted structure of the human Achilles tendonM. Edama et all.Scand J Med Sci Sports 2015: 25: e497–e503

Twisted structure

No Consensus about grade of torsion

Anatomy of Achilles Tendon

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https://www.google.it/url?url=https://www.pinterest.com/lswelker/amazing-structures/&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjHyOPb7sjSAhVMvxQKHQtpAcI4FBDBbgg6MBI&usg=AFQjCNGGsuQJ30a22_mz7F8RMAhw1j1V5A


Princìpi generali di Anatomia e “Meccanobiologia” tendinea

Overpronation Impaired Achilles blood flow (mid-portion)

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https://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj5tYmewbzSAhWIF5oKHSIEDGsQjRwIBw&url=https://sportspodiatryinfo.wordpress.com/2011/02/02/choosing-running-shoes-the-evidence-behind-the-recommendations/&bvm=bv.148747831,d.bGs&psig=AFQjCNG4OQGyaE84W7yP5fMaOXUgP1P3TA&ust=1488704881168404


In tendinopathy:- innervation has been identified to consist of excessive and protracted

nerve ingrowth in the tendon proper, suggesting pro-inflammatory,nociceptive and hypertrophic (degenerative) tissue responses

In metabolic disorders (eg. Diabetes)- impaired tendon healing seems to be related to dysregulation ofneuronal growth factors

Targeted approaches to the peripheral nervous system including

neuronal mediators and their receptors may prove to be effective

therapies for painful, degenerative and traumatic tendon disordersSITOD


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Princìpi generali di Anatomia e “Meccanobiologia” tendinea

Importance of Subcutaneous Bursa

Highest Score of innervation

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https://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjI4oPwyrzSAhWEHpoKHSMwD2wQjRwIBw&url=https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=zm2450&bvm=bv.148747831,d.bGs&psig=AFQjCNGYxmJhYrwXsIl05kKB9OsRmVEKIQ&ust=1488707760604836


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«BAD – USE» (under/overuse)

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Insertional Tendinopathy Midportion Tendinopathy

- 2 – 6 cm proximal to the insertion- Possibile paratenonitis- Area of poor blood circulation- Possibile spontaneous rupture

Achilles Tendinopathy Collective Term

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https://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiUkZuPlb3SAhVmAZoKHQK5AoYQjRwIBw&url=https://www.betterbraces.com/injury-info-center/ankle-injury-guide/achilles-bursitis&bvm=bv.148747831,d.bGs&psig=AFQjCNGJl9CL2JmiAevwQ2VmTXx-4EE2Zw&ust=1488727675290760


A uniform and clear terminology is necessary for proper

research, diagnostics and treatmentANATOMIC LOCATION, SYMPTOMS, CLINICAL FINDINGS, HISTOPATHOLOGY

Haglund’s disease, Haglund’s syndrome, Haglund’s deformity, pump bump

(calcaneus altus; high prow heels; knobbly heels; cucumber heel)

2011

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https://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjbqffx2rzSAhXJXCwKHWXrAngQjRwIBw&url=http://www.portmelbournephysio.com.au/achilles-tendinopathy/&psig=AFQjCNG-bu_Sx6KU6mlrUyRrYqZ9uslWLQ&ust=1488712089935714


1. Mid-portion Achilles tendinopathy:a clinical syndrome characterized by a combination of pain, swelling and impaired performance. It includes, but is not limited to, the histopathological diagnosis of tendinosis

2. Achilles paratendinopathy:an acute or chronic inflammation and/or degeneration of the thin membrane around the Achilles tendon. There are clear distinctions between acuteparatendinopathy and chronic paratendinopathy, both in symptoms as in histopathology

3. Insertional Achilles tendinopathy:located at the insertion of the Achilles tendon onto the calcaneus, bone spurs and calcifications in the tendon proper at the insertion site may exist

