Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness

Effects of high frequency strengthening on pain sensitivity and function in female runners with chronic patellofemoral pain

OBJECTIVE

To investigate the effects of a high frequency strengthening program on function, pain, and pain sensitization in female runners with chronic patellofemoral pain (PFP).

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Thirty female runners (mean age 32 ± 8.1 years) with chronic PFP completed an 8-week home strengthening program.

MAIN OUTCOME MEASURES

Variables assessed at baseline, 8-weeks, and 12 weeks included single leg step down test (SLSD), pain, Anterior Knee Pain Scale (AKPS), University of Wisconsin Running Injury and Recovery Index (UWRI), and quantitative sensory testing.

RESULTS

There was large and statistically significant improvement at 8 and 12 weeks for average knee pain (ηp2 = 0.334, p < 0.001), worst knee pain (ηp2 = 0.351, p < 0.001), SLSD (ηp2 = 0.161, p = 0.001), AKPS (ηp2 = 0.463, p < 0.001), and UWRI (ηp2 = 0.366, p < 0.001). A medium to large effect and statistically significant improvement in pressure pain threshold testing was found for all local and remote structures (ηp2 range, 0.110 to 0.293, range p < 0.001 to p = 0.009) at 8 and 12 weeks.

CONCLUSIONS

There was a significant decrease in local and remote hyperalgesia via mechanical and thermal pain sensitivity testing in female runners with chronic PFP. There was a large effect and significant improvement in self-reported pain and function.

Therapeutic exercises in the clinical practice of Brazilian physical therapists in the management of rotator cuff tendinopathy: An online survey

The objective of this study was to investigate how Brazilian physical therapists (PTs) use therapeutic exercises in the rehabilitation of individuals with rotator cuff (RC) tendinopathy. The study used an online survey with a mix of 62 open- and closed-ended questions divided into three sections: participant demographics, professional experience, and clinical practice in the rehabilitation of patients with RC tendinopathy. One hundred and fifty-nine Brazilian physical therapists completed the survey. Most of our sample recommended isometric exercises (69.9%) in the initial phase of rehabilitation and eccentric exercises (47.4%) in the advanced phase. However, there was a wide variability in determining the volume of exercises, particularly with isometric exercises. Most of our sample considered patient comfort and pain levels when adjusting exercise intensity, regardless of exercise type. The majority (48.40%) recommended weekly reassessment and modification of exercises. Additionally, despite pain being a key factor for discharge and the primary adverse effect of exercise, most of our sample would not discontinue exercises in case of pain during the early and late phases of rehabilitation. Despite the lack of consensus on some aspects, the clinical practice of our sample is in line with the current literature and practice in other countries. However, further research and implementation are crucial to enhance future rehabilitation outcomes, including exploring the exercise training volume, the safety and effectiveness of exercising with pain and identifying the optimal pain level for best results.

Individual distribution of muscle hypertrophy among hamstring muscle heads: Adding muscle volume where you need is not so simple

PURPOSE

The aim of this study was to determine whether a 9-week resistance training program based on high load (HL) versus low load combined with blood flow restriction (LL-BFR) induced a similar (i) distribution of muscle hypertrophy among hamstring heads (semimembranosus, SM; semitendinosus, ST; and biceps femoris long head, BF) and (ii) magnitude of tendon hypertrophy of ST, using a parallel randomized controlled trial.

METHODS

A total of 45 participants were randomly allocated to one of three groups: HL, LL-BFR, and control (CON). Both HL and LL-BFR performed a 9-week resistance training program composed of seated leg curl and stiff-leg deadlift exercises. Freehand 3D ultrasound was used to assess the changes in muscle and tendon volume.

RESULTS

The increase in ST volume was greater in HL (26.5 ± 25.5%) compared to CON (p = 0.004). No difference was found between CON and LL-BFR for the ST muscle volume (p = 0.627). The change in SM muscle volume was greater for LL-BFR (21.6 ± 27.8%) compared to CON (p = 0.025). No difference was found between HL and CON for the SM muscle volume (p = 0.178).There was no change in BF muscle volume in LL-BFR (14.0 ± 16.5%; p = 0.436) compared to CON group. No difference was found between HL and CON for the BF muscle volume (p = 1.0). Regarding ST tendon volume, we did not report an effect of training regimens (p = 0.411).

CONCLUSION

These results provide evidence that the HL program induced a selective hypertrophy of the ST while LL-BFR induced hypertrophy of SM. The magnitude of the selective hypertrophy observed within each group varied greatly between individuals. This finding suggests that it is very difficult to early determine the location of the hypertrophy among a muscle group.

Patellar Tendon Load Progression during Rehabilitation Exercises: Implications for the Treatment of Patellar Tendon Injuries

PURPOSE

This study aimed to evaluate patellar tendon loading profiles (loading index, based on loading peak, loading impulse, and loading rate) of rehabilitation exercises to develop clinical guidelines to incrementally increase the rate and magnitude of patellar tendon loading during rehabilitation.

METHODS

Twenty healthy adults (10 females/10 males, 25.9 ± 5.7 yr) performed 35 rehabilitation exercises, including different variations of squats, lunge, jumps, hops, landings, running, and sports specific tasks. Kinematic and kinetic data were collected, and a patellar tendon loading index was determined for each exercise using a weighted sum of loading peak, loading rate, and cumulative loading impulse. Then the exercises were ranked, according to the loading index, into tier 1 (loading index ≤0.33), tier 2 (0.33 < loading index <0.66), and tier 3 (loading index ≥0.66).

RESULTS

The single-leg decline squat showed the highest loading index (0.747). Other tier 3 exercises included single-leg forward hop (0.666), single-leg countermovement jump (0.711), and running cut (0.725). The Spanish squat was categorized as a tier 2 exercise (0.563), as was running (0.612), double-leg countermovement jump (0.610), single-leg drop vertical jump (0.599), single-leg full squat (0.580), double-leg drop vertical jump (0.563), lunge (0.471), double-leg full squat (0.428), single-leg 60° squat (0.411), and Bulgarian squat (0.406). Tier 1 exercises included 20 cm step up (0.187), 20 cm step down (0.288), 30 cm step up (0.321), and double-leg 60° squat (0.224).

CONCLUSIONS

Three patellar tendon loading tiers were established based on a combination of loading peak, loading impulse, and loading rate. Clinicians may use these loading tiers as a guide to progressively increase patellar tendon loading during the rehabilitation of patients with patellar tendon disorders and after anterior cruciate ligament reconstruction using the bone-patellar tendon-bone graft.

Behaviour change and rehabilitation adherence in adults with tendinopathy: a scoping review

PURPOSE

This scoping review aimed to identify behaviour change strategies influencing rehabilitation adherence in adults with tendinopathy, a common musculoskeletal condition requiring prolonged rehabilitation with poor adherence and variable outcomes.

METHODS

Following the Joanna Briggs Institute (JBI) methodology, seven databases were searched until April 2023. Records included reviews, intervention, and qualitative studies published in English. Behaviour change strategies were deductively coded and mapped to the capability, opportunity, and motivation model of behaviour (COM-B).

RESULTS

Eighty-six articles were retained. The primary behaviour change strategies in tendinopathy rehabilitation reports addressed Psychological Capability; from knowledge through education, instruction, and self-monitoring using exercise diaries. Also, Social Opportunity involves demonstration and monitoring of rehabilitation behaviour, and Physical Opportunity focuses on time-efficient programs with access to equipment and health professionals. Few reports addressed Automatic Motivation (positive reinforcement and habit formation). Barriers identified in the reports were Reflective Motivation (negative beliefs and fears), Physical Opportunity (time-constraints), and Physical Capability (pain and comorbidities).

