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Rhim HC, Shin J, Kang J, Dyrek P, Crockett Z, Galido P, Wade C, Hollander K, Borg-Stein J, Sampson S, Tenforde AS. Use of extracorporeal shockwave therapies for athletes and physically active individuals: a systematic review. Br J Sports Med 2024; 58:154-163. [PMID: 38228375 DOI: 10.1136/bjsports-2023-107567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To determine the efficacy of extracorporeal shockwave therapy (ESWT) and investigate outcomes following the use of ESWT for athletes and physically active individuals. DESIGN Systematic review. DATA SOURCES We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and searched four databases: PubMed (NLM), Embase (Elsevier), CINAHL Complete (EBSCO) and Web of Science (Clarivate). ELIGIBILITY CRITERIA FOR SELECTING STUDIES Included studies were randomised controlled trials, cohort and case-control studies, cases series and reports that evaluated outcomes following ESWT for athletes, physically active individuals and occupational groups requiring regular physical activity such as military cadets. RESULTS 56 studies with 1874 athletes or physically active individuals were included. Using the Oxford level of evidence rating, included studies were 18 level I (32.1%), 3 level II (5.4%), 10 level III (17.9%), 13 level IV (23.2%) and 12 level V (21.4%). Based on the level I studies, ESWT may be effective alone in plantar fasciitis, lateral epicondylitis and proximal hamstring tendinopathy and as an adjunct to exercise treatment in medial tibial stress syndrome and osteitis pubis in athletes or physically active individuals. In most studies, athletes were allowed to continue activities and training and tolerated ESWT with minimal side effects. CONCLUSION ESWT may offer an efficacious treatment alone or as an adjunct to concurrent exercise therapy in selected sports-related injuries and without major adverse events. Further high-level research is needed to better define the role and clinical outcomes of ESWT.
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Affiliation(s)
- Hye Chang Rhim
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jaehyung Shin
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jane Kang
- Riverside University Health System, Moreno Valley, California, USA
| | - Paige Dyrek
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Zack Crockett
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Pearl Galido
- Western University of Health Sciences, Pomona, California, USA
| | - Carrie Wade
- Countway Library, Harvard Medical School, Boston, Massachusetts, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Joanne Borg-Stein
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | | | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
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Merry K, MacPherson MM, Blazey P, Fearon A, Hunt M, Morrissey D, Napier C, Reid D, Whittaker JL, Willy RW, Scott A. Current practice, guideline adherence, and barriers to implementation for Achilles tendinopathy rehabilitation: a survey of physical therapists and people with Achilles tendinopathy. BMJ Open Sport Exerc Med 2024; 10:e001678. [PMID: 38347858 PMCID: PMC10860067 DOI: 10.1136/bmjsem-2023-001678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 02/15/2024] Open
Abstract
Objective To explore clinical practice patterns of physical therapists (PTs) who treat people with Achilles tendinopathy (AT), and identify perceived barriers and facilitators for prescribing and engaging with therapeutic exercise among PTs and people with AT. Methods Two cross-sectional surveys were electronically distributed between November 2021 and May 2022; one survey was designed for PTs while the second was for people with AT. Survey respondents answered questions regarding their physical therapy training and current practice (PTs), injury history and management (people with AT), and perceived barriers and facilitators (PTs and people with AT). Results 341 PTs and 74 people with AT completed the surveys. In alignment with clinical practice guidelines, more than 94% of PTs surveyed (97% of whom had some form of advanced musculoskeletal training) prioritise patient education and therapeutic exercise. Patient compliance, patient knowledge, and the slow nature of recovery were barriers to prescribing therapeutic exercise reported by PTs, while time, physical resources, and a perceived lack of short-term treatment effectiveness were barriers for people with AT. Conclusions Consistent with clinical practice guidelines, PTs with advanced training reported prioritising therapeutic exercise and education for managing AT. However, both PTs and people with AT identified many barriers to prescribing or engaging with therapeutic exercise. By addressing misconceptions about the time burden and ineffectiveness of exercise, and by overcoming access issues to exercise space and equipment, PTs may be able to improve intervention adherence and subsequently outcomes for people with AT.
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Affiliation(s)
- Kohle Merry
- Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Paul Blazey
- Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Angie Fearon
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, southeastern Australia, Australia
| | - Michael Hunt
- Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Dylan Morrissey
- Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, London, UK
| | - Christopher Napier
- Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Duncan Reid
- Physiotherapy, Auckland University of Technology, Auckland, New Zealand
| | - Jackie L Whittaker
- Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard W Willy
- Physical Therapy and Rehabilitation Sciences, University of Montana, Missoula, Montana, USA
| | - Alex Scott
- Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
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Osborne JWA, Menz HB, Whittaker GA, Landorf KB. Development of a foot and ankle strengthening program for the treatment of plantar heel pain: a Delphi consensus study. J Foot Ankle Res 2023; 16:67. [PMID: 37789375 PMCID: PMC10546707 DOI: 10.1186/s13047-023-00668-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND People with plantar heel pain (PHP) have reduced foot and ankle muscle function, strength and size, which is frequently treated by muscle strengthening exercises. However, there has been little investigation of what exercises are used and there is no sound evidence base to guide practice. This study aimed to develop a consensus-driven progressive muscle strengthening program for PHP. METHODS Thirty-eight experts were invited to participate in the study over three rounds. Round 1 was an open-ended questionnaire that provided the core characteristics of progressive strengthening programs designed for three different adult patient types with PHP (younger athletic, overweight middle-aged, older), which were presented as vignettes. In Round 2, experts indicated their agreement to the proposed exercises and training variables. In Round 3, experts were presented with amendments to the exercises based on responses from Round 2 and indicated their agreement to those changes. Consensus was achieved when > 70% of experts agreed. RESULTS Two experts were ineligible and 12 declined, leaving 24 (67%) who participated in Round 1. Eighteen (75%) completed all three rounds. From Round 1, progressive strengthening programs were developed for the three vignettes, which included 10 different exercises and three training variables (sets / repetitions, weight, and frequency). In Round 2, 68% (n = 17) of exercises and 96% (n = 72) of training variables reached consensus. In Round 3, only exercise changes were presented and 100% of exercises reached consensus. CONCLUSIONS This study provides three progressive strengthening programs agreed to by experts that can be used in future clinical trials to determine the effectiveness of muscle strengthening for PHP. In addition, clinicians could use the programs as part of a rehabilitation strategy with the caveat that they may change as more research is conducted.
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Affiliation(s)
- John W A Osborne
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Victoria, 3086, Australia.
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Victoria, 3086, Australia.
| | - Hylton B Menz
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Victoria, 3086, Australia
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Victoria, 3086, Australia
| | - Glen A Whittaker
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Victoria, 3086, Australia
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Victoria, 3086, Australia
| | - Karl B Landorf
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Victoria, 3086, Australia
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Victoria, 3086, Australia
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Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023; 27:1-389. [PMID: 37929629 PMCID: PMC10641714 DOI: 10.3310/tfws2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
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.
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Affiliation(s)
- Kay Cooper
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Lyndsay Alexander
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - David Brandie
- Sportscotland Institute of Sport, Airthrey Road, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Isabelle Harrison
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Colin MacLean
- Library Services, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Laura Mitchell
- NHS Grampian, Physiotherapy Department, Ellon Health Centre, Schoolhill, Ellon, Aberdeenshire, UK
| | - Dylan Morrissey
- William Harvey Research Institute, School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, UK
| | - Rachel Ann Moss
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | | | - Joanna Shim
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
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Hawks M, Clauson E, Hughes P, Lauters R, Crawford P. Treatment of Insertional Achilles Tendinopathy Using Adjunct Electroacupuncture Therapy: A Randomized Controlled Trial. Med Acupunct 2023; 35:76-81. [PMID: 37095788 PMCID: PMC10122242 DOI: 10.1089/acu.2022.0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
Objective Achilles tendinopathy is a common musculoskeletal condition associated with decreased functionality. The insertional variant (<2cm from the calcaneus) is less responsive to eccentric-exercise therapy. This study looked at the effect of electroacupuncture (EA) + eccentric exercise for treating insertional Achilles tendinopathy. Materials and Methods Fifty-two active duty and Department of Defense beneficiaries older than 18 years of age with insertional Achilles tendinopathy were randomized to treatment with either eccentric exercise or eccentric exercise with EA. They were evaluated at 0, 2, 4, 6, and 12 weeks. The treatment group received EA treatment in the first 4 visits. The Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A; scored 0-100; higher score = increased function) was used to assess the patients and patient-reported pain (0-10, increasing pain with score) pre- and post-demonstration of the exercises during each visit. Results Both the treatment group (53.6% reduction; confidence interval [CI]: 2.1, 3.9; P < 0.001) and the control group (37.5% reduction; CI: 0.4, 2.9; P = 0.023) reported decreased pain between the first and last visit. The treatment group had reduced pain (mean difference [MD] = 1.0; P < 0.01) between pre- and post-eccentric-exercise performance at each visit, while the control group did not (MD = -0.3; P = 0.065). VISA-A scores did not show a difference in functional improvement between the groups (P = 0.296). Conclusions EA as an adjunct to eccentric therapy significantly improves short-term pain control for insertional Achilles tendinopathy.
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Affiliation(s)
| | - Erik Clauson
- Eglin AFB Family Medicine Residency, Eglin AFB, FL, USA
| | - Pamela Hughes
- Saint Louis University Southwest Illinois Family Medicine Residency, Scott AFB, IL, USA
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Kenny M, Ranabahu T, Vallance P, Zhang Y, Gurr J, Färnqvist K, Rathi S, Cridland K, Munteanu SE, Malliaras P. Exercise adherence in trials of therapeutic exercise interventions for common musculoskeletal conditions: A scoping review. Musculoskelet Sci Pract 2023; 65:102748. [PMID: 37030090 DOI: 10.1016/j.msksp.2023.102748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 03/02/2023] [Accepted: 03/13/2023] [Indexed: 04/10/2023]
Abstract
OBJECTIVE The aims of the scoping review were to: (1) evaluate how commonly trialists assess and report adherence to exercise intervention for common musculoskeletal conditions and (2) report the levels of adherence to exercise for musculoskeletal conditions and whether this was influenced by variables of interest. METHODS Medline, Cinahl, Embase, Emcare, and SPORTDiscus databases were searched using predefined terms. Published randomised controlled trials were included. Trials were included if they investigated the effectiveness of an exercise intervention for low back pain, shoulder pain, Achilles tendinopathy and knee osteoarthritis (we selected a priori as indicative common musculoskeletal conditions). Data extraction was performed independently by teams of two reviewers. Descriptive consolidation and qualitative synthesis were performed. RESULTS 321 trials were included; less than half (46.7%, 150/321) measured adherence. When adherence was assessed, 21% (31/150) of trials did not report the results. Adherence levels were greater when people were supervised. Reporting adherence was more common in registered trials. Adherence was measured most frequently via self-report (47.3%, 71/150) followed by supervised sessions (32.0%, 48/150) or combination of both (20.7%, 31/150). The majority of trials (97.0%, 97/100) reported the level of adherence in terms of a frequency. CONCLUSIONS A majority of trials investigating exercise interventions for common musculoskeletal conditions do not assess exercise adherence. Trials that were registered reported exercise adherence more frequently. The majority of trials measure adherence via self-report with reliance on only one dimension of exercise adherence (frequency).