4. Retrocalcaneal bursitis:an inflammation of the bursa in the recess between the anterior inferior side of

the Achilles tendon and the posterosuperior aspect of the calcaneus (retrocalcaneal recess)

5. Superficial calcaneal bursitis:inflammation of the bursa located between a calcaneal prominence or the

Achilles tendon and the skin(Van Dijk et all 2011)SITOD

http://www.google.it/url?url=http://newsite.vfitphysio.co.uk/achilles-tendonitis/&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjA7LjD-sjSAhXCwBQKHVdSDJQQwW4IGjAC&usg=AFQjCNFFHtdT2l4UX68hNDFd9vpHdgPaVw

https://www.google.it/url?url=https://www.sportordination.com/en/sporttraumatologie/achilles-tendon/&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwiWq6SE-8jSAhWGXBQKHajwBxI4FBDBbggqMAo&usg=AFQjCNHS7lnQN8HmyvYMTNyqO0MVsnMYhA

http://www.google.it/url?url=http://www.slideshare.net/vhjokhi/insertional-tendinopathy-of-tendoachilles&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjnjbOL_cjSAhWG7xQKHQwvCGY4KBDBbggqMAo&usg=AFQjCNGNTdT9B75OWqsM9ynoZXM7iZ9Bag


Quadri CliniciIn stadio iniziale, il dolore si manifesta soprattutto all’inizio ed al termine dell’attività sportiva ..

.. Negli stadi piu’ avanzati il dolore puo’ inficiare le attività sportive e della vita quotidiana

FASE ACUTA• Edema entesi e/o tendine• Dolorabilità alla palpazione e pressione• Possibile arrossamento locale• Possibile crepitio alla palpazione

FASE CRONICA• Dolorabilità al movimento attivo• Edema localizzato/nodularità• NO crepitio né edemaSITOD

http://www.benchmarkphysiotherapy.com.au/achilles-tendinopathy/

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj5vtS8qJDKAhXGlA8KHVDJAA4QjRwIBw&url=http://achillestendon.com/types-of-injuries/&psig=AFQjCNG2eBraOmxbzLZvYQf09ukcgucVrA&ust=1452002363754237


DIAGNOSTICA STRUMENTALE

• 1a ECOGRAFIAIspessimento/ridotta ecogenicità

Osteofiti / calcificazioni / Lesioni parziali

EntesopatiaAchilleo

TendinopatiaAchilleo

• 1b ECOGRAFIA con valutazione Power DopplerNeovascolarizzazione (infiammazione neurogenica)

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2. RMN• RMN è consigliabile in caso di dolore prolungato

ed edema considerevole

• Importante per rilevare lesioni parziali o subtotalidel tendine

• Utile per diagnosticare patologie dell‘osso(bone bruise, fratture da stress, tumori)

RariTumori

Fratture da stressBorsite

Tendinopatia del „corpo“Lesioni parziali

DIAGNOSTICA STRUMENTALE

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http://m1.wyanokecdn.com/24d512bc1d06417cd711e589e2da92d4.jpg


DD – Rh e u m a t i c D i s e a s e s

Effective treatment strategy:

- Control of inflammation

- “Biomechanical” attentionSITOD


Onde d’Urto nella Tendinopatia dell’Achilleo: razionale terapeutico ed applicazioni cliniche

Opzioni Terapeutiche non ESWT

• Monitoraggio e correzione di fattori di rischio e/o patologie concomitanti

• Modifica programmi di allenamento sportivo

• Ortesi „et similaria“

• Terapie fisiche

• Stretching ed esercizi eccentrici

• FANS (short term)

• Terapia infiltrativa con Acido Ialuronico

• Fattori di Crescita Autologhi (PRP)

Risk of Tendond Ruptureafter Corticosteroid Injection !!

Se fallimento terapia conservativa Chirurgia

Paavola M et all.Foot Ankle Clin 2002 Sep;7(3):501-13.

