Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations

Immediate and Short-Term Effects of Short- and Long-Duration Isometric Contractions in Patellar Tendinopathy

OBJECTIVES

Isometric muscle contractions are used in the management of patellar tendinopathy to manage pain and improve function. Little is known about whether long- or short-duration contractions are optimal to improve pain. This study examined the immediate and short-term (4 weeks) effects of long- and short-duration isometric contraction on patellar tendon pain, and tendon adaptation.

DESIGN

Repeated measures within groups.

SETTING

Clinical primary care.

PATIENTS

Participants (n = 16, males) with patellar tendinopathy.

INTERVENTION

Short-duration (24 sets of 10 seconds) or long-duration (6 sets of 40 seconds) isometric knee extension loading (85% maximal voluntary contraction), for 4 weeks.

MAIN OUTCOME MEASURE

Immediate change in pain with single-leg decline squat (SLDS) and hop, as well as change in pain and tendon adaptation [within-session anterior-posterior (AP) strain] were assessed over 4 weeks.

RESULTS

Pain was significantly reduced after isometric loading on both SLDS (P < 0.01) and hop tests (P < 0.01). Pain and quadriceps function improved over the 4 weeks (P < 0.05). There was significant AP strain at each measurement occasion (P < 0.01). Although transverse strain increased across the training period from ∼14% to 22%, this was not significant (P = 0.08).

CONCLUSIONS

This is the first study to show that short-duration isometric contractions are as effective as longer duration contractions for relieving patellar tendon pain when total time under tension is equalized. This finding provides clinicians with greater options in prescription of isometric loading and may be particularly useful among patients who do not tolerate longer duration contractions. The trend for tendon adaptation over the short 4-week study period warrants further investigation.

Physiotherapists deliver management broadly consistent with recommended practice in rotator cuff tendinopathy: An observational study

BACKGROUND

Rotator cuff tendinopathy is a common and disabling cause of shoulder pain. While conservative treatment is recommended as initial management, recent findings suggest that general practitioners and rheumatologists do not consistently align with recommended care. This study aimed to survey Australian physiotherapists to explore the extent to which recommended management is being applied.

METHODS

A cross-sectional online survey.

RESULTS

Five hundred and two Australian physiotherapists completed the survey. Results demonstrated the majority of physiotherapists provide conservative management consistent with guideline recommendations, through delivery of exercise and education, comparable to management by physiotherapists in the United Kingdom, Belgium and the Netherlands. Parameters and construction of exercise treatment programs were highly variable within the cohort, qualitative analysis highlighting varied reasoning underpinning these management decisions.

CONCLUSIONS

Australian physiotherapists are broadly consistent with providing recommended management, however heterogeneity exists in the methods and parameters of treatment delivery.

Patellar tendinopathy outcome predictors in jumping athletes: feasibility of measures for a cohort study

OBJECTIVES

The main aim was to assess feasibility by testing data collection procedures for a cohort study. Measurements validity and reliability were secondary objectives.

DESIGN

Feasibility study.

SETTING

Combination of remote contact, assessment in clinic and biomechanical evaluation.

PARTICIPANTS

36 jumping athletes (female:17, male:19) equally spread between those with patellar tendinopathy, other knee problems and controls.

MAIN OUTCOME MEASURES

Measurements validity, reliability and feasibility.

RESULTS

There was no systematic difference between administration methods for patient reported outcome measures and miscellaneous questions (range of d = -0.32 to 0.26) without any order effect (all p > 0.05) except KOOS-PF (p = 0.02). Questionnaires' inter-session reliability was moderate to excellent (ICCs = 0.68-0.93). Pain maps were 94% matched between methods. Training load recall percentage decreased until week-3 with only 20% maintaining a training diary completing the full 6 weeks. The graded loaded challenge was clinically applicable, biomechanically valid with increasing load through progression and reliable (ICCs = 0.63-0.98).

CONCLUSION

The tested questionnaires were valid and reliable for online use, therefore being suitable for clinical and research purposes. A shorter survey to reduce burden and collecting training load using shorter recall duration should improve feasibility. Biomechanical measures were valid and reliable, and a graded loaded challenge, suitable for further testing, has been defined.

Staging achilles tendinopathy using ultrasound imaging: the development and investigation of a new ultrasound imaging criteria based on the continuum model of tendon pathology

Aim

To develop a standardised ultrasound imaging (USI)-based criteria for the diagnosis of tendinopathy that aligns with the continuum model of tendon pathology. Secondary aims were to assess both the intra-rater and inter-rater reliability of the criteria.

Methods

A criteria was developed following a face validity assessment and a total of 31 Achilles tendon ultrasound images were analysed. Intra-rater and inter-rater reliability were assessed for overall tendinopathy stage (normal, reactive/early dysrepair or late dysrepair/degenerative) as well as for individual parameters (thickness, echogenicity and vascularity). Quadratic weighted kappa (k_w) was used to report on reliability.

Results

Intra-rater reliability was ‘substantial’ for overall tendinopathy staging (k_w rater A; 0.77, 95% CI 0.59 to 0.94, rater B; 0.70, 95% CI 0.52 to 0.89) and ranged from ‘substantial’ to ‘almost perfect’ for thickness (k_w rater A; 0.75, 95% CI 0.59 to 0.90, rater B; 0.84, 95% CI 0.71 to 0.98), echogenicity (k_w rater A; 0.78, 95% CI 0.62 to 0.95, rater B; 0.73, 95% CI 0.58 to 0.89) and vascularity (k_w rater A; 0.86, 95% CI 0.74 to 0.98, rater B; 0.89, 95% CI 0.79 to 0.99). Inter-rater reliability ranged from ‘substantial’ to ‘almost perfect’ for overall tendinopathy staging (k_w round 1; 0.75, 95% CI 0.58 to 0.91, round 2; 0.81, 95% CI 0.63 to 0.99), thickness (k_w round 1; 0.65, 95% CI 0.48 to 0.83, round 2; 0.77, 95% CI 0.60 to 0.93), echogenicity (k_w round 1; 0.70, 95% CI 0.54 to 0.85, round 2; 0.76, 95% CI 0.58 to 0.94) and vascularity (k_w round 1; 0.89, 95% CI 0.79 to 0.99, round 2; 0.86, 95% CI 0.74 to 0.98). Inter-rater reliability increased from ‘substantial’ in round 1 (k_w 0.75, 95% CI 0.58 to 0.91) to ‘almost perfect’ in round 2 (0.81, 95% CI 0.63 to 0.99).

Conclusion

Intra-rater and inter-rater reliability were ‘substantial’ to ‘almost perfect’ when utilising an USI-based criteria to diagnose Achilles tendinopathy. This is the first study to use the continuum model of tendon pathology to develop an USI-based criteria to diagnose tendinopathy.

Role of mechanical factors in the clinical presentation of plantar heel pain: Implications for management

Plantar heel pain is a common musculoskeletal foot disorder that can have a negative impact on activities of daily living and it is of multifactorial etiology. A variety of mechanical factors, which result in excessive load at the plantar fascia insertion, are thought to contribute to the onset of the condition. This review presents the evidence for associations between commonly assessed mechanical factors and plantar heel pain, which could guide management. Plantar heel pain is associated with a higher BMI in non-athletic groups, reduced dorsiflexion range of motion, as well as reduced strength in specific foot and ankle muscle groups. There is conflicting, or insufficient evidence regarding the importance of foot alignment and first metatarsophalangeal joint range of motion. Plantar heel pain appears to be common in runners, with limited evidence for greater risk being associated with higher mileage or previous injuries. Conflicting evidence exists regarding the relationship between work-related standing and plantar heel pain, however, longer standing duration may be associated with plantar heel pain in specific worker groups. The evidence presented has been generated through studies with cross-sectional designs, therefore it is not known whether any of these associated factors have a causative relationship with plantar heel pain. Longitudinal studies are needed to ascertain whether the strength and flexibility impairments associated with plantar heel pain are a cause or consequence of the condition, as well as to establish activity thresholds that increase risk. Intervention approaches should consider strategies that improve strength and flexibility, as well as those that influence plantar fascia loading such as body weight reduction, orthoses and management of athletic and occupational workload.

Landing Biomechanics, But Not Physical Activity, Differ in Young Male Athletes With and Without Patellar Tendinopathy

OBJECTIVE

To examine differences in biomechanical and physical activity load in young male athletes with and without patellar tendinopathy.