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Affiliation(s)
- Matthew Kenny
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia.
| | | | - Patrick Vallance
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
| | - Yuxin Zhang
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | | | - Kenneth Färnqvist
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Instituet, Sweden
| | | | - Kate Cridland
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
| | - Shannon E Munteanu
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
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7
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The relationship between psychological, cognitive, and contextual factors and rehabilitation outcomes in Achilles tendinopathy: A prospective feasibility cohort study. Phys Ther Sport 2023; 60:132-140. [PMID: 36796168 DOI: 10.1016/j.ptsp.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVES This study aimed to investigate the feasibility of conducting a full-scale study investigating the influence of patient-related factors on rehabilitation outcomes in Achilles tendinopathy (AT). A secondary aim was to investigate preliminary relationships between patient-related factors and clinical outcomes at 12- and 26- weeks. DESIGN feasibility cohort. SETTING Australian healthcare settings. METHODS Participants with AT receiving physiotherapy in Australia were recruited via treating physiotherapists and online. Data were collected online at baseline, 12- and 26-weeks. Progression criteria for a full-scale study were recruitment rate of ≥10 per month, conversion rate ≥20%, and response rate to questionnaires ≥80%. The relationship between patient-related factors and clinical outcomes was investigated using Spearman's rho correlation coefficient. RESULTS The average recruitment rate was 5/month, conversion rate was 97%, and response rate to questionnaires was ≥97% at all timepoints. There was a fair to moderate correlation (rho = 0.225 to 0.683) between patient-related factors and clinical outcomes at the 12-week, but no to weak correlation at the 26-week (rho = 0.002 to 0.284). CONCLUSIONS Feasibility outcomes suggest a future full-scale cohort study is feasible with the caveat of utilizing strategies to improve recruitment rate. Preliminary bivariate correlations at 12-weeks warrant further investigations in larger studies.
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Radovanović G, Bohm S, Arampatzis A, Legerlotz K. In Achilles Tendinopathy the Symptomatic Tendon Differs from the Asymptomatic Tendon While Exercise Therapy Has Little Effect on Asymmetries-An Ancillary Analysis of Data from a Controlled Clinical Trial. J Clin Med 2023; 12:jcm12031102. [PMID: 36769750 PMCID: PMC9918090 DOI: 10.3390/jcm12031102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND As inter-limb asymmetries can be associated with higher injury risk, we aimed to investigate their role in Achilles tendinopathy patients. METHODS In Achilles tendinopathy patients (n = 41), we assessed inter-limb asymmetries of mechanical, material, and morphological musculoskeletal properties and function and how those were affected by 12 weeks of exercise intervention (high-load protocol, n = 13; Alfredson protocol, n = 11). Moreover, we assessed whether asymmetry reductions correlated with improved Patient-Reported Outcomes (VISA-A score). RESULTS At baseline, tendinopathic tendons demonstrated lower tendon force (p = 0.017), lower tendon stress (p < 0.0001), larger tendon cross-sectional area (CSA) (p < 0.001), and increased intratendinous (p = 0.042) and tendon overall (p = 0.021) vascularization. For the high-load group, PRE-to-POST asymmetry comparisons revealed an asymmetry increase for the counter-movement jump (CMJ) (p = 0.034) and PRE-to-POST VISA-A score improvements correlated with CSA asymmetry reductions (p = 0.024). Within the Alfredson group, PRE-to-POST VISA-A score improvements correlated with CMJ asymmetry reductions (p = 0.044) and tendon stiffness asymmetry increases (p = 0.037). POST-to-POST in-between group comparisons revealed lower asymmetry in the high-load group for tendon elongation (p = 0.021) and tendon strain (p = 0.026). CONCLUSIONS The tendinopathic limb differs from the asymptomatic limb while therapeutic exercise interventions have little effect on asymmetries. Asymmetry reductions are not necessarily associated with tendon health improvements.
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Affiliation(s)
- Goran Radovanović
- Movement Biomechanics, Institute of Sports Sciences, Humboldt-Universität zu Berlin, 10099 Berlin, Germany
- Department Performance, Neuroscience, Therapy and Health, Faculty of Health Sciences, Medical School Hamburg—University of Applied Sciences and Medical University, 20457 Hamburg, Germany
- Institute of Interdisciplinary Exercise Science and Sports Medicine, Faculty of Health Sciences, Medical School Hamburg—University of Applied Sciences and Medical University, 20457 Hamburg, Germany
- Correspondence: ; Tel.: +49-030-2093-46052
| | - Sebastian Bohm
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, 10099 Berlin, Germany
| | - Adamantios Arampatzis
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, 10099 Berlin, Germany
| | - Kirsten Legerlotz
- Movement Biomechanics, Institute of Sports Sciences, Humboldt-Universität zu Berlin, 10099 Berlin, Germany
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9
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Radovanović G, Bohm S, Peper KK, Arampatzis A, Legerlotz K. 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. SPORTS MEDICINE - OPEN 2022; 8:149. [PMID: 36538166 PMCID: PMC9768072 DOI: 10.1186/s40798-022-00545-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Goran Radovanović
- grid.7468.d0000 0001 2248 7639Institute of Sports Sciences, Movement Biomechanics, Humboldt-Universität zu Berlin, Philippstr. 13, 10115 Berlin, Germany ,grid.11500.350000 0000 8919 8412Department Performance, Neuroscience, Therapy and Health, Medical School Hamburg, Faculty of Health Sciences, University of Applied Sciences and Medical University, 20457 Hamburg, Germany ,grid.11500.350000 0000 8919 8412Institute of Interdisciplinary Exercise Science and Sports Medicine, Medical School Hamburg, University of Applied Sciences and Medical University, 20457 Hamburg, Germany
| | - Sebastian Bohm
- grid.7468.d0000 0001 2248 7639Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, 10099 Berlin, Germany
| | - Kim Kristin Peper
- grid.6936.a0000000123222966Munich Institute of Robotics and Machine Intelligence, Technische Universität München, 80992 Munich, Germany
| | - Adamantios Arampatzis
- grid.7468.d0000 0001 2248 7639Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, 10099 Berlin, Germany
| | - Kirsten Legerlotz
- grid.7468.d0000 0001 2248 7639Institute of Sports Sciences, Movement Biomechanics, Humboldt-Universität zu Berlin, Philippstr. 13, 10115 Berlin, Germany
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10
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Hanlon SL, Bley BC, Silbernagel KG. Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol. BMJ Open Sport Exerc Med 2022; 8:e001301. [PMID: 36111126 PMCID: PMC9454050 DOI: 10.1136/bmjsem-2021-001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 11/05/2022] Open
Abstract
Calcaneal apophysitis and Achilles tendinopathy are common overuse injuries characterised by insidious posterior heel pain with activity. Calcaneal apophysitis is commonly diagnosed in adolescents, although Achilles tendinopathy is understudied in the adolescent population and is therefore rarely considered until adulthood. Exercise therapy and activity modification have the highest level of evidence for treating Achilles tendinopathy, while calcaneal apophysitis is treated with anecdotal and passive treatment or complete rest. It remains unknown whether exercise therapy is effective for adolescents with heel pain related to either diagnosis. This is a pilot and feasibility study. Thirty participants between the ages of 7 years and 17 years with posterior heel pain will be recruited from the local community and club sports team and local physicians, school nurses, and athletic trainers through flyers and social media. Participants will be asked to complete evaluations and treatment sessions every 4 weeks with three virtual visits every 2 weeks in between for 12 weeks. All participants will receive standardised treatment consisting of daily Achilles tendon loading exercises and education on pain-guided activity modification. Feasibility outcomes will include recruitment, enrolment, retention and compliance. Clinical outcomes will include the measures of symptom severity, quality of life, tendon morphology and lower extremity function. This protocol will provide preliminary data to inform a larger clinical trial based on the feasibility of the proposed intervention and methodology. Additionally, the results will provide preliminary evidence on whether Achilles tendon injury occurs in the adolescent population. The trial is registered with clinicaltrials.gov (ID:1652996).
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Affiliation(s)
- Shawn L Hanlon
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
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11
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Wu Y, Qian J, Li K, Li W, Yin W, Jiang H. Farrerol alleviates collagenase-induced tendinopathy by inhibiting ferroptosis in rats. J Cell Mol Med 2022; 26:3483-3494. [PMID: 35582962 PMCID: PMC9189353 DOI: 10.1111/jcmm.17388] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 04/21/2022] [Accepted: 04/28/2022] [Indexed: 02/05/2023] Open
Abstract
Tendinopathy is mainly characterized by local pain, functional limitation and decreased athletic ability, which seriously affects the quality of life of patients and the career of athletes. Farrerol (FA), one of the main active compounds extracted from Rhododendron and plants in the Rhododendron family, has a wide range of pharmacological activities, such as immunomodulatory, anti-inflammatory and antiviral effects. However, the effect of FA on tendinopathy is unclear. Here, we investigated the pharmacological effect and mechanism of FA in tendon injury through collagenase-induced tendinopathy in vivo and RSL3-induced tenocytes injury in vitro. The results showed that FA alleviated the infiltration of inflammatory cells, promoted tenogenesis and improved mechanical properties of the Achilles tendon in rats. In addition, ferroptosis inducer RSL3 inhibits the tenogenesis in vitro and in vivo, which accelerates the progression of tendinopathy. Moreover, FA effectively inhibited iron accumulation and alleviated ferroptosis in the Achilles tendon. Using in vitro experiments, we found that FA antagonized ferroptosis by reducing lipid peroxidation and iron accumulation in tenocytes. Finally, we found that glutathione peroxidase 4 silencing could block the protective effect of FA on ferroptosis of tenocytes. Therefore, the results of this study suggest that FA can relieve collagenase-induced tendinopathy by inhibiting ferroptosis, and reveal that FA may be a potentially effective drug for the treatment of tendinopathy in the future.
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Affiliation(s)
- Yongfu Wu
- Department of Pharmacy, Yuebei People's Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong, China
| | - Jun Qian
- Department of Orthopaedic Spine SurgeryAffiliated Hengyang HospitalSouthern Medical University (Hengyang Central Hospital)HengyangHunanChina
| | - Kang Li
- Department of OrthopaedicsGeneral Hospital of Southern Theatre CommandGuangzhouGuangdongChina
| | - Wenjun Li
- Department of OrthopaedicsYuebei People's Hospital Affiliated to Shantou University Medical CollegeShaoguanGuangdongChina
| | - Wenhua Yin
- Department of Orthopaedics, Yuebei People's Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong, China
| | - Huaji Jiang
- Department of Orthopaedics, Yuebei People's Hospital Affiliated to Shantou University Medical College, Shaoguan, Guangdong, China
- Department of Immunology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
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12
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Krogh TP, Jensen TT, Madsen MN, Fredberg U. An Isometric and Functionally Based 4-Stage Progressive Loading Program in Achilles Tendinopathy: A 12-Month Pilot Study. TRANSLATIONAL SPORTS MEDICINE 2022; 2022:6268590. [PMID: 38655172 PMCID: PMC11022783 DOI: 10.1155/2022/6268590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 04/26/2024]
Abstract
Background Achilles tendinopathy (AT) is a common musculoskeletal disorder, and its management remains challenging. Hypothesis/Purpose. By conducting a pilot study, we aimed to assess the feasibility, safety, and clinical improvement of a new home-based 4-stage rehabilitation program with progressive loading including isometric exercises on a small scale prior to setting up a randomized controlled trial. Methods Ten recreational athletes with chronic midportion AT were included. The primary outcome was change in VISA-A score after 1, 2, 3, 6, and 12 months. Secondary outcomes included tenderness on palpation of the tendon and ultrasonographic changes after 6 months. Results Average VISA-A improvements of 26.9 points (P=0.004) and 35.4 points (P=0.006) were observed at 6- and 12-month follow-up, respectively. Tenderness on palpation of the tendon (0-10) was reduced from 5.5 to 2.5 (P < 0.001). Color Doppler ultrasound activity (0-4) was reduced by 50%, from an average of grade 2 to grade 1 (P=0.023). The hypoechoic cross-sectional area of the Achilles tendon was reduced from an average of 29.1% to 8.5% (P=0.001). Tendon thickness showed no statistically significant change (P=0.415). Conclusion Following the 4-stage rehabilitation program for AT based on isometric training and progressive loading, we observed improvement in both VISA-A score and ultrasonography in a group of athletes who had previously failed to benefit from standard AT rehabilitation. The study was feasible in terms of high adherence to the program and with no observed safety issues. The results of this pilot study support a further assessment of this specific approach for rehabilitation in a future randomized controlled trial.
