Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation

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

Background

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

Review questions

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

Methods

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

Results

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

Limitations

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

Conclusion

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

Future work

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

Study registration

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

Funding

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

Patient ratings in exercise therapy for the management of tendinopathy: a systematic review with meta-analysis

OBJECTIVE

To synthesise exercise therapy intervention data investigating patient rating outcomes for the management of tendinopathy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials investigating exercise therapy interventions and reporting patient rating outcomes.

SETTING

Any setting in any country listed as very high on the human development index.

PARTICIPANTS

People with a diagnosis of any tendinopathy of any severity or duration.

INTERVENTIONS

Exercise therapy for the management of tendinopathy comprising five different therapy classes: 1) resistance; 2) plyometric; 3) vibration; 4) flexibility, and 5) movement pattern retraining modalities, were considered for inclusion.

MAIN OUTCOME MEASURES

Outcomes measuring patient rating of condition, including patient satisfaction and Global Rating of Change (GROC).

RESULTS

From a total of 124 exercise therapy studies, 34 (Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95%CrI: 0.53-0.73], and the pooled estimate for percentage of maximum GROC was 53 [95%CrI: 38-69%]. The proportion of patients reporting positive satisfaction and perception of change increased with longer follow-up periods from treatment onset.

CONCLUSION

Patient satisfaction and GROC appear similar and are ranked moderately high demonstrating that patients generally perceive exercise therapies positively. Further research including greater consistency in measurement tools is required to explore and where possible, identify patient- and exercise-related moderating factors that can be used to improve person-centred care.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO ID=CRD42020168187 CONTRIBUTION OF PAPER.

Achilles Tendinopathy Pathogenesis and Management: A Narrative Review

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of the reporting quality of resistance training interventions in randomised controlled trials for lower limb tendinopathy: A systematic review

OBJECTIVES

1. To describe what exercises and intervention variables are used in resistance training interventions in randomised controlled trials for lower limb tendinopathy 2. To assess completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework. 3. To assess the implementation of scientific resistance training principles. 4. To assess therapeutic quality of exercise interventions with the i-CONTENT tool.

DATA SOURCES

We searched MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library databases.

REVIEW METHODS

Systematic review of randomised controlled trials that reported using resistance exercises for lower limb tendinopathies.

RESULTS

We included 109 RCTs. Eccentric heel drops were the most common exercise (43 studies), followed by isotonic heel raises (21), and single leg eccentric decline squats (18). Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0-13, with an average score of 9/13, and only 7 studies achieved a full 13/13. Reporting of items from the CERT ranged from 0-18, with an average score of 14/19. No study achieved a full 19/19, however 5 achieved 18/19. Scoring for resistance training principles ranged from 1-10, with only 11 studies achieving 10/10. Reporting across studies for the i-CONTENT tool ranged from 2-7, with an average score of 5 across included studies. A total of 19 studies achieved a full 7/7 score. Less than 50% of studies achieved an overall low risk of bias, highlighting the methodological concerns throughout studies.

CONCLUSION

The reporting of exercise descriptors and intervention content was generally high across RCTs for lower limb tendinopathy, with most allowing exercise replication. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

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.

The implementation of resistance training principles in exercise interventions for lower limb tendinopathy: A systematic review

OBJECTIVES

The primary purpose of this systematic review is to examine the literature on resistance training interventions for lower limb tendinopathy to evaluate the proportion of interventions that implemented key resistance training principles (specificity, progression, overload, individualisation) and reported relevant prescription components (frequency, intensity, sets, repetitions) and reported intervention adherence.

METHODS

Two reviewers performed a systematic review after screening titles and abstracts based on eligibility criteria. Identified papers were obtained in full text, with data extracted regarding the implementation of resistance training principles. Included articles were evaluated by the Cochrane risk of bias tool, with a scoring tool out of 10 used for implementation and reporting of the 5 key principles. Scientific databases were searched in November 2020 and included Medline, CINAHL, AMED, and Sportsdiscus.

RESULTS

52 randomised controlled trials investigating resistance training in five different lower limb tendinopathies were included. Although most studies considered the principles of progression (92%) and individualisation (88%), only 19 studies (37%) appropriately described how this progression in resistance was achieved, and only 18 studies (35%) reported specific instruction on how individualisation was applied. Adherence was considered in 27 studies (52%), with only 17 studies (33%) reporting the levels of adherence. In the scoring criteria, only 5 studies (10%) achieved a total maximum score of 10, with 17 studies (33%) achieving a maximum score of 8 for implementing and reporting the principles of specificity, overload, progression and individualisation.

