Current trends in tendinopathy management

How long does tendinopathy last if left untreated? Natural history of the main tendinopathies affecting the upper and lower limb: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Natural history of disease refers to the progression of a disease process in an individual over time, in the absence of treatment. Understanding natural history of tendinopathies is key for clinicians to make accurate prognostic predictions and design effective intervention studies.

OBJECTIVE

To quantify the natural history of the main tendinopathies regarding pain and function and to compare outcomes between untreated individuals and those receiving treatment.

METHODS

A systematic literature search was conducted until February 2023, across PubMed, Cochrane, Embase and Scopus databases. Selection criteria included randomized controlled trials (RCTs) with a "wait-and-see" group and cohort studies with ≥3 months of follow-up reporting on pain and function-related outcomes. Standardized mean differences (SMDs) of "wait-and-see" groups were pooled using a random-effects inverse-variance model. Risk of bias was assessed using Cochrane Risk-of-Bias (RoB2), and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Six RCTs were included, encompassing 518 subjects with tendinopathy. Pooled results demonstrated significant pain (SMD = 0.30, 95%CI: 0.19-0.41) and physical function improvement (SMD = 0.38, 95%CI: 0.28-0.48). These estimates remained consistent regardless of age or follow-up duration. In rotator cuff tendinopathy, untreated individuals improved but did not fully recover at one year, with similar outcomes to other interventions (e.g., surgery). Subjects with lateral elbow, patellar and achilles tendinopathies when untreated, did not fully resolve symptoms within 12-16 weeks.

CONCLUSIONS

This review provides limited conclusions about natural history of tendinopathies. Future studies should incorporate true no-intervention groups to accurately reflect tendinopathy's natural progression.

Assessing Bioprinted Functionalized Grafts for Biological Tendon Augmentation In Vitro

Tendinopathy, characterized by inflammatory and degenerative changes, presents challenges in sports and medicine. In addressing the limitations of conservative management, this study focuses on developing tendon grafts using extrusion bioprinting with platelet-rich plasma (PRP)-infused hydrogels loaded with tendon cells. The objective is to understand paracrine interactions initiated by bioprinted tendon grafts in either inflamed or non-inflamed host tissues. PRP was utilized to functionalize methacrylate gelatin (GelMA), incorporating tendon cells for graft bioprinting. Bioinformatic analyses of overexpressed proteins, predictive of functional enrichment, revealed insights into PRP graft behavior in both non-inflamed and inflamed environments. PRP grafts activated inflammatory pathways, including Interleukin 17 (IL-17), neuroinflammation, Interleukin 33 (IL-33), and chemokine signaling. Interleukin 1 beta (IL-1b) in the graft environment triggered p38 mitogen-activated protein kinase (MAPK) signaling, nuclear factor kappa light chain enhancer of activated B cells (NF-kB) canonical pathway, and Vascular Endothelial Growth Factor (VEGF) signaling. Biological enrichment attributed to PRP grafts included cell chemotaxis, collagen turnover, cell migration, and angiogenesis. Acellular PRP grafts differed from nude grafts in promoting vessel length, vessel area, and junction density. Angiogenesis in cellular grafts was enhanced with newly synthesized Interleukin 8 (IL-8) in cooperation with IL-1b. In conclusion, paracrine signaling from PRP grafts, mediated by chemokine activities, influences cell migration, inflammation, and angiogenic status in host tissues. Under inflammatory conditions, newly synthesized IL-8 regulates vascularization in collaboration with PRP.

Rehabilitation following ulnar collateral ligament injury of the elbow in a female acrobatic athlete: A case report

BACKGROUND

The mechanism of injury and the conservative rehabilitation of the ulnar collateral ligament of the elbow (UCL) are well studied and reported in overhead athletes, while research on gymnastic athletes is sparse. Evidence suggests exercise as the mainstay in UCL injury rehabilitation. With this report, we aimed to provide a complete rehabilitation protocol following a partial UCL tear of an acrobatic athlete, where exercise and adjunct treatments, such as manual therapy, were used in a progressive staged rehabilitation.

CASE DESCRIPTION

A 16-year-old female acrobatic athlete was diagnosed with partial tear of the anterior band of UCL. The rehabilitation included progressive exercise loading in conjunction with manual therapy for 10 sessions in 8 weeks. Pain, UCL special tests, the Disabilities of Arm, Shoulder and Hand Score Questionnaire (DASH), and the Upper Limb Functional Index (ULFI) were assessed and administered at baseline and at 3, 6, 10 weeks, and 3 months.

RESULTS

Improvement in all outcome measures was noted at the 3-month follow-up indicating a substantial reduction in pain and disability, and an increase in stability of the elbow joint. Return to training was achieved at 8 weeks from the initial visit, while return to sport at the pre-injury level was achieved at 3 months.

CONCLUSION

Progressive exercise loading along with the addition of manual therapy is an effective intervention for the rehabilitation and return to sport following a partial UCL tear. A progressive staged rehabilitation guideline for acrobatic athletes with UCL injuries has been provided to be used and guide clinical practice.

LEVEL OF EVIDENCE

Level IV.

In vitro collagen biomarkers in mechanically stimulated human tendon cells: a systematic review

OBJECTIVE

The aim of this study was to comprehensively examine and summarize the available in vitro evidence regarding the relationship between mechanical stimulation and biomarkers of collagen synthesis in human-derived tendon cells.

METHODS

Systematic review with narrative analyses and risk of bias assessment guided by the Health Assessment and Translation tool. The electronic databases MEDLINE (Ovid), EMBASE (Ovid), CENTRAL (Ovid) and COMPENDEX (Engineering Village) were systematically searched from inception to 3 August 2023. Inclusion criteria encompassed English language, original experimental, or quasi-experimental in vitro publications that subjected human tendon cells to mechanical stimulation, with collagen synthesis (total collagen, type I, III, V, XI, XII, and XIV) and related biomarkers (matrix metalloproteinases, transforming growth factor β, scleraxis, basic fibroblast growth factor) as outcomes.

RESULTS

Twenty-one publications were included. A pervasive definite high risk of bias was evident in all included studies. Owing to incomplete outcome reporting and heterogeneity in mechanical stimulation protocols, planned meta-analyses were unfeasible. Reviewed data suggested that human tendon cells respond to mechanical stimulation with increased synthesis of collagen (e.g., COL1A1, procollagen, total soluble collagen, etc.), scleraxis and several matrix metalloproteinases. Results also indicate that mechanical stimulation dose magnitude may influence synthesis in several biomarkers.

CONCLUSIONS

A limited number of studies, unfortunately characterized by a definite high risk of bias, suggest that in vitro mechanical stimulation primarily increases type I collagen synthesis by human tendon cells. Findings from this systematic review provide researchers and clinicians with biological evidence concerning the possible beneficial influence of exercise and loading on cellular-level tendon adaptation.

Efficacy of ultrasound-guided galvanic electrolysis technique and physical therapy in patients with Achilles' tendinopathy: A pilot randomised controlled trial

BACKGROUND

Ultrasound-guided galvanic electrolysis technique (USGET) is an innovative mini-invasive intervention with the potential to optimise outcomes in the treatment of Achille's tendinopathy (AT).

OBJECTIVE

The aim of this pilot study is to evaluate the efficacy of adding USGET to conventional eccentric exercise treatment in patients with chronic AT.

METHODS

Inclusion criteria were patients with unilateral non-insertional AT, pain lasting > 3 months, aged 25-60 years. Patients were randomised in two groups receiving the same physiotherapy treatment (2 sessions per week for 8 weeks). In addition, the experimental group received three USGET stimulations, one every 15 days. Outcome measures were assessment of Achilles tendinopathy severity using the Victorian Institute of Sport Assessment-Achilles (VISA-A) and pain intensity using the Visual Analogue Scale (VAS). Assessment points occurred at the onset of treatment (T0), its conclusion (T1), and subsequent follow-ups at one (T2) and two months (T3).