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Affiliation(s)
- Thøger Persson Krogh
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Sports Medicine, Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Center for Sports Medicine, Regional Hospital of Northern Denmark, Hjørring, Denmark
| | - Thomas Theis Jensen
- Department of Sports Medicine, Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Merete Nørgaard Madsen
- Interdisciplinary Research Unit, Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Center for Sports Medicine, Regional Hospital of Northern Denmark, Hjørring, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Copenhagen, Denmark
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13
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Topalović I, Nešić D. Application of shock wave therapy in the treatment of calcific tendinopathies. MEDICINSKI PODMLADAK 2022. [DOI: 10.5937/mp73-35808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Tendons are the soft tissue that connects muscles to bones. They are made of collagen and elastin, they are strong and solid, and have no possibility of contraction. Their strength helps us to move. Recovery of tendon injuries is long-lasting and can take more than six months. If a tendon is shed during a time injury, calcification occurs at the site of the injury and the disease is called calcifying tendinopathy. The very existence of calcifications is an indication for treatment with a mechanical shock wave (Shock wave). Mechanical shock waves can act in focus or radially. The difference between focused and radial waves is primarily in their physical basis. Focused shock waves differ from radial shock waves in terms of therapeutic depth of penetration into the tissue. The basic biological effect of a mechanical shock wave is stimulating. The energy of the mechanical shock wave acts at the cellular level by stimulating the reduction of inflammation and pain in the tissue. Using mechanical shock wave in the treatment of calcified tendinopathies, a safe method for breaking calcifications was obtained. Shock wave can be applied to using: different frequency, different number of strokes, as well as different strength of strokes in their studies. The choice of parameters for the application depends on whether it is calcified or non-calcified tendinopathy. Indications for the use are: painful shoulder, heel spur, plantar fasciitis, tennis elbow, Achilles tendon tendinopathy, jumping knee, patellar tendinitis, myalgia, myogelosis and muscular tendon overstrain syndrome. Contraindications for the use are: the existence of prostheses, knees and hips, as well as various orthopedic material, pacemaker, as well as the presence of chronic diseases such as multiple sclerosis, amyotrophic lateral sclerosis or tumors. The application of a mechanical shock wave is new, non-invasive method, easy to apply, always reduces pain and practically without side effects. This method has a special role in the treatment of chronic inflammation of diseased tendons, with or without calcification. The only dilemma in the application of a mechanical shock wave can be in the number of applications as well as the time break between the applications of two consecutive mechanical shock waves therapy.
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14
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Habets B, van Cingel REH, Backx FJG, van Elten HJ, Zuithoff P, Huisstede BMA. No Difference in Clinical Effects When Comparing Alfredson Eccentric and Silbernagel Combined Concentric-Eccentric Loading in Achilles Tendinopathy: A Randomized Controlled Trial. Orthop J Sports Med 2021; 9:23259671211031254. [PMID: 34722783 PMCID: PMC8554573 DOI: 10.1177/23259671211031254] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/08/2021] [Indexed: 12/05/2022] Open
Abstract
Background: Alfredson isolated eccentric loading and Silbernagel concentric–eccentric loading have both shown beneficial effects on clinical symptoms in midportion Achilles tendinopathy (AT), but they have never been compared directly. Purpose: To test for differences in clinical effects at 1-year follow-up between Alfredson and Silbernagel loading in midportion AT. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 40 recreational athletes were allocated to the Alfredson group (AG) or the Silbernagel group (SG). The primary outcome was the difference in the Victorian Institute of Sports Assessment–Achilles (VISA-A) at 1-year follow-up. Secondary outcomes were the visual analog scale for pain during activities of daily living (VAS-ADL) and sports activities (VAS–sports), the EuroQol 5 Dimensions instrument (EQ-5D), and global perceived effect score. Measurements were performed at baseline and 12-week, 26-week, and 1-year follow-up. Analysis was performed using a linear mixed-regression model with intervention (AG vs SG), time (12 weeks, 26 weeks, and 1 year postoperatively), and intervention-by-time interaction. Results: The VISA-A score improved for both AG and SG, from 60.7 ± 17.1 at baseline to 89.4 ± 13.0 at 1-year follow-up and from 59.8 ± 22.2 to 83.2 ± 22.4, respectively (P < .001 for both). Because the interaction term did not significantly improve the model, we reported a treatment effect without interaction term, indicating a constant difference at each follow-up. The linear mixed model with correction for baseline VISA-A and confounders revealed a nonsignificant treatment effect (2.4 [95% CI, –8.5 to 13.3]; P = .656). In addition, after adjustment for the respective baseline values and confounders, nonsignificant treatment effects were found for the VAS-ADL (–2.0 [95% CI, –11.3 to 7.3]; P = .665) and VAS-sports (1.3 [95% CI, –12.8 to 15.3], P = .858). The EQ-5D subscales improved in both groups. After 1 year, significantly more SG participants considered themselves improved (77.3% [SG] vs 50.0% [AG]; P = .04). Conclusion: No differences in clinical effects were found between Alfredson and Silbernagel loading at up to 1-year follow-up. Both programs significantly improved clinical symptoms, and given their high adherence rates, offering either of them as a home-based program with limited supervision appears to be an effective treatment strategy for midportion AT. Registration: NTR5638 (Netherlands Trial Register number).
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Affiliation(s)
- Bas Habets
- Sports Medical Center Papendal, Arnhem, the Netherlands.,Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, the Netherlands
| | - Robert E H van Cingel
- Sports Medical Center Papendal, Arnhem, the Netherlands.,Research Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frank J G Backx
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, the Netherlands
| | - Hilco J van Elten
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Peter Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bionka M A Huisstede
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, the Netherlands
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15
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Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy. J Orthop Sports Phys Ther 2021; 51:440-448. [PMID: 34074130 PMCID: PMC8410667 DOI: 10.2519/jospt.2021.10271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To identify latent subgroups among patients with Achilles tendinopathy, describe patient characteristics and clinical attributes that defined each subgroup, and develop a clinical classification model for subgroup membership. DESIGN Cross-sectional study. METHODS One hundred forty-five participants (men, n = 73; mean ± SD age, 51 ± 14 years) with clinically diagnosed Achilles tendinopathy completed a baseline evaluation, including demographics and medical history, patient-reported outcome measures, a clinical exam, tendon structure measures via ultrasound imaging and continuous shear-wave elastography, and a functional test battery. Subgroups were identified using mixture modeling. We compared the subgroups using a 1-way analysis-of-variance or chi-square test and the Tukey post hoc test to identify defining attributes. We developed a clinical classification model using logistic regression and receiver operating characteristic curves. RESULTS Three latent subgroups were identified and named by their distinctive patient characteristics and clinical attributes. The activity-dominant subgroup (n = 67), on average, had the highest physical activity level, function, and quality of life; reported mild symptoms; and was the youngest. The psychosocial-dominant subgroup (n = 56), on average, had the worst symptoms, impaired function, heightened psychological factors, the poorest quality of life, minimal tendon structural alterations, and was obese and predominantly female. The structure-dominant subgroup (n = 22), on average, had the most tendon structural alterations, severe functional deficits, moderate symptoms and psychological factors, reduced quality of life, and was the oldest, obese, and predominantly male. The clinical classification model correctly classified 85% (123/145) of participants. CONCLUSION Three Achilles tendinopathy subgroups (activity dominant, psychosocial dominant, and structure dominant) differed in patient characteristics and clinical attributes. J Orthop Sports Phys Ther 2021;51(9):440-448. Epub 1 Jun 2021. doi:10.2519/jospt.2021.10271.
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16
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Burton I. Autoregulation in Resistance Training for Lower Limb Tendinopathy: A Potential Method for Addressing Individual Factors, Intervention Issues, and Inadequate Outcomes. Front Physiol 2021; 12:704306. [PMID: 34421641 PMCID: PMC8375597 DOI: 10.3389/fphys.2021.704306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/06/2021] [Indexed: 01/08/2023] Open
Abstract
Musculoskeletal disorders, such as tendinopathy, are placing an increasing burden on society and health systems. Tendinopathy accounts for up to 30% of musculoskeletal disorders, with a high incidence in athletes and the general population. Although resistance training has shown short-term effectiveness in the treatment of lower limb tendinopathy, more comprehensive exercise protocols and progression methods are required due to poor long-term outcomes. The most common resistance training protocols are predetermined and standardized, which presents significant limitations. Current standardized protocols do not adhere to scientific resistance training principles, consider individual factors, or take the importance of individualized training into account. Resistance training programs in case of tendinopathy are currently not achieving the required intensity and dosage, leading to high recurrence rates. Therefore, better methods for individualizing and progressing resistance training are required to improve outcomes. One potential method is autoregulation, which allows individuals to progress training at their own rate, taking individual factors into account. Despite the finding of their effectiveness in increasing the strength of healthy athletes, autoregulation methods have not been investigated in case of tendinopathy. The purpose of this narrative review was 3-fold: firstly, to give an overview and a critical analysis of the individual factors involved in tendinopathy and current resistance training protocols and their limitations. Secondly, to give an overview of the history, methods, and application of autoregulation strategies both in sports performance and physiotherapy. Finally, a theoretical adaptation of a current tendinopathy resistance training protocol using autoregulation methods is presented, providing an example of how the method could be implemented in clinical practice or future research.
