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Deng J, Breda SJ, Eygendaal D, Oei EHG, de Vos RJ. Association Between Physical Tests and Patients-Reported Outcomes in Athletes Performing Exercise Therapy for Patellar Tendinopathy: A Secondary Analysis of the JUMPER Study. Am J Sports Med 2023; 51:3523-3532. [PMID: 37815096 PMCID: PMC10623612 DOI: 10.1177/03635465231200241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/31/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Physical tests are commonly used in patellar tendinopathy to aid the clinical diagnosis, assess the prognosis, and monitor treatment. However, it is still unknown whether these physical measures are associated with patient-reported outcomes after exercise therapy. PURPOSE To identify the prognostic value of baseline physical test results and to determine the association between physical response after exercise therapy and clinical improvement over 24 weeks. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS This study recruited 76 consecutive athletes with patellar tendinopathy who were randomized to 2 different programs of exercise therapy for 24 weeks. Athletes underwent a range of physical tests before and during exercise therapy (12 and 24 weeks), including isometric muscle strength (quadriceps and hip abductors), muscle flexibility (quadriceps, hamstrings, soleus, and gastrocnemius), vertical jump height, and visual analog scale (VAS) scores by palpation, after 3 jump trials, and after single-leg squat (VAS-SLS). The Victorian Institute of Sports Assessment-Patella (VISA-P) questionnaire was used as the primary patient-reported outcome. Linear mixed-effect models were used to assess the prognostic value of baseline physical tests. The change in VISA-P score was further dichotomized into clinical responsiveness (≥14 points) and nonresponsiveness (<14 points). Multiple linear and logistic regression models were performed to evaluate associations between physical response and clinical improvement. RESULTS Of the 76 included patients, 67 (88%) had complete follow-ups. The estimated mean VISA-P score increased by 23 points (95% CI, 19-28 points) after 24 weeks. No association was found between any baseline physical test results and a 24-week change in VISA-P score (all Pinteraction > .2, using the likelihood ratio test). Improvement in VAS-SLS after exercise therapy was not associated with VISA-P improvement after adjustment (β = -1.76; P = .01; Bonferroni-corrected P = .10; R2 = 36.3%). No associations were found between changes in other physical test results and clinical improvement (all P > .05). CONCLUSION In patients with patellar tendinopathy, physical test results including strength and flexibility in the lower limb, jump performance, and pain levels during pain-provoking tests were not identified as prognostic factors for patient-reported outcomes after exercise therapy. Similarly, changes in physical test results were not associated with changes in patient-reported outcomes after adjustments. These results do not support using physical test results to estimate prognosis or monitor treatment response. REGISTRATION NCT02938143 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Jie Deng
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Stephan J Breda
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Denise Eygendaal
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Edwin HG Oei
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Robert-Jan de Vos
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023; 27:1-389. [PMID: 37929629 PMCID: PMC10641714 DOI: 10.3310/tfws2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
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.
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Affiliation(s)
- Kay Cooper
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Lyndsay Alexander
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - David Brandie
- Sportscotland Institute of Sport, Airthrey Road, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Isabelle Harrison
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Colin MacLean
- Library Services, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Laura Mitchell
- NHS Grampian, Physiotherapy Department, Ellon Health Centre, Schoolhill, Ellon, Aberdeenshire, UK
| | - Dylan Morrissey
- William Harvey Research Institute, School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, UK
| | - Rachel Ann Moss
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | | | - Joanna Shim
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
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Young JL, Schroeder JD, Westrick RB, Nowak M, Rhon DI. A Population-Level Summary of Health Care Utilization for the Management of Patellar Tendinopathy in the Military Health System. J Knee Surg 2022; 35:1071-1078. [PMID: 35850134 DOI: 10.1055/s-0042-1751266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patellar tendinopathy (PT) is a common nontraumatic orthopaedic disorder of the knee suffered by many service members. Understanding the make-up of usual care for PT at the system level can better frame current clinical gaps and areas that need improvement. Exercise therapy is recommended as a core treatment for PT, but it is unclear how often it is used as a part of usual care for PT within the Military Health System (MHS). The purpose of the study was to identify interventions used in the management of PT and the timing of these interventions. A secondary purpose was to determine if exercise therapy use was associated with reduced recurrence of knee pain. In total, 4,719 individuals aged 17 to 50 years in the MHS diagnosed with PT between 2010 and 2011 were included. Pharmacological and nonpharmacological interventions, visits to specialty providers, and imaging services were captured. Descriptive statistics were used to report the findings. Interventions were further categorized as being part of initial care (within the first 7 days), the initial episode of care (within the first 60 days), or the 2-year time period after diagnosis. Linear regression assessed the relationship between the number of exercise therapy visits in the initial episode of care and recurrences of knee pain. In total, 50.6% of this cohort had no more than one medical visit total for PT. Exercise therapy (18.2%) and nonsteroidal anti-inflammatory drugs (4.3%) were the two most used interventions in the initial episode of care. Radiographs were ordered for 23.1% of the cohort in the initial episode of care. The number of exercise therapy visits a patient received during the initial episode of care was not associated with recurrences of knee pain. Half of the individuals received no further care beyond an initial visit for the diagnosis of PT. Exercise therapy was the most common intervention used during the initial episode of care, but exercise therapy did not influence the recurrence of knee pain.