CONCLUSIONS

Further research should explore the impact of education on beliefs, fears, and pain-management, as well as the effectiveness of teaching habit formation for improved time-management. Implementing these behaviour change strategies may enhance tendinopathy rehabilitation adherence, improving clinical trial efficacy, guiding clinical practice, and impacting patient outcomes.

Effects of exercise-based interventions on gluteal tendinopathy. Systematic review with meta-analysis

The objective of this review was to evaluate the effect of exercise on pain intensity, function, and quality of life in individuals with gluteal tendinopathy. Searches were carried out in PUBMED, EMBASE, CINAHL, Cochrane Library, and PEDro databases. Randomized or quasi-randomized controlled trials were included. Five studies met the eligibility criteria, comparing exercise-based interventions with minimal interventions and/or corticosteroid injections. Three studies, involving 383 participants, were included in the quantitative analysis. Meta-analyses showed that exercise is superior to minimal intervention for function in short-term [mean difference (MD) = 10.24; 95% confidence interval (95%CI) = 5.98, 14.50) and long-term (MD = 6.54; 95%CI = 1.88, 11.21]). However, no difference was observed for quality of life in the short [standardized mean difference (SMD) = 0.33; 95%CI = -0.29, 0.94] and long-term (SMD = 0.11; 95%CI = -0.16, 0.37). The effect of exercise was no different from that of corticosteroid injections for pain intensity in the short (MD = 1.25; 95%CI = -3.56, 6.05) and long-term (MD = -1.37; 95%CI = -3.72, 0.98]). In conclusion, exercise is superior to minimal interventions for function in the short- and long-term in individuals with gluteal tendinopathy. Exercise and corticosteroid injections had similar effects on pain intensity, however, exercise showed a higher treatment success rate when compared to corticosteroid injections in this population. The GRADE analysis revealed that the certainty of the evidence ranges from low to very low, therefore, large high-quality randomized controlled trials are recommended.PROSPERO registration number: CRD42021242853.

Current practice, guideline adherence, and barriers to implementation for Achilles tendinopathy rehabilitation: a survey of physical therapists and people with Achilles tendinopathy

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.

Maximal Lower Limb Strength in Patellar Tendinopathy: A Systematic Review With Meta-Analysis

OBJECTIVE

To investigate whether lower limb strength is reduced in people with patellar tendinopathy (PT) compared with asymptomatic control individuals or the asymptomatic contralateral limb.

DATA SOURCES

MEDLINE, PubMed, Scopus, and Web of Science.

STUDY SELECTION

To be included in the systematic review and meta-analysis, studies were required to be peer reviewed, published in the English language, and case control investigations; include participants with a clinical diagnosis of PT and an asymptomatic control or contralateral limb group; and include an objective measure of lower limb maximal strength.

DATA EXTRACTION

We extracted descriptive statistics for maximal strength for the symptomatic and asymptomatic limbs of individuals with PT and the limb(s) of the asymptomatic control group, inferential statistics for between-groups differences, participant characteristics, and details of the strength-testing protocol. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for analytical cross-sectional studies.

DATA SYNTHESIS

Of the 23 included studies, 21 reported knee strength, 3 reported hip strength, and 1 reported ankle strength. Random-effects models (Hedges g) were used to calculate the pooled effect sizes (ESs) of muscle strength according to the direction of joint movement and type of contraction. The pooled ESs (95% CI) for maximal voluntary isometric contraction knee-extension strength, concentric knee-extension strength, and concentric knee-flexion strength were 0.54 (0.27, 0.80), 0.78 (0.30, 1.33), and 0.41 (0.04, 0.78), respectively, with all favoring greater strength in the asymptomatic control group. Researchers of 2 studies described maximal eccentric knee-extensor strength with no differences between the PT and asymptomatic control groups. In 3 studies, researchers measured maximal hip strength (abduction, extension, and external rotation), and all within-study ESs favored greater strength in the asymptomatic control group.

CONCLUSIONS

Isometric and concentric knee-extensor strength are reduced in people with PT compared with asymptomatic control individuals. In contrast, evidence for reduced eccentric knee-extension strength in people with PT compared with asymptomatic control individuals is limited and inconsistent. Although evidence is emerging that both knee-flexion and hip strength may be reduced in people with PT, more examination is needed to confirm this observation.

Assessing calf exercise fidelity among people with Achilles tendinopathy using videos recorded via Zoom®: an observational study

PURPOSE

Exercise fidelity is a fundamental aspect of exercise prescription by physiotherapists. Assessing exercise fidelity via telehealth (videoconference) is potentially useful but its reproducibility has not been assessed. The objective was to evaluate agreement (reproducibility) of video rating of calf exercise fidelity within (over four weeks) and between telehealth raters and compared with live rating.

METHODS

Nineteen videos of participants with AT undertaking calf exercises were rated by physiotherapists in person (live) and by watching pre-recorded videos (replicating telehealth). Three forms of agreement were assessed: (i) between live assessment and recorded video (telehealth) assessment; (ii) between telehealth raters (inter-rater); (iii) agreement within telehealth raters over four weeks (intra-rater).

RESULTS

There was weak to almost perfect agreement (Kappa = 0.65 to 1.00, rater 1, Kappa = 0.57 to 1.00, rater 2) between the telehealth and live raters. There was moderate to almost perfect agreement (Kappa = 0.65 to 1.00) when assessing intra-rater reliability, aside from one of the six criteria (quality of movement).

CONCLUSION

Assessing calf exercise fidelity via videos recorded on Zoom® appears to demonstrate weak or greater agreement versus live rating and over time. Inter-rater agreement was lower, suggesting that the criteria developed may be better suited to use by individual raters over time.Implications for rehabilitationTelehealth assessment (when compared with live, in person assessment) shows a moderate or greater agreement for the majority of assessment criteria when assessing calf exercise fidelity.The calf exercise fidelity criteria developed can be used as an adjunct to assessment and management of people with Achilles Tendinopathy.Intra-rater assessment was shown to be moderately or more consistent over a four-week period when assessing calf exercise fidelity.

Which Psychological and Psychosocial Constructs Are Important to Measure in Future Tendinopathy Clinical Trials? A Modified International Delphi Study With Expert Clinician/Researchers and People With Tendinopathy

OBJECTIVE: To identify which psychological and psychosocial constructs to include in a core outcome set to guide future clinical trials in the tendinopathy field. DESIGN: Modified International Delphi study. METHODS: In 3 online Delphi rounds, we presented 35 psychological and psychosocial constructs to an international panel of 38 clinician/researchers and people with tendinopathy. Using a 9-point Likert scale (1 = not important to include, 9 = critical to include), consensus for construct inclusion required ≥70% of respondents rating "extremely critical to include" (score ≥7) and ≤15% rating "not important to include" (score ≤3). Consensus for exclusion required ≥70% of respondents rating "not important to include" (score ≤3) and ≤15% of rating "critical to include" (score ≥7). RESULTS: Thirty-six participants (95% of 38) completed round 1, 90% (n = 34) completed round 2, and 87% (n = 33) completed round 3. Four constructs were deemed important to include as part of a core outcome set: kinesiophobia (82%, median: 8, interquartile range [IQR]: 1.0), pain beliefs (76%, median: -7, IQR: 1.0), pain-related self-efficacy (71%, median: 7, IQR: 2.0), and fear-avoidance beliefs (73%, median: -7, IQR: 1.0). Six constructs were deemed not important to include: perceived injustice (82%), individual attitudes of family members (74%), social isolation and loneliness (73%), job satisfaction (73%), coping (70%), and educational attainment (70%). Clinician/researchers and people with tendinopathy reached consensus that kinesiophobia, pain beliefs, pain self-efficacy, and fear-avoidance beliefs were important psychological constructs to measure in tendinopathy clinical trials. J Orthop Sports Phys Ther 2024;54(1):1-12. Epub 20 September 2023. doi:10.2519/jospt.2023.11903.