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Affiliation(s)
- Ian Burton
- National Health Service (NHS) Grampian, Aberdeen, United Kingdom
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17
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Modi S, Turner D, Hennessy K. Non-pharmacological interventions and corticosteroid injections for the management of the Achilles tendon in inflammatory arthritis: a systematic review. J Foot Ankle Res 2021; 14:48. [PMID: 34246295 PMCID: PMC8272330 DOI: 10.1186/s13047-021-00484-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Achilles tendon (AT) pathologies, particularly Achilles enthesitis, are common in inflammatory arthritis (IA). Although there are various non-pharmacological interventions and injection therapies available, it is unknown if these interventions are effective for people with IA, as this population is often excluded from studies investigating the management of AT pathologies. This study aimed to identify and critically appraise the evidence for non-pharmacological interventions and corticosteroid injections in the management of AT pathology in those with IA. METHODS All studies which met the inclusion criteria (AT interventions in adults with a working clinical diagnosis of IA, English language) were identified from the following databases: Medline, Embase, CINAHL and the Cochrane Library. The search strategies used the search terms 'spondyloarthropathies', 'inflammatory arthritis', 'achilles tendon', 'physical therapy', 'conservative management', 'injections', and related synonyms. Studies included were quantitative longitudinal design, such as randomised controlled trials, pseudo randomised and non-randomised experimental studies, observational studies, cohort studies, and case control studies. All outcome measures were investigated, quality assessment to determine internal and external validity of included studies was undertaken, and qualitative data synthesis was conducted. RESULTS Of the 10,911 articles identified in the search strategy, only two studies that investigated the efficacy of corticosteroid injections for the management of the AT in IA met the inclusion criteria, and no studies were identified for non-pharmacological interventions. Both injection studies had low quality rating for internal and external validity, and thus overall validity. The included studies only investigated two outcome domains: pain and ultrasound (US) (B Mode and Doppler) identified abnormalities and vascularity in the AT. There is weak evidence suggesting a short-term improvement (6-12 weeks) in pain and for the reduction in some abnormal US (B-Mode and Doppler) detectable features (entheseal thickness, bursitis, and entheseal vascularity) at the AT and surrounding structures post-corticosteroid injection. CONCLUSION Weak evidence is available regarding the efficacy of corticosteroid injections in reducing pain and inconclusive evidence for the improvement of abnormal US detectable features. No studies were identified for non-pharmacological interventions. It is evident from the lack of relevant literature that there is an urgent need for more studies assessing non-pharmacological interventions for the AT in people with IA.
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Affiliation(s)
- Shaily Modi
- Western Sydney Local Health District, NSW Health, PO Box 574, Wentworthville, NSW 2145 Australia
| | - Deborah Turner
- School of Clinical Sciences, Queensland University of Technology, GPO Box 2434, Brisbane, QLD 4001 Australia
- School of Health Sciences, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
| | - Kym Hennessy
- School of Health Sciences, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
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18
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Gargano G, Oliviero A, Oliva F, Maffulli N. Small interfering RNAs in tendon homeostasis. Br Med Bull 2021; 138:58-67. [PMID: 33454750 DOI: 10.1093/bmb/ldaa040] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Tenogenesis and tendon homeostasis are guided by genes encoding for the structural molecules of tendon fibres. Small interfering RNAs (siRNAs), acting on gene regulation, can therefore participate in the process of tendon healing. SOURCES OF DATA A systematic search of different databases to October 2020 identified 17 suitable studies. AREAS OF AGREEMENT SiRNAs can be useful to study reparative processes of tendons and identify possible therapeutic targets in tendon healing. AREAS OF CONTROVERSY Many genes and growth factors involved in the processes of tendinopathy and tendon healing can be regulated by siRNAs. It is however unclear which gene silencing determines the expected effect. GROWING POINTS Gene dysregulation of growth factors and tendon structural proteins can be influenced by siRNA. AREAS TIMELY FOR DEVELOPING RESEARCH It is not clear whether there is a direct action of the siRNAs that can be used to facilitate the repair processes of tendons.
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Affiliation(s)
- Giuseppe Gargano
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni di Dio e Ruggi D'Aragona, Via San Leonardo 1, 84131 Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy
| | - Antonio Oliviero
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni di Dio e Ruggi D'Aragona, Via San Leonardo 1, 84131 Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy
| | - Francesco Oliva
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni di Dio e Ruggi D'Aragona, Via San Leonardo 1, 84131 Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni di Dio e Ruggi D'Aragona, Via San Leonardo 1, 84131 Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, Italy.,Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, UK
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19
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Yeh CH, Calder JD, Antflick J, Bull AMJ, Kedgley AE. Maximum dorsiflexion increases Achilles tendon force during exercise for midportion Achilles tendinopathy. Scand J Med Sci Sports 2021; 31:1674-1682. [PMID: 33864294 DOI: 10.1111/sms.13974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 11/30/2022]
Abstract
Rehabilitation is an important treatment for non-insertional Achilles tendinopathy. To date, eccentric loading exercises (ECC) have been the predominant choice; however, mechanical evidence underlying their use remains unclear. Other protocols, such as heavy slow resistance loading (HSR), have shown comparable outcomes, but with less training time. This study aims to identify the effect of external loading and other variables that influence Achilles tendon (AT) force in ECC and HSR. Ground reaction force and kinematic data during ECC and HSR were collected from 18 healthy participants for four loading conditions. The moment arms of the AT were estimated from MRIs of each participant. AT force then was calculated using the ankle torque obtained from inverse dynamics. In the eccentric phase, the AT force was not larger than in the concentric phase in both ECC and HSR. Under the same external load, the force through the AT was larger in ECC with the knee bent than in HSR with the knee straight due to increased dorsiflexion angle of the ankle. Multivariate regression analysis showed that external load and maximum dorsiflexion angle were significant predictors of peak AT force in both standing and seated positions. Therefore, to increase the effectiveness of loading the AT, exercises should apply adequate external load and reach maximum dorsiflexion during the movement. Peak dorsiflexion angle affected the AT force in a standing position at twice the rate of a seated position, suggesting standing could prove more effective for the same external loading and peak dorsiflexion angle.
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Affiliation(s)
- Chia-Han Yeh
- Department of Bioengineering, Imperial College London, London, UK
| | - James D Calder
- Department of Bioengineering, Imperial College London, London, UK.,Fortius Clinic, London, UK
| | | | - Anthony M J Bull
- Department of Bioengineering, Imperial College London, London, UK
| | - Angela E Kedgley
- Department of Bioengineering, Imperial College London, London, UK
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20
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Fares MY, Khachfe HH, Salhab HA, Zbib J, Fares Y, Fares J. Achilles tendinopathy: Exploring injury characteristics and current treatment modalities. Foot (Edinb) 2021; 46:101715. [PMID: 33039245 DOI: 10.1016/j.foot.2020.101715] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/19/2020] [Accepted: 07/03/2020] [Indexed: 02/04/2023]
Abstract
Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.
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Affiliation(s)
- Mohamad Y Fares
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon; College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, Scotland, UK.
| | - Hussein H Khachfe
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Hamza A Salhab
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Jad Zbib
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Youssef Fares
- Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Färnqvist K. Treating tendinopathies – are we searching for a needle in a haystack, when we should include the whole haystack? EUROPEAN JOURNAL OF PHYSIOTHERAPY 2021. [DOI: 10.1080/21679169.2020.1773921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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22
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Färnqvist K, Morrissey D, Malliaras P. Factors associated with outcome following exercise interventions for Achilles tendinopathy: A systematic review. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2020; 26:e1889. [PMID: 33351235 DOI: 10.1002/pri.1889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 10/15/2020] [Accepted: 11/21/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This systematic review aimed to synthesize current evidence on contributing factors influencing outcome following exercise management for Achilles tendinopathy (AT). DATA SOURCES Databases (PubMed, Embase, and Cochrane Library) were searched from inception to February 2020. STUDY SELECTION Studies investigating factors (e.g., age, BMI) associated with outcome (e.g., pain and function questionnaires) following exercise interventions for AT were included. DATA EXTRACTION Data were extracted into a standardized form, including patient demographics, population sample, study type, factors associated with outcome, and outcome measures. DATA SYNTHESIS Meta-analysis was planned to be performed, where appropriate. Where data could not be pooled, we summarized the findings descriptively. RESULTS Six studies investigating 11 different factors were included; overall the quality of evidence was poor. There was conflicting evidence that imaging measures had an association with a change in VISA-A outcome. These included signal intensity and tendon size determined by MRI, and Ultrasound Tissue Characterization echopattern. Three studies found that duration of symptoms was not associated with a change in VISA-A. Also, three studies found that age, and one study found that prior sporting activity level, were not associated with outcome. Baseline pain with activity, baseline VISA-A, sex, and BMI were inconsistently associated with specific outcomes. CONCLUSION Due to the poor quality of evidence overall, no firm conclusions can be drawn. At best, there was inconsistent evidence that imaging factors, baseline pain and function, BMI, and sex showed some associations with outcomes, but these findings need to be confirmed in more extensive studies.
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Affiliation(s)
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary, University of London, London, UK.,Barts Health NHS Trust, London, UK
| | - Peter Malliaras
- Sports and Exercise Medicine, Queen Mary, University of London, London, UK.,Department of Physiotherapy, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
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Vajapey S, Ghenbot S, Baria MR, Magnussen RA, Vasileff WK. Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review. Sports Health 2020; 13:258-264. [PMID: 33252310 DOI: 10.1177/1941738120951764] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results. OBJECTIVE To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure. DATA SOURCES PubMed, MEDLINE, EMBASE, and Google Scholar. STUDY SELECTION The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected. RESULTS There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking. CONCLUSION PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.
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Affiliation(s)
- Sravya Vajapey
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - Sennay Ghenbot
- The Ohio State University School of Medicine, Columbus, Ohio
| | - Michael R Baria
- Department of Physical Medicine & Rehabilitation, The Ohio State University, Columbus, Ohio
| | - Robert A Magnussen
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - W Kelton Vasileff
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
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Mitham K, Mallows A, Debenham J, Seneviratne G, Malliaras P. Conservative management of acute lower limb tendinopathies: A systematic review. Musculoskeletal Care 2020; 19:110-126. [PMID: 32979021 DOI: 10.1002/msc.1506] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Most knowledge regarding conservative management for lower limb tendinopathy (LLT) is for persistent symptoms, with less known about conservative management of acute LLT. Sub-optimal management of acute LLT is detrimental in many regards, not least the likely conversion to persistent symptoms. OBJECTIVES To synthesise existing literature on conservative management of acute LLTs. DESIGN Systematic review of relevant literature (PROSPERO [ID: CRD42018117882]). METHOD A search was made of multiple databases (MEDLINE, CINAHL and EMBASE) using relevant search terms. Titles, abstracts and then full texts were filtered to find articles that met the strict inclusion/exclusion criteria. Searching, data extraction and quality assessment, using the Grading of Recommendations Assessment, Development and Evaluation, were done independently by two authors. To understand how the interventions impacted the duration of reported symptoms, results were split into three time points: short-term (<4 weeks), medium-term (4-12 weeks) and long-term (>12 weeks). RESULTS Thirteen studies (n = 534) met the criteria for inclusion. There was very low level of certainty for the effectiveness of interventions at short-term, medium-term and long-term follow ups. However, there were large effects seen across a number of different treatments on pain intensity and disability in LLTs. CONCLUSIONS This review demonstrates that limited evidence currently exists to guide the management of acute LLT, and the quality of the existing evidence is collectively low. These findings inform the discussion of different treatment options with patients in a shared decision-making process to empower and enable the patient.
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Affiliation(s)
| | - Adrian Mallows
- School of Sport, Rehabilitation & Exercise Sciences, University of Essex, Colchester, UK
| | - James Debenham
- School of Physiotherapy, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | | | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Monash University, Clayton, Victoria, Australia
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25
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Girgis B, Duarte JA. Physical therapy for tendinopathy: An umbrella review of systematic reviews and meta-analyses. Phys Ther Sport 2020; 46:30-46. [PMID: 32877858 DOI: 10.1016/j.ptsp.2020.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/01/2020] [Accepted: 08/04/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To summarize evidence in the last decade regarding the efficacy of physical therapy interventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs) and/or meta-analyses (MAs). METHODS Electronic search of PubMed, PEDro, and Scopus database was performed from year 2010 to January 2020. The methodological quality of the identified studies was assessed using the AMSTAR 2 tool. Studies scoring 9 points or higher were further analyzed using GRADE principles. RESULTS 40 SRs and/or MAs were included in qualitative synthesis, whereas only 5 MAs were included in quantitative synthesis. Low-level laser therapy (LLLT) intervention showed a pooled improvement in pain reduction of 1.53 cm; 95% CI, [1.14, 1.91] (I2 = 1.9%, p = 0.361) on visual analogue scale, and grip strength of 9.59 kg; 95% CI, [5.90, 13.27]. CONCLUSIONS Moderate-quality evidence may support these following interventions: LLLT revealed a statistically and potentially clinically significant improvement in pain and function on the short-term. Extracorporeal shockwave therapy showed a statistically significant enhancement in pain and function at all follow-up durations; however, its clinical significance was undetermined. Eccentric exercise was supported by qualitative evidence only. Caution is advised when interpreting results due to possible pathological differences in tendinopathy at each region.
