Journal of musculoskeletal & neuronal interactions
The plantaris tendon is increasingly recognised as an important factor in midportion Achilles ten... more The plantaris tendon is increasingly recognised as an important factor in midportion Achilles tendinopathy. Its innervation pattern is completely unknown. Plantaris tendons (n=56) and associated peritendinous tissue from 46 patients with midportion Achilles tendinopathy and where the plantaris tendon was closely related to the Achilles tendon were evaluated. Morphological evaluations and stainings for nerve markers [general (PGP9.5), sensory (CGRP), sympathetic (TH)], glutamate NMDA receptor and Schwann cells (S-100β) were made. A marked innervation, as evidenced by evaluation for PGP9.5 reactions, occurred in the peritendinous tissue located between the plantaris and Achilles tendons. It contained sensory and to some extent sympathetic and NMDAR1-positive axons. There was also an innervation in the zones of connective tissue within the plantaris tendons. Interestingly, some of the nerve fascicles showed a partial lack of axonal reactions. New information on the innervation patterns...
Background:“Tennis elbow” is a difficult condition to treat. Ultrasonography (US) and colour Dopp... more Background:“Tennis elbow” is a difficult condition to treat. Ultrasonography (US) and colour Doppler (CD) guided injections with polidocanol targeting the area with increased blood flow in the extensor origin have shown promising clinical results.Objective:To evaluate and compare effects of US and CD guided intratendinous injections with sclerosing polidocanol and a local anaesthetic (lidocaine + epinephrine), in patients with tennis elbow.Design:Prospective, randomised, controlled, double-blind, crossover study.Setting:Sports Medicine Unit, Umeå University.Patients:32 patients (36 elbows), age range 27 to 66 years, with a long duration of elbow pain diagnosed as tennis elbow, were included in the study. All patients were followed up 3 and 12 months after treatment. Two patients were excluded due to other interventions during the study.Interventions:One US and CD guided injection with the sclerosing agent polidocanol (group 1) or the local anaesthetic lidocaine plus epinephrine (gro...
Full-thickness patellar cartilage defects are often, but not always, associated with disabling an... more Full-thickness patellar cartilage defects are often, but not always, associated with disabling anterior knee-pain and inability to take part in regular daily activities. There is no treatment of choice for this condition. It is well known that the cells in the cambium layer of the periosteum are pluripotent and can differentiate into hyaline (or hyaline-like) cartilage, especially if in a joint environment and under the influence of continous passive motion. In a few clinical studies autologous periosteum transplants alone have been used in the treatment of full thickness patellar cartilage defects. The results are varying. At our clinic, autologous periosteum transplantation alone, followed by continous passive motion (CPM) in the immediate postoperative period and non-weight bearing loading for 3 months, has shown promising clinical results. The best clinical results have been achieved on traumatic (fracture, contusion, dislocation) cartilage defects, where 83% of patients have be...
Metabolic factors such as cholesterol appear to play an important role in the development of Achi... more 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 tendin...
Journal of Musculoskeletal & Neuronal Interactions, 2017
Background: The peritendinous connective tissues can have importance in chronic tendon pain. Rece... more Background: The peritendinous connective tissues can have importance in chronic tendon pain. Recently cytokine TNF-α has been suggested to be involved in tendinopathic processes. It is not known how TNF-α 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 βIII-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...
In recent years, the plantaris tendon has been implicated in the development of chronic painful m... more 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. Cite this article: Bone Joint J 2016;98-B:1312–19.
Background: The mechanism that causes pain in chronic Achilles tendinosis is not known. However, ... more Background: The mechanism that causes pain in chronic Achilles tendinosis is not known. However, high resolution colour Doppler ultrasound has shown that neovascularisation may be involved. Objective: To investigate if sclerosing the neovessels would affect the level of tendon pain. Methods: The effect of colour Doppler ultrasound guided injection of a sclerosing agent, polidocanol, against neovessels was studied in 10 patients (seven men and three women, mean age 55 years) with painful chronic mid-portion Achilles tendinosis. Results: Eight patients were satisfied with the results of treatment. There was significantly reduced pain during activity (reported on a visual analogue scale (VAS)) and no remaining neovascularisation after an average of two injections. Two patients were not satisfied, and neovascularisation remained. At the six month follow up, the same eight patients remained satisfied and could perform Achilles tendon loading activities as desired. Their VAS score had dec...