DESIGN

Cross-sectional cohort study.

METHODS

Forty-one young male athletes (15-28 years of age) were categorized into 3 distinct groups: symptomatic athletes with patellar tendon abnormalities (PTA) (n = 13), asymptomatic athletes with PTA (n = 14), and a control group of asymptomatic athletes without PTA (n = 14). Participants underwent a laboratory biomechanical jump-landing assessment and wore an accelerometer for 1 week of physical activity monitoring.

RESULTS

The symptomatic group demonstrated significantly less patellar tendon force loading impulse in the involved limb compared with both the control and asymptomatic groups (P<.05), with large effects (d = 0.91-1.40). There were no differences in physical activity between the 3 groups (P>.05).

CONCLUSION

Young male athletes with symptomatic patellar tendinopathy demonstrated smaller magnitudes of patellar tendon force loading impulse during landing compared to both asymptomatic athletes with patellar tendinopathy and healthy control participants. However, these 3 distinct groups did not differ in general measures of physical activity. Future investigations should examine whether comprehensively monitoring various loading metrics may be valuable to avoid both underloading and overloading patterns in athletes with patellar tendinopathy. J Orthop Sports Phys Ther 2020;50(3):158-166. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9065.

Tissue-Specific T2 * Biomarkers in Patellar Tendinopathy by Subregional Quantification Using 3D Ultrashort Echo Time MRI

Background

Quantitative MRI of patellar tendinopathy (PT) can be challenging due to spatial variation of T₂* relaxation times.

Purpose

1) To compare T₂* quantification using a standard approach with analysis in specific tissue compartments of the patellar tendon. 2) To evaluate test–retest reliability of different methods for fitting ultrashort echo time (UTE)‐relaxometry data.

Study Type

Prospective.

Subjects

Sixty‐five athletes with PT.

Field Strength/Sequence

3D UTE scans covering the patellar tendon were acquired using a 3.0T scanner and a 16‐channel surface coil.

Assessment

Voxelwise median T₂* was quantified with monoexponential, fractional‐order, and biexponential fitting. We applied two methods for T₂* analysis: first, a standard approach by analyzing all voxels covering the proximal patellar tendon. Second, within subregions of the patellar tendon, by using thresholds on biexponential fitting parameter percentage short T₂* (0–30% for mostly long T₂*, 30–60% for mixed T₂*, and 60–100% for mostly short T₂*).

Statistical Tests

Average test–retest reliability was assessed in three athletes using coefficients‐of‐variation (CV) and coefficients‐of‐repeatability (CR).

Results

With standard image analysis, we found a median [interquartile range, IQR] monoexponential T₂* of 6.43 msec [4.32–8.55] and fractional order T₂* 4.39 msec [3.06–5.78]. The percentage of short T₂* components was 52.9% [35.5–69.6]. Subregional monoexponential T₂* was 13.78 msec [12.11–16.46], 7.65 msec [6.49–8.61], and 3.05 msec [2.52–3.60] and fractional order T₂* 11.82 msec [10.09–14.44], 5.14 msec [4.25–5.96], and 2.19 msec [1.82–2.64] for 0–30%, 30–60%, and 60–100% short T₂*, respectively. Biexponential component short T₂* was 1.693 msec [1.417–2.003] for tissue with mostly short T₂* and long T₂* of 15.79 msec [13.47–18.61] for mostly long T₂*. The average CR (CV) was 2 msec (15%), 2 msec (19%) and 10% (22%) for monoexponential, fractional order and percentage short T₂*, respectively.

Data Conclusion

Patellar tendinopathy is characterized by regional variability in binding states of water. Quantitative multicompartment T₂* analysis in PT can be facilitated using a voxel selection method based on using biexponential fitting parameters.

Level of Evidence

1

Technical Efficacy Stage

1 J. Magn. Reson. Imaging 2020;52:420–430.

Rethinking Patellar Tendinopathy and Partial Patellar Tendon Tears: A Novel Classification System

BACKGROUND

Patellar tendinopathy is an overuse injury of the patellar tendon frequently affecting athletes involved in jumping sports. The tendinopathy may progress to partial patellar tendon tears (PPTTs). Current classifications of patellar tendinopathy are based on symptoms and do not provide satisfactory evidence-based treatment guidelines.

PURPOSE

To define the relationship between PPTT characteristics and treatment guidelines, as well as to develop a magnetic resonance imaging (MRI)-based classification system for partial patellar tendon injuries.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

MRI characteristics and clinical treatment outcomes were retrospectively reviewed for 85 patients with patellar tendinopathy, as well as 86 physically active control participants who underwent MRI of the knee for other conditions. A total of 56 patients had a PPTT and underwent further evaluation for tear size and location. The relationship between tear characteristics and clinical outcome was defined with use of statistical comparisons and univariate and logistic regression models.

RESULTS

Of the 85 patients, 56 had partial-thickness patellar tendon tears. Of these tears, 91% involved the posterior and posteromedial regions of the proximal tendon. On axial MRI views, patients with a partial tear had a mean tendon thickness of 10 mm, as compared with 6.2 mm for those without (P < .001). Eleven patients underwent surgery for their partial-thickness tear. All of these patients had a tear >50% of tendon thickness (median thickness of tear, 10.3 mm) on axial views. Logistic regression showed that tendon thickness >8.8 mm correlated with the presence of a partial tear, while tendon thickness >11.45 mm and tear thickness >55.7% predicted surgical management.

CONCLUSION

Partial-thickness tears are located posterior or posteromedially in the proximal patellar tendon. The most sensitive predictor for detecting the presence of a partial tear was patellar tendon thickness, in which thickness >8.8 mm was strongly correlated with a tear of the tendon. Tracking thickness changes on axial MRI may predict the effectiveness of nonoperative therapy: athletes with patellar tendon thickness >11.5 mm and/or >50% tear thickness on axial MRI were less likely to improve with nonoperative treatment. A novel proposed classification system for partial tears, the Popkin-Golman classification, can be used to guide treatment decisions for these patients.

High-energy dose of therapeutic ultrasound in the treatment of patellar tendinopathy: protocol of a randomized placebo-controlled clinical trial

BACKGROUND

Patellar tendinopathy is an extremely debilitating condition and its treatment usually requires a combination of clinical approaches. Therapeutic ultrasound (TUS) is one of the most available electrophysical agent in rehabilitation settings; however, there is also a lack of high-quality studies that test different dosimetric aspects of TUS. Thus, the purpose of this study is to evaluate the short-, medium-, and long-term effects of the combination of high-energy TUS with a rehabilitation program for patellar tendinopathy.

METHODS

This will be a randomized, placebo-controlled trial with blinding of patients, assessors, and therapist. The setting is an outpatient physical therapy clinic. We will recruit 66 participants (male and female) aged between 18 and 40 years and presenting with patellar tendinopathy. A treatment combining high-energy dose TUS and a rehabilitation program for patellar tendinopathy will be delivered twice a week for 8 weeks. The control group will receive the same treatment, but with a placebo TUS. The effectiveness of the intervention will be measured at the beginning (baseline), midpoint (4 weeks), and end of treatment (8 weeks), as well as at 3- and 6-months post-treatment. Primary outcomes will be pain intensity (visual analogue scale, VAS), and VISA-P questionnaire and primary time points will be baseline (T0) and the end of the program (T2). Also, IPAQ-short form questionnaire, muscle strength (manual dynamometry), 2D kinematics, pain pressure threshold (PPT) algometry, thermography, and magnetic resonance imaging (MRI) will be collected.

DISCUSSION

TUS will be applied in an attempt to enhance the results obtained with the rehabilitation program proposed in this study, as well as stimulate some repair responses in individuals undergoing treatment for patellar tendinopathy, which in turn may optimize and improve treatment programs for patellar tendinopathy as well as to establish new guidelines for the application of TUS.

TRIAL REGISTRATION

This study was prospectively registered at April-3rd-2018 and updated at September-1st-2019 in the Brazilian Registry of Clinical Trials (REBEC) under the registration number: RBR-658n6w.