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Affiliation(s)
- Jodi L Young
- Department of Physical Therapy Program, Bellin College, Green Bay, Wisconsin
| | - Jeremy D Schroeder
- Sports and Exercise Medicine, Madigan Army Medical Center, Tacoma, Washington
| | - Richard B Westrick
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts
| | - Matthew Nowak
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Daniel I Rhon
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts
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Chen Y, Lyu K, Lu J, Jiang L, Zhu B, Liu X, Li Y, Liu X, Long L, Wang X, Xu H, Wang D, Li S. Biological response of extracorporeal shock wave therapy to tendinopathy in vivo (review). Front Vet Sci 2022; 9:851894. [PMID: 35942112 PMCID: PMC9356378 DOI: 10.3389/fvets.2022.851894] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Tendinopathy is a degenerative disease of the tendons caused by prolonged overstretching or overuse of the tendons. It accounts for a large proportion of musculoskeletal disorders which can occur in all age groups. The management of tendinopathy is typically conservative. In clinical practice, when other conservative treatments fail, extracorporeal shock wave therapy (ESWT) is normally used as an efficient alternative to surgical management. Several basic studies have shown that ESWT with lower energy flux densities can produce some biological responses in vivo to tendinopathy and may accelerate the initiation of the healing process in injured tendons. ESWT has a positive impact on the interactive chain of biological response, enhancing the signaling pathways of angiogenesis through mechanical conduction, and promoting cell proliferation and collagen formation. Finally, it helps tissue regeneration by controlling inflammation. The purpose of this review is to summarize the biological responses generated by ESWT in tendinopathy through a comprehensive review of the published literature. Although ESWT has been used clinically for the treatment of tendinopathies for nearly decades, less is known about the experimental studies of its biological effects on tendon tissue. Further studies on the biological response of ESWT for tendon injuries in vivo are needed in the future in order to provide better management to patients.
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Affiliation(s)
- Yixuan Chen
- School of Physical Education, Southwest Medical University, Luzhou, China
| | - Kexin Lyu
- School of Physical Education, Southwest Medical University, Luzhou, China
| | - Jingwei Lu
- School of Physical Education, Southwest Medical University, Luzhou, China
| | - Li Jiang
- School of Physical Education, Southwest Medical University, Luzhou, China
| | - Bin Zhu
- School of Physical Education, Southwest Medical University, Luzhou, China
| | - Xueli Liu
- School of Physical Education, Southwest Medical University, Luzhou, China
| | - Yujie Li
- School of Physical Education, Southwest Medical University, Luzhou, China
| | - Xinyue Liu
- School of Physical Education, Southwest Medical University, Luzhou, China
| | - Longhai Long
- The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoqiang Wang
- The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Houping Xu
- The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
- Houping Xu
| | - Dingxuan Wang
- School of Physical Education, Southwest Medical University, Luzhou, China
- Dingxuan Wang
| | - Sen Li
- The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
- *Correspondence: Sen Li
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Burton I. Interventions for prevention and in-season management of patellar tendinopathy in athletes: A scoping review. Phys Ther Sport 2022; 55:80-89. [DOI: 10.1016/j.ptsp.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
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Zhu Y, Chang T, Wang X, Zhang Z. Bibliometric Study of Exercise and Tendinopathy Research from 2001 to 2020. MEDICAL SCIENCE MONITOR : INTERNATIONAL MEDICAL JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022; 28:e934016. [PMID: 35110518 PMCID: PMC8822849 DOI: 10.12659/msm.934016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Tendinopathy is a tendon disease that often occurs in athletes. Many studies have revealed that exercise therapy is beneficial for the nonoperative management of tendinopathy. However, the general aspect bibliometric analysis of this global research topic associated with exercise and tendinopathy is lacking. The present study aimed to make a bibliometric analysis of worldwide development tendency and research hotspots in exercise and tendinopathy research from 2001 to 2020. Material/Methods Using the Web of Science, articles and reviews published between 2001 and 2020 were retrieved from the Science Citation Index Expanded database. CiteSpace was used to analyze the relationship among publications, countries, institutions, journals, authors, references, and keywords. Results In total, 857 