The current status of various preclinical therapeutic approaches for tendon repair

Tendons are fibroblastic structures that link muscle and bone. There are two kinds of tendon injuries, including acute and chronic. Each form of injury or deterioration can result in significant pain and loss of tendon function. The recovery of tendon damage is a complex and time-consuming recovery process. Depending on the anatomical location of the tendon tissue, the clinical outcomes are not the same. The healing of the wound process is divided into three stages that overlap: inflammation, proliferation, and tissue remodeling. Furthermore, the curing tendon has a high re-tear rate. Faced with the challenges, tendon injury management is still a clinical issue that must be resolved as soon as possible. Several newer directions and breakthroughs in tendon recovery have emerged in recent years. This article describes tendon injury and summarizes recent advances in tendon recovery, along with stem cell therapy, gene therapy, Platelet-rich plasma remedy, growth factors, drug treatment, and tissue engineering. Despite the recent fast-growing research in tendon recovery treatment, still, none of them translated to the clinical setting. This review provides a detailed overview of tendon injuries and potential preclinical approaches for treating tendon injuries.

Manual therapy and exercise for lateral elbow pain

BACKGROUND

Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain.

OBJECTIVES

To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain.

SEARCH METHODS

We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication.

SELECTION CRITERIA

We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals.

MAIN RESULTS

Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials).

AUTHORS' CONCLUSIONS

Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.

Percutaneous tendon dry needling and thrust manipulation as an adjunct to multimodal physical therapy in patients with lateral elbow tendinopathy: A multicenter randomized clinical trial

OBJECTIVE

The purpose of this study was to assess the effects of adding electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization, and ultrasound in patients with lateral elbow tendinopathy.

DESIGN

Randomized, single-blinded, multicenter, parallel-group trial.

SETTING

Thirteen outpatient physical therapy clinics in nine different US states.

PARTICIPANTS

One hundred and forty-three participants (n = 143) with lateral elbow tendinopathy were randomized.

INTERVENTION

Cervical spine manipulation, extremity manipulation, and percutaneous tendon electrical dry needling plus multimodal physical therapy (n = 73) or multimodal physical therapy (n = 70) alone.

MAIN MEASURES

The primary outcome was elbow pain intensity and disability as measured by the Patient-Rated Tennis Elbow Evaluation at baseline, 1 week, 4 weeks, and 3 months. Secondary outcomes included the Numeric Pain Rating Scale, Tennis Elbow Functional Scale, Global Rating of Change, and medication intake.

RESULTS

The 2 × 4 analysis of covariance demonstrated that individuals with lateral elbow tendinopathy receiving electrical dry needling and thrust manipulation plus multimodal physical therapy experienced significantly greater improvements in disability (Patient-Rated Tennis Elbow Evaluation: F = 19.675; P < 0.001), elbow pain intensity (Numeric Pain Rating Scale: F = 22.769; P < 0.001), and function (Tennis Elbow Function Scale: F = 13.269; P < 0.001) than those receiving multimodal physical therapy alone at 3 months. The between-group effect size was large for pain and disability (Patient-Rated Tennis Elbow Evaluation: standardized mean difference = 1.13; 95% confidence interval: 0.78, 1.48) in favor of the electrical dry needling and thrust manipulation group.

CONCLUSIONS

The inclusion of percutaneous tendon electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization and ultrasound was more effective than multimodal physical therapy alone in individuals with lateral elbow tendinopathy.Trial Registration: www.clinicaltrials.gov NCT03167710 May 30, 2017.

Photobiomodulation combination therapy as a new insight in neurological disorders: a comprehensive systematic review

Preclinical and clinical studies have indicated that combining photobiomodulation (PBM) therapy with other therapeutic approaches may influence the treatment process in a variety of disorders. The purpose of this systematic review was to determine whether PBM-combined therapy provides additional benefits over monotherapies in neurologic and neuropsychiatric disorders. In addition, the review describes the most commonly used methods and PBM parameters in these conjunctional approaches.To accomplish this, a systematic search was conducted in Google Scholar, PubMed, and Scopus databases through January 2024. 95 potentially eligible articles on PBM-combined treatment strategies for neurological and neuropsychological disorders were identified, including 29 preclinical studies and 66 clinical trials.According to the findings, seven major categories of studies were identified based on disease type: neuropsychiatric diseases, neurodegenerative diseases, ischemia, nerve injury, pain, paresis, and neuropathy. These studies looked at the effects of laser therapy in combination with other therapies like pharmacotherapies, physical therapies, exercises, stem cells, and experimental materials on neurological disorders in both animal models and humans. The findings suggested that most combination therapies could produce synergistic effects, leading to better outcomes for treating neurologic and psychiatric disorders and relieving symptoms.These findings indicate that the combination of PBM may be a useful adjunct to conventional and experimental treatments for a variety of neurological and psychological disorders.

The Effects of Soft-Tissue Techniques and Exercise in the Treatment of Patellar Tendinopathy-Systematic Review and Meta-Analysis

BACKGROUND

Patellar tendinopathy is a degenerative clinical disorder that causes load-related pain in the lower pole of the patella or patellar tendon. It predominantly affects young male athletes engaged in sports involving repetitive tendon loading, particularly explosive jumping. The combination of manual techniques with therapeutic exercise is hypothesized to provide greater benefits than exercise alone.

OBJECTIVE

The aim of this study is to analyze the scientific evidence regarding the effects of soft-tissue techniques combined with therapeutic exercise versus therapeutic exercise alone on pain intensity and function in individuals with patellar tendinopathy.

METHODS

A systematic review with meta-analysis was conducted following the PRISMA guidelines. PubMed, Lilacs, IBECS, CENTRAL, WOS, SciELO, Academic Search, CINAHL, SportDiscus, PEDro, and Google Scholar databases were consulted. Randomized controlled trials and quasi-randomized trials focusing on the effects of soft-tissue techniques combined with therapeutic exercise (experimental group) versus therapeutic exercise alone (control group) on pain and function in individuals aged 16 years and older with patellar tendinopathy were selected. The Cochrane tool for risk-of-bias assessment and the PEDro scale for methodological quality were used.

RESULTS AND DISCUSSION

A total of six studies (n = 309; age range = 16-40 years), considered to have a low risk of bias and moderate-to-high methodological quality, were included. The results showed improvements in function in the experimental group (mean of 60% on the Visa-P scale) and pain in the experimental group (mean decrease of 2 points in the VAS scale). There were improvements in 50% of the studies when comparing variables between the experimental and control groups.

CONCLUSIONS

The combination of manual techniques, such as dry needling, percutaneous electrolysis, transverse friction massage, and stretching, along with a squat on a 25° inclined plane, appears to be effective in the treatment of patellar tendinopathy. Static stretching of the quadriceps before and after the squat five times per week, along with dry needling or percutaneous electrolysis sessions twice a week for 8 weeks, is recommended. However, future studies analyzing groups with passive techniques versus therapeutic exercise are needed to standardize the treatment and establish the optimal dose.

Effects of a Conventional Treatment Plus Scapular Exercises Program in Patients With Chronic Lateral Elbow Tendinopathy: A Pre-Post Single-Group Study

BACKGROUND

Weakness of the shoulder girdle muscles has been reported in patients with chronic lateral elbow tendinopathy. The aim of this study was to assess the short- and long-term effects of a conventional treatment plus scapular exercises program in patients with chronic lateral elbow tendinopathy.