Intratendon delivery of leukocyte-rich platelet-rich plasma at early stage promotes tendon repair in a rabbit Achilles tendinopathy model

Tendinopathy is a great obstacle in clinical practice due to its poor regenerative capacity. The influence of different stages of tendinopathy on effects of leukocyte-rich platelet-rich plasma (Lr-PRP) has not been elucidated. The aim of this study is to investigate the optimal time point for delivery of Lr-PRP on tendinopathy. A tendinopathy model was established by local collagenase injection on the rabbit Achilles tendon. Then after collagenase induction, following treatments were applied randomly on the lesion: (a) 200 μl of Lr-PRP at 1 week (PRP-1 group), (b) 200 μl of saline at 1 week (Saline-1 group), (c) 200 μl of Lr-PRP at 4 weeks (PRP-2 group), and (d) 200 μl of saline at 4 weeks (Saline-2 group). Six weeks after collagenase induction, outcomes were assessed by magnetic resonance imaging, cytokine quantification, gene expression, histology, and transmission electron microscopy. Our results demonstrated that PRP-1 group had the least cross-sectional area and lesion percent of the involved tendon, as well as the lowest signal intensity in magnetic resonance imaging among all groups. However, the PRP-2 group showed larger cross-sectional area than saline groups. Enzyme-linked immunosorbent assay indicated that PRP-1 group had a higher level of interleukin-10 but lower level of interleukin-6 when compared with PRP-2 and saline groups. Meanwhile, the highest expression of collagen (Col) 1 in PRP-1 and Col 3, matrix metalloproteinase (MMP)-1, and MMP-3 in PRP-2 was found. Histologically, the PRP-1 showed better general scores than PRP-2, and no significant difference was found between the PRP-2 and saline groups. For transmission electron microscopy, PRP-1 had the largest mean collagen fibril diameter, and the PRP-2 group showed even smaller mean collagen fibril diameter than saline groups. In conclusion, intratendon delivery of Lr-PRP at early stage showed beneficial effect for repair of tendinopathy but not at late stage. For translation of our results to clinical circumstances, further studies are still needed.

Autologous bone marrow expanded mesenchymal stem cells in patellar tendinopathy: protocol for a phase I/II, single-centre, randomized with active control PRP, double-blinded clinical trial

Introduction

Patellar tendon overuse injuries are common in athletes. Imaging may show a change in tissue structure with tendon thickening and disruption of the intratendinous substance. We wish to test the hypothesis that both autologous bone marrow expanded mesenchymal stem cells and autologous leukocyte-poor platelet-rich plasma (LP-PRP) implanted into the area of the disrupted tendinopathic patellar tendon will restore function, but tendon regeneration tissue will only be observed in the subjects treated with autologous bone marrow expanded mesenchymal stem cells.

Methods and analysis

This is a single-centre, pilot phase I/II, double-blinded clinical trial with randomisation with active control. Twenty patients with a diagnosis of patellar tendinopathy with imaging changes (tendon thickening and disruption of the intratendinous substance at the proximal portion of the patellar tendon) will be randomised in a 1:1 ratio to receive a local injection of either bone-marrow autologous mesenchymal stem cells (MSC), isolated and cultured under GMP at The Institute of Biology and Molecular Genetics (IBGM) (Spain) or P-PRP. The study will have two aims: first, to ascertain whether a clinically relevant improvement after 3, 6 and 12 months according to the visual analogue scale (VAS), Victorian Institute of Sport Assessment for patellar tendons (VISA-P) and dynamometry scales (DYN) will be achieved; and second, to ascertain whether the proposed intervention will restore tendon structure as determined by ultrasonography (US), Doppler ultrasonography (DUS), and innovative MRI and ultrasound techniques: Magnetic Resonance T2 FAT SAT (UTE, Ultrashort Echo TE) sequence and Ultrasound Tissue Characterization (UTC). Patients who are randomised to the P-PRP treatment group but do not achieve a satisfactory primary endpoint after 6 months will be offered treatment with MSC.

Trial registration

NCT03454737.

Revolving doors of tendinopathy: definition, pathogenesis and treatment

The ultimate cure for the tendon pathology continues to elude current science. Despite great steps in technology, the causation and treatment is still not clear. The number of different theories and treatment modalities in the literature may confuse clinicians and patients. In this paper we outline the definitions, evolution of pathogenesis and treatment for tendinopathy. By highlighting these, the aim of this paper is to guide the practitioner in counselling and treating their patients.

Low prevalence of patellar tendon abnormality and low incidence of patellar tendinopathy in female collegiate volleyball players

The prevalence of patellar tendinopathy has been reported to be as high as 50% in elite male volleyball (VB) players; however, the rate of injury in female collegiate VB athletes is unknown. The purpose of this study was to 1) identify the prevalence of ultrasonographic evidence of patellar tendon abnormality at the start of the preseason in female collegiate VB players; 2) report the incidence of tendinopathy during the season; and 3) determine if the preseason presence of tendon abnormality is associated with onset of disease. One hundred and six female collegiate VB players had both patellar tendons imaged. Incidence of patellar tendinopathy was tracked during the course of the 4-month season. Twenty-two athletes presented with ultrasonographic evidence of patellar tendon abnormality in at least one knee at the start of the preseason. The incidence of time-loss patellar tendinopathy was 0.26 (95% CI: 0.04, 0.85) per 1000 athletic exposures. This study was unable to determine if preseason presence of tendon abnormality was associated with a greater risk of tendinopathy due to power. The prevalence of tendon abnormality in the preseason and the incidence of patellar tendinopathy in female collegiate VB players are lower than that observed in other populations.

Relative difference among 27 functional measures in patients with knee osteoarthritis: an exploratory cross-sectional case-control study

Background

To raise the effectiveness of interventions, clinicians should evaluate important biopsychosocial aspects of the patient’s situation. There is limited knowledge of which factors according to the International Classification of Function, Disability, and Health (ICF) are most deviant between patients with knee osteoarthritis (KOA) and healthy individuals. To assist in measures’ selection, we aimed to quantify the differences between patients with KOA and healthy controls on various measures across the ICF dimensions of body function, activity, and participation.

Methods

We performed an exploratory cross-sectional case-control study. In total, 28 patients with mild-to-moderate KOA (mean age 61 years, 64% women) referred by general physicians to a hospital’s osteoarthritis-school, and 31 healthy participants (mean age 55 years, 52% women), volunteered. We compared between-group differences on 27 physical and self-reported measures derived from treatment guidelines, trial recommendations, and trial/outcome reviews. Independent t-test, Chi-square, and Mann-Whitney U test evaluated the significance for continuous parametric, dichotomous, and ordinal data, respectively. For parametric data, effect sizes were calculated as Cohen’s d. For non-parametric data, ds were estimated by p-values and sample sizes according to statistical formulas. Finally, all ds were ranked and interpreted after Hopkins’ scale. An age-adjusted sensitivity-analysis on parametric data validated those conclusions.

Results

Very large differences between patients and controls were found on the Pain numeric rating scale¹, the Knee Injury and Osteoarthritis Scale (KOOS, all subscales)², as well as the Örebro Musculoskeletal psychosocial scale³ (P < 0.0001). Large differences were found on the Timed 10-steps-up-and-down stair climb test⁴ and Accelerometer registered vigorous-intensity physical activity in daily life⁵ (P < 0.001). Respectively, these measures clustered on ICF as follows: ¹body function, ²all three ICF-dimensions, ³body function and participation, ⁴activity, and ⁵participation.

Limitations

The limited sample excluded elderly patients with severe obesity.

Conclusions

Very large differences across all ICF dimensions were indicated for the KOOS and Örebro questionnaires together for patients aged 45–70 with KOA. Clinicians are suggested to use them as means of selecting supplementary measures with appropriate discriminative characteristics and clear links to effective therapy. Confirmative studies are needed to further validate these explorative and partly age-unadjusted conclusions.

Evidence based treatment options for common knee injuries in runners

The purpose of this paper is to review the current literature regarding conservative treatment options for the three most common knee injuries in runners including patellofemoral pain syndrome (PFPS), iliotibial band friction syndrome (ITBFS), and patellar tendinopathy (PT). Each diagnosis is discussed using current research to describe the pathophysiology, evaluation process, and evidence based effective treatment strategies including therapeutic exercise, manual therapy, neuromuscular re-education, and modalities. The result is a comprehensive overview of each diagnosis and a research-based approach to effectively evaluate and treat each condition for best outcomes.

