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Vila-Dieguez O, Heindel MD, Awokuse D, Kulig K, Michener LA. Exercise for rotator cuff tendinopathy: Proposed mechanisms of recovery. Shoulder Elbow 2023; 15:233-249. [PMID: 37325389 PMCID: PMC10268139 DOI: 10.1177/17585732231172166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 06/17/2023]
Abstract
Rotator cuff (RC) tendinopathy is a common recurrent cause of shoulder pain, and resistance exercise is the first-line recommended intervention. Proposed causal mechanisms of resistance exercise for patients with RC tendinopathy consist of four domains: tendon structure, neuromuscular factors, pain and sensorimotor processing, and psychosocial factors. Tendon structure plays a role in RC tendinopathy, with decreased stiffness, increased thickness, and collagen disorganization. Neuromuscular performance deficits of altered kinematics, muscle activation, and force are present in RC tendinopathy, but advanced methods of assessing muscle performance are needed to fully assess these factors. Psychological factors of depression, anxiety, pain catastrophizing, treatment expectations, and self-efficacy are present and predict patient-reported outcomes. Central nervous system dysfunctions also exist, specifically altered pain and sensorimotor processing. Resisted exercise may normalize these factors, but limited evidence exists to explain the relationship of the four proposed domains to trajectory of recovery and defining persistent deficits limiting outcomes. Clinicians and researchers can use this model to understand how exercise mediates change in patient outcomes, develop subgroups to deliver patient-specific approach for treatment and define metrics to track recovery over time. Supporting evidence is limited, indicating the need for future studies characterizing mechanisms of recovery with exercise for RC tendinopathy.
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Affiliation(s)
- Oscar Vila-Dieguez
- Division of Biokinesiology & Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Matthew D. Heindel
- Division of Biokinesiology & Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Daniel Awokuse
- Division of Biokinesiology & Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Kornelia Kulig
- Division of Biokinesiology & Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Lori A. Michener
- Division of Biokinesiology & Physical Therapy, University of Southern California, Los Angeles, CA, USA
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Rieder F, Wiesinger HP, Herfert J, Lampl K, Hecht S, Niebauer J, Maffulli N, Kösters A, Müller E, Seynnes OR. Whole body vibration for chronic patellar tendinopathy: A randomized equivalence trial. Front Physiol 2022; 13:1017931. [PMID: 36338477 PMCID: PMC9633993 DOI: 10.3389/fphys.2022.1017931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/06/2022] [Indexed: 02/02/2023] Open
Abstract
Purpose: Whole body vibration (WBV) triggers anabolic responses in various tissues, including tendons, without requiring high force production. In this waitlist-controlled equivalence trial, we tested its clinical effectiveness as an alternative treatment for patellar tendinopathy against conventional heavy slow resistance training (HSR). Methods: Thirty-nine patients were randomized to either 3 months of WBV training (n = 13), HSR training (n = 11), or a waitlist control (WLC) group (n = 15). In a partly cross-over design, 14 patients of the WLC group were redistributed to one of the two intervention groups (5 in WBV, 9 in HSR). Pre- and post-intervention testing included pain assessments (VAS), functional limitations (VISA-P), knee extension strength and tendon morphological, mechanical and material properties. Follow-up measurements (VAS, VISA-P) were performed in the WBV and HSR groups 6 months after the intervention. Results: Comparisons with the WLC group revealed significant improvements in VISA-P and VAS scores after HSR (41%, p = 003; 54%, p = 0.005) and WBV (22%, p = 0.022; 56%, p = 0.031) training. These improvements continued until follow-up (HSR: 43%, 56%; WBV: 24%, 37%). Pre-post improvements in VAS scores were equivalent between WBV and HSR groups but inconclusive for the VISA-P score and all pre-test to follow up comparisons. The mid-tendon cross-sectional area was significantly reduced after WBV (-5.7%, p = 0.004) and HSR (-3.0%, p = 0.004) training compared to WLC although the equivalence test between interventions was inconclusive. Conclusion: Whole body vibration improved symptoms typically associated with patellar tendinopathy. This type of intervention is as effective as HSR against maximum pain, although equivalence could not be confirmed for other variables. The beneficial responses to WBV and HSR treatments persisted for 6 months after the end of the intervention. Clinical Trial Registration: https://www.drks.de/drks_web/setLocale_EN.do, identifier DRKS00011338.
