Achilles tendon disorders are among the more common maladies seen by sports medicine physicians. Understanding the anatomy and biomechanics of the Achilles tendon and contiguous structures is essential to the diagnosis and treatment of Achilles tendon overuse injuries. Posterior heel pain is multifactorial and includes paratenonitis, tendinosis, tendinosis with partial rupture, insertional tendinitis, retrocalcaneal bursitis, and subcutaneous tendo-Achilles bursitis. Each of these entities is distinct, but they often occur in combination. Although most cases of this disorder are successfully treated nonoperatively, a small subgroup of recalcitrant cases may benefit from surgical intervention. Complete ruptures in active, athletic persons should be treated operatively in most cases and result in predictably good outcomes. There may be some cases that escape early recognition and require a reconstructive procedure to salvage a potentially severe functional deficit.

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

We retrospectively studied 17 cases of distal pectoralis major muscle rupture to compare the results of repair in acute and chronic injuries and to compare operative and nonoperative treatment. Thirteen patients underwent surgery (six acute injuries [less than 2 weeks after injury] and seven chronic injuries) and four had nonoperative management. The mean age of the patients at injury was 29, and 10 of the 17 injuries were the result of weight lifting. Follow-up ranged from 18 months to 6 years (mean, 28 months). All patients subjectively rated strength, pain, motion, function with strenuous sporting activities, cosmesis, and overall satisfaction. Objectively, patients were examined for range of motion, deformity, atrophy, and strength. Isokinetic strength testing was performed in eight patients: six treated operatively (three acute and three chronic) and two treated nonoperatively. Overall subjective ratings were 96% in the acute group, 93% in the chronic group, and only 51% in the nonoperative group. Isokinetic testing showed that patients operated on for acute injuries had the highest adduction strength (102% of the opposite side) compared with patients with chronic injuries (94%) or nonoperative treatment (71%). There were no statistically significant subjective or objective differences in outcome between the patients treated operatively for acute or chronic injuries, but these patients fared significantly better than patients treated nonoperatively.

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Objective: To assess if ultrasound guided autologous blood injection is an effective treatment for medial epicondylitis. Methods: Twenty patients (13 men, 7 women) with refractory medial epicondylitis with symptom duration of 12 months underwent sonographic evaluation. Tendinosis was confirmed according to three sonographic criteria: echo texture, interstitial tears and neovascularity. The tendon was then dry needled and autologous blood was injected. Patients were reviewed at 4 weeks and at 10 months. VAS scores and modified Nirschl scores were assessed pre-procedure and post-procedure. Results: There was significant reduction in VAS pain score between pre-procedure and 10 months postprocedure when it had a median (IQR) of 1.00 (1-1.75), range 0-7. The median (IQR) Nirschl score, which at pre-procedure was 6.00 (5-7), range 4-7, had decreased at 4 weeks to 4.00 (2.25-5), range 2-7, and at 10 months to 1.00 (1-1.75), range 0-7, revealing a significant decrease (z = 3.763, p,0.001). The hypo-echoic change in the flexor tendon significantly decreased between pre-procedure, when there was a mean (SD) of 6.45 (1.47), and at 10 months, when it was 3.85 (2.37) (p,0.001). Doppler ultrasound showed that neovascularity decreased between pre-procedure, when there was a mean (SD) of 6.10 (1.62), range 4-9, and at 10 months, when it was 3.60 (2.56), range 0-9 (p,0.001). Discussion: The combined action of dry needling and autologous blood injection under ultrasound guidance appears to be an effective treatment for refractory medial epicondylitis as demonstrated by a significant decrease in VAS pain and a fall in the modified Nirschl scores.

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Rupture of the anterior cruciate ligament (ACL) of the knee is a commonly occurring injury in the athletic population. Associated meniscal and chondral injury is well recognised. This occurs both at the time of index injury and also secondarily over time in the ACL-deficient knee as a result of several related pathways culminating in osteoarthritis. ACL reconstruction is a well established surgical technique for treatment of symptomatic instability in ACL-deficient knees but the role of ACL reconstruction in the prevention of osteoarthritis remains unclear. This article reviews the contemporary literature on the pathophysiology of chondral and meniscal loss in ACL-injured knees and the role of current treatment techniques, including surgical reconstruction of ligamentous, meniscal and chondral pathology, in altering the natural history of the ACL-deficient knee.

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