RESULTS

Out of the 52 patients who met the study inclusion criteria, two participants withdrew from the study, resulting in a total of 50 subjects who completed the research. None of the parameters showed a different distribution at T1 (p> 0.337). At T2, there was a statistical difference in VISA-A (p= 0.010) and its subscales and VAS (p= 0.002) in the USGET group. At T3, both groups improved with a statistical difference observed in VISA-A (p< 0.001) and its subscales Pain (p= 0.004), Function (p= 0.003) and Sport (p= 0.002), but the EG patients showed a greater improvement. No adverse events were reported.

CONCLUSION

The effect of USGET combined with eccentric exercise appears to be a safe and effective technique for achieving pain relief and functional recovery in the medium term, supporting the integrated use of USGET as a rehabilitative treatment option for patients with chronic AT.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS AND DISCUSSION

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

CONCLUSIONS

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

A pilot study exploring the use of hyaluronic acid in treating insertional achilles tendinopathy

PURPOSE

This study explores the use of ultrasound-guided Hyaluronic Acid (HA) injections for Insertional Achilles Tendinopathy (IAT).

METHODS

A cohort of 15 ankles diagnosed with IAT received three weekly ultrasound-guided HA injections. The Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire scored the severity of symptoms and functional impairment before treatment, and at one and six months post-treatment.

RESULTS

Significant improvement was observed in VISA-A scores post-treatment, rising from an average baseline of 34.8 ± 15.2 (11-63) to 53.6 ± 20.9 (15-77) after one month, and then to 50.7 ± 18.6 (20-75) after six months. No adverse reactions were noted, underscoring the safety of the intervention.

CONCLUSION

The pilot study presents HA injections as a potentially effective treatment for IAT, while interpretation of these findings must take into account the variability in results, indicating a range of patient responses. It encourages further research to confirm these findings and to explore HA's full potential in managing IAT, despite the limitations of a small sample size and lack of control group.

There is a Lack of Clinical Homogeneity in Lower-Limb Tendinopathy Trials: A Scoping Review

OBJECTIVE: It is unclear if clinical trials of treatments for lower-limb tendinopathies include clinically homogeneous participant populations (an assumption for pooling in meta-analyses). We assessed the recruitment setting and participant characteristics used in randomized controlled trials (RCTs) that were investigating any treatment for lower-limb tendinopathies. DESIGN: Scoping review. METHODS: We conducted a systematic literature search in the PubMed, Embase, Cochrane CENTRAL, and Web of Science databases. All RCTs that were investigating treatments for lower-limb tendinopathies in an adult population (≥18 years) were eligible for inclusion. At least 2 authors conducted independent screening and selection of full-text papers, and extracted data from included studies. RESULTS: Of 18 341 records, 342 RCTs (21 897 participants) were eligible for inclusion and data extraction. The most common diagnoses were plantar fasciopathy (n = 195, 57%), Achilles tendinopathy (n = 82, 24%), and patellar tendinopathy (n = 41, 12%). Secondary care (n = 144, 42%) was the most reported recruitment setting, followed by an open setting (n = 44, 13%). In 93 (27%) RCTs, the recruitment setting was not described. We found high heterogeneity in participant characteristics (eg, symptom duration, age, body mass index, and the Victorian Institute of Sport Assessment [VISA] questionnaire score) within and between recruitment settings. CONCLUSION: Our results question whether clinical homogeneity can be adequately assumed in clinical trials of lower-limb tendinopathies due to the lack of clear reporting of the recruitment setting and the variability within and between recruitment settings of key participant characteristics. These findings threaten assumptions for meta-analyses in lower-limb tendinopathies. J Orthop Sports Phys Ther 2024;54(1):1-10. Epub 5 December 2023. doi:10.2519/jospt.2023.11722.

Effect of movement-evoked and tonic experimental pain on muscle force production

INTRODUCTION

When performing an exercise or a functional test, pain that is evoked by movement or muscle contraction could be a stronger stimulus for changing how individuals move compared to tonic pain. We investigated whether the decrease in muscle force production is larger when experimentally-induced knee pain is directly associated to the torque produced (movement-evoked) compared to a constant painful stimulation (tonic).

METHODS

Twenty-one participants performed three isometric knee extension maximal voluntary contractions without pain (baseline), during pain, and after pain. Knee pain was induced using sinusoidal electrical stimuli at 10 Hz over the infrapatellar fat pad, applied continuously or modulated proportionally to the knee extension torque. Peak torque and contraction duration were averaged across repetitions and normalized to baseline.

RESULTS

During tonic pain, participants reported lower pain intensity during the contraction than at rest (p < 0.001), whereas pain intensity increased with contraction during movement-evoked pain (p < 0.001). Knee extension torque decreased during both pain conditions (p < 0.001), but a larger reduction was observed during movement-evoked compared to tonic pain (p < 0.001). Participants produced torque for longer during tonic compared to movement-evoked pain (p = 0.005).

CONCLUSION

Our results indicate that movement-evoked pain was a more potent stimulus to reduce knee extension torque than tonic pain. The longer contraction time observed during tonic pain may be a result of a lower perceived pain intensity during muscle contraction. Overall, our results suggest different motor adaptation to tonic and movement-evoked pain and support the notion that motor adaptation to pain is a purposeful strategy to limit pain. This mechanistic evidence suggests that individuals experiencing prevalently tonic or movement-evoked pain may exhibit different motor adaptations, which may be important for exercise prescription.

Physical therapy interventions used to treat individuals with biceps tendinopathy: a scoping review

BACKGROUND

Shoulder pain related to pathology of the long head of the biceps tendon (LHBT) can be debilitating. Chronic LHBT tendinopathy is a common condition that is difficult to treat. Little consensus exists regarding the optimal approach to treating individuals with LHBT tendinopathy.

OBJECTIVE

To systematically scope the literature to identify and present the available information regarding physical therapist interventions used for the management of individuals with LHBT tendinopathy including types of interventions used or recommended.

METHODS

A scoping review of physical therapist interventions used to treat LHBT was conducted of the CINAHL, Embase, Medline, and SportDiscus databases. Full text records reporting physical therapist-based interventions in individuals with proximal LHBT pathology were included. Articles not written in English were excluded.

RESULTS

Of the 4059 records identified, 14 articles met the inclusion criteria. Interventions used to treat LHBT tendinopathy identified in quantitative studies included: extracorporeal shock wave therapy, polarized light, ultrasound, low-level laser, iontophoresis, general exercise, eccentric training, stretching, dry needling, and joint mobilization. Interventions described in literature reviews, clinical commentaries, and a Delphi study included: therapeutic modalities, manual therapy, exercise, dry needling, and patient education.

CONCLUSION

This scoping review reported interventions primarily based on therapeutic modalities in quantitative studies while literature reviews, clinical commentaries, and a Delphi study described the addition of manual therapy, patient education, exercise, and dry needling. Overall, there is a dearth of evidence detailing the conservative management of LHBT tendinopathy.

