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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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Pavlova AV, Shim JSC, Moss R, Maclean C, Brandie D, Mitchell L, Greig L, Parkinson E, Alexander L, Tzortziou Brown V, Morrissey D, Cooper K, Swinton PA. Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis. Br J Sports Med 2023; 57:1327-1334. [PMID: 37169370 PMCID: PMC10579176 DOI: 10.1136/bjsports-2022-105754] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To investigate potential moderating effects of resistance exercise dose components including intensity, volume and frequency, for the management of common tendinopathies. DESIGN Systematic review with meta-analysis and meta-regressions. DATA SOURCES Including but not limited to: MEDLINE, CINAHL, SPORTDiscus, ClinicalTrials.gov and ISRCTN Registry. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised and non-randomised controlled trials investigating resistance exercise as the dominant treatment class, reporting sufficient information regarding ≥2 components of exercise dose. RESULTS A total of 110 studies were included in meta-analyses (148 treatment arms (TAs), 3953 participants), reporting on five tendinopathy locations (rotator cuff: 48 TAs; Achilles: 43 TAs; lateral elbow: 29 TAs; patellar: 24 TAs; gluteal: 4 TAs). Meta-regressions provided consistent evidence of greater pooled mean effect sizes for higher intensity therapies comprising additional external resistance compared with body mass only (large effect size domains: β BodyMass: External = 0.50 (95% credible interval (CrI): 0.15 to 0.84; p=0.998); small effect size domains (β BodyMass: External = 0.04 (95% CrI: -0.21 to 0.31; p=0.619)) when combined across tendinopathy locations or analysed separately. Greater pooled mean effect sizes were also identified for the lowest frequency (less than daily) compared with mid (daily) and high frequencies (more than once per day) for both effect size domains when combined or analysed separately (p≥0.976). Evidence for associations between training volume and pooled mean effect sizes was minimal and inconsistent. SUMMARY/CONCLUSION Resistance exercise dose is poorly reported within tendinopathy management literature. However, this large meta-analysis identified some consistent patterns indicating greater efficacy on average with therapies prescribing higher intensities (through inclusion of additional loads) and lower frequencies, potentially creating stronger stimuli and facilitating adequate recovery.
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Affiliation(s)
| | - Joanna S C Shim
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Rachel Moss
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Colin Maclean
- Library Services, Robert Gordon University, Aberdeen, UK
| | - David Brandie
- Physiotherapy, Sportscotland Institute of Sport, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | | | | | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, Barts Health NHS Trust, London, UK
| | - Kay Cooper
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Paul A Swinton
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
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3
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Arora NK, Sharma S, Sharma S, Arora IK. 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. Foot (Edinb) 2022; 53:101927. [PMID: 36037777 DOI: 10.1016/j.foot.2022.101927] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 04/05/2022] [Accepted: 04/16/2022] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Nitin Kumar Arora
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, Acentral University, New Delhi, India; Hochschule fur Gesundheit Bochum, 44801, Germany
| | - Saurabh Sharma
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, Acentral University, New Delhi, India.
| | - Shalini Sharma
- Department of Physiotherapy, Geri Care Home, Melbourne, Victoria, Australia
| | - Ishant Kumar Arora
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, Acentral University, New Delhi, India
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4
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Savva C, Karagiannis C, Korakakis V, Efstathiou M. The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review. J Man Manip Ther 2021; 29:276-287. [PMID: 33769226 PMCID: PMC8491707 DOI: 10.1080/10669817.2021.1904348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.
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Affiliation(s)
- Christos Savva
- Department of Health Science, European University, Nicosia, Cyprus
| | | | | | - Michalis Efstathiou
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus
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5
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Yeh CH, Calder JD, Antflick J, Bull AMJ, Kedgley AE. Maximum dorsiflexion increases Achilles tendon force during exercise for midportion Achilles tendinopathy. Scand J Med Sci Sports 2021; 31:1674-1682. [PMID: 33864294 DOI: 10.1111/sms.13974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 11/30/2022]
Abstract
Rehabilitation is an important treatment for non-insertional Achilles tendinopathy. To date, eccentric loading exercises (ECC) have been the predominant choice; however, mechanical evidence underlying their use remains unclear. Other protocols, such as heavy slow resistance loading (HSR), have shown comparable outcomes, but with less training time. This study aims to identify the effect of external loading and other variables that influence Achilles tendon (AT) force in ECC and HSR. Ground reaction force and kinematic data during ECC and HSR were collected from 18 healthy participants for four loading conditions. The moment arms of the AT were estimated from MRIs of each participant. AT force then was calculated using the ankle torque obtained from inverse dynamics. In the eccentric phase, the AT force was not larger than in the concentric phase in both ECC and HSR. Under the same external load, the force through the AT was larger in ECC with the knee bent than in HSR with the knee straight due to increased dorsiflexion angle of the ankle. Multivariate regression analysis showed that external load and maximum dorsiflexion angle were significant predictors of peak AT force in both standing and seated positions. Therefore, to increase the effectiveness of loading the AT, exercises should apply adequate external load and reach maximum dorsiflexion during the movement. Peak dorsiflexion angle affected the AT force in a standing position at twice the rate of a seated position, suggesting standing could prove more effective for the same external loading and peak dorsiflexion angle.
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Affiliation(s)
- Chia-Han Yeh
- Department of Bioengineering, Imperial College London, London, UK
| | - James D Calder
- Department of Bioengineering, Imperial College London, London, UK.,Fortius Clinic, London, UK
| | | | - Anthony M J Bull
- Department of Bioengineering, Imperial College London, London, UK
| | - Angela E Kedgley
- Department of Bioengineering, Imperial College London, London, UK
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6
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Vajapey S, Ghenbot S, Baria MR, Magnussen RA, Vasileff WK. Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review. Sports Health 2020; 13:258-264. [PMID: 33252310 DOI: 10.1177/1941738120951764] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results. OBJECTIVE To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure. DATA SOURCES PubMed, MEDLINE, EMBASE, and Google Scholar. STUDY SELECTION The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected. RESULTS There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking. CONCLUSION PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.