METHODS

A single-group prestudy and poststudy were conducted. The primary outcome was the Patient-Rated Tennis Elbow Evaluation questionnaire score. Secondary outcomes were grip strength; Disabilities of the Arm, Shoulder, and Hand questionnaire score; Visual Analogue Scale score at rest and at grip, and presence of scapular dyskinesis.

RESULTS

A total of 65 patients (72.3% females), with a mean age of 41.8 years, were analyzed. At the end of 6 weeks, the results showed clinically and statistically significant differences (P < .05). At 1-year follow-up, the differences were: Patient-Rated Tennis Elbow Evaluation -31 points (P < .001); grip strength +33.6% (P < .001); Disabilities of the Arm, Shoulder, and Hand -34.2 points (P < .001); Visual Analogue Scale at rest -2.5 cm (P < .001); and Visual Analogue Scale at grip -2.3 cm (P < .001).

CONCLUSION

At the end of 6 weeks and at 1-year follow-up, conventional treatment plus scapular exercises program showed statistically and clinically significant differences in all functional outcomes assessed in patients with lateral elbow tendinopathy.

Unraveling the link: locomotor activity exerts a dual role in predicting Achilles tendon healing and boosting regeneration in mice

Introduction

Tendon disorders present significant challenges in the realm of musculoskeletal diseases, affecting locomotor activity and causing pain. Current treatments often fall short of achieving complete functional recovery of the tendon. It is crucial to explore, in preclinical research, the pathways governing the loss of tissue homeostasis and its regeneration. In this context, this study aimed to establish a correlation between the unbiased locomotor activity pattern of CRL:CD1 (ICR) mice exposed to uni- or bilateral Achilles tendon (AT) experimental injuries and the key histomorphometric parameters that influence tissue microarchitecture recovery.

Methods

The study involved the phenotyping of spontaneous and voluntary locomotor activity patterns in male mice using digital ventilated cages (DVC®) with access to running wheels either granted or blocked. The mice underwent non-intrusive 24/7 long-term activity monitoring for the entire study period. This period included 7 days of pre-injury habituation followed by 28 days post-injury.

Results and discussion

The results revealed significant variations in activity levels based on the type of tendon injury and access to running wheels. Notably, mice with bilateral lesions and unrestricted wheel access exhibited significantly higher activity after surgery. Extracellular matrix (ECM) remodeling, including COL1 deposition and organization, blood vessel remodeling, and metaplasia, as well as cytological tendon parameters, such as cell alignment and angle deviation were enhanced in surgical (bilateral lesion) and husbandry (free access to wheels) groups. Interestingly, correlation matrix analysis uncovered a strong relationship between locomotion and microarchitecture recovery (cell alignment and angle deviation) during tendon healing. Overall, this study highlights the potential of using mice activity metrics obtained from a home-cage monitoring system to predict tendon microarchitecture recovery at both cellular and ECM levels. This provides a scalable experimental setup to address the challenging topic of tendon regeneration using innovative and animal welfare-compliant strategies.

Eccentric Exercises on the Board with 17-Degree Decline Are Equally Effective as Eccentric Exercises on the Standard 25-Degree Decline Board in the Treatment of Patellar Tendinopathy

Background and Objectives: Patellar tendinopathy is one of the most significant problems in jumping and running athletes. Eccentric quadriceps exercise has been introduced into the therapy of patients with patellar tendinopathy in order to avoid weakening the tendon during rehabilitation. The use of decline boards with a decline angle of 25° has been the cornerstone of therapy over the last two decades. Biomechanical studies have suggested that an equal or potentially better outcome could be achieved with lower angles of decline (up to 16°). Materials and Methods: In this present research, we compared the effects of two various decline board angles on the clinical outcome of patients treated for patellar tendinopathy by performing eccentric quadriceps exercises. Patients were randomly allocated into two groups: patients practicing on the standard board with a 25° decline, and patients practicing on the 17° decline (n = 35 per group). Results: After 6 weeks of exercise, we found a significant improvement in all the clinical scores (VISA-P score, KOOS score, Lysholm Knee Questionnaire/Tegner Activity Scale, and VAS scale) of treated patients. However, there was no significant difference between the patients who performed eccentric quadriceps exercises on the standard 25° decline board and those exercising on the 17° decline board. A smaller additional degree of improvement was visible at the end of the follow-up period (at 12 weeks), but, again, no statistical difference could be detected between the investigated groups. We conclude that both treatment options provide similar short-term and midterm benefits regarding improvements in pain and clinical scores. The improvement in clinical scores does not depend on age, sex, BMI, or the professional sport of the patient. Conclusions: Our findings encourage changes in the decline angle of the board in the case of a patient's discomfort in order to achieve better compliance without affecting the recovery.

A Review of Physiotherapy Techniques Used in the Treatment of Tennis Elbow

Tennis elbow, a common musculoskeletal disorder also known as lateral epicondylitis, causes pain and tenderness on the outside of the elbow. Although it is frequently linked to repetitive motions, such as those in racquet sports, it can affect people in a variety of occupations and activities. Tennis elbow can be treated conservatively with physiotherapy, which focuses on pain management, functional recovery, and recurrence prevention. The goal of this review is to give a thorough overview of the physiotherapy methods used to treat tennis elbow. In order to determine the most effective treatment options, it is crucial to comprehend the pathophysiology and etiology of tennis elbow from the outset of the study. The assessment and diagnosis of tennis elbow are next covered, emphasizing the importance of physiotherapists in correctly diagnosing the ailment and distinguishing it from other musculoskeletal problems that are comparable to it. This study primarily focuses on the numerous physiotherapy therapies for tennis elbow, which may include but are not limited to, and the section examines the use of manual treatments to treat pain and enhance joint function, including joint mobilizations, soft tissue massage, and myofascial release. Exercise rehabilitation covers the value of tailored workouts to bolster the weak muscles and enhance the elbow joint's biomechanics. Numerous workout regimens are covered, such as eccentric training and progressive resistance exercises, as well as modalities. Therapeutic agents frequently make use of modalities such as ultrasound, laser therapy, and cryotherapy. It may also make use of complementary therapeutic agents such as taping and bracing. In summary, this in-depth analysis highlights the crucial role that physical therapy plays in the treatment of tennis elbow. It seeks to give practitioners a useful tool for enhancing the care and results of patients with this common and crippling ailment by summarizing the most recent research and best practices in physiotherapy approaches.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis

OBJECTIVE

To investigate potential moderating effects of resistance exercise dose components including intensity, volume and frequency, for the management of common tendinopathies.

DESIGN

Systematic review with meta-analysis and meta-regressions.

DATA SOURCES

Including but not limited to: MEDLINE, CINAHL, SPORTDiscus, ClinicalTrials.gov and ISRCTN Registry.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised and non-randomised controlled trials investigating resistance exercise as the dominant treatment class, reporting sufficient information regarding ≥2 components of exercise dose.