Precision and Safety of Ultrasound-Guided versus Palpation-Guided Needle Placement on the Patellar Tendon: A Cadaveric Study

For decades, needling interventions have been performed based on manual palpation and anatomic knowledge. The increasing use of real-time ultrasonography in clinical practice has improved the accuracy and safety of needling techniques. Although currently ultrasound-guided procedures are routinely used for patellar tendon pathology, e.g., during percutaneous electrolysis, the accuracy of these procedures is still unknown. This study used a cadaveric model to compare and evaluate both the accuracy and safety of ultrasound-guided and palpation-guided needling techniques for the patellar tendon. A total of five physical therapists performed a series of 20 needle insertion task each (n = 100), 10 insertions based on manual palpation (n = 50) and 10 insertions guided with ultrasound (n = 50) to place a needle along the interface between the patellar tendon and Hoffa's fat pad. All procedures were performed on cryopreserved knee specimens. Distance to the targeted tissue, time of the procedure, accurate rate of insertions, number of passes, and unintentional punctured structures between both applications (with and without ultrasound guiding) were compared. The results revealed higher accuracy (100% vs. 80%), a lower distance from needle to the targeted tissue (0.25 ± 0.65 vs. 2.5 ± 1.9 mm), longer surface of contact with the needle (15.5 ± 6.65 vs. 4.7 ± 7.5 mm), and a lower frequency of patellar tendon puncture (16% vs. 52%, p < 0.001) with the ultrasound-guided procedure as opposed to palpation-guided one. Nevertheless, the ultrasound-guided procedure took longer (54.8 ± 26.8 vs. 23.75 ± 15.4 s) and required more passes (2.55 ± 1.9 vs. 1.5 ± 0.95) to be conducted than the palpation-guided procedure (all, p < 0.001). According to these findings, the accuracy of invasive procedures applied on the patellar tendon is higher when conducted with ultrasound guidance than when conducted just on manual palpation or anatomical landmark. These results suggest that ultrasound could improve the clinical application of invasive procedures at the fat-patellar tendon interface. Due to the anatomical features of the targeted tissue, some procedures require this precision, so the use of ultrasound is recommended.

The Functions and Mechanisms of Tendon Stem/Progenitor Cells in Tendon Healing

Tendon injury is one of the prevalent disorders of the musculoskeletal system in orthopedics and is characterized by pain and limitation of joint function. Due to the difficulty of spontaneous tendon healing, and the scar tissue and low mechanical properties that usually develops after healing. Therefore, the healing of tendon injury remains a clinical challenge. Although there are a multitude of approaches to treating tendon injury, the therapeutic effects have not been satisfactory to date. Recent studies have shown that stem cell therapy has a facilitative effect on tendon healing. In particular, tendon stem/progenitor cells (TSPCs), a type of stem cell from tendon tissue, play an important role not only in tendon development and tendon homeostasis, but also in tendon healing. Compared to other stem cells, TSPCs have the potential to spontaneously differentiate into tenocytes and express higher levels of tendon-related genes. TSPCs promote tendon healing by three mechanisms: modulating the inflammatory response, promoting tenocyte proliferation, and accelerating collagen production and balancing extracellular matrix remodeling. However, current investigations have shown that TSPCs also have a negative effect on tendon healing. For example, misdifferentiation of TSPCs leads to a "failed healing response," which in turn leads to the development of chronic tendon injury (tendinopathy). The focus of this paper is to describe the characteristics of TSPCs and tenocytes, to demonstrate the roles of TSPCs in tendon healing, while discussing the approaches used to culture and differentiate TSPCs. In addition, the limitations of TSPCs in clinical application and their potential therapeutic strategies are elucidated.

Pain neuroscience education in persistent painful tendinopathies: A scoping review from the Tendon PNE Network

OBJECTIVE

to conduct and report a scoping review of the available evidence of the effects and content of pain neuroscience education for patients with persistent painful tendinopathies.

METHODS

PubMed, Embase, Web of Science, CINAHL, SPORTDiscus, and grey literature databases were searched from database inception to May 2022. Randomised and non-randomised controlled trials, non-controlled clinical trials, cohort studies, case series, case studies including people with persistent painful tendinopathy aged ≥18 years, a pain education intervention, and in English were included. Studies were excluded if they were cross-sectional studies, reviews, editorials, abstracts, or full-text not available or if included heterogeneous study cohorts, patients with tendon rupture, or patients with systemic diseases.

RESULTS

five studies (n = 164) were included. Pain neuroscience education entailed face-to-face discussion sessions or educational materials including videos, brochures, paper drawings, and review questions. All studies used pain neuroscience education in conjunction with other interventions, obtaining significant benefits in outcomes related to pain, physical performance, or self-reported function, among others.

CONCLUSIONS

The application of pain neuroscience education in conjunction with other interventions seemed to improve several outcomes. However, considering the current knowledge about tendon pain and the scarcity of well-designed trials studying pain neuroscience education in tendinopathy, additional research is needed.

Ultrasonographic appearance of supraspinatus and biceps tendinopathy improves in dogs treated with low-intensity extracorporeal shock wave therapy: a retrospective study

Objective

This study aimed to determine whether dogs with shoulder tendinopathy diagnosed via musculoskeletal ultrasound would show improvement in imaging after treatment using piezoelectric shockwave therapy and rest.

Methods

Medical records were reviewed for dogs diagnosed with biceps and/or supraspinatus tendinopathy via musculoskeletal ultrasound, treated using piezowave shockwave, and re-imaged post-treatment. Data collected included patient signalment, duration and grade of lameness, prior rest, piezowave dose, and patient outcome, including a return to sport where applicable. Images were scored using an adapted ultrasound grading scale, in addition to obtaining cross-sectional area measurements. Statistics included Shapiro-Wilk tests (normality), Wilcoxon matched pairs signed rank tests (pre- vs. post-treatment comparisons), and Spearman's correlation coefficients (lameness grade vs. ultrasound score) (significant at P < 0.05).

Results

In total, 26 of 30 dogs had pathology involving both the biceps and supraspinatus tendons in one limb, with 27 of 30 having tendon/s affected bilaterally. For both tendons, post-treatment cross-sectional area and ultrasound score were significantly lower than pre-treatment (P < 0.001). Lameness decreased clinically (P < 0.0001) following piezowave shockwave treatment regardless of the tendons involved, but the lameness score did not correlate with the ultrasound score for either tendon.

Conclusion

Dogs with tendinopathy of the biceps brachii and supraspinatus showed significant improvement on follow-up musculoskeletal ultrasound and lameness evaluation after the treatment of their tendons using piezoelectric shockwave therapy with rest.

Clinical significance

Canine biceps brachii and supraspinatus tendinopathy can cause variable lameness and ultrasonographic appearance, which improves after shockwave therapy and rest. The ultrasound scoring system and cross-sectional area assessment provide useful outcome measures for clinical cases.

First Metatarsophalangeal Joint Pain in Athletes: Diagnosis, Management, and Return to Play Considerations

ABSTRACT

The first metatarsal-phalangeal joint plays a key role for athletes of various disciplines. When an athlete presents for evaluation of pain at this joint, there are several causes that should be considered. The purpose of this article is to review common injuries including turf toe, sand toe, extensor and flexor hallucis longus tendinopathy, sesamoiditis, and metatarsalgia and provide current evidence-based recommendations for diagnosis, management, and return to play considerations. Conditions not specific to athletes like gout and hallux rigidus also are discussed. Mechanism of injury, physical examination, and imaging such as weight-bearing radiographs and point-of-care ultrasound can help with diagnosis. Treatment of many of these injuries begins with nonsurgical management strategies including footwear or activity modification, physical therapy, and select interventions.

Pro-inflammatory activity of long noncoding RNA FOXD2-AS1 in Achilles tendinopathy

Achilles tendinopathy is a prevalent clinical problem that plagues athletes and general populations. Achilles tendon healing is a complex process, and so far, there is no successful long-term solution to Achilles tendinopathy in the field of microsurgery due to its poor natural regeneration ability. Limitations in understanding the pathogenesis of Achilles tendon development and Achilles tendon injury hinder clinical treatment developments. There is an increasing demand for innovative conservative treatments that can improve Achilles tendon injury. In this study, a Sprague-Dawley rat model of Achilles tendinopathy was established. Lentiviral vectors that interfere with the expression of FOXD2-AS1, miR-21-3p, or PTEN were injected every 3 days. Rats were euthanized after 3 weeks, and the effect of FOXD2-AS1, miR-21-3p, or PTEN on Achilles tendon healing was analyzed by histological observation, biomechanical test, and examinations of inflammatory factors and tendon markers. As measured, downregulating FOXD2-AS1 or upregulating miR-21-3p improved histological structure, suppressed inflammation, promoted the expression of tendon markers, and optimized the biomechanical properties of Achilles tendon. Upregulating PTEN was capable of reversing the promoting effect of inhibition of FOXD2-AS1 on Achilles tendon healing. As concluded, deficiency of FOXD2-AS1 accelerates the healing of Achilles tendon injury and improves tendon degeneration by regulating the miR-21-3p/PTEN axis and promoting the activation of the PI3K/AKT signaling pathway.