The Basas Spanish Squat: Superimposition of Electrical Stimulation to Optimize Patellar Tendon Strain: A Case Series

Background

The Basas Spanish Squat with electrical stimulation (E-stim) has shown promising results as a potential key exercise in treatment of athletes with patellar tendinopathy. Gold standard exercise therapy for tendon injuries consists of tendon loading exercises, or exercises that appropriately applies high levels of mechanical strain to the tendon. The theoretical pathway in which the Basas Spanish Squat with E-stim improves tendinopathy has been speculated to be the additional strain applied through the patellar tendon during superimposition of E-stim. This theory, however, has yet to be confirmed.

Purpose

The purpose of this case series was to compare patellar tendon strain, during the Basas Spanish Squat with, and without E-stim, and open kinetic chain knee extension.

Methods

Four healthy participants performed the three exercises while a physical therapist collected simultaneous unilateral ultrasound images from the patellar tendon. Strain was calculated as the change in patellar tendon length during contraction divided by the resting length.

Results

Amongst all participants, patellar tendon strain was smallest during the Basas Spanish Squat without E-stim, followed by the open kinetic chain knee extension at 60% maximum voluntary isometric contraction. The Basas Spanish Squat with E-stim yielded approximately double or more strain compared to the without E-stim condition and demonstrated higher level of strain compared to open kinetic chain knee extension in all participants.

Conclusion

The findings reflect a clear trend of increased strain through the patellar tendon when E-stim was superimposed. The results support the theory that the Basas Spanish Squat with E-stim increases patellar tendon strain and could explain the reported clinical benefits in individuals with patellar tendinopathy.

Level of Evidence

4, Case series.

S.P.O.R.R.T.-A Comprehensive Approach to the Assessment and Non-Operative Management of Overuse Knee Conditions in Youth Athletes

PURPOSE OF REVIEW

The evaluation of a young athlete with an overuse injury to the knee involves a comprehensive approach. There are a number of elements to consider including assessments of skeletal maturity (biologic maturation), workload (training load + competition load), sport specialization status, and biomechanics. The type of injury and treatment, as well as future prognosis, may be influenced by these and other factors.

RECENT FINDINGS

Calculating the percentage of predicted adult height (PPAH) is a valuable tool in assessing overuse injury patterns and diagnoses in youth athletes. Modifiable and non-modifiable overuse injury risk factors require monitoring from clinicians as young athletes mature and develop over time. Training and rehabilitation programs should be adapted to account for these. In this manuscript, we seek to introduce a novel, comprehensive approach: S.P.O.R.R.T. (Skeletal Maturity, Prior Injury Risk, One Sport Specialization, Rehabilitation, Return to Play, Training Recommendations) (Fig. 1). Overuse, non-traumatic injuries to the knee in youth athletes will be presented in a case-based and evidence-based model to provide a framework for a comprehensive approach to the assessment and treatment of youth athletes with overuse injuries.

The JUMPFOOD study: additional effect of hydrolyzed collagen and vitamin C to exercise treatment for patellar tendinopathy (jumper's knee) in athletes-study protocol for a double-blind randomized controlled trial

BACKGROUND

Patellar tendinopathy (PT) is a common problem in jumping athletes. Management can be challenging and treatment outcome is not always successful. In combination with tendon loading exercises, hydrolyzed collagen/vitamin C supplementation appears to have a promising effect on the recovery of tendinopathy. The aim of this study is to evaluate whether the use of oral supplementation of hydrolyzed collagen and vitamin C in combination with progressive tendon loading exercises (PTLE) is superior to PTLE and placebo on VISA-P score (which rates pain, function, sports participation) after 24 weeks for athletes with PT.

METHODS

The JUMPFOOD study is a double-blinded, two-armed randomized controlled trial, in which the effectiveness of oral supplementation of hydrolyzed collagen/vitamin C combined with PTLE compared to PTLE with placebo on pain and recovery of function in athletes with PT will be investigated. Seventy-six athletes aged 16-40 years, with symptoms of PT for at least 12 weeks, who play sports at least once a week will be included. All participants will receive education, advice with regard to load management and a PTLE program according to the Dutch guidelines for anterior knee pain. In addition, the intervention group will receive daily 10 g hydrolyzed collagen and 40 mg vitamin C supplementation for 24 weeks whereas the control group receives 10 g maltodextrin placebo supplementation. Measurements will take place at baseline and at 12 and 24 weeks' follow-up. Primary outcome is the VISA-P score, which evaluates pain, function, and sports participation. For secondary outcome measures, data with regard to pain during functional tests, flexibility measurements, blood withdrawals, imaging characteristics of the tendon, and health questionnaires will be collected. During the follow-up period, participants will register sports participation, amount of training and tendon load, pain during sports, co-medication, and side-effects in a digital weekly diary.

DISCUSSION

The JUMPFOOD study is the first large RCT to study the effectiveness of hydrolyzed collagen/vitamin C supplementation in combination with the PTLE program in athletes with patellar tendinopathy. If supplementation of collagen/vitamin C appears to be effective, this treatment can be implemented in daily sports medicine practice to improve the treatment outcome of patients with PT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05407194. Registered on 7 June 2022.

Plantar Flexor Weakness and Pain Sensitivity Cannot Be Assumed in Midportion Achilles Tendinopathy

Introduction/Purpose

The purpose of this study was to determine the following in persons with midportion Achilles tendinopathy (AT): 1) maximal strength and power; 2) neural drive during maximal contractions and contractile function during electrically evoked resting contractions; and 3) whether pain, neural drive, and contractile mechanisms contribute to differences in maximal strength.

Methods

Twenty-eight volunteers (14 AT, 14 controls) completed isometric, concentric, and eccentric maximal voluntary contractions (MVCs) of the plantar flexors in a Biodex™ dynamometer. Supramaximal electrical stimulation of the tibial nerve was performed to quantify neural drive and contractile properties of the plantar flexors. Pain sensitivity was quantified as the pressure-pain thresholds of the Achilles tendon, medial gastrocnemius, and upper trapezius.

Results

There were no differences in plantar flexion strength or power between AT and controls (isometric MVC: P = 0.95; dynamic MVC: P = 0.99; power: P = 0.98), nor were there differences in neural drive and contractile function (P = 0.55 and P = 0.06, respectively). However, the mechanisms predicting maximal strength differed between groups: neural drive predicted maximal strength in controls (P = 0.02) and contractile function predicted maximal strength in AT (P = 0.001). Although pain did not mediate these relationships (i.e., between maximal strength and its contributing mechanisms), pressure-pain thresholds at the upper trapezius were higher in AT (P = 0.02), despite being similar at the calf (P = 0.24) and Achilles tendon (P = 0.40).

Conclusions

There were no deficits in plantar flexion strength or power in persons with AT, whether evaluated isometrically, concentrically, or eccentrically. However, the mechanisms predicting maximal plantar flexor strength differed between groups, and systemic pain sensitivity was diminished in AT.