RESULTS

A total of 110 studies were included in meta-analyses (148 treatment arms (TAs), 3953 participants), reporting on five tendinopathy locations (rotator cuff: 48 TAs; Achilles: 43 TAs; lateral elbow: 29 TAs; patellar: 24 TAs; gluteal: 4 TAs). Meta-regressions provided consistent evidence of greater pooled mean effect sizes for higher intensity therapies comprising additional external resistance compared with body mass only (large effect size domains: β BodyMass: External = 0.50 (95% credible interval (CrI): 0.15 to 0.84; p=0.998); small effect size domains (β BodyMass: External = 0.04 (95% CrI: -0.21 to 0.31; p=0.619)) when combined across tendinopathy locations or analysed separately. Greater pooled mean effect sizes were also identified for the lowest frequency (less than daily) compared with mid (daily) and high frequencies (more than once per day) for both effect size domains when combined or analysed separately (p≥0.976). Evidence for associations between training volume and pooled mean effect sizes was minimal and inconsistent.

SUMMARY/CONCLUSION

Resistance exercise dose is poorly reported within tendinopathy management literature. However, this large meta-analysis identified some consistent patterns indicating greater efficacy on average with therapies prescribing higher intensities (through inclusion of additional loads) and lower frequencies, potentially creating stronger stimuli and facilitating adequate recovery.

Identifying characteristics of resistance-based therapeutic exercise interventions for Achilles tendinopathy: A scoping review

OBJECTIVE

This scoping review describes resistance-based therapeutic exercise intervention characteristics for Achilles tendinopathy (AT) treatment (e.g., therapeutic dose, underlying mechanisms targeted by exercise) and assesses participant reporting characteristics.

METHODS

Seven electronic databases were searched; studies delivering a resistance exercise-focused treatment for individuals with AT were included. The Template for Intervention Description and Replication (TIDieR) and the ICON 2019 'Recommended standards for reporting participant characteristics in tendinopathy research' checklists framed data extraction, and study quality was assessed using the Mixed Methods Appraisal Tool 2018 version.

RESULTS

68 publications (describing 59 studies and 72 exercise programs) were included. Results demonstrate that therapeutic exercise interventions for AT are well reported according to the TIDieR checklist, and participant characteristics are well reported according to the ICON checklist. Various underlying therapeutic mechanisms were proposed, with the most common being increasing tendon strength, increasing calf muscle strength, and enhancing collagen synthesis.

CONCLUSIONS

While evidence suggests that resistance-based therapeutic exercise interventions are effective in treating AT, more reporting on program fidelity, adherence, and compliance is needed. By summarizing currently published AT exercise programs and reporting key intervention characteristics in a single location, this review can assist clinicians in developing individualized resistance training programs for people with AT.

The effectiveness of "Dijital Steps" web based telerehabilitation system for patient with hindfoot pain: A randomised controlled trial

OBJECTIVE

The aim of the study was to evaluate and compare effective therapeutic options for hindfoot pain, develop and investigate the effectiveness of tele-rehabilitation systems, and ensure patients perform their exercises and preventive measures regularly and accurately, while monitoring results.

METHODS

Hindfoot pain (HP) patients (N = 77 with 120 feet) were admitted to this study and divided into two pathologies; Plantar Fasciitis and Achilles Tendinopathy. Patients in each pathology were randomized into three different rehabilitation programs-web-based telerehabilitation (PF-T & AT-T), -hands-on healing techniques combined with exercise (PF-C & AT-C)-unsupervised home exercise (PF-H & AT-H) program. Disability, activity restrictions, first-step pain, dorsiflexion-plantar flexion range of motion and kinesiophobia scores were recorded. The outcomes of the study groups were collected pre-post intervention (8thweek). Telerehabilitation system was developed via user-driven innovation and tested before using formally.

RESULTS

Each group had significant improvements in pain, disability, functional status and kinesiophobia (p < 0.001). In terms of functional status, PF-C had a statistically significant difference from others (p < 0.001). There was no difference between the groups for the pain scores in both pathologies. (p > 0.001). However, web-based telerehabilitation (PF-T & AT-T) were found to be more effective on kinesiophobia compared to the other groups (p < 0.001).

CONCLUSIONS

The presented web-based telerehabilitation system for management of hindfoot pain is an effective way and might be preferred instead of unsupervised home exercise specially for kinesiophobia. Additionally, Foot and ankle stretching and strengthening exercises protocols, myofascial releasing and mulligan concept manual therapy are effective modalities in terms of ROM, VISA-A, FAAM, FFI, TSK and VAS scores for hindfoot pain. The results indicated that three promised different rehabilitation protocols could be an effective strategy for HP.

Comparability of the Effectiveness of Different Types of Exercise in the Treatment of Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy (AT) is a common condition both in athletes and the general population. The purpose of this study is to highlight the most effective form of exercise in managing pain-related symptoms and functional capacity as well as in a return to life activities, ensuring the quality of life of patients with AT, and creating a protocol to be used in rehabilitation. We conducted a systematic review of the published literature in Pubmed, Scopus, Science Direct, and PEDro for Randomised Controlled Trials concerning interventions that were based exclusively on exercise and delivered in patients 18-65 years old, athletes and non-athletes. An amount of 5235 research articles generated from our search. Five met our inclusion criteria and were included in the review. Research evidence supports the effectiveness of a progressive loading eccentric exercise program based on Alfredson's protocol, which could be modified in intensity and pace to fit the needs of each patient with AT. Future research may focus on the optimal dosage and load of exercise in eccentric training and confirm the effectiveness of other type of exercise, such as a combination of eccentric-concentric training or heavy slow resistance exercise. Pilates could be applied as an alternative, useful, and friendly tool in the rehabilitation of AT.

BESS patient care pathway: Tennis elbow

This article provides a guidance summary for the management of lateral elbow tendinopathy (LET) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of the rating quality of the literature and grading the strength of available evidence. The process began by assembling a guideline development group of volunteers including orthopaedic surgeons, trainees, physiotherapists, rheumatologists, radiologists and patients. Virtual meetings were organised to set out explicit PICO questions, including specification of all important outcomes (including patient reported tennis elbow evaluation (PRTEE) as an important primary outcome) to determine the clinical effectiveness of common treatment options for LET compared with no treatment or placebo. Clinical librarian searched (date 31 April 2022) for available systematic reviews and randomised controlled trials reviewing the management of the LET January 2011 onwards and evidence was collected and summarized using explicit GRADE criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations were characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of alternative management options. This informative summary provides the quality of available evidence for the management of LET.

The "Selfie Test": A Novel Test for the Diagnosis of Lateral Epicondylitis

Background: Lateral epicondylitis (LE) is one of the most diagnosed elbow pathologies. The purpose of this study was to determine the diagnostic test accuracy of a new test (selfie test) for the diagnosis of LE. Methods: Medical data were collected from adult patients who presented with LE symptoms and ultrasound findings that supported the diagnosis. Patients underwent a physical examination, including provocative tests for diagnosis as well as the selfie test, and were asked to fill out the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire and subjectively rate the activity of their affected elbow. Results: Thirty patients were included in this study (seventeen females, 57%). The mean age was 50.1 years old (range of 35 to 68 years). The average duration of symptoms was 7 ± 3.1 months (range of 2 to 14 months). The mean PRTEE score was 61.5 ± 16.1 (range of 35 to 98), and the mean subjective elbow score was 63 ± 14.2 (range of 30 to 80). Mill's, Maudsley's, Cozen's, and the selfie tests had sensitivities of 0.867, 0.833, 0.967, and 0.933, respectively, with corresponding positive predictive values of 0.867, 0.833, 0.967, and 0.933. Conclusions: The selfie test's active nature, which allows patients to perform the assessment themselves, could be a valuable addition to the diagnostic process, potentially improving the accuracy of the diagnosis of LE (levels of evidence: IV).