CONCLUSION

There is meaningful variability and methodological concerns regarding the application and reporting of resistance training principles, particularly progression and individualisation, along with intervention adherence throughout studies. Collectively, these findings have important implications for the prescription of current resistance training interventions, including the design and implementation of future interventions for populations with lower limb tendinopathies.

Achilles tendinopathy: Exploring injury characteristics and current treatment modalities

Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.

Achilles tendinopathy

BACKGROUND

Achilles Tendinopathy (AT) is essentially a failed healing response with haphazard proliferation of tenocytes, abnormalities in tenocytes with disruption of collagen fibers, and subsequent increase in non-collagenous matrix.

METHODS

The diagnosis of Achilles tendinopathy is clinical, and MRI and utrasound imaging can be useful in differential diagnosis. Conservative manegement, open surgery or minimally invasive techniques are available. Injections and physical therapy are also vauable options.

RESULTS

Eccentric exercises are useful tools to manage the pathology. If the condition does not ameliorate, shock wave therapy, or nitric oxide patches might be considered. Peritendinous injections or injections at the interface between the Achilles tendon and Kager's triangle could be considered if physical therapy should fail. Surgery is indicated after 6 months of non-operative management.

CONCLUSIONS

The clinical diagnosis and management of AT are not straightforward. Hence, patients should understand that symptoms may recur with either conservative or surgical approaches.

Progression criteria in loading exercise programmes in lower limb tendinopathy: a protocol for a systematic review and meta-analysis

INTRODUCTION

Lower limb tendinopathies have high rates of incidence and prevalence. Their symptomatology affects the functional capacity of people to exercise and work, being an important cause of economic and social burden. The evidence from the last decades points to therapeutic exercise as the first-line treatment in tendinopathies due to its good short-term and long-term clinical outcomes. However, there is no consensus about how the load progression should be managed throughout the therapeutic exercise programmes.

METHODS AND ANALYSIS

This systematic review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The present protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO). The search will be performed through PubMed and Scopus by two reviewers, including references, from inception to 31 August 2019. It will include randomised controlled trials that: included patients with Achilles, patellar or gluteal tendinopathy; assessed pain, function or performance; and included at least one group where progressive physical exercise was administered as monotherapy. The quality of the studies included will be assessed using the Physiotherapy Evidence Database scale. The Grading of Recommendations, Assessment, Development and Evaluation Working Group approach will be used to assess the quality of the evidence. A meta-analysis will be performed if there is sufficient homogeneity across the interventions and outcomes measures to ensure pooling.

ETHICS AND DISSEMINATION

Ethical approval is not necessary for this systematic review protocol. Regardless of its nature, the results obtained in this study will be published in a peer-reviewed journal and presented at a relevant conference.

PROSPERO REGISTRATION NUMBER

CRD42018110997.

Updates in Tendinopathy Treatment Options

Tendinopathy is a common but disabling condition. The term describes a complex, multifaceted pathology of the tendon characterized by pain, decreased function, and reduced exercise tolerance. Tendinopathy accounts for up to 30% of general practice musculoskeletal consultations. Advances in understanding the disease process include inflammation as part of the early tendinopathy process. Once thought to not contribute to the early process of tendon degeneration, this hypothesis has been refuted. This allows guidance in conservative treatment. However, when conservative treatments fail, there are minimally invasive injections and ultrasonic debridement techniques that offer an intermediate treatment step with low reported morbidity.

Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol

Background

Eccentric exercises are the only conservative treatment that has shown good clinical results in studies of Achilles tendinopathy (AT), but success rates vary, indicating the need for alternative treatments. Soft tissue treatments are widely used for AT, but strong scientific evidence is lacking to support those treatments.

Purpose/Hypotheses

This study aimed to determine whether pressure massage to the calf muscles is a useful treatment for AT and to compare this treatment versus an eccentric exercise protocol. Our first hypothesis was that pressure massage treatment is equivalent or superior to eccentric exercises with regard to pain reduction time (ie, pain would be reduced more quickly with pressure massage). The second hypothesis was that pressure massage is equivalent or superior to eccentric exercises with regard to function of the calf muscles.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A total of 60 patients with AT were randomized into 3 groups: group 1 underwent an eccentric exercise protocol, group 2 underwent pressure massage, and group 3 underwent pressure massage and the eccentric exercise protocol. Patients were evaluated with the Icelandic version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-IS), an algometer to test the pressure pain threshold (PPT) of the Achilles tendon, tests for ankle range of motion (ROM), and real-time ultrasonographic (US) scanning of tendon thickness and degree of neovascularization. Measurements for VISA-A-IS, PPT, and ROM were taken at 0, 4, 8, 12, and 24 weeks. US scan measurements were taken at 0, 12, and 24 weeks. Mixed-model analysis of variance was used for statistical analysis.