Wearable sensor and machine learning estimate tendon load and walking speed during immobilizing boot ambulation

The purpose of this study is to develop a wearable paradigm to accurately monitor Achilles tendon loading and walking speed using wearable sensors that reduce subject burden. Ten healthy adults walked in an immobilizing boot under various heel wedge conditions (30°, 5°, 0°) and walking speeds. Three-dimensional motion capture, ground reaction force, and 6-axis inertial measurement unit (IMU) signals were collected. We used a Least Absolute Shrinkage and Selection Operator (LASSO) regression to predict peak Achilles tendon load and walking speed. The effects of altering sensor parameters were also explored. Walking speed models (mean absolute percentage error (MAPE): 8.81 ± 4.29%) outperformed tendon load models (MAPE: 34.93 ± 26.3%). Models trained with subject-specific data performed better than models trained without subject-specific data. Removing the gyroscope, decreasing the sampling frequency, and using combinations of sensors did not change the usability of the models, having inconsequential effects on model performance. We developed a simple monitoring paradigm that uses LASSO regression and wearable sensors to accurately predict (MAPE ≤ 12.6%) Achilles tendon loading and walking speed while ambulating in an immobilizing boot. This paradigm provides a clinically implementable strategy to longitudinally monitor patient loading and activity while recovering from Achilles tendon injuries.

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

Background

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

Review questions

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

Methods

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

Results

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

Limitations

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

Conclusion

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

Future work

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

Study registration

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

Funding

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

Evidence for exercise therapy in patients with hand and wrist tendinopathy is limited: A systematic review

BACKGROUND

Several studies reported the efficacy of exercise therapy in hand and wrist tendinopathy. However, no systematic review synthesized the effect of exercise therapy on these patients.

PURPOSE

This study aimed to perform a systematic review to summarize evidence if exercise therapy may be considered an effective treatment in conservative management for patients with hand and wrist tendinopathy.

STUDY DESIGN

This was a systematic review.

METHODS

A literature search in MEDLINE, Cochrane Library, PEDro, and Embase was conducted from their inception until April 10, 2022. Two independent reviewers included the studies administering exercise therapy in patients with hand and/or wrist tendinopathy in the review and extrapolated the data. Methodological quality was assessed using the framework developed by Murad et al for case reports and case series and the PEDro score for clinical trials.

RESULTS

Seven case reports, 3 case series, and 2 randomized controlled studies were included and methodologically evaluated, obtaining a low score for all the analyzed studies. The total number of included patients in the analyzed studies was 106, of which 54 were female, 13 were male, and 39 were not specified. The type of exercise was widespread and often not really well described: it varies from eccentric forearm training to mobilization with movement, passing through strengthening exercises, grip proprioception training, and self-management exercises according to the McKenzie method. The dosage was often not precise, making it difficult to reproduce the therapeutic proposals. Exercise therapy was always administered together with different treatments; therefore, its efficacy alone is difficult to distinguish, although in some cases, the patients improved pain and functionality.

CONCLUSIONS

Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. Future research is strongly recommended to determine the appropriate dosage of the exercise therapy to determine clinical changes in these patients.

Putting the fear-avoidance model into practice - what can patients with chronic low back pain learn from patients with Achilles tendinopathy and vice versa?

BACKGROUND

Fear-avoidance variables are present in patients with musculoskeletal pain conditions, such as chronic low back pain (CLBP) and Achilles tendinopathy (AT) and can lead to reduced function and recovery. It is unknown how these variables relate in populations with different etiologies but similar pain provocation mechanisms.

OBJECTIVE

To compare kinesiophobia, pain catastrophizing, and disability between these two groups.

METHODS

Patients with CLBP and those with AT were included. Tampa Scale of Kinesiophobia (TSK-17) and Pain Catastrophizing Scale (PCS-13) were evaluated in both groups. The CLBP group completed the Oswestry Disability Index (ODI) and the AT group completed the PROMIS-29 questionnaire. Gait speed was calculated for each group. Disability outcomes were normalized between groups.

RESULTS

119 patients in the CLBP group (64 female, 46 ± 8 years) and 83 patients in the AT group (42 female, 48 ± 12 years) were included. Both groups (CLBP, AT) presented with high prevalence of kinesiophobia (67%, 55%) but the CLBP group presented with higher prevalence of pain catastrophizing (22%, 2%). The CLBP group demonstrated higher levels of disability via normalized ODI (MD= 12.4, 95% CI: 9.2, 15.5) but the AT group demonstrated slower gait speed (MD= 0.1 m/s, 95% CI: 0.0, 0.2).

CONCLUSION

Similarly high prevalence of kinesiophobia was found in patients with CLBP and patients with AT. While the CLBP group reported greater prevalence of catastrophizing thoughts and greater disability, the AT group had slower gait speed. Overall, these findings demonstrate that CLBP and AT have similarities that may allow clinicians to learn from one to inform treatment of the other.

CLINICAL TRIAL REGISTRATION NUMBERS

NCT03523325, ISRCTN17115599.

Achilles Tendinopathy Pathogenesis and Management: A Narrative Review

The Achilles tendon is the thickest and strongest tendon of the human body, and it is frequently injured during sports activity. The incidence of Achilles tendon pathologies has increased over recent decades, especially in the last few years, because of increased sports participation among the general population and due to the diffusion of competitive sports at a high level. Tendinopathies are common in athletes and in middle-aged overweight patients. The term "tendinopathy" refers to a condition characterised clinically by pain and swelling, with functional limitations of tendon and nearby structures, and consequently to chronic failure of healing response process. Tendinopathies can produce marked morbidity, and at present, scientifically validated management modalities are limited. Despite the constantly increasing interest and number of studies about Achilles tendinopathy (AT), there is still not a consensual point of view on which is the best treatment, and its management is still controversial. AT can be treated conservatively primarily, with acceptable results and clinical outcomes. When this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions with a relatively high rate of success with few complications and the decision for treatment in patients with AT should be tailored on patient's needs and level of activity. The aim of this article is to give insights about the pathogenesis and most used and recent treatment options for AT.

Bibliometric Analysis of the Top 50 Most Influential Studies on Patellar Tendon Injury

Background

There is a wide range of literature on patellar tendon injury, making it increasingly difficult to stay informed on the most influential studies in this field. It is essential to be familiar with the foundational articles of patellar tendon injury research to understand the current state of the literature and deliver high quality care.

Purpose

To objectively identify the 50 most influential articles relating to patellar tendon injury and conduct a bibliometric analysis to identify key features of these articles.

Study Design

Cross-sectional study.

Methods

The Clarivate Analytics Web of Knowledge database was utilized to gather metrics on the 50 most cited articles on patellar tendon injury on June 27, 2022. The information extracted from each article included publication year, number of citations, author information, article type, level of evidence, country of origin, journal name, study focus, and industry influence.

Results

The top 50 studies were cited a total of 8543 times and published between 1977 and 2015. The majority of articles were published after 2003, and the majority of citations were accrued after 2011. The most prevalent article types were cohort studies (n = 23), and the majority of studies were of evidence level 2 (n = 14) or 4 (n = 13). Australia and the United States (US) each published the most studies (n = 11). Only 4 (8%) studies focused on patellar tendon rupture, and 12 (24%) of the top 50 studies were associated with industry.

Conclusion

The majority of the top 50 most influential articles in patellar tendon injury were published and accumulated citations in the past 10 to 20 years. Non-US countries, institutions, and journals published many of the top 50 studies, reflecting a global interest and commitment to research in this field. Patellar tendon rupture and surgical repair represents a minority of research in the top 50 studies and could be a point of growth in the future.