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Affiliation(s)
- Beshoy Girgis
- CIAFEL, Faculty of Sport, University of Porto, R. Dr. Plácido Costa, 91, 4200-450, Porto, Portugal.
| | - José Alberto Duarte
- CIAFEL, Faculty of Sport, University of Porto, R. Dr. Plácido Costa, 91, 4200-450, Porto, Portugal.
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26
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Hasani F, Haines TP, Munteanu SE, Vicenzino B, Malliaras P. Efficacy of different load intensity and time-under-tension calf loading protocols for Achilles tendinopathy (the LOADIT trial): protocol for a randomised pilot study. Pilot Feasibility Stud 2020; 6:99. [PMID: 32685183 PMCID: PMC7359581 DOI: 10.1186/s40814-020-00639-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 06/29/2020] [Indexed: 02/08/2023] Open
Abstract
Background Modifying variables in exercise prescription can produce specific effects on Achilles tendinopathy outcomes. This study aims to determine the feasibility of conducting an adequately powered randomised trial in the future to assess the efficacy of different load intensity and time-under-tension exercise parameters for improving pain and function in individuals with persistent midportion Achilles tendinopathy. Methods The trial is designed as prospective, four-armed feasibility and randomised pilot trial with 3 months follow-up. Interventions will be provided in a gym setting. The investigator, who will be blind to the allocation of participants, will conduct all pre- and post-intervention assessments. Forty-eight male participants with Achilles tendinopathy will be recruited from the community. We will use a 2 × 2 factorial design with factors of load intensity (six or eighteen repetitions maximum) and time-under-tension (two or six second repetitions). Participants will be randomised into one of the testing groups: six RM with two second repetitions, six RM with six second repetitions, eighteen RM with two second repetitions or eighteen RM with six second repetitions. Trial feasibility will be indicated by the rate of conversion, recruitment and retention, adherence to the interventions by participants, the utility of videoconferencing mode for weekly exercise supervision, incidence of adverse events, and feasibility of future economic evaluation. The secondary clinical outcomes will assess pain and disability, participant impression of change, satisfaction, health-related quality of life, physical activity, work absenteeism, psychological measures at baseline, 6 and 12 weeks, and plantarflexor contractile dysfunction (torque, rate of force development and muscle force steadiness) at baseline and 12 weeks. These clinical outcomes are primarily measured to provide information regarding potential treatment effects and trends. Discussion The proposed study and follow-up powered randomised trial will be a first step towards determining exercise dose parameters that may optimise outcomes for Achilles tendinopathy. We have chosen to focus on load intensity and time-under-tension, as these parameters are important for tendon adaptation. This work has the potential to lead to more effective exercise loading interventions for Achilles tendinopathy. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12618001315202. Registered retrospectively on August 6th, 2018.
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Affiliation(s)
- Fatmah Hasani
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Frankston, Victoria 3199 Australia.,Physiotherapy Department, Security Forces Hospital Program, Riyadh, 11481 Kingdom of Saudi Arabia
| | - Terry P Haines
- School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Frankston, Victoria 3199 Australia
| | - Shannon E Munteanu
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria 3086 Australia.,La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria 3086 Australia
| | - Bill Vicenzino
- Sports Injuries Rehabilitation and Prevention for Health Research Unit, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland Australia
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Frankston, Victoria 3199 Australia
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Association Between Clinical and Imaging Outcomes After Therapeutic Loading Exercise in Patients Diagnosed With Achilles or Patellar Tendinopathy at Short- and Long-Term Follow-up: A Systematic Review. Clin J Sport Med 2020; 30:390-403. [PMID: 29952842 DOI: 10.1097/jsm.0000000000000624] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the association between clinical and imaging outcomes after therapeutic loading exercise in Achilles tendinopathy (AT) and patellar tendinopathy (PT) populations at both short- and long-term follow-up. DATA SOURCES The PUBMED and EMBASE databases were searched (up to June 2017) to identify articles that meet the inclusion criteria: (1) patients diagnosed with AT (insertional or midportion) or PT; (2) rehabilitation based on therapeutic loading exercise; and (3) assessment of clinical outcomes and tendon structure using an imaging modality. MAIN RESULTS Two independent reviewers screened 2894 search results, identifying 21 suitable studies. According to the studies included in this review, clinical results showed significant improvements for patients with AT and PT after eccentric exercise (ECC) and heavy slow resistance (HSR) at short- and long-term follow-up. Imaging outcomes were not consistent. Moderate-to-strong evidence for patients with AT suggested an association between clinical outcomes and imaging outcomes (tendon thickness and tendon neovascularization) after ECC at long-term follow-up. For patients with PT, there was moderate evidence supporting an association between clinical outcomes (questionnaire score and pain) and imaging (tendon thickness and tendon neovascularization) after ECC at short-term follow-up. For both the AT and PT groups, there was moderate evidence for an association between clinical outcomes and tendon thickness and neovascularization after HSR exercise. Results related to the HSR exercise should be interpreted with caution because of the small number of studies. CONCLUSIONS Based on the findings of the present review, the use of imaging outcomes as a complementary examination to the clinical assessment was confirmed. Overall, an improvement in clinical outcomes seems to be associated with a reduction in tendon thickness and tendon neovascularization. Clinicians should be aware that during the interpretation of the imaging outcomes, factors such as tendinopathy location, exercise modality performed, and a follow-up period should be considered.
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Extracorporeal Shock Wave Therapy Immediately Affects Achilles Tendon Structure and Widespread Pressure Pain Thresholds in Healthy People: A Repeated-Measures Observational Study. Am J Phys Med Rehabil 2020; 98:806-810. [PMID: 31021822 DOI: 10.1097/phm.0000000000001203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Extracorporeal shockwave therapy is a common clinical treatment for tendinopathy, yet negative effects on tendon structure have been shown in animal studies. This study aimed to investigate the effect of extracorporeal shockwave therapy in healthy participants (i.e., no Achilles tendon pain or pathology). DESIGN This study examined the effect of three bouts of weekly extracorporeal shockwave therapy for 3 wks in 13 healthy participants. Outcomes measures assessed were as follows: (a) Achilles tendon structure, quantified using ultrasound tissue characterization (before and 3 hrs after extracorporeal shockwave therapy), (b) pressure pain thresholds, over the Achilles tendon and common extensor tendon origin (before, immediately after, and 3 hrs after extracorporeal shockwave therapy), and (c) hop pain (before and immediately after extracorporeal shockwave therapy). RESULTS There was a significant reduction in echo type I (P < 0.05) and increase in echo type II (P < 0.05) at 3 hrs after the first extracorporeal shockwave therapy session that recovered to baseline levels before week 2. There were no significant changes in ultrasound tissue characterization echo pattern observed in subsequent sessions. There were increased pressure pain thresholds immediately after extracorporeal shockwave therapy at the common extensor tendon origin but no significant change at the Achilles tendon. Pressure pain thresholds returned to baseline at 3 hrs after extracorporeal shockwave therapy. There were no significant changes in pressure pain threshold in subsequent sessions. CONCLUSIONS Extracorporeal shockwave therapy resulted in transient changes to tendon structure and widespread hyperalgesia.
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Head J, Mallows A, Debenham J, Travers MJ, Allen L. The efficacy of loading programmes for improving patient-reported outcomes in chronic midportion Achilles tendinopathy: A systematic review. Musculoskeletal Care 2019; 17:283-299. [PMID: 31763774 DOI: 10.1002/msc.1428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/01/2019] [Accepted: 08/05/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Achilles tendinopathy is a common type of overuse condition, with isolated eccentric loading (ECL) programmes being the principal conservative treatment of choice. However, alternative protocols, involving different contraction types, have more recently been investigated. The purpose of the present review was to examine the evidence from studies comparing two or more different types of loading programmes in relation to patient-reported outcomes for people with Achilles tendinopathy. METHODS A systematic review was undertaken, and the risk of bias of included papers were assessed using the Cochrane Risk of Bias tool. An electronic search of CINAHL, MEDLINE, Embase and SPORTDiscus was undertaken from their inception to May 2018. The eligibility criteria for selecting studies were randomized controlled or clinical controlled trials investigating two or more different loading programmes for chronic (>3 months) Achilles tendinopathy. RESULTS Seven articles were included in the review. Low-quality evidence exists that a do-as-tolerated modification of the Alfredson programme is more effective than the standardized programme at improving function in the short term. Very-low-quality evidence suggests that ECL is superior at reducing pain levels than concentric in isolation, but no more effective at improving pain or disability than concentric-eccentric programmes. CONCLUSIONS There is conflicting evidence regarding the superiority of ECL over other contraction types, challenging the current approach to managing Achilles tendinopathy. There is also evidence that do-as-tolerated repetition volumes are more effective at improving function in the short term compared with those recommended by the standardized Alfredson protocol.
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Affiliation(s)
- John Head
- School of Sport Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex, UK
| | - Adrian Mallows
- School of Sport Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex, UK
| | - James Debenham
- School of Physiotherapy, The University of Notre Dame, Fremantle, WA, Australia
| | - Mervyn J Travers
- School of Physiotherapy, University of Notre Dame Australia, Fremantle, WA, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, WA, Australia
| | - Lorraine Allen
- School of Sport Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex, UK
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O'Neill S, Radia J, Bird K, Rathleff MS, Bandholm T, Jorgensen M, Thorborg K. Acute sensory and motor response to 45-s heavy isometric holds for the plantar flexors in patients with Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 2019; 27:2765-2773. [PMID: 29974171 PMCID: PMC6706360 DOI: 10.1007/s00167-018-5050-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 06/28/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to explore the immediate effects of heavy isometric plantar flexor exercise on sensory output (pain during a functional task and mechanical pain sensitivity) and motor output (plantar flexor torque) in individuals with Achilles tendinopathy. METHODS Sixteen subjects with Achilles tendinopathy participated in the study, mean (SD) age 48.6 (8.9) years and Victorian institute assessment-Achilles (VISA-A) score 61.3 (23.0). Sensory testing assessing pain during a functional task, mechanical pain sensitivity and motor output, and plantar flexor peak torque was completed prior to the intervention. All subjects completed a 45-s heavy isometric plantar flexor contraction and were then re-tested using the same sensory and motor tests. Motor output was assessed using isokinetic dynamometry at speeds previously identified as of interest in subjects with Achilles tendinopathy. RESULTS Only 9 of the 16 subjects experienced pain during a functional task, self-reported pain was 4.2 (1.9) numerical rating scale (NRS) pre-intervention and 4.9 (3.2) NRS postintervention (n.s.). Mechanical pressure sensitivity was 446.5 (± 248.5) g/mm2 pre-intervention and 411.8 (± 211.8) g/mm2 post-intervention (n.s.). Mean concentric plantar flexor torque at 90 and 225°/s was 47.1 (14.5) and 33.6 (11.6) Nm, respectively, pre-intervention and 53.0 (18.5) and 33.4 (6.6) Nm post-intervention (p = 0.039 and n.s.). Eccentric torque at 90°/s was 98.5 (34.2) Nm preintervention versus 106.0 (41.4) Nm post-intervention (n.s.). CONCLUSION In this exploratory study, patients with Achilles tendinopathy had a varied sensory and motor output response to heavy isometric contractions. Using the recommended approach of heavy 45-s isometric contractions did not offer a meaningful acute benefit for sensory or motor output for subjects with Achilles tendinopathy. Based on this study, heavy 45-s isometric contractions cannot be recommended for immediate pain relief or improved motor output for patients with Achilles tendinopathy. LEVEL OF EVIDENCE IV, prospective cohort study.
