Thøger Persson Krogh

Background. Achilles tendinopathy (AT) is a common musculoskeletal disorder, and its management remains challenging. Hypothesis/Purpose. By conducting a pilot study, we aimed to assess the feasibility, safety, and clinical improvement of a new home-based 4-stage rehabilitation program with progressive loading including isometric exercises on a small scale prior to setting up a randomized controlled trial. Methods. Ten recreational athletes with chronic midportion AT were included. The primary outcome was change in VISA-A score after 1, 2, 3, 6, and 12 months. Secondary outcomes included tenderness on palpation of the tendon and ultrasonographic changes after 6 months. Results. Average VISA-A improvements of 26.9 points ( ) and 35.4 points ( ) were observed at 6- and 12-month follow-up, respectively. Tenderness on palpation of the tendon (0–10) was reduced from 5.5 to 2.5 ( ). Color Doppler ultrasound activity (0–4) was reduced by 50%, from an average of grade 2 to grade 1 ( ). The hypoechoic cross-sectional area of the Achilles tendon was reduced from an average of 29.1% to 8.5% ( ). Tendon thickness showed no statistically significant change ( ). Conclusion. Following the 4-stage rehabilitation program for AT based on isometric training and progressive loading, we observed improvement in both VISA-A score and ultrasonography in a group of athletes who had previously failed to benefit from standard AT rehabilitation. The study was feasible in terms of high adherence to the program and with no observed safety issues. The results of this pilot study support a further assessment of this specific approach for rehabilitation in a future randomized controlled trial.

We report a case of lower limb rhabdomyolysis in an elite dancer after one training session of electromyostimulation (EMS). Due to immobilisation after an overload injury in the left foot, EMS was used to counteract loss of muscle mass. The EMS training session was initiated shortly after the injury and consisted of two sets of activation of left leg quadriceps, shin and calf muscles. Each set involved 25 repetitions with an EMS intensity varying between 15–30 mA (35 Hz). Workload was 6 seconds of activation and 7 seconds resting time. Each EMS‐induced muscle contraction was stopped by voluntary co‐activation of the various antagonist muscles to generate a maximal concentric‐eccentric load on the muscle involved. 36 hours after the training session the dancer was admitted to hospital due to rhabdomyolysis. Creatine kinase (CK) levels reached a maximum of 26,200 IU/L, and the dancer was hospitalized for 4 days. With our case we highly advocate for the development of safe and validated EMS training protocols. All personnel, manufactures and athletes working with EMS should be aware of the potentially serious adverse events.

Plantar fasciitis (PF) affects 7% to 10% of the population. The long-term prognosis is unknown. Our study had 4 aims: (1) to assess the long-term prognosis of PF, (2) to evaluate whether baseline characteristics (sex, body mass index, age, smoking status, physical work, exercise-induced symptoms, bilateral heel pain, fascia thickness, and presence of a heel spur) could predict long-term outcomes, (3) to assess the long-term ultrasound (US) development in the fascia, and (4) to assess whether US-guided corticosteroid injections induce atrophy of the heel fat pad. Cohort study; Level of evidence, 3. From 2001 to 2011 (baseline), 269 patients were diagnosed with PF based on symptoms and US. At follow-up (2016), all patients were invited to an interview regarding their medical history and for clinical and US re-examinations. Kaplan-Meier survival estimates were used to estimate the long-term prognosis, and a multiple Cox regression analysis was used for the prediction model. In all, 174 patients (91 women, 83 men) participated in the study. All were interviewed, and 137 underwent a US examination. The mean follow-up was 9.7 years from the onset of symptoms and 8.9 years from baseline. At follow-up, 54% of patients were asymptomatic (mean duration of symptoms, 725 days), and 46% still had symptoms. The risk of having PF was 80.5% after 1 year, 50.0% after 5 years, 45.6% after 10 years, and 44.0% after 15 years from the onset of symptoms. The risk was significantly greater for women (P < .01) and patients with bilateral pain (P < .01). Fascia thickness decreased significantly in both the asymptomatic and symptomatic groups (P < .01) from 6.9 mm and 6.7 mm, respectively, to 4.3 mm in both groups. Fascia thickness (P = .49) and presence of a heel spur (P = .88) at baseline had no impact on prognosis. At follow-up, fascia thickness and echogenicity had normalized in only 24% of the asymptomatic group. The mean fat pad thickness was 9.0 mm in patients who had received a US-guided corticosteroid injection and 9.4 mm in those who had not been given an injection (P = .66). The risk of having PF in this study was 45.6% at a mean 10 years after the onset of symptoms. The asymptomatic patients had PF for a mean 725 days. The prognosis was significantly worse for women and patients with bilateral pain. Fascia thickness decreased over time regardless of symptoms and had no impact on prognosis, and neither did the presence of a heel spur. Only 24% of asymptomatic patients had a normal fascia on US at long-term follow-up. A US-guided corticosteroid injection did not cause atrophy of the heel fat pad. Our observational study did not allow us to determine the efficacy of different treatment strategies.

