Asymptomatic Achilles, patellar, and quadriceps tendinopathy: A longitudinal clinical and ultrasonographic study in elite fencers A. Giombini 1 , S. Dragoni 2 , A. Di Cesare 3 , M. Di Cesare 4 , A. Del Buono 5 , N. Maffulli 6 1 Department of Health Sciences, University of Molise, Molise, Italy, 2 Institute of Sports Medicine and Science, Rome, Italy, 3 Department of Physical Medicine and Rehabilitation, University of Rome ‘La Sapienza’, Rome, Italy, 4 Centre for International Education, University of Sussex, London, UK, 5 Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Rome, Italy, 6 Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK Corresponding author: Nicola Maffulli, Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK. Tel: ••, Fax: ••, E-mail: n.maffulli@qmul.ac.uk Accepted for publication 17 August 2011 Lower limb tendon changes detected at imaging are common among asymptomatic athletes. We aimed to pro- spectively assess the clinical status, tendon structure, and vascularity of lower limb tendons of elite fencers, and predict the risk of developing symptoms over time. Clini- cal examination, ultrasonographic changes (US), and Power Doppler (PD) flow of both the Achilles, patellar, and quadriceps tendon were assessed in 37 elite fencers in January 2007 and 3 years after. Two hundred and twenty- two tendons were examined. At the last appointment, patellar tendons diagnosed as abnormal at baseline were more likely to develop symptoms than normal those (P < 0.05, Fisher’s exact test), while US and PD abnormalities on Achilles and quadriceps tendons were no predictive for development of symptoms over years. A very low percentage of tendons diagnosed as normal at baseline (1.45%) showed US abnormalities at 3-year follow-up. In asymptomatic elite fencers, structural changes are relatively common at US and PD assessment of Achilles, quadriceps, and patellar tendons. It seems unlikely that additional PD investigations provide further information or change prognosis in patients with US diag- nosis of tendinopathy. Introduction In fencing, muscle groups are asymmetrically recruited (Nystrom et al., 1990; Murgu & Buschbacher, 2006) to perform complex movements, and loads are differently distributed between upper and lower limbs (Stewart et al., 1977; Sapega et al., 1984). Fencers are less pre- disposed to injury than basketball, volleyball, and soccer players (Harmer, 2008a). Nevertheless, overuse tendin- opathies, especially of the lower limbs, are very frequent in elite fencers (Harmer, 2008b; Roi & Bianchedi, 2008). In clinical practice, ultrasonography (US) is the method of choice to diagnose tendinopathy accurately and non- invasively, to assess the morphological and dynamic aspects of tendon structure, and to carry out image- guided injections (Claudon et al., 2002; Klauser & Peet- rons, 2009). US structural alterations have been widely described in tendons of symptomatic and asymptomatic athletes (Cook et al., 1998, 2004a). Since US and mag- netic resonance imaging abnormalities may precede tendon pain for a variable time (Malliaras et al., 2006), these findings may be of dubious diagnostic interest on their own, unless accompanied by clinical examination (Maffulli et al., 1987; Lian et al., 1996; Cook et al., 2000a, 2001a). On the other hand, Doppler neovascular- ity, being commonly associated with tendon pain (Ohberg et al., 2001; Richards et al., 2001; Zanetti et al., 2003), is considered of greater diagnostic utility. Gray- scale US abnormalities, including diffuse thickening (associated with reduced echogenicity) and focal hypoe- choicity, have been seen in both patellar and Achilles tendons in active athletes with or without pain (Cook et al., 2001b; Malliaras et al., 2006, 2008). It is unknown whether gray-scale US abnormalities change in appear- ance over time, and whether changes occur progressively in a defined sequence. The relationship between gray- scale US, Doppler neovascularity, and tendon pain has been only partially investigated (Malliaras et al., 2010). In Achilles tendons, neovascularity is more likely asso- ciated with pain in the presence of an underlying hypoe- choic region (Ohberg et al., 2001), rather than of a diffuse thickening (Malliaras et al., 2008). This suggests that the likelihood of developing pain may differ between the two gray-scale US abnormalities. This lon- gitudinal, clinical, and ultrasonographic study sought to clarify whether asymptomatic gray-scale changes of Toppan Best-set Premedia Limited Journal Code: SMS Proofreader: Mony Article No: SMS1400 Delivery date: 1 September 2011 Page Extent: 6 Scand J Med Sci Sports 2011: ••: ••–•• doi: 10.1111/j.1600-0838.2011.01400.x © 2011 John Wiley & Sons A/S 1 2 3 4 5