Effects of kinesiophobia and pain on performance and willingness to perform jumping tests in Achilles tendinopathy: A cross-sectional study

Triceps surae muscle forces during dynamic exercises in patients with Achilles tendinopathy: A cross-sectional study

PURPOSE

The aim of this study was to investigate the individual triceps surae muscle forces during the execution of six different functional movements and rehabilitation exercises in patients with Achilles tendinopathy compared to a control group.

METHODS

Triceps surae muscle forces of 15 participants with Achilles tendinopathy (AT) and 15 healthy controls were estimated through a combination of experimental data and musculo-skeletal modeling. Three-dimensional motion capture and force plates were used to collect the ankle and knee joint angles and moments during three functional movements (walking, heel walking, and toe walking) and three rehabilitation exercises (bilateral heel drop, unilateral heel drop with extended knee and with flexed knee). A dynamic optimization method was used to obtain the modeled triceps surae muscle forces. Force-sharing strategies were calculated at the peak triceps surae muscle force and compared between groups.

RESULTS

Lower peak triceps surae forces were obtained for the AT group during dynamic exercises. Across all exercises, the average contribution of the soleus (SOL) to the total triceps surae muscle force was the largest (60.83 ± 13.89% [AT] > 56.90 ± 16.18% [healthy]), followed by the gastrocnemius medialis (29.87 ± 10.67% [AT] < 32.19 ± 12.90% [healthy]) and the gastrocnemius lateralis (9.30 ± 4.31% [AT] < 10.91 ± 4.66% [healthy]). The triceps surae force-sharing strategy was different for the toe walking, heel walking, and the bilateral and unilateral heel drop with extended knee.

CONCLUSION

This study provides evidence for altered triceps surae muscle force-sharing strategies during dynamic tasks in patients with AT. The influence of altered muscle force-sharing on the subtendon nonuniformity and/or the tendon loading should be explored in future work.

Kinesiophobia contributes to worse functional and patient-reported outcome measures in Achilles tendinopathy: a systematic review

PURPOSE

To assess the effect of kinesiophobia or fear of reinjury on patient-reported outcome measures and physical performance measures in patients with chronic Achilles tendinopathy (AT).

METHODS

Three databases were systematically screened for studies from inception to May 22nd, 2023 for literature investigating the impact of kinesiophobia on PROMs or physical performance metrics in AT. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, pain, level of activity, self-reported injury severity, quality of life, single-leg hop performance, and heel-raise performance were recorded. Data was presented primarily in a narrative summary fashion. The MINORS score was used for all studies to perform a quality assessment of included studies.

RESULTS

Six studies comprising 705 patients were included in this review. Variations of the Tampa Scale of Kinesiophobia (TSK-11 or TSK-17) were used in all studies. TSK scores were strongly correlated with the Pain Catastrophizing Score (PCS) and Visual Analogue Scale (VAS) scores and were correlated with decreased Victorian Institute of Sports Assessment Achilles (VISA-A) and Foot and Ankle Outcome Scores Quality of Life (FAOS-QoL) subscale scores. Kinesiophobia was associated with heel raise completion with conflicting evidence on correlations with hop test performance.

CONCLUSION

Increased kinesiophobia scores (> 35 points), measured by TSK are associated with worse PROMs, including increased pain, decreased quality of life, increased self-reported severity, and is also associated with poorer physical performance measures in patients with AT.

LEVEL OF EVIDENCE

IV.

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.

Biopsychosocial approach to tendinopathy

Tendinopathy describes a spectrum of changes that occur in damaged tendons, leading to pain and reduced function that remains extremely challenging for all clinicians. There is an increasing awareness of the influence that psychological and psychosocial components, such as self-efficacy and fear-avoidance, have on rehabilitation outcomes in musculoskeletal medicine. Although it is widely accepted that psychological/psychosocial factors exist in tendinopathy, there is currently a distinct lack of trials measuring how these factors affect clinical outcomes. Biopsychosocial treatments acknowledge and address the biological, psychological and social contributions to pain and disability are currently seen as the most efficacious approach to chronic pain. Addressing and modulating these factors are crucial in the pathway of personalised treatments in tendinopathy and offer a real opportunity to drive positive outcomes in patients. In this education review, we also provide the current evidence-based guidance on psychological and psychosocial developments in musculoskeletal medicine and how these may be translated to treating tendinopathy using a biopsychosocial model.

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.

Kinesiophobia Severity Categories and Clinically Meaningful Symptom Change in Persons With Achilles Tendinopathy in a Cross-Sectional Study: Implications for Assessment and Willingness to Exercise

Objectives: (1) Validate thresholds for minimal, low, moderate, and high fear of movement on the 11-item Tampa Scale of Kinesiophobia (TSK-11), and (2) Establish a patient-driven minimal clinically important difference (MCID) for Achilles tendinopathy (AT) symptoms of pain with heel raises and tendon stiffness.

Methods: Four hundred and forty-two adults with chronic AT responded to an online survey, including psychosocial questionnaires and symptom-related questions (severity and willingness to complete heel raises and hops). Kinesiophobia subgroups (Minimal ≤ 22, Low 23–28, Moderate 29–35, High ≥ 36 scores on the TSK-11), pain MCID subgroups (10-, 20-, 30-, >30-points on a 0- to 100-point scale), and stiffness MCID subgroups (5, 10, 20, >20 min) were described as median [interquartile range] and compared using non-parametric statistics.

Results: Subgroups with higher kinesiophobia reported were less likely to complete three heel raises (Minimal = 93%, Low = 74%, Moderate = 58%, High = 24%). Higher kinesiophobia was associated with higher expected pain (Minimal = 20.0 [9.3–40.0], Low = 43.0 [20.0–60.0], Moderate = 50.0 [24.0–64.0], High = 60.5 [41.3–71.0]) yet not with movement-evoked pain (Minimal = 25.0 [5.0–43.0], Low = 31.0 [18.0–59.0], Moderate = 35.0 [20.0–60.0], High = 43.0 [24.0–65.3]). The most common pain MCID was 10 points (39% of respondents). Half of respondents considered a 5-min (35% of sample) or 10-min (16%) decrease in morning stiffness as clinically meaningful.

Conclusions: Convergent validity of TSK-11 thresholds was supported by association with pain catastrophizing, severity of expected pain with movement, and willingness to complete tendon loading exercises. Most participants indicated that reducing their pain severity to the mild range would be clinically meaningful.