articles were found in this study. Over the past 20 years, there was a marked increase in the number of publications. A total of 194 different scholarly journals were dedicated to the categories Sport Sciences, Orthopedics, and Rehabilitation. The USA and La Trobe University were the most prolific country and institution, respectively. The British Journal of Sports Medicine was the prominent journal for research on exercise and tendinopathy and had the most publications. The analysis of keywords showed that rehabilitation, rotator cuff tendinopathy, stiffness, and disability of individuals with tendinopathy had become the research focus in this field. Conclusions Bibliometric analysis provides a historical and scientific perspective on exercise and tendinopathy research, providing relevant researchers, funding agencies, and policymakers with valuable information to explore the current research status, hotspots, and new directions for future research.
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Affiliation(s)
- Yuanchun Zhu
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China (mainland)
| | - Tiantian Chang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China (mainland)
| | - Xueqiang Wang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China (mainland)
| | - Zhijie Zhang
- Rehabilitation Therapy Center, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan, China (mainland)
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Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice. Dis Mon 2022; 68:101314. [PMID: 34996610 DOI: 10.1016/j.disamonth.2021.101314] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Tendinopathy is labeled by many authors as a troublesome, common pathology, present in up to 30% medical care consultations involving musculoskeletal conditions. Despite the lasting interest for addressing tendon pathology, current researchers agree that even the exact definition of the term tendinopathy is unclear. Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context. One of the main goals of current clinical management is to personalize treatment approaches to adapt them to the many different needs of the population. Tendons are complex structures that unite muscles and bones with two main objectives: to transmit forces and storage and release energy. Regarding the tensile properties of the tendons, several authors argued that tendons have higher tensile strength compared with muscles, however, are considered less flexible. Tendinopathy is an accepted term which is used to indicated a variety of tissue conditions that appear in injured tendons and describes a non-rupture damage in the tendon or paratendon, which is intensified with mechanical loading Even when the pathoetiology of tendinopathy is unclear, there is a wide array of treatments available to treat and manage tendinopathy. Although tendinitis usually debuts with an inflammatory response, the majority of chronic tendinopathies do not present inflammation and so the choosing of treatment should vary depending on severity, compliance, pain and duration of symptoms. The purpose of this article is to review and provide an overview about the currently research of the tendon diagnosis, management and etiology.
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Burton I. Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: A narrative review. SPORTS MEDICINE AND HEALTH SCIENCE 2021; 4:8-17. [PMID: 35782779 PMCID: PMC9219268 DOI: 10.1016/j.smhs.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022] Open
Abstract
Tendinopathy is a chronic degenerative musculoskeletal disorder that is common in both athletes and the general population. Exercise and extracorporeal shockwave therapy (ESWT) is among the most common treatments used to mediate tendon healing and regeneration. The review presents the current understanding of mechanisms of action of ESWT and exercise in isolation and briefly synthesises evidence of their effectiveness for various tendinopathies. The central purpose of the review is to synthesize research findings investigating the combination of ESWT and exercise for five common tendinopathies (plantar heel pain, rotator cuff, lateral elbow, Achilles, and patellar tendinopathy) and provide recommendations on clinical applicability. Collectively, the available evidence indicates that ESWT combined with exercise in the form of eccentric training, tissue-specific stretching, or heavy slow resistance training are effective for specific tendinopathies and can therefore be recommended in treatment. Whilst there are at present a limited number of studies investigating combined EWST and exercise approaches, there is evidence to suggest that the combination improves outcomes in the treatment of plantar heel pain, Achilles, lateral elbow, and rotator cuff tendinopathy. However, despite overall positive outcomes in patellar tendinopathy, the combined treatment has not been shown at present to offer additional benefit over eccentric exercise alone.