Non-surgical treatment of patellar tendinopathy: A systematic review of randomized controlled trials

STUDY DESIGN

Systematic review of randomized controlled trials.

OBJECTIVES

To determine the most effective non-surgical treatment interventions for reducing pain and improving function for patients with patellar tendinopathy.

METHODS

Studies considered for this systematic review were from peer-reviewed journals published between January 2012 and September 2017. All included studies used a visual analogue scale (VAS) to evaluate the participant's pain. The majority of the included studies also used the Victorian Institute of Sport Assessment Patellar Tendinopathy (VISA-P questionnaire) to assess participant's symptoms and function.

RESULTS

Nine randomized controlled trials fit the inclusion criteria and were analyzed. The results of three studies supported the use of isometric exercise to reduce pain immediately. One study found patellar strapping and sports taping to be effective for reduction in pain during sport and immediately after. Eccentric exercise, Dry Needling (DN) (2 studies), injections with Platelet Rich Plasma (PRP), Autologous Blood Injection (ABI), and saline were found to have a more sustained effect on reducing pain and improving knee function.

CONCLUSION

Isometric exercise, patellar strapping, sports taping, eccentric exercise, injections with PRP, ABI, and saline and DN demonstrated a short-term pain relieving and functional improvement effect in subjects with patellar tendinopathy. Longer term follow up on interventions involving eccentric exercise, DN, and injections with PRP, ABI and saline showed sustained pain reduction and improvement in knee function.

LEVEL OF EVIDENCE

Level 1.

Patellofemoral Pain

Patellofemoral pain (PFP) is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee. The onset of symptoms can be slow or acutely develop with a worsening of pain accompanying lower-limb loading activities (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running). Symptoms can restrict participation in physical activity, sports, and work, as well as recur and persist for years. This clinical practice guideline will allow physical therapists and other rehabilitation specialists to stay up to date with evolving PFP knowledge and practices, and help them to make evidence-based treatment decisions. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.

Prevalence of Patellar Tendinopathy and Patellar Tendon Abnormality in Male Collegiate Basketball Players: A Cross-Sectional Study

CONTEXT

Patellar tendinopathy (PT) is a degenerative condition known to affect athletes who participate in sports such as basketball and volleyball. Patellar tendinopathy is a challenging condition to treat and may cause an athlete to prematurely retire from sport. The prevalence of PT in male collegiate basketball players is unknown.

OBJECTIVE

To determine the prevalence of PT and patellar tendon abnormality (PTA) in a population of male collegiate basketball players.

DESIGN

Cross-sectional study.

SETTING

National Collegiate Athletic Association Divisions II and III, National Association of Intercollegiate Athletics, and Northwest Athletic Conference male collegiate basketball teams were assessed in a university laboratory setting.

PATIENTS OR OTHER PARTICIPANTS

Ninety-five male collegiate basketball players (age = 20.0 ± 1.7 years).

MAIN OUTCOME MEASURE(S)

A diagnostic ultrasound image of an athlete's patellar tendon was obtained from each knee. Patellar tendinopathy was identified based on a player's symptoms (pain with palpation) and the presence of a hypoechoic region on an ultrasonographic image.

RESULTS

A majority of participants, 53 of 95 (55.8%), did not present with pain during palpation or ultrasonographic evidence of PTA. Thirty-two basketball players (33.7%) displayed ultrasonographic evidence of PTA in at least 1 knee; 20 of those athletes (21.1%) had PT (pain and tendon abnormality). Nonstarters were 3.5 times more likely to present with PTA (odds ratio = 3.5, 95% confidence interval = 1.3, 9.6; P = .017) and 4 times more likely to present with PT (odds ratio = 4.0, 95% confidence interval = 1.1, 14.8; P = .038) at the start of the season.

CONCLUSIONS

One in 3 male collegiate basketball players presented with either PT or PTA. Sports medicine professionals should evaluate basketball athletes for PT and PTA as part of a preseason screening protocol.

Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: A single cohort feasibility study

OBJECTIVES

To examine the feasibility of recommended education and exercise supplemented by a hopping intervention implemented based on self-reported pain over 12 weeks for recreational runners with Achilles tendinopathy.

DESIGN

Single cohort feasibility study.

SETTING

One private physiotherapy clinic in Melbourne, Australia.

PARTICIPANTS

Fifteen male recreational runners with midportion Achilles tendinopathy.

MAIN OUTCOME MEASURES

Recruitment and adherence measures, adverse events, intervention acceptability and treatment effect trends were measured at baseline, 4 and 12 weeks.

RESULTS

Recruitment (100%), retention (87%) and follow-up (93%) rates were high. Exercise adherence was 70% (SD = 12.7) but fidelity was 50% (SD = 13.9). Three participants suffered adverse events (undertaking activities contrary to advice). Participants reported the education package, perceived benefit, and feedback frequency as intervention enablers; while the onerous time commitment was regarded a barrier. At 12 weeks, five participants were satisfied and eight very satisfied, while VISA-A had improved 24 ± 20.65 points (μ2 = 0.740).

CONCLUSIONS

A randomised control trial including recommended education and exercise with a pain-guided hopping intervention as treatment for recreational runners with midportion Achilles tendinopathy may be warranted, once strategies to improve adherence and reduce adverse events are addressed.

The Beliefs and Attitudes of Cypriot Physical Therapists Regarding the Use of Deep Friction Massage

Background: Deep friction massage (DFM) is a widely used technique by physical therapists worldwide for chronic pain management. According to Dr. James Cyriax, compliance with the proposed guidelines is vital to obtain the desired therapeutic results. Objectives: This study explored the beliefs and attitudes of Cypriot physical therapists to DFM and their compliance with the suggested guidelines to identify any empirical-based application patterns and compare them to the suggestions of Cyriax. In addition, the prevalence of DFM use in clinical practice in Cyprus was investigated. Methods: Questionnaires, consisting of 18 multiple choice questions and a table of six sub-questions, were distributed to 90 local physical therapists. Results: A total of 70% of respondents declared that they perform DFM in their daily practice. The respondents answered 11 out of the 19 technical questions in compliance with the guidelines. Conclusion: The study revealed the DFM application pattern of Cypriot physical therapists. The compliance percentage of this pattern to Cyriax guidelines was 58% in general and 62.5% for patients with chronic conditions.

How strong is the evidence that conservative treatment reduces pain and improves function in individuals with patellar tendinopathy? A systematic review of randomised controlled trials including GRADE recommendations

OBJECTIVE

To determine the effectiveness of conservative treatment (CT) on pain and function in patients with patellar tendinopathy (PT) compared with minimal intervention (MI) or other invasive intervention, or in addition to decline eccentric squat.

METHODS

Searches were performed in MEDLINE, Embase, Cochrane, PEDro, SPORTDiscus, CINAHL and AMED databases. All randomised trials that evaluated CT (any intervention not involving invasive procedures or medication) in individuals with PT were included. Two reviewers screened studies, extracted data and assessed risk of bias of all included studies. Where suitable, meta-analyses were conducted; we assessed certainty of the evidence using GRADE methodology.

RESULTS

When compared with MI, CT did not improve pain (weighted mean difference (WMD) -2.6, 95% CI -6.5 to 1.2) or function (WMD 1.8, 95% CI -2.4 to 6.1) in the short-term (up to 3 months) follow-up. When compared with invasive intervention, CT did not improve pain (WMD 0.7, 95% CI -0.1 to 1.4) or function (WMD -6.6, 95% CI -13.3 to 0.2) in the short-term follow-up. No overall effects were found for combined CT (when a conservative intervention was added to decline eccentric squat) on pain (WMD -0.5, 95% CI -1.4 to 0.4) or function (WMD -2.3, 95 % -9.1 to 4.6) at short-term follow-up. Single studies showed an effect on pain with iontophoresis at short-term follow-up (d = 2.42) or dry needling at medium/long-term follow-up (d = 1.17) and function with exercise intervention at medium/long-term follow-up (over 3 months) (d = 0.83).

SUMMARY/CONCLUSION

Our estimates of treatment effect have only low to very low certainty evidence to support them. This field of sports medicine/sports physiotherapy urgently needs larger, high-quality studies with pain and function among the potential primary outcomes.

Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline

BACKGROUND

A small number of randomized controlled trials have found ultrasound-guided injection of platelet-rich plasma (PRP) to be no more effective than saline for several tendinopathies; limited information exists for patellar tendinopathy. In addition, different PRP formulations that produce varying concentrations of leukocytes have not been directly compared for patellar tendinopathy.

PURPOSE/HYPOTHESIS

To determine if a single ultrasound-guided PRP injection, either leukocyte-rich PRP (LR-PRP) or leukocyte-poor PRP (LP-PRP), was superior to saline injection for the treatment of patellar tendinopathy. The null hypothesis was that no treatment would be superior to another for the treatment of patellar tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Athletes with patellar tendinopathy for ≥6 months (Blazina stage IIIB) were assessed for eligibility in a multisite single-blind controlled trial. There were 3 injection arms: LR-PRP, LP-PRP, and saline. Patients received a single ultrasound-guided injection, followed by 6 weeks of supervised rehabilitation (heavy slow resistance training, concentric and eccentric, 3 times per week). Outcome measures-Victorian Institute of Sport Assessment (patellar; VISA-P), pain during activity, and global rating of change-were assessed at 6 and 12 weeks and 6 and 12 months. VISA-P score at 12 weeks was the primary outcome. Fifty-seven patients (19 in each group) were included in an intention-to-treat analysis. Secondary outcome measures included pain during activity and patients' global rating of change.

RESULTS

Study retention was 93% at 12 weeks and 79% after 1 year. There was no significant difference in mean change in VISA-P score, pain, or global rating of change among the 3 treatment groups at 12 weeks or any other time point. After 1 year, the mean (SD) outcomes for the LR-PRP, LP-PRP, and saline groups were as follows, respectively: VISA-P-58 (29), 71 (20), and 80 (18); pain-4.0 (2.4), 2.4 (2.3), and 2.0 (1.9); global rating of change-4.7 (1.6), 5.6 (1.0), and 5.7 (1.2) ( P > .05 for all outcomes).

CONCLUSION

Combined with an exercise-based rehabilitation program, a single injection of LR-PRP or LP-PRP was no more effective than saline for the improvement of patellar tendinopathy symptoms.

REGISTRATION

NCT02116946 (ClinicalTrials.gov identifier).

Cyriax Friction Massage-Suggestions for Improvements

Background and objectives: Cyriax friction massage is a widely known and used technique in the field of chronic pain management. Despite its frequent use in daily clinical practice, the technique lacks evidence to support its therapeutic value. While this might be due to various factors, the authors of this paper suggest that the technique might need to be improved and/or modernized according to the recent literature. The purpose of this letter is to further analyze our point of view. Materials and Methods: Using the most relevant methods to the subject literature, the authors intended to point out a few technical details that might need reconsideration and/or modernization. Results: An appropriate terminology is suggested in the text. Further, suggestions are made regarding the technique’s interval time, a possible addition of self-treatment, a discussion of the combination with Mill’s manipulation, tendon positioning and other parameters. Conclusions: As a therapeutic value has not yet been clearly documented, and since the modernization and/or improvement of the technique might be needed, we suggest that this technique should not be used as a first-line treatment for the management of chronic pain.

Isometric Exercise to Reduce Pain in Patellar Tendinopathy In-Season: Is It Effective "on the Road"?

OBJECTIVE

To investigate the effectiveness of an isometric squat exercise using a portable belt, on patellar tendon pain and function, in athletes during their competitive season.

DESIGN

Case series with no requirements to change any aspect of games or training. The object of this pragmatic study was to investigate this intervention in addition to "usual management." A control or sham intervention was considered unacceptable to teams.

SETTING

In-season.

PARTICIPANTS

A total of 25 male and female elite and subelite athletes from 5 sports.

INTERVENTION

5 × 30-second isometric quadriceps squat exercise using a rigid belt completed over a 4-week period.

MAIN OUTCOME MEASURES

(1) single-leg decline squat (SLDS)-a pain provocation test for the patellar tendon (numerical rating score of pain between 0 and 10), (2) VISA-P questionnaire assessing patellar tendon pain and function, and (3) self-reported adherence with completing the exercise over a 4-week period.

RESULTS

Baseline SLDS pain was high for these in-season athletes, median 7.5/10 (range 3.5-9) and was significantly reduced over the 4-week intervention (P < 0.001, ES r = 0.580, median change 3.5). VISA-P scores improved after intervention (P < 0.001, ES r = 0.568, mean change 12.2 ± 8.9, percentage mean change 18.8%, where minimum clinical important difference of relative change for VISA-P is 15.4%-27%). Adherence was high; athletes reported completing the exercise 5 times per week.

CONCLUSIONS

This pragmatic study suggests that a portable isometric squat reduced pain in-season for athletes with patellar tendinopathy (PT). This form of treatment may be effective, but clinical trials with a control group are needed to confirm the results.

Comparison of the Effect of 5 Different Treatment Options for Managing Patellar Tendinopathy: A Secondary Analysis

OBJECTIVE

Currently, no treatments exist for patellar tendinopathy (PT) that guarantee quick and full recovery. Our objective was to assess which treatment option provides the best chance of clinical improvement and to assess the influence of patient and injury characteristics on the clinical effect of these treatments.

DESIGN

A secondary analysis was performed on the combined databases of 3 previously performed double-blind randomized controlled trials.

PATIENTS

In total, 138 patients with PT were included in the analysis.

INTERVENTIONS

Participants were divided into 5 groups, based on the treatment they received: Extracorporeal shockwave therapy (ESWT) (n = 31), ESWT plus eccentric training (n = 43), eccentric training (n = 17), topical glyceryl trinitrate patch plus eccentric training (n = 16), and placebo treatment (n = 31).

MAIN OUTCOME MEASURES

Clinical improvement (increase of ≥13 points on the Victorian Institute of Sport Assessment-Patella score) after 3 months of treatment.

RESULTS

Fifty-two patients (37.7%) improved clinically after 3 months of treatment. Odds ratios (ORs) for clinical improvement were significantly higher in the eccentric training group (OR 6.68, P = 0.009) and the ESWT plus eccentric training group (OR 5.42, P = 0.015) compared with the other groups. We found evidence that a high training volume, a longer duration of symptoms, and older age negatively influence a treatment's clinical outcome (trend toward significance).

CONCLUSIONS

Our study confirmed the importance of exercise, and eccentric training in particular, in the management of PT. The role of ESWT remains uncertain. Further research focusing on the identified prognostic factors is needed to be able to design patient-specific treatment protocols for the management of PT.

Potential Nervous System Sensitization in Patients With Persistent Lower Extremity Tendinopathies: 3 Case Reports

BACKGROUND

Tendinopathy is a condition often associated with pain and functional and sport performance limitations. While targeted exercise prescriptions are often effective, many patients with tendinopathy develop persistent symptoms. Emerging evidence suggests a possible link between nervous system sensitization and tendinopathy. If so, identifying and treating specific pain mechanisms may improve outcomes.

CASE DESCRIPTION

Three patients were seen in physical therapy for complaints of ongoing chronic tendon pain and self-reported disability, despite being treated previously and receiving evidence-informed care. Upon examination, each patient demonstrated signs consistent with possible dysfunction of central pain mechanisms. Joint mobilization, pain neuroscience education, and aerobic exercise were primary interventions in each case to decrease pain and improve function.

OUTCOMES

The 3 patients were treated for 5 sessions over the course of 8 weeks. Clinically significant improvement was noted in measures of pain, self-reported function, and pressure pain thresholds. At discharge, all patients were able to run without symptoms, and improvement was maintained at 1-year follow-up.

DISCUSSION

Tendinopathy, while often described as local pain and dysfunction, may be associated with dysfunction of the nervous system. Identifying and treating pain mechanisms in addition to relevant impairments may be an appropriate intervention approach for individuals with tendinopathy.

LEVEL OF EVIDENCE

Therapy, level 4. J Orthop Sports Phys Ther 2019;49(4):272-279. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8600.

Histopathological study of the infrapatellar fat pad in the rat model of patellar tendinopathy: A basic study

BACKGROUND

Patellar tendinopathy is difficult to successfully treat. This study aimed to characterize the pathological changes of the infrapatellar fat pad (IPFP) in patellar tendinopathy (PT), and to investigate the influence of PT on the development of fibrotic changes in the IPFP.