Results

All groups improved when evaluated with VISA-A-IS scores (P < .0001). The pressure massage group improved significantly more than the eccentric exercise group at week 4, which was the only between-group difference. Ankle ROM increased significantly over time (ROM bent knee P = .006 and ROM straight knee P = .034), but no significant difference was found between groups. No significant difference was found in evaluations of PPT or US scan measurements.

Conclusion

Pressure massage is a useful treatment for Achilles tendinopathy. Compared with eccentric exercise treatment, pressure massage gives similar results. Combining the treatments did not improve the outcome.

Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p = .003) and Lauge-Hansen classification (p = .003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p = .044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.

Previous foot injuries associated with a greater likelihood of Achilles tendon ruptures in professional American football players

OBJECTIVES

The purpose of this study was to build on current understanding of Achilles tendon (AT) ruptures in football through the examination of lower extremity injury rates (IR) in the season prior to AT rupture.

METHODS

An online review was conducted to document AT ruptures in the National Football League (NFL) from the 2010-11 through 2016-17 seasons. Player-specific information was gathered through the online search, injury reports, or video analysis. Injury incidence was recorded for each season. Descriptive statistics were calculated for all variables. IRs per 1000 athlete-exposures with 95% confidence intervals (CI) were established. Injury rate ratios (IRR) with 95% CI were calculated to evaluate differences in IR with statistical significance established at p < 0.05.

RESULTS

From the 2010-11 to 2016-17 NFL seasons, 109 AT ruptures were identified. 36 athletes participated in the NFL the season prior and sustained a total of 40 injuries. Thirty-two (32/40, 80%) of the injuries involved the lower extremity. The most frequent body parts injured in the NFL season prior to AT rupture were the knee (n = 8, 22.5%), upper leg and thigh (n = 7, 17.5%), lower leg and shin (n = 5, 12.5%), and ankle (n = 5, 12.5%). The overall IR for the AT rupture group was not significantly different than the NFL group (IRR: 0.94, 0.68-1.31 95% CI, p = 0.73). The AT rupture group demonstrated a significantly increased rate of foot injuries compared to the NFL cohort (IRR: 2.58, 1.16-5.77 95% CI, p = 0.02).

CONCLUSION

There was an increased identified incidence of AT ruptures in the NFL from 2010 to 2017 compared to AT ruptures reported from 1997 to 2002. There was no significant difference in lower extremity IR the season prior to AT rupture. Only foot injuries demonstrated an increased IR the season prior to AT rupture compared to an NFL cohort. Eleven athletes sustained 2 AT ruptures and all 11 players sustained the subsequent AT rupture to the contralateral limb.

Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis

OBJECTIVES

To assess the efficacy of exercise, orthoses and splinting on function, pain and quality of life (QoL) for the management of mid-portion and insertional Achilles tendinopathy, and to compare different types, applications and modes of delivery within each intervention category.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, CINAHL, Embase, AMED, WHO ICTRP, Web of Science, PEDro and Cochrane Library from inception to October 2017. Citation tracking of published studies and conference proceedings and contacting experts in the field.

STUDY ELIGIBILITY CRITERIA

Controlled clinical trials evaluating either exercise, orthoses or splinting for the management of Achilles tendinopathy.

METHODS

Independent reviewers undertook searches, screening and risk of bias appraisal. Primary outcomes of interest were function, pain and QoL.

RESULTS

Twenty-two studies were included (1137 participants). Moderate level evidence favoured eccentric exercise over control for improving pain and function in mid-portion tendinopathy. Moderate level evidence favoured eccentric exercise over concentric exercise for reducing pain. There was moderate level evidence of no significant difference in pain or function between eccentric exercise and heavy slow resistance exercise. There was low level evidence that eccentric exercise was not superior to stretching for pain or QoL. There was moderate level evidence that a combined exercise protocol was not superior to a lower dosage protocol for improving functional performance. There was moderate to low level evidence of a significant difference in pain (mean difference (MD) 6.3 mm, 95% CI -4.45 to 17.04, moderate) or function (MD 1.83 Victoria Institute of Sport Assessment points, 95% CI -7.47 to 11.12, low) between high-dose and low-dose eccentric training. There was high to moderate level evidence of no difference in pain (moderate) or function (high) between orthoses and control. There was low level evidence of no significant benefit in adding a night splint to an eccentric exercise programme for function, and moderate level evidence for no reduction in pain (MD -3.50, 95% CI -10.49 to 3.48). Eccentric exercise was not superior to splinting for pain (moderate evidence) or function (low level evidence).

SUMMARY

We conditionally recommend exercise for improving pain and function in mid-portion Achilles tendinopathy. The balance of evidence did not support recommendation of one type of exercise programme over another. We conditionally recommend against the addition of a splint to an eccentric exercise protocol and we do not recommend the use of orthoses to improve pain and function in Achilles tendinopathy.

