A treatment algorithm for managing Achilles tendinopathy: new treatment options

Achilles tendinopathy research has a gender data gap: A systematic review and meta-analysis

PURPOSE

A persisting gender bias has been recently highlighted in orthopaedics and sports medicine. The aim of this study was to evaluate the volume of gender-specific data and gender-specific results in the treatment of a common tendon disease, Achilles tendinopathy.

METHODS

Pubmed, Cochrane, and Web of Science were searched to identify all clinical studies focusing on Achilles tendinopathy treatment. The Visual Analogue Scale (VAS) and Victorian Institute of Sport Assessment-Achilles (VISA-A) data of women and men of the studies that disaggregated results by gender were collected, and a meta-analysis was conducted. Treatment response within and in between gender categories was evaluated, focusing on overall gender-disaggregated data, as well as within each of the three treatment categories: conservative treatment, injective treatment and surgical treatment. A formal risk of bias analysis was conducted using Downs and Black's grading system.

RESULTS

Out of the 8796 papers screened, 178 were included after the screening. The number of female study participants grew from 20% up to 1990 to 48% in the years 2019-2022. Only 373 out of 3423 (11%) female patients and 685 of 4352 (16%) male patients were found in sex-disaggregated studies. A meta-analysis was conducted on the 14 papers that reported sex-disaggregated data for VAS and VISA-A. The meta-analysis revealed that there was no difference in the overall treatment response between women and men and that both genders showed an overall significant treatment benefit in terms of VAS and VISA-A values. However, significant differences were documented within the treatment categories. While no differences were found in surgical studies, in conservative treatment studies, men experienced lower posttreatment VAS values (p = 0.004). The largest difference was found in injective treatments, with men experiencing a larger change in VAS values (men = -3.0, women = -1.0, p = 0.016) and higher posttreatment VISA-A values (p = 0.032).

CONCLUSION

This systematic review and meta-analysis showed a lack of awareness of the importance of sex-specific data within Achilles tendinopathy treatment research. The proportion of female study subjects has grown over the years, but there is still a large data gap caused by the absence of sex-disaggregated data. The omission of sex-disaggregated data causes the loss of valuable knowledge on the true effectiveness of current Achilles tendinopathy treatment. The results of this study indicate that women profit less from available treatments, particularly injective approaches, which prompts further research for treatment adaptation by gender.

LEVEL OF EVIDENCE

Level IV.

Effectiveness of Kinesiotherapy in the Treatment of Achilles Tendinopathy-A Narrative Review

This narrative review of kinesiotherapy methods in the treatment of Achilles tendinopathy (AT) encompassed a diverse range of studies, including athletes and untrained people, healthy or injured, undergoing kinesiotherapy treatments. Most experimental studies (86%) reported results related to pain perception, 27% to the range of motion, and 27% to biomechanical assessment. However, the studies showed notable heterogeneity in the outcomes associated with the interventions, and, in this review of kinesiotherapy protocols for AT, a prominent observation emerged regarding their efficacy, suggesting a more favorable impact on pain and tendon stiffness management when comparing the measured parameters between the trained and untrained groups. The importance of tailoring the treatment approach based on the individual's athletic background and conditioning status is underscored. There is a need for personalized rehabilitation strategies in athletic populations. The average duration of kinesiotherapy in the treatment of tendinopathy was 15.3 weeks. This observation underscores the potential of kinesiotherapy interventions as a viable treatment option for individuals with Achilles tendon issues. These findings underscore the urgent need for further research to provide stakeholders with more comprehensive directions for future studies. The results may be helpful for doctors, physiotherapists, trainers, and researchers interested in this topic.

Anti-inflammatory effects of sericin and swimming exercise in treating experimental Achilles tendinopathy in rat

The aim of this study was to assess the effectiveness of combining sericin with swimming exercise as a treatment for type-I collagenase-induced Achilles tendinopathy (AT) in rats, with a focus on inflammatory cytokines. An experimental AT model was established using type-I collagenase in male Sprague-Dawley rats, categorized into five groups: Group 1 (Control + Saline), Group 2 (AT), Group 3 (AT + exercise), Group 4 (AT + sericin), and Group 5 (AT + sericin + exercise). Intratendinous sericin administration (0.8 g/kg/mL) took place from days 3 to 6, coupled with 30 min daily swimming exercise sessions (5 days/week, 4 weeks). Serum samples were analyzed using ELISA for tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), interleukin-10 (IL-10), and total antioxidant-oxidant status (TAS-TOS), alongside histopathological and immunohistochemical assessments of Achilles tendon samples. Elevated TNF-α and IL-1β and decreased IL-10 levels were evident in Group 2; Of these, TNF-α and IL-1β were effectively reduced and IL-10 increased across all treatment groups, particularly groups 4 and 5. Serum TAS was notably lower in Group 2 and significantly increased in Group 5 compared to Group 2. Histopathologically, Group 2 displayed severe degeneration, irregular fibers, and round cell nuclei, while Group 5 exhibited decreased degeneration and spindle-shaped fibers. The Bonar score increased in Group 2 and decreased in groups 4 and 5. Collagen type-I alpha-1 (Col1A1) expression was notably lower in Group 2 (P = 0.001) and significantly increased in groups 4 and 5 compared to Group 2 (P = 0.011 and 0.028, respectively). This study underscores the potential of sericin and swimming exercises in mitigating inflammation and oxidative stress linked to AT pathogenesis, presenting a promising combined therapeutic strategy.

Current concept review of Achilles tendinopathy

Achilles tendinopathy is a common overuse injury affecting the ankle and foot. It manifests as a clinical condition that includes pain, edema, and decreased functionality. This condition can be broadly categorized into two main types based on anatomical location: insertional and noninsertional tendinopathy. The development of Achilles tendinopathy involves various factors, both internal and external. Patients with Achilles tendinopathy often experience stiffness worsened by prolonged rest, and pain exacerbated by physical activity. These symptoms can limit work activity and sports participation, with many patients facing discomfort while wearing shoes due to heel sensitivity. Diagnosis is primarily clinical, although MRI and ultrasound imaging can aid in differential diagnosis. Identifying risk factors and understanding the patient's biomechanics assist in accurate diagnosis and subsequent management. Management of Achilles tendinopathy involves a range of conservative and surgical options. However, due to varying results in clinical studies, a definitive gold standard treatment has not emerged. Eccentric exercises are a valuable tool in managing the condition. The recommend treatments such as shock wave therapy or nitric oxide patches are sought if symptoms do not improve. Peritendinous injections could be options if physical therapy proves ineffective. Surgical intervention is required after six months of conservative treatment. Recent research on Achilles tendinopathy emphasizes the need for individualized treatment plans that address its multifaceted nature. Combining biomechanical analysis, advanced imaging, and patient-specific factors is key to achieving optimal outcomes. Additionally, preventive strategies focusing on proper training techniques, load management, and addressing modifiable risk factors play a critical role in reducing the incidence of this condition. In conclusion, this article provides a current overview of Achilles tendinopathy. It highlights the importance of a comprehensive approach to understanding its causes, pathophysiology, diagnosis, and management strategies.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Recent advances of exosomes in soft tissue injuries in sports medicine: A critical review on biological and biomaterial applications

Sports medicine is generally associated with soft tissue injuries including muscle injuries, meniscus and ligament injuries, tendon ruptures, tendinopathy, rotator cuff tears, and tendon-bone healing during injuries. Tendon and ligament injuries are the most common sport injuries accounting for 30-40% of all injuries. Therapies for tendon injuries can be divided into surgical and non-surgical methods. Surgical methods mainly depend on the operative procedures, the surgeons and postoperative interventions. In non-surgical methods, cell therapy with stem cells and cell-free therapy with secretome of stem cell origin are current directions. Exosomes are the main paracrine factors of mesenchymal stem cells (MSCs) containing biological components such as proteins, nucleic acids and lipids. Compared with MSCs, MSC-exosomes (MSC-exos) possess the capacity to escape phagocytosis and achieve long-term circulation. In addition, the functions of exosomes from various cell sources in soft tissue injuries in sports medicine have been gradually revealed in recent years. Along with the biological and biomaterial advances in exosomes, exosomes can be designed as drug carriers with biomaterials and exosome research is providing promising contributions in cell biology. Exosomes with biomaterial have the potential of becoming one of the novel therapeutic modalities in regenerative researches. This review summarizes the derives of exosomes in soft tissue regeneration and focuses on the biological and biomaterial mechanism and advances in exosomal therapy in soft tissue injuries.