Wearable sensor and machine learning accurately estimate tendon load and walking speed during immobilizing boot ambulation

Achilles tendon injuries are treated with progressive weight bearing to promote tendon healing and restore function. Patient rehabilitation progression are typically studied in controlled, lab settings and do not represent the long-term loading experienced during daily living. The purpose of this study is to develop a wearable paradigm to accurately monitor Achilles tendon loading and walking speed using low-cost sensors that reduce subject burden. Ten healthy adults walked in an immobilizing boot under various heel wedge conditions (30°, 5°, 0°) and walking speeds. Three-dimensional motion capture, ground reaction force, and 6-axis inertial measurement unit (IMU) signals were collected per trial. We used Least Absolute Shrinkage and Selection Operator (LASSO) regression to predict peak Achilles tendon load and walking speed. The effects of using only accelerometer data, different sampling frequency, and multiple sensors to train the model were also explored. Walking speed models outperformed (mean absolute percentage error (MAPE): 8.41 ± 4.08%) tendon load models (MAPE: 33.93 ± 23.9%). Models trained with subject-specific data performed significantly better than generalized models. For example, our personalized model that was trained with only subject-specific data predicted tendon load with a 11.5 ± 4.41% MAPE and walking speed with a 4.50 ± 0.91% MAPE. Removing gyroscope channels, decreasing sampling frequency, and using combinations of sensors had inconsequential effects on models performance (changes in MAPE < 6.09%). We developed a simple monitoring paradigm that uses LASSO regression and wearable sensors to accurately predict Achilles tendon loading and walking speed while ambulating in an immobilizing boot. This paradigm provides a clinically implementable strategy to longitudinally monitor patient loading and activity while recovering from Achilles tendon injuries.

Achilles tendon forces and pain during common rehabilitation exercises in male runners with Achilles tendinopathy. A laboratory study

OBJECTIVES

To estimate Achilles tendon forces and their relationship with self-reported pain in runners with Achilles tendinopathy (AT) during common rehabilitation exercises.

DESIGN

Cross-sectional.

SETTING

Laboratory.

PARTICIPANTS

24 recreational male runners (45.92 (8.24) years old; 78.20 (8.01) kg; 177.17 (6.69) cm) with symptomatic AT.

MAIN OUTCOME MEASURES

Kinematic and kinetic data were collected to estimate Achilles tendon forces during 12 commonly prescribed exercises. Achilles tendon forces were estimated from biomechanical data and normalised to the participant's bodyweight. The secondary aim was to investigate the relationship between Achilles tendon forces and pain during these exercises.

RESULTS

Two exercise clusters were identified based on Achilles tendon forces. Cluster1 included various exercises including double heel raises, single heel raises, and walking (range: 1.10-2.76 BWs). Cluster2 included running, jumping and hopping exercises (range: 5.13-6.35 BWs). Correlation between tendon forces and pain was at best low for each exercise (range: -0.43 - 0.20). Higher force exercises lead to more tendon load for a given amount of pain (R² = 0.7505; y = 0.2367x + 0.6191).

CONCLUSION

This study proposes a hierarchical exercise progression based on Achilles tendon forces to guide treatment of runners with AT. Achilles tendon forces and pain are not correlated in runners with AT.

The relationship between psychological, cognitive, and contextual factors and rehabilitation outcomes in Achilles tendinopathy: A prospective feasibility cohort study

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.

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

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.

Biomechanics and lower limb function are altered in athletes and runners with achilles tendinopathy compared with healthy controls: A systematic review

Achilles tendinopathy (AT) is a debilitating injury in athletes, especially for those engaged in repetitive stretch-shortening cycle activities. Clinical risk factors are numerous, but it has been suggested that altered biomechanics might be associated with AT. No systematic review has been conducted investigating these biomechanical alterations in specifically athletic populations. Therefore, the aim of this systematic review was to compare the lower-limb biomechanics of athletes with AT to athletically matched asymptomatic controls. Databases were searched for relevant studies investigating biomechanics during gait activities and other motor tasks such as hopping, isolated strength tasks, and reflex responses. Inclusion criteria for studies were an AT diagnosis in at least one group, cross-sectional or prospective data, at least one outcome comparing biomechanical data between an AT and healthy group, and athletic populations. Studies were excluded if patients had Achilles tendon rupture/surgery, participants reported injuries other than AT, and when only within-subject data was available.. Effect sizes (Cohen's d) with 95% confidence intervals were calculated for relevant outcomes. The initial search yielded 4,442 studies. After screening, twenty studies (775 total participants) were synthesised, reporting on a wide range of biomechanical outcomes. Females were under-represented and patients in the AT group were three years older on average. Biomechanical alterations were identified in some studies during running, hopping, jumping, strength tasks and reflex activity. Equally, several biomechanical variables studied were not associated with AT in included studies, indicating a conflicting picture. Kinematics in AT patients appeared to be altered in the lower limb, potentially indicating a pattern of "medial collapse". Muscular activity of the calf and hips was different between groups, whereby AT patients exhibited greater calf electromyographic amplitudes despite lower plantar flexor strength. Overall, dynamic maximal strength of the plantar flexors, and isometric strength of the hips might be reduced in the AT group. This systematic review reports on several biomechanical alterations in athletes with AT. With further research, these factors could potentially form treatment targets for clinicians, although clinical approaches should take other contributing health factors into account. The studies included were of low quality, and currently no solid conclusions can be drawn.

Relationships between surrogate measures of mechanical and psychophysiological load, patellar tendon adaptations, and neuromuscular performance in NCAA division I men's volleyball athletes

Introduction

Patellar tendon adaptations occur in response to mechanical load. Appropriate loading is necessary to elicit positive adaptations with increased risk of injury and decreased performance likely if loading exceeds the capacity of the tendon. The aim of the current study was to examine intra-individual associations between workloads and patellar tendon properties and neuromuscular performance in collegiate volleyball athletes.

Methods

National Collegiate Athletics Association Division I men's volleyball athletes (n = 16, age: 20.33 ± 1.15 years, height: 193.50 ± 6.50 cm, body mass: 84.32 ± 7.99 kg, bodyfat%: 13.18 ± 4.72%) competing across 9 weeks of in-season competition participated. Daily measurements of external workloads (i.e., jump count) and internal workloads [i.e., session rating of perceived exertion (sRPE)] were recorded. Weekly measurements included neuromuscular performance assessments (i.e., countermovement jump, drop jump), and ultrasound images of the patellar tendon to evaluate structural adaptations. Repeated measures correlations (r-rm) assessed intra-individual associations among performance and patellar tendon metrics.

Results

Workload measures exhibited significant negative small to moderate (r-rm =-0.26-0.31) associations with neuromuscular performance, negative (r-rm = -0.21-0.30), and positive (r-rm = 0.20-0.32) small to moderate associations with patellar tendon properties.

Discussion

Monitoring change in tendon composition and performance adaptations alongside workloads may inform evidence-based frameworks toward managing and reducing the risk of the development of patellar tendinopathy in collegiate men's volleyball athletes.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

SECONDARY OUTCOMES

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

CONCLUSION

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

CLINICAL TRIALS REGISTRATION NUMBER

NCT02732782.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Surgical or non-surgical treatment of plantar fasciopathy (SOFT): study protocol for a randomized controlled trial

Background

Plantar fasciopathy is the most common reason for complaints of plantar heel pain and one of the most prevalent musculoskeletal conditions with a reported lifetime incidence of 10%. The condition is normally considered self-limiting with persistent symptoms that often last for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. Heavy-slow resistance training and radiofrequency microtenotomy for the treatment of plantar fasciopathy have shown potentially positive effects on short- and long-term outcomes (> 3 months). However, the effect of heavy-slow resistance training compared with a radiofrequency microtenotomy treatment is currently unknown. This trial compares the efficacy of heavy-slow resistance training and radiofrequency microtenotomy treatment with supplemental standardized patient education and heel inserts in improving the Foot Health Status Questionnaire pain score after 6 months in patients with plantar fasciopathy.

Methods

In this randomized superiority trial, we will recruit 70 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of two groups: (1) heavy-slow resistance training, patient education and a heel insert (n = 35), and (2) radiofrequency microtenotomy treatment, patient education and a heel insert (n = 35). All participants will be followed for 1 year, with the 6-month follow-up considered the primary endpoint. The primary outcome is the Foot Health Status Questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a Global Perceived Effect scale, the physical activity level, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment.