Achilles Tendinopathy

Achilles tendinopathy is a common cause of disability. Despite the economic and social relevance of the problem, the causes and mechanisms of Achilles tendinopathy remain unclear. Tendon vascularity, gastrocnemius-soleus dysfunction, age, sex, body weight and height, pes cavus, and lateral ankle instability are considered common intrinsic factors. The essence of Achilles tendinopathy is a failed healing response, with haphazard proliferation of tenocytes, some evidence of degeneration in tendon cells and disruption of collagen fibers, and subsequent increase in noncollagenous matrix. Tendinopathic tendons have an increased rate of matrix remodeling, leading to a mechanically less stable tendon which is more susceptible to damage. The diagnosis of Achilles tendinopathy is mainly based on a careful history and detailed clinical examination. The latter remains the best diagnostic tool. Over the past few years, various new therapeutic options have been proposed for the management of Achilles tendinopathy. Despite the morbidity associated with Achilles tendinopathy, many of the therapeutic options described and in common use are far from scientifically based. New minimally invasive techniques of stripping of neovessels from the Kager's triangle of the tendo Achillis have been described, and seem to allow faster recovery and accelerated return to sports, rather than open surgery. A genetic component has been implicated in tendinopathies of the Achilles tendon, but these studies are still at their infancy.

Achilles tendon structure differs between competitive distance runners and nonrunners despite no clinical signs or symptoms of midsubstance tendinopathy

Achilles tendinopathy affects many running athletes and often leads to chronic pain and functional deficits. Although changes in tendon structure have been linked with tendinopathy, the effects of distance running on tendon structure are not well understood. Therefore, the purpose of this study was to characterize structural differences in the Achilles tendons in healthy young adults and competitive distance runners using quantitative ultrasound analyses. We hypothesized that competitive distance runners with no clinical signs or symptoms of tendinopathy would have quantitative signs of tendon damage, characterized by decreased collagen alignment and echogenicity, in addition to previous reports of thicker tendons. Longitudinal ultrasound images of the right Achilles tendon midsubstance were acquired in competitive distance runners and recreationally active adults. Collagen organization, mean echogenicity, and tendon thickness were quantified using image processing techniques. Clinical assessments confirmed that runners had no signs or symptoms of tendinopathy, and controls were only included if they had no history of Achilles tendon pain or injuries. Runner tendons were 40% less organized, 48% thicker, and 41% less echogenic compared with the control tendons ( P < 0.001). Young adults engaged in competitive distance running have structurally different tendons than recreationally active young adults.

NEW & NOTEWORTHY In this study, we quantified the Achilles tendon substructure in distance runners, and a control group of young adults, to determine whether distance running elicits structural adaptations of the tendon. We found that competitive distance runners have structurally compromised Achilles tendons despite not showing any clinical signs or symptoms of tendon injury. These findings suggest that distance running may stimulate structural changes as a protective mechanism against tendon pain and dysfunction.

Nonsurgical Management of Midsubstance Achilles Tendinopathy

Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery.

The Effectiveness of Physical Agents for Lower-Limb Soft Tissue Injuries: A Systematic Review

Study Design Systematic review. Background Soft tissue injuries to the lower limb bring a substantial health and economic burden to society. Physical agents are commonly used to treat these injuries. However, the effectiveness of many such physical agents is not clearly established in the literature. Objective To evaluate the effectiveness and safety of physical agents for soft tissue injuries of the lower limb. Methods We searched 5 databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies. Paired reviewers independently screened the retrieved literature and appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a high risk of bias were excluded. We synthesized low-risk-of-bias studies according to principles of best-evidence synthesis. Results We screened 10261 articles. Of 43 RCTs identified, 20 had a high risk of bias and were excluded from the analysis, and 23 RCTs had a low risk of bias and were included in the analysis. The available higher-quality evidence suggests that patients with persistent plantar fasciitis may benefit from ultrasound or foot orthoses, while those with persistent midportion Achilles tendinopathy may benefit from shockwave therapy. However, the current evidence does not support the use of shockwave therapy for recent plantar fasciitis, low-Dye taping for persistent plantar fasciitis, low-level laser therapy for recent ankle sprains, or splints for persistent midportion Achilles tendinopathy. Finally, evidence on the effectiveness of the following interventions is not established in the current literature: (1) shockwave therapy for persistent plantar fasciitis, (2) cryotherapy or assistive devices for recent ankle sprains, (3) braces for persistent midportion Achilles tendinopathy, and (4) taping or electric muscle stimulation for patellofemoral pain syndrome. Conclusion Almost half the identified RCTs that evaluated the effectiveness of physical agents for the management of lower-limb soft tissue injuries had a high risk of bias. High-quality RCTs are still needed to assess the effectiveness of physical agents for managing the broad range of lower-limb soft tissue injuries. The effectiveness of most interventions remains unclear. Level of Evidence Therapy, 1a. Protocol registered July 10, 2014 with PROSPERO (CRD42014010621). J Orthop Sports Phys Ther 2016;46(7):523-554. Epub 6 Jun 2016. doi:10.2519/jospt.2016.6521.

