The role of eccentric exercise in sport injuries rehabilitation

INTRODUCTION

Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field.

SOURCES OF DATA

A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as 'eccentric exercise', 'sports injuries rehabilitation', 'tendinopathy', 'hamstrings strain' 'adductor injuries' and 'ACL reconstruction rehabilitation'.

AREAS OF AGREEMENT

EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation.

AREA OF CONTROVERSY

The lack of standardization of protocols, the variable amount, quality and follow-up of studies, the different anatomy and pathophysiology of the therapeutic targets limit the evidence of applicability of EE to sports injuries.

GROWING POINTS

The role of pathology and biomechanics in the response to EE should be further investigated.

AREAS TIMELY FOR DEVELOPING RESEARCH

New randomized controlled trials should test the effectiveness of standardized EE regimens to various sites of sports injuries.

Six-months pain relief and functional recovery after intra-articular injections with hyaluronic acid (mw 500-730 KDa) in trapeziometacarpal osteoarthritis

BACKGROUND

this retrospective open label study evaluates the efficacy and tolerability of intra-articular injections of Hyaluronic Acid (HA) (MW 500-730 KDa - Hyalgan®) for the treatment of pain and disability of trapeziometacarpal joint osteoarthritis (TMCJ OA).

METHODS

fifty eight patients, 50 females (86%) and 8 male (14%), aged between 40-75 years, suffering from TMCJ OA according to Kellgren-Laurence grades 2-3 on standard plain radiography, were included. Patients with known inflammatory arthritis, previous thumb trauma and intra-articular (i.a.) injections with corticosteroids were excluded. Primary endpoints were: pain (VAS), NSAID intake, radial and palmar ab-/adduction, pinch strength. All patients received an i.a. injection of 0.8 mL of HA (MW 500-730 KDa) once weekly for three weeks. Control examinations were carried out at 1, 3, and 6 months.

RESULTS

intra-articular HA injections have significantly reduced spontaneous and provoked pain and improved hand mobility. At 1,3, and 6 months from baseline, the spontaneous and provoked pain revealed a statistically significant improvement (p<0,0001). NSAID's intake evidenced a statistically significant reduction against baseline (p<0.017). The adverse events (21%) were related to local symptoms such as pain during or following HA administration.

CONCLUSIONS

this study shows that i.a. HA injections for TMCJ OA can induce a significant improvement of function associated to stiffness decrease and pain relief.

In vitro tenocyte metabolism in aging and oestrogen deficiency

Little is known about tendons and tenocyte biological behaviour during aging and, especially, oestrogen deficiency. The aim of this study was to evaluate in vitro the proliferation and metabolism of tenocytes isolated from the Achilles tendons of ovariectomised (OVX), middle-aged (OLD) and young (YOUNG) rats. An in vitro model of micro-wound healing was also used to assess age and oestrogen deficiency differences in tendon healing. In standard culture condition, OLD and OVX tenocytes showed a significantly lower proliferation rate, collagen I, aggrecan and elastin than YOUNG ones. In OVX group, fibronectin and elastin significantly decreased in comparison to YOUNG and OLD groups, respectively, whereas vascular endothelial growth factor and metalloproteinases-13 increased than those of both YOUNG and OLD groups. In the micro-wound healing model, tenocytes from both OVX and OLD showed a significantly lower healing rate, proliferation rate, collagen I and nitrix oxide in comparison to YOUNG. OVX elastin value was significantly lower than YOUNG one and OVX healing rate and cell migration speed, proliferation rate and fibronectin results were lower, whereas collagen III and metalloproteinase-13 higher in comparison to both YOUNG and OLD groups. These results highlighted how aging and, more significantly, oestrogen deficiency negatively affect tendon metabolism and healing. Our work improves the body of knowledge on the effects of senescence and oestrogen deficiency on tenocyte behaviour and allows further studies to find solution for the prevention of tendon injuries in aging and menopause.