Clinical effectiveness of pulsed electromagnetic field therapy as an adjunct treatment to eccentric exercise for Achilles tendinopathy: a randomised controlled trial

BACKGROUND

The Achilles tendon is the largest and strongest tendon in the human body. Achilles tendinopathy (AT) is a common clinical problem with Achilles overuse. Eccentric exercise is often used as an initial treatment for these patients. Most patients with AT experienced moderate to severe pain, limiting the incentive to perform eccentric exercise. It is difficult for them to complete eccentric exercise for 3 months consecutively to obtain significant improvements. Using PEMF as an adjunct, there could be immediate pain relief and improved response to eccentric exercise by modulating the mechanical properties of the Achilles tendon. Participants may experience less pain while performing eccentric exercises to increase compliance with the rehabilitation programme.

METHODS

This prospective randomised double-blinded, placebo-controlled trial aims to investigate the treatment effects of PEMF for participants with AT. All participants are randomised into two groups: the intervention group (n = 20; active PEMF treatment and eccentric exercise) and the control group (n = 20; sham treatment and eccentric exercise). Researchers perform self-reported, functional and ultrasonographic outcomes during baseline assessment, 4 weeks, 8 weeks follow-ups, and 3 and 6 months follow-ups after the commencement of the PEMF treatment.

DISCUSSION

AT is a common clinical condition affecting athletes and sedentary populations. It is essential to investigate treatment adjuncts to improve rehabilitation outcomes for these patients. This trial may demonstrate the effectiveness of PEMF in relieving pain, improving function, and restoring mechanical changes of the tendon in participants with AT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05316961. Registered on 7th April 2022.

Lateral Epicondylitis: Critical Analysis Review of Current Nonoperative Treatments

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Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm.

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The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time.

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Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments.

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In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

Eccentric exercise is more effective than other exercises in the treatment of mid-portion Achilles tendinopathy: systematic review and meta-analysis

Achilles tendinopathy (AT) is one of the most frequent overuse injuries in the ankle. The evidence base for its conservative management AT continues to evolve, but there is still a gap in the evidence for the efficacy of any modality of treatment in high-quality studies. This systematic review and meta-analysis investigated the efficacy of EE in improving pain and function in adult patients with mid-portion Achilles tendinopathy compared to other forms of exercise. A search was performed in PubMed, BIREME, SportDiscus, Cinahl, Web of Science and PEDro, in November 2022. The methodological quality was evaluated using the Risk of Bias 2 tool (RoB2) of the Cochrane collaboration, and the meta-analysis was performed using the Review Manager 5.1 program. 2024 articles were identified and eight fulfilled the inclusion criteria. RoB2 presented a final score with 62.5% of the studies presented "some concerns", and 37.5% (five and three articles, respectively) presenting "high risk" of bias. EE was effective for the managment of AT. The only variable for which a meta-analysis was possible was pain (five articles), analysed with the visual analogue scale/numerical visual scale. The mean difference (MD) in treatment effect using EE was - 1.21 (- 2.72 to - 0.30) with a 95% of confidence interval (CI), thus identifying a significant positive effect for the improvement of pain in patients with AT in whom EE was used. EE is effective in the management of AT. The meta-analysis shows the need for appropriately powered randomized controlled trials with better design, the use of standard outcome measures and well-planned protocols for conservative management of AT.Level of evidence: Level 1.Registration: CRD42018118016.

The roles and therapeutic potentialof mesenchymal stem/stromal cells and their extracellular vesicles in tendinopathies

Tendinopathies encompass a highly prevalent, multi-faceted spectrum of disorders, characterized by activity-related pain, compromised function, and propensity for an extended absence from sport and the workplace. The pathophysiology of tendinopathy continues to evolve. For decades, it has been related primarily to repetitive overload trauma but more recently, the onset of tendinopathy has been attributed to the tissue's failed attempt to heal after subclinical inflammatory and immune challenges (failed healing model). Conventional tendinopathy management produces only short-term symptomatic relief and often results in incomplete repair or healing leading to compromised tendon function. For this reason, there has been increased effort to develop therapeutics to overcome the tissue's failed healing response by targeting the cellular metaplasia and pro-inflammatory extra-cellular environment. On this basis, stem cell-based therapies have been proposed as an alternative therapeutic approach designed to modify the course of the various tendon pathologies. Mesenchymal stem/stromal cells (MSCs) are multipotent stem cells often referred to as "medicinal signaling cells" due to their immunomodulatory and anti-inflammatory properties that can produce a pro-regenerative microenvironment in pathological tendons. However, the adoption of MSCs into clinical practice has been limited by FDA regulations and perceived risk of adverse events upon infusion in vivo. The introduction of cell-free approaches, such as the extracellular vesicles of MSCs, has encouraged new perspectives for the treatment of tendinopathies, showing promising short-term results. In this article, we review the most recent advances in MSC-based and MSC-derived therapies for tendinopathies. Preclinical and clinical studies are included with comment on future directions of this rapidly developing therapeutic modality, including the importance of understanding tissue loading and its relationship to any treatment regimen.

Evidence-Based High-Loading Tendon Exercise for 12 Weeks Leads to Increased Tendon Stiffness and Cross-Sectional Area in Achilles Tendinopathy: A Controlled Clinical Trial

BACKGROUND

Assuming that the mechanisms inducing adaptation in healthy tendons yield similar responses in tendinopathic tendons, we hypothesized that a high-loading exercise protocol that increases tendon stiffness and cross-sectional area in male healthy Achilles tendons may also induce comparable beneficial adaptations in male tendinopathic Achilles tendons in addition to improving pain and function.

OBJECTIVES

We investigated the effectiveness of high-loading exercise in Achilles tendinopathy in terms of inducing mechanical (tendon stiffness, maximum strain), material (Young's modulus), morphological (tendon cross-sectional area (CSA)), maximum voluntary isometric plantar flexor strength (MVC) as well as clinical adaptations (Victorian Institute of Sports Assessment-Achilles (VISA-A) score and pain (numerical rating scale (NRS))) as the primary outcomes. As secondary outcomes, drop (DJ) and counter-movement jump (CMJ) height and intratendinous vascularity were assessed.

METHODS

We conducted a controlled clinical trial with a 3-month intervention phase. Eligibility criteria were assessed by researchers and medical doctors. Inclusion criteria were male sex, aged between 20 and 55 years, chronic Achilles tendinopathy confirmed by a medical doctor via ultrasound-assisted assessment, and a severity level of less than 80 points on the VISA-A score. Thirty-nine patients were assigned by sequential allocation to one of three parallel arms: a high-loading intervention (training at ~ 90% of the MVC) (n = 15), eccentric exercise (according to the Alfredson protocol) as the standard therapy (n = 15) and passive therapy (n = 14). Parameters were assessed pre- and-post-intervention. Data analysis was blinded.

RESULTS

Primary outcomes: Plantar flexor MVC, tendon stiffness, mean CSA and maximum tendon strain improved only in the high-loading intervention group by 7.2 ± 9.9% (p = 0.045), 20.1 ± 20.5% (p = 0.049), 8.98 ± 5.8% (p < 0.001) and -12.4 ± 10.3% (p = 0.001), respectively. Stiffness decreased in the passive therapy group (-7.7 ± 21.2%; p = 0.042). There was no change in Young's modulus in either group (p > 0.05). The VISA-A score increased in all groups on average by 19.8 ± 15.3 points (p < 0.001), while pain (NRS) dropped by -0.55 ± 0.9 points (p < 0.001).