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Affiliation(s)
- Sravya Vajapey
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - Sennay Ghenbot
- The Ohio State University School of Medicine, Columbus, Ohio
| | - Michael R Baria
- Department of Physical Medicine & Rehabilitation, The Ohio State University, Columbus, Ohio
| | - Robert A Magnussen
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - W Kelton Vasileff
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
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7
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Girgis B, Duarte JA. Physical therapy for tendinopathy: An umbrella review of systematic reviews and meta-analyses. Phys Ther Sport 2020; 46:30-46. [PMID: 32877858 DOI: 10.1016/j.ptsp.2020.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/01/2020] [Accepted: 08/04/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To summarize evidence in the last decade regarding the efficacy of physical therapy interventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs) and/or meta-analyses (MAs). METHODS Electronic search of PubMed, PEDro, and Scopus database was performed from year 2010 to January 2020. The methodological quality of the identified studies was assessed using the AMSTAR 2 tool. Studies scoring 9 points or higher were further analyzed using GRADE principles. RESULTS 40 SRs and/or MAs were included in qualitative synthesis, whereas only 5 MAs were included in quantitative synthesis. Low-level laser therapy (LLLT) intervention showed a pooled improvement in pain reduction of 1.53 cm; 95% CI, [1.14, 1.91] (I2 = 1.9%, p = 0.361) on visual analogue scale, and grip strength of 9.59 kg; 95% CI, [5.90, 13.27]. CONCLUSIONS Moderate-quality evidence may support these following interventions: LLLT revealed a statistically and potentially clinically significant improvement in pain and function on the short-term. Extracorporeal shockwave therapy showed a statistically significant enhancement in pain and function at all follow-up durations; however, its clinical significance was undetermined. Eccentric exercise was supported by qualitative evidence only. Caution is advised when interpreting results due to possible pathological differences in tendinopathy at each region.
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Affiliation(s)
- Beshoy Girgis
- CIAFEL, Faculty of Sport, University of Porto, R. Dr. Plácido Costa, 91, 4200-450, Porto, Portugal.
| | - José Alberto Duarte
- CIAFEL, Faculty of Sport, University of Porto, R. Dr. Plácido Costa, 91, 4200-450, Porto, Portugal.
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8
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Murphy MC, Travers MJ, Chivers P, Debenham JR, Docking SI, Rio EK, Gibson W. Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis. Br J Sports Med 2019; 53:1070-1077. [PMID: 30636702 DOI: 10.1136/bjsports-2018-099934] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess the effectiveness of heavy eccentric calf training (HECT) in comparison with natural history, traditional physiotherapy, sham interventions or other exercise interventions for improvements in pain and function in mid-portion Achilles tendinopathy. DESIGN A systematic review and meta-analysis were conducted as per the PRISMA guidelines. DATA SOURCES PUBMED, CINAHL (Ovid) and CINAHL (EBSCO) were searched from inception until 24 September 2018. ELIGIBILITY CRITERIA Randomised controlled trials comparing HECT to natural history, sham exercise, traditional physiotherapy and other exercise interventions were included. Primary outcome assessing pain and function was the Victorian Institute of Sports Assessment-Achilles. RESULTS Seven studies met the inclusion criteria. This review suggests HECT may be superior to both natural history, mean difference (MD) (95% CI) of 20.6 (11.7 to 29.5, one study) and traditional physiotherapy, MD (95% CI) of 17.70 (3.75 to 31.66, two studies). Following removal of one study, at high risk of bias, due to pre-planned sensitivity analysis, this review suggests HECT may be inferior to other exercise interventions, MD (95% CI) of -5.65 (-10.51 to -0.79, three studies). However, this difference is unlikely to be clinically significant. CONCLUSION Current evidence suggests that HECT may be superior to natural history and traditional physiotherapy while HECT may be inferior to other exercise interventions. However, due to methodological limitations, small sample size and a lack of data we are unable to be confident in the results of the estimate of the effect, as the true effect is likely to be substantially different. SYSTEMATIC REVIEW REGISTRY PROSPERO registration number: CRD4201804493 PROTOCOL REFERENCE: This protocol has been published open access: Murphy M, Travers MJ, Gibson, W. Is heavy eccentric calf training superior to natural history, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy? Systematic Reviews 2018; 7: 58.
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Affiliation(s)
- Myles Calder Murphy
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.,SportsMed Subiaco, St John of God Health Care, Subiaco, Western Australia, Australia.,Sports Science Sports Medicine Department, Western Australian Cricket Association, East Perth, Western Australia, Australia
| | - Mervyn J Travers
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Bentley, Western Australia, Australia
| | - Paola Chivers
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.,Exercise Medicine Research Institute & School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - James Robert Debenham
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Sean Iain Docking
- Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia
| | - Ebonie Kendra Rio
- Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia
| | - William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
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9
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Murphy M, Travers M, Gibson W, Chivers P, Debenham J, Docking S, Rio E. Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis. Sports Med 2018; 48:1875-1891. [PMID: 29766442 DOI: 10.1007/s40279-018-0932-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mid-portion Achilles tendinopathy is prevalent within both the athletic and non-athletic populations and loading protocols for Achilles tendinopathy are effective over time, though the rate of symptom change throughout rehabilitation is unknown. OBJECTIVE The objective of this study was to determine the rate of change in pain and function over time in patients while completing a loading protocol for mid-portion Achilles tendinopathy. METHODS A systematic review and longitudinal meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases PubMed, CINAHL (Ovid) and CINAHL (EBSCO) were searched for articles published from inception until 31 July, 2017. Our search focused on clinical trials and cohort studies examining changes in pain and function when completing a loading protocol for mid-portion Achilles tendinopathy. The primary outcome measure assessing pain and function was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. RESULTS A total of 31 separate cohorts (24 studies) were eligible, with follow-up ranging from 2 weeks to 6 months. The data were pooled to create the mean (standard deviation) of change from baseline at each time point. The data demonstrated an improvement in pain and function as early as 2 weeks that appeared to peak at 12 weeks with a mean (standard deviation) of 21.11 (6.61) points of change on the VISA-A. CONCLUSION The improvement in pain and function during rehabilitation suggests future research should be directed toward investigating contributing mechanisms as tendon structure on imaging does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following the inception of a loading protocol. Systematic Review Registry: PROSPERO registration number: CRD42017062737 ( https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=62737 ).