Posterior Rotator Cuff Tears: Is Extracorporeal Shockwave Therapy a Risk Factor?

Background

Negative effects of extracorporeal shock wave therapy (ESWT) on vulnerable tendon structures have been reported. Meanwhile, tears of the posterior rotator cuff tendon, which is thinner than the anterior, are not common, and the clinical features remain poorly understood. Therefore, we evaluated the relationship between ESWT and posterior rotator cuff tears (RCTs) by investigating the risk factors.

Methods

Of 294 patients who underwent rotator cuff repair between October 2020 and March 2021, a posterior RCT more than 1.5 cm from the biceps tendon or an isolated infraspinatus tear was identified in 24 (8.1%, group P). Sixty-two patients (21%) with an anterior RCT within 1.5 cm of the biceps tendon were analyzed as a control group (group A). Preoperative clinical characteristics were assessed to determine the risk factors of posterior RCTs.

Results

Calcific deposits were more frequently observed in group P (n = 7, 29.2%) than group A (n = 6, 9.7%, p = 0.024). Further, those in group P were more likely to undergo ESWT (n = 18, 75.0%) than those in group A (n = 15, 24.2%, p < 0.001). Of these, 7 patients experiencing calcific tendinitis from group P (29.2%) and 4 from group A (6.5%, p = 0.005) underwent ESWT for calcification removal. Furthermore, 11 patients experiencing tendinopathy from group P (45.8%), and 11 from group A (17.7%, p = 0.007) underwent ESWT for pain relief. The mean level of fatty infiltration of the supraspinatus was significantly higher in group A than group P (1.8 vs. 1.0, p < 0.001).

Conclusions

Since a high prevalence rate of posterior RCTs was related to ESWT, it should be carefully considered when treating calcific tendinitis or pain in patients experiencing tendinopathy.

Eye Melanoma Diagnosis System using Statistical Texture Feature Extraction and Soft Computing Techniques

BACKGROUND

Eye melanoma is deforming in the eye, growing and developing in tissues inside the middle layer of an eyeball, resulting in dark spots in the iris section of the eye, changes in size, the shape of the pupil, and vision.

OBJECTIVE

The current study aims to diagnose eye melanoma using a gray level co-occurrence matrix (GLCM) for texture extraction and soft computing techniques, leading to the disease diagnosis faster, time-saving, and prevention of misdiagnosis resulting from the physician's manual approach.

MATERIAL AND METHODS

In this experimental study, two models are proposed for the diagnosis of eye melanoma, including backpropagation neural networks (BPNN) and radial basis functions network (RBFN). The images used for training and validating were obtained from the eye-cancer database.

RESULTS

Based on our experiments, our proposed models achieve 92.31% and 94.70% recognition rates for GLCM+BPNN and GLCM+RBFN, respectively.

CONCLUSION

Based on the comparison of our models with the others, the models used in the current study outperform other proposed models.

The use of physical function capacity measures in the management of lower limb tendinopathy: A scoping review of expert recommendations

BACKGROUND

Physical function capacity measures are recommended as outcome measures for people with lower limb tendinopathy.

OBJECTIVE

(i) Explore measures of physical function capacity recommended by experts in lower limb tendinopathy (ii) the context they were used, (ii) identify recommended criteria for exercise progression and return to sport or activity.

DESIGN

Scoping Review.

METHOD

Three databases were searched using keywords for lower limb tendinopathy and physical function capacity to identify studies that outlined a progressive exercise rehabilitation program. A 15-item tool was used for data extraction.

RESULTS

26 studies were included, only eight recommended a physical function capacity measure. There were 10 physical function capacity measures identified for a range of lower limb tendinopathies including patellar (50%), Achilles (13%), proximal hamstring (13%), gluteal (13%), combined patellar and Achilles (13%). Pain was the most common criterion that was used to determine the progression of rehabilitation (96%), with physical function capacity measures rarely used (12%).

CONCLUSION

Physical function capacity measures are used infrequently across expert recommended exercise rehabilitation programs. There remains a high reliance on pain as the criterion for progression of exercises during rehabilitation. There is a need to develop measures of physical function capacity to better inform and progress rehabilitation.

Efficacy of percutaneous electrolysis for the treatment of tendinopathies: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of percutaneous electrolysis for the treatment of patients with tendinopathies.

DATA SOURCES

A systematic search of publications was conducted in Pubmed, Cinahl, Medline, Scopus and Web of Science.

METHODS

The Oxford 2011 Levels of Evidence and the Jadad scale were used to assess the quality of studies. The mean and standard deviation were obtained for each study group and used to calculate the effect size. The DerSimonian and Laird method was used to develop a random-effects model.

RESULTS

Of the 14 articles, four applied percutaneous electrolysis to the knee, three to the shoulder, three to the elbow, two to the hip and two to the ankle and foot. A meta-analysis on intensity of pain (evaluated with algometer and the Visual Analogue Scale) was performed on studies comparing percutaneous electrolysis with a control group, indicating that the groups treated with percutaneous electrolysis had better results (p = 0.01). Although percutaneous electrolysis did not overcome the analgesic effect achieved by corticosteroid injections.

CONCLUSIONS

The percutaneous electrolysis is effective for the treatment of tendinopathies. The combination of this technique with eccentric training has proven to be one of the most effective treatments to date for improving pain. PROSPERO Registration: CRD42021230005.

Psychosocial and individual factors affecting Quality of Life (QoL) in patients suffering from Achilles tendinopathy: a systematic review

BACKGROUND

Achilles tendinopathy (AT) is a joint condition that causes functional restrictions and pain. This condition negatively impacts patients' social connectedness and psychological well-being, reducing their quality of life (QoL). This review aims to summarise the current information on QoL in patients suffering from AT from different angles: compared to a healthy population, reported individual factors that influence it and the effects of some AT interventions on QoL.

METHODS

A systematic review was conducted at PubMed, Cochrane, Google Scholar, and PsycINFO using tendinopathy and QoL-related keywords up to November 2021. Articles were included if they compared QoL to demographic factors such as age or gender, lifestyle factors (physical activity levels), comorbidity factors (diabetes, obesity), and/or a control group.

RESULTS

Three hundred twenty-nine articles were reviewed; 23 met the inclusion criteria. SF-36, EQ-5D, and VISA-A were the most common instrument used. Patients with AT reported low QoL when compared to no AT population. When women were compared to men, women reported worse QoL. The patients who participated in different exercise programs (strengthening and stretching) showed improvements in QoL. Surgical AT intervention improved QoL, although results varied by age.

CONCLUSION

AT has a substantial impact on QoL. In AT patients, QoL is also influenced by specific individual factors, including gender and physical activity. Exercise, education, and surgical treatment improve QoL. We suggest more research on AT patients to better understand the aspects leading to poor QoL.

The role of progressive, therapeutic exercise in the management of upper limb tendinopathies: A systematic review and meta-analysis

BACKGROUND

Among upper limb tendinopathies, rotator cuff-related shoulder pain and lateral elbow tendinopathy are the most representative disorders. Therapeutic exercise arises as an effective approach, but there is no consensus about the optimal progression criteria.

OBJECTIVE

To compare progression criteria and effectiveness of isolated, progressive exercises in the management of upper limb tendinopathies. Additionally, to perform a meta-analysis of pain/function for the selected programs.

DESIGN

Systematic Review and Meta-Analysis.

METHOD

Database search of randomized-controlled-trials including progressive exercise was conducted in PubMed and Scopus until October 2020. Meta-analysis' inclusion criteria were: no data duplicity; 3-months follow-up; comparison between any type of progressive exercise program. Risk of bias was assessed with PEDro score, and level of evidence followed GRADE guidelines. Effect size was calculated with Cohen's d.