SECONDARY OUTCOMES

CMJ height decreased for all groups (-0.63 ± 4.07 cm; p = 0.005). There was no change in DJ height and vascularity (p > 0.05) in either group.

CONCLUSION

Despite an overall clinical improvement, it was exclusively the high-loading intervention that induced significant mechanical and morphological adaptations of the plantar flexor muscle-tendon unit. This might contribute to protecting the tendon from strain-induced injury. Thus, we recommend the high-loading intervention as an effective (alternative) therapeutic protocol in Achilles tendinopathy rehabilitation management in males.

CLINICAL TRIALS REGISTRATION NUMBER

NCT02732782.

Low-Level Laser and Light Therapy After Total Knee Arthroplasty Improves Postoperative Pain and Functional Outcomes: A Three-Arm Randomized Clinical Trial

Background

We examined the effect of low-level laser therapy (LLLT) and Bioptron light therapy on pain and function following primary total knee arthroplasty.

Methods

A single-center, single-surgeon, prospective randomized clinical trial was performed with 3 groups of 15 patients: LLLT (804 nm), light (Bioptron; Bioptron AG, Wollerau, Switzerland), and controls. Range of motion (ROM), visual analog scale pain, opiate consumption (oxycodone in milligrams), knee swelling, and the Knee Society Score (KSS) were assessed before the surgery and on postoperative day 2, postoperative day 3, month 3, and month 12 after the operation.

Results

The preoperative scores were similar between groups. A higher ROM was observed with the LLLT group at all follow-ups except at the 12-month follow-up (3-month ROM: 116.8° vs 104.0° vs 92.3°; P < .001). The knee swelling at 3 months was similar between the LLLT and light groups (2.1 cm), which was lower than that in controls (2.1 cm, P < .001). Furthermore, visual analog scale pain decreased more in the LLLT group than in other groups (8.5 vs 7.2 vs 6.0 points) at 3 months (P = .04) but was similar at 12 months (P > .05). Also, the LLLT group consumed fewer opiate painkillers during the first month (48.3 vs 60.3 mg of oxycodone, P = .02). In the LLLT group, the KSS at 3 and 12 months and the KSS function score at 3 months exceeded minimally clinically important differences (P < .05).

Conclusions

In the early stages of recovery after total knee arthroplasty, LLLT and Bioptron light therapy could be helpful to control immediate and acute knee pain and swelling, reduce the need for opioids, improve ROM and functional scores, and improve recovery.

Level of Evidence

Therapeutic level I.

Physical modalities with eccentric exercise are no better than eccentric exercise alone in the treatment of chronic achilles tendinopathy: A systematic review and meta-analysis

BACKGROUND

To investigate the available evidence and conduct a systematic review with meta-analysis to determine the effectiveness of physical modalities combined with eccentric exercise (PMEE) with eccentric exercise (EE) alone for improvements in pain and function in individuals with chronic Achilles tendinopathy (AT) at short-term (4 weeks) and long-term (12-16 weeks) follow-ups.

MATERIALS AND METHODS

A systematic literature review identified 8 papers (from 6404 possible inclusions) that allowed the comparison of PMEE with EE alone, in the treatment of chronic AT. We extracted the mean and standard deviations for Victorian Institute of Sports Assessment Achilles Tendinopathy (VISA-A), Numerical Pain Rating Scale (NPRS), and load-induced pain (NRS). Standardized mean difference (SMD) of the included variables was presented, and all the studies had low risk of bias.

RESULTS

Non-significant results were achieved for short-term (pooled SMD = 0.03; 95% CI= -0.46 to 0.53, p = 0.89, I2 = 60%) and long- term follow-ups (pooled SMD =0.43; 95% CI= -0.05 to 0.92, p = 0.08, I2 = 82%) of VISA-A. Short-term (pooled SMD = -0.16; 95% CI= -0.72 to 0.40, p = 0.57, I2 = 40%) and long-term (pooled SMD = -0.39;95% CI= -1.11 to 0.32, p = 0.28, I2 = 62%) follow-up analysis of NPRS and long-term(pooled SMD = -0.46; 95% CI= -1.08 to 0.15, p = 0.14, I2 = 74%) follow-up of load induced pain also demonstrated non-significant improvements when comparing two groups.

CONCLUSION

Meta- analysis of the results published in the 8 papers that met theinclusion criteria showed no significant differences between PMEE and EE, in terms of load-induced pain (NRS) and numerical pain rating scales (NPRS) at 4 and 12-16 weeks. Thus, the meta-analysis reflects the other cited published work that PMEE shows no greater advantage than EE in the treatment of Chronic Achilles Tendinopathy.

Effectiveness of polarized polychromatic light therapy on myofascial trigger points in chronic non-specific low back pain: a single blinded randomized controlled trial

Background

Phototherapy has been used for the treatment of chronic low back pain. However, the effect of linear polarized polychromatic light (PL) has not been examined on myofascial trigger points in patients with chronic non-specific low back pain (NSLBP).

Objectives

To investigate the effectiveness of PL on pain intensity, pain sensitivity of active myofascial trigger points (MTrPs) in gluteus medius (GM) and quadratus lamborum (QL) muscles, back disability, and lumbar range of motion in chronic NSLBP.

Methods

Forty-two participants of both genders with chronic NSLBP were randomly allocated into two equal groups: group A (Linear polarized polychromatic light (PL): 21 participants received polarized light therapy in the range of red and near-infrared rays on myofascial trigger points of bilateral GM and QL muscles for 5 min/point followed by stretching and strengthening exercises for 4 weeks. Group B (Sham PL): 21 participants received the same program but with sham linear polarized polychromatic light therapy. Numeric pain rating scale, pressure algometer, and Roland-Morris Disability Questionnaire were used to measure pain intensity, pain sensitivity (as represented by pain pressure threshold (PPT) of MTrPs of the target muscles and back disability respectively. Further, lumbar flexion, extension, and bilateral rotation were examined with a tape measure, while bilateral side bending were examined with a universal goniometer.

Results

After the intervention program, significant improvements (p < 0.05) in pain intensity, PPT of MTrPs of left GM (Effect Size (ES): 1.23) and bilateral QL muscles (ES Rt QL: 0.9; Lt QL: 1.56) were found in group A in comparison with group B. Nevertheless, the two groups displayed similar improvements (p > 0.05) in lumbar range of motion and back disability.

Conclusion

Linear polarized polychromatic light therapy in the range of red and near-infrared rays improves pain intensity and pain sensitivity of myofascial trigger points in chronic NSLBP.

Trial registration

PACTR, PACTR202111577053926. Registered 22 June 2019-Prospectively registered.

Lateral elbow tendinopathy and artificial intelligence: Binary and multilabel findings detection using machine learning algorithms

Background

Ultrasound (US) is a valuable technique to detect degenerative findings and intrasubstance tears in lateral elbow tendinopathy (LET). Machine learning methods allow supporting this radiological diagnosis.

Aim

To assess multilabel classification models using machine learning models to detect degenerative findings and intrasubstance tears in US images with LET diagnosis.