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Affiliation(s)
- S O'Neill
- School of Allied Health, University of Leicester, Leicester, UK.
| | - J Radia
- School of Allied Health, University of Leicester, Leicester, UK
| | - K Bird
- School of Allied Health, University of Leicester, Leicester, UK
| | - M S Rathleff
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - T Bandholm
- Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Clinical Research Center, Amager-Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopedic Surgery, Clinical Research Center, Amager-Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M Jorgensen
- Department of Geriatrics, Aalborg University Hospital, Aalborg, Denmark
| | - K Thorborg
- Sport Orthopedic Research Center-Copenhagen (SORC-C), Amager-Hvidovre University Hospital, Copenhagen, Denmark
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Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: A single cohort feasibility study. Phys Ther Sport 2019; 40:107-116. [PMID: 31518777 DOI: 10.1016/j.ptsp.2019.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/13/2019] [Accepted: 08/13/2019] [Indexed: 01/10/2023]
Abstract
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.
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McAuliffe S, Tabuena A, McCreesh K, O'Keeffe M, Hurley J, Comyns T, Purtill H, O'Neill S, O'Sullivan K. Altered Strength Profile in Achilles Tendinopathy: A Systematic Review and Meta-Analysis. J Athl Train 2019; 54:889-900. [PMID: 31386582 DOI: 10.4085/1062-6050-43-18] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Persistent strength deficits secondary to Achilles tendinopathy (AT) have been postulated to account for difficulty engaging in tendon-loading movements, such as running and jumping, and may contribute to the increased risk of recurrence. To date, little consensus exists on the presence of strength deficits in AT. Consequently, researchers are uncertain about the appropriate methods of assessment that may inform rehabilitation in clinical practice. OBJECTIVE To evaluate and synthesize the literature investigating plantar-flexion (PF) strength in individuals with AT. STUDY SELECTION Two independent reviewers searched 9 electronic databases using an agreed-upon set of key words. DATA EXTRACTION Data were extracted from studies comparing strength measures (maximal, reactive, and explosive strength) between individuals with AT and healthy control participants or between the injured and uninjured sides of people with AT. The Critical Appraisal Skills Programme Case-Control Study Checklist was used to assess the risk of bias for the included studies. DATA SYNTHESIS A total of 19 studies were eligible. Pooled meta-analyses for isokinetic dynamometry demonstrated reductions in maximal strength (concentric PF peak torque [PT] slow [Hedges g = 0.52, 44% deficit], concentric PF PT fast [Hedges g = 0.61, 38% deficit], and eccentric PF PT slow [Hedges g = 0.26, 18% deficit]). Reactive strength, particularly during hopping, was also reduced (Hedges g range = 0.32-2.61, 16%-35% deficit). For explosive strength, reductions in the rate of force development (Hedges g range = 0.31-1.73, 10%-21% deficit) were observed, whereas the findings for ground reaction force varied but were not consistently altered. CONCLUSIONS Individuals with AT demonstrated strength deficits compared with the uninjured side or with asymptomatic control participants. Deficits were reported across the strength spectrum for maximal, reactive, and explosive strength. Clinicians and researchers may need to adapt their assessment of Achilles tendon function, which may ultimately help to optimize rehabilitation outcomes.
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Affiliation(s)
- Seán McAuliffe
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Ariane Tabuena
- School of Allied Health, University of Limerick, Ireland
| | - Karen McCreesh
- School of Allied Health, University of Limerick, Ireland
| | - Mary O'Keeffe
- School of Allied Health, University of Limerick, Ireland
| | - John Hurley
- School of Allied Health, University of Limerick, Ireland
| | - Tom Comyns
- Department of Physical Education and Sports Science, University of Limerick, Ireland
| | - Helen Purtill
- Department of Mathematics & Statistics, University of Limerick, Ireland
| | - Seth O'Neill
- Department of Medical & Social Care Education, University of Leicester, United Kingdom
| | - Kieran O'Sullivan
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,School of Allied Health, University of Limerick, Ireland
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Rabusin CL, Menz HB, McClelland JA, Evans AM, Landorf KB, Malliaras P, Docking SI, Munteanu SE. Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (the HEALTHY trial): study protocol for a randomised trial. J Foot Ankle Res 2019; 12:20. [PMID: 30949243 PMCID: PMC6429802 DOI: 10.1186/s13047-019-0325-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/27/2019] [Indexed: 11/10/2022] Open
Abstract
Background Mid-portion Achilles tendinopathy is a common musculoskeletal condition characterised by degeneration of the Achilles tendon, which causes pain and disability. Multiple non-surgical treatments have been advocated for this condition including calf muscle eccentric exercise and in-shoe heel lifts. Although adherence is challenging, there is evidence to suggest that calf muscle eccentric exercise is effective in decreasing pain and improving function in people with Achilles tendinopathy. Heel lifts reduce ankle joint dorsiflexion and Achilles tendon strain, however their efficacy in the management of Achilles tendinopathy is unclear. This article describes the design of a parallel-group randomised trial comparing the efficacy of heel lifts to calf muscle eccentric exercise for Achilles tendinopathy. Methods Ninety-two participants with Achilles tendinopathy will be randomised to one of two groups: (i) a heel lift group that will receive pre-fabricated 12 mm in-shoe heel lifts (Clearly Adjustable®), or (ii) an exercise group that will be advised to carry out a calf muscle eccentric exercise program (twice a day, 7 days a week, for 12 weeks). Outcome measures will be obtained at baseline, 2, 6 and 12 weeks; the primary endpoint for assessing efficacy being 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. Secondary outcome measures will include thickness and integrity of the Achilles tendon (using ultrasound tissue characterisation [UTC]), participant perception of treatment effect on pain and function (using the 7-point Patient Global Impression of Change scale), severity of pain at the Achilles tendon (using a 100 mm visual analogue scale) in the previous week, health status (using the EuroQol-5D-5L™ questionnaire), physical activity levels (using the 7-day Recall Physical Activity Questionnaire) and calf muscle function (using the standing heel rise test). Data will be analysed using the intention to treat principle. Discussion The HEALTHY trial (Heel lifts versus calf muscle eccentric Exercise for AchiLles TendinopatHY) is the first randomised trial to compare the efficacy of heel lifts to calf muscle eccentric exercise in reducing pain and improving function in people with Achilles tendinopathy. A pragmatically designed trial was developed to ensure that if the interventions are found to be effective, the findings can be readily implemented in clinical practice. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12617001225303. Registered on August 22nd, 2017.
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Affiliation(s)
- Chantel L Rabusin
- 1Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia.,3La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia
| | - Hylton B Menz
- 1Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia.,3La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia
| | - Jodie A McClelland
- 2Discipline of Physiotherapy, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia.,3La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia
| | - Angela M Evans
- 1Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia
| | - Karl B Landorf
- 1Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia.,3La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia
| | - Peter Malliaras
- 4Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria 3199 Australia
| | - Sean I Docking
- 3La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia
| | - Shannon E Munteanu
- 1Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia.,3La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia
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Stefansson SH, Brandsson S, Langberg H, Arnason A. Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol. Orthop J Sports Med 2019; 7:2325967119834284. [PMID: 30915381 PMCID: PMC6429908 DOI: 10.1177/2325967119834284] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Eccentric exercises are the only conservative treatment that has shown good clinical results in studies of Achilles tendinopathy (AT), but success rates vary, indicating the need for alternative treatments. Soft tissue treatments are widely used for AT, but strong scientific evidence is lacking to support those treatments. Purpose/Hypotheses This study aimed to determine whether pressure massage to the calf muscles is a useful treatment for AT and to compare this treatment versus an eccentric exercise protocol. Our first hypothesis was that pressure massage treatment is equivalent or superior to eccentric exercises with regard to pain reduction time (ie, pain would be reduced more quickly with pressure massage). The second hypothesis was that pressure massage is equivalent or superior to eccentric exercises with regard to function of the calf muscles. Study Design Randomized controlled trial; Level of evidence, 1. Methods A total of 60 patients with AT were randomized into 3 groups: group 1 underwent an eccentric exercise protocol, group 2 underwent pressure massage, and group 3 underwent pressure massage and the eccentric exercise protocol. Patients were evaluated with the Icelandic version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-IS), an algometer to test the pressure pain threshold (PPT) of the Achilles tendon, tests for ankle range of motion (ROM), and real-time ultrasonographic (US) scanning of tendon thickness and degree of neovascularization. Measurements for VISA-A-IS, PPT, and ROM were taken at 0, 4, 8, 12, and 24 weeks. US scan measurements were taken at 0, 12, and 24 weeks. Mixed-model analysis of variance was used for statistical analysis. Results All groups improved when evaluated with VISA-A-IS scores (P < .0001). The pressure massage group improved significantly more than the eccentric exercise group at week 4, which was the only between-group difference. Ankle ROM increased significantly over time (ROM bent knee P = .006 and ROM straight knee P = .034), but no significant difference was found between groups. No significant difference was found in evaluations of PPT or US scan measurements. Conclusion Pressure massage is a useful treatment for Achilles tendinopathy. Compared with eccentric exercise treatment, pressure massage gives similar results. Combining the treatments did not improve the outcome.
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Affiliation(s)
- Stefan H Stefansson
- The Research Centre of Movement Science, Department of Physical Therapy, University of Iceland, Reykjavik, Iceland.,Physical Therapy and Medical Centre, Orkuhusid, Reykjavik, Iceland
| | | | - Henning Langberg
- CopenRehab, Institute of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Arni Arnason
- The Research Centre of Movement Science, Department of Physical Therapy, University of Iceland, Reykjavik, Iceland.,Gaski Physical Therapy, Reykjavik, Iceland
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Freed L, Ellis MB, Johnson K, Haddon TB. Fasciotomy and Surgical Tenotomy for Chronic Achilles Insertional Tendinopathy A Retrospective Study Using Ultrasound-Guided Percutaneous Microresection. J Am Podiatr Med Assoc 2019; 109:1-8. [PMID: 30964321 DOI: 10.7547/15-168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Achilles insertional tendon pathology is a common condition affecting a broad range of patients. When conservative treatments are unsuccessful, the traditional open resection, debridement, and reattachment of the Achilles tendon is a variably reliable procedure with significant risk of morbidity. Fasciotomy and surgical tenotomy using ultrasound-guided percutaneous microresection is used on various tendons in the body, but the efficacy has not been examined specifically for the Achilles tendon. METHODS A retrospective review evaluated 26 procedures in 25 patients who underwent Achilles fasciotomy and surgical tenotomy. The Foot Function Index was used to quantify pain, disability, activity limitation, and overall scores. RESULTS Mean Foot Function Index scores were as follows: pain, 8.53%; disability, 7.91%; activity limitation, 2.50%; and overall, 6.97%. Twenty index procedures were successful, and two patients repeated the procedure successfully for an overall 84.6% success rate in patients with chronic insertional pathology with mean surveillance of 16 months. There were no infections or systemic complications. CONCLUSIONS Ultrasound-guided percutaneous microresection is a safe and minimally invasive percutaneous alternative that can be used before proceeding to a more invasive open procedure.