Effectiveness of Exercise Treatments with or without Adjuncts for Common Lower Limb Tendinopathies: A Living Systematic Review and Network Meta-analysis

INTRODUCTION

Exercise therapy is usually prescribed as first-line treatment for lower limb tendinopathies. The multitude of exercise- and non-exercise-based management options can be overwhelming for the treating sports professional and patient alike. We chose to investigate the comparative effectiveness of exercise therapy with or without adjuncts for managing the commonest lower limb tendinopathies.

METHODS

Through an extensive systematic literature search using multiple databases, we aimed to identify eligible randomised controlled trials (RCTs) on Achilles tendinopathy, patellar tendinopathy or greater trochanteric pain syndrome (GTPS) that included at least one exercise intervention in their treatment arms. Our primary outcomes were patient-reported pain and function (Victorian Institute of Sport Assessment; VISA). Follow-up was defined as short-term (≤ 12 weeks), mid-term (> 12 weeks to < 12 months) and long-term (≥ 12 months). The risk of bias and strength of evidence were assessed with the Cochrane Collaboration and GRADE-NMA tools, respectively. Analyses were performed separately for each one of the three tendinopathies.

RESULTS

A total of 68 RCTs were included in the systematic review. All pairwise comparisons that demonstrated statistically and clinically significant differences between interventions were based on low or very low strength of evidence. Based on evidence of moderate strength, the addition of extracorporeal shockwave therapy to eccentric exercise in patellar tendinopathy was associated with no short-term benefit in pain or VISA-P. From the network meta-analyses, promising interventions such as slow resistance exercise and therapies administered alongside eccentric exercise, such as topical glyceryl trinitrate for patellar tendinopathy and high-volume injection with corticosteroid for Achilles tendinopathy were based on low/very low strength of evidence.

CONCLUSION

In this network meta-analysis, we found no convincing evidence that any adjuncts administered on their own or alongside exercise are more effective than exercise alone. Therefore, we recommend that exercise monotherapy continues to be offered as first-line treatment for patients with Achilles and patellar tendinopathies and GTPS for at least 3 months before an adjunct is considered. We provide treatment recommendations for each tendinopathy. PROSPERO registration number CRD42021289534.

The Addition of a Krackow Rip Stop Suture Augment After Achilles Tendon Debridement for Insertional Achilles Tendinopathy: A Biomechanical Study

BACKGROUND

In the operative treatment of insertional Achilles tendinopathy, the Achilles tendon is often released from its insertion to allow for adequate debridement of pathologic tissue. The use of a double row suture anchor construct has become increasingly favorable among surgeons after Achilles tendon debridement. This study hypothesized that the addition of a Krackow rip stop suture augment to the double row suture anchor construct would increase the repair's maximum load to failure. A biomechanically stronger repair would potentially decrease the risk of catastrophic failure with early weight-bearing or accidental forced dorsiflexion after operative management for insertional Achilles tendinopathy.

METHODS

Fourteen cadaveric specimens were used to compare the 2 repair techniques. Achilles tendons were debrided and repaired using either a double row suture anchor with and without the additional Krackow rip stop suture augment. The 2 repair techniques were compared using an axial-torsion testing system to measure average load to failure.

RESULTS

The average load to failure for the double row suture anchor repair alone was 152.00 N. The average load to failure for the tendons with the double row suture anchor with the Krackow rip stop augment was 383.08 N. An independent-samples Mann-Whitney U-test was conducted and the suture anchor plus Krackow augment group had a significantly higher load to failure (P = .011, Mann-Whitney U = 5.00, n1 = n2 = 7, P < .05, 2-tailed).

CONCLUSION

This study confirmed that the addition of a Krakow rip stop augment to the double row suture anchor is able to increase the maximum load to failure when compared to the double row suture anchor alone. These results suggest the potential of this added technique to decrease the risk of catastrophic failure.

Republication of "Uses of Braces and Orthotics for Conservative Management of Foot and Ankle Disorders"

Nonsurgical management is almost always considered the first-line treatment for the vast majority of foot and ankle pathologies. Foot orthoses, shoe modifications, and therapeutic footwear are considered essential tools for successful conservative management of different foot and ankle disorders. Orthopedic foot and ankle surgeons should have a meticulous understanding of the lower extremity biomechanics as well as the pathoanatomy and the sequelae of diseases affecting the foot and/or ankle. This is essential to the understanding of the desired effects of the different inserts, orthotics, shoe modifications, or braces that may be prescribed for these conditions. In this article, we will summarize the orthoses used for treatment of the most commonly encountered foot and ankle pathologies, with the exclusion of treatment for the diabetic foot because of the unique requirements of that disease process.

Ultrasonography-guided Intervention in the Achilles Tendon and Plantar Fascia

Tendinopathy is very common in the foot and ankle. Achilles tendinopathy is a painful overuse injury that often occurs in athletes, especially those who participate in running and jumping sports. Plantar fasciitis is the most frequent cause of plantar pain in the adult heel. Initial treatment of these conditions is conservative. However, in some cases symptoms only improve slowly, and many cases are intractable. When conservative management fails, ultrasonography guided injections are indicated. We discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, retrocalcaneal bursitis, and plantar fasciitis. We describe the different agents that can be used and the various ultrasonography-guided procedures that offer technical and practical information to improve daily clinical practice.

Effect of Symptom Duration on Injury Severity and Recovery in Patients With Achilles Tendinopathy

Background

Achilles tendinopathy is a common overuse condition. Distinguishing between early- and late-stage tendinopathy may have implications on treatment decisions and recovery expectations.

Purpose

To compare the effects of time and baseline measures of tendon health on outcomes among patients with varying symptom durations after 16 weeks of comprehensive exercise treatment.

Study Design

Cohort study; Level of evidence, 3.

Methods

Participants (N = 127) were categorized into 4 groups based on the number of months since symptom onset: ≤3 months (n = 24); between >3 and ≤6 months (n = 25); between >6 and ≤12 months (n = 18); or >12 months (n = 60). All participants received 16 weeks of standardized exercise therapy and pain-guided activity modification. Outcomes representing symptoms, lower extremity function, tendon structure, mechanical properties, psychological factors, and patient-related factors were assessed at baseline and at 8 and 16 weeks after the initiation of exercise therapy. Chi-square tests and 1-way analysis of variance were used to compare baseline measures between groups.Time, group, and interaction effects were evaluated using linear mixed models.

Results

The mean age of the participants was 47.8 ± 12.6 years, 62 participants were women, and symptoms ranged from 2 weeks to 274 months. No significant differences were found among symptom duration groups at baseline for any measure of tendon health. At 16 weeks, all groups demonstrated improvements in symptoms, psychological factors, lower extremity function, and tendon structure, with no significant differences among the groups (P > .05).

Conclusion

Symptom duration did not influence baseline measures of tendon health. Additionally, no differences were observed among the different symptom duration groups in response to 16 weeks of exercise therapy and pain-guided activity modification.