Cardiovascular & hematological agents in medicinal chemistry, 2007
The chronic painful tendon (tendinopathy, tendinosis) is generally considered difficult to treat,... more The chronic painful tendon (tendinopathy, tendinosis) is generally considered difficult to treat, not seldom causing long-term disability and sometimes ending the sports or work carreér. Most common sites for tendinopathy are the Achilles-, patellar-, extensor carpi radialis brevis (ERCB)-, and supraspinatus tendons. The origin of pain has for many years been unknown, but recently, by using ultrasound (US) + colour Doppler (CD), immunohistochemical analyses of tendon biopsies, and diagnostic injections of local anaestesia, we found a close relationship between areas with vasculo-neural ingrowth and tendon pain. Sensory nerves (Substance-P-SP and Calcitonin Gene Related Peptide-CGRP) were found inside and outside the vascular wall. In following clinical studies we have demonstrated good short-and mid-term clinical results using treatment with US+CD-guided sclerosing polidocanol injections, targeting the area with neovessels outside the tendon. Two-year follow ups have showed remainin...
ABSTRACT Introduction: Tennis elbow/extensor carpi radialis brevis (ECRB) tendinopathy is well kn... more ABSTRACT Introduction: Tennis elbow/extensor carpi radialis brevis (ECRB) tendinopathy is well known to be difficult to treat. There is no concensus about treatment. Material and methods: Five patients (3 females and 2 males, mean age 43 years) with a long duration (12–48 months) of pain symptoms related to Tennis elbow were in local anaesthesia treated with an ultrasound (US)+Doppler (CD)-guided open scraping procedure. Where the US+CD examination showed a localised high blood flow, there was macroscopically a richly vascularised fatty infiltration. This tissue, containing paratendinous fibrous tissue, blood vessels and fat, was carefully scraped loose and sent for immunohistochemical staining. The general nerve marker PGP 9.5 was studied. Results: In all specimens there were multiple nerve structures, often located in close relation to blood vessels and sometimes also inside blood vessel walls. Discussion: These findings might indicate that a major source of pain related to Tennis elbow is located in the tissues superficial to the extensor origin.Characterisation of the nerves is on-going. These new findings might have implications for new treatment strategies.
Scandinavian Journal of Medicine and Science in Sports, 2002
The aim of this investigation was to study the consequences of anterior cruciate ligament injurie... more The aim of this investigation was to study the consequences of anterior cruciate ligament injuries in female soccer players. Special interest was focused on young female soccer players (< 16 years) sustaining anterior cruciate ligament injuries when playing at a senior level, which means playing together with players 19 years or older. In Sweden, all players belonging to an organized soccer club are insured by the same insurance company, the Folksam Insurance Company. Data of all soccer-related knee injuries in females reported to the Folksam Insurance Company between 1994 and 1998 were collected. A questionnaire was sent to 978 females who were registered to have sustained a knee injury before the age of 20 years. The response rate was 79%. Three hundred and ninety-eight female soccer players who had sustained an anterior cruciate ligament injury before the age of 19 years were analysed. Most of their anterior cruciate ligament injuries had been diagnosed using arthroscopy or magnetic resonance imaging (84%). Thirty-eight percent of the players had been injured before the age of 16 years. Of these, 39% were injured when playing in senior teams. When playing in senior teams 59% of the players below the age of 16 years and 44% of the players 16 years or older sustained their ACL injuries during contact situations. At the time of this investigation (2-7 years after the anterior cruciate ligament injury), altogether 78% (n = 311) reported that they had stopped playing soccer. The most common reason (80%) was symptoms from their anterior cruciate ligament-injured knee. It appears that many young female soccer players injure their anterior cruciate ligament when playing at a senior level. Therefore, we suggest that female soccer players under the age of 16 years should be allowed to participate only in practice sessions but not games at a senior level.
Scandinavian Journal of Medicine and Science in Sports, 2001
In this prospective study, injuries in 153 adolescent female soccer players were recorded during ... more In this prospective study, injuries in 153 adolescent female soccer players were recorded during one outdoor season (April-October). The overall injury incidence rate was 6.8 per 1000 h soccer (games and practice) and the incidence rate of traumatic injury 9.1 and 1.5 per 1000 player-hours in games and practice, respectively. Sixty-three players (41%) sustained 79 injuries. Sixty-six percent of the injuries were traumatic and 34% were overuse injuries. Most of the traumatic injuries occurred during games. Eighty-nine percent of the injuries were located in the lower extremities and 42% occurred in the knee or ankle. The most frequent type of injury was ankle sprain (22.8%). Forty-one percent of the traumatic injuries and 56% of the ankle sprains were re-injuries. Most of the injuries were of moderate severity (52%), while 34% were minor and 14% were major. Most of the major injuries were traumatic such as knee ligament injuries and ankle sprains.