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Affiliation(s)
- Lewis Freed
- East Valley Foot and Ankle Specialists, Mesa, AZ
| | - Mark B. Ellis
- Department of Podiatry, George E. Wahlen VA Medical Center, Salt Lake City, UT
| | - Kate Johnson
- A Step Ahead Foot and Ankle Center, Fort Collins, CO
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Riel H, Vicenzino B, Jensen MB, Olesen JL, Holden S, Rathleff MS. The effect of isometric exercise on pain in individuals with plantar fasciopathy: A randomized crossover trial. Scand J Med Sci Sports 2018; 28:2643-2650. [PMID: 30203866 DOI: 10.1111/sms.13296] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 01/02/2023]
Abstract
Isometric exercise is commonly recommended for immediate pain relief in individuals suffering from lower limb tendinopathies, despite the limited evidence supporting its analgesic effect. Due to the similarities between plantar fasciopathy and tendinopathies, the aim of this trial was to investigate the acute effect of isometric exercise on pain, compared to isotonic exercise, or walking, in individuals with plantar fasciopathy. We recruited 20 individuals with plantar fasciopathy for this prospectively-registered, participant-blinded, randomized, superiority crossover trial (ClinicalTrials.gov: NCT03264729). Participants attended three exercise sessions (isometric, isotonic, or walking) in a randomized order, within a 2-week period. Both isometric and isotonic exercises were performed standing with the forefoot on a step bench, while walking was performed barefoot. The primary outcome was pain (measured on a 0-100-mm VAS) during a pain-aggravating activity. Secondary outcomes included pressure pain threshold (PPT) under the heel, and plantar fascia thickness (PFT). All outcomes were measured before and after each exercise session. There were no significant differences between the three exercises on pain (P = 0.753), PPTs (P = 0.837), or PFT (P = 0.718). Further, there was no change in pain from before to after any of the exercises (isometric exercise 2.7 mm [95% CI: -12.2; 6.8], isotonic exercise -3.4 mm [95% CI: -5.0; 11.8], or walking 1.6 mm [95% CI: -16.1; 12.9]). Contrary to expectations, isometric exercise was no better than isotonic exercise or walking at reducing pain in individuals with plantar fasciopathy. None of the exercises induced any systematic analgesic effect.
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Affiliation(s)
- Henrik Riel
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg East, Denmark
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences: Physiotherapy: Sports Injury Rehabilitation and Prevention for Health, The University of Queensland, St. Lucia, Queensland, Australia
| | - Martin Bach Jensen
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg East, Denmark
| | - Jens Lykkegaard Olesen
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg East, Denmark.,Institute of Sports Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Sinead Holden
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg East, Denmark.,Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg East, Denmark
| | - Michael Skovdal Rathleff
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg East, Denmark.,Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg East, Denmark.,Department of occupational therapy and physiotherapy, Aalborg University Hospital, Aalborg, Denmark
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Wilson F, Walshe M, O'Dwyer T, Bennett K, Mockler D, Bleakley C. Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis. Br J Sports Med 2018; 52:1564-1574. [PMID: 30170996 DOI: 10.1136/bjsports-2017-098913] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To assess the efficacy of exercise, orthoses and splinting on function, pain and quality of life (QoL) for the management of mid-portion and insertional Achilles tendinopathy, and to compare different types, applications and modes of delivery within each intervention category. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, CINAHL, Embase, AMED, WHO ICTRP, Web of Science, PEDro and Cochrane Library from inception to October 2017. Citation tracking of published studies and conference proceedings and contacting experts in the field. STUDY ELIGIBILITY CRITERIA Controlled clinical trials evaluating either exercise, orthoses or splinting for the management of Achilles tendinopathy. METHODS Independent reviewers undertook searches, screening and risk of bias appraisal. Primary outcomes of interest were function, pain and QoL. RESULTS Twenty-two studies were included (1137 participants). Moderate level evidence favoured eccentric exercise over control for improving pain and function in mid-portion tendinopathy. Moderate level evidence favoured eccentric exercise over concentric exercise for reducing pain. There was moderate level evidence of no significant difference in pain or function between eccentric exercise and heavy slow resistance exercise. There was low level evidence that eccentric exercise was not superior to stretching for pain or QoL. There was moderate level evidence that a combined exercise protocol was not superior to a lower dosage protocol for improving functional performance. There was moderate to low level evidence of a significant difference in pain (mean difference (MD) 6.3 mm, 95% CI -4.45 to 17.04, moderate) or function (MD 1.83 Victoria Institute of Sport Assessment points, 95% CI -7.47 to 11.12, low) between high-dose and low-dose eccentric training. There was high to moderate level evidence of no difference in pain (moderate) or function (high) between orthoses and control. There was low level evidence of no significant benefit in adding a night splint to an eccentric exercise programme for function, and moderate level evidence for no reduction in pain (MD -3.50, 95% CI -10.49 to 3.48). Eccentric exercise was not superior to splinting for pain (moderate evidence) or function (low level evidence). SUMMARY We conditionally recommend exercise for improving pain and function in mid-portion Achilles tendinopathy. The balance of evidence did not support recommendation of one type of exercise programme over another. We conditionally recommend against the addition of a splint to an eccentric exercise protocol and we do not recommend the use of orthoses to improve pain and function in Achilles tendinopathy.
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Affiliation(s)
- Fiona Wilson
- School of Medicine, Discipline of Physiotherapy, Trinity College Dublin, Dublin, Ireland
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Tom O'Dwyer
- School of Medicine, Discipline of Physiotherapy, Trinity College Dublin, Dublin, Ireland
| | - Kathleen Bennett
- RCSI Population and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David Mockler
- John Stearne Library, Trinity Centre for Health Sciences, St. James Hospital, Dublin, Ireland
| | - Christopher Bleakley
- Department of Physical Therapy, Congdon School of Health Sciences, High Point University, High Point, North Carolina, USA
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38
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Vasta S, Papalia R, Albo E, Maffulli N, Denaro V. Top orthopedic sports medicine procedures. J Orthop Surg Res 2018; 13:190. [PMID: 30064451 PMCID: PMC6069744 DOI: 10.1186/s13018-018-0889-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 07/12/2018] [Indexed: 12/14/2022] Open
Abstract
Orthopedic sports medicine is a subspecialty of Orthopedics that focuses on managing pathological conditions of the musculoskeletal system arising from sports practice. When dealing with athletes, timing is the most difficult issue to face. Typically, athletes aim to return to play as soon as possible and at the pre-injury level. This means that management should be optimized to combine the need for prompt return to sport and to the biologic healing time of the musculo-skeletal. This poses a great challenge to sport medicine surgeons, who need to follow with attention to the latest scientific evidence to offer their patients the best available treatment options. We briefly review the most commonly performed orthopedic sports medicine procedures, outlining the presently available scientific evidence on their indications and outcomes.
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Affiliation(s)
- Sebastiano Vasta
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico, University of Rome, Via Alvaro del Portillo, 200, Rome, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico, University of Rome, Via Alvaro del Portillo, 200, Rome, Italy.
| | - Erika Albo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico, University of Rome, Via Alvaro del Portillo, 200, Rome, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine, Salerno, Italy.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico, University of Rome, Via Alvaro del Portillo, 200, Rome, Italy
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39
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Kay MC, Kucera KL. Mixed Methods Designs for Sports Medicine Research. Clin Sports Med 2018; 37:401-412. [PMID: 29903382 DOI: 10.1016/j.csm.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Mixed methods research is a relatively new approach in the field of sports medicine, where the benefits of qualitative and quantitative research are combined while offsetting the other's flaws. Despite its known and successful use in other populations, it has been used minimally in sports medicine, including studies of the clinician perspective, concussion, and patient outcomes. Therefore, there is a need for this approach to be applied in other topic areas not easily addressed by one type of research approach in isolation, such as the retirement from sport, effects of and return from injury, and catastrophic injury.
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Affiliation(s)
- Melissa C Kay
- Department of Exercise and Sport Science, Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, University of North Carolina at Chapel Hill, 209 Fetzer Hall, CB #8700, Chapel Hill, NC 27599, USA.
| | - Kristen L Kucera
- Department of Exercise and Sport Science, Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, University of North Carolina at Chapel Hill, 209 Fetzer Hall, CB #8700, Chapel Hill, NC 27599, USA
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40
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Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther 2018; 48:A1-A38. [PMID: 29712543 DOI: 10.2519/jospt.2018.0302] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.
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Moya D, Ramón S, Schaden W, Wang CJ, Guiloff L, Cheng JH. The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders. J Bone Joint Surg Am 2018; 100:251-263. [PMID: 29406349 DOI: 10.2106/jbjs.17.00661] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Daniel Moya
- Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Silvia Ramón
- Hospital Quirón, Barcelona, Fundación García Cugat, Spain
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42
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Mascaró A, Cos MÀ, Morral A, Roig A, Purdam C, Cook J. Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.apunts.2017.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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43
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Barton CJ, Merolli MA. It is time to replace publish or perish with get visible or vanish: opportunities where digital and social media can reshape knowledge translation. Br J Sports Med 2017; 53:594-598. [PMID: 29146754 DOI: 10.1136/bjsports-2017-098367] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Christian J Barton
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Victoria, Australia
| | - Mark A Merolli
- School of Health Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia.,Health and Biomedical Informatics Centre, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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Habets B, van Cingel REH, Backx FJG, Huisstede BMA. Alfredson versus Silbernagel exercise therapy in chronic midportion Achilles tendinopathy: study protocol for a randomized controlled trial. BMC Musculoskelet Disord 2017; 18:296. [PMID: 28693535 PMCID: PMC5504829 DOI: 10.1186/s12891-017-1656-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/04/2017] [Indexed: 11/10/2022] Open
Abstract
Background Midportion Achilles tendinopathy (AT) is a common overuse injury, usually requiring several months of rehabilitation. Exercise therapy of the ankle plantar flexors (i.e. tendon loading) is considered crucial during conservative rehabilitation. Alfredson’s isolated eccentric and Silbernagel’s combined concentric-eccentric exercise programs have both shown beneficial results, but it is unknown whether any of these programs is superior for use in clinical practice. Therefore, the primary objective of this study is to compare the effectiveness of both programs on clinical symptoms. Secondary objectives are to compare the effectiveness of both programs on quality of life and functional outcome measures, to investigate the prognostic value of baseline characteristics, to investigate differences in cost-effectiveness. Methods/Design Eighty-six recreational athletes (21–60 years of age) with unilateral chronic midportion AT (i.e. ≥ 3 months) will be included in this multicenter assessor blinded randomized controlled trial. They will be randomly allocated to either a group performing the Alfredson isolated eccentric training program (n = 43), or a group performing the Silbernagel combined concentric-eccentric program (n = 43). In the Alfredson group, participants will perform eccentric heel-drops on their injured side, twice daily for 12 weeks, whereas in the Silbernagel group, participants perform various concentric-eccentric heel-raise exercises, once daily for 12 weeks. Primary outcome measure will be the Victorian Institute of Sport Assessment – Achilles (VISA-A) questionnaire. Secondary outcomes will be a visual analogue scale (VAS) for pain during daily activities and sports, duration of morning stiffness, global perceived effect, the 12-item Short Form Health Survey and the Euroqol instrument, and functional performance measured with the heel-raise test and the countermovement jump. Additionally, alongside the RCT, a cost-effectiveness analysis will be performed. Assessments will be performed at baseline and after 12, 26, and 52 weeks. Discussion This study is the first to directly compare the Alfredson and the Silbernagel exercise program in a randomized trial. The results can further enlarge the evidence base for choosing the most appropriate exercise program for patients with midportion AT. Trial registration Dutch Trial register: NTR5638. Date of registration: 7 January 2016.