Biomechanics and lower limb function are altered in athletes and runners with achilles tendinopathy compared with healthy controls: A systematic review

Achilles tendinopathy (AT) is a debilitating injury in athletes, especially for those engaged in repetitive stretch-shortening cycle activities. Clinical risk factors are numerous, but it has been suggested that altered biomechanics might be associated with AT. No systematic review has been conducted investigating these biomechanical alterations in specifically athletic populations. Therefore, the aim of this systematic review was to compare the lower-limb biomechanics of athletes with AT to athletically matched asymptomatic controls. Databases were searched for relevant studies investigating biomechanics during gait activities and other motor tasks such as hopping, isolated strength tasks, and reflex responses. Inclusion criteria for studies were an AT diagnosis in at least one group, cross-sectional or prospective data, at least one outcome comparing biomechanical data between an AT and healthy group, and athletic populations. Studies were excluded if patients had Achilles tendon rupture/surgery, participants reported injuries other than AT, and when only within-subject data was available.. Effect sizes (Cohen's d) with 95% confidence intervals were calculated for relevant outcomes. The initial search yielded 4,442 studies. After screening, twenty studies (775 total participants) were synthesised, reporting on a wide range of biomechanical outcomes. Females were under-represented and patients in the AT group were three years older on average. Biomechanical alterations were identified in some studies during running, hopping, jumping, strength tasks and reflex activity. Equally, several biomechanical variables studied were not associated with AT in included studies, indicating a conflicting picture. Kinematics in AT patients appeared to be altered in the lower limb, potentially indicating a pattern of "medial collapse". Muscular activity of the calf and hips was different between groups, whereby AT patients exhibited greater calf electromyographic amplitudes despite lower plantar flexor strength. Overall, dynamic maximal strength of the plantar flexors, and isometric strength of the hips might be reduced in the AT group. This systematic review reports on several biomechanical alterations in athletes with AT. With further research, these factors could potentially form treatment targets for clinicians, although clinical approaches should take other contributing health factors into account. The studies included were of low quality, and currently no solid conclusions can be drawn.

A combination of omega-3 and exercise reduces experimental Achilles tendinopathy induced with a type-1 collagenase in rats

This study aimed to evaluate the effectiveness of omega-3 supplementation with exercise in a collagenase-induced Achilles tendinopathy (AT) rat model. Experimental groups (healthy control (HC), AT, exercise (Ex), omega-3 (W), and Ex+W) were randomly allocated. After a week of adaptation, oral omega-3 was initiated for 8 weeks (5 days/week). The exercise groups performed treadmill running for 30 min/day (5 days/week, 20 m/min, 8 weeks) following one week of adaptation (10 m/min, 15 min/day). Matrix metalloproteinase-13 (MMP-13), interleukin-1 beta (IL-1β), tumor necrosis factor-alpha (TNF-α), and total antioxidant-oxidant status (TAS) levels were determined in serum samples. Tendon samples were obtained for biomechanical, histopathological, and immunohistochemical assessments. Ultimate tensile force, yield force, stiffness values, collagen type-I alpha 1 expression, and serum TAS significantly decreased (P < 0.05) in AT vs. HC. These values and expression significantly increased in the Ex+W group vs. AT. Serum MMP-13, IL-1β, and TNF-α levels decreased in all treatment groups vs. AT. The most significant decrease was found in the Ex+W group (P < 0.01). Histopathologically, the improvement in degeneration was statistically significant in the Ex+W group (P < 0.05). Immunohistochemically, MMP-13, IL-1β, TNF-α, and nitric oxide synthase-2 expression was decreased in all treatment groups vs. AT. In conclusion, omega-3 and exercise might be recommended in AT patients.

Achilles tendinopathy and plantar fasciopathy: Are we ignoring calcaneal bone morphology? - A radiological assessment of calcaneal parameters

BACKGROUND

A radiological study was conducted to determine whether calcaneal morphological differences contribute to the pathophysiology of Achilles tendinopathy and plantar fasciopathy. This study is aimed to support our new hypothesis to explain the pathophysiology leading to recalcitrant disease and also to identify the role of calcaneal osteotomy for treating these conditions.

MATERIALS AND METHODS

Calcaneal width and height distance deviation from centre of ankle joint rotation was measured on standardised lateral weight bearing Ankle radiographs. A comparison was made between control group and study group to identify the differences in measured parameters.

RESULTS

Significant difference (P = 0.05) was observed in calcaneal width distance in study group with Achilles tendinopathy. In Plantar fasciopathy the vertical distance was reduced suggesting flattening of arch in study group. However, the difference was not statistically significant.

CONCLUSION

The study identifies the importance of evaluating calcaneal morphology for patients with recalcitrant Achilles tendinopathy and plantar fasciopathy. A new hypothesis is proposed to explain the high stresses produced in entire Achilles -calcaneus -plantar fascia unit which leads to chronic inflammatory response and intra substance degeneration.

Does additional extracorporeal shock wave therapy improve the effect of isolated percutaneous radiofrequency coblation in patients with insertional Achilles tendinopathy? Study protocol for a randomized controlled clinical trial

BACKGROUND

No conclusive evidence recommends a prior treatment for insertional Achilles tendinopathy (IAT). It is theorized that both percutaneous radiofrequency coblation and extracorporeal shockwave therapy (ESWT) relieve pain within the insertion. However, no clinical evidence shows that either treatment promotes the regeneration of the tendon or if the combination of these 2 interventions offers better function and less pain than one therapy.

METHODS

The study is a randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients with insertional Achilles tendinopathy who are not satisfied with the effect of conservative treatment will be screened. A minimum of 38 patients will be enrolled after deciding to participate in the trial on an informed basis. Then the intervention group and the control group perform radial ESWT and sham-ESWT respectively at 6 months after percutaneous radiofrequency coblation. The primary outcome will be the Victorian Institute of Sports Assessment Achilles (VISA-A) Score. Secondary outcome measures will be Foot and Ankle Outcome Score (FAOS) scale, visual analog scale (VAS), Tegner Score, and MRI ultra-short echo time (UTE) T2* value. The assessments will occur in 6 months, 1 year, and 2 years, post-operatively. The differences between the 2 groups will be conducted as intention-to-treat basis.

DISCUSSION

We aim to investigate if radiofrequency coblation associated with ESWT can provide more encouraging imaging findings as well as functional and clinical outcomes regarding the treatment of the IAT comparing to the single radiofrequency coblation treatment.

TRIAL REGISTRATION

ChiCTR1800017898; pre-results. Registered on 20 August 2018.

Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol

Calcaneal apophysitis and Achilles tendinopathy are common overuse injuries characterised by insidious posterior heel pain with activity. Calcaneal apophysitis is commonly diagnosed in adolescents, although Achilles tendinopathy is understudied in the adolescent population and is therefore rarely considered until adulthood. Exercise therapy and activity modification have the highest level of evidence for treating Achilles tendinopathy, while calcaneal apophysitis is treated with anecdotal and passive treatment or complete rest. It remains unknown whether exercise therapy is effective for adolescents with heel pain related to either diagnosis.

This is a pilot and feasibility study. Thirty participants between the ages of 7 years and 17 years with posterior heel pain will be recruited from the local community and club sports team and local physicians, school nurses, and athletic trainers through flyers and social media. Participants will be asked to complete evaluations and treatment sessions every 4 weeks with three virtual visits every 2 weeks in between for 12 weeks. All participants will receive standardised treatment consisting of daily Achilles tendon loading exercises and education on pain-guided activity modification. Feasibility outcomes will include recruitment, enrolment, retention and compliance. Clinical outcomes will include the measures of symptom severity, quality of life, tendon morphology and lower extremity function.

This protocol will provide preliminary data to inform a larger clinical trial based on the feasibility of the proposed intervention and methodology. Additionally, the results will provide preliminary evidence on whether Achilles tendon injury occurs in the adolescent population.

The trial is registered with clinicaltrials.gov (ID:1652996).

The Effectiveness of Extracorporeal Shockwave Therapy for Midportion Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy is one of the most common lower limb injuries in both athletes and the general population. Despite the plethora of conservative treatment options available for the management of Achilles tendinopathy, as many as one in four patients will go on to require surgery. Extracorporeal shockwave therapy (ESWT) has emerged as a promising treatment option and has been successful in the management of other common musculoskeletal injuries such as plantar fasciitis. However, the evidence for ESWT in the management of Achilles tendinopathy remains inconclusive. Therefore, the aim of this systematic review was to evaluate the current evidence for the use of ESWT in the management of midportion Achilles tendinopathy.