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Kim DK, Ahn J, Kim SA, Go EJ, Lee DH, Park SC, Shetty AA, Kim SJ. Improved Healing of Rabbit Patellar Tendon Defects After an Atelocollagen Injection. Am J Sports Med 2021; 49:2924-2932. [PMID: 34343026 DOI: 10.1177/03635465211030508] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patellar tendinopathy is a common cause of limitations in daily life activities in young and/or active people. The patellar tendon consists of a complex of collagen fibers; therefore, collagen could be used as a scaffold in the treatment of patellar tendinopathy. PURPOSE To evaluate the healing capacity of injected atelocollagen as a treatment scaffold for patellar tendon defect and, hence, its potential for the treatment of patellar tendinopathy. STUDY DESIGN Controlled laboratory study. METHODS After receiving a full-thickness patellar tendon defect, 24 New Zealand White rabbits were divided into a control group (without treatment) and an experimental group that received an atelocollagen injection into the defect. Six rabbits from each group were subsequently used for either histologic scoring or biomechanical testing. The Mann-Whitney U test was used to compare histologic evaluation scores and load to failure between the 2 groups. Statistical significance was set at P < .05. RESULTS The experimental group showed excellent repair of the damaged patellar tendon and good remodeling of the defective area. In contrast, the control group showed defective healing with loose, irregular matrix fibers and adipose tissue formation. A statistically significant difference was found between the 2 groups in both histologic scores and biomechanical tests at postoperative week 12. CONCLUSION Injection of atelocollagen significantly improved the regeneration of damaged patellar tendons. CLINICAL RELEVANCE Atelocollagen gel injections could be used to treat patellar tendinopathy in outpatient clinic settings.
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Affiliation(s)
- Duck Kyu Kim
- Department of Orthopaedic Surgery, Barosun Hospital, Seoul, Republic of Korea
| | - Jiyong Ahn
- Department of Orthopaedic Surgery, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Seon Ae Kim
- Department of Orthopaedic Surgery, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Jeong Go
- Department of Orthopaedic Surgery, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Hwan Lee
- Department of Orthopaedic Surgery, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Chan Park
- Department of Orthopaedic Surgery, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Asode Ananthram Shetty
- Institute of Medical Sciences, Faculty of Medicine and Social Care, Canterbury Christ Church University, Canterbury, Kent, UK
| | - Seok Jung Kim
- Department of Orthopaedic Surgery, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
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Saltychev M, Johansson J, Kemppi V, Juhola J. Effectiveness of topical glyceryl trinitrate in treatment of tendinopathy - systematic review and meta-analysis. Disabil Rehabil 2021; 44:5804-5810. [PMID: 34330192 DOI: 10.1080/09638288.2021.1958067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this meta-analysis was to evaluate the evidence on the effectiveness of glycerin trinitrate (NTG) measured by pain severity. MATERIALS AND METHODS CENTRAL, MEDLINE, EMBASE, SCOPUS, and WEB of SCIENCE databases were searched in November 2020. The study selection was performed by two independent reviewers. The risk of systematic bias was assessed according to the Cochrane Collaboration's domain-based evaluation framework. RESULTS Of 87 identified records, the meta-analysis was conducted on eight RCTs. When grouping by the type of tendinopathy and combining the estimates obtained from all available time points, the pooled standardized difference in means (SMD) was -0.80 (95% CI -1.34 to -0.26), and the number needed to treat 3.53 (95% upper confidence limit 12.4). When combining all the available data (all types of tendinopathy and all time points), the pooled SMD was -1.57 (95% CI -2.47 to -0.67). Overall heterogeneity was high. The risk of systematic bias was low in most of the selected studies. CONCLUSIONS There is no evidence that NTG is more effective to reduce pain in tendinopathy than placebo. The effects of NTG were insignificant or borderline significant (probably insignificant clinically) concerning rotator cuff tendinopathy, Achilles tendinopathy, patellar tendinopathy, and lateral epicondylitis.IMPLICATIONS FOR REHABILITATIONA meta-analysis conducted on eight RCTs found no evidence that topical glycerin trinitrate is more effective to reduce pain in tendinitis than placebo.The effects were insignificant or borderline significant concerning rotator cuff tendinitis, Achilles tendinitis, patellar tendinitis, and lateral epicondylitis.The effects were independent of the dosage used.