RESULTS

Eleven studies were included. GRADE revealed low-quality evidence for meta-analysis of pain during activity (d = 0.29) and function (d = 0.33) at 3 months. Progression criteria were categorised into two divisions, being pain the central concept. Pain (rest/activity/night) and function improved significantly within-group, but between-group changes were heterogeneous. Meta-analysis regarding pain showed good homogeneity with significant, moderate effects (I² = 20%; p = 0.005; mean d = 0.29); function yielded important heterogeneity with non-significant, moderate effects (I² = 81%; p = 0.17; mean d = 0.33).

CONCLUSIONS

Pain was the most frequent benchmark when modulating and progressing the exercises, although other criteria were found such as fatigue or self-perceived ability. Progressive exercise seems effective to manage upper limb tendinopathies, but the superiority of a progression criterion against others remains unclear. Low-quality evidence supported progressive exercise with eccentric components in adding a significant and moderate effect on pain/function at short-term.

Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience

Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.

Development of high resilience spiral wound suture-embedded gelatin/PCL/heparin nanofiber membrane scaffolds for tendon tissue engineering

This study develops a spiral wound scaffold based on gelatin/PCL/heparin (GPH) nanofiber membranes for tendon tissue engineering. By embedding sutures in dual layers of aligned GPH nanofiber membranes, prepared from mixed electrospinning of gelatin and PCL/heparin solutions, we fabricate a high resilience scaffold intended for the high loading environment experienced by tendons. The basic fibroblast growth factor (bFGF) was anchored to GPH scaffold through bioaffinity between heparin and bFGF, aim to provide biological cues for maintenance of tenogenic phenotype. In addition, the aligned nanofiber morphology is expected to provide physical cues toward seeded tenocytes. With sustained release of bFGF, GPH-bFGF can enhance proliferation, up-regulate tenogenic gene expression, and increase synthesis of tendon-specific proteins by tenocytes in vitro. Furthermore, by properly maintaining tendon phenotypes, GPH-bFGF/tenocytes constructs showed improved mechanical properties over GPH-bFGF. From in vivo study using GPH-bFGF/tenocytes constructs to repair rabbit Achilles tendon defects, neotendon tissue formation was confirmed from histological staining and biomechanical analysis. These findings collectively demonstrate that the newly designed GPH-bFGF scaffold could provide a niche for inducing tendon tissue regeneration by effectively restoring the tendon tissue structure and function.

Irisin promotes the proliferation and tenogenic differentiation of rat tendon-derived stem/progenitor cells via activating YAP/TAZ

Tendinopathy is a common tendon disorder characterized by pain, swelling, and dysfunction. Current evidence has demonstrated that the depletion of stem cell pool and non-tenogenic differentiation of tendon-derived stem/progenitor cells (TSPCs) might account for the pathogenesis of tendinopathy. FNDC5/Irisin, as a novel exercise-induced myokine, is proved to be involved in the exercise-induced protective effects on musculoskeletal disorders. However, whether irisin can affect TSPCs fate is still unknown. To ascertain the roles of irisin on the proliferation and tenogenic differentiation of TSPCs, rat TSPCs were isolated and incubated with irisin. Cell viability, phenotypic changes, and related signaling pathways were evaluated by CCK-8 assay, colony formation assay, real-time PCR, Western blot, immunofluorescence, and proteasome activity assay. We found that irisin treatment increased the proliferative and colony-forming abilities, and promoted the tenogenic differentiation of TSPCs by upregulating the expression of YAP/TAZ. In conclusion, our work showed for the first time that irisin promotes the proliferation and tenogenic differentiation of rat TSPCs in vitro by activating YAP/TAZ, and the process was associated with a ubiquitin-proteasome proteolytic pathway. In conclusion, irisin and agents targeting YAP/TAZ may be promising therapeutic options for tendinopathy.

Cell therapy efficacy and safety in treating tendon disorders: a systemic review of clinical studies

Purpose

Despite substantial animal evidence, cell therapy in humans remains in its infancy. The purpose of this study was to examine the potential therapeutic effects and safety of cell therapy in the treatment of tendon disorders.

Methods

According to the PRISMA guideline, a systematic review was performed on clinical studies concerning cell therapy in tendon disorders. A comprehensive search including the 5 databases of MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library until December 2021 was carried out and associated with hand searching. The quality of the eligible studies was assessed using the tools suggested by Cochrane recommendations. Qualitative synthesis was performed in 2 tables and discussed separately for rotator cuff, elbow, patella, Achilles, and gluteal tendons.

Results

Through 6017 records, 22 studies were included in the qualitative synthesis, including 658 patients. All the studies administered autologous cells, except one that used allogenic adipose-derived mesenchymal stem cells (Allogenic AD-MSC). Almost all studies demonstrated the safety of cell injection in their follow-up period with no serious side effects or immunologic reactions, with only a few related minor adverse events in some cases.

The included studies showed the effectiveness of cell injection in tendinopathies of different sites, rotator cuff, elbow, patella, Achilles, and gluteal tendons. Among the rotator cuff studies, 4 comparative studies claimed that cell therapy is a more efficient treatment with a lower retear rate and pain level compared to the control group. However, one study found no differences between the groups. No controlled study has been performed on elbow tendinopathies, but 5 case series demonstrated the effectiveness of cell injection in elbow tendon disorders. For Achilles tendinopathies, only one randomized controlled trial (RCT) found that both cell therapy and control groups showed significant pain reduction and functional improvement with no statistical differences at the 6 months follow-up, but the cell therapy group had improved faster at earlier follow-ups. Patellar tendinopathy was studied in 2 RCTs, one did not show a significant difference and the other showed superior improvement compared to controls.

Conclusion

Cell therapy showed promising results and the available evidence suggests that it is safe at several sites of tendon disease. Based on available evidence, cell therapy should be suggested in specific conditions at each site. To approve cell therapy for tendon diseases, randomized clinical trials are required with a large sample size and long-term follow-ups.

Level of evidence

IV

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00520-9.

Upper Body Injuries in Golfers

PURPOSE OF REVIEW

Golf is a sport that can be played by an athlete of any age, which enhances its popularity. Each golfer's swing is unique, and there is no "right" way to swing the golf club; however, the professional golfer often has more of a consistent swing as opposed to an amateur golfer. A collaborative, team approach involving the golfer with a swing coach, physical therapist, and physician often can be informative on how to prevent golf injury, but also how to treat golf injury if it occurs.

RECENT FINDINGS

As a rotational sport, the golfer needs to be trained and treated with respect for how the body works as a linkage system or kinetic chain. A warm-up is recommended for every golfer before practicing or playing, and this warm-up should account for every segment of the linkage system. Though it has been thought of as a relatively safe sport, injuries can be seen with golfers of any age or skill level, and upper body injuries involving the cervical and thoracic spine, shoulder, elbow, and wrist are common. A narrative review is provided here of the epidemiology of golf injury and common injuries involving each of these upper body regions. In addition, treatment and injury prevention recommendations are discussed.

New frontiers of tendon augmentation technology in tissue engineering and regenerative medicine: a concise literature review

Tissue banking programs fail to meet the demand for human organs and tissues for transplantation into patients with congenital defects, injuries, chronic diseases, and end-stage organ failure. Tendons and ligaments are among the most frequently ruptured and/or worn-out body tissues owing to their frequent use, especially in athletes and the elderly population. Surgical repair has remained the mainstay management approach, regardless of scarring and adhesion formation during healing, which then compromises the gliding motion of the joint and reduces the quality of life for patients. Tissue engineering and regenerative medicine approaches, such as tendon augmentation, are promising as they may provide superior outcomes by inducing host-tissue ingrowth and tendon regeneration during degradation, thereby decreasing failure rates and morbidity. However, to date, tendon tissue engineering and regeneration research has been limited and lacks the much-needed human clinical evidence to translate most laboratory augmentation approaches to therapeutics. This narrative review summarizes the current treatment options for various tendon pathologies, future of tendon augmentation, cell therapy, gene therapy, 3D/4D bioprinting, scaffolding, and cell signals.