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Affiliation(s)
- Bas Habets
- Papendal Sports Medical Center, Papendallaan 7, 6816 VD, Arnhem, The Netherlands. .,Department of Rehabilitation, Physical Therapy Science and Sports, Rudolf Magnus Institute of Neurosciences, University Medical Center Utrecht, P.O. Box 85500, Utrecht, 3508 GA, The Netherlands.
| | - Robert E H van Cingel
- Papendal Sports Medical Center, Papendallaan 7, 6816 VD, Arnhem, The Netherlands.,Research Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Frank J G Backx
- Department of Rehabilitation, Physical Therapy Science and Sports, Rudolf Magnus Institute of Neurosciences, University Medical Center Utrecht, P.O. Box 85500, Utrecht, 3508 GA, The Netherlands
| | - Bionka M A Huisstede
- Department of Rehabilitation, Physical Therapy Science and Sports, Rudolf Magnus Institute of Neurosciences, University Medical Center Utrecht, P.O. Box 85500, Utrecht, 3508 GA, The Netherlands
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45
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Boesen AP, Hansen R, Boesen MI, Malliaras P, Langberg H. Effect of High-Volume Injection, Platelet-Rich Plasma, and Sham Treatment in Chronic Midportion Achilles Tendinopathy: A Randomized Double-Blinded Prospective Study. Am J Sports Med 2017; 45:2034-2043. [PMID: 28530451 DOI: 10.1177/0363546517702862] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse. PURPOSE To determine whether eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment-Achilles [VISA-A]). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up. RESULTS VISA-A scores improved in all groups at all time points ( P < .05), with greater improvement in the HVI group (mean ± SEM, 6 weeks = 27 ± 3 points; 12 weeks = 29 ± 4 points) versus PRP (6 weeks = 14 ± 4; 12 weeks = 15 ± 3) and placebo (6 weeks = 10 ± 3; 12 weeks = 11 ± 3) at 6 and 12 weeks ( P < .01) and in the HVI (22 ± 5) and PRP (20 ± 5) groups versus placebo (9 ± 3) at 24 weeks ( P < .01). VAS scores improved in all groups at all time points ( P < .05), with greater decrease in HVI (6 weeks = 49 ± 4 mm; 12 weeks = 45 ± 6 mm; 24 weeks = 34 ± 6 mm) and PRP (6 weeks = 37 ± 7 mm; 12 weeks = 41 ± 7 mm; 24 weeks = 37 ± 6 mm) versus placebo (6 weeks = 23 ± 6 mm; 12 weeks = 30 ± 5 mm; 24 weeks = 18 ± 6 mm) at all time points ( P < .05) and in HVI versus PRP at 6 weeks ( P < .05). Tendon thickness showed a significant decrease only in HVI and PRP groups during the intervention, and this was greater in the HVI versus PRP and placebo groups at 6 and 12 weeks ( P < .05) and in the HVI and PRP groups versus the placebo group at 24 weeks ( P < .05). Muscle function improved in the entire cohort with no difference between the groups. CONCLUSION Treatment with HVI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. Registration: NCT02417987 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Anders Ploug Boesen
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Orthopaedic Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Rudi Hansen
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Peter Malliaras
- Department of Physiotherapy, School of Primary Health Care Faculty of Medicine, Nursing and Health Science, Monash University, Frankston, Victoria, Australia
| | - Henning Langberg
- CopenRehab, Institute of Social Medicine, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Habets B, Smits H, Backx F, van Cingel R, Huisstede B. Hip muscle strength is decreased in middle-aged recreational male athletes with midportion Achilles tendinopathy: A cross-sectional study. Phys Ther Sport 2017; 25:55-61. [DOI: 10.1016/j.ptsp.2016.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/21/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
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McClinton S, Luedke L, Clewley D. Nonsurgical Management of Midsubstance Achilles Tendinopathy. Clin Podiatr Med Surg 2017; 34:137-160. [PMID: 28257671 DOI: 10.1016/j.cpm.2016.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery.
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Affiliation(s)
- Shane McClinton
- Doctor of Physical Therapy Program, Des Moines University, 3200 Grand Avenue, Des Moines, IA 50312, USA.
| | - Lace Luedke
- Kinesiology Department, University of Wisconsin-Oshkosh, 108B Albee Hall, 800 Algoma Boulevard, Oshkosh, WI 54901, USA
| | - Derek Clewley
- Division of Doctor of Physical Therapy, Duke University, 2200 West Main Street, B-230, Durham, NC 27705, USA
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48
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Izukura H, Miyagi M, Harada T, Ohshiro T, Ebihara S. Low Level Laser Therapy in patients with chronic foot and ankle joint pain. Laser Ther 2017; 26:19-24. [PMID: 28740325 PMCID: PMC5515707 DOI: 10.5978/islsm.17-or-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 12/20/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIMS Chronic foot and ankle joint pain is one of the most frequent complaints which is regularly seen in the out-patient clinic of our medical institute. In previous studies we have reported on the benefits of low level laser therapy (LLLT) for chronic pain in the elbow, hand, finger and the lower back. The present study examined the effects of LLLT on chronic foot and ankle joint pain. MATERIALS AND METHODS Over the past 5 years, 17 subjects visited the out-patient clinic with complaints of chronic foot and ankle joint pain of a variety of aetiologies. The patients received LLLT using a 1000 mW semi-conductor laser device, delivering 20.1 J/cm2 per point at 830 nm in continuous wave. Each patient was given four shots per session per foot twice a week for 4 weeks. RESULTS A visual analogue scale (VAS) was used to determine the effects of LLLT for the chronic pain and after the end of the treatment regimen a significant improvement was observed (p < 0.01). All but 2 of the patients showed improvement: excellent (2) and good (13). After treatment, no significant differences were observed in the ankle joint range of motion, however. Discussions with the patients revealed that it was important for them to learn how to avoid overuse of the ankle when walking, poor walking posture and a poor pacing technique that would caused them foot and ankle pain in everyday life. Following these postural guidelines could ensure continuous benefits from the treatment. CONCLUSION The present study demonstrated that LLLT was an effective form of treatment for chronic foot and ankle joint pain, in conjunction with postural education during all activities of daily living.
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Affiliation(s)
- Hideaki Izukura
- Department of Rehabilitation Medicine Toho University School of Medicine; and
| | - Midori Miyagi
- Department of Rehabilitation Medicine Toho University School of Medicine; and
| | - Takashi Harada
- Department of Rehabilitation Medicine Toho University School of Medicine; and
| | - Toshio Ohshiro
- Japan Medical Laser Laboratory, Shinanomachi Shinjuku-ku Tokyo Japan
| | - Satoru Ebihara
- Department of Rehabilitation Medicine Toho University School of Medicine; and
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Lui PPY. Tendinopathy in diabetes mellitus patients-Epidemiology, pathogenesis, and management. Scand J Med Sci Sports 2017; 27:776-787. [PMID: 28106286 DOI: 10.1111/sms.12824] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2016] [Indexed: 12/15/2022]
Abstract
Chronic tendinopathy is a frequent and disabling musculo-skeletal problem affecting the athletic and general populations. The affected tendon is presented with local tenderness, swelling, and pain which restrict the activity of the individual. Tendon degeneration reduces the mechanical strength and predisposes it to rupture. The pathogenic mechanisms of chronic tendinopathy are not fully understood and several major non-mutually exclusive hypotheses including activation of the hypoxia-apoptosis-pro-inflammatory cytokines cascade, neurovascular ingrowth, increased production of neuromediators, and erroneous stem cell differentiation have been proposed. Many intrinsic and extrinsic risk/causative factors can predispose to the development of tendinopathy. Among them, diabetes mellitus is an important risk/causative factor. This review aims to appraise the current literature on the epidemiology and pathology of tendinopathy in diabetic patients. Systematic reviews were done to summarize the literature on (a) the association between diabetes mellitus and tendinopathy/tendon tears, (b) the pathological changes in tendon under diabetic or hyperglycemic conditions, and (c) the effects of diabetes mellitus or hyperglycemia on the outcomes of tendon healing. The potential mechanisms of diabetes mellitus in causing and exacerbating tendinopathy with reference to the major non-mutually exclusive hypotheses of the pathogenic mechanisms of chronic tendinopathy as reported in the literature are also discussed. Potential strategies for the management of tendinopathy in diabetic patients are presented.
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Affiliation(s)
- P P Y Lui
- Headquarter, Hospital Authority, Hong Kong SAR, China
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Sanz-López F, Berzosa Sánchez C, Hita-Contreras F, Cruz-Diaz D, Martínez-Amat A. Ultrasound Changes in Achilles Tendon and Gastrocnemius Medialis Muscle on Squat Eccentric Overload and Running Performance. J Strength Cond Res 2016; 30:2010-8. [PMID: 26677829 DOI: 10.1519/jsc.0000000000001298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Sanz-López, F, Berzosa Sánchez, C, Hita-Contreras, F, Cruz-Diaz, D, and Martínez-Amat, A. Ultrasound changes in Achilles tendon and gastrocnemius medialis muscle on squat eccentric overload and running performance. J Strength Cond Res XX(X): 000-000, 2015-Previous studies have proven the adaptation to load in the Achilles tendon and gastrocnemius muscle after different types of exercise, such as running, heel drop training, and a variety of sports. These findings have been applied to improve performance and in the treatment and prevention of overuse injuries. However, the effects that squat performance may have on the Achilles tendon and gastrocnemius muscle are still unknown. Squats are a widely used training exercise that involves calf-muscle activation. Similarly, no reports have been published regarding the adaptation to load of trained and untrained subjects during several consecutive days of running. The purpose of this study was to analyze changes in the Achilles tendon and in the pennation angles of the gastrocnemius medialis after eccentric overload training and within 3 days of running. Twenty healthy males who volunteered for this study were divided into 2 groups. Subjects in the eccentric overload training (ECC) group performed 6 weeks of eccentric overload training (twice weekly, 4 sets of 7 repetitions in a Yoyo squat device) before the running intervention. All participants, ECC and control (CONT) groups, ran on 3 consecutive days. After the eccentric training, an increase in the cross-sectional area of the Achilles tendon and in the pennation angle was observed. As for the running intervention, the behavior of tissues in both groups was similar. These results suggest that eccentric overload training with squats promotes changes in the Achilles tendon and in the pennation angle of the gastrocnemius medialis muscle. Nevertheless, significant changes in the tissue do not appear between the running performance of trained and untrained subjects.
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Affiliation(s)
- Fernando Sanz-López
- 1ValorA Research Group, Health Sciences Faculty, Universidad San Jorge, Zaragoza, Spain; 2Department of Health Sciences, Faculty of Health Sciences, University of Jaén, Jaén, Spain; and 3Research Group CTS-026 "Study Group on Physical Activity, Physiotherapy and Health"
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