Discussion

By comparing the two treatment options, we should be able to answer if radiofrequency microtenotomy compared with heavy-slow resistance training is superior in patients with plantar fasciopathy.

Trial registration

ClinicalTrials.gov NCT03854682. Prospectively registered on February 26, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06785-w.

Foundational Principles and Adaptation of the Healthy and Pathological Achilles Tendon in Response to Resistance Exercise: A Narrative Review and Clinical Implications

Therapeutic exercise is widely considered a first line fundamental treatment option for managing tendinopathies. As the Achilles tendon is critical for locomotion, chronic Achilles tendinopathy can have a substantial impact on an individual's ability to work and on their participation in physical activity or sport and overall quality of life. The recalcitrant nature of Achilles tendinopathy coupled with substantial variation in clinician-prescribed therapeutic exercises may contribute to suboptimal outcomes. Further, loading the Achilles tendon with sufficiently high loads to elicit positive tendon adaptation (and therefore promote symptom alleviation) is challenging, and few works have explored tissue loading optimization for individuals with tendinopathy. The mechanism of therapeutic benefit that exercise therapy exerts on Achilles tendinopathy is also a subject of ongoing debate. Resultingly, many factors that may contribute to an optimal therapeutic exercise protocol for Achilles tendinopathy are not well described. The aim of this narrative review is to explore the principles of tendon remodeling under resistance-based exercise in both healthy and pathologic tissues, and to review the biomechanical principles of Achilles tendon loading mechanics which may impact an optimized therapeutic exercise prescription for Achilles tendinopathy.

Is the VISA-A Still Seaworthy, or Is It in Need of Maintenance?

Background

The Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire is validated and widely used in Achilles tendinopathy. How well it can evaluate treatment outcomes is not well understood.

Purpose

To evaluate the responsiveness of the VISA-A in midportion Achilles tendinopathy and compare it with other patient-reported outcome measures.

Study Design

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

Methods

Enrolled were 97 participants with clinically diagnosed Achilles tendinopathy (median age, 50 years [interquartile range, 18 years]; symptom duration, 10 months [interquartile range, 28.7 months). The participants underwent a baseline evaluation and completed between 1 and 6 follow-up evaluations at 8, 16, 24, 32, 40, and/or 48 weeks. Participants completed the VISA-A, the Patient Reported Outcomes Measurement Information System short form Version 2.0 (PROMIS) Physical Function and Pain Interference subscales, and the Tampa Scale for Kinesiophobia (TSK). Three thresholds were evaluated with a receiver operating characteristic analysis (minimal clinically important difference [MCID], substantial benefit [SB], and complete recovery [CR]) using an 11-point global rating of change scale as an anchor. Thresholds were evaluated on raw scores as well as changes from baseline.

Results

The VISA-A was able to detect all 3 thresholds for changes over time, with raw scores >70.5, >77.5, and >89.5 representing the MCID, SB, and CR, respectively; thresholds for changes from baseline on the VISA-A were increases of 23.5, 19.5, and 37.5 points from baseline, respectively. The PROMIS subscale raw scores had identical thresholds for SB and CR (52.45 for Physical Function and 45.6 for Pain Interference). A score <34.5 on the TSK was the threshold for SB.

Conclusion

The VISA-A was the most responsive outcome measure evaluated. Raw scores had increasingly higher thresholds for the MCID, SB, and CR, which were therefore logically consistent.

Effects of Heavy Slow Resistance Training Combined With Corticosteroid Injections or Tendon Needling in Patients With Lateral Elbow Tendinopathy: A 3-Arm Randomized Double-Blinded Placebo-Controlled Study

BACKGROUND

Lateral elbow tendinopathy is a disabling tendon overuse injury. It remains unknown if a corticosteroid injection (CSI) or tendon needling (TN) combined with heavy slow resistance (HSR) training is superior to HSR alone in treating lateral elbow tendinopathy.

PURPOSE/HYPOTHESIS

The purpose was to investigate the effects of HSR combined with either (1) a CSI, (2) TN, or (3) placebo needling (PN) as treatment for lateral elbow tendinopathy. We hypothesized that 12 weeks of HSR in combination with a CSI or TN would have superior effects compared with PN at 12, 26, and 52 (primary endpoint) weeks' follow-up on primary (Disabilities of the Arm, Shoulder and Hand [DASH] score) and secondary outcomes in patients with chronic unilateral lateral elbow tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 60 patients with chronic unilateral lateral elbow tendinopathy were randomized to perform 12 weeks of home-based HSR with elastic band exercises combined with either (1) a CSI, (2) TN, or (3) PN, and at 12, 26, and 52 weeks, we assessed the primary outcome, the DASH score, and secondary outcomes: shortened version of the DASH (QuickDASH) score, pain (numerical rating scale [NRS] score), pain-free grip strength, and hypervascularization (power Doppler area).

RESULTS

A CSI, TN, and PN improved patient outcomes equally based on the DASH (Δ20 points), QuickDASH (Δ21 points), and NRS (Δ2.5 points) scores after 12 weeks. Further, after 12 weeks, a CSI also resulted in decreased hypervascularization (power Doppler area) compared with PN (Δ-2251 pixels, P = .0418). Except for the QuickDASH score (CSI increased score by Δ15 points compared with PN; P = .0427), there were no differences between the groups after 52 weeks.

CONCLUSION

These results suggest that 12 weeks of HSR improved symptoms in both the short and the long term and that a CSI or TN did not amplify this effect. In addition, a CSI seemed to impair patient-reported outcomes compared with HSR alone at long-term follow-up.

REGISTRATION

NCT02521298 (ClinicalTrials.gov identifier).

Subject-Specific 3D Models to Investigate the Influence of Rehabilitation Exercises and the Twisted Structure on Achilles Tendon Strains

The Achilles tendon (AT) is the largest tendon of the human body and has a primary role in locomotor activities. The complex structure of the AT includes twisting of three sub-tendons, non-uniform tissue deformations and differential triceps surae muscle forces. The main aim of this study was to investigate the impact of commonly used rehabilitation exercises (walking on heels, walking on toes, unilateral heel rise, heel drop with extended knee and heel drop with the knee bent) and different twists on AT strains. 3D freehand ultrasound based subject-specific geometry and subject-specific muscle forces during different types of rehabilitation exercises were used to determine tendon strains magnitudes and differences in strains between the sub-tendons. In addition, three Finite Element models were developed to investigate the impact of AT twist. While walking on heels developed the lowest average strain, heel drop with knee bent exhibited the highest average strain. The eccentric heel drop resulted in higher peak and average strain, compared to concentric heel rise for all the three models. The isolated exercises (heel rise and heel drop) presented higher average strains compared to the functional exercises (walking tasks). The amount of twist influences the peak strains but not the average. Type I consistently showed highest peak strains among the five rehabilitation exercises. The ranking of the exercises based on the AT strains was independent of AT twist. These findings might help clinicians to prescribe rehabilitation exercises for Achilles tendinopathy based on their impact on the AT strains.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials

OBJECTIVE

To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors.

STUDY SELECTION

Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation.

DATA SYNTHESIS

We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field.

RESULTS

Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct.