Materials and methods

A retrospective study was performed. US images and medical records from patients with LET diagnosis from January 1st, 2017, to December 30th, 2018, were selected. Datasets were built for training and testing models. For image analysis, features extraction, texture characteristics, intensity distribution, pixel-pixel co-occurrence patterns, and scales granularity were implemented. Six different supervised learning models were implemented for binary and multilabel classification. All models were trained to classify four tendon findings (hypoechogenicity, neovascularity, enthesopathy, and intrasubstance tear). Accuracy indicators and their confidence intervals (CI) were obtained for all models following a K-fold-repeated-cross-validation method. To measure multilabel prediction, multilabel accuracy, sensitivity, specificity, and receiver operating characteristic (ROC) with 95% CI were used.

Results

A total of 30,007 US images (4,324 exams, 2,917 patients) were included in the analysis. The RF model presented the highest mean values in the area under the curve (AUC), sensitivity, and also specificity by each degenerative finding in the binary classification. The AUC and sensitivity showed the best performance in intrasubstance tear with 0.991 [95% CI, 099, 0.99], and 0.775 [95% CI, 0.77, 0.77], respectively. Instead, specificity showed upper values in hypoechogenicity with 0.821 [95% CI, 0.82, −0.82]. In the multilabel classifier, RF also presented the highest performance. The accuracy was 0.772 [95% CI, 0.771, 0.773], a great macro of 0.948 [95% CI, 0.94, 0.94], and a micro of 0.962 [95% CI, 0.96, 0.96] AUC scores were detected. Diagnostic accuracy, sensitivity, and specificity with 95% CI were calculated.

Conclusion

Machine learning algorithms based on US images with LET presented high diagnosis accuracy. Mainly the random forest model shows the best performance in binary and multilabel classifiers, particularly for intrasubstance tears.

Issues Related to the Effectiveness of Extracorporeal Shock Wave Therapy for the Management of Lateral Elbow Tendinopathy

One of the most popular recommended physical therapy modalities for the management of lateral elbow tendinopathy (LET) is extracorporeal shock wave therapy (ESWT) [...]

Meniscal lesion or patellar tendinopathy? A case report of an adolescent soccer player with knee pain

BACKGROUND

Injuries to the meniscus are particularly prevalent in soccer players, with an incidence of 0.448 injuries per 1000 hours of playing. However, in the adolescent soccer player population, it has been reported that up to 63% of asymptomatic knees may demonstrate horizontal or oblique tears on MRI. These results may negatively influence clinical decision-making and plan of management for adolescent soccer players with knee problems.

CASE PRESENTATION

A case of a 15-year-old soccer player is presented after having been diagnosed by his family physician with a left lateral meniscus tear as per MRI, following a 10-week period of anterior knee pain. He presented to a chiropractor for a second opinion before consulting with the orthopedic surgeon.

MANAGEMENT AND OUTCOME

Recommendations for progressive rehabilitation owing to the lack of clinical evidence for meniscal abnormality were made. A primary diagnosis of left patellar tendinopathy was determined and after a 6-week comprehensive rehabilitation program, the patient made a complete recovery.

SUMMARY

A thorough history, physical examination, and understanding of the patient's injury mechanism are suggested before confirming/refuting suspicions of meniscal abnormalities via MRI. This will help to inform better clinical decision-making as well as decrease the occurrence of unnecessary imaging.

Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear–avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear–avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

Effectiveness of Lateral Elbow Tendinopathy Treatment Depends on the Content of Biologically Active Compounds in Autologous Platelet-Rich Plasma

Autologous platelet-rich plasma (PRP) injection is an alternative treatment option for patients with lateral elbow tendinopathy. The treatment is supposed to accelerate tissue regeneration by providing high concentrations of growth factors derived from platelets. The aim of the study was to assess the relationship between the content of biologically active compounds in PRP and the clinical effect of the treatment. Thirty patients with lateral elbow tendinopathy treated with a single PRP injection, were evaluated. The pain intensity (measured by a visual analogue scale (VAS)), the pressure pain threshold (PPT), the grip strength and strength of the main arm and forearm muscle groups, and the functional outcome (measured by the Disability of Arm, Shoulder and Hand (DASH) and Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaires), were assessed before PRP injection and at one- and three-months follow-up. Flow cytometry measurements of the growth factors and inflammatory cytokines in PRP were performed, and the results were used to establish the relationship between those molecules and the clinical outcome. After three months from the intervention, the minimal clinically important difference in pain reduction and functional improvement was observed in 67% and 83% of patients, respectively. Positive correlations were found between the extent of pain reduction after three months and concentrations in the PRP of platelets, epidermal growth factor (EGF), vascular endothelial growth factor, and platelet-derived growth factors. The concentration of EGF in the PRP significantly correlated with an improvement in grip strength, strength of wrist extensors, and the size of functional improvement measured by the PRTEE. The local injection of PRP is a safe and effective treatment option for lateral elbow tendinopathy, and the clinical outcome is correlated with concentrations of its biologically active compounds.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BACKGROUND

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

METHODS

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

CONCLUSIONS

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

Assessment of the reporting quality of resistance training interventions in randomised controlled trials for lower limb tendinopathy: A systematic review

OBJECTIVES

1. To describe what exercises and intervention variables are used in resistance training interventions in randomised controlled trials for lower limb tendinopathy 2. To assess completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework. 3. To assess the implementation of scientific resistance training principles. 4. To assess therapeutic quality of exercise interventions with the i-CONTENT tool.

DATA SOURCES

We searched MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library databases.

REVIEW METHODS

Systematic review of randomised controlled trials that reported using resistance exercises for lower limb tendinopathies.

RESULTS

We included 109 RCTs. Eccentric heel drops were the most common exercise (43 studies), followed by isotonic heel raises (21), and single leg eccentric decline squats (18). Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0-13, with an average score of 9/13, and only 7 studies achieved a full 13/13. Reporting of items from the CERT ranged from 0-18, with an average score of 14/19. No study achieved a full 19/19, however 5 achieved 18/19. Scoring for resistance training principles ranged from 1-10, with only 11 studies achieving 10/10. Reporting across studies for the i-CONTENT tool ranged from 2-7, with an average score of 5 across included studies. A total of 19 studies achieved a full 7/7 score. Less than 50% of studies achieved an overall low risk of bias, highlighting the methodological concerns throughout studies.

CONCLUSION

The reporting of exercise descriptors and intervention content was generally high across RCTs for lower limb tendinopathy, with most allowing exercise replication. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation

The objectives of this scoping review were as follows: (1) to describe what exercises and intervention variables are used in resistance training interventions for lower limb tendinopathy,  (2) to assess the completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework, and (3) to assess the implementation of scientific resistance training principles. We searched MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, and Cochrane Library databases. Randomized controlled trials, cohort studies, case series, case reports, and observational studies that reported using resistance exercises for lower limb tendinopathies were considered for inclusion, with 194 studies meeting the inclusion criteria. Completeness of the reporting of exercise descriptors and programme variables was assessed by the CERT and the Toigo and Boutellier framework. Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0 to 13, with an average score of 9/13, with only 9 studies achieving a full 13/13. Reporting of items from the CERT ranged from 0 to 18, with an average score of 13/19. No study achieved a full 19/19; however, 8 achieved 18/19. Scoring for resistance training principles ranged from 1 to 10, with only 14 studies achieving 10/10. Eccentric heel-drops were the most common exercise (75 studies), followed by isotonic heel raises (38), and single-leg eccentric decline squats (27). The reporting of exercise descriptors and intervention content was high across studies, with most allowing exercise replication, particularly for Achilles and patellar tendinopathy. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Patellar Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

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Patellar tendinopathy is an attritional injury of the patellar tendon that is frequently identified in jumping athletes. Through repetitive or explosive movements, considerable loads and high peak strains are generated across the patellar tendon.