Open surgical treatment for chronic midportion Achilles tendinopathy: faster recovery with the soleus fibres transfer technique

PURPOSE

The study aimed to compare two methods of open surgical treatment for midportion Achilles tendinopathy in sportsmen. A novel technique consisting in transferring some soleus fibres into the degenerated tendon to improve its vascularization and longitudinal tenotomies are evaluated and compared.

METHODS

From 2006 to 2011, fifty-two competitive and noncompetitive athletes affected by midportion Achilles tendinopathy were surgically treated and prospectively evaluated at 6 months and at a final 4-year mean follow-up. Twenty patients had longitudinal tenotomies, and thirty-two had soleus fibres transfer. Clinical outcome was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Time to return to walk and to run and tendon thickening were also recorded.

RESULTS

Patients in the soleus transfer group had a higher increase in AOFAS and VISA-A score at 6 months and at the mean 4-year final follow-up (by 5.4 points, 95 % CI 2.9-7.9, p < 0.001 and by 5.7 points, 95 % CI 2.5-8.9, p = 0.001, for AOFAS and VISA, respectively). They also needed less time to return to run: 98.9 ± 17.4 days compared to 122.2 ± 26.3 days for the longitudinal tenotomies group (p = 0.0019). The soleus transfer group had a greater prevalence of tendon thickening (59.4 % compared to 30.0 % in the longitudinal tenotomies group, p = 0.037).

CONCLUSIONS

Open surgery for midportion Achilles tendinopathy is safe and effective in medium term. Despite similar outcomes in postoperative functional scores, soleus transfer allows a faster recovery but has a higher incidence of tendon thickening. These results should suggest the use of the soleus graft technique in high-level athletes.

LEVEL OF EVIDENCE

Prospective comparative study, Level II.

Effectiveness of orthotic devices in the treatment of Achilles tendinopathy: a systematic review

Orthotic devices such as foot orthoses, splints, taping and bracing are recommended for Achilles tendinopathy (AT). This systematic review was conducted to review the current evidence for the effectiveness of orthotic devices for the treatment of mid-portion or insertional AT. Electronic bibliographic databases (MEDLINE, EMBASE, Current Contents, CINAHL and SPORTDiscus) were searched in May 2014. The methodological quality of included studies was evaluated using the Quality Index. Where possible, effects were determined using standardised mean differences. The strength of evidence for each intervention was determined according to the quality and number of studies. Twelve studies satisfied the inclusion criteria; nine studies investigated mid-portion AT, whilst three studies did not distinguish between mid-portion and insertional pathology. Weak evidence showed that foot orthoses were equivalent to physical therapy, and equivalent to no treatment. Very weak evidence supported the use of adhesive taping alone or when combined with foot orthoses. Moderate evidence showed that the AirHeel™ brace was as effective as a calf muscle eccentric exercise programme, and weak evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. Weak evidence showed that an ankle joint dorsiflexion night splint was equally effective to a calf muscle eccentric exercise programme, and strong evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. These findings may aid clinical decision making in the context of AT, however further high-quality studies are required.

Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols

Although eccentric exercise training has shown favorable results in chronic mid-portion Achilles tendinopathy, the optimum dosage remains unknown. A systematic review of the literature was performed in accordance with the PRISMA guidelines, in order to describe different exercise protocols and to determine the most effective training parameters. An extensive search in MEDLINE, EMBASE, CINAHL, and CENTRAL revealed 14 randomized and clinical controlled trials. Strong evidence was found for the Alfredson exercise protocol. In this 12-week protocol, exercises are performed 3 × 15 repetitions twice daily, both with a straight and bent knee. Exercises are performed at slow speed, and load is increased when exercises are without pain. Strong evidence was also found for gradual onset of exercises during the first week of the Alfredson program, but no uniformity of protocols exists. Other exercise protocols did achieve similar results, but many studies had some methodological shortcomings or lacked a detailed description of their training parameters. Because of the heterogeneity of study populations and outcome measures, and lack of reporting of training compliance data, a definitive conclusion regarding the most effective training parameters could not be made. Further research comparing the content of different exercise protocols is warranted.