Ultrasonography (US) of the common extensor tendon (CET) of the elbow is often part of the assessment of patients with lateral epicondylitis. This US assessment is currently based on general tendinopathy references and not well-defined US entities. To describe CET thickness, color Doppler activity, and bony spurs on US in asymptomatic volunteers and to investigate the influence of sex, age, height, body mass index (BMI), weight, and elbow dominance on the measurements. Cross-sectional study; Level of evidence, 3. Tendon thickness, color Doppler activity, and bony spurs of the CET were measured sonographically in 264 adults (50% women) aged 20 to 96 years. Two different tendon-thickness measuring techniques were applied, labeled the “plateau measure” and the “1-cm measure.” Color Doppler activity was based on a 0 to 4 rating scale (negative, grades 0 and 1; positive, grades 2-4). A bony spur was defined as a bony outgrowth (≥0.3 mm) arising at the insertional site of the CET. With both tendon-thickness measuring techniques, the CET in the dominant elbow was thicker than that in the nondominant elbow, and male tendons were thicker than female tendons (all P ≤ .03). In regression analysis, tendon thickness correlated with weight, color Doppler activity, and arm dominance for both measuring techniques in multiple regression analysis. In addition, the plateau measure correlated with height and the presence of bony spurs. No correlations were observed regarding BMI, sex, or age. Positive color Doppler activity was found in 9% of examined elbows, with no difference between the sexes regarding dominant versus nondominant elbows (all P ≥.20). Bony spurs were found to increase with age, from 23% for people in their 20s to 74% in people older than 70 years. Bony spurs were more common in the dominant elbow (P ≤ .01). Women had a higher prevalence of bony spurs than men, but only in the dominant elbow (P = .03). This study presents the US characteristics and normal values of the CET. In 264 asymptomatic participants, the CET was found to be thicker in men and in the dominant elbow. No difference in tendon thickness could be demonstrated with regard to different age groups. Color Doppler activity was found to be positive in nearly 1 of 10 asymptomatic subjects. Bony spurs were a common finding; they increased in prevalence with every decade in age and were considered part of the aging process. Normal variations in CET morphologic characteristics should therefore be considered when implementing US in trials and clinical practice.

Achilles tendinopathy (AT) is a common and difficult to treat musculoskeletal disorder. To examine whether 1 injection of platelet-rich plasma (PRP) would improve outcomes more effectively than placebo (saline) after 3 months in patients with AT. Randomized controlled trial; Level of evidence, 1. A total of 24 patients with chronic AT (median disease duration, 33 months) were randomized (1:1) to receive either a blinded injection of PRP (n = 12) or saline (n = 12). The primary endpoint was improvement in Victorian Institute of Sports Assessment–Achilles (VISA-A) score at 3 months. Secondary outcomes were pain at rest, pain while walking, pain when tendon was squeezed, ultrasonographic changes in tendon thickness, and color Doppler activity. Patients were informed that they could drop out after 3 months if they were dissatisfied with the treatment. After 3 months, all 24 patients were reassessed (no dropouts). No difference between the PRP and the saline group could be observed with regard to the primary outcome (VISA-A score: mean difference [MD], –1.3; 95% CI, −17.8 to 15.2; P = .868). Secondary outcomes were pain at rest (MD, 1.6; 95% CI, −0.5 to 3.7; P = .137), pain while walking (MD, 0.8; 95% CI, −1.8 to 3.3; P = .544), pain when tendon was squeezed (MD, 0.3; 95% CI, −0.2 to 0.9; P = .208), color Doppler activity (MD, 0.3; 95% CI, −0.2 to 0.8; P = .260), and tendon thickness (MD, 0.8 mm; 95% CI, 0.1 to 1.6 mm; P = .030). After the 3-month follow-up, a large dropout was observed: 75% of patients in the PRP group and 33% in the saline group. PRP injection did not result in an improved VISA-A score over a 3-month period in patients with chronic AT compared with placebo. The only secondary outcome demonstrating a statistically significant difference between the groups was change in tendon thickness; this difference indicates that a PRP injection could increase tendon thickness compared with saline injection. The conclusions are limited to the 3 months after treatment owing to the large dropout rate.