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This leads to microinjury of tendon fibers, local mucoid degeneration, and loss of the fibrocartilaginous tissue that attaches tendon to bone.

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Management of patellar tendinopathy often begins with nonoperative modalities: progressive tendon loading and eccentric rehabilitative exercise programs are the most effective. While a variety of additional treatment modalities are available, the comparative efficacy of these supportive treatments is not well differentiated at this time.

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In this article, we analyze the existing literature regarding nonoperative treatment of patellar tendinopathy and provide additional insight on the effectiveness of current modalities.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Stop Using the Eccentric Exercises as the Gold Standard Treatment for the Management of Lateral Elbow Tendinopathy

The most common tendinopathy in the elbow area is the Lateral elbow tendinopathy (LET) [...].

The effect of ultrasound therapy on lateral epicondylitis: A meta-analysis

OBJECTIVE

Lateral epicondylitis is a common musculoskeletal disorder, and ultrasound therapy is one of the most used treatments in the clinic. The effect remains uncertain, and the present paper aims to figure it out with a meta-analysis.

METHODS

The Pubmed, Cochrane library, and Embase databases were searched for relevant studies published before Jure 1, 2021. Continuous variables were compared by calculating the standard difference of the means, whereas categorical dichotomous variables were assessed using relative risks. A random-effects model was used if the heterogeneity statistic was significant; otherwise, a fixed-effects model was used.

RESULTS

Thirteen studies were included in the quantitative analysis, including 442 participants (287 ultrasonic treated patients and 155 controls). The VAS scale decreased markedly after ultrasound therapy (P = .027). However, no statistically significant difference could be found between ultrasound therapy and the control groups at all post-treatment time points. Similarly, no benefits could be found when comparing the pre- and post-treatment grip strength with ultrasonic therapy (P = .324). Moreover, though ultrasound treatment always continues for a long time, the present study demonstrated there were no additional benefits when comparing short- and long-term outcomes.

CONCLUSIONS

The ultrasound therapy is helpful to relieve pain for LE patients, but no such benefit could be found for grip strength. However, it has no significant advantage against other conservative treatments like rest and brace.

Bibliometric Study of Exercise and Tendinopathy Research from 2001 to 2020

Background

Tendinopathy is a tendon disease that often occurs in athletes. Many studies have revealed that exercise therapy is beneficial for the nonoperative management of tendinopathy. However, the general aspect bibliometric analysis of this global research topic associated with exercise and tendinopathy is lacking. The present study aimed to make a bibliometric analysis of worldwide development tendency and research hotspots in exercise and tendinopathy research from 2001 to 2020.

Material/Methods

Using the Web of Science, articles and reviews published between 2001 and 2020 were retrieved from the Science Citation Index Expanded database. CiteSpace was used to analyze the relationship among publications, countries, institutions, journals, authors, references, and keywords.

Results

In total, 857 articles were found in this study. Over the past 20 years, there was a marked increase in the number of publications. A total of 194 different scholarly journals were dedicated to the categories Sport Sciences, Orthopedics, and Rehabilitation. The USA and La Trobe University were the most prolific country and institution, respectively. The British Journal of Sports Medicine was the prominent journal for research on exercise and tendinopathy and had the most publications. The analysis of keywords showed that rehabilitation, rotator cuff tendinopathy, stiffness, and disability of individuals with tendinopathy had become the research focus in this field.

Conclusions

Bibliometric analysis provides a historical and scientific perspective on exercise and tendinopathy research, providing relevant researchers, funding agencies, and policymakers with valuable information to explore the current research status, hotspots, and new directions for future research.

Efficacy of ultrasound therapy for the treatment of lateral elbow tendinopathy (the UCICLET Trial): study protocol for a three-arm, prospective, multicentre, randomised controlled trial

INTRODUCTION

Lateral elbow tendinopathy (LET) is a highly prevalent disease among the middle-aged population, with no consensus on optimal management. Non-operative treatment is generally accepted as the first-line intervention. Ultrasound (US) therapy has been reported to be beneficial for various orthopaedic diseases, including tendinopathy. The purpose of this study is to investigate the efficacy of US for LET treatment.

METHODS AND ANALYSIS

This protocol entails a three-arm, prospective, multicentre, randomised controlled trial. Seventy-two eligible participants with clinically confirmed LET will be assigned to either (1) US, (2) corticosteroid injections or (3) control group. All participants will receive exercise-based therapy as a fundamental intervention. The primary outcome is Patient-rated Tennis Elbow Evaluation. The secondary outcomes include Visual Analogue Scale for pain, shortened version of the Disabilities of the Arm, Shoulder and Hand for upper limb disability, pain free/maximum grip strength, Work Limitations Questionnaire-25 for functional limitations at work, EuroQol-5D for general health, Hospital Anxiety and Depression Scale for mental status, Global Rating of Change for treatment success and recurrence rate, and Mahomed Scale for the participant's satisfaction. Adverse events will be recorded. Intention-to-treat analyses will be used.

ETHICS AND DISSEMINATION

Ethics committees of all clinical centres have approved this study. The leading centre is Shanghai Sixth People's Hospital, whose approval number is 2021-153. New versions with appropriate amendments will be submitted to the committee for further approval. Final results will be published in peer-reviewed journals and presented at local, national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100050547.

Effects of β-Hydroxy β-Methylbutyric Supplementation in Combination with Conservative Non-Invasive Treatments in Athletes with Patellar Tendinopathy: A Pilot Study

The aim of the present study was to analyze the effect of conservative non-invasive treatments based on eccentric training, stretching and extracorporeal shock wave therapy (ESWT) supplemented with β-Hydroxy β-methylbutyric (HMB) or placebo (PLAC) on body composition, pain and muscular function (jump ability, muscular power and muscular strength) in athletes with patellar tendinopathy (PT). In a double-blind randomized trial, 8 athletes (4 males and 4 females) performed a physical rehabilitation for 4 weeks. They were randomly divided into two experimental groups (two males and two females in each one) that ingested HMB (HMBG) or PLAC (PLACG). In pre- and post-intervention were assessed body composition, pain, countermovement jump (CMJ), back-squat (BS) for analyzing peak power (W) (PPPP), load (kg) associated to PPPP (PPKG) and mean velocity (m/s) (PPMV) in addition to a 5-RM leg extension tests. An interaction intervention·supplementation (p = 0.049; Ƞ2p = 0.774) was observed in the height reached in the CMJ as an intervention effect in PPPP detected for the HMBG (p = 0.049). In addition, an enhancement in PPKG (p = 0.028; Ƞ2p = 0.842) was detected in the intervention, but not in PPMV, as an increase in the intervention in the 5-RM test (p = 0.001; Ƞ2p = 0.981) was observed. No changes were noted on body composition or pain (p > 0.05). The combination of eccentric training with stretching and ESWT increased concentric muscular power and strength after 4 weeks without changes in body lean mass or pain. In addition, HMB supplementation could enhance the power muscular performance in athletes with PT, optimizing the intervention adaptions.