Modelling and in vivo evaluation of tendon forces and strain in dynamic rehabilitation exercises: a scoping review

OBJECTIVES

Although exercise is considered the preferred approach for tendinopathies, the actual load that acts on the tendon in loading programmes is usually unknown. The objective of this study was to review the techniques that have been applied in vivo to estimate the forces and strain that act on the human tendon in dynamic exercises used during rehabilitation.

DESIGN

Scoping review.

DATA SOURCES

Embase, PubMed, Web of Science and Google Scholar were searched from database inception to February 2021.

ELIGIBILITY CRITERIA

Cross-sectional studies available in English or Spanish language were included if they focused on evaluating the forces or strain of human tendons in vivo during dynamic exercises. Studies were excluded if they did not evaluate tendon forces or strain; if they evaluated running, walking, jumping, landing or no dynamic exercise at all; and if they were conference proceedings or book chapters.

DATA EXTRACTION AND SYNTHESIS

Data extracted included year of publication, study setting, study population characteristics, technique used and exercises evaluated. The studies were grouped by the types of techniques and the tendon location.

RESULTS

Twenty-one studies were included. Fourteen studies used an indirect methodology based on inverse dynamics, nine of them in the Achilles and five in the patellar tendon. Six studies implemented force transducers for measuring tendon forces in open carpal tunnel release surgery patients. One study applied an optic fibre technique to detect forces in the patellar tendon. Four studies measured strain using ultrasound-based techniques.

CONCLUSIONS

There is a predominant use of inverse dynamics, but force transducers, optic fibre and estimations from strain data are also used. Although these tools may be used to make general estimates of tendon forces and strains, the invasiveness of some methods and the loss of immediacy of others make it difficult to provide immediate feedback to the individuals.

Tendinopathies and Pain Sensitisation: A Meta-Analysis with Meta-Regression

The presence of pain sensitisation has been documented and reported as being a possible cause of treatment failure and pain chronicity in several musculoskeletal conditions, such as tendinopathies. The aim of the present study is to analyse existing evidence on pain sensitisation in tendinopathies comparing the local and distant pain thresholds of healthy and affected subjects with distinct analysis for different tendinopathies. PubMed, Cochrane Central Register, Scopus, and Web Of Science were systematically searched after registration on PROSPERO (CRD42020164124). Level I to level IV studies evaluating the presence of pain sensitisation in patients with symptomatic tendinopathies, documented through a validated method, were included. A meta-analysis was performed to compare local, contralateral, and distant pain thresholds between patients and healthy controls with sub-analyses for different tendinopathies. Meta-regressions were conducted to evaluate the influence of age, activity level, and duration of symptoms on results. Thirty-four studies out of 2868 were included. The overall meta-analysis of local pressure pain thresholds (PPT) documented an increased sensitivity in affected subjects (p < 0.001). The analyses on contralateral PPTs (p < 0.001) and distant PPTs (p = 0.009) documented increased sensitivity in the affected group. The results of the sub-analyses on different tendinopathies were conflicting, except for those on lateral epicondylalgia. Patients’ activity level (p = 0.02) and age (p = 0.05) significantly influenced local PPT results. Tendinopathies are characterized by pain sensitisation, but, while features of both central and peripheral sensitisation can be constantly detected in lateral epicondylalgia, results on other tendinopathies were more conflicting. Patients’ characteristics are possible confounders that should be taken into account when addressing pain sensitisation.

Physical Therapy Interventions for the Management of Biceps Tendinopathy: An International Delphi Study

Background

Shoulder pain related to the long head of the biceps tendon (LHBT) tendinopathy can be debilitating and difficult to treat especially in athletes who often elect for surgical intervention. Conservative management is recommended but there are limited established guidelines on the physical therapy (PT) management of the condition.

Hypothesis/Purpose

The purpose of this study was to establish consensus on conservative, non-surgical physical therapy interventions for individuals with LHBT tendinopathy using the Delphi method approach.

Study Design

Delphi Study.

Methods

Through an iterative process, experts in the PT field rated their agreement with a list of proposed treatment interventions and suggested additional interventions during each round. Agreement was measured using a four-point Likert scale. Descriptive statistics including median and percentage agreement were used to measure agreement. Data analysis at the end of Round III produced, by consensus, a list of PT interventions recommended for the management of individuals with LHBT tendinopathy. Consensus was defined as an a priori cutoff of ≥75% agreement.

Results

The respondent group included 29 international experts in the PT management of individuals with shoulder pain. At the conclusion of the study 61 interventions were designated as recommended based on consensus amongst experts and 9 interventions were not recommended based on the same criteria, 15 interventions did not achieve consensus.

Conclusion

There is a lack of well-defined, PT interventions used to treat LHBT tendinopathy. Expert respondents reached consensus on multimodal interventions including exercise, manual therapy and patient education to manage LHBT tendinopathy.

Level of Evidence

5.

The Effectiveness of Dry Needling Combined With Therapeutic Exercises in Treating Tendinopathy Conditions: A Systematic Review

CONTEXT

Approximately 70,000 Americans miss work annually due to tendinopathies causing pain, disability, and lower quality of life. Various conservative treatments have been demonstrated to improve outcomes in these conditions. Dry needling (DN) and therapeutic exercise are 2 such interventions that have been proposed to be a positive intervention for addressing tendinopathy.

OBJECTIVE

To summarize the best available evidence on the use of DN and exercise combined to treat tendinopathy.

EVIDENCE ACQUISITION

PubMed, EBSCOHost, and Web of Science were systematically searched from inception to March 2021. Articles were assessed to determine eligibility and evaluated for methodological quality using the PEDro scale. The PRISMA guidelines were used for this review. Inclusion criteria consisted of use of DN in combination with therapeutic exercise, human participants, and active tendinopathy pathology.

EVIDENCE SYNTHESIS

Seven studies met the inclusion and exclusion criteria, which averaged 6/11 on the PEDro scale. The level of agreement of evaluators was 94%. Current evidence supports the use of DN combined with therapeutic exercises, especially those including eccentric exercises, can improve pain and function for various tendinopathies. However, limited evidence exists regarding specific therapeutic interventions to be combined with DN.

CONCLUSION

There is moderate, level B evidence to suggest the use of DN techniques targeted at the tendon and combined with eccentric therapeutic exercise to improve pain and functional outcomes for tendinopathies.

Progression of rotator cuff tendon pathology in manual wheelchair users with spinal cord injury: A 1-year longitudinal study

OBJECTIVE

To investigate the progression of rotator cuff tendon pathology across one year in manual wheelchair (MWC) users with spinal cord injury (SCI) and matched able-bodied individuals, and to explore the association between pain, age, and duration of wheelchair use with the progression of rotator cuff pathology.

DESIGN

Longitudinal cohort study, 1-year follow-up.

SETTING

Outpatient clinic at a tertiary medical center.

PARTICIPANTS

Twenty-four adult MWC users with SCI (20 men) with an average age (SD) of 37(12) years and 24 age and sex-matched able-bodied individuals.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Presence of shoulder pain was collected. Magnetic resonance imaging (MRI) abnormalities of rotator cuff tendons including tendinopathy and tendon tears at baseline and 1-year follow-up visits were graded by a board-certified musculoskeletal radiologist, and three categories of tendon pathology scores including individual tendon scores, unilateral cuff scores, and bilateral cuff scores were calculated for each participant.