Purpose: Tennis elbow, also known as lateral epicondylitis (LE), is a common disorder often assessed by ultrasound. The aim of this study was to evaluate the ultrasonographic outcomes and methods used in LE research and clinical practice. Materials and Methods: This study was designed as an intra- and interobserver reliability and agreement study. Ultrasonographic examination of the common extensor tendon of the elbow was performed. The intraobserver study examined tendon thickness twice in 20 right elbows from 20 healthy individuals at an interval of 7 to 12 days. The interobserver study examined tendon thickness, color Doppler activity, and bony spurs in 18 right elbows in 9 healthy individuals and 9 patients with LE. Two trained rheumatologists performed the interobserver examinations with the same scanner on the same day. The main outcomes were intra- and interclass correlation (ICC) and agreement. Results: In the intraobserver study, the ICC with regard to tendon thickness ranged from 0.76 to 0.81, depending on the measurement techniques used. The agreement ranged from 0.06 to 0.13 mm. In the interobserver study, the tendon thickness ICC ranged from 0.45 to 0.65 and the agreement ranged from –0.17 to 0.13 mm. The ICC for color Doppler activity was 0.93, with agreement in 14/18 (78 %) of the cases. A perfect reliability was demonstrated for bony spurs, with an ICC of 1 and exact agreement in 18/18 (100 %) of the cases. Conclusion: Good to excellent reliability was obtained for all measurements. The ultrasonographic techniques evaluated in this trial can be recommended for use in both research and clinical practice. Ziel: Der Tennisellbogen, auch bekannt als Epicondylitis lateralis humeri (LE) ist eine häufige, oftmals sonografisch bewertete Erkrankung. Das Ziel dieser Studie war die Einschätzung der sonografischen Ergebnisse und der Methoden, die in der LE-Forschung und klinischen Praxis Anwendung finden. Material und Methoden: Diese Studie wurde als Intra- und Interobserver-Übereinstimmungsstudie konzipiert. Es wurde eine sonografische Untersuchung der gemeinsamen Strecksehne des Ellbogens durchgeführt. In der Intraobserver-Studie wurde zweimal die Sehnendicke in 20 rechten Ellbogen von 20 Gesunden in einem Abstand von 7 bis 12 Tagen bestimmt. Die Interobserver-Studie untersuchte Sehnendicke, Farbdoppleraktivität und Knochensporne in 18 rechten Ellbogen von 9 Gesunden und 9 Patienten mit LE. Zwei ausgebildete Rheumatologen führten die Interobserver-Untersuchungen mit demselben Gerät am gleichen Tag durch. Als Hauptresultate wurden die Intra- und Interklasse-Korrelationen (ICC) sowie die Übereinstimmung erhoben. Ergebnisse: In der Intraobserver-Studie erstreckte sich der ICC in Bezug auf die Sehnendicke, je nach verwendeter Messtechnik, von 0,76 bis 0,81. Die Übereinstimmung lag zwischen 0,06 und 0,13 mm. In der Interobserver-Studie erstreckte sich der ICC der Sehnendicke von 0,45 bis 0,65, die Übereinstimmung lag zwischen –0,17 und 0,13 mm. Der ICC für die Doppler-Aktivität betrug 0,93 mit einer Übereinstimmung in 14/18 Fällen (78 %). Eine ausgezeichnete Übereinstimmung wurde für Knochensporne gezeigt, mit einem ICC von 1 und einer exakten Übereinstimmung (100 %) in 18/18 Fällen. Schlussfolgerung: In allen Messungen wurde eine gute bis ausgezeichnete Übereinstimmung erzielt. Die in dieser Studie bewerteten sonografischen Techniken können sowohl für die Forschung als auch für die klinische Praxis empfohlen werden.