A comprehensive literature search was conducted using the databases MEDLINE (Pubmed), AMED, EMBASE, CINAHL, and CENTRAL. The databases were searched from their inception to December 2021. This was conducted to identify randomised control trials (RCTs) evaluating the effectiveness of ESWT versus control treatment in the management of midportion Achilles tendinopathy.

Following a comprehensive search of the literature, a total of 283 articles were identified. Following the screening of titles and abstracts, 236 articles were excluded. The main reasons for exclusion were the identification of duplicates, non-randomised studies, and the use of ESWT on other pathology. Following the exclusion of 236 articles, 47 articles were retrieved for full-text review. Of these 47 articles, 40 were excluded leaving a total of 7 RCTs eligible for inclusion in this review. There was consistent evidence from 4 RCTs that ESWT is effective in the management of midportion Achilles tendinopathy.

This review suggests that ESWT is a safe and effective modality for treating midportion Achilles tendinopathy as it reduces pain and improves function. The best available evidence suggests that a combination of ESWT with eccentric exercises and stretching may be even more effective than ESWT alone. Further research is required to confirm this and to determine the optimum ESWT treatment protocol.

Fibrocartilaginous Tissue: Why Does It Fail to Heal?

Tendons and ligaments are critical components in the function of the musculoskeletal system, as they provide stability and guide motion for the biomechanical transmission of forces into bone. Several common injuries in the foot and ankle require the repair of ruptured or attenuated tendon or ligament to its osseous insertion. Understanding the structure and function of injured ligaments and tendons is complicated by the variability and unpredictable nature of their healing. The healing process at the tendon/ligament to bone interface is challenging and often frustrating to foot and ankle surgeons, as they have a high failure rate necessitating the need for revision.

Failed Surgery for Achilles Tendinopathy

Treatments of Achilles tendinopathy continue to evolve. The body of literature is inadequate to provide a comprehensive guide to evaluation and treat failed surgeries. Issues related to failed surgical treatment may be divided into infection/wound issue, mechanical failure, and persistent pain. Awareness of the potential problems described in this article will allow surgeons to have a foundation in clinical assessment and making accurate diagnoses. Various surgical treatment options are available and should be executed carefully to treat individualized patient conditions.

A “cell-free treatment” for tendon injuries: adipose stem cell-derived exosomes

Tendon injuries are widespread and chronic disorders of the musculoskeletal system, frequently caused by overload of the tendons. Currently, the most common treatment for tendon injuries is "cell-free therapy", of which exosomes, which can treat a host of diseases, including immune disorders, musculoskeletal injuries and cardiovascular diseases, are one kind. Among the many sources of exosomes, adipose-derived stem cell exosomes (ASC-Exos) have better efficacy. This is attributed not only to the ease of isolation of adipose tissue, but also to the high differentiation capacity of ASCs, their greater paracrine function, and immunomodulatory capacity compared to other exosomes. ASC-Exos promote tendon repair by four mechanisms: promoting angiogenesis under hypoxic conditions, reducing the inflammatory response, promoting tendon cell migration and proliferation, and accelerating collagen synthesis, thus accelerating tendon healing. This review focuses on describing studies of preclinical experiments with various exosomes, the characteristics of ASC-Exos and their mechanisms of action in tendon healing, as well as elaborating the limitations of ASC-Exos in clinical applications.

Does Additional Dietary Supplementation Improve Physiotherapeutic Treatment Outcome in Tendinopathy? A Systematic Review and Meta-Analysis

A systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of dietary supplements in addition to physiotherapeutic treatment on pain and functional outcomes. PubMed, The Cochrane Library, Web of Science, and Embase were searched from inception to November 2021 (Prospero registration: CRD42021291951). Studies were eligible if the interventions consisted of physiotherapeutic approaches that were combined with dietary supplementation and if they reported measures of pain and/or function. Six studies were included in the meta-analysis. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated and analysed using a Review Manager software. Subgroup analysis was performed to explore possible associations between the study characteristics and the effectiveness of the intervention. Additional dietary supplementation during physiotherapeutic treatment significantly improved the reduction in pain score (SMD = −0.74, 95% CI, −1.37 to −0.10; p < 0.05), while it had no effect on functional outcomes (SMD = 0.29, 95% CI, 0.00 to 0.58; p > 0.05). This systematic review and meta-analysis suggests that additional nutritional interventions may improve physiotherapeutic treatment outcomes in the management of tendinopathies.

Application of Orthobiologics in Achilles Tendinopathy: A Review

Orthobiologics are biological materials that are intended for the regeneration of bone, cartilage, and soft tissues. In this review, we discuss the application of orthobiologics in Achilles tendinopathy, more specifically. We explain the concepts and definitions of each orthobiologic and the literature regarding its use in tendon disorders. The biological potential of these materials can be harnessed and administered into injured tissues, particularly in areas where standard healing is disrupted, a typical feature of Achilles tendinopathy. These products contain a wide variety of cell populations, cytokines, and growth factors, which have been shown to modulate many other cells at local and distal sites in the body. Collectively, they can shift the state of escalated inflammation and degeneration to reestablish tissue homeostasis. The typical features of Achilles tendinopathy are failed healing responses, persistent inflammation, and predominant catabolic reactions. Therefore, the application of orthobiologic tools represents a viable solution, considering their demonstrated efficacy, safety, and relatively easy manipulation. Perhaps a synergistic approach regarding the combination of these orthobiologics may promote more significant clinical outcomes rather than individual application. Although numerous optimistic results have been registered in the literature, additional studies and clinical trials are still highly desired to further illuminate the clinical utility and efficacy of these therapeutic strategies in the management of tendinopathies.

The Functions and Mechanisms of Low-Level Laser Therapy in Tendon Repair (Review)

Tendon injury is a common disease of the musculoskeletal system, accounting for roughly 30%–40% of sports system disorder injuries. In recent years, its incidence is increasing. Many studies have shown that low-level laser therapy (LLLT) has a significant effect on tendon repair by firstly activating cytochrome C oxidase and thus carrying out the photon absorption process, secondly acting in all the three phases of tendon repair, and finally improving tendon recovery. The repair mechanisms of LLLT are different in the three phases of tendon repair. In the inflammatory phase, LLLT mainly activates a large number of VEGF and promotes angiogenesis under hypoxia. During the proliferation phase, LLLT increases the amount of collagen type III by promoting the proliferation of fibroblasts. Throughout the remodeling phase, LLLT mainly activates M2 macrophages and downregulates inflammatory factors, thus reducing inflammatory responses. However, it should also be noted that in the final phase of tendon repair, the use of LLLT causes excessive upregulation of some growth factors, which will lead to tendon fibrosis. In summary, we need to further investigate the functions and mechanisms of LLLT in the treatment of tendon injury and to clarify the nature of LLLT for the treatment of diverse tendon injury diseases.

Free Achilles tendon strain during selected rehabilitation, locomotor, jumping, and landing tasks

A better understanding of the strains experienced by the Achilles tendon during commonly prescribed exercises and locomotor tasks is needed to improve efficacy of Achilles tendon training and rehabilitation programs. The aim of this study was to estimate in vivo free Achilles tendon strain during selected rehabilitation, locomotor, jumping, and landing tasks. Sixteen trained runners with no symptoms of Achilles tendinopathy participated in this study. Personalised free Achilles tendon moment arm and force-strain curve were obtained from imaging data and used in conjunction with motion capture and surface electromyography to estimate free Achilles tendon strain using electromyogram-informed neuromusculoskeletal modelling. There was a strong correspondence between Achilles tendon force estimates from the present study and experimental data reported in the literature (R² > 0.85). The average tendon strain was highest for maximal hop landing (8.8±1.6%), lowest for walking at 1.4 m/s (3.1±0.8%) and increased with locomotor speed during running (run 3.0 m/s: 6.5±1.6%; run 5.0 m/s: 7.9±1.7%) and during heel rise exercise with added mass (BW: 5.8±1.3%; 1.2 BW: 6.9±1.7%). The peak tendon strain was highest during running (5 m/s: 13.7±2.5%) and lowest during walking (1.4 m/s: 7±1.8%). Overall findings provide a preliminary evidence base for exercise selection to maximise anabolic tendon remodelling during training and rehabilitation of the Achilles tendon.