ISMuLT Guidelines for muscle injuries

Muscle injuries are frequent in high demand sports. No guidelines are available in the scientific literature. ISMuLT, the "Italian Society of Muscles, Ligaments and Tendons", in line with its multidisciplinary mission, is proud to cover this gap.

Muscle, Ligaments and Tendons Journal. Basic principles and recommendations in clinical and field science research

The design, implementation, evaluation, interpretation and report of research is a key important for the science. The research required minimize the uncertainty, therefore we encourage all authors of respect how much can possible the contents in this official editorial also in order to stimulate interest and debate about constructive change in the use of statistics in our disciplines1,2. Authors are required to confirm that these standards and laws have been adhered to by formally citing this editorial within the methods section of their own manuscript.

Autologous conditioned serum for the treatment of osteoarthritis and other possible applications in musculoskeletal disorders

INTRODUCTION

The therapeutic use of interleukin 1 (IL-1) cytokine receptor antagonists (IL-1RA) has promoted the development of new biological therapies for osteoarthritis (OA). Autologous conditioned serum (ACS) is an alternative, safe and well-tolerated treatment in OA. Sources of data We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, Embase, SportDiscus, Pedro and Google scholar databases using keywords such as 'interleukin 1', 'osteoarthritis' and 'autologous conditioned serum'.

AREAS OF AGREEMENT

ACS, containing endogenous anti-inflammatory cytokines including IL-1RA and several growth factors, could reduce pain and increase function and mobility in mild to moderate knee OA. AREA OF CONTROVERSY: Given the limited data available on the composition of ACS, the mechanisms through which ACS produces clinical improvement, the duration of its effect and the changes in cytokine levels after repeated injections are still unknown. Growing points Although previous clinical data are encouraging and confirm the safety of this modality, given the limitations of current studies, there should be additional, controlled trials to further confirm efficacy for the use of ACS in OA treatment. AREA TIMELY FOR DEVELOPING RESEARCH: ACS can lead to enhancement of tissue regeneration and to reduction of degenerative mechanisms.

The meniscus tear. State of the art of rehabilitation protocols related to surgical procedures

Meniscal injuries represent one of the most frequent lesions in sport practicing and in particular in soccer players and skiers. Pain, functional limitation and swelling are typical symptoms associated with meniscal tears. Epidemiological studies showed that all meniscal lesions, in different sports athletes, involves 24% of medial meniscus, while 8% of lateral meniscus and about 20-30% of meniscal lesions are associated with other ligament injuries. Meniscal tears can be treated conservatively or surgically. Surgery leads in many cases to complete resolution of symptoms and allows the return to sport activity. However many studies show that this treatment can induce more frequently the development of degenerative conditions if not correctly associated to a specific rehabilitation protocol. The aim of this article is to compare different timing in specific rehabilitation programs related to the most actual surgical options.

Comparison of 2 hyaluronic acid drugs for the treatment of temporomandibular joint osteoarthritis

PURPOSE

To compare the effectiveness of 2 treatment protocols providing 5 weekly temporomandibular joint (TMJ) arthrocenteses immediately followed by injections of 2 different molecular weight hyaluronic acid (HA) drugs to manage symptoms in patients with inflammatory-degenerative TMJ disease.

MATERIALS AND METHODS

Patients with a Research Diagnostic Criteria for Temporomandibular Disorders diagnosis of osteoarthritis were randomly assigned to 1 of 2 study groups receiving either low- or medium-molecular weight HA after arthrocentesis. The level of maximum pain at chewing was the primary outcome variable, and maximum pain at rest, subjective chewing efficiency, functional limitation, treatment tolerability, perceived treatment effectiveness, and jaw range-of-motion function in millimeters were the secondary outcomes. All variables were assessed and compared between groups at baseline, at the end of treatment, and 3 months later.

RESULTS

Forty subjects entered the study. At the end of the follow-up period, all the outcome variables improved in both groups of patients. A between-group comparison of changes over time showed that differences were not significant for any of the outcome variables, that is, pain at chewing (F = 0.056, P = .815), pain at rest (F = 0.383, P = .541), chewing efficiency (F = 0.050, P = .825), functional limitation (F = 0.268, P = .609), and mouth opening (F = 0.003, P = .954). In addition, no between-group differences were shown for perceived treatment effectiveness and treatment tolerability.