Background: Lateral epicondylitis (LE) is a common musculoskeletal disorder for which an effective treatment strategy remains unknown. Purpose: To examine whether a single injection of platelet-rich plasma (PRP) is more effective than placebo (saline) or glucocorticoid in reducing pain in adults with LE after 3 months. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 60 patients with chronic LE were randomized (1:1:1) to receive either a blinded injection of PRP, saline, or glucocorticoid. The primary end point was a change in pain using the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire at 3 months. Secondary outcomes were ultrasonographic changes in tendon thickness and color Doppler activity. Results: Pain reduction at 3 months (primary end point) was observed in all 3 groups, with no statistically significant difference between the groups; mean differences were the following: glucocorticoid versus saline: −3.8 (95% CI, −9.9 to 2.4); PRP versus saline: −2.7 (95% CI, −8.8 to 3.5); and glucocorticoid versus PRP: −1.1 (95% CI, −7.2 to 5.0). At 1 month, however, glucocorticoid reduced pain more effectively than did both saline and PRP; mean differences were the following: glucocorticoid versus saline: −8.1 (95% CI, −14.3 to −1.9); and glucocorticoid versus PRP: −9.3 (95% CI, −15.4 to −3.2). Among the secondary outcomes, at 3 months, glucocorticoid was more effective than PRP and saline in reducing color Doppler activity and tendon thickness. For color Doppler activity, mean differences were the following: glucocorticoid versus PRP: −2.6 (95% CI, −3.1 to −2.2); and glucocorticoid versus saline: −2.0 (95% CI, −2.5 to −1.6). For tendon thickness, mean differences were the following: glucocorticoid versus PRP: −0.5 (95% CI, −0.8 to −0.2); and glucocorticoid versus saline: −0.8 (95% CI, −1.2 to −0.5). Conclusion: Neither injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at the primary end point at 3 months. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month in contrast to the other therapies. Injection of glucocorticoid in LE reduces both color Doppler activity and tendon thickness compared with PRP and saline.

Background: Injection therapy with glucocorticoids has been used since the 1950s as a treatment strategy for lateral epicondylitis (tennis elbow). Lately, several novel injection therapies have become available. Purpose: To assess the comparative effectiveness and safety of injection therapies in patients with lateral epicondylitis. Study Design: Systematic review and meta-analysis. Methods: Randomized controlled trials comparing different injection therapies for lateral epicondylitis were included provided they contained data for change in pain intensity (primary outcome). Trials were assessed using the Cochrane risk of bias tool. Network (random effects) meta-analysis was applied to combine direct and indirect evidence within and across trial data using the final end point reported in the trials, and results for the arm-based network analyses are reported as standardized mean differences (SMDs). Results: Seventeen trials (1381 participants; 3 [18%] at low risk of bias) assessing injection with 8 different treatments—glucocorticoid (10 trials), botulinum toxin (4 trials), autologous blood (3 trials), platelet-rich plasma (2 trials), and polidocanol, glycosaminoglycan, prolotherapy, and hyaluronic acid (1 trial each)—were included. Pooled results (SMD [95% confidence interval]) showed that beyond 8 weeks, glucocorticoid injection was no more effective than placebo (−0.04 [−0.45 to 0.35]), but only 1 trial (which did not include a placebo arm) was at low risk of bias. Although botulinum toxin showed marginal benefit (−0.50 [−0.91 to −0.08]), it caused temporary paresis of finger extension, and all trials were at high risk of bias. Both autologous blood (−1.43 [−2.15 to −0.71]) and platelet-rich plasma (−1.13 [−1.77 to −0.49]) were also statistically superior to placebo, but only 1 trial was at low risk of bias. Prolotherapy (−2.71 [−4.60 to −0.82]) and hyaluronic acid (−5.58 [−6.35 to −4.82]) were both more efficacious than placebo, whereas polidocanol (0.39 [−0.42 to 1.20]) and glycosaminoglycan (−0.32 [−1.02 to 0.38]) showed no effect compared with placebo. The criteria for low risk of bias were only met by the prolotherapy and polidocanol trials. Conclusion: This systematic review and network meta-analysis of randomized controlled trials found a paucity of evidence from unbiased trials on which to base treatment recommendations regarding injection therapies for lateral epicondylitis.