Powerdopplersonografische Befunde der Achillessehnen von 953 Langstreckenläufern – eine Querschnittsstudie

Zusammenfassung

Ziel: Das Ziel dieser Querschnittsuntersuchung war, die Häufigkeit Tendinopathie-typischer Ultraschallbefunde der Achillessehnen in einem großen Kollektiv wettkampforientierter Langstreckenläufer zu erfassen und mit klinisch-anamnestischen und anthropometrischen Probandendaten zu korrelieren. Material und Methode: 1906 Achillessehnen von 953 Läufern wurden in Längs- und Querschnitt powerdopplersonografisch untersucht (Toshiba Aplio SSA-770A/ 80, 12 MHz). Die Sehnendicke sowie die Häufigkeit pathologischer Ultraschallbefunde (Hypo-/Hyperechogenitäten, spindelförmige Verdickung, Neovaskularisationen) wurden dokumentiert und in Abhängigkeit der anthropometrischen Daten und der Anamnese bezüglich akuter und chronischer Achillessehnenbeschwerden analysiert. Ergebnisse: Sowohl bei beschwerdefreien Läufern als auch in der Gesamtgruppe zeigte sich ein statistisch signifikanter Zusammenhang zwischen Sehnendicke und Alter, Körpergröße und Körpergewicht (CC 0,24 – 0,38, p < 0,001). Probanden mit bestehenden oder abgeheilten Achillessehnenbeschwerden wiesen statistisch signifikant dickere Sehnen und häufiger pathologische B-Bild-Befunde bzw. Gefäßneubildungen auf (p < 0,001). Während Hypoechogenitäten und Sehnenverdickungen bei asymptomatischen Läufern selten zu finden waren (< 10 %), konnten mit dem hochauflösenden Powerdoppler „Advanced Dynamic Flow” bei 35 % dieser gesunden Probanden intratendinöse Gefäße detektiert werden. Schlussfolgerung: Entgegen häufig geäußerter Annahmen finden sich mit modernen Sonografiegeräten auch in Sehnen asymptomatischer Laufsportler häufig Mikrogefäße, deren pathologische Relevanz daher kritisch diskutiert werden muss.

Abstract

Aim: The aim of this cross-sectional study was to assess the frequency of tendinopathy-typical Doppler sonographic changes in the Achilles tendons of long distance runners and to correlate these findings with anamnestic and anthropometric data of the subjects. Materials and Methods: 1906 Achilles tendons of 953 long distance runners were examined by ultrasound and power Doppler (Toshiba Aplio SSA-770A/ 80 12 MHz). Ultrasound images (spindle-shaped thickening, hypoechoic/hyperechoic lesions, neovascularizations) were analyzed in relation to the runners’ anthropometrical data and history of Achilles tendon complaints. Results: In asymptomatic runners as well as in the overall group, there was a statistically significant correlation between tendon thickness and age, height and weight (CC 0.24 – 0.38, p < 0.001). Runners with current or healed Achilles tendon complaints displayed a statistically significant thickening of the tendons, as well as an increase in hypoechoic lesions and neovascularizations (p < 0.001). While grayscale abnormalities were rarely found in asymptomatic runners (< 10 %), neovascularization was detected in 35 % of healthy test persons using the high-resolution power Doppler ”Advanced Dynamic Flow”. Conclusion: Contrary to frequent assumption, neovascularization is often found in tendons of asymptomatic runners, using modern power Doppler equipment. The pathological relevance of single microvessels in asymptomatic tendons must, therefore, be critically discussed.