CONCLUSIONS

Similar positive effectiveness was shown for 2 treatment protocols for TMJ osteoarthritis (ie, 5-session single-needle arthrocentesis plus low- or medium-molecular weight HA).

Biological properties of mesenchymal Stem Cells from different sources

Mesenchymal stem cells (MSCs) are adult, nonhematopoietic, stem cells that were initially isolated from bone marrow. Now they can be isolated from almost every tissue of the body. They have the ability to self-renew and differentiate into multiple cell lineage, including bone, chondrocytes, adipocytes, tenocytes and cardiomyocytes, and it makes them an attractive cell source for a new generation of cell-based regenerative therapies. In this review we try to summarize data on sources and the biological properties of MSCs.

Painful os Acromiale: Conservative Management in a Young Swimmer Athlete

An os acromiale (OA) arises from a fusion failure of the anterior acromial apophysis. This case report presents the successful management of a painful OA associated to rotator cuff impingement in a competitive swimmer, based on ultrasonographic diagnosis and conservative management. Rest from sport activity, oral anti-inflammatory drugs and previous attempt of treatment of shoulder pain were ineffective. After two months of conservative treatment consisting of avoidance of swimming, local anti-inflammatory, physical therapy with ice, strengthening exercises with elastic bands to strengthen the scapular stabilizing muscles, rotator cuff and lowering humeral head muscles, the patient was pain free and all specific clinical tests for impingement syndrome (Neer, Hawkins, Whipple and Yocum tests) were negative. Digital compression of the OA site was not painful, and the Jobe and Palm-up tests were negative. The athlete returned to swim continuing the rehabilitation exercises, and the successful results were maintained at one year follow up. An unstable and symptomatic OA can be easily diagnosed with ultrasound exam. Rehabilitation for rotator cuff tendinopathies or/and bursitis can be a valid alternative to surgery. Key pointsAn os acromiale (OA) arises from a fusion failure of the anterior acromial apophysis.A correct diagnosis of OA associated to rotator cuff impingement can be performed by ultrasonographic exam.A conservative management of rotator cuff impingement syndrome, associated to OA, can be planned in athletic patients as a valid alternative to surgery.

Treatment of adhesive capsulitis: a review

Adhesive capsulitis is a condition "difficult to define, difficult to treat and difficult to explain from the point of view of pathology". This Codman's assertion is still actual because of a variable nomenclature, an inconsistent reporting of disease staging and many types of treatment. There is no consensus on how the best way best to manage patients with this condition, so we want to provide an evidence-based overview regarding the effectiveness of conservative and surgical interventions to treat adhesive capsulitis.

Insertional tendinopathy of the adductors and rectus abdominis in athletes: a review

Insertional tendinopathy of the adductors and rectus abdominis is common in male athletes, especially in soccer players. It may be worsened by physical activity and it usually limits sport performance. The management goal in the acute phase consists of analgesic and anti-inflammatory drugs and physical rehabilitation. In the early stages of rehabilitation, strengthening exercises of adductors and abdominal muscles, such as postural exercises, have been suggested. In the sub-acute phase, muscular strength is targeted by overload training in the gym or aquatherapy; core stability exercises seem to be useful in this phase. Finally, specific sport actions are introduced by increasingly complex exercises along with a preventive program to limit pain recurrences.

Goniometer evaluation of thoracic kyphosis and lumbar lordosis in subjects during growth age: a validity study

INTRODUCTION

The aim of the present study is to evaluate the validity of a pocket compass needle goniometer (IncliMed®, University of Padua) to measure the thoracic kyphosis and lumbar lordosis in children and adolescent.

MATERIAL AND METHODS

In a group of 128 adolescent the same clinician (FC) measured the thoracic kyphosis and lumbar lordosis according to the goniometer technique and the Cobb angle on lateral spinal radiographs. The linear regression analysis and the Bland and Altman criteria were used for the data analysis.