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Affiliation(s)
- Myles Murphy
- School of Physiotherapy, University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, WA, 6959, Australia.
- SportsMed Subiaco, St John of God Health Care, Subiaco, WA, Australia.
- Sports Science Sports Medicine Department, Western Australian Cricket Association, East Perth, WA, Australia.
| | - Mervyn Travers
- School of Physiotherapy, University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, WA, 6959, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, WA, Australia
| | - William Gibson
- School of Physiotherapy, University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, WA, 6959, Australia
| | - Paola Chivers
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
- Exercise Medicine Research Institute and School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - James Debenham
- School of Physiotherapy, University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, WA, 6959, Australia
| | - Sean Docking
- La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
| | - Ebonie Rio
- La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
- Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Bundoora, Australia
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10
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Nishikawa KC, Lindstedt SL, LaStayo PC. Basic science and clinical use of eccentric contractions: History and uncertainties. JOURNAL OF SPORT AND HEALTH SCIENCE 2018; 7:265-274. [PMID: 30356648 PMCID: PMC6189250 DOI: 10.1016/j.jshs.2018.06.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 12/30/2017] [Accepted: 01/09/2018] [Indexed: 05/18/2023]
Abstract
The peculiar attributes of muscles that are stretched when active have been noted for nearly a century. Understandably, the focus of muscle physiology has been primarily on shortening and isometric contractions, as eloquently revealed by A.V. Hill and subsequently by his students. When the sliding filament theory was introduced by A.F. Huxley and H.E. Huxley, it was a relatively simple task to link Hill's mechanical observations to the actions of the cross bridges during these shortening and isometric contractions. In contrast, lengthening or eccentric contractions have remained somewhat enigmatic. Dismissed as necessarily causing muscle damage, eccentric contractions have been much more difficult to fit into the cross-bridge theory. The relatively recent discovery of the giant elastic sarcomeric filament titin has thrust a previously missing element into any discussion of muscle function, in particular during active stretch. Indeed, the unexpected contribution of giant elastic proteins to muscle contractile function is highlighted by recent discoveries that twitchin-actin interactions are responsible for the "catch" property of invertebrate muscle. In this review, we examine several current theories that have been proposed to account for the properties of muscle during eccentric contraction. We ask how well each of these explains existing data and how an elastic filament can be incorporated into the sliding filament model. Finally, we review the increasing body of evidence for the benefits of including eccentric contractions into a program of muscle rehabilitation and strengthening.
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Affiliation(s)
- Kiisa C. Nishikawa
- Center for Bioengineering Innovation and Department of Biological Sciences, Northern Arizona University, Flagstaff, AZ 86011, USA
| | - Stan L. Lindstedt
- Center for Bioengineering Innovation and Department of Biological Sciences, Northern Arizona University, Flagstaff, AZ 86011, USA
- Corresponding author
| | - Paul C. LaStayo
- Department of Physical Therapy and Athletic Training, University of Utah, 520 Wakara Way, Salt Lake City, UT 86011, USA
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11
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Cook JL, Stasinopoulos D, Brismée JM. Insertional and mid-substance Achilles tendinopathies: eccentric training is not for everyone - updated evidence of non-surgical management. J Man Manip Ther 2018; 26:119-122. [PMID: 30042626 DOI: 10.1080/10669817.2018.1470302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Jill L Cook
- La Trobe University Sport and Exercise Research Centre, Melbourne, Australia.,Director of Cyprus Musculoskeletal and Sports Trauma Research Center & European University Cyprus, Nicosia, Cyprus.,Center for Rehabilitation Research, Department of Rehabilitation Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Dimitrios Stasinopoulos
- Director of Cyprus Musculoskeletal and Sports Trauma Research Center & European University Cyprus, Nicosia, Cyprus.,Center for Rehabilitation Research, Department of Rehabilitation Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jean-Michel Brismée
- Center for Rehabilitation Research, Department of Rehabilitation Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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12
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Murphy M, Travers M, Gibson W. Is heavy eccentric calf training superior to wait-and-see, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy? Syst Rev 2018; 7:58. [PMID: 29653591 PMCID: PMC5899347 DOI: 10.1186/s13643-018-0725-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mid-portion Achilles tendinopathy (AT) is prevalent amongst athletic and non-athletic populations with pain, stiffness and impaired function typically reported. While different management options exist, loading protocols remain the best available intervention and have been shown to be effective in the management of AT. Trials investigating loading in AT have used a variety of different protocols, and recent narrative reviews suggest that no protocol is superior to another when comparing outcomes in pain and function. However, there has been no systematic review or meta-analysis completed to determine this. Furthermore, the narrative review did not consider wait-and-see or sham interventions, thus a systematic review and met-analysis which includes wait-and-see or sham interventions is warranted. METHODS A systematic review and meta-analyses will be conducted as per the PRISMA guidelines. The databases PUBMED, CINAHL (Ovid) and CINAHL (EBSCO) will be searched for articles published from inception to 31 December 2017. Our search focuses on studies examining the improvement of pain and function when completing a loading program for mid-portion AT. Only randomised/ quasi-randomised trials will be included while case reports and case series will be excluded. The primary outcome assessing pain and function will be the Victorian Institute Sports Assessment - Achilles (VISA-A). Two reviewers will screen articles, extract data and assess the risk of bias independently with a third reviewer resolving any disagreements between the two reviewers. A meta-analysis will then be performed on the data (if appropriate) to determine if the traditional heavy load calf training protocol described by Alfredson is superior to wait-and-see, sham intervention, traditional physiotherapy, and other forms of exercise rehabilitation. DISCUSSION This systematic review and meta-analysis will allow us to investigate if there are difference in pain and function when comparing wait-and-see, sham interventions, traditional physiotherapy and different exercise interventions to the traditional heavy eccentric calf training protocol for mid-portion Achilles tendon pain. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42018084493 .
