Systematische Literaturanalyse über exzentrisches Training bei chronischer Patellatendinopathie: Gibt es einen Standard?

Effectiveness of eccentric strengthening in the treatment of lateral elbow tendinopathy: A systematic review with meta-analysis

STUDY DESIGN

Meta-analysis.

INTRODUCTION

Lateral elbow tendinopathy is a common condition with an annual incidence of up to 3% of the population. Eccentric strengthening has shown promise as a method to treat lateral elbow tendinopathy, but is unclear if it is superior to other forms of treatment.

PURPOSE OF THE STUDY

The purpose of this study was to investigate the effectiveness of eccentric strengthening compared with other forms of strengthening and pain-relieving modalities on pain, strength, and function in people with lateral elbow tendinopathy.

METHODS

Five electronic databases were searched. Reference lists of selected articles were hand-searched. Outcomes were defined a priori. Meta-analyses were performed using a random effects model with standardized mean differences, test of heterogeneity, and sensitivity analyses.

RESULTS

Eight articles were included in this review. When comparing eccentric strengthening to other forms of strengthening and pain-relieving modalities, there were significant large effect size of 1.12 (CI: 0.31-1.93) and 1.22 (CI: 0.25-2.18) in reducing pain and improving function in the short-term, respectively. In long-term, results were inconclusive on all outcomes.

DISCUSSION

A treatment program using eccentric strengthening of adequate intensity and duration seemed to be most effective for treating lateral elbow tendinopathy.

CONCLUSIONS

The state of science of best care for lateral elbow tendinopathy is still in its infancy. Large, high-quality randomized controlled trials with clearly defined strengthening regime are needed to determine optimal dosage to maximize treatment effects. Recommendations were provided based on careful synthesis of findings from this review and current evidence in literature.

Effects of a strength protocol combined with electrical stimulation on patellar tendinopathy: 42 months retrospective follow-up on 6 high-level jumping athletes

STUDY DESIGN

A retrospective study.

INTRODUCTION

Patellar tendinopathy (PT) or jumper's knee (JK) in elite athletes is a challenging condition for sports medicine professionals. This study analyzes the development of a protocol using eccentric, isometric, concentric exercises, and electrostimulation to treat elite athletes suffering from JK. The semiannual strength protocol was completed during a total of 36 months by six high-level jumping athletes with chronic painful JK. Pain during patellar tendon loading activity was evaluated on a visual analogue pain scale (VAS). Upon protocol completion, promising clinical results were evidenced by significant pain reduction during tendon loading activity.

MATERIAL AND METHODS

Six high level jumping athletes with chronic painful JK completed a semiannual strength program using eccentric, isometric, concentric and electrical stimulation exercises. The protocol was done 12 weeks in the winter pre-season and 10 weeks in the summer pre-season, for altogether 36 months, with an interruption of the protocol at 24 months for 6 months. Pain during patellar tendon loading activity was evaluated on a visual analogue pain scale (VAS), before the first session and then every 6 months, coinciding with the competitive phase, the time of maximum pain.

RESULTS

There was a significant (p < 0.01) decrease in the VAS from start to the 18, 24 and 48 months follow-ups.

CONCLUSIONS

In a small group of high level jumping athletes with chronic painful JK, a strength protocol combined with electrical stimulation showed promising clinical results with significant pain reduction during tendon loading activity.

Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double-Blinded Randomized Study

OBJECTIVE

To evaluate the effectiveness of a combined treatment of focused shockwave therapy (ESWT) and eccentric training compared with sham-shockwave therapy (placebo) and eccentric training in participants with patellar tendinopathy (PT) after 24 weeks.

DESIGN

Randomized controlled trial.

SETTING

Sports medicine departments of a university hospital and a general hospital in the Netherlands.

PARTICIPANTS

Fifty-two physically active male and female participants with a clinical diagnosis of PT (mean age: 28.6 years; range, 18-45) were randomly allocated to the ESWT (n = 22) or sham shockwave (n = 30).