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Affiliation(s)
- Mikhail Saltychev
- Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Jouni Johansson
- Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Viljami Kemppi
- Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Juhani Juhola
- Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland.,Rehabilitation and Therapy Department, Health Services, Welfare Division, Turku, Finland
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Sprague AL, Couppé C, Pohlig RT, Snyder-Mackler L, Silbernagel KG. Pain-guided activity modification during treatment for patellar tendinopathy: a feasibility and pilot randomized clinical trial. Pilot Feasibility Stud 2021; 7:58. [PMID: 33632313 PMCID: PMC7905015 DOI: 10.1186/s40814-021-00792-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/08/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Activity modification is a key component of patellar tendinopathy treatment but there is a lack of evidence guiding activity modification prescription. Use of activity modification in treatment studies has varied widely and the impact of those recommendations has not been directly investigated or compared. The purpose of this study was to assess (1) the feasibility of using pain-guided activity modification during treatment for patellar tendinopathy and (2) if our outcome measures are responsive to changes in tendon health over the course of treatment. METHODS This was an unblinded, randomized two-arm pilot and feasibility study randomized clinical trial with parallel assignment, conducted in Newark, DE. Individuals between the ages of 16 and 40 years old with patellar tendinopathy were included. Participants were randomly assigned to a pain-guided activity (PGA) or pain-free activity (PFA) group using a spreadsheet-based randomization scheme. All participants received standardized treatment using a modified version of the heavy-slow resistance protocol 3×/week for 12 weeks. For the first 6 weeks, the PGA group used the Pain-Monitoring Model to guide activity outside of treatment and the PFA group was restricted from running, jumping, or activities that provoked their patellar tendon pain. Feasibility outcomes included recruitment, enrollment, randomization, compliance, and retention percentages. Clinical evaluations were conducted at baseline, 6, and 12 weeks to assess symptom severity, psychological factors, tendon morphology and mechanical properties, lower extremity function, and quadriceps muscle performance. RESULTS In a ~ 13-month period, 108 individuals were screened, 47/108 (43.5%) were eligible for participation, and 15/47 (32.0%) of those were enrolled (9 PGA, 6 PFA). The recruitment rate was 1.15 participants/month. The mean ± SD compliance with treatment was PGA: 86.1 ± 13.0% and PFA: 67.1 ± 30.7%. There was one missed evaluation session and two adverse events, which were not due to study interventions. Changes exceeding the smallest detectable change were observed for at least one outcome in each domain of tendon health. CONCLUSIONS Use of pain-guided activity modification during exercise therapy for patellar tendinopathy was found to be feasible, and the proposed outcome measures appropriate. Computer-based allocation concealment, blinding of evaluators, and greater recruitment of high-level athletes should be implemented in future trials. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03694730 . Registered 3rd of October, 2018.
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Affiliation(s)
- Andrew L Sprague
- Department of Physical Therapy, University of Delaware, Newark, DE, USA.
- Department of Biomechanics and Movement Science, University of Delaware, Newark, DE, USA.
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Christian Couppé
- Department of Orthopaedic Surgery M, Faculty of Health and Medical Sciences, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Bispebjerg Hospital, Copenhagen, Denmark
- IOC Research Center Copenhagen Center for Injury Prevention and Protection of Athlete Health, Bispebjerg Hospital, Copenhagen, Denmark
| | - Ryan T Pohlig
- Biostatistic Core Facility, College of Health Sciences, University of Delaware, Newark, DE, USA
| | - Lynn Snyder-Mackler
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
- Department of Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
- Department of Biomedical Engineering, University of Delaware, Newark, DE, USA
| | - Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
- Department of Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
- Department of Biomedical Engineering, University of Delaware, Newark, DE, USA
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Abstract