Management of Patellar Tendinopathy Through Monitoring, Load Control, and Therapeutic Exercise: A Systematic Review

CONTEXT

Patellar tendinopathy presents with persistent tendon pain located in the lower pole of the patella and loss of function related to mechanical load. Although its pathogenesis is not completely clear, conservative treatment including exercise is the main intervention of patellar tendinopathy treatment.

OBJECTIVE

To describe the efficacy of patellar tendinopathy management through therapeutic exercise, and control and monitoring of loads.

EVIDENCE ACQUISITION

MEDLINE, WoS, Cochrane Plus, PEDro, and the gray literature were searched from inception to July 2021. Based on the PICO strategy, the inclusion criteria were clinical trials published in English or Spanish; outcomes of function, pain, and strength; patients with patellar tendinopathy with no age or gender limitations; using an active intervention; and at least a methodological quality equal to or greater than 3 points on the Jadad scale. All data were analyzed by 2 independent reviewers (P.N.-M. and D.H.-G.). Studies were qualitatively synthesized using a descriptive synthesis. The methodological quality and risk of bias assessment were performed with the PEDro and Jadad scale, respectively.

EVIDENCE SYNTHESIS

A total of 136 articles were identified, of which 12 met the eligibility criteria. All of them were regarded as presenting a moderate risk of bias and their methodological quality was considered acceptable to good. Recovering patellar tendinopathy with therapeutic exercise seems to significantly improve function, pain, and strength after intervention and even lasted over time.

CONCLUSION

A treatment based on load monitoring and physical exercise has proven to be effective in rehabilitating patellar tendinopathy, with positive results in the short and medium term.

Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies

Objectives

We performed a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) to provide insights into the effectiveness of available treatment modalities in patellar tendinopathy(PT).

Methods

Several databases were searched in May 2021 for RCTs assessing the effectiveness of any intervention compared with any other intervention, placebo or no treatment for pain and/or function in PT. The risk of bias and strength of evidence were assessed with the Cochrane Collaboration and GRADE (Grading of Recommendations, Assessment, Development and Evaluations)/GRADE-NMA tools.

Results

A total of 37 RCTs were eligible that assessed 33 different interventions and their combinations, most represented by single studies. Based on pairwise meta-analyses of two RCTs, extracorporeal shockwave therapy (ESWT) does not appear to be superior to sham ESWT (eccentric exercise in both groups) for short-term pain (mean differences (MD) +0.1, 95% CI (−0.8 to 1), p=0.84) or function (MD −1.8, 95% CI (–8 to 4.4), p=0.57). Based on a pairwise meta-analysis of three RCTs, isometric exercise appears as effective as isotonic exercise for immediate postintervention pain relief (MD −1.03, 95% CI (−2.6 to 0.5), p=0.19). Our NMA showed that topical glyceryl trinitrate (GTN) and hyaluronic acid injection, both combined with eccentric exercise and moderate, slow resistance exercise had the highest probability of being the most effective interventions (low/very low strength of evidence).

Conclusions

Promising interventions with inadequate evidence, such as topical GTN, hyaluronic acid injections and isometric and slow resistance exercise, should be further investigated through high-quality RCTs. Meanwhile, eccentric loading with or without adjuncts should remain the first-line treatment for all individuals with patellar tendinopathy.

Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: A narrative review

Tendinopathy is a chronic degenerative musculoskeletal disorder that is common in both athletes and the general population. Exercise and extracorporeal shockwave therapy (ESWT) is among the most common treatments used to mediate tendon healing and regeneration. The review presents the current understanding of mechanisms of action of ESWT and exercise in isolation and briefly synthesises evidence of their effectiveness for various tendinopathies. The central purpose of the review is to synthesize research findings investigating the combination of ESWT and exercise for five common tendinopathies (plantar heel pain, rotator cuff, lateral elbow, Achilles, and patellar tendinopathy) and provide recommendations on clinical applicability. Collectively, the available evidence indicates that ESWT combined with exercise in the form of eccentric training, tissue-specific stretching, or heavy slow resistance training are effective for specific tendinopathies and can therefore be recommended in treatment. Whilst there are at present a limited number of studies investigating combined EWST and exercise approaches, there is evidence to suggest that the combination improves outcomes in the treatment of plantar heel pain, Achilles, lateral elbow, and rotator cuff tendinopathy. However, despite overall positive outcomes in patellar tendinopathy, the combined treatment has not been shown at present to offer additional benefit over eccentric exercise alone.

Effectiveness of eccentric strengthening in the treatment of lateral elbow tendinopathy: A systematic review with meta-analysis

STUDY DESIGN

Meta-analysis.

INTRODUCTION

Lateral elbow tendinopathy is a common condition with an annual incidence of up to 3% of the population. Eccentric strengthening has shown promise as a method to treat lateral elbow tendinopathy, but is unclear if it is superior to other forms of treatment.

PURPOSE OF THE STUDY

The purpose of this study was to investigate the effectiveness of eccentric strengthening compared with other forms of strengthening and pain-relieving modalities on pain, strength, and function in people with lateral elbow tendinopathy.

METHODS

Five electronic databases were searched. Reference lists of selected articles were hand-searched. Outcomes were defined a priori. Meta-analyses were performed using a random effects model with standardized mean differences, test of heterogeneity, and sensitivity analyses.

RESULTS

Eight articles were included in this review. When comparing eccentric strengthening to other forms of strengthening and pain-relieving modalities, there were significant large effect size of 1.12 (CI: 0.31-1.93) and 1.22 (CI: 0.25-2.18) in reducing pain and improving function in the short-term, respectively. In long-term, results were inconclusive on all outcomes.

DISCUSSION

A treatment program using eccentric strengthening of adequate intensity and duration seemed to be most effective for treating lateral elbow tendinopathy.

CONCLUSIONS

The state of science of best care for lateral elbow tendinopathy is still in its infancy. Large, high-quality randomized controlled trials with clearly defined strengthening regime are needed to determine optimal dosage to maximize treatment effects. Recommendations were provided based on careful synthesis of findings from this review and current evidence in literature.

Tendinopathy and tendon material response to load: What we can learn from small animal studies

Tendinopathy is a debilitating disease that causes as much as 30% of all musculoskeletal consultations. Existing treatments for tendinopathy have variable efficacy, possibly due to incomplete characterization of the underlying pathophysiology. Mechanical load can have both beneficial and detrimental effects on tendon, as the overall tendon response depends on the degree, frequency, timing, and magnitude of the load. The clinical continuum model of tendinopathy offers insight into the late stages of tendinopathy, but it does not capture the subclinical tendinopathic changes that begin before pain or loss of function. Small animal models that use high tendon loading to mimic human tendinopathy may be able to fill this knowledge gap. The goal of this review is to summarize the insights from in-vivo animal studies of mechanically-induced tendinopathy and higher loading regimens into the mechanical, microstructural, and biological features that help characterize the continuum between normal tendon and tendinopathy. STATEMENT OF SIGNIFICANCE: This review summarizes the insights gained from in-vivo animal studies of mechanically-induced tendinopathy by evaluating the effect high loading regimens have on the mechanical, structural, and biological features of tendinopathy. A better understanding of the interplay between these realms could lead to improved patient management, especially in the presence of painful tendon.