Journal of musculoskeletal & neuronal interactions
The plantaris tendon is increasingly recognised as an important factor in midportion Achilles ten... more The plantaris tendon is increasingly recognised as an important factor in midportion Achilles tendinopathy. Its innervation pattern is completely unknown. Plantaris tendons (n=56) and associated peritendinous tissue from 46 patients with midportion Achilles tendinopathy and where the plantaris tendon was closely related to the Achilles tendon were evaluated. Morphological evaluations and stainings for nerve markers [general (PGP9.5), sensory (CGRP), sympathetic (TH)], glutamate NMDA receptor and Schwann cells (S-100β) were made. A marked innervation, as evidenced by evaluation for PGP9.5 reactions, occurred in the peritendinous tissue located between the plantaris and Achilles tendons. It contained sensory and to some extent sympathetic and NMDAR1-positive axons. There was also an innervation in the zones of connective tissue within the plantaris tendons. Interestingly, some of the nerve fascicles showed a partial lack of axonal reactions. New information on the innervation patterns...
Background:“Tennis elbow” is a difficult condition to treat. Ultrasonography (US) and colour Dopp... more Background:“Tennis elbow” is a difficult condition to treat. Ultrasonography (US) and colour Doppler (CD) guided injections with polidocanol targeting the area with increased blood flow in the extensor origin have shown promising clinical results.Objective:To evaluate and compare effects of US and CD guided intratendinous injections with sclerosing polidocanol and a local anaesthetic (lidocaine + epinephrine), in patients with tennis elbow.Design:Prospective, randomised, controlled, double-blind, crossover study.Setting:Sports Medicine Unit, Umeå University.Patients:32 patients (36 elbows), age range 27 to 66 years, with a long duration of elbow pain diagnosed as tennis elbow, were included in the study. All patients were followed up 3 and 12 months after treatment. Two patients were excluded due to other interventions during the study.Interventions:One US and CD guided injection with the sclerosing agent polidocanol (group 1) or the local anaesthetic lidocaine plus epinephrine (gro...
Full-thickness patellar cartilage defects are often, but not always, associated with disabling an... more Full-thickness patellar cartilage defects are often, but not always, associated with disabling anterior knee-pain and inability to take part in regular daily activities. There is no treatment of choice for this condition. It is well known that the cells in the cambium layer of the periosteum are pluripotent and can differentiate into hyaline (or hyaline-like) cartilage, especially if in a joint environment and under the influence of continous passive motion. In a few clinical studies autologous periosteum transplants alone have been used in the treatment of full thickness patellar cartilage defects. The results are varying. At our clinic, autologous periosteum transplantation alone, followed by continous passive motion (CPM) in the immediate postoperative period and non-weight bearing loading for 3 months, has shown promising clinical results. The best clinical results have been achieved on traumatic (fracture, contusion, dislocation) cartilage defects, where 83% of patients have be...
Metabolic factors such as cholesterol appear to play an important role in the development of Achi... more 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 tendin...
Journal of Musculoskeletal & Neuronal Interactions, 2017
Background: The peritendinous connective tissues can have importance in chronic tendon pain. Rece... more Background: The peritendinous connective tissues can have importance in chronic tendon pain. Recently cytokine TNF-α has been suggested to be involved in tendinopathic processes. It is not known how TNF-α 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 βIII-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...
In recent years, the plantaris tendon has been implicated in the development of chronic painful m... more 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. Cite this article: Bone Joint J 2016;98-B:1312–19.
Background: The mechanism that causes pain in chronic Achilles tendinosis is not known. However, ... more Background: The mechanism that causes pain in chronic Achilles tendinosis is not known. However, high resolution colour Doppler ultrasound has shown that neovascularisation may be involved. Objective: To investigate if sclerosing the neovessels would affect the level of tendon pain. Methods: The effect of colour Doppler ultrasound guided injection of a sclerosing agent, polidocanol, against neovessels was studied in 10 patients (seven men and three women, mean age 55 years) with painful chronic mid-portion Achilles tendinosis. Results: Eight patients were satisfied with the results of treatment. There was significantly reduced pain during activity (reported on a visual analogue scale (VAS)) and no remaining neovascularisation after an average of two injections. Two patients were not satisfied, and neovascularisation remained. At the six month follow up, the same eight patients remained satisfied and could perform Achilles tendon loading activities as desired. Their VAS score had dec...
