Tendonitis — why should the scalpel wait?

Aim of the study: Although the incidence of midportion Achilles tendinopathy is under 1% in the general population, it is quite a common disease in runners that is characterized by the symptom triad of pain, swelling and impaired physical performance.

Results: Histopathologically, mostly degenerative changes in the tendon structure are found, sometimes accompanied by intra- and paratendinous inflammation.Treatment options are conservative or surgical, but conservative ones should be tried first. The best evidence is available for eccentric exercise protocols, which represent the gold standard in conservative treatment options, followed by extracorporal shockwave (ECSW) therapy and corticoid injections.In about 25% of all cases, because of unsatisfactory nonoperative treatment results, surgery is recommended. Open, minimally invasive as well as tenoscopic methods exist, which show patients' satisfactory rates of about 80%. The return to sport or full physical performance is variable and may take up to 18 months for both treatment regimens.

Aim of the study: Patellar tendinopathy is a common cause of pain in athletes' knees. Historically, it has been related to jumping sports, such as volleyball and basketball.

Results: The nonsurgical treatment of patellar tendinopathy is focused on eccentric exercises and often has good results. Other experimental options, with variable levels of evidence, are available for recalcitrant cases. Surgical treatment is indicated for cases that are refractory to nonsurgical treatment. Open or arthroscopic surgery can be performed; the two methods are comparable, but arthroscopic surgery results in a faster recovery time.

Aim of the study: Tendinopathies are challenging conditions frequent in athletes and in middle-aged overweight patients with no history of increased physical activity. The term "tendinopathy" refers to a clinical condition characterised by pain, swelling, and functional limitations of tendons and nearby structures, the effect of chronic failure of healing response.

Results: Achilles and patellar tendons are among the most vulnerable tendons, and among the most frequent lower extremity overuse injuries. Achilles and patellar tendinopathies can be managed primarily conservatively, obtaining good results and clinical outcomes, but, when this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions, and, if performed well, they lead to a relatively high rate of success with few complications. The purpose of this narrative review is to critically examine the recent available scientific literature to provide evidence-based opinions on these two common and troublesome conditions.

Aim of the study: Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear.

Results: It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches.

Aim of the study: Disorders of the iliopsoas can be a significant source of groin pain in the athletic population. Commonly described pathologic conditions include iliopsoas bursitis, tendonitis, impingement, and snapping.

Results: Commonly described pathologic conditions include iliopsoas bursitis, tendonitis, impingement, and snapping. The first-line treatment for iliopsoas disorders is typically conservative, including activity modification, physical therapy, nonsteroidal anti-inflammatory drugs, and corticosteroid injections. Surgical treatment can be considered if the patient fails conservative measures and typically involves arthroscopic lengthening of the musculotendinous unit and treatment of concomitant intra-articular abnormality. Tendon release has been described: in the central compartment, in the peripheral compartment, and at the lesser trochanter, with similar outcomes observed between the techniques.

Aim of the study: Achilles tendinitis and posterior heel pain are caused by a wide variety of disorders. Understanding of the functional anatomy and pathomechanics of the Achilles tendon is essential for diagnosis and adequate therapy.

Results: In obese patients the deforming forces on the rear foot position and thereby overuse of the achillis tendon due to the overweight are increased. Lack of training with loss of muscular compensation or forefoot disorders also favor overuse problems. A sudden increase of load in an attempt of loosing weight by unaccustomed exercise, without giving the tissue adequate time for adaptation may lead to the start of the symptoms. Therapy of Achilles tendinitis is preferably conservative, in chronic cases operative therapy depends on the structures involved.

Aim of the study: Acute calcific tendinitis of the longus colli (LCT) is a rare, benign condition that frequently mimics retropharyngeal abscesses (RPA), a true surgical emergency. We present a 34-yearold woman presenting with 4 days of severe posterior neck pain, stiffness, and odynophagia.

Results: Contrast-enhanced computed tomography (CT) demonstrated a retropharyngeal fluid collection; however, the absence of peripheral ring enhancement and the presence of a pathognomonic calcification anterior to the C1 arch pointed toward LCT. This distinction allowed for successful conservative management with NSAIDs and steroids, preventing unnecessary surgical drainage. This case underscores the critical utility of contrast CT in distinguishing the benign, non-enhancing effusion of LCT from the ring-enhancing abscess of RPA. Recognition of this radiographic pattern is essential to avoid potential morbidity associated with misdiagnosis and overtreatment.

Aim of the study: Hydroxyapatite deposition disease (HADD) is a relatively common disorder characterised by periarticular deposition of calcium hydroxyapatite, most frequently involving tendons of the glenohumeral joint. Although calcific deposits typically produce a self-limiting inflammatory response, mass-like presentations at atypical sites can mimic trauma, infection or soft tissue neoplasia, posing a significant diagnostic challenge.

Results: We report an unusual presentation of mass-like calcific tendinitis within the flexor carpi ulnaris (FCU) tendon of the distal forearm-an atypical location for HADD presenting as a painful soft tissue swelling. Multimodality imaging, including radiography, MRI and CT, was instrumental in characterising the deposit and excluding alternative diagnoses. The patient was treated with ultrasound-guided barbotage using a large bore needle system, with significant reduction in deposit volume and symptom relief. This case highlights the importance of considering HADD in the differential diagnosis of painful soft tissue masses at atypical sites, where multimodal imaging is essential for accurate characterisation and ultrasound-guided barbotage represents an effective minimally invasive treatment alternative to surgery.

Aim of the study: To compare the midterm clinical and radiographic outcomes of extracorporeal shockwave therapy (ESWT) and ultrasound-guided needling (UGN) in symptomatic calcific tendinitis of the rotator cuff (RCCT).

Results: The minimum follow-up in this study was 5 years (mean 6.8 ± 1.1 years; range 60-106 months). Sixty-seven (82%) of the original 82 patients were included (43 females; 64%, mean age 51.8 ± 9.0 years). Baseline CMS was 67.4 ± 12.5. At 5 years, the mean CMS was 94.4 ± 6.4 and 93.3 ± 13.6 for ESWT and UGN, respectively (P = .67). Ninety-four percent of both groups achieved the minimal clinically important difference threshold value for CMS. Additional treatment was received by 42% and 26% of ESWT and UGN, respectively (P = .17). No recurrence of calcific deposits was found in treated tendons. New deposits in a different rotator cuff tendon were observed in 15% of UGN patients. Patients with RCCT treated with ESWT and UGN show excellent midterm clinical and radiographic outcomes, with most achieving clinically important difference threshold values without significant intergroup differences.