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Affiliation(s)
- Florian Rieder
- Institute of Physical Medicine and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria,Department of Sport and Exercise Science, Paris-Lodron University Salzburg, Salzburg, Austria,*Correspondence: Florian Rieder,
| | - Hans-Peter Wiesinger
- Department of Sport and Exercise Science, Paris-Lodron University Salzburg, Salzburg, Austria
| | - Jürgen Herfert
- Institute of Physical Medicine and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria,Red Bull Athlete Performance Center, Thalgau, Austria
| | - Katrin Lampl
- Institute of Physical Medicine and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Stefan Hecht
- Institute of Radiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Josef Niebauer
- Institute of Physical Medicine and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria,Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy,Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, United Kingdom,School of Pharmacy and Bioengineering, Keele University School of Medicine, Staffordshire, United Kingdom
| | - Alexander Kösters
- Department of Sport and Exercise Science, Paris-Lodron University Salzburg, Salzburg, Austria
| | - Erich Müller
- Department of Sport and Exercise Science, Paris-Lodron University Salzburg, Salzburg, Austria
| | - Olivier R. Seynnes
- Department of Physical Performance, Norwegian School of Sport Science, Oslo, Norway
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Martínez F, Abián P, Jiménez F, Abián-Vicén J. The Effects of Eccentric Contraction Execution Time on the Properties of the Patellar Tendon. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159296. [PMID: 35954651 PMCID: PMC9367933 DOI: 10.3390/ijerph19159296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to assess the effects of eccentric contraction execution time on the morphological and elastic properties of the patellar tendon (PT) in a six-week, single-leg decline squat (SLDS) exercise training program. In addition, the effects of a six-week detraining period on the same variables were evaluated. Fifty participants were randomized into the control group (CG; n = 15), experimental group 1 (EG6s; n = 17; eccentric contraction execution time = 6 s) and experimental group 2 (EG3s; n = 18; eccentric contraction execution time = 3 s). The thickness and elastographic index (EI) in different regions of interest (ROIs) in the PT were measured after 6 weeks of eccentric training using the single-leg decline squat exercise (three sessions per week, 80% of the eccentric one-repetition maximum) and after 6 weeks of detraining. There was an increase in the thickness of the PT in the different ROIs analyzed in both experimental groups at the end of the training period. Especially worth noting was the increase in the thickness of the PT at the proximal level in EG3s (p = 0.001), and the increase at the distal level in EG6s (p = 0.001). On the other hand, there was a reduction in EI in EG6S at the end of the intervention program (p = 0.021), and both experimental groups increased EI in the three regions of interest analyzed after the detraining period (p < 0.01). In conclusion, the execution time of the eccentric contraction in the SLDS exercise determines the anatomical level of the morphological adaptations in the PT. These morphological adaptations are lost after 6 weeks of detraining, producing an increase in tendon stiffness.
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Affiliation(s)
- Fernando Martínez
- Performance and Sport Rehabilitation Laboratory, Faculty of Sport Sciences, University of Castilla-La Mancha, 45071 Toledo, Spain; (F.M.); (F.J.)
| | - Pablo Abián
- Faculty of Humanities and Social Sciences, Comillas Pontifical University, 28049 Madrid, Spain;
| | - Fernando Jiménez
- Performance and Sport Rehabilitation Laboratory, Faculty of Sport Sciences, University of Castilla-La Mancha, 45071 Toledo, Spain; (F.M.); (F.J.)
| | - Javier Abián-Vicén
- Performance and Sport Rehabilitation Laboratory, Faculty of Sport Sciences, University of Castilla-La Mancha, 45071 Toledo, Spain; (F.M.); (F.J.)