The clinical diagnosis of Achilles tendinopathy: a scoping review

Background

Achilles tendinopathy describes the clinical presentation of pain localised to the Achilles tendon and associated loss of function with tendon loading activities. However, clinicians display differing approaches to the diagnosis of Achilles tendinopathy due to inconsistency in the clinical terminology, an evolving understanding of the pathophysiology, and the lack of consensus on clinical tests which could be considered the gold standard for diagnosing Achilles tendinopathy. The primary aim of this scoping review is to provide a method for clinically diagnosing Achilles tendinopathy that aligns with the nine core health domains.

Methodology

A scoping review was conducted to synthesise available evidence on the clinical diagnosis and clinical outcome measures of Achilles tendinopathy. Extracted data included author, year of publication, participant characteristics, methods for diagnosing Achilles tendinopathy and outcome measures.

Results

A total of 159 articles were included in this scoping review. The most commonly used subjective measure was self-reported location of pain, while additional measures included pain with tendon loading activity, duration of symptoms and tendon stiffness. The most commonly identified objective clinical test for Achilles tendinopathy was tendon palpation (including pain on palpation, localised tendon thickening or localised swelling). Further objective tests used to assess Achilles tendinopathy included tendon pain during loading activities (single-leg heel raises and hopping) and the Royal London Hospital Test and the Painful Arc Sign. The VISA-A questionnaire as the most commonly used outcome measure to monitor Achilles tendinopathy. However, psychological factors (PES, TKS and PCS) and overall quality of life (SF-12, SF-36 and EQ-5D-5L) were less frequently measured.

Conclusions

There is significant variation in the methodology and outcome measures used to diagnose Achilles tendinopathy. A method for diagnosing Achilles tendinopathy is proposed, that includes both results from the scoping review and recent recommendations for reporting results in tendinopathy.

The Role of Hyaluronic Acid in Sport-Related Tendinopathies: A Narrative Review

Tendinopathy is a complex clinical condition with a rising incidence and prevalence, particularly during sports practice. For the return to play in affected patients, adequate functional and structural recovery of the tendon is the ultimate goal, avoiding the high risk of recurrence. In this perspective, local therapies alongside exercise are showing promising results. Despite evidence suggesting hyaluronic acid (HA) injections as effective in the treatment of tendinopathy, current recommendations about the management of this condition do not include this intervention. HA seems to be an effective therapeutic option for the management of sport-related tendinopathies, but further studies with a larger sample size are needed to confirm available findings. In this narrative review, we analyzed available literature about the rationale of the use of HA in the management of tendon injury and, particularly, in sport-related tendinopathies.

Influence of Footwear on Posture and Comfort in Elite Rugby Players

Influence of footwear on posture in athletes is poorly documented despite its potential impact on biomechanics and injury risk. The aim of this study was to investigate effects of different footwear geometries on comfort and posture on a cohort of 48 elite rugby players. Spine posture was characterized by photogrammetry, while center of pressure was measured by means of a force platform. Three different footwear outsoles architectures (one rugby shoe with flat outsole, one rugby shoe with a 10 mm heel rise and foot arch support, and a running shoe with a 10mm heel rise and foot arch support) were compared to non-shod in randomized order. Then comfort felt at the level of foot and spine was also estimated by subjective questionnaires. Compared to the flat rugby model, both other models induced significantly (p<0.05) greater comfort at the level of foot and spine, a slight shift toward of center of pressure and a spinal posture closer to that observed when non-shod. The footwear geometry influences comfort and posture at the level of the foot as well as spine and should be considered in a dual purpose of injury prevention and performance.

Implicit motor imagery of the foot and hand in people with Achilles tendinopathy: a left right judgement study

OBJECTIVE

To determine if impairment in motor imagery processes is present in Achilles tendinopathy (AT), as demonstrated by a reduced ability to quickly and accurately identify the laterality (left-right judgement) of a pictured limb. Additionally, this study aimed to use a novel data pooling approach to combine data collected at 3 different sites via meta-analytical techniques that allow exploration of heterogeneity.

DESIGN

Multi site case-control study.

METHODS

Three independent studies with similar protocols were conducted by separate research groups. Each study-site evaluated left/right judgement performance for images of feet and hands using Recognise© software and compared performance between people with AT and healthy controls. Results from each study-site were independently collated, then combined in a meta-analysis.

RESULTS

126 participants (40 unilateral, 22 bilateral AT cases, 61 controls) were included. There were no differences between AT cases and controls for hand image accuracy and reaction time. Contrary to the hypothesis, there were no differences in performance between those with AT and controls for foot image reaction time, however there were conflicting findings for foot accuracy, based on four separate analyses. There were no differences between the affected and unaffected sides in people with unilateral AT.

CONCLUSIONS

Impairments in motor imagery performance for hands were not found in this study and we found inconsistent results for foot accuracy. This contrasts to studies in persistent pain of limbs, face and knee osteoarthritis, and suggests that differences in pathoaetiology or patient demographics may uniquely influence proprioceptive representation.

Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy

OBJECTIVE

To identify latent subgroups among patients with Achilles tendinopathy, describe patient characteristics and clinical attributes that defined each subgroup, and develop a clinical classification model for subgroup membership.

DESIGN

Cross-sectional study.

METHODS

One hundred forty-five participants (men, n = 73; mean ± SD age, 51 ± 14 years) with clinically diagnosed Achilles tendinopathy completed a baseline evaluation, including demographics and medical history, patient-reported outcome measures, a clinical exam, tendon structure measures via ultrasound imaging and continuous shear-wave elastography, and a functional test battery. Subgroups were identified using mixture modeling. We compared the subgroups using a 1-way analysis-of-variance or chi-square test and the Tukey post hoc test to identify defining attributes. We developed a clinical classification model using logistic regression and receiver operating characteristic curves.

RESULTS

Three latent subgroups were identified and named by their distinctive patient characteristics and clinical attributes. The activity-dominant subgroup (n = 67), on average, had the highest physical activity level, function, and quality of life; reported mild symptoms; and was the youngest. The psychosocial-dominant subgroup (n = 56), on average, had the worst symptoms, impaired function, heightened psychological factors, the poorest quality of life, minimal tendon structural alterations, and was obese and predominantly female. The structure-dominant subgroup (n = 22), on average, had the most tendon structural alterations, severe functional deficits, moderate symptoms and psychological factors, reduced quality of life, and was the oldest, obese, and predominantly male. The clinical classification model correctly classified 85% (123/145) of participants.

CONCLUSION

Three Achilles tendinopathy subgroups (activity dominant, psychosocial dominant, and structure dominant) differed in patient characteristics and clinical attributes. J Orthop Sports Phys Ther 2021;51(9):440-448. Epub 1 Jun 2021. doi:10.2519/jospt.2021.10271.

Non-pharmacological interventions and corticosteroid injections for the management of the Achilles tendon in inflammatory arthritis: a systematic review

BACKGROUND

Achilles tendon (AT) pathologies, particularly Achilles enthesitis, are common in inflammatory arthritis (IA). Although there are various non-pharmacological interventions and injection therapies available, it is unknown if these interventions are effective for people with IA, as this population is often excluded from studies investigating the management of AT pathologies. This study aimed to identify and critically appraise the evidence for non-pharmacological interventions and corticosteroid injections in the management of AT pathology in those with IA.

