Original article Site of maximum neovascularisation correlates with the site of pain in recalcitrant mid-tendon Achilles tendinopathy Kiran Divani a , Otto Chan b , Nat Padhiar a , Richard Twycross-Lewis a , Nicola Maffulli a , Tom Crisp b , Dylan Morrissey a, * a Centre for Sports and Exercise Medicine, Mile End Hospital, London E14DG, United Kingdom b London Independent Hospital, I Beaumont Square, London E1, United Kingdom article info Article history: Received 16 November 2009 Received in revised form 18 March 2010 Accepted 24 March 2010 Keywords: Achilles tendinopathy Neovascularisation Pain abstract Background: Neovascularisation is associated with pain in Achilles tendinopathy (AT). The anatomical relationship between ultrasound (US)-defined indicators of tendinopathy and clinically determined pain sites has not been investigated. Purpose: To measure the spatial correlation between the sites of maximum palpated tenderness, site of patient-indicated pain, maximum US-determined neovascularisation and maximum antero-posterior tendon thickness in patients with chronic recalcitrant AT (CRAT). Methods: A custom-designed measuring apparatus and clinical examination were used to measure the sites of maximum tenderness and subjectively defined pain on 29 tendons from patients diagnosed with mid-tendon CRAT. All tendons had been previously non-responsive to eccentric loading. Maximal neo- vascularisation and tendon thickness were measured by US scanning in conjunction with the measuring device. Results: A significant association exists between clinically determined pain and neovascularisation (r ¼ 0.85, p < 0.001), patient reported pain (r ¼ 0.91, p < 0.001), maximal tendon thickness (r ¼ 0.91, p < 0.001), maximal thickness and maximal neovascularisation (r ¼ 0.86, p < 0.001). Conclusion: Sites of subjectively defined pain, clinically palpated tenderness, tendon thickness and neovascularisation are anatomically associated. Palpation can be reliably used as a clinical guide when planning interventions in patients with CRAT. Ó 2010 Elsevier Ltd. All rights reserved. 1. Introduction Achilles tendinopathy (AT) is common in elite and recreational athletes, particularly runners, basketball players and other jumping athletes (Maffulli, 1998; Reiter et al., 2004; Jarvinen et al., 2005; Vora et al., 2005; Longo et al., 2009; Rees et al., 2009). The non- athletic population can be frequently affected (Rolf and Movin, 1997; Sharma and Maffulli, 2006). Achilles tendinopathy commonly manifests as pain in the tendon during initial loading, subsiding with continued activity. As the condition becomes chronic, pain can become persistent, resulting in activity curtail- ment or cessation (Kvist, 1994; el Hawary et al., 1997). Many patients respond to conservative management but some do not, with this recalcitrant group being the subject of this study. Studies using Doppler ultrasonography have shown that tendi- nopathic Achilles tendons can exhibit mid-tendon and insertional enlargement, disrupted fibrillar pattern, collagen disarray and tendon neovascularity (Khan and Cook, 2000; Maffulli et al., 2000; Leung and Griffith, 2008; Rompe et al, 2008). These structural changes, including neurovascular ingrowth, are associated with nocioceptive pathophysiology in recalcitrant non-insertional Achilles tendinopathy but this relationship has yet to be assessed in a systematic fashion clinically (Alfredson et al., 2003). The correlation between neovascularisation and tendon changes, including localised thickening and focal hypoechoic areas, has been well described in symptomatic tendons (Leung and Griffith, 2008). Treatments resulting in significant symptomatic improvements in Achilles tendinopathy, such as eccentric calf loading programmes, high volume image guided injections (HVIGI) and sclerosing injections, typically result in reduction of both neovascularity and tendon thickening (Astrom and Westlin, 1994; Ohberg and Alfredson, 2004; Lind et al., 2006; Chan et al, 2008). Although increased microcirculatory blood flow and other intratendinous changes have been reported to be closely related to pain (Astrom and Westlin, 1994; Ohberg et al., 2001), we are not * Corresponding author. Tel.: þ44 2082238459; fax: þ44 2082238930. E-mail address: dylan.morrissey@thpct.nhs.uk (D. Morrissey). Contents lists available at ScienceDirect Manual Therapy journal homepage: www.elsevier.com/math 1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2010.03.011 Manual Therapy 15 (2010) 463e468