RESULTS

Fifty-four percent of the MWC users reported shoulder pain at both time points which was significantly higher than able-bodied cohort at baseline (17%, P = 0.012) and year 1 (21%, P = 0.021). Rotator cuff tendon pathology was detected as mainly mild tendinopathies and low-grade partial-thickness tears in both cohorts at both time points but was more common in MWC users. The results for the bilateral cuff scores indicated a significant (P < 0.008) progression of rotator cuff tendon pathology in the MWC users over one year. MRI findings did not change significantly for the able-bodied cohort across time. There was no association of pain, age, or duration of MWC use with progression of rotator cuff pathology in MWC user cohort.

CONCLUSION

MWC users had a higher prevalence of pain than matched able-bodied cohort, but pain was minimal and not function-limiting. Bilateral cuff TOTAL scores showed pathology progression in MWC users, but MRI findings remained stable in the able-bodied cohort. MWC users were 3.4 times more likely to experience pathology progression than the able-bodied cohort.

Does Additional Dietary Supplementation Improve Physiotherapeutic Treatment Outcome in Tendinopathy? A Systematic Review and Meta-Analysis

A systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of dietary supplements in addition to physiotherapeutic treatment on pain and functional outcomes. PubMed, The Cochrane Library, Web of Science, and Embase were searched from inception to November 2021 (Prospero registration: CRD42021291951). Studies were eligible if the interventions consisted of physiotherapeutic approaches that were combined with dietary supplementation and if they reported measures of pain and/or function. Six studies were included in the meta-analysis. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated and analysed using a Review Manager software. Subgroup analysis was performed to explore possible associations between the study characteristics and the effectiveness of the intervention. Additional dietary supplementation during physiotherapeutic treatment significantly improved the reduction in pain score (SMD = −0.74, 95% CI, −1.37 to −0.10; p < 0.05), while it had no effect on functional outcomes (SMD = 0.29, 95% CI, 0.00 to 0.58; p > 0.05). This systematic review and meta-analysis suggests that additional nutritional interventions may improve physiotherapeutic treatment outcomes in the management of tendinopathies.

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.

Prevalence of Achilles tendinopathy in physical exercise: A systematic review and meta-analysis

This comprehensive systematic review and meta-analysis assessed the prevalence of Achilles tendinopathy (AT) in physical exercise (PE). Specifically, we estimate the overall risk of AT in physical exercise and compare sport-specific estimates of AT risk. PubMed, Web of Science, Cochrane Library, and SPORTDiscus were searched before the 1^st of October 2021. Random-effects, subgroup analysis, sensitivity analysis and meta-regressions were conducted, involving 16 publications. This meta-analysis found that the overall prevalence of AT was 0.06 (95%CI, 0.04–0.07). The prevalence of Achilles tendon rupture was 0.03 (95%CI, 0.02–0.05). Subgroup analysis showed that the prevalence of AT increased with age, the highest among the group aged over 45 (0.08; 95%CI, 0.04–0.11), and the lowest among the group under 18 years old (0.02; 95%CI, 0.01–0.03). The gymnastics and ball games had the highest prevalence of AT, at (0.17; 95%CI, 0.14–0.20) and (0.06; 95%CI, 0.02–0.11), respectively. The prevalence of AT in athletes (0.06; 95%CI, 0.04–0.08) was higher than that of amateur exercisers (0.04; 95%CI, 0.02–0.06) and there was no difference in the prevalence of AT between males and females. There are differences in the prevalence of AT in different ages, sport events and characteristics of participants. This systematic review and meta-analysis suggested that it was necessary to pay more attention to AT in people who were older or engaged in gymnastics.

Substance P, A Promising Therapeutic Target in Musculoskeletal Disorders

A large number of studies have focused on the role of substance P (SP) and the neurokinin-1 receptor (NK1R) in the pathogenesis of a variety of medical conditions. This review provides an overview of the role of the SP-NK1R pathway in the pathogenesis of musculoskeletal disorders and the evidence for its role as a therapeutic target for these disorders, which are major public health problems in most countries. To summarize, the brief involvement of SP may affect tendon healing in an acute injury setting. SP combined with an adequate conjugate can be a regenerative therapeutic option in osteoarthritis. The NK1R antagonist is a promising agent for tendinopathy, rheumatoid arthritis, and osteoarthritis. Research on the SP-NK1R pathway will be helpful for developing novel drugs for osteoporosis.

Mechanisms of Achilles Tendon Rupture in National Basketball Association Players

A systematic search was performed of online databases for any Achilles tendon (AT) injuries occurring within the National Basketball Association (NBA). Video was obtained of injuries occurring during competition and downloaded for analysis in Dartfish. NBA athletes (n = 27) were identified with AT rupture over a 30-year period (1991–2021). Of the 27 NBA athletes found to have AT ruptures (mean age: 29.3 [3.3] y; average time in the NBA: 8.5 [3.8] y), 15 in-game videos were obtained for analysis. Noncontact rupture was presumed to have occurred in 12/13 cases. Eight of the 13 athletes had possession of the ball during time of injury. The ankle joint of the injured limb for all 13 athletes was in a dorsiflexed position during the time of injury (47.9° [6.5°]). All 13 athletes performed a false-step mechanism at time of injury where they initiated the movement by taking a rearward step posterior to their center of mass with the injured limb before translating forward. NBA basketball players that suffered AT ruptures appeared to present with a distinct sequence of events, including initiating a false step with ankle dorsiflexion of the injured limb at the time of injury.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSION

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

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

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

Sharp pain in a normal Achilles tendon of a professional female football player was related to a plantaris tendon in a rare position: a case report

BACKGROUND

Plantaris tendinopathy and plantaris-associated Achilles tendinopathy can be responsible for chronic pain in the Achilles tendon midportion, often accompanied by medial tenderness. As conservative treatments are less successful for this patient group, proper diagnosis is important for decision making. This report presents a case with plantaris tendinopathy in a rare (superficial) location.

CASE PRESENTATION

This article describes a pain history and treatment timeline of a professional Swedish female soccer player (32 years old, Northern European ethnicity, white) who suffered from sharp pain in the Achilles tendon midportion and tenderness on the medial and superficial side for about 2 years. Conservative treatments, including eccentric exercises, were not successful and, to some extent, even caused additional irritation in that region. Ultrasound showed a wide and thick plantaris tendon located on the superficial side of the Achilles tendon midportion. The patient was surgically treated with local removal of the plantaris tendon. After surgery there was a relatively quick (4-6 weeks) rehabilitation, with immediate weight bearing, gradual increased loading, and return to running activities after 4 weeks. At follow-up at 8 weeks, the patient was running and had not experienced any further episodes of sharp pain during change of direction or sprinting.

CONCLUSIONS

The plantaris tendon should be considered as a possible source of Achilles tendon pain. This case study demonstrates that the plantaris tendon can be found in unexpected (superficial) positions and needs to be carefully visualized during clinical and imaging examinations.

Autoregulation in Resistance Training for Lower Limb Tendinopathy: A Potential Method for Addressing Individual Factors, Intervention Issues, and Inadequate Outcomes

Musculoskeletal disorders, such as tendinopathy, are placing an increasing burden on society and health systems. Tendinopathy accounts for up to 30% of musculoskeletal disorders, with a high incidence in athletes and the general population. Although resistance training has shown short-term effectiveness in the treatment of lower limb tendinopathy, more comprehensive exercise protocols and progression methods are required due to poor long-term outcomes. The most common resistance training protocols are predetermined and standardized, which presents significant limitations. Current standardized protocols do not adhere to scientific resistance training principles, consider individual factors, or take the importance of individualized training into account. Resistance training programs in case of tendinopathy are currently not achieving the required intensity and dosage, leading to high recurrence rates. Therefore, better methods for individualizing and progressing resistance training are required to improve outcomes. One potential method is autoregulation, which allows individuals to progress training at their own rate, taking individual factors into account. Despite the finding of their effectiveness in increasing the strength of healthy athletes, autoregulation methods have not been investigated in case of tendinopathy. The purpose of this narrative review was 3-fold: firstly, to give an overview and a critical analysis of the individual factors involved in tendinopathy and current resistance training protocols and their limitations. Secondly, to give an overview of the history, methods, and application of autoregulation strategies both in sports performance and physiotherapy. Finally, a theoretical adaptation of a current tendinopathy resistance training protocol using autoregulation methods is presented, providing an example of how the method could be implemented in clinical practice or future research.