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Affiliation(s)
- Myles Murphy
- School of Physiotherapy, The University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, Western Australia 6959 Australia
- SportsMed Subiaco, St John of God Health Care, Subiaco, Australia
- Sports Science Sports Medicine Department, Western Australian Cricket Association, East Perth, Australia
| | - Mervyn Travers
- School of Physiotherapy, The University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, Western Australia 6959 Australia
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia
| | - William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, 19 Mouat Street, PO Box 1225, Fremantle, Western Australia 6959 Australia
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13
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Mascaró A, Cos MÀ, Morral A, Roig A, Purdam C, Cook J. Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.apunts.2017.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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14
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THE REHABILITATION OF A RUNNER WITH ILIOPSOAS TENDINOPATHY USING AN ECCENTRIC-BIASED EXERCISE-A CASE REPORT. Int J Sports Phys Ther 2017; 12:1150-1162. [PMID: 29234566 DOI: 10.26603/ijspt20171150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose While there is much discussion about tendinopathy in the literature, there is little reference to the less common condition of iliopsoas tendinopathy, and no documentation of the condition in runners. The iliopsoas is a major decelerator of the hip and eccentric loading of the iliopsoas is an important component of energy transfer during running. Eccentric training is a thoroughly researched method of treating tendinopathy but has shown mixed results. The purpose of this case report is to describe the rehabilitation of a runner with iliopsoas tendinopathy, and demonstrate in a creative eccentric-biased technique to assist with treatment. A secondary objective is to illustrate how evidence on intervention for other tendinopathies was used to guide rehabilitation of this seldom described condition. Case Description The subject was a 39-year-old female middle distance runner diagnosed with iliopsoas tendinopathy via ultrasound, after sudden onset of left anterior groin pain. Symptoms began after a significant increase in running load, and persisted, despite rest, for three months. The intervention consisted of an eccentric-biased hip flexor exercise, with supportive kinetic chain exercises and progressive loading in a return to running program. Outcomes The Copenhagen Hip and Groin Outcome Score, the Visual Analogue Scale, the Global Rating of Change Scale and manual muscle testing scores all improved after 12 weeks of intervention with further improvement at the five-year follow up. After 12 weeks of intervention, the subject was running without restriction and had returned to her pre-injury running mileage at the five-year follow up. Discussion The eccentric-biased exercise in conjunction with exercises addressing the kinetic chain and a progressive tendon loading program, were successful in the rehabilitation of this subject with iliopsoas tendinopathy. This case report is the first to provide a description on the rehabilitation of iliopsoas tendinopathy, and offers clinicians suggestions and guidance for treatment and exercise choice in the clinical environment. Level of Evidence 5.
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Abat F, Alfredson H, Cucchiarini M, Madry H, Marmotti A, Mouton C, Oliveira JM, Pereira H, Peretti GM, Romero-Rodriguez D, Spang C, Stephen J, van Bergen CJA, de Girolamo L. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach. J Exp Orthop 2017; 4:18. [PMID: 28560707 PMCID: PMC5449348 DOI: 10.1186/s40634-017-0092-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/12/2017] [Indexed: 12/05/2022] Open
Abstract
Chronic tendinopathies represent a major problem in the clinical practice of sports orthopaedic surgeons, sports doctors and other health professionals involved in the treatment of athletes and patients that perform repetitive actions. The lack of consensus relative to the diagnostic tools and treatment modalities represents a management dilemma for these professionals. With this review, the purpose of the ESSKA Basic Science Committee is to establish guidelines for understanding, diagnosing and treating this complex pathology.
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Affiliation(s)
- F Abat
- Department of Orthopaedic Sports Medicine, ReSport Clinic, Passeig Fabra i Puig 47, 08030, Barcelona, Spain.