Cardiovascular & hematological agents in medicinal chemistry, 2007
The chronic painful tendon (tendinopathy, tendinosis) is generally considered difficult to treat,... more The chronic painful tendon (tendinopathy, tendinosis) is generally considered difficult to treat, not seldom causing long-term disability and sometimes ending the sports or work carreér. Most common sites for tendinopathy are the Achilles-, patellar-, extensor carpi radialis brevis (ERCB)-, and supraspinatus tendons. The origin of pain has for many years been unknown, but recently, by using ultrasound (US) + colour Doppler (CD), immunohistochemical analyses of tendon biopsies, and diagnostic injections of local anaestesia, we found a close relationship between areas with vasculo-neural ingrowth and tendon pain. Sensory nerves (Substance-P-SP and Calcitonin Gene Related Peptide-CGRP) were found inside and outside the vascular wall. In following clinical studies we have demonstrated good short-and mid-term clinical results using treatment with US+CD-guided sclerosing polidocanol injections, targeting the area with neovessels outside the tendon. Two-year follow ups have showed remainin...
ABSTRACT Introduction: Tennis elbow/extensor carpi radialis brevis (ECRB) tendinopathy is well kn... more ABSTRACT Introduction: Tennis elbow/extensor carpi radialis brevis (ECRB) tendinopathy is well known to be difficult to treat. There is no concensus about treatment. Material and methods: Five patients (3 females and 2 males, mean age 43 years) with a long duration (12–48 months) of pain symptoms related to Tennis elbow were in local anaesthesia treated with an ultrasound (US)+Doppler (CD)-guided open scraping procedure. Where the US+CD examination showed a localised high blood flow, there was macroscopically a richly vascularised fatty infiltration. This tissue, containing paratendinous fibrous tissue, blood vessels and fat, was carefully scraped loose and sent for immunohistochemical staining. The general nerve marker PGP 9.5 was studied. Results: In all specimens there were multiple nerve structures, often located in close relation to blood vessels and sometimes also inside blood vessel walls. Discussion: These findings might indicate that a major source of pain related to Tennis elbow is located in the tissues superficial to the extensor origin.Characterisation of the nerves is on-going. These new findings might have implications for new treatment strategies.
Scandinavian Journal of Medicine and Science in Sports, 2002
The aim of this investigation was to study the consequences of anterior cruciate ligament injurie... more The aim of this investigation was to study the consequences of anterior cruciate ligament injuries in female soccer players. Special interest was focused on young female soccer players (< 16 years) sustaining anterior cruciate ligament injuries when playing at a senior level, which means playing together with players 19 years or older. In Sweden, all players belonging to an organized soccer club are insured by the same insurance company, the Folksam Insurance Company. Data of all soccer-related knee injuries in females reported to the Folksam Insurance Company between 1994 and 1998 were collected. A questionnaire was sent to 978 females who were registered to have sustained a knee injury before the age of 20 years. The response rate was 79%. Three hundred and ninety-eight female soccer players who had sustained an anterior cruciate ligament injury before the age of 19 years were analysed. Most of their anterior cruciate ligament injuries had been diagnosed using arthroscopy or magnetic resonance imaging (84%). Thirty-eight percent of the players had been injured before the age of 16 years. Of these, 39% were injured when playing in senior teams. When playing in senior teams 59% of the players below the age of 16 years and 44% of the players 16 years or older sustained their ACL injuries during contact situations. At the time of this investigation (2-7 years after the anterior cruciate ligament injury), altogether 78% (n = 311) reported that they had stopped playing soccer. The most common reason (80%) was symptoms from their anterior cruciate ligament-injured knee. It appears that many young female soccer players injure their anterior cruciate ligament when playing at a senior level. Therefore, we suggest that female soccer players under the age of 16 years should be allowed to participate only in practice sessions but not games at a senior level.
Scandinavian Journal of Medicine and Science in Sports, 2001
In this prospective study, injuries in 153 adolescent female soccer players were recorded during ... more In this prospective study, injuries in 153 adolescent female soccer players were recorded during one outdoor season (April-October). The overall injury incidence rate was 6.8 per 1000 h soccer (games and practice) and the incidence rate of traumatic injury 9.1 and 1.5 per 1000 player-hours in games and practice, respectively. Sixty-three players (41%) sustained 79 injuries. Sixty-six percent of the injuries were traumatic and 34% were overuse injuries. Most of the traumatic injuries occurred during games. Eighty-nine percent of the injuries were located in the lower extremities and 42% occurred in the knee or ankle. The most frequent type of injury was ankle sprain (22.8%). Forty-one percent of the traumatic injuries and 56% of the ankle sprains were re-injuries. Most of the injuries were of moderate severity (52%), while 34% were minor and 14% were major. Most of the major injuries were traumatic such as knee ligament injuries and ankle sprains.
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