Effect of a common exercise programme with an individualised progression criterion based on the measurement of neuromuscular capacity versus current best practice for lower limb tendinopathies (MaLaGa trial): a protocol for a randomised clinical trial

INTRODUCTION

High-load resistance training has shown positive effects in pain and function in lower limb tendinopathies. However, some authors suggest that current exercise programmes produce an increase in tolerance to load and exercise in general but without fixing some existing issues in tendinopathy. This may indicate the need to include training aspects not currently taken into account in the current programmes. The main objective of this study will be to compare the effect of a common exercise protocol for the three predominant lower limb tendinopathies (Achilles, patellar and gluteal), based on an individualised control of the dose and training of specific aspects of the neuromuscular system versus the current best practice for each location.

METHODS AND ANALYSIS

This study will be conducted among people with mid-portion Achilles, patellar or gluteal tendinopathy. The participants allocated to the experimental group will perform a 14-week innovative common therapeutic exercise programme. Participants allocated to the control group will carry out a 14-week exercise programme based on the best current practice for each of the studied locations. The Victorian Institute of Sports Assessment questionnaire will be considered the primary outcome. Pain, central sensitisation, fear avoidance behaviour, quality of life, treatment satisfaction, lower-limb strength and function, and high-density electromyography profile will be evaluated as secondary outcomes. Outcomes will be assessed at baseline, 7 weeks, after the intervention (week 14), 26 weeks and 52 weeks.

ETHICS AND DISSEMINATION

The study has been approved by the Portal de Ética de la Investigación Biomédica de Andalucía Ethics Committee (1221-N-19). All participants will be informed about the purpose and content of the study and written informed consent will be completed. The results of this study will be published in a peer-reviewed journal and will be disseminated electronically and in print.

TRIAL REGISTRATION NUMBER

NCT03853122; Pre-results.

The Epidemiology, Risk Factors, and Nonsurgical Treatment of Injuries Related to Endurance Running

ABSTRACT

Running is a popular form of exercise that is easily accessible to various populations; endurance running, defined as distances beyond 5 km, continues to grow within the sport. Endurance running-related injuries are common in the lower extremities and are primarily overuse related. A multitude of risk factors for injury exist, including extrinsic factors, such as running distance and frequency, and intrinsic factors, such as biomechanics and nutrition status. Training and rehabilitation techniques vary with a general focus on strengthening and gradual increase in activity, but evidence is mixed, and it is difficult to generalize programs across different running populations. Management of specific running groups, including youth runners, is an area in which additional research is needed. New treatments, such as orthobiologics and wearable technology, have promising potential to optimize performance and recovery and minimize injury. However, they need to be further evaluated with high-quality studies.

The effect of low-level red and near-infrared photobiomodulation on pain and function in tendinopathy: a systematic review and meta-analysis of randomized control trials

Background

Tendinopathy is a common clinical condition that can significantly affect a person’s physical function and quality of life. Despite exercise therapy being the mainstay of tendinopathy management, there are many potential adjunct therapies that remain under investigated, one of which is photobiomodulation (PBM). PBM uses varied wavelengths of light to create a biological effect. While PBM is used frequently in the management of tendinopathy, high quality evidence supporting its utility is lacking.

Methods

A systematic search of the Pubmed, CINAHL, SCOPUS, Cochrane Database, Web of Science and SPORTSDICUS databases was performed for eligible articles in August 2020. Randomized Control Trials that used red or near-infrared PBM to treat tendinopathy disorders that made comparisons with a sham or ‘other’ intervention were included. Pain and function data were extracted from the included studies. The data were synthesized using a random effects model. The meta-analysis was performed using the mean difference (MD) and standardized mean difference (SMD) statistics.

Results

A total of 17 trials were included (n = 835). When compared solely to other interventions PBM resulted in similar decreases in pain (MD -0.09; 95% CI − 0.79 to 0.61) and a smaller improvement in function (SMD -0.52; 95% CI − 0.81 to − 0.23). When PBM plus exercise was compared to sham treatment plus exercise, PBM demonstrated greater decreases in pain (MD 1.06; 95% CI 0.57 to 1.55) and improved function (MD 5.65; 95% CI 0.25 to 11.04). When PBM plus exercise was compared to other interventions plus exercise, no differences were noted in pain levels (MD 0.31; 95% CI − 0.07 to 0.70). Most studies were judged as low-risk of bias. The outcome measures were classified as very low to moderate evidence quality according to the Grading of Recommendation, Development and Evaluation tool.

Conclusion

There is very-low-to-moderate quality evidence demonstrating that PBM has utility as a standalone and/or adjunctive therapy for tendinopathy disorders.

Trial registration

PROPERO registration number: CRD42020202508.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00306-z.

"Smart Exosomes": A Smart Approach for Tendon Regeneration

Shoulder tendon injuries are the common musculoskeletal disorder resulting in significant pain and disability. These injuries are characterized by chronic inflammation and tissue degeneration. Tendon pathology exhibits poor innate healing ability, enhanced inflammation, disorganized collagen fibers, calcification, and scar tissue formation affecting the normal healing process. Extracellular vesicle, especially exosomes, treatment has been emerging as a potential regenerative strategy improving the outcomes and biomechanical properties, accelerating tenocyte proliferation and migration, reducing inflammation, and facilitating the healing at tendon-bone interface. In this article, we critically reviewed the potential role of exosomes in tendon regeneration and their applications to accelerate the healing response following injury. In addition, the article provides novel insights on the concept of "Smart Exosomes" by programming/manipulating the secretome contents and functions of exosomes in the management of shoulder tendon injury.

Motor Control Exercises Compared to Strengthening Exercises for Upper- and Lower-Extremity Musculoskeletal Disorders: A Systematic Review With Meta-Analyses of Randomized Controlled Trials

OBJECTIVE

The purpose of this review was to compare the efficacy of motor control exercises (MCEs) to strengthening exercises for adults with upper- or lower-extremity musculoskeletal disorders (MSKDs).

METHODS

Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane CENTRAL, and CINAHL. Randomized controlled trials were identified on the efficacy of MCEs compared to strengthening exercises for adults with upper- or lower-extremity MSKDs. Data were extracted with a standardized form that documented the study characteristics and results. For pain and disability outcomes, pooled mean differences (MDs) and standardized mean differences (SMDs) were calculated using random-effects inverse variance models.

RESULTS

Twenty-one randomized controlled trials (n = 1244 participants) were included. Based on moderate-quality evidence, MCEs lead to greater pain (MD = -0.41 out of 10 points; 95% CI = -0.72 to -0.10; n = 626) and disability reductions (SMD = -0.28; 95% CI = -0.43 to -0.13; n = 713) when compared to strengthening exercises in the short term; these differences are not clinically important. When excluding trials on osteoarthritis (OA) participants and evaluating only the trials involving participants with rotator cuff-related shoulder pain, shoulder instability, hip-related groin pain, or patellofemoral pain syndrome, there is moderate quality evidence that MCEs lead to greater pain (MD = -0.74 out of 10 points; 95% CI = -1.22 to -0.26; n = 293) and disability reductions (SMD = -0.40; 95% CI = -0.61 to -0.19; n = 354) than strengthening exercises in the short term; these differences might be clinically important.

CONCLUSIONS

MCEs lead to statistically greater pain and disability reductions when compared to strengthening exercises among adults with MSKDs in the short term, but these effects might be clinically important only in conditions that do not involve OA. Inclusion of new trials might modify these conclusions.

IMPACT

These results suggest that MCEs could be prioritized over strengthening exercises for adults with the included non-OA MSKDs; however, results are unclear for OA disorders.