| | - H Alfredson
- Sports Medicine Unit, University of Umeå, Umeå, Sweden.,Alfredson Tendon Clinic Inc, Umeå, Sweden.,Pure Sports Medicine Clinic, ISEH, UCLH, London, UK
| | - M Cucchiarini
- Molecular Biology, Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr Bldg 37, 66421, Homburg/Saar, Germany
| | - H Madry
- Lehrstuhl für Experimentelle Orthopädie und Arthroseforschung, Universität des Saarlandes, Gebäude 37, Kirrbergerstr 1, 66421, Homburg, Germany
| | - A Marmotti
- Department of Orthopaedics and Traumatology, San Luigi Gonzaga Hospital, Orbassano, University of Turin, Turin, Italy
| | - C Mouton
- Department of Orthopedic Surgery, Clinique d'Eich-Centre Hospitalier de Luxembourg, 76, rue d'Eich, L-1460, Luxembourg, Luxembourg
| | - J M Oliveira
- 3B's Research Group - Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark, Zona Industrial da Gandra, 4805-017, Barco, GMR, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga, Guimarães, Portugal
| | - H Pereira
- 3B's Research Group University of Minho, ICVS/3B's-PT Government Associate Laboratory, Braga, Guimarães, Portugal.,Orthopedic Department Centro Hospitalar Póvoa de Varzim, Vila do Conde, Portugal.,Ripoll y De Prado Sports Clinic - FIFA Medical Centre of Excellence, Murcia, Madrid, Spain
| | - G M Peretti
- IRCCS Istituto Ortopedico Galeazzi, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - D Romero-Rodriguez
- Department of Physical Therapy and Sports Rehabilitation, ReSport Clinic Barcelona, Barcelona, Spain.,EUSES Sports Science, University of Girona, Girona, Spain
| | - C Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden
| | - J Stephen
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.,The Biomechanics Group, Department of Mechanical Engineering, Imperial College, London, UK
| | - C J A van Bergen
- Department of Orthopedic Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - L de Girolamo
- Orthopaedic Biotechnology Laboratory, Galeazzi Orthopaedic Institute, Milan, Italy
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Abstract
Noninsertional Achilles tendinopathy often responds to nonoperative treatment. When nonoperative treatment fails, the clinician must distinguish between paratendinopathy and noninsertional tendinopathy. In paratendinopathy, myofibroblasts synthesize collagen, causing adhesions, and the paratenon may be released or excised. If a core area of tendinopathy is identified on MRI, the area is excised longitudinally and repaired with a side-to-side suture. If greater than 50% of the tendon diameter is excised, the authors recommend a short flexor hallucis longus tendon transfer with an interference screw. A turndown flap of the gastrocnemius aponeurosis is also described with good results.
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Affiliation(s)
- William T DeCarbo
- The Orthopedic Group, 800 Plaza Drive, Suite 240, Belle Vernon, PA 15012, USA.
| | - Mark J Bullock
- Saginaw Valley Bone and Joint Center, 5483 Gratiot Road, Saginaw, MI 48638, USA
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17
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Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6492597. [PMID: 27885357 PMCID: PMC5112330 DOI: 10.1155/2016/6492597] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/20/2016] [Indexed: 12/30/2022]
Abstract
Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options.
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18
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Zwiers R, Wiegerinck JI, van Dijk CN. Treatment of midportion Achilles tendinopathy: an evidence-based overview. Knee Surg Sports Traumatol Arthrosc 2016; 24:2103-11. [PMID: 25366192 DOI: 10.1007/s00167-014-3407-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 10/22/2014] [Indexed: 12/14/2022]
Abstract
UNLABELLED In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ruben Zwiers
- Department of Orthopaedic Surgery, Academical Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Johannes I Wiegerinck
- Department of Orthopaedic Surgery, Academical Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academical Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
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19
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Borda J, Selhorst M. The use of compression tack and flossing along with lacrosse ball massage to treat chronic Achilles tendinopathy in an adolescent athlete: a case report. J Man Manip Ther 2016; 25:57-61. [PMID: 28855793 DOI: 10.1080/10669817.2016.1159403] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Achilles tendinopathy is an overuse injury that often affects individuals engaged in recreational or competitive level activity. Although most patients experience satisfactory results with therapy, a substantial portion fail to respond to traditional treatment. The purpose of this case study is to describe the successful use of compression tack and flossing (CTF) with lacrosse ball massage (LBM) in the treatment of an adolescent athlete with Achilles tendinopathy who had failed to respond to traditional treatment. CASE DESCRIPTION The patient was a 14-year old female diagnosed with chronic Achilles tendinopathy. She presented with 8/10 left posterior ankle pain during activity and scored 66/80 on the Lower Extremity Functional Scale (LEFS). After six weeks of PT consisting of eccentric exercise, proprioceptive training, and iontophoresis, the patient continued to report pain during sport and no significant improvements on the LEFS. With traditional PT failing to resolve symptoms, the patient was treated with CTF and LBM. OUTCOMES The outcomes of interest were the LEFS and the ability to participate in sport without pain. After only two sessions focusing on CTF and LBM, she had 0/10 pain during sport and scored a 79/80 on the LEFS. Patient was discharged to continue with a home exercise program consisting of CTF and LBM, and eccentric exercise. DISCUSSION The patient's outcomes significantly improved after CTF and LBM was added to eccentric exercise. These results suggest that this intervention may be a viable adjunct treatment for Achilles tendinopathy; however further research, including controlled clinical trials and long-term outcome data, are warranted.
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Affiliation(s)
- Jennifer Borda
- Sports and Orthopedic Physical Therapy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mitchell Selhorst
- Sports and Orthopedic Physical Therapy, Nationwide Children's Hospital, Columbus, OH, USA
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20
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Jayaseelan DJ, Kecman M, Alcorn D, Sault JD. Manual therapy and eccentric exercise in the management of Achilles tendinopathy. J Man Manip Ther 2016; 25:106-114. [PMID: 28559670 DOI: 10.1080/10669817.2016.1183289] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Chronic Achilles tendinopathy (AT) is an overuse condition seen among runners. Eccentric exercise can decrease pain and improve function for those with chronic degenerative tendon changes; however, some individuals have continued pain requiring additional intervention. While joint mobilization and manipulation has not been studied in the management in Achilles tendinopathy, other chronic tendon dysfunction, such as lateral epicondylalgia, has responded well to manual therapy (MT). Three runners were seen in physical therapy (PT) for chronic AT. They were prescribed eccentric loading exercises and calf stretching. Joint mobilization and manipulation was implemented to improve foot and ankle mobility, decrease pain, and improve function. Immediate within-session changes in pain, heel raise repetitions, and pressure pain thresholds (PPT) were noted following joint-directed MT in each patient. Each patient improved in self-reported function on the Achilles tendon specific Victorian Institute for Sport Assessment questionnaire (VISA-A), pain levels, PPT, joint mobility, ankle motion, and single-leg heel raises at discharge and 9-month follow-up. The addition of MT directed at local and remote sites may enhance the rehabilitation of patients with AT. Further research is necessary to determine the efficacy of adding joint mobilization to standard care for AT. LEVEL OF EVIDENCE Case series. Therapy, Level 4.