METHODS

All studies which met the inclusion criteria (AT interventions in adults with a working clinical diagnosis of IA, English language) were identified from the following databases: Medline, Embase, CINAHL and the Cochrane Library. The search strategies used the search terms 'spondyloarthropathies', 'inflammatory arthritis', 'achilles tendon', 'physical therapy', 'conservative management', 'injections', and related synonyms. Studies included were quantitative longitudinal design, such as randomised controlled trials, pseudo randomised and non-randomised experimental studies, observational studies, cohort studies, and case control studies. All outcome measures were investigated, quality assessment to determine internal and external validity of included studies was undertaken, and qualitative data synthesis was conducted.

RESULTS

Of the 10,911 articles identified in the search strategy, only two studies that investigated the efficacy of corticosteroid injections for the management of the AT in IA met the inclusion criteria, and no studies were identified for non-pharmacological interventions. Both injection studies had low quality rating for internal and external validity, and thus overall validity. The included studies only investigated two outcome domains: pain and ultrasound (US) (B Mode and Doppler) identified abnormalities and vascularity in the AT. There is weak evidence suggesting a short-term improvement (6-12 weeks) in pain and for the reduction in some abnormal US (B-Mode and Doppler) detectable features (entheseal thickness, bursitis, and entheseal vascularity) at the AT and surrounding structures post-corticosteroid injection.

CONCLUSION

Weak evidence is available regarding the efficacy of corticosteroid injections in reducing pain and inconclusive evidence for the improvement of abnormal US detectable features. No studies were identified for non-pharmacological interventions. It is evident from the lack of relevant literature that there is an urgent need for more studies assessing non-pharmacological interventions for the AT in people with IA.

Short- and Intermediate-Term Results of Extracorporeal Shockwave Therapy for Noninsertional Achilles Tendinopathy

BACKGROUND

Earlier randomized controlled trials (RCTs) reported only midterm (3-4 months) results of extracorporeal shockwave therapy (ESWT) as a treatment for noninsertional Achilles tendinopathy (NAT). This study compared the effectiveness of an eccentric loading program followed by stretching exercises combined with ESWT (study group) or sham ESWT (control group) for treating chronic NAT in both the short and long term.

METHODS

This double-blind RCT was conducted between 2018 and 2020. Adult patients with unilateral NAT who failed standard conservative treatment were randomly allocated to either group. Function and pain were assessed at baseline, 1 month, and 16 months using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) and visual analog scale (VAS), respectively. Mixed-design analysis of variance and nonparametric statistics were performed. Twenty-two men and 28 women aged 18 to 40 years were allocated into 2 equally matched groups.

RESULTS

Function and pain scores in the study group were not significantly different from control group scores at baseline (VISA-A: 22.2 ± 6.5 vs 21.0 ± 5.2 and VAS: 8 ± 1 vs 8 ± 1, respectively). Both groups significantly improved posttreatment (VISA-A: 85 ± 6.2 vs 53.4 ± 7.7 and VAS: 1 ± 2 vs 7 ± 2, respectively). At the 16-month follow-up, outcome scores declined slightly but significantly in the study group (VISA-A: 80 ± 5.3; VAS: 3 ± 2) and improved in the control group (VISA-A: 67 ± 5.6; VAS: 5 ± 1). However, both groups were significantly better than baseline. At both time points, the study group had significantly superior scores (statistically and clinically) than the control group (P = .0001).

CONCLUSION

Combining calf eccentric loading with stretching exercises resulted in significant improvements in the pain and functional scores in patients with NAT. Adding ESWT to this combined protocol resulted in significantly greater improvements in both the short and long term.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Maximum dorsiflexion increases Achilles tendon force during exercise for midportion Achilles tendinopathy

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.

Achilles tendinopathy: Exploring injury characteristics and current treatment modalities

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

Endoscopic Flexor Hallucis Longus Transfer for Achilles Noninsertional Tendinopathy: Description of Surgical Technique and Functional Outcomes

Background. The transfer of the flexor hallucis longus (FHL) tendon is an established treatment for replacing a dysfunctional Achilles tendon. Objectives. (1) Describe a new technique for endoscopic FHL transfer for noninsertional Achilles tendinopathy and (2) describe the functional outcomes and complications after endoscopic and open FHL transfer. Materials and Method. Retrospective study of patients who underwent open or endoscopic FHL transfer between 2014 and 2016. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot scale was used preoperatively and postoperatively to measure the functional results. Results. We included 18 endoscopic FHL transfers and 24 open FHL transfers. The mean age of endoscopic and open procedures was 47.5 years (range 25-77 years) and 61.2 years (range 43-72 years), respectively. An improvement on the average AOFAS of 52.8% (31.9 points) was observed in the endoscopy group during the follow-up from the baseline. The mean improvement in AOFAS score for the open group was 41.4% (24.5 points). Four and 7 cases reported complications in the endoscopy and open FHL transfer groups, respectively. Conclusion. While both procedures were effective in treating noninsertional Achilles tendinopathy, the described arthroscopic treatment led to a greater improvement in the AOFAS score and is slightly less prone to lasting complications.Level of Evidence: Level IV: Case series.

The effect of lumbar spine manipulation on pain and disability in Achilles tendinopathy. A case report

BACKGROUND/PURPOSE

Cervical and thoracic spine manipulation has been found to reduce tendon pain and disability in lateral epicondylalgia and rotator cuff tendinopathy. Based on these findings, the application of lumbar spine manipulation may also provide similar improvements in Achilles tendinopathy (AT). Therefore, the purpose of this study was to evaluate the effect of lumbar spine manipulation on pain and disability in a patient experiencing AT.

CASE DESCRIPTION

A 44 years old male ex-football player presented with a 20-year history of persistent Achilles tendon pain (ATP) consistent with AT diagnosis. The patient attended 12 treatment sessions receiving a high-velocity, low amplitude lumbar spine manipulation. Outcome measures were collected at baseline, 2 weeks, 4 weeks, 3 months and 6 months and included pain in visual analogue scale, the American Orthopedic Foot and Ankle Score, the 36-Item Short Form Health Survey and the Victorian Institute of Sport Assessment-Achilles questionnaire. Pressure pain threshold was also assessed using an electronic pressure algometer.

OUTCOMES

Improvement in all outcome measures was noted 6-months post intervention. Outcome measures indicated substantial improvements in both the patient's pain and disability. The patient was able to perform activities of daily living without difficulties, suggesting higher level of function and quality of life at 6-months post initial evaluation.

CONCLUSION

These findings have demonstrated the positive effects of lumbar spine manipulation on ATP and disability. Further studies, specifically clinical trials investigating the effect of lumbar spine manipulation or combining this technique with exercises and functional activities are suggested.

Efficacy of different load intensity and time-under-tension calf loading protocols for Achilles tendinopathy (the LOADIT trial): protocol for a randomised pilot study

Background

Modifying variables in exercise prescription can produce specific effects on Achilles tendinopathy outcomes. This study aims to determine the feasibility of conducting an adequately powered randomised trial in the future to assess the efficacy of different load intensity and time-under-tension exercise parameters for improving pain and function in individuals with persistent midportion Achilles tendinopathy.

Methods

The trial is designed as prospective, four-armed feasibility and randomised pilot trial with 3 months follow-up. Interventions will be provided in a gym setting. The investigator, who will be blind to the allocation of participants, will conduct all pre- and post-intervention assessments. Forty-eight male participants with Achilles tendinopathy will be recruited from the community. We will use a 2 × 2 factorial design with factors of load intensity (six or eighteen repetitions maximum) and time-under-tension (two or six second repetitions). Participants will be randomised into one of the testing groups: six RM with two second repetitions, six RM with six second repetitions, eighteen RM with two second repetitions or eighteen RM with six second repetitions. Trial feasibility will be indicated by the rate of conversion, recruitment and retention, adherence to the interventions by participants, the utility of videoconferencing mode for weekly exercise supervision, incidence of adverse events, and feasibility of future economic evaluation. The secondary clinical outcomes will assess pain and disability, participant impression of change, satisfaction, health-related quality of life, physical activity, work absenteeism, psychological measures at baseline, 6 and 12 weeks, and plantarflexor contractile dysfunction (torque, rate of force development and muscle force steadiness) at baseline and 12 weeks. These clinical outcomes are primarily measured to provide information regarding potential treatment effects and trends.