Acute achilles tendon rupture in athletes

The incidence of AT rupture has increased in recent decades. AT ruptures frequently occur in the third or fourth decade of life in sedentary individuals who play sport occasionally. Ruptures also occur in elite athletes. Clinical examination must be followed by imaging. Conservative management and early mobilization can achieve excellent results, but the rerupture rate is not acceptable for the management of young, active, or athletic individuals. Open surgery is the most common option for AT ruptures, but there are risks of superficial skin breakdown and wound problems. These problems can be prevented with percutaneous repair.

A systematic review of single-bundle versus double-bundle anterior cruciate ligament reconstruction

INTRODUCTION

Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction is becoming increasingly common. However, no definitive data on the superiority of DB reconstruction have been shown when compared with single-bundle (SB) ACL reconstruction.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of keywords such as 'ACL', 'reconstruction', 'DB' and 'SB'. Only articles published in peer-reviewed journals were included in this systematic review.

AREAS OF AGREEMENT

Several new techniques are available for ACL reconstruction. DB ACL reconstruction could provide better outcome for patients in terms of closer restoration of normal knee biomechanics and improving the rotatory laxity of the knee.

AREAS OF CONTROVERSY

Data are lacking to allow definitive conclusions on the use of DB reconstruction techniques for routine management of patients with ACL tear.

GROWING POINTS

Given the limitations of the current studies, it is not possible to recommend systematic use of DB ACL reconstruction. Even though biomechanical results are encouraging, subjective patient evaluation is similar for SB and DB reconstruction.

AREAS TIMELY FOR DEVELOPING RESEARCH

Studies of higher levels of evidence, for instances large adequately powered randomized trials, should be conducted to bring new insight in this field. With the current evidence available, a simple SB ACL reconstruction is a suitable technique, and it should be not abandoned until stronger scientific evidence in favour of DB ACL reconstruction will be produced.

Physical therapies for Achilles tendinopathy: systematic review and meta-analysis

BACKGROUND

Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Conservative or physical therapies are accepted as first-line management of AT; however, despite a growing volume of research, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews provide preliminary evidence for non-surgical interventions for AT, but lack key quality components as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement. The aim of this study was to conduct a systematic review and meta-analysis (where possible) of the evidence for physical therapies for AT management.

METHODS

A comprehensive strategy was used to search 11 electronic databases from inception to September 2011. Search terms included Achilles, tendinopathy, pain, physical therapies, electrotherapy and exercise (English language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomised controlled trials (RCTs) were included if they evaluated at least one non-pharmacological, non-surgical intervention for AT using at least one outcome of pain and/or function. Two independent reviewers screened 2852 search results, identifying 23 suitable studies, and assessed methodological quality and risk of bias using a modified PEDro scale. Effect size calculation and meta-analyses were based on fixed and random effects models respectively.

RESULTS

Methodological quality ranged from 2 to 12 (/14). Four studies were excluded due to high risk of bias, leaving 19 studies, the majority of which evaluated midportion AT. Effect sizes from individual RCTs support the use of eccentric exercise. Meta-analyses identified significant effects favouring the addition of laser therapy to eccentric exercise at 12 weeks (pain VAS: standardised mean difference -0.59, 95% confidence interval -1.11 to -0.07), as well as no differences in effect between eccentric exercise and shock wave therapy at 16 weeks (VISA-A:-0.55,-2.21 to 1.11). Pooled data did not support the addition of night splints to eccentric exercise at 12 weeks (VISA-A:-0.35,-1.44 to 0.74). Limited evidence from an individual RCT suggests microcurrent therapy to be an effective intervention.

CONCLUSIONS

Practitioners can consider eccentric exercise as an initial intervention for AT, with the addition of laser therapy as appropriate. Shock wave therapy may represent an effective alternative. High-quality RCTs following CONSORT guidelines are required to further evaluate the efficacy of physical therapies and determine optimal clinical pathways for AT.

Histopathology of rotator cuff tears

The pathogenesis of rotator cuff tears is multifactorial. Tendon abnormalities of the rotator cuff include alteration of collagen fiber structure, tenocytes, cellularity, and vascularity. Ruptured tendons show marked collagen degeneration and disordered arrangement of collagen fibers. Fibroblast population decreases as the size of the tear in the rotator cuff increases. The larger fibroblast population seen in the smaller tears is also actively proliferating and is part of an active reparative process. Inflammatory cell infiltrate correlates inversely to rotator cuff tear size in the torn supraspinatus tendon samples, with larger tears showing a marked reduction in all cell types. As tear size increase, there is also a progressive decrease in the number of blood vessels. Whether rotator cuff tear heals spontaneously is an important pathologic and clinical question. Histologic changes indicative of repair and inflammation lead to consider biological options in addition to biomechanical treatment of the rotator cuff tears.