METHODS

Forty male Wistar rats were randomly divided into PT (n = 20) and control groups (n = 20). Bacterial collagenase I (patellar tendinopathy group) or saline (control) was injected, intratendinous, into the patellar tendon. Rats were sacrificed at week 12. The whole knee joint was sagittally sectioned and stained with hematoxylin-eosin and Masson's trichrome. The IPFP samples were graded according to cellularity, fibrosis, and vascularity. The whole IPFP and blue-stained area was measured. Mann-Whitney U tests were used to compare the between-group differences of each score and quantitative value.

RESULTS

Scores for cellularity were three (2-3) and 0 (0-1) in the PT and control groups, respectively (P < 0.01). Mean scores for fibrosis were two (1-3) and 0 (0-1) in the PT and control groups, respectively (P < 0.01). Mean scores for vascularity were two (2-3) and one (1-1) in the PT and control groups, respectively (P < 0.01). There was a significant difference in the total score between the PT and control groups (seven (5-8) and two (1-3), respectively) (P < 0.01). Average percentages of the fibrous area of the IPFP were 38.2 ± 26.5% and 11.2 ± 3.9% in the patellar tendinopathy and control groups, respectively (P < 0.01).

CONCLUSION

The IPFP in the patellar tendinopathy group showed greater cellularity, fibrosis, and vascularity than the control group.

Modifiable risk factors for patellar tendinopathy in athletes: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis identifying (1) potential modifiable risk factors and (2) associated modifiable factors for patellar tendinopathy in athletes.

DESIGN

A systematic review and meta-analysis was conducted. Risk of bias was assessed using the Newcastle-Ottawa Scale and grouped based on study design. Meta-analytic statistics were performed for items reported by five or more studies. A strength of evidence rating is provided for items not appropriate for meta-analysis.

DATA SOURCES

PubMed, Web of Science, Scopus and Cinahl were searched on 14 November 2017.

ELIGIBILITY CRITERIA

Quantitative, original research reporting potential modifiable risk factors or associated factors, comparing athletes with patellar tendinopathy with a group without the injury.

RESULTS

862 records were screened and 31 articles were included (6 prospective, 25 cross-sectional). There was a lack of strong evidence for any potential modifiable risk factor or associated factors. There was limited or conflicting evidence that decreased ankle dorsiflexion range of motion, decreased posterior thigh and quadriceps flexibility, greater volume of jump training, more volleyball sets played per week, greater countermovement jump (CMJ) height and greater activity volume are potential modifiable risk factors. Meta-analysis supported greater activity volume (Cohen's d=0.22, 95% CI 0.06 to 0.39, p=0.008), higher body weight (0.36, 0.17 to 0.55, p<0.001) and greater CMJ height (0.31, 0.07 to 0.56, p=0.01) as associated modifiable factors.

CONCLUSIONS

There is a lack of strong evidence for any potential modifiable risk factors or associated factors. Factors with lower levels of support may be of interest in designing prevention programmes but require further research in high-quality, prospective studies.

Diagnostic Accuracy of a Self-report Measure of Patellar Tendinopathy in Youth Basketball

BACKGROUND

To engage clinicians in diagnosing patellar tendinopathy in large surveillance studies is often impracticable. The Oslo Sports Trauma Research Centre-patellar tendinopathy (OSTRC-P) questionnaire, a self-report measure adapted from the OSTRC questionnaire, may provide a viable alternative.

OBJECTIVES

To evaluate the diagnostic accuracy of the OSTRC-P questionnaire in detecting patellar tendinopathy in youth basketball players when compared to clinical evaluation.

METHODS

Following the STAndards for Reporting of Diagnostic accuracy studies guidelines, the researchers recruited 208 youth basketball players (13-18 years of age) for this prospective diagnostic accuracy validation study. Participants completed the OSTRC-P questionnaire (index test) prior to a clinical evaluation (reference standard) by a physical therapist blinded to OSTRC-P questionnaire results. Sensitivity, specificity, predictive value, likelihood ratio, and posttest probability were calculated. Linear regression was used to examine the association between the OSTRC-P questionnaire severity score and the patellar tendinopathy severity rating during a single-leg decline squat.

RESULTS

The final analysis included 169 players. The OSTRC-P questionnaire had a sensitivity of 79% (95% confidence interval [CI]: 65%, 90%), specificity of 98% (95% CI: 94%, 100%), positive predictive value of 95% (95% CI: 83%, 99%), negative predictive value of 92% (95% CI: 86%, 96%), positive likelihood ratio of 48 (95% CI: 12, 191), and negative likelihood ratio of 0.21 (95% CI: 0.12, 0.37). The posttest probabilities were 95% and 8%, given positive and negative results, respectively. A positive association was found between OSTRC-P questionnaire severity score and single-leg decline squat rating (β = 0.08; 95% CI: 0.03, 0.12; P = .001).

CONCLUSION

The OSTRC-P questionnaire is an acceptable alternative to clinical evaluation for self-reporting patellar tendinopathy and grading its severity in settings involving youth basketball players.

LEVEL OF EVIDENCE

Diagnosis, level 1b. J Orthop Sports Phys Ther 2018;48(10):758-766. Epub 27 Apr 2018. doi:10.2519/jospt.2018.8088.

Classification of Tendon Matrix Change Using Ultrasound Imaging: A Systematic Review and Meta-analysis

Ultrasound imaging (US) is an accurate and reliable method used to diagnose tendinopathy. This systematic review was aimed at identifying common criteria and parameters used to diagnose tendinopathy, the methodological quality of studies and the predictive value of US. Nineteen studies met the inclusion criteria, with the Achilles, quadriceps and patella tendons being investigated. Overall, there was significant heterogeneity between the criteria used to diagnose tendinopathy utilising US. The methodological quality of included studies was "good." Additionally, meta-analysis revealed that US-identified abnormalities were predictive of future symptoms, and classification of tendinopathy using three US defined parameters indicated a higher relative risk of developing clinical tendinopathy compared with the use of two US-defined parameters. Further research into the development of a standardised US criterion that incorporates both clinical and US findings is required to allow for greater consistency in the diagnosis of tendinopathy.

Proposing a Patellar Tendinopathy Screening tool following a systematic review

BACKGROUND

Patellar tendinopathy (PT) is an overuse injury of the knee. The mechanism of injury is associated with repetitive stress on the patellar tendon of the knee as a result of explosive movement. Patellar tendinopathy is prevalent in all populations and is associated with intrinsic and extrinsic risk factors.

OBJECTIVES

Primarily, the objective was to report on the intrinsic and extrinsic risk factors for PT, entailing a systematic review of the literature; the secondary objective was to use these risk factors to compile a proposed PT screening tool from the review and standard outcome measures.

METHOD

A systematic review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Elimination criteria of the articles included duplicates, titles, abstracts and methodological quality. The evidence was collected, characterised with regard to the intrinsic and extrinsic risk factors and summarised descriptively.

RESULTS

The search yielded 157 feasible articles prior to commencement of article elimination. Six articles were included with a mean methodological quality score of 69%. Eight intrinsic and five extrinsic risk factors were identified. These identified risk factors are all relevant to the pathology and formed the basis for a proposed PT screening tool. The Victorian Institute of Sports Assessment for Patellar Tendinopathy Questionnaire, Visual Analog Scale and the Pain Provocation Test are also included in the proposed test.

CONCLUSION

Intrinsic and extrinsic risk factors for PT were identified, and consequently, the proposed PT screening tool was formulated for possible future testing in appropriate studies.

CLINICAL IMPLICATIONS

Prevention of PT through intrinsic and extrinsic risk factor identification, and implementation in the clinical setup as a possible outcome measurement tool with which to verify functional improvement in PT rehabilitation.

Nonpharmacological Management of Persistent Pain in Elite Athletes: Rationale and Recommendations

Persistent pain is common in elite athletes. The current review arose from a consensus initiative by the International Olympic Committee to advance the development of a standardized, scientific, and evidence-informed approach to management. We suggest that optimal management of persistent pain in elite athletes requires an understanding of contemporary pain science, including the rationale behind and implementation of a biopsychosocial approach to care. We argue that athletes and clinicians need to understand the biopsychosocial model because it applies to both pain and the impact of pain with special reference to the sport setting. Management relies on thorough and precise assessment that considers contributing factors across nociceptive, inflammatory, neuropathic, and centrally acting domains; these can include contextual and psychosocial factors. Pain management seeks to remove contributing factors wherever possible through targeted education; adjustment of mechanical loading, training, and performance schedules; psychological therapies; and management of inflammation.