Key words

tendons - ultrasound power Doppler - epidemiology - muscular - extremities

Literatur

• 1 Fredberg U, Bolvig L. Significance of ultrasonographically detected asymptomatic tendinosis in the patellar and achilles tendons of elite soccer players: a longitudinal study.  Am J Sports Med. 2002;  30 488-491
• 2 Ulreich N, Kainberger F, Huber W. et al . Achilles tendon and sports.  Radiologe. 2002;  42 811-817
• 3 Silbernagel K G, Thomee R, Eriksson B I. et al . Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study.  Am J Sports Med. 2007;  35 897-906
• 4 Mayer F, Hirschmuller A, Muller S. et al . Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy.  Br J Sports Med. 2007;  41 e6
• 5 Paavola M, Paakkala T, Kannus P. et al . Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. A comparison between pre-operative ultrasonography and surgical findings.  Acta Radiol. 1998;  39 612-619
• 6 Astrom M, Gentz C F, Nilsson P. et al . Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases.  Skeletal Radiol. 1996;  25 615-620
• 7 Leung J L, Griffith J F. Sonography of chronic Achilles tendinopathy: a case-control study.  J Clin Ultrasound. 2008;  36 27-32
• 8 Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections.  Knee Surg Sports Traumatol Arthrosc. 2003;  11 334-338
• 9 Ohberg L, Alfredson H. Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?.  Knee Surg Sports Traumatol Arthrosc. 2004;  12 465-470
• 10 Ohberg L, Lorentzon R, Alfredson H. Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation.  Knee Surg Sports Traumatol Arthrosc. 2001;  9 233-238
• 11 Richards P J, Dheer A K, McCall I M. Achilles tendon (TA) size and power Doppler ultrasound (PD) changes compared to MRI: a preliminary observational study.  Clinical Radiol. 2001;  56 843-850
• 12 Zanetti M, Metzdorf A, Kundert H P. et al . Achilles tendons: clinical relevance of neovascularization diagnosed with power Doppler US.  Radiology. 2003;  227 556-560
• 13 Cook J L, Malliaras P, De Luca J. et al . Neovascularization and pain in abnormal patellar tendons of active jumping athletes.  Clin J Sport Med. 2004;  14 296-299
• 14 Reiter M, Ulreich N, Dirisamer A. et al . Colour and power Doppler sonography in symptomatic Achilles tendon disease.  Int J Sports Med. 2004;  25 301-305
• 15 Alfredson H, Thorsen K, Lorentzon R. In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E 2 in chronic Achilles tendon pain.  Knee Surg Sports Traumatol Arthrosc. 1999;  7 378-381
• 16 Andersson G, Danielson P, Alfredson H. et al . Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis.  Knee Surg Sports Traumatol Arthrosc. 2007;  15 1272-1279
• 17 Silvestri E, Biggi E, Molfetta L. et al . Power Doppler analysis of tendon vascularization.  Int J Tissue React. 2003;  25 149-158
• 18 Leung J L, Griffith J F. Sonography of chronic Achilles tendinopathy: A case-control study.  J Clin Ultrasound. 2008;  36 27-32
• 19 Peers K H, Brys P P, Lysens R J. Correlation between power Doppler ultrasonography and clinical severity in Achilles tendinopathy.  Int Orthop. 2003;  27 180-183
• 20 van Snellenberg W, Wiley J P, Brunet G. Achilles tendon pain intensity and level of neovascularization in athletes as determined by color Doppler ultrasound.  Scand J Med Sci Sports. 2007;  17 530-534
• 21 de Vos R J, Weir A, Cobben L P. et al . The value of power Doppler ultrasonography in Achilles tendinopathy: a prospective study.  Am J Sports Med. 2007;  35 1696-1701
• 22 Knobloch K, Yoon U, Vogt P M. Acute and overuse injuries correlated to hours of training in master running athletes.  Foot Ankle Int. 2008;  29 671-676
• 23 Boesen M I, Koenig M J, Torp-Pedersen S. et al . Tendinopathy and Doppler activity: the vascular response of the Achilles tendon to exercise.  Scand J Med Sci Sports. 2006;  16 463-469
• 24 Cook J L, Kiss Z S, Ptasznik R. et al . Is vascularity more evident after exercise? Implications for tendon imaging.  AJR. 2005;  185 1138-1140
• 25 Langberg H, Olesen J, Skovgaard D. et al . Age related blood flow around the Achilles tendon during exercise in humans.  Europ J Appl Physiol. 2001;  84 246-248
• 26 Ohberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment.  Br J Sports Med. 2002;  36 173-175; discussion 176 – 177
• 27 Khan K M, Forster B B, Robinson J. et al . Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study.  Br J Sports Med. 2003;  37 149-153
• 28 Richards P J, Win T, Jones P W. The distribution of microvascular response in Achilles tendonopathy assessed by colour and power Doppler.  Skeletal Radiol. 2005;  34 336-342
• 29 Jarauta E, Junyent M, Gilabert R. et al . Sonographic evaluation of Achilles tendons and carotid atherosclerosis in familial hypercholesterolemia.  Atherosclerosis. 2008;  204 345-347
• 30 Soila K, Karjalainen P T, Aronen H J. et al . High-resolution MR imaging of the asymptomatic Achilles tendon: new observations.  AJR. 1999;  173 323-328
• 31 Kainberger F, Engel A, Trattnig S. et al . Sonographic structural analysis of the Achilles tendon and biomechanical implications.  Ultraschall in Med. 1992;  13 28-30
• 32 Pang B S, Ying M. Sonographic measurement of achilles tendons in asymptomatic subjects: variation with age, body height, and dominance of ankle.  J Ultrasound Med. 2006;  25 1291-1296
• 33 Nicol A M, McCurdie I, Etherington J. Use of ultrasound to identify chronic Achilles tendinosis in an active asymptomatic population.  J R Army Med Corps. 2006;  152 212-216
• 34 Cook J, Khan K. The treatment of resistant, painful tendinopathies results in frustration for athletes and health professionals alike.  Am J Sports Med. 2003;  31 327-328; author reply 328
• 35 Lind B, Ohberg L, Alfredson H. Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2-year follow-up.  Knee Surg Sports Traumatol Arthrosc. 2006;  14 1327-1332
• 36 Koenig M J, Torp-Pedersen S, Holmich P. et al . Ultrasound Doppler of the Achilles tendon before and after injection of an ultrasound contrast agent – findings in asymptomatic subjects.  Ultraschall in Med. 2007;  28 52-56