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Affiliation(s)
- Dhinu J Jayaseelan
- Department of Physical Therapy and Health Care Sciences, The George Washington University, Washington, DC, USA
| | | | | | - Josiah D Sault
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
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21
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Photobiomodulation and eccentric exercise for Achilles tendinopathy: a randomized controlled trial. Lasers Med Sci 2015; 31:127-35. [DOI: 10.1007/s10103-015-1840-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/18/2015] [Indexed: 10/22/2022]
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22
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Habets B, van Cingel REH. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols. Scand J Med Sci Sports 2015; 25:3-15. [PMID: 24650048 DOI: 10.1111/sms.12208] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2014] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- B Habets
- Papendal Sports Medical Center, Arnhem, The Netherlands; Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
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23
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom
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Frizziero A, Trainito S, Oliva F, Nicoli Aldini N, Masiero S, Maffulli N. The role of eccentric exercise in sport injuries rehabilitation. Br Med Bull 2014; 110:47-75. [PMID: 24736013 DOI: 10.1093/bmb/ldu006] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field. SOURCES OF DATA A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as 'eccentric exercise', 'sports injuries rehabilitation', 'tendinopathy', 'hamstrings strain' 'adductor injuries' and 'ACL reconstruction rehabilitation'. AREAS OF AGREEMENT EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation. AREA OF CONTROVERSY The lack of standardization of protocols, the variable amount, quality and follow-up of studies, the different anatomy and pathophysiology of the therapeutic targets limit the evidence of applicability of EE to sports injuries. GROWING POINTS The role of pathology and biomechanics in the response to EE should be further investigated. AREAS TIMELY FOR DEVELOPING RESEARCH New randomized controlled trials should test the effectiveness of standardized EE regimens to various sites of sports injuries.
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Affiliation(s)
- Antonio Frizziero
- Department of Physical and Rehabilitation Medicine, University of Padova, Italy
| | - Sabina Trainito
- Department of Physical and Rehabilitation Medicine, University of Padova, Italy
| | - Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome 'Tor Vergata' School of Medicine, Rome, Italy
| | - Nicolò Nicoli Aldini
- Department Rizzoli RIT, Laboratory of Biocompatibility, Technological Innovations and Advanced Therapies, Rizzoli Orthopedic Institute, Bologna, Italy
| | - Stefano Masiero
- Department of Physical and Rehabilitation Medicine, University of Padova, Italy
| | - Nicola Maffulli
- Department of Physical and Rehabilitation Medicine, University of Salerno, Italy Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital Mann Ward, 275 Bancroft Road, London E1 4DG, UK Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK
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25
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Kjaer M, Heinemeier KM. Eccentric exercise: acute and chronic effects on healthy and diseased tendons. J Appl Physiol (1985) 2014; 116:1435-8. [DOI: 10.1152/japplphysiol.01044.2013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Eccentric exercise can influence tendon mechanical properties and matrix protein synthesis. mRNA for collagen and regulatory factors thereof are upregulated in animal tendons, independent of muscular contraction type, supporting the view that tendon, compared with skeletal muscle, is less sensitive to differences in type and/or amount of mechanical stimulus with regard to expression of collagen, regulatory factors for collagen, and cross-link regulators. In overused (tendinopathic) human tendon, eccentric exercise training has a beneficial effect, but the mechanism by which this is elicited is unknown, and slow concentric loading appears to have similar beneficial effects. It may be that tendinopathic regions, as long as they are subjected to a certain magnitude of load at a slow speed, independent of whether this is eccentric or concentric in nature, can reestablish their normal tendon fibril alignment and cell morphology.
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Affiliation(s)
- Michael Kjaer
- Institute of Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Katja M. Heinemeier
- Institute of Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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26
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Grigg NL, Wearing SC, O’Toole JM, Smeathers JE. The effect of exercise repetition on the frequency characteristics of motor output force: Implications for Achilles tendinopathy rehabilitation. J Sci Med Sport 2014; 17:13-7. [DOI: 10.1016/j.jsams.2013.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 03/18/2013] [Accepted: 03/28/2013] [Indexed: 11/30/2022]
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Whole-body vibration versus eccentric training or a wait-and-see approach for chronic Achilles tendinopathy: a randomized clinical trial. J Orthop Sports Phys Ther 2013; 43:794-803. [PMID: 24175595 DOI: 10.2519/jospt.2013.4762] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Randomized clinical trial. OBJECTIVES To test the hypothesis that whole-body vibration training results in greater improvements in symptoms and pain, structural changes, and muscle flexibility and strength of the triceps surae muscle-tendon unit than those achieved with eccentric training or with a wait-and-see approach. BACKGROUND The potential use of vibration training for the treatment of Achilles tendinopathy has not been explored. METHODS Fifty-eight patients (mean age, 46.0 years) with Achilles tendinopathy were randomly assigned to a 12-week intervention using whole-body vibration training, eccentric training, or a wait-and-see approach. Pain, tendon structure and path, and muscle flexibility and strength were assessed at baseline and follow-up, and compared using mixed-factor analyses of variance. RESULTS Pain improvements at the midsection of the tendon were greater in the vibration- and eccentric-training groups than in the wait-and-see group (mean difference from the vibration-training group, -18.0; 95% confidence interval [CI]: -35.0, -1.1; mean difference from the eccentric-training group, -27.0; 95% CI: -50.9, -3.1). Improvements in pain at the musculotendinous junction were greater in the eccentric-training group than in the other groups (mean difference from the vibration-training group, -31.4; 95% CI: -60.7, -2.0; mean difference from the wait-and-see group, -50.2; 95% CI: -82.3, -18.1). Improvements in most participants were achieved in the vibration-training group, followed by the eccentric-training group. CONCLUSION Vibration training may be an alternative or a complementary treatment in patients who do not respond well to eccentric training, especially in those with insertional pain. LEVEL OF EVIDENCE Therapy, level 2b-.