The relationship between acute pain and dynamic postural stability indices in individuals with patellar tendinopathy

BACKGROUND

Patellar tendinopathy is a common condition resulting in persistent pain, frequently reported during physical activity. The relationship between dynamic postural stability and pain in these individuals is unclear and how it may affect postural stability.

RESEARCH QUESTION

Is there a relationship between acute pain and dynamic postural stability indices in individuals with patellar tendinopathy?

METHODS

Twenty-two recreationally active individuals with patellar tendinopathy participated. Participants performed a two-legged jump and landed on a single test-limb on a force platform. They completed 100 mm visual analogue scales (VAS) before and after landing trials. Anterior-posterior (APSI), medial-lateral (MLSI), vertical (VSI), and composite (DPSI) stability indices were calculated from ground reaction force data. The relationship between stability indices and VAS for pain as well as pain change scores were assessed via non-parametric Spearman's rho (ρ) rank correlations (p≤.05).

RESULTS

Baseline pain was not significantly correlated with any stability indices. Post-landing pain was significantly correlated with MLSI (ρ = 0.540, p = 0.004) while, VSI (ρ = 0.353, p = 0.053) and DPSI (ρ = 0.347, p = 0.057) had moderate, yet insignificant correlations. Pain change scores demonstrated a large correlation with MLSI (ρ = 0.598, p = 0.002).

SIGNIFICANCE

As pain increased in individuals with patellar tendinopathy, dynamic postural stability indices values increased, indicating more difficulty transitioning from a dynamic to static state. Although balance deficits are not typically associated with patellar tendinopathy, it appears pain and dynamic postural stability may be related in these individuals.

Pain mapping of the anterior knee: injured athletes know best

Background and aims

Research investigating differences in pain location and distribution across conditions is lacking. Mapping a patient’s pain may be a useful way of understanding differences in presentations, however the use of pain mapping during a pain provocation task has not been investigated. The aim of this study was to assess the reliability of patient and clinician rated pain maps during a pain provocation task for the anterior knee.

Methods

Participants were recruited from a larger study of professional Australian rules football players (n=17). Players were invited to participate if they reported a current or past history of patellar tendon pain. No clinical diagnosis was performed for this reliability study. Participants were asked to point on their own knee where they usually experienced pain, which was recorded by a clinician on a piloted photograph of the knee using an iPad. Participants then completed a single leg decline squat (SLDS), after which participants indicated where they experienced pain during the task with their finger, which was recorded by a clinician. Participants then recorded their own self-rated pain map. This process was repeated 10 min later. Pain maps were subjectively classified into categories of pain location and spread by two raters. Pain area was quantified by the number of pixels shaded. Intra- and inter-rater reliability (between participants and clinicians) were analysed for pain area, similarity of location as well as subjective classification.

Results

Test-retest reliability was good for participants (intraclass correlation coefficients [ICC]=0.81) but only fair for clinicians (ICC=0.47) for pain area. There was poor agreement between participants and clinicians for pain area (ICC=0.16) and similarity of location (Jaccard index=0.19). Clinicians had good inter- and intra-rater reliability of classification of pain spread (k=0.75 and 0.67).

Conclusions

Participant completed pain maps were more reliable than clinician pain maps. Clinicians were reliable at classifying pain based on location and type of spread.

Implications

Clinicians should ask patients to complete their own pain maps following a pain provocation test, to elicit the most reliable and consistent understanding of their pain perception.

Predictors of clinical success in runners with patellofemoral pain: Secondary analyses of a randomized clinical trial

OBJECTIVES

To identify predictors of outcome to a rehabilitation program focused on education and management of training loads in runners with patellofemoral pain (PFP).

DESIGN

Secondary analyses of a randomized clinical trial.

METHODS

Fifty-eight runners with PFP (62% female, aged 31.2±6.6years, running 20.3±5.6km/week) were included in analyses. Following baseline collection of demographics, anthropometry, symptomatology, isometric strength, running mechanics and radiological data, runners were randomized to one of the three 8-week intervention program: (1) Education on symptoms management and training modifications; (2) Education+Exercise program; (3) Education+Gait retraining. Clinical success was defined as an increase ≥13.6% on the Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS) at 3 months following program completion. Potential predictors were entered into logistic regression analyses.

RESULTS

Forty-five runners (78%) were categorized as Success. Together, KOS-ADLS score (<70%), knee extension isometric strength (<70% bodyweight), presence of patellar tendinopathy (Grade >0) and level of usual pain (>2/10) at baseline predicted treatment outcome with 87.9% accuracy. The model provided sensitivity of 0.93 (95% C.I. 0.82-0.98), specificity of 0.69 (95% C.I. 0.42-0.87), positive likelihood ratio of 3.0 (95% C.I. 1.3-6.9), and negative likelihood ratio of 0.1 (95% C.I. 0-0.3). The best individual predictors were KOS-ADLS score and knee extension strength.

CONCLUSIONS

The combination of KOS-ADLS, knee extensors strength, patellar tendon integrity and usual pain best predicted clinical outcome of runners with PFP following an intervention that had a common education component. Further testing is needed before a clinical prediction rule can be recommended to clinicians.

Individuals Post Achilles Tendon Rupture Exhibit Asymmetrical Knee and Ankle Kinetics and Loading Rates During a Drop Countermovement Jump

Study Design Cross-sectional laboratory study. Background Asymmetrical knee loading during jogging and hopping has been reported in individuals who have ruptured their Achilles tendon. No studies have examined knee loads in individuals post Achilles tendon rupture during high-demand tasks, such as single-limb landings. Objectives We sought to determine whether individuals post Achilles tendon rupture demonstrated asymmetrical knee loads and impact forces during drop countermovement jumps (CMJs). Methods Achilles tendon length and the single-leg heel-rise test for endurance were assessed in 34 individuals (31 male) 6.1 ± 2.0 years post Achilles tendon rupture. Movement patterns were assessed during a drop CMJ. Data were analyzed via repeated-measures analyses of variance, with comparisons between limbs and prior treatment history (surgery versus nonsurgery). Results An 8.6% longer Achilles tendon (P<.001) was found in the involved limb. During the single-leg heel-rise test, the involved limb demonstrated 22.4% less endurance and 14.6% lower heel-rise height (all, P<.001). During the landing phase of the drop CMJ, the involved limb exhibited 39.6% greater loading rate (P<.001), 16.8% greater eccentric knee power (P = .048), but 21.6% lower eccentric ankle power (P<.001). During the take-off phase, the involved limb exhibited 12.1% lower jump height and 19.9% lower concentric ankle power (both, P<.001). Conclusion Elevated eccentric knee joint power and higher loading rates during a drop CMJ in individuals who experienced Achilles tendon rupture several years earlier may be a compensation pattern for reduced plantar flexor function. This movement pattern may place individuals who have had an Achilles tendon rupture at greater risk for knee injuries. J Orthop Sports Phys Ther 2018;48(1):34-43. Epub 26 Oct 2017. doi:10.2519/jospt.2018.7684.

Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy

STUDY DESIGN

RCT.

INTRODUCTION

Lateral elbow tendinopathy is a common clinical condition. eccentric exercises. eccentric-concentric loading and, isometric exercises are indicated to reduce and manage tendon pain.

PURPOSE OF THE STUDY

To compare the effectiveness of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy.

METHODS

A randomized clinical trial was carried out in a rheumatology and rehabilitation center. A group of 34 patients with later elbow tendinopathy was randomly allocated to Group A (n = 11) who underwent eccentric training, Group B had eccentric-concentric and Group C who had eccentric-concentric and isometric training. All patients received 5 treatments per week for 4 weeks. Pain was evaluated using a visual analog scale and function using a visual analog scale and pain-free grip strength at the end of the 4-week course of treatment (week 4) and 1 month (week 8) after the end of treatment.

RESULTS

The eccentric-concentric training combined with isomentric contractions produced the largest effect in the reduction of pain and improvement of function at the end of the treatment (P < .05) and at any of the follow-up time points (P < .05).

CONCLUSION

The eccentric-concentric training combined with isomentric contractions was the most effective treatment. Future well-designed studies are needed to confirm the results of the present trial.