- Correspondence: ; Tel.: +34-925268800 (ext. 5522)
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Pieters D, Wezenbeek E, De Ridder R, Witvrouw E, Willems T. Acute Effects of Warming Up on Achilles Tendon Blood Flow and Stiffness. J Strength Cond Res 2020; 36:2717-2724. [PMID: 33337692 DOI: 10.1519/jsc.0000000000003931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
ABSTRACT Pieters, D, Wezenbeek, E, De Ridder, R, Witvrouw, E, and Willems, T. Acute effects of warming up on Achilles tendon blood flow and stiffness. J Strength Cond Res XX(X): 000-000, 2020-The aim of this study was to investigate the acute effect of frequently used warm-up exercises on the Achilles tendon blood flow and stiffness. In doing so, we want to explore which exercises are suitable to properly prepare the athlete's Achilles tendon in withstanding high amounts of loading during sport activities. This knowledge could help sport physicians and physiotherapists when recommending warm-up exercises that are able to improve sport performance while reducing the injury susceptibility. Achilles tendon blood flow and stiffness measurements of 40 healthy subjects (20 men and 20 women) aged between 18 and 25 years were obtained before and immediately after 4 different warm-up exercises: running, plyometrics, eccentric heel drops, and static stretching. The effect of these warm-up exercises and possible covariates (sex, age, body mass index, rate of perceived exertion, and sports participation) on the Achilles tendon blood flow and stiffness was investigated with linear mixed models. The level of significance was set at α = 0.05. The results of this study showed a significant increase in Achilles tendon blood flow and stiffness after 10 minutes of running (p < 0.001 and p < 0.001) and plyometrics (p < 0.001 and p = 0.039). Static stretching and eccentric exercises elicited no significant changes. From these results, it could be suggested that warm-up exercises should be intensive enough to properly prepare the Achilles tendon for subsequent sport activities. When looking at Achilles tendon blood flow and stiffness, we advise the incorporation of highly intensive exercises such as running and plyometrics within warm-up programs.
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Affiliation(s)
- Dries Pieters
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
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Changes on Tendon Stiffness and Clinical Outcomes in Athletes Are Associated With Patellar Tendinopathy After Eccentric Exercise. Clin J Sport Med 2020; 30:25-32. [PMID: 31855909 DOI: 10.1097/jsm.0000000000000562] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Eccentric exercise is commonly used as a form of loading exercise for individuals with patellar tendinopathy. This study investigated the change of mechanical properties and clinical outcomes and their interrelationships after a 12-week single-legged decline-board exercise with and without extracorporeal shockwave therapy (ESWT). DESIGN Randomized controlled trial. SETTING Outpatient clinic of a university. PARTICIPANTS Thirty-four male in-season athletes with patellar tendinopathy for more than 3 months were randomized into exercise and combined groups. INTERVENTIONS The exercise group received a 12-week single-legged decline-squat exercise, and the combined group performed an identical exercise program in addition to a weekly session of ESWT in the initial 6 weeks. MAIN OUTCOME MEASURES Tendon stiffness and strain were examined using ultrasonography and dynamometry. Visual analog scale and Victoria Institute of Sports Assessment-patella (VISA-p) score were used to assess pain and dysfunction. These parameters were measured at preintervention and postintervention. RESULTS Significant time effect but no significant group effect on the outcome measures; significant reduction in tendon stiffness (P = 0.02) and increase in tendon strain (P = 0.00); and reduction of intensity of pain (P = 0.00) and dysfunction (P = 0.00) were observed. Significant correlations between changes in tendon stiffness and VISA-p score (ρ = -0.58, P = 0.05); alteration in tendon strain, pain intensity (ρ = -0.63, P = 0.03); and VISA-p score (ρ = 0.60, P = 0.04) were detected after the exercise program. CONCLUSIONS Eccentric exercise-induced modulation on tendon mechanical properties and clinical symptoms are associated in athletes with patellar tendinopathy.
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Ho KY, Harty M, Kellogg J, Teter K, Lee SP, Chang YJ, Bashford G. Patellar tendon morphology in trans-tibial amputees utilizing a prosthesis with a patellar-tendon-bearing feature. Sci Rep 2019; 9:16392. [PMID: 31704989 PMCID: PMC6841932 DOI: 10.1038/s41598-019-52747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/22/2019] [Indexed: 11/09/2022] Open
Abstract
A patellar-tendon-bearing (PTB) bar is a common design feature used in the socket of trans-tibial prostheses to place load on the pressure-tolerant tissue. As the patellar tendon in the residual limb is subjected to the perpendicular compressive force not commonly experienced in normal tendons, it is possible for tendon degeneration to occur over time. The purpose of this study was to compare patellar tendon morphology and neovascularity between the residual and intact limbs in trans-tibial amputees and healthy controls. Fifteen unilateral trans-tibial amputees who utilized a prosthesis with a PTB feature and 15 age- and sex- matched controls participated. Sonography was performed at the proximal, mid-, and distal portions of each patellar tendon. One-way ANOVAs were conducted to compare thickness and collagen fiber organization and a chi-square analysis was used to compare the presence of neovascularity between the three tendon groups. Compared to healthy controls, both tendons in the amputees exhibited increased thickness at the mid- and distal portions and a higher degree of collagen fiber disorganization. Furthermore, neovascularity was more common in the tendon of the residual limb. Our results suggest that the use of a prosthesis with a PTB feature contributes to morphological changes in bilateral patellar tendons.