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http://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=http://www.stopfootpainfast.com/library/orthotics-podiatrist-in-piscataway-and-hillsborough-new-jersey.cfm&psig=AFQjCNF6tmvepLe6tNnTLLaQR4_v4fT-GA&ust=1451995087799187


Tendinopathy = Clinical Syndrome

.. a failed healing response of the tendon

Zhang J et all, 2010

TendonStem Cells

(TSCs)

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Knee Surg Sports Traumatol Arthrosc (2011) 19:835–841

Mid-portion Achilles Tendinopathy

Tendinosis implies histopathological diagnosis of tendon degeneration

without clinical or histological signs of intratendinous inflammation,

and is NOT necessarily symptomatic

However, it should be kept in mind that, although the histological term

‘tendinosis’ is also widely used, the essential lesion of tendinopathy is

not, strictu sensu, of a degenerative nature: it has the features of a

failed healing response, in which the tendon attempts to heal, but, for

some reason, including, possibly, continuous inappropriate mechanical

stimuli, the healing process appears non-finalisedSITOD


Visco V et al, Muscles, Ligaments and Tendons Journal 2014; 4 (3): 357-361

Experimental studies on the biological effects ofextracorporeal shock wave therapy on tendon

models. A review of the literature

Vincenzo Visco, Maria Chiara Vulpiani, Maria Rosaria Torrisi, Andrea Ferretti, Antonio Pavan, Mario Vetrano

“ .. several reports have investigated the effects of ESWT on animal models and different kind of cultured cells .. “

Our contribute in establishing the potential outcome of ESWT

on human primary cultured tenocytes, derived from healthy compared to ruptured

tendons, have supported the growing evidence that

shock waves may supply faster post-injury recoverySITOD

http://functionalanatomyseminars.files.wordpress.com/2010/11/tendinosis.jpg

https://www.google.it/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjHr63RuL3SAhXEA5oKHccbDlQQjRwIBw&url=http://sciencepole.com/be-up-to-date/&bvm=bv.148747831,d.bGs&psig=AFQjCNEX_WQY2cQlNZW9wV8mxr7Iyq1a2g&ust=1488737244099761


This study provide a novel insight into the biological mechanisms

underpinning the observed clinical effects of ESWT in humans in vivo

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http://functionalanatomyseminars.files.wordpress.com/2010/11/tendinosis.jpg



Oncotarget. 2016 Feb 9;7(6):6410-23

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SW THERAPEUTICAL INDICATIONS Achilles Tendinopathy

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SW THERAPEUTICAL INDICATIONS Achilles Tendinopathy

«So far, no differentiation can be done between different treatment modalities,

such as application pressure, EFD or frequency.

Further studies have to focus on this missing evidence

to further improve the outcome after ESWT»

Gerdesmayer L et all, IJS 2015

• Pain > 3 months

• Ineffective conservative treatment

For Achillodynia the study results are still inhomogeneous

Both fSW and RW studies show positive outcomeSITOD


ESWT in Achilles Tendinopathy – State of the Art

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Recommended Treatment Protocol focused SW (fSW)

No local anaesthesia Coupling: Ultrasound gel

From 3 to 4 treatments(as a standard) (eventually repeatable cycles)

EFD max: 0,15 - 0, 20 mJ/mm² Interval: 1 - 2 weeks Frequency: 3 - 5 Hz Impulses: different protocols according to the different sources:

600 – 1000/session (electroidraulic source) 2000 – 2400/session (electromagnetic source)2400 – 3000/session (piezoelectric source)

Localization: - U.S (in-line, off-line or US-assisted)- Direction- BiofeedbackSITOD


No local anaesthesia Coupling: Ultrasound gel

From 3 to 6 treatments(as a standard) (eventually repeatable cycles)

Energy max: 4 bar Interval: 1 week Frequency: 6 - 10 Hz Impulses: 2000-3000/session Localization: - Direction;