Discussion

The proposed study and follow-up powered randomised trial will be a first step towards determining exercise dose parameters that may optimise outcomes for Achilles tendinopathy. We have chosen to focus on load intensity and time-under-tension, as these parameters are important for tendon adaptation. This work has the potential to lead to more effective exercise loading interventions for Achilles tendinopathy.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12618001315202. Registered retrospectively on August 6th, 2018.

Association Between Clinical and Imaging Outcomes After Therapeutic Loading Exercise in Patients Diagnosed With Achilles or Patellar Tendinopathy at Short- and Long-Term Follow-up: A Systematic Review

OBJECTIVE

To determine the association between clinical and imaging outcomes after therapeutic loading exercise in Achilles tendinopathy (AT) and patellar tendinopathy (PT) populations at both short- and long-term follow-up.

DATA SOURCES

The PUBMED and EMBASE databases were searched (up to June 2017) to identify articles that meet the inclusion criteria: (1) patients diagnosed with AT (insertional or midportion) or PT; (2) rehabilitation based on therapeutic loading exercise; and (3) assessment of clinical outcomes and tendon structure using an imaging modality.

MAIN RESULTS

Two independent reviewers screened 2894 search results, identifying 21 suitable studies. According to the studies included in this review, clinical results showed significant improvements for patients with AT and PT after eccentric exercise (ECC) and heavy slow resistance (HSR) at short- and long-term follow-up. Imaging outcomes were not consistent. Moderate-to-strong evidence for patients with AT suggested an association between clinical outcomes and imaging outcomes (tendon thickness and tendon neovascularization) after ECC at long-term follow-up. For patients with PT, there was moderate evidence supporting an association between clinical outcomes (questionnaire score and pain) and imaging (tendon thickness and tendon neovascularization) after ECC at short-term follow-up. For both the AT and PT groups, there was moderate evidence for an association between clinical outcomes and tendon thickness and neovascularization after HSR exercise. Results related to the HSR exercise should be interpreted with caution because of the small number of studies.

CONCLUSIONS

Based on the findings of the present review, the use of imaging outcomes as a complementary examination to the clinical assessment was confirmed. Overall, an improvement in clinical outcomes seems to be associated with a reduction in tendon thickness and tendon neovascularization. Clinicians should be aware that during the interpretation of the imaging outcomes, factors such as tendinopathy location, exercise modality performed, and a follow-up period should be considered.

Tendon Morphology and Mechanical Properties Are Associated With the Recovery of Symptoms and Function in Patients With Achilles Tendinopathy

Background:

Achilles tendinopathy is a debilitating overuse injury characterized by pain, altered Achilles tendon structure, and impaired functional performance. Evaluating tendon structure as part of the physical examination may help establish a well-defined prognosis. However, the usefulness of measuring tendon structure for developing a prognosis has been questioned since structural abnormalities can exist without symptoms.

Purpose:

To determine whether initial measures of tendon morphology and mechanical properties were associated with patient-reported symptoms and calf muscle endurance at baseline, 6-month follow-up, and 1-year follow-up by prospectively following a cohort of individuals with Achilles tendinopathy.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A total of 59 participants with midportion or insertional Achilles tendinopathy completed an initial assessment and follow-up assessments at 6 months and 1 year. At the initial assessment, patient-reported symptoms, calf muscle endurance, and Achilles tendon thickening were evaluated, and Achilles tendon mechanical properties were estimated. At the 6-month and 1-year follow-up assessments, patient-reported symptoms and calf muscle endurance were reevaluated.

Results:

Greater Achilles tendon thickening at the initial assessment was consistently associated with worse patient-reported symptoms and calf muscle endurance at each assessment. Changes in symptoms over the year were moderated by the initial shear modulus of the tendon, with a lower shear modulus associated with less improvement in symptoms. Lower viscosity at the initial assessment was also associated with worse calf muscle endurance at each assessment.

Conclusion:

Measures of tendon morphology and mechanical properties appear to be associated with patient-reported symptoms and calf muscle function for patients with Achilles tendinopathy.

Achilles tendinopathy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Differences Between Long Distance Road Runners and Trail Runners in Achilles Tendon Structure and Jumping and Balance Performance

BACKGROUND

Load and joint kinematics change with differences in running surface. Running regularly on trails compared to roads might influence the load on the Achilles tendon and its adaptations, along with other factors such as balance, strength, and proprioception.

OBJECTIVE

To investigate Achilles tendon structure and functional tests in road and trail runners.

DESIGN

Cross-sectional study.

SETTING

Laboratory, sport sciences college.

PARTICIPANTS

The study included 26 road and 17 trail runners who run at least three times per week with a minimum of 20 km per week and who participated in running competitions over the preceding 2 years.

METHODS

Each participant was examined for Achilles tendon structure (via ultrasound tissue characterization [UTC] imaging) and underwent functional tests in addition to completing a demographic questionnaire.

MAIN OUTCOME MEASUREMENTS

The percentages of echo types I, II, III, and IV (degree of structural homogeneity) within the tendon, tendon length and width, tendon cross-sectional area (via UTC imaging); Ankle inversion movement discrimination ability (via Active Movement Extent Discrimination Apparatus device); dynamic postural balance (via Y balance test); jumping performance (by Triple hop distance test); and Hip muscle abduction muscle strength (by hand-held dynamometry).

RESULTS

Percentage of echo type I was significantly lower while echo type II was higher in the road group compared with the trail group (67.3% type I and 28.9% type II in the road group compared with 74.1% type I and 22.1% type II in the trail group, P < .001). No differences between genders were found and no significant differences between groups were found for the other tests.

CONCLUSION

Tendon integrity as examined with UTC is different between road and trail runners. This suggests an influence of running surface on Achilles tendon structure. This difference was not reflected in other tests, thus the influence of tendon structure on function needs further examination.

Vibration increases multifidus cross-sectional area versus cryotherapy added to chronic non-insertional Achilles tendinopathy eccentric exercise

OBJECTIVE

To assess multifidus muscle thickness, cross-sectional area (CSA) and disability in patients with chronic non-insertional Achilles tendinopathy (AT) who developed an eccentric exercise (EE) vibration program compared to an EE program with cryotherapy.

DESIGN

Single-blinded randomized clinical trial.

SETTING

Outpatient clinic.

PARTICIPANTS

A total sample of 61 patients diagnosed with chronic non-insertional AT was recruited and randomly divided into two groups. A group (n = 30) developed the EE program plus vibration and B group (n = 31) received the EE program plus cryotherapy for 12 weeks. Multifidus thickness and CSA were measured at rest and during maximal isometric contraction by ultrasound imaging. The Victorian Institute for Sport Assessment (VISA-A) was used to asses functionality.

RESULTS

Multifidus CSA was statistically significant increased (P < 0.05) for the EE vibration program group with respect to EE plus cryotherapy during maximal isometric contraction and at rest at 12-weeks after intervention in individuals with chronic non-insertional AT. Despite both interventions showed differences for the multifidus thickness and AT disability variables over time, there were not between-groups differences.

CONCLUSIONS

Authors encourage the use of vibration with respect to cryotherapy added to EE programs in order to enhance multifidus CSA in addition to lower limb functionality in individuals who suffer from chronic non-insertional AT.

Novel Interventions for Recalcitrant Achilles Tendinopathy: Benefits Seen Following High-Volume Image-Guided Injection or Extracorporeal Shockwave Therapy-A Prospective Cohort Study

OBJECTIVE

To compare the outcomes for patients with chronic noninsertional Achilles tendinopathy following extracorporeal shockwave therapy (ESWT) and high-volume image-guided injection (HVIGI).