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Affiliation(s)
- Kai-Yu Ho
- Department of Physical Therapy, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, NV, 89154, USA.
| | - Michelle Harty
- Department of Physical Therapy, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, NV, 89154, USA
| | - Jessica Kellogg
- Department of Physical Therapy, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, NV, 89154, USA
| | - Kelly Teter
- Department of Physical Therapy, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, NV, 89154, USA
| | - Szu-Ping Lee
- Department of Physical Therapy, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, NV, 89154, USA
| | - Yu-Jen Chang
- Division of Physical Therapy, West Virginia University, 64 Medical Center Drive, P.O. Box 9226, Morgantown, WV, 26506, USA
| | - Gregory Bashford
- Department of Biological Systems Engineering, University of Nebraska-Lincoln, 230 L. W. Chase Hall, P. O. Box 830726, Lincoln, NE, 68583, USA
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Nuri L, Obst SJ, Newsham-West R, Barrett RS. Three-dimensional morphology and volume of the free Achilles tendon at rest and under load in people with unilateral mid-portion Achilles tendinopathy. Exp Physiol 2018; 103:358-369. [DOI: 10.1113/ep086673] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/28/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Leila Nuri
- School of Allied Health Sciences, Menzies Health Institute Queensland; Griffith University; Gold Coast QLD 4222 Australia
| | - Steven J. Obst
- School of Health, Medical and Applied Sciences; Central Queensland University; Bundaberg QLD 4670 Australia
| | - Richard Newsham-West
- School of Allied Health Sciences, Menzies Health Institute Queensland; Griffith University; Gold Coast QLD 4222 Australia
| | - Rod S. Barrett
- School of Allied Health Sciences, Menzies Health Institute Queensland; Griffith University; Gold Coast QLD 4222 Australia
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Nuri L, Obst SJ, Newsham-West R, Barrett RS. The tendinopathic Achilles tendon does not remain iso-volumetric upon repeated loading: insights from 3D ultrasound. J Exp Biol 2017; 220:3053-3061. [DOI: 10.1242/jeb.159764] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/12/2017] [Indexed: 12/22/2022]
Abstract
Mid-portion Achilles tendinopathy (MAT) alters the normal three-dimensional (3D) morphology of the Achilles tendon (AT) at rest and under a single tensile load. However, how MAT changes the 3D morphology of AT during repeated loading remains unclear. This study compared the AT longitudinal, transverse and volume strains during repeated loading in MAT with those of the contralateral tendon in people with unilateral MAT. Ten adults with unilateral MAT performed 10 successive 25 second submaximal (50%) voluntary isometric plantarflexion contractions with both legs. Freehand 3D ultrasound scans were recorded and used to measure whole AT, free AT, and proximal AT longitudinal strains and free AT cross-sectional area (CSA) and volume strains. The free AT experienced higher longitudinal and CSA strain and reached steady state following a greater number of contractions (5 contractions) in MAT compared to the contralateral tendon (3 contractions). Further, free tendon CSA and volume strained more in MAT than contralateral tendon from the first contraction, whereas free AT longitudinal strain was not greater than the contralateral tendon until the fourth contraction. Volume loss from the tendon core therefore preceded the greater longitudinal strain in MAT. Overall, these findings suggest that the tendinopathic free AT experiences an exaggerated longitudinal and transverse strain response under repeated loading that is underpinned by an altered interaction between solid and fluid tendon matrix components. These alterations are indicative of accentuated poroelasticity and an altered local stress-strain environment within the tendinopathic free tendon matrix, which could affect tendon remodelling via mechanobiological pathways.
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Affiliation(s)
- Leila Nuri
- School of Allied Health Sciences, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Steven J. Obst
- School of Health, Medical and Applied Sciences, Central Queensland University, Bundaberg, Queensland, Australia
| | - Richard Newsham-West
- School of Allied Health Sciences, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Rod S. Barrett
- School of Allied Health Sciences, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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