INTERVENTIONS

Extracorporeal shockwave therapy and sham shockwave were applied in 3 sessions at 1-week intervals with a piezoelectric device. All participants were instructed to perform eccentric exercises (3 sets of 15 repetitions twice a day) for 3 months on a decline board at home.

MAIN OUTCOME MEASURES

The Victorian Institute of Sport Assessment-Patella (VISA-P) scores (primary), pain scores during functional knee loading tests, and Likert score (secondary) were registered at baseline and at 6, 12, and 24 weeks after the start with the ESWT or sham-shockwave treatment.

RESULTS

No significant differences for the primary and secondary outcome measures were found between the groups. In the ESWT/eccentric group, the VISA-P increased from 54.5 ± 15.4 to 70.9 ± 17.8, whereas the VISA-P in the sham-shockwave/eccentric group increased from 58.9 ± 14.6 to 78.2 ± 15.8 (between-group change in VISA-P at 24 weeks -4.8; 95% confidence interval, -12.7 to 3.0, P = 0.150).

CONCLUSIONS

This study showed no additional effect of 3 sessions ESWT in participants with PT treated with eccentric exercises. The results should be interpreted with caution because of small sample size and considerable loss to follow-up, particularly in the ESWT group.

Results of Surgical Treatment of Chronic Patellar Tendinosis (Jumper's Knee): A Systematic Review of the Literature

PURPOSE

To review the literature concerning surgical treatment options for chronic patellar tendinosis (jumper's knee), a common problem among athletes. When conservative treatment fails, surgical treatment is required.

METHODS

Systematic review of the literature concerning the results of current surgical treatment options for chronic patellar tendinosis. All articles of studies with an evidence level ≥IV from January 2000 until February 2015 presenting the surgical outcome after arthroscopic as well as open treatment of chronic patellar tendinosis were included. The literature research of the PubMed database was performed using the following key words: "patellar" and "tendinitis," "tendonitis," "tendinosis" or "tendinopathy"; "inferior patellar pole"; "jumper's knee"; "surgical treatment" and "open" or "arthroscopic patellar tenotomy."

RESULTS

A systematic review of the literature was performed especially to point out the effectiveness of arthroscopic treatment of chronic patellar tendinosis. The results revealed good clinical results for arthroscopic as well as open treatment of chronic patellar tendinosis that is refractory to conservative treatment in athletes. An average success rate of 87% was found for the open treatment group and of 91% for the arthroscopic treatment group. However, after open surgery, the mean time of return to the preinjury level of activity is 8 to 12 months, with a certain number of patients/athletes who cannot return to the preinjury level of activity.

CONCLUSIONS

Minimally invasive, arthroscopically assisted or all-arthroscopic procedures may lead to a significantly faster return to sporting activities and may, therefore, be the preferred method of surgical treatment.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

The role of eccentric exercise in sport injuries rehabilitation

INTRODUCTION

Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field.

SOURCES OF DATA

A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as 'eccentric exercise', 'sports injuries rehabilitation', 'tendinopathy', 'hamstrings strain' 'adductor injuries' and 'ACL reconstruction rehabilitation'.

AREAS OF AGREEMENT

EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation.

AREA OF CONTROVERSY

The lack of standardization of protocols, the variable amount, quality and follow-up of studies, the different anatomy and pathophysiology of the therapeutic targets limit the evidence of applicability of EE to sports injuries.

GROWING POINTS

The role of pathology and biomechanics in the response to EE should be further investigated.

AREAS TIMELY FOR DEVELOPING RESEARCH

New randomized controlled trials should test the effectiveness of standardized EE regimens to various sites of sports injuries.

Tendinopathy in sport

CONTEXT

Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited.

EVIDENCE ACQUISITION

The authors conducted a MEDLINE search on tendinopathy, or "tendonitis" or "tendinosis" or "epicondylitis" or "jumpers knee" from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature.

RESULTS

Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies.

CONCLUSIONS

Novel targeted therapies are emerging, but multicenter trials are needed to confirm the results of exercise and mini-invasive treatments.