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Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013; 43:267-86. [PMID: 23494258 DOI: 10.1007/s40279-013-0019-z] [Citation(s) in RCA: 234] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
INTRODUCTION Achilles and patellar tendinopathy are overuse injuries that are common among athletes. Isolated eccentric muscle training has become the dominant conservative management strategy for Achilles and patellar tendinopathy but, in some cases, up to 45 % of patients may not respond. Eccentric-concentric progressing to eccentric (Silbernagel combined) and eccentric-concentric isotonic (heavy-slow resistance; HSR) loading have also been investigated. In order for clinicians to make informed decisions, they need to be aware of the loading options and comparative evidence. The mechanisms of loading also need to be elucidated in order to focus treatment to patient deficits and refine loading programmes in future studies. OBJECTIVES The objectives of this review are to evaluate the evidence in studies that compare two or more loading programmes in Achilles and patellar tendinopathy, and to review the non-clinical outcomes (potential mechanisms), such as improved imaging outcomes, associated with clinical outcomes. METHODS Comprehensive searching (MEDLINE, EMBASE, CINAHL, Current Contents and SPORTDiscus(™)) identified 403 studies. Two authors independently reviewed studies for inclusion and quality. The final yield included 32 studies; ten compared loading programmes and 28 investigated at least one potential mechanism (six studies compared loading programmes and investigated potential mechanisms). RESULTS This review has identified limited (Achilles) and conflicting (patellar) evidence that clinical outcomes are superior with eccentric loading compared with other loading programmes, questioning the currently entrenched clinical approach to these injuries. There is equivalent evidence for Silbernagel combined (Achilles) and greater evidence for HSR loading (patellar). The only potential mechanism that was consistently associated with improved clinical outcomes in both Achilles and patellar tendon rehabilitation was improved neuromuscular performance (e.g. torque, work, endurance), and Silbernagel-combined (Achilles) HSR loading (patellar) had an equivalent or higher level of evidence than isolated eccentric loading. In the Achilles tendon, a majority of studies did not find an association between improved imaging (e.g. reduced anteroposterior diameter, proportion of tendons with Doppler signal) and clinical outcomes, including all high-quality studies. In contrast, HSR loading in the patellar tendon was associated with reduced Doppler area and anteroposterior diameter, as well as greater evidence of collagen turnover, and this was not seen following eccentric loading. HSR seems more likely to lead to tendon adaptation and warrants further investigation. Improved jump performance was associated with Achilles but not patellar tendon clinical outcomes. The mechanisms associated with clinical benefit may vary between loading interventions and tendons. CONCLUSION There is little clinical or mechanistic evidence for isolating the eccentric component, although it should be made clear that there is a paucity of good quality evidence and several potential mechanisms have not been investigated, such as neural adaptation and central nervous system changes (e.g. cortical reorganization). Clinicians should consider eccentric-concentric loading alongside or instead of eccentric loading in Achilles and patellar tendinopathy. Good-quality studies comparing loading programmes and evaluating clinical and mechanistic outcomes are needed in both Achilles and patellar tendinopathy rehabilitation.
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Affiliation(s)
- Peter Malliaras
- Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary, University of London, London, UK.
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Bayliss AJ, Klene FJ, Gundeck EL, Loghmani MT. Treatment of a patient with post-natal chronic calf pain utilizing instrument-assisted soft tissue mobilization: a case study. J Man Manip Ther 2012; 19:127-34. [PMID: 22851875 DOI: 10.1179/2042618611y.0000000006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Musculoskeletal pain is commonly reported by pre- and postnatal women, with the most common complaint being low back pain. However, lower leg pain is also frequently reported by women particularly in the third trimester. The purpose of the case study is to illustrate how instrument-assisted soft tissue mobilization (ISTM) can be used to treat a patient with a 2-year history of chronic calf pain. The subject was a 35-year-old female who developed calf pain during the last trimester of her pregnancy following severe lower leg edema. The calf pain was present for the 2 years following delivery and was described as a dull ache, typically aggravated by direct pressure on the calf, prolonged standing, and stairs. An X-ray, magnetic resonance imaging (MRI) with contrast, and ultrasound Doppler study prior to referral ruled out tumors, vascular, lymphatic, or skeletal bone abnormalities. However, her MRI did show a dense superficial venous tissue asymmetry in the same location of her symptoms. Impairments were minimal; the only asymmetrical objective findings were calf length, strength, and soft tissue restrictions detected on palpation. After nine treatments incorporating an ISTM approach, soft tissue mobility, pain, calf strength, and lower extremity functional scale score all improved and her symptoms were abolished.
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Affiliation(s)
- Amy J Bayliss
- Department of Physical Therapy, Indiana University, Indianapolis, IN, USA
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van der Plas A, de Jonge S, de Vos RJ, van der Heide HJL, Verhaar JAN, Weir A, Tol JL. A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med 2011; 46:214-8. [PMID: 22075719 PMCID: PMC3277725 DOI: 10.1136/bjsports-2011-090035] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results. Aim To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson's heel-drop exercise programme. Study design Part of a 5-year follow-up of a previously conducted randomised controlled trial. Methods 58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded. Results In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051). Conclusion At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson's heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.