LEVEL OF EVIDENCE

III.

THE REHABILITATION OF A RUNNER WITH ILIOPSOAS TENDINOPATHY USING AN ECCENTRIC-BIASED EXERCISE-A CASE REPORT

Background and Purpose

While there is much discussion about tendinopathy in the literature, there is little reference to the less common condition of iliopsoas tendinopathy, and no documentation of the condition in runners. The iliopsoas is a major decelerator of the hip and eccentric loading of the iliopsoas is an important component of energy transfer during running. Eccentric training is a thoroughly researched method of treating tendinopathy but has shown mixed results. The purpose of this case report is to describe the rehabilitation of a runner with iliopsoas tendinopathy, and demonstrate in a creative eccentric-biased technique to assist with treatment. A secondary objective is to illustrate how evidence on intervention for other tendinopathies was used to guide rehabilitation of this seldom described condition.

Case Description

The subject was a 39-year-old female middle distance runner diagnosed with iliopsoas tendinopathy via ultrasound, after sudden onset of left anterior groin pain. Symptoms began after a significant increase in running load, and persisted, despite rest, for three months. The intervention consisted of an eccentric-biased hip flexor exercise, with supportive kinetic chain exercises and progressive loading in a return to running program.

Outcomes

The Copenhagen Hip and Groin Outcome Score, the Visual Analogue Scale, the Global Rating of Change Scale and manual muscle testing scores all improved after 12 weeks of intervention with further improvement at the five-year follow up. After 12 weeks of intervention, the subject was running without restriction and had returned to her pre-injury running mileage at the five-year follow up.

Discussion

The eccentric-biased exercise in conjunction with exercises addressing the kinetic chain and a progressive tendon loading program, were successful in the rehabilitation of this subject with iliopsoas tendinopathy. This case report is the first to provide a description on the rehabilitation of iliopsoas tendinopathy, and offers clinicians suggestions and guidance for treatment and exercise choice in the clinical environment.

Level of Evidence

5.

Effects of Altering Trunk Position during Landings on Patellar Tendon Force and Pain

PURPOSE

This study aimed to verify the immediate effects of altering sagittal plane trunk position during jump landings on lower limb biomechanics, patellar tendon force, and pain of athletes with and without patellar tendinopathy.

METHODS

Twenty-one elite male athletes were categorized into three groups: athletes with patellar tendinopathy (TG; n = 7), asymptomatic athletes with patellar tendon abnormalities (n = 7), and asymptomatic athletes without tendon abnormalities (CG; n = 7). A biomechanical evaluation was conducted while the athletes performed drop landings from a bench in a self-selected trunk position (SS). Afterward, the athletes were randomly assigned to land with either a flexed trunk position (FLX) or an extended trunk position (EXT). Variables of interest for this study included sagittal plane peak kinematics, kinetics, patellar tendon force, and pain during the landing tasks.

RESULTS

Peak patellar tendon force, knee extensor moment, and knee pain decreased in the FLX landing compared with the SS landing, regardless of group. In addition, peak patellar tendon force, knee extensor moment, and vertical ground reaction force were smaller in the FLX landing compared with the EXT landing. The TG had smaller peak ankle dorsiflexion compared with the CG during jump landings, regardless of trunk position.

CONCLUSIONS

Landing with greater trunk flexion decreased patellar tendon force in elite jumping athletes. An immediate decrease in knee pain was also observed in symptomatic athletes with a more flexed trunk position during landing. Increasing trunk flexion during landing might be an important strategy to reduce tendon overload in jumping athletes.

Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach

Chronic tendinopathies represent a major problem in the clinical practice of sports orthopaedic surgeons, sports doctors and other health professionals involved in the treatment of athletes and patients that perform repetitive actions. The lack of consensus relative to the diagnostic tools and treatment modalities represents a management dilemma for these professionals. With this review, the purpose of the ESSKA Basic Science Committee is to establish guidelines for understanding, diagnosing and treating this complex pathology.

Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain?A randomised clinical trial

Design

Single-blind randomised clinical trial.

Objective

To compare the effects of three 8-week rehabilitation programmes on symptoms and functional limitations of runners with patellofemoral pain (PFP).

Methods

Sixty-nine runners with PFP were randomly assigned to one of three intervention groups: (1) education on symptoms management and training modifications (education); (2) exercise programme in addition to education (exercises); (3) gait retraining in addition to education (gait retraining). Symptoms and functional limitations were assessed at baseline (T0), and after 4, 8 and 20 weeks (T4, T8 and T20) using the Knee Outcome Survey of the Activities of Daily Living Scale (KOS-ADLS) and visual analogue scales (VASs) for usual pain, worst pain and pain during running. Lower limb kinematics and kinetics during running, and isometric strength were also evaluated at T0 and T8. The effects of rehabilitation programmes were assessed using two-way analysis of variance.

Results

No significant group × time interactions (p<0.447) were found for KOS-ADLS and VASs. All three groups showed similar improvements at T4, T8 and T20 compared with T0 (p<0.05). Only the exercises group increased knee extension strength following rehabilitation (group × time: p<0.001) and only the gait retraining group (group × time: p<0.001) increased step rate (+7.0%) and decreased average vertical loading rate (−25.4%).

Conclusion

Even though gait retraining and exercises improved their targeted mechanisms, their addition to education did not provide additional benefits on symptoms and functional limitations. Appropriate education on symptoms and management of training loads should be included as a primary component of treatment in runners with PFP.

Trial registration number

ClinicalTrials.gov (NCT02352909).

Elevated Knee Joint Kinetics and Reduced Ankle Kinetics Are Present During Jogging and Hopping After Achilles Tendon Ruptures

BACKGROUND

Deficits in plantarflexor function are common after an Achilles tendon rupture. These deficits may result in an altered distribution of joint loads during lower extremity tasks.

HYPOTHESIS

We hypothesized that, regardless of treatment, the Achilles tendon-ruptured limb would exhibit deficits in ankle kinematics and joint power while exhibiting elevated knee joint power and patellofemoral joint loads during walking, jogging, and hopping. We further hypothesized that this loading pattern would be most evident during jogging and hopping.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty-four participants (17 participants treated surgically, 17 treated nonsurgically) were tested at a mean 6.1 ± 2.0 years after an Achilles tendon rupture. Lower extremity kinematics and kinetics were assessed while participants completed walking, jogging, and single-legged hopping trials. Patellofemoral joint stress was calculated via a musculoskeletal model. Data were analyzed via mixed-model repeated analyses of variance (α = .05) and the limb symmetry index (LSI).

RESULTS

No differences ( P ≥ .05) were found between the surgical and nonsurgical groups. In both groups, large side-to-side deficits in the plantarflexion angle at toeoff (LSI: 53.5%-73.9%) were noted during walking, jogging, and hopping in the involved limb. Side-to-side deficits in the angular velocity were only present during jogging (LSI: 93.5%) and hopping (LSI: 92.5%). This pattern was accompanied by large deficits in eccentric (LSI: 80.8%-94.7%) and concentric (LSI: 82.2%-84.7%) ankle joint powers in the involved limb during all tasks. Interestingly, only jogging and hopping demonstrated greater knee joint loads when compared with the uninvolved limb. Concentric knee power was greater during jogging (LSI: 117.2%) and hopping (LSI: 115.9%) compared with the uninvolved limb. Similarly, peak patellofemoral joint stress was greater in the involved limb during jogging (LSI: 107.5%) and hopping (LSI: 107.1%), while only hopping had a greater loading rate of patellofemoral joint stress (LSI: 110.9%).

CONCLUSION

Considerable side-to-side deficits in plantarflexor function were observed during walking, jogging, and hopping in patients after an Achilles tendon rupture. As a possible compensation, increased knee joint loads were present but only during jogging and hopping.

CLINICAL RELEVANCE

These data suggest that after an Achilles tendon rupture, patients may be susceptible to greater mechanical loading of the knee during sporting tasks, regardless of surgical or nonsurgical treatment.

November 2016 Letter to the Editor-in-Chief

Letter to the Editor-in-Chief of JOSPT as follows: "Use of the VISA-P as a Clinical Measure in Research" with Authors' Response J Orthop Sports Phys Ther 2016;46(11):1012-1014. doi:10.2519/jospt.2016.0203.