Ultrasound Survey May Help Athletes Prevent Tendon Damage

Becky McCall

March 10, 2011

March 10, 2011 (Vienna, Austria) — Elite athletes are at risk for patellar and Achilles tendonitis and progressive damage even after intense physical exercise is stopped. In addition, they can be asymptomatic, prompting a need to monitor these individuals with ultrasonography, according to a new longitudinal study of rugby players.

Chiara Martini, MD, from the University of Genoa in Italy, presented her results here at the European Congress of Radiology 2011. She conducted a 5-year ultrasound survey of functional overload injuries of patellar and Achilles tendons in elite rugby players.

"Rugby players operate in a high-risk situation for overload injury, which causes an inflammatory reaction of the connective tissue, which envelops the tendons and often develops degenerative tendinous changes, which are painful and disabling — particularly in the Achilles and patellar tendons," Dr. Martini told Medscape Medical News.

She added that revealing such findings in rugby players with ultrasound investigations might help prevent overload injuries by having players adopt corrective action, such as physiotherapy or personalized training programs, if required. "This would slow down or reverse the process of damage and prevent pain and other adverse clinical outcomes."

Dr. Martini's study compared data from elite athletes with those from a group of healthy nonathlete volunteers, matched for age and sex, to highlight any morphostructural differences possibly related to functional overload.

In 2005, 52 asymptomatic athletes underwent ultrasound of their Achilles and patellar tendons. Among these were 26 professional rugby players (mean age, 25 years) and 26 control patients. The athletes stopped their professional activity from 13 to 58 months after initial evaluation (mean, 33 months).

Patellar measurements were taken at rest (supine, knee flexion 30 degrees) and recorded on longitudinal scans at the proximal third, mean third, and distal third. Achilles measurements were bilateral, whereas the ankle was prone and flexed. The measures were performed on axial scans that included latero-lateral diameter and antero-posterior diameter. All patients were also evaluated for internal fibrillar structure, focal hypoechoic areas, and calcifications.

Tendon thickness, focal hypoechoic areas, and calcifications in players and control subjects were compared between 2005 and 2010. The mean tendon thickness was significantly higher in the athlete group than in the control group: the mean value of the patellar tendon in the proximal third was 5.3 vs 3.8 mm, in the mean third was 5.1 vs 3.6 mm, and in the distal third was 5.0 vs 3.6 mm; the antero-posterior diameter of the Achilles tendon was 6.4 vs 5.7 mm and the latero-lateral diameter was 16.1 vs 12.8 mm.

In 2005, hypoechoic areas were found in 27% of the athlete group and 5% of the control group, and calcifications were found in 15% and 3%, respectively. By 2010, hypoechoic areas had increased to 32% in the athlete group and 8% in the control group, and calcifications were found in 16% and 3%, respectively.

"All athletes who presented focal hypoechoic areas and/or calcifications at baseline were found to have them increased in number and size at 5 years. Two athletes who were healthy at baseline were found to have 1 focal hypoechoic area and 1 calcification at the 5-year follow-up," said Dr. Martini.

"In conclusion, we found that the incidence of degenerative hypoechoic areas in asymptomatic rugby players had increased at 5-year follow-up, even though most of them had ceased their intense activity. I recommend that rugby players undergo evaluations of their tendons with ultrasonography even if they are asymptomatic, because they may suddenly have a lesion, and many athletes find they have to stop their careers because of Achilles tendon injuries."

David Wilson, MD, consultant musculoskeletal radiologist from Nuffield Orthopaedic Centre, National Health Service Trust, Oxford, United Kingdom, asked Dr. Martini whether the tendon might actually change in size just because of training — without injury. Dr. Martini replied that it was unclear whether the tendon change was a result of training or because rugby players are bigger and heavier than other people. This was not addressed in her study, but she suggested that this might be evaluated in a future study.

Peter Malliaras, MD, senior clinical lecturer, Queen Mary University, London, United Kingdom, and specialist physiotherapist in unresponsive tendonopathies among elite athletes, commented on the study. "This is an interesting study of progression of ultrasound pathology among active rugby players. Our research has shown that up to a quarter of volleyball players have similar asymptomatic pathology in their patellar tendons that does not seem to impair their function. So yes, ultrasound is sensitive to change in tendon pathology or tendon degeneration with activity over time, but this information may not allow us to predict people with pain or dysfunction."

Dr. Wilson added that "it is the long-term changes that are most significant. It suggests that rest and early active care may be much more important than we realized in the past."

Dr. Martini, Dr. Malliaras, and Dr. Wilson have disclosed no relevant financial relationships.

European Congress of Radiology (ECR) 2011. Presented March 5, 2011


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