RESULTS

A strong concordance existed between radiological and goniometer evaluation of the thoracic kyphosis (linear regression coefficient: b=0.897;p=0.000), but poor concordance existed at the lumbar lordosis evaluation (b=0.526;p=0.000); so we introduced a modification of the original traditional Cobb method of measurement with improved the linear regression coefficient (b=0.820,p=0.000).

CONCLUSIONS

Our results confirm the clinical utility of goniometer assessment for the quantification of thoracic kyphosis and lumbar lordosis in children and adolescent.

A prospective observational study of the clinical efficacy and safety of intra-articular sodium hyaluronate in synovial joints with osteoarthritis

BACKGROUND

Clinical trials have demonstrated the safety and efficacy of hyaluronic acid-based products for the treatment of synovial joints affected by osteoarthritis (OA), but data from observational studies of normal medical practice are sparse.

AIM

This study investigated the safety and efficacy of intra-articular (IA) sodium hyaluronate (MW 1500-2000 KDa; Hyalubrix®) in the treatment of synovial joint OA.

DESIGN

This is prospective, and observational study.

SETTING

This study was carried out at 47 specialist centers for physiatrists, orthopedics and rheumatology in Italy; the enrolled population, 1266 outpatient, was predominantly female (66%, 840/1266), with a mean age of 66 years, and a mean weight of 74 kg.

POPULATION

The Participants with OA received IA injections of the study treatment (2 mL) once per week for 3 weeks. The knee was the joint most commonly affected by OA (right knee 802/1266 [63%]; left knee 598/1266 [47%]), and the longest median duration of disease occurred in the carpal joint (right carpal joint 40 months; left carpal joint 60 months).

METHODS

The primary endpoints were tolerability and details of usage of the IA sodium hyaluronate syringe device. Efficacy parameters included assessment of self-reported pain via the Visual Analogue Scale (VAS), and evaluation of motor function via the Health Assessment Questionnaire (HAQ). Quality of life (QoL) was assessed using the Euro QoL questionnaire (Clinical Trial Registration Number: ISRCTN 42690497).

RESULTS

Data from 1266 participants were collected. The adverse event (AE) rate was 0.8% (95% CI, 0.4 to 1.5). Thirteen AEs were reported, 12 of which were mild or moderate in severity. Only one participant discontinued study treatment following an AE. No serious adverse events occurred. Coadministration of local anesthetic was required by up to 10% of patients. Statistically significant improvements in VAS, HAQ and EuroQoL were recorded in multiple joints (P<0.0001 for each).

CONCLUSION

The study treatment was safe and well tolerated.

CLINICAL REHABILITATION IMPACT

. The study treatment reduced pain, improved mobility, and increased QoL in participants with OA.

Effect of training and sudden detraining on the patellar tendon and its enthesis in rats

Background

Different conditions may alter tendon characteristics. Clinical evidence suggests that tendon injuries are more frequent in athletes that change type, intensity and duration of training. Aim of the study was the assessment of training and especially detraining on the patellar tendon (PT) and its enthesis.

Methods

27 male adult Sprague-Dawley rats were divided into 3 groups: 20 rats were trained on a treadmill for 10 weeks. Of these, 10 rats were euthanized immediately after training (trained group), and 10 were caged without exercise for 4 weeks before being euthanized (de-trained group). The remaining 7 rats were used as controls (untrained rats). PT insertion, structure (collagen fiber organization and proteoglycan, PG, content), PT thickness, enthesis area, and subchondral bone volume at the enthesis were measured by histomorphometry and microtomography.

Results

Both PG content and collagen fiber organization were significantly lower in untrained and detrained animals than in trained ones (p < 0.05 and p < 0.0001). In the detrained group, fiber organization and PG content were worse than that of the untrained groups and the untrained group showed a significantly higher score than the detrained group (p < 0.05). In the trained group, the PT was significantly thicker than in untrained group (p < 0.05). No significant differences in the enthesis area and subchondral bone volume among the three groups were seen.