BACKGROUND Extracorporeal shock wave therapy (ESWT) has shown benefits in patients with nonunion or delayed bone healing, pseudarthrosis, and avascular necrosis of bone. Until now, these effects were explained by the release of growth factors, activation of cells, and microfractures occurring after ESWT. Microcirculation is an important factor in bone healing and may be compromised in fractured scaphoids because its blood supply comes from the distal end. Due to this perfusion pattern, the scaphoid bone is prone to nonunion after fracture. The ability of ESWT to enhance microcirculation parameters in soft tissue was of interest to determine if it improves microcirculation in the scaphoid. QUESTIONS/PURPOSES (1) Does capillary blood flow increase after a single session of ESWT in the scaphoid? (2) Do oxygen saturation in the bone and postcapillary venous filling pressure increase after a single session of ESWT in the scaphoid? METHODS ESWT (0.3 mJ/mm, 8Hz, 1000 impulses) was applied to the intact scaphoid of 20 volunteers who were without wrist pain and without any important metabolic disorders. Mean age was 43 ± 14 years, 12 men and eight women (40% of total). Volunteers were recruited from January 2017 to May 2017. No anesthetic was given before application of ESWT. An innovative probe designed for measurements in bone by compressing soft tissue and combining laser-Doppler flowmetry and spectrophotometry was used to noninvasively measure parameters of microcirculation in the scaphoid. Blood flow, oxygenation, and venous filling pressure were assessed before and at 1, 2, 3, 5, 10, 15, 20, 25, and 30 minutes after ESWT application. Room temperature, humidity, ambient light and measuring sequences were kept consistent. A paired t-test was performed to compare experimental data with baseline (p < 0.05 taken as significant). RESULTS At baseline, capillary blood flow of the bone was 108 ± 46 arbitrary units (AUs) (86 to 130). After treatment with ESWT, it was 129 ± 44 AUs (106 to 150; p = 0.011, percentage change of 19 %) at 1 minute, 138 ± 46 AUs (116 to 160; p = 0.002, percentage change of 28%) at 2 minutes, 146 ± 54 AUs (121 to 171; p = 0.002, percentage change of 35%) at 3 minutes and 150 ± 52 AUs (126 to 174; p < 0.001, percentage change of 39%) at 5 minutes. It remained elevated until the end of the measuring period at 30 minutes after treatment at 141 ± 42 AUs (121 to 161; p = 0.002) versus baseline). Oxygen saturation and postcapillary venous filling pressure in bone showed no change, with the numbers available. CONCLUSIONS A single session of ESWT increased capillary blood flow in the scaphoid during measuring time of 30 minutes. Bone oxygenation and postcapillary venous filling pressure, however, did not change. Because increased oxygenation is needed for improved bone healing, it remains unclear if a sole increase in capillary blood flow can have clinical benefits. As the measuring period was limited to only 30 minutes, bone oxygenation and postcapillary filling pressure may subsequently show change only after the measuring-period ended. CLINICAL RELEVANCE Further studies need to evaluate if increased capillary blood flow can be sustained for longer periods and if bone oxygenation and postcapillary venous filling pressure remain unchanged even after prolonged or repetitive ESWT applications. Moreover, clinical studies must validate if increased microcirculation has a positive impact on bone healing and to determine if ESWT can be therapeutically useful on scaphoid fractures and nonunions.
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13
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Maciel Rabello L, Zwerver J, Stewart RE, van den Akker-Scheek I, Brink MS. Patellar tendon structure responds to load over a 7-week preseason in elite male volleyball players. Scand J Med Sci Sports 2019; 29:992-999. [PMID: 30942914 PMCID: PMC6850050 DOI: 10.1111/sms.13428] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 02/28/2019] [Accepted: 03/27/2019] [Indexed: 12/28/2022]
Abstract
The purpose of this study was to investigate the relation between external and internal load and the response of the patellar tendon structure assessed with ultrasound tissue characterization (UTC) in elite male volleyball players during preseason. Eighteen players were followed over 7 weeks, measuring four load parameters during every training and match: volume (minutes played), rating of perceived exertion (RPE) (ranging from 6 to 20), weekly load (RPE*volume), and jump frequency (number of jumps). Patellar tendon structure was measured biweekly using UTC, which quantifies tendon matrix stability resulting in four different echo types (I‐IV). On average, players spent 615 min/wk on training and matches with an RPE of 13.9 and a jump frequency of 269. Load evaluation shows significant changes over the 7 weeks: Volume and weekly load parameters were significantly higher in week 3 than week 7 and in week 4 than week 2. Weekly load performed in week 4 was significantly higher than week 7. No significant changes were observed in tendon structure. On the non‐dominant side, no significant correlations were found between changes in load parameters and echo types. At the dominant side, a higher weekly volume and weekly load resulted in a decrease of echo type I and a higher mean RPE in an increase of echo type II. The results of this study show that both external and internal load influence changes in patellar tendon structure of elite male volleyball players. Monitoring load and the effect on patellar tendon structure may play an important role in injury prevention.
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Affiliation(s)
- Lucas Maciel Rabello
- Department of Sports and Exercise Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes Zwerver
- Department of Sports and Exercise Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Roy E Stewart
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Sports and Exercise Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michel S Brink
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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