- US-assisted- Biofeeback

Possibility to combine

fSW & RW treatments

Miofascial Trigger Points treatment

Muscle relaxation

Recommended Treatment Protocol - Radial Waves (RW)

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Onde d’Urto Eco – guidate/assistite

Vantaggi Generali

Corretto Inquadramento Diagnostico

• Targeting (non solo muscolo – scheletrico, es. cuore)

• Monitoraggio evoluzione del quadro clinico

• Possibilità di «personalizzare» i protocolli di terapia

• Ottimizzazione tempo e risorse

• Ottimizzazione risultati e Valorizzazione metodica SITOD


HA (2) >> SW (3) at 3 months

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Both ESWT and PRP therapy are effective and safe

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Insertional Tendinopathy

Comparison SW (radial) vs. Radiofrequency ablation and Eccentric Exc.

18 months follow - up

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Electrohydraulic source

Monthly sessions (n° 3)

1, 6, 12 months Follow - Up

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Evitare attività fisica intensa in corso di ESWT e durante le 4 - 6 settimane

successive

Eccentric Loading program and Stretching excercises(Rompe JD et all, Am J Sports Med. 2009 Mar;37(3):463-70)

Modifica dei programmi di allenamento sportivo

Valutazione dei risultati

non prima di 8 - 12 settimane

Protocollo di Trattamento Post – ESWT

Alfredsonn H. et all, Am J Sports Med 1998SITOD


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CHELT Therapy >> SW

Insertional Tendinopathy

In the ESWT group, the patients received three sessions at 3- to 4-day intervals of 1,600 impulses with an energy flux density (EFD) of 0.05-0.07 mJ/mm(2). Both groups of participants

performed stretching and eccentric exercises over a 2-month period

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ESWT is not a simple palliative tool but could be a curative therapy(it reduces pain / inflammation /neuroinflammationand seems to induces tissutal trophic and remodellingeffects at long term follow – up)

SW treatment (standard protocols) applied on acute cases and surgical complications(persistent pain and edema, loss of function, fibrosis) early reduction of acute signs and symptoms (1 – 2 weeks) more rapid functional recovery reduction of adhesions and partial tissue remodeling (2 – 3 months)

ESWT – Personal Experience in Achilles Tendinopathy

at Humanitas Research Hospital (Milan, Italy)

.. Work in Progress ..SITOD


Take Home Messages

Ormai sorpassata la fase «pioneristica» possibile utilizzo «versatile» e con effetto sinergico con altre terapie

Possibile alternativa/complemento al trattamento chirurgico

Evitare attività fisica intensa durante la terapia e per le 4 – 6 settimanesuccessive al trattamento/ modifica programmi allenamento sportivo

Possibile trattare anche strutture correlate (muscolo, osso, fascia)

Necessari ulteriori studi clinici per ottimizzare i risultati, aumentare evidenza scientifica, «customizzare» i protocolli di terapiaSITOD


Take Home Messages

• Le OU rappresentano un valido strumento terapeutico ai fini della rigenerazione e rimodellamento tissutali, da sole o in combinazione con altre procedure mediche, strumentali o chirurgiche

• Molto utile in indicazioni standard, ed in ogni caso in cui sia necessario stimolare la rigenerazione e/o il rimodellamento tissutali terapia sicura e versatile, se si rispettano le regole della GOOD CLINICAL PRACTICE

• Benchè talora apparentemente non efficaci se richiesto intervento chirurgico, le O.U precedentemente eseguite, possono assicurare un piu’ rapido miglioramento e rigenerazione nell’immediato post – operatorio.

• O.U sono in ogni caso sempre molto utili

• E’ necessario attendere anche diverse settimane, per osservare effetti di rigenerazioneSITOD

Documents

La Tendinopatia dell’ Achilleo SITODAgostino Achilleo.pdf · • Stretching ed esercizi eccentrici • FANS (short term) • Terapiafiltrativa in con Acido Ialuronico • Fattori