Conclusions

Moderate exercise exerts a protective effect on the PT structure while sudden discontinuation of physical activity has a negative effect on tendons. The present results suggest that after a period of sudden de-training (such as after an injury) physical activity should be restarted with caution and with appropriate rehabilitation programs.

One step open synovectomy without adjuvant therapy for diffuse pigmented villonodular synovitis of the knee in a soccer player

Pigmented villonodular synovitis is a proliferative disease involving joints, bursas and tendon sheaths with typical histological changes in the synovial tissue. A local and diffuse form are described. Aetiology is uncertain, MRI is helpful to establish the diagnosis, which is confirmed with by biopsy. Treatment is based on the principles of tumor resection: arthroscopically in the local form, or by a open synovectomy in the diffuse form, often followed by adjuvant radiotherapy. The rate of recurrence is high, but differs in consideration of the treatment chosen. We report a 35 year old soccer player with diffuse pigmented villonodular synovitis with a history of chronic swelling knee. The patient underwent a one step open synovectomy without adjuvant therapy, with the conservation of the heads of gastrocnemius muscle. At five years of follow-up, the patient had no sign of recurrence of the condition. One step open synovectomy in this patient showed an excellent outcome with the return to his previous sport. The short follow-up and the neoplastic characteristic of the disease cannot exclude the risk of recurrence.

Effects of an adapted physical activity program in a group of elderly subjects with flexed posture: clinical and instrumental assessment

BACKGROUND

Flexed posture commonly increases with age and is related to musculoskeletal impairment and reduced physical performance. The purpose of this clinical study was to systematically compare the effects of a physical activity program that specifically address the flexed posture that marks a certain percentage of elderly individuals with a non specific exercise program for 3 months.

METHODS

Participants were randomly divided into two groups: one followed an Adapted Physical Activity program for flexed posture and the other one completed a non-specific physical activity protocol for the elderly. A multidimensional clinical assessment was performed at baseline and at 3 months including anthropometric data, clinical profile, measures of musculoskeletal impairment and disability. The instrumental assessment of posture was realized using a stereophotogrammetric system and a specific biomechanical model designed to describe the reciprocal position of the body segments on the sagittal plane in a upright posture.

RESULTS

The Adapted Physical Activity program determined a significant improvement in several key parameters of the multidimensional assessment in comparison to the non-specific protocol: decreased occiput-to-wall distance, greater lower limb range of motion, better flexibility of pectoralis, hamstrings and hip flexor muscles, increased spine extensor muscles strength. Stereophotogrammetric analysis confirmed a reduced protrusion of the head and revealed a reduction in compensative postural adaptations to flexed posture characterized by knee flexion and ankle dorsiflexion in the participants of the specific program.

CONCLUSION

The Adapted Physical Activity program for flexed posture significantly improved postural alignment and musculoskeletal impairment of the elderly. The stereophotogrammetric evaluation of posture was useful to measure the global postural alignment and especially to analyse the possible compensatory strategies at lower limbs in flexed posture.

Hyperostosis and osteitis in Sapho syndrome: conservative or surgical treatment

Sapho syndrome is characterized by synovitis, acne, pustulosis, hyperostosis and osteitis. It is a rare disease, with a benign prognosis; at the osteoarticular level it is painful and is characterized by episodes of arthritis of an intermittent and at times disabling nature. The etiopathogenesis of Sapho syndrome is still not clearly defined: some authors suggest a probable correlation with an infective agent, others instead include Sapho among seronegative spondylites. The treatment of symptomatic skeletal injuries (hyperostosis, osteitis) is controversial and not classified. In the rare cases reported in the literature surgical treatment has not proven to be more effective than conservative treatment. The authors report the poor evolution of the disease in a patient affected with Sapho syndrome who came to our observation after being submitted to medullary decompression of the femoral diaphysis because of the presence of metaphyseal hyperostosis of the left femur.