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Affiliation(s)
- A van der Plas
- Sports Medicine Department, The Hague Medical Centre Antoniushove, Burgemeester Banninglaan 1, Leidschendam, The Netherlands
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Electromyographic analysis of an eccentric calf muscle exercise in persons with and without Achilles tendinopathy. Phys Ther Sport 2011; 13:150-5. [PMID: 22814448 DOI: 10.1016/j.ptsp.2011.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 07/20/2011] [Accepted: 08/02/2011] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To compare surface electromyographic (EMG) activity of the gastrocnemius and soleus muscles between persons with and without Achilles tendinopathy (AT) during an eccentric muscle exercise in different knee joint positions. DESIGN Repeated measures design. SETTING Research laboratory. PARTICIPANTS Participants (n = 18) diagnosed with AT and 18 control subjects were recruited. MAIN OUTCOME MEASURES Gastrocnemius and soleus muscle activity was examined by surface (EMG) during extended and flexed knee joint conditions while performing the eccentric training technique. The EMG data were expressed as a percentage of a maximum voluntary contraction (MVC). RESULTS EMG activity was notably higher (mean difference: 10%, effect size: 0.59) in those subjects with AT. Irrespective of the presence of AT, there was a significant interaction effect between muscle and joint position. The gastrocnemius muscle was significantly more active in the extended knee condition and soleus muscle activity was unchanged across joint positions. CONCLUSIONS The results indicated that the presence of AT influenced calf muscle activity levels during performance of the eccentric exercise. There were differences in muscle activity during the extended and flexed knee conditions. This result does support performing Alfredson, Pietila, Jonsson, and Lorentzon (1998) eccentric exercise in an extended knee position but the specific effects of the knee flexed position on the Achilles tendon during eccentric exercise have yet to be determined, particularly in those with AT.
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Verrall G, Schofield S, Brustad T, Physio D. Chronic Achilles tendinopathy treated with eccentric stretching program. Foot Ankle Int 2011; 32:843-9. [PMID: 22097158 DOI: 10.3113/fai.2011.0843] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Dip Physio
- Sunnaas Rehabilitation Hospital, Askim, Norway
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Reinking M. Tendinopathy in athletes. Phys Ther Sport 2011; 13:3-10. [PMID: 22261424 DOI: 10.1016/j.ptsp.2011.06.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 06/11/2011] [Accepted: 06/17/2011] [Indexed: 02/07/2023]
Abstract
Overuse related tendon pain is a significant problem in sport and can interfere with and, in some instances, end an athletic career. This article includes a consideration of the biology of tendon pain including a review of tendon anatomy and histopathology, risk factors for tendon pain, semantics of tendon pathology, and the pathogenesis of tendon pain. Evidence is presented to guide the physical therapist in clinical decision-making regarding the examination of and intervention strategies for athletes with tendon pain.
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Affiliation(s)
- Mark Reinking
- Saint Louis University, Department of Physical Therapy and Athletic Training, Doisy College of Health Sciences, 3437 Caroline Mall, Saint Louis, MO 63104, USA.
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Maffulli N, Longo UG, Loppini M, Denaro V. Current treatment options for tendinopathy. Expert Opin Pharmacother 2011; 11:2177-86. [PMID: 20569088 DOI: 10.1517/14656566.2010.495715] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Nicola Maffulli
- Queen Mary University of London, Mile End Hospital, Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, 275 Bancroft Road, London E1 4 DG, UK.
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Guilhem G, Guével A, Cornu C. A standardization method to compare isotonic vs. isokinetic eccentric exercises. J Electromyogr Kinesiol 2010; 20:1000-6. [DOI: 10.1016/j.jelekin.2010.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Revised: 03/24/2010] [Accepted: 03/24/2010] [Indexed: 11/29/2022] Open
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Munteanu SE, Landorf KB, Menz HB, Cook JL, Pizzari T, Scott LA. Efficacy of customised foot orthoses in the treatment of Achilles tendinopathy: study protocol for a randomised trial. J Foot Ankle Res 2009; 2:27. [PMID: 19852853 PMCID: PMC2775021 DOI: 10.1186/1757-1146-2-27] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 10/24/2009] [Indexed: 11/10/2022] Open
Abstract
Background Achilles tendinopathy is a common condition that can cause marked pain and disability. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. The exception to this is eccentric calf muscle exercises, which have become a standard non-surgical intervention for Achilles tendinopathy. Foot orthoses have also been advocated as a treatment for Achilles tendinopathy, but the long-term efficacy of foot orthoses for this condition is unknown. This manuscript describes the design of a randomised trial to evaluate the efficacy of customised foot orthoses to reduce pain and improve function in people with Achilles tendinopathy. Methods One hundred and forty community-dwelling men and women aged 18 to 55 years with Achilles tendinopathy (who satisfy inclusion and exclusion criteria) will be recruited. Participants will be randomised, using a computer-generated random number sequence, to either a control group (sham foot orthoses made from compressible ethylene vinyl acetate foam) or an experimental group (customised foot orthoses made from semi-rigid polypropylene). Both groups will be prescribed a calf muscle eccentric exercise program, however, the primary difference between the groups will be that the experimental group receive customised foot orthoses, while the control group receive sham foot orthoses. The participants will be instructed to perform eccentric exercises 2 times per day, 7 days per week, for 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. The secondary outcome measures will be participant perception of treatment effect, comfort of the foot orthoses, use of co-interventions, frequency and severity of adverse events, level of physical activity and health-related quality of life (assessed using the Short-Form-36 questionnaire - Version two). Data will be collected at baseline, then at 1, 3, 6 and 12 months. Data will be analysed using the intention to treat principle. Discussion This study is the first randomised trial to evaluate the long-term efficacy of customised foot orthoses for the treatment of Achilles tendinopathy. The study has been pragmatically designed to ensure that the study findings are generalisable to clinical practice. Trial registration Australian New Zealand Clinical Trials Registry Number: ACTRN12609000829213.
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Affiliation(s)
- Shannon E Munteanu
- Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora 3086, Victoria, Australia.
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