Biological strategies to enhance healing of the avascular area of the meniscus

Meniscal injuries in the vascularized peripheral part of the meniscus have a better healing potential than tears in the central avascular zone because meniscal healing principally depends on its vascular supply. Several biological strategies have been proposed to enhance healing of the avascular area of the meniscus: abrasion therapy, fibrin clot, organ culture, cell therapy, and applications of growth factors. However, data are too heterogeneous to achieve definitive conclusions on the use of these techniques for routine management of meniscal lesions. Although most preclinical and clinical studies are very promising, they are still at an experimental stage. More prospective randomised controlled trials are needed to compare the different techniques for clinical results, applicability, and cost-effectiveness.

Scaffolds in tendon tissue engineering

Tissue engineering techniques using novel scaffold materials offer potential alternatives for managing tendon disorders. Tissue engineering strategies to improve tendon repair healing include the use of scaffolds, growth factors, cell seeding, or a combination of these approaches. Scaffolds have been the most common strategy investigated to date. Available scaffolds for tendon repair include both biological scaffolds, obtained from mammalian tissues, and synthetic scaffolds, manufactured from chemical compounds. Preliminary studies support the idea that scaffolds can provide an alternative for tendon augmentation with an enormous therapeutic potential. However, available data are lacking to allow definitive conclusion on the use of scaffolds for tendon augmentation. We review the current basic science and clinical understanding in the field of scaffolds and tissue engineering for tendon repair.

Tissue engineered strategies for skeletal muscle injury

Skeletal muscle injuries are common in athletes, occurring with direct and indirect mechanisms and marked residual effects, such as severe long-term pain and physical disability. Current therapy consists of conservative management including RICE protocol (rest, ice, compression and elevation), nonsteroidal anti-inflammatory drugs, and intramuscular corticosteroids. However, current management of muscle injuries often does not provide optimal restoration to preinjury status. New biological therapies, such as injection of platelet-rich plasma and stem-cell-based therapy, are appealing. Although some studies support PRP application in muscle-injury management, reasons for concern persist, and further research is required for a standardized and safe use of PRP in clinical practice. The role of stem cells needs to be confirmed, as studies are still limited and inconsistent. Further research is needed to identify mechanisms involved in muscle regeneration and in survival, proliferation, and differentiation of stem cells.

Growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration

Intervertebral disc (IVD) degeneration is frequent, appearing from the second decade of life and progressing with age. Conservative management often fails, and patients with IVD degeneration may need surgical intervention. Several treatment strategies have been proposed, although only surgical discectomy and arthrodesis have been proved to be predictably effective. Biological strategies aim to prevent and manage IVD degeneration, improving the function and anabolic and reparative capabilities of the nucleus pulposus and annulus fibrosus cells and inhibiting matrix degradation. At present, clinical applications are still in their infancy. Further studies are required to clarify the role of growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration.

Advances in meniscal tissue engineering

Meniscal tears are the most common knee injuries and have a poor ability of healing. In the last few decades, several techniques have been increasingly used to optimize meniscal healing. Current research efforts of tissue engineering try to combine cell-based therapy, growth factors, gene therapy, and reabsorbable scaffolds to promote healing of meniscal defects. Preliminary studies did not allow to draw definitive conclusions on the use of these techniques for routine management of meniscal lesions. We performed a review of the available literature on current techniques of tissue engineering for the management of meniscal tears.

Chronic Achilles tendinopathy treated with eccentric stretching program

BACKGROUND

This study assessed the efficacy of a modified eccentric heel-drop program (reduced time and increased duration of stretch) in treating chronic Achilles tendinopathy.

METHODS

Athletes with at least 12 weeks of symptoms diagnosed clinically as chronic Achilles tendinopathy were enrolled in the study. The only treatment recommended was a 6-week eccentric stretching regimen, with each stretch being maintained for at least 15 seconds. Athletes were followed to assess the response to treatment using a Visual Analogue Scale (VAS) for pain and a patient effectiveness rating for treatment satisfaction as well as time to return to pre-injury activity level. Followup was successful in 156 (82%) of the athletes. A total of 190 athletes were seen with chronic Achilles tendinopathy.

RESULTS

Mid-substance injuries were diagnosed in 168 (88%) with the remainder 22 (12%) having distal insertional injuries. Pain as assessed by VAS reduced from mean of 7.2 at commencement of the regimen to 2.9 (p<0.01) after 6 weeks of stretching. Six months post commencement of program mean pain was 1.1. Patient satisfaction was rated at 7 or above (excellent) in 124 (80%) of the athletes. For mid-substance injuries the satisfaction rating was excellent in 86%. Overall mean time to return to pre-morbid activity was 10 weeks.