CONCLUSION

There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

Effects of isometric loading intensity on patellar tendon microvascular response

Acute increases in tendon blood flow and oxygenation after stress (i.e., hyperemic response) can enhance tendon recovery. While loading intensity is a fundamental part of resistance training programs, its effects on tendon's hyperemic response are unknown. This study aimed to compare acute changes in total (total hemoglobin [THb]) and oxygenated hemoglobin (HbO₂ ) concentrations in the patellar tendon after isometric exercise at different intensities. Thirteen participants performed 8 (5 s) isometric knee extensions at 25%, 50%, and 75% maximal load (maximal voluntarily isometric contraction [MVIC]), separated by 20 min recovery, prescribed in randomized and counterbalanced order. Changes in patellar tendon THb, HbO₂ and deoxygenated hemoglobin (HHb) in response to exercise at each intensity were measured using near-infrared spectroscopy. Post-exercise, HbO₂ increased with 50% ( η p 2 $$ {\eta}_p^2 $$  = 0.305, f = 5.26, p < 0.01) and 75% ( η p 2 $$ {\eta}_p^2 $$  = 0.245, f = 4.56, p < 0.01) but not 25% ( η p 2 $$ {\eta}_p^2 $$  = 0.088, f = 1.16, p = 0.339) MVIC, while THb increased in 50% ( η p 2 $$ {\eta}_p^2 $$  = 0.305, f = 5.26, p = 0.01) but not 25% ( η p 2 $$ {\eta}_p^2 $$  = 0.067, f = 0.865, p = 0.51) or 75% ( η p 2 $$ {\eta}_p^2 $$  = 0.126, f = 1.729, p = 0.14) MVIC. Additionally, increasing load from 25% to 50% MVIC resulted in greater THb (f = 2.459, p = 0.43), HbO₂ (f = 3.389, p = 0.13) and HHb (f = 0.320, p = 0.01) post-exercise responses, but no differences were observed between 50% and 75% MVIC (THb: f = 0.748, p = 0.59; HbO₂ : f = 0.825, p = 0.54; HHb: f = 0.713, p = 0.62). Our results suggest there is a loading threshold at ~50% MVIC at which the tendon hyperemic response is fully achieved. Training above this intensity is not expected to provide any additional change to the tendon microvascular response. Therefore, moderate loading seems to be sufficient to fully elicit the patellar tendon hyperemic response that's believed to stimulate tendon healing.

Evaluating daily physical activity and biomechanical measures using wearable technology in people with Achilles tendinopathy: A descriptive exploratory study

BACKGROUND

Load management is considered an important factor for prevention and treatment of Achilles tendinopathy. However, little attention has been given to monitoring daily load objectively in this population.

OBJECTIVES

We aimed to explore patterns in proxies of daily load derived from a six-axis inertial measurement unit (IMU) over a one-week period and the concordance between day-to-day fluctuation in pain intensity and IMU measures.

DESIGN

Descriptive exploratory study.

METHOD

Ten participants with Achilles tendinopathy (age: 53.00 ± 12.37) wore an IMU on the affected ankle for one week. Participants were contacted via text message three times daily to rate their worst pain intensity. Physical activity and biomechanical measures derived from the IMU signals including daily number of steps, peak stride rate, peak shank acceleration, and peak shank angular velocity were calculated.

RESULTS

The relationship between weekly worst pain and physical activity levels appeared modest; with increased steps not seeming to be linked to increased or reduced pain levels. According to the daily pain and daily IMU measures, a concordant pattern was evident in younger, highly active participants. However, in the middle-aged/older less active participants, there was either a fluctuation in pain intensity without fluctuation in the IMU measures, or a stable pattern of both pain and IMU measures.

CONCLUSIONS

Our exploratory study results suggest that continuous monitoring of proxies of daily load measures in parallel with pain may provide information about load management strategies in people with Achilles tendinopathy. Monitoring of these proxies may ultimately have a role in improving Achilles tendinopathy management.

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

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

Neuromechanical changes in Achilles tendinopathy and the effects of exercise-induced mechanical tendon loading: a protocol for a systematic review

INTRODUCTION

Achilles tendinopathy (AT) is a debilitating overuse injury characterised by pain, impaired functional performance, morpho-mechanical changes to the Achilles tendon and triceps surae neuromuscular alterations. Loading-based exercise has become the principal non-surgical choice for the treatment of AT; however, mechanistic evidence by which loading-based treatment may help to resolve tendon pain remains unclear. This systematic review aims to summarise the evidence of the neuromechanical changes produced by AT and by exercise-induced mechanical loading.

METHODS AND ANALYSIS

This systematic review protocol was informed and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-P) and the Cochrane Handbook for Systematic Reviews of Interventions. Pubmed, MEDLINE, EMBASE, CINAHL Plus, Web of Science and SPORTDiscus electronic databases will be searched from inception to February 2021. Additionally, grey literature and key journals will be reviewed. Risk of bias will be determined independently by two reviewers using the version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2) and the risk of bias in non-randomised studies - of interventions (ROBINS-I) tool according to Cochrane recommendations. Quality of the cumulative evidence will be assessed with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines. If homogeneity exists between groups of studies, a random-effects meta-analysis will be conducted. If not, results will be synthesised narratively.

ETHICS AND DISSEMINATION

Our findings will be disseminated through publication in a peer-reviewed journal and presented at conferences. No ethical approval was required.

PROSPERO REGISTRATION NUMBER

CRD42021231933.

Novel interventions for recalcitrant patella tendinopathy: Results may favour autologous blood injection (ABI) over radial-extra-corporeal shockwave therapy (r-ESWT) - A prospective cohort study

BACKGROUND

Patella tendinopathy is a common condition in a number of sports and can have a significant impact on activity and quality of life. Whilst rehabilitation leads to improvements in the majority of cases, a number of adjunct treatments are available for resistant cases with limited evidence supporting the use of one treatment over another.Hypothesis/Purpose: To compare the outcomes for patients with chronic patella tendinopathy, following either radial-Extra-Corporeal Shockwave Therapy (r-ESWT) or Autologous Blood Injection (ABI).

STUDY DESIGN

Prospective cohort study.

METHODS

28 consecutive patients with chronic patella tendinopathy, treated with radial-ESWT (n = 14) or ABI (n = 14), with minimum three-month follow-up. Mean age 34.2 years, mean duration of symptoms 32.8 months. Patients received either three sessions of radial-Extra-Corporeal Shockwave Therapy (one session per week for 3 weeks), or two ultrasound-guided Autologous Blood Injections (2 injections performed 2-4 weeks apart). All patients received standardised after-care, including continuation of a structured home exercise programme of flexibility and progressive loading (eccentric strengthening) exercises. Main Outcome Measures were Victoria Institute of Sport - Patella questionnaire (VISA-P), plus 0-10 Visual Analogue Scale (VAS) for self-reported levels of "average pain".

RESULTS

There were statistically significant improvements in self-reported measures of pain/function following either procedure at 6-weeks and at 3-months, but only in the ABI group at 6-months. At 3-months: VISA-P was improved from 32.4% ± 11.7%-60.0% ± 20.7% (p < 0.01) in the ABI group, and from 34.2% ± 14.6%-48.9% ± 17.8% (p < 0.001) in the r-ESWT group.

CONCLUSIONS

Patients with chronic patella tendinopathy improved at 6-weeks and 3-months following either ABI or r-ESWT procedure, with significant benefits at 6-months seen only in the ABI group. Between group analysis demonstrated improved outcomes favouring ABI compared to r-ESWT at the 6-month timepoint using VISA-P, and at all time-points using VAS as outcome measures. The small sample sizes in this pragmatic study are however noted, which limit interpretation, and larger more robust studies are required to investigate this further. This pragmatic prospective cohort study demonstrates improvements following either r-ESWT or ABI procedures, with results potentially favouring ABI over r-ESWT for patients with chronic patella tendinopathy.