CONCLUSION

A modified 6-week eccentric heel-drop training regimen as the only treatment for chronic Achilles tendinopathy resulted in a high degree of patient satisfaction, reduced pain and a successful return to pre-morbid activity levels. These results were best for mid-substance rather than insertional tendinopathy.

Current treatment options for tendinopathy

IMPORTANCE OF THE FIELD

Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management.

AREAS COVERED IN THIS REVIEW

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy.

WHAT THE READER WILL GAIN

The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined.

TAKE-HOME MESSAGE

Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.

Effect of dihydrotestosterone on cultured human tenocytes from intact supraspinatus tendon

The role of hormones in the pathogenesis of tendinopathy is not well recognised, even though the use of anabolic steroids is correlated with a higher incidence of spontaneous tendon ruptures. The aim of this study was to investigate the effects of dihydrotestosterone (DHT) on human tenocyte cultures from the intact supraspinatus tendon of male subjects. Cultured human tenocytes were seeded into culture plates at a density of 5 x 10(4) cells per well and incubated for 24 h. Then, 10(-9) M-10(-7) M DHT or Dulbecco's modified Eagle's medium (DMEM) only (control) was added to the culture plate wells. Cell morphology assessment and cell proliferation tests were performed 48, 72 and 96 h after DHT treatment. DHT-treated tenocytes showed an increased proliferation rate at DHT concentration higher than 10(-8) M. Differences in cell numbers between control and DHT-treated cells were statistically significant (P < 0.05) after 48 and 72 h of treatment with DHT concentrations of 10(-8) and 10(-7) M. The tenocytes treated with DHT (10(-8) and 10(-7) M) became more flattened and polygonal compared to control cells that maintained their fibroblast-like appearance during the experiment at each observation time. In conclusion, in vitro, progressive increasing concentration of DHT at doses greater than 10(-8) M had direct effects on male human tenocytes, increasing cell number after 48 and 72 h of treatment, and leading to a dedifferentiated phenotype after 48 h of treatment. This effect can be important during tendon-healing and repair, when active proliferation is required. Our results represent preliminary evidence for a possible correlation between testosterone abuse and shoulder tendinopathy.

New options in the management of tendinopathy

Tendon injuries can be acute or chronic, and caused by intrinsic or extrinsic factors, either alone or in combination. Tendinopathies are a common cause of disability in occupational medicine and account for a substantial proportion of overuse injuries in sports. Tendinopathy is essentially a failed healing response, with haphazard proliferation of tenocytes, abnormalities in tenocytes, with disruption of collagen fibres and subsequent increase in noncollagenous matrix. The scientific evidence base for managing tendinopathies is limited. What may appear clinically as an "acute tendinopathy" is actually a well advanced failure of a chronic healing response in which there is neither histologic nor biochemical evidence of inflammation. In this review we report the new options for the management of tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, injections (intratendinous injections of corticosteroids, aprotinin, polidocanol platelet-rich plasma, autologous blood injection, high-volume injections) and surgery. Open surgery aims to excise fibrotic adhesions, remove areas of failed healing and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New surgical techniques aim to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. These procedures are intrinsically different from the classical ones in present use, because they do not attempt to address directly the pathologic lesion, but act only to denervate them. They include endoscopy, electrocoagulation, and minimally invasive stripping. Further randomized controlled trials are necessary to clarify better the best therapeutic options for the management of tendinopathy.

No influence of age, gender, weight, height, and impact profile in achilles tendinopathy in masters track and field athletes

BACKGROUND

Achilles tendinopathy is commonly reported by athletes involved in activities that include running and jumping. Despite the prevalence of the problem, causative factors in Achilles tendinopathy remain poorly understood.

HYPOTHESIS

In Masters track and field athletes, there is no influence of age, gender, weight, height, and impact profile in developing Achilles tendinopathy.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

During the European Veterans Athletics Championships in Poznań, Poland, in July 2006, 178 athletes (110 men and 68 women; mean age, 54.1 years; range, 35-94 years) were evaluated with the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. A fully trained orthopaedic surgeon made a diagnosis of Achilles tendinopathy according to clinical criteria.

RESULTS

There was no effect of gender on the presence of Achilles tendinopathy (P = .14). No significant track and field specialty effect upon the frequency of Achilles tendinopathy was found on the VISA-A questionnaire scores (P = .32). Equally, there was no effect of track and field specialty on the VISA-A score (P = .31). No correlation was found between age and VISA-A score (P = .36). There was no statistically significant difference in either prevalence of Achilles tendinopathy or VISA-A score between high-impact and low-impact athletes (P = .19 and P = .31, respectively).

CONCLUSION

In competing Masters track and field athletes, we did not find any influence of age, gender, weight, height, or impact profile on the development of Achilles tendinopathy. Additional research is required to improve our understanding of the causative factors in Achilles tendinopathy.