Putting "Heavy" into Heavy Slow Resistance

The body of literature on tendinopathy management has come a long way in the last few decades and a variety of changes in the clinical approach have emerged from this research. One particular approach that shows promise has been called "heavy slow resistance" (HSR), and this has been the subject of investigation in a number of randomized controlled trials. While the premise for this approach is defensible, a critical examination of the implementation of these HSR protocols results in some concerns when compared to basic exercise science principles. This article lays out some considerations that will help future investigators to improve their exercise prescription approaches in this area.

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

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

Acceleration Profiles and the Isoinertial Squatting Exercise: Is There a Direct Effect on Concentric-Eccentric Force, Power, and Neuromuscular Efficiency?

OBJECTIVE

To examine the selective influences of distinct acceleration profiles on the neuromuscular efficiency, force, and power during concentric and eccentric phases of isoinertial squatting exercise.

DESIGN

Cross-sectional study.

SETTING

Biomechanics laboratory of the university.

PARTICIPANTS

A total of 38 active adults were divided according to their acceleration profiles: higher (n = 17; >2.5 m/s2) and lower acceleration group (n = 21; <2.5 m/s2).

INTERVENTION

All subjects performed squats until failure attached to an isoinertial conic pulley device monitored by surface electromyography of rectus femoris, vastus medialis, vastus lateralis, biceps femoris, and semitendinosus.

MAIN OUTCOME MEASURES

An incremental optical encoder was used to assess maximal and mean power and force during concentric and eccentric phases. The neuromuscular efficiency was calculated using the mean force and the electromyographic linear envelope.

RESULTS

Between-group differences were observed for the maximal and mean force (Prange = .001-.005), power (P = .001), and neuromuscular efficiency (Prange = .001-.03) with higher significant values for the higher acceleration group in both concentric and eccentric phases.

CONCLUSION

Distinct acceleration profiles affect the neuromuscular efficiency, force, and power during concentric and eccentric phases of isoinertial squatting exercise. To ensure immediate higher levels of power and force output without depriving the neuromuscular system, acceleration profiles higher than 2.5 m/s2 are preferable. The acceleration profiles could be an alternative to evolve the isoinertial exercise.

Patient perspectives on participation in exercise-based rehabilitation for Achilles tendinopathy: A qualitative study

BACKGROUND

Achilles tendinopathy (AT) is common, and can be traumatic or insidious in onset and short-lasting or persistent in nature. Factors influencing the experience of pain are poorly understood; little is known about mechanisms driving pain and the response (or lack of) to rehabilitation. Despite this, there is a growing body of evidence supporting the use of exercise to manage AT. Interestingly, variation in exercise approach does not appear to significantly impact outcome. Patients' perceptions of factors related to rehabilitation that may influence outcome could provide a valuable addition to help guide future research and practice.

OBJECTIVES

The aim of this study is to gain an insight into patients' experiences of participating in an exercise-based rehabilitation programme for AT.

METHOD

A qualitative interpretive description design. Data generated from semi-structured interviews were analysed thematically using the guidelines set out by Braun and Clarke.

FINDINGS

This is the first study to use a qualitative method of inquiry to gain data on the experiences of people undertaking exercise-based rehabilitation for AT. The four major themes that were identified from the data were: (1) 'understanding the impact' (2) 'expectations' (3) 'what matters' and (4) 'the burden of exercise'.

CONCLUSIONS

Given the uncertainty surrounding the mechanisms of effect of our treatments, the insights provide a platform from which researchers and clinicians can consider further in the management of people with Achilles tendinopathy. Specifically, it has highlighted that patients value a flexible, supportive approach embracing the biopsychosocial impact of AT on the individual.

Foot and Lower Limb Clinical and Structural Changes in Overuse Injured Recreational Runners Using Floating Heel Shoes: Preliminary Results of a Randomised Control Trial

Foot-strike and the associated load rate are factors related to overuse injuries in runners. The purpose of this study was to analyse structural and functional changes in runners using floating heel running shoes, compared with runners using conventional footwear. A randomised control trial was conducted. Twenty runners with overuse injuries were followed over a 12-week gait retraining programme using floating heel running shoes or their conventional footwear. Pain was measured with pressure pain thresholds (PPTs), structural changes were measured with ultrasonography, and severity and impact of injury was scored on the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O). Statistical differences were found between groups after the intervention (p < 0.001), with a medium size effect SE = 0.8, and the floating heel running shoes group reached higher PPTs values. Participants using floating heel running shoes showed higher OSTRC-O scores than those using their conventional footwear (p < 0.05), with higher scores after the intervention (p < 0.05). A 12-week gait retraining programme using floating heel running shoes had positive effects on the injury recovery process when compared to the use of conventional footwear, with significant differences in terms of pain and impact on sports activity.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.

Efficacy of high-volume injections with and without corticosteroid compared with sham for Achilles tendinopathy: a protocol for a randomised controlled trial

Introduction

Achilles tendinopathy (AT) is a common and disabling musculoskeletal condition. First-line management involving Achilles tendon loading exercise with, or without, other modalities may not resolve the problem in up to 44% of cases. Many people receive injections. Yet there are no injection treatments with demonstrated long-term efficacy. The aim of the trial is to examine the 12-month efficacy of high-volume injection (HVI) with corticosteroid and HVI without corticosteroid versus sham injection among individuals with AT.

Methods and analysis

The trial is a three-arm, parallel group, double-blind, superiority randomised controlled trial that will assess the efficacy of HVI with and without corticosteroid versus sham up to 12 months. We will block-randomise 192 participants to one of the three groups with a 1:1:1 ratio, and both participants and outcome assessors will be blinded to treatment allocation. All participants will receive an identical evidence-based education and exercise intervention. The primary outcome measure will be the Victorian Institute of Sport Assessment - Achilles (VISA-A) at 12 months post-randomisation, a validated, reliable and disease-specific measure of pain and function. Choice of secondary outcomes was informed by core outcome domains for tendinopathy. Data will be analysed using the intention-to-treat principle.

Ethics and dissemination

Ethics approval was obtained via the Monash University Human Ethics Committee (no: 13138). The study is expected to be completed in 2024 and disseminated via peer review publication and conference presentations.

Trial registration number

Australia and New Zealand Clinical trials registry (ACTRN12619001455156).

Treatment preferences and use of diagnostic imaging in midportion Achilles tendinopathy by Australian allied health professionals

OBJECTIVES

The objectives of this study were to examine the treatment preferences and use of diagnostic imaging by Australian allied health professionals in the management of midportion Achilles tendinopathy.

DESIGN

Cross-sectional survey of Australian allied health professionals.

METHODS

An online survey was distributed to registered Australian physiotherapists, podiatrists, myotherapists, exercise physiologists, osteopaths, and chiropractors between September 2018 and October 2019. This survey captured information on clinician demographic, treatment modalities, frequency of use and the reasons for their preferences. A descriptive analysis of the data was employed with nominal and ordinal data analysed using frequency counts.

RESULTS

Valid responses were captured from 283 respondents, the majority (229, 80.9%) being physiotherapists. Exercise-based therapy and education were the most commonly used treatments (98.6% and 92.6%, respectively), with the majority of respondents (91.8% and 89.3%) stating that they "always" provided these interventions. Respondents stated that they utilised a number of exercise modalities within the last three years (median = 3, IQR = 3 to 4). Other interventions used as adjunct treatments included heel lifts for shoes (70.0%), massage (59.4%), and taping (40.3%). The majority of respondents (76.7%) never or rarely used diagnostic imaging, citing its limited impact on treatment decision-making and potential for negative impact on patient outcomes.

CONCLUSIONS

Australian allied health professionals predominantly use exercise and education, but also use adjuncts such as heel lifts and massage, in the management of midportion Achilles tendinopathy. The results of this study may inform research priorities to generate high quality evidence that best reflects clinical practice.