DESIGN

Prospective cohort study.

SETTING

Hospital-based Sports Medicine Outpatient Clinic.

PATIENTS

Sixty-three consecutive patients with chronic noninsertional Achilles tendinopathy, treated with ESWT (n = 22) or HVIGI (n = 41), with minimum 3-month follow-up. Mean age was 51.2 years, and mean duration of symptoms was 27.8 months.

INTERVENTIONS

Patients received either 3 sessions of ESWT (1 session per week) or a single ultrasound-guided HVIGI (10 mL of 1% lidocaine and 40 mLs of sterile saline). All patients received standardized aftercare, including continuation of a structured home exercise program of flexibility and eccentric strengthening exercises.

MAIN OUTCOME MEASURES

Zero to 10 visual analog scale (VAS) for self-reported "average pain" and "average stiffness" values. In addition, Victoria Institute of Sport-Achilles questionnaire, (VISA-A), and Manchester-Oxford Foot Questionnaire (MOXFQ).

RESULTS

This study demonstrated statistically significant improvements in self-reported measures of pain and stiffness following either procedure. At 3 months, VAS (pain) was improved from 6.74 ± 1.31 to 3.57 ± 2.37 (P < 0.001) following HVIGI and from 6.57 ± 1.61 to 4.35 ± 2.55 (P = 0.002) following ESWT. At 3 months, VISA-A improved from 35% ± 17% to 51% ± 22% (P < 0.001) following HVIGI and from 34% ± 15% to 49% ± 15% (P < 0.001) following ESWT. Statistically significant improvements were only recorded at 6 weeks for ESWT and at 3 months for HVIGI using MOXFQ. No statistically significant differences were seen between the groups at any period studied.

CONCLUSIONS

Patients improved to statistically significant extent following either a HVIGI or ESWT procedure, with no significant differences seen between the groups. The small sample sizes in this pragmatic study are noted, which limit interpretation, and larger more robust studies are required to investigate this further.

CLINICAL RELEVANCE

This pragmatic prospective cohort study demonstrates improvements following either ESWT or HVIGI procedures, with no significant differences seen between the groups.

Ultrasound Imaging of the Abdominal Wall and Trunk Muscles in Patients with Achilles Tendinopathy versus Healthy Participants

Purpose: To compare and quantify with ultrasound imaging (USI) the inter-recti distance (IRD), rectus abdominis (RA), external oblique (EO), internal oblique (IO), transversus abdominis (TrAb), and multifidus thickness and the RA and multifidus cross-sectional area (CSA) between individuals with and without chronic mid-portion Achilles tendinopathy (AT). Methods: A cross-sectional study. A sample of 143 patients were recruited and divided into two groups: A group comprised of chronic mid-portion AT (n = 71) and B group composed of healthy subjects (n = 72). The IRD, RA, EO, IO, TrAb, and multifidus thickness, as well as RA and multifidus CSA, were measured by USI. Results: USI measurements for the EO (p = 0.001), IO (p = 0.001), TrAb (p = 0.041) and RA (p = 0.001) thickness were decreased as well as IRD (p = 0.001) and multifidus thickness (p = 0.001) and CSA (p = 0.001) were increased for the tendinopathy group with respect the healthy group. Linear regression prediction models (R² = 0.260 − 0.494; p < 0.05) for the IRD, RA, EO, and IO thickness (R² = 0.494), as well as multifidus CSA and thickness were determined by weight, height, BMI and AT presence. Conclusions: EO, IO, TrAb, and RA thickness was reduced and IRD, multifidus thickness and CSA were increased in patients with AT.

Conservative treatment of Achilles tendon partial tear in a futsal player: A case report

Background and purpose: Achilles tendon is the most commonly injured part in the lower limb, especially in athletes. Treatment options for Achilles tendinopathy and total rupture are well described; however, there is a lack of information regarding treatment protocols for partial tears. Thus, the purpose of this case report was to describe the examination, intervention and outcomes of patient who suffered an acute Achilles tendon partial tear. Case description: A case is described here, in which the diagnosis of Achilles tendon partial tear was based on both magnetic resonance imaging and physical evaluation. Both the patient and the physical therapy team opted for non-surgical treatment. A 12-week course of conservative treatment including exercise, tendon loading, electrical stimulation, and photobiomodulation is described. Outcomes: Ankle dorsiflexion range of motion and hop tests. Discussion: This case report demonstrated that non-surgical treatment for Achilles tendon partial tear was effective for this patient and enabled the athlete to return to pre-injury levels of activity 6 months following the injury.

Objective assessment of stiffness in the gastrocnemius muscle in patients with symptomatic Achilles tendons

OBJECTIVES

To establish quantitative values of stiffness for the gastrocnemius muscle in patients diagnosed with Achilles tendinopathy.

DESIGN

Case-control study with a single (cross sectional) time point of patients diagnosed with unilateral Achilles tendinopathy and an asymptomatic group.

METHODS

Sample of 50 participants: 25 participants with symptomatic unilateral Achilles tendinopathy (symptomatic group) with the asymptomatic side of this group used as a control (control group 1). A third group of 25 participants with asymptomatic Achilles tendons (control group 2). Mechanical stiffness parameters, including natural oscillation frequency (F), dynamic stiffness (S), mechanical stress relaxation time (R), logarithmic decrement (D) and creep (C), were assessed using the MyotonPRO. Measurements at the medial and lateral gastrocnemii were taken as non-weight bearing (NWB) and weight bearing (WB).

RESULTS

Significant (p<0.05) differences were observed between the mean symptomatic group and control groups 1 and 2 in the WB and NWB conditions for natural oscillation frequency (F), dynamic stiffness (S), and creep (C). There was a significant reduction in S WB and conversely a significant increase in S of the symptomatic group NWB. Creep (C) and mechanical stress relaxation time (R) were significantly (p<0.05) less in the symptomatic group NWB. Significant differences were observed between the NWB and WB data sets for logarithmic decrement (D). NWB D demonstrated significantly (p<0.05) higher scores than the WB condition.

CONCLUSION

This study demonstrated that there was a significant reduction in stiffness of the gastrocnemius muscle in participants with Achilles tendinopathy compared with the two control groups. The WB MyotonPRO measures for the symptomatic groups of F and S were significantly lower, indicating a decrease in the tonal properties (F) and dynamic stiffness (S) of the muscle. The application of MyotonPRO technology to measure changes in stiffness in the gastrocnemius muscle may be useful to measure as part of a rehabilitation programme where specific attention could be placed to increase the tonal properties of the muscle. Further studies are required to develop a robust clinical application of this technology, particularly with regard to Achilles tendinopathy.

Intrinsic foot muscles morphological modifications in patients with Achilles tendinopathy: A novel case-control research study

OBJECTIVE

To compare the thickness and cross-sectional area (CSA) of the Abductor Hallucis Brevis (AHB), Flexor Digitorum Brevis (FDB) and Flexor Hallucis Brevis (FHB) in subjects with and without chronic mid-portion Achilles tendinopathy (AT).

DESIGN

A case-control research study.

SETTING

A private clinic.

PARTICIPANTS

A total sample of 143 subjects was recruited for the study and divided in two groups, such as chronic mid-portion AT group (n = 71) and healthy group (n = 72).

MAIN OUTCOME MEASURES

Ultrasound B-Mode imaging was used to measure the thickness and CSA of the AHB, FDB and FHB in subjects with and without chronic mid-portion AT at rest.

RESULTS

USI measurements of the AHB (p < .001) and FDB (p < .001) thicknesses, as well as FDB (p = .005) and FHB CSA (p = .048), were increased for the tendinopathy group with respect to healthy group. However, FHB muscle thickness (p < .001) increases were showed for the control group with respect the tendinopathy group.

CONCLUSIONS

USI measurements of ABH and FDB thicknesses, as well as FDB and FHB CSA, were increased in patients who suffered from AT with respect to healthy group.

Relationship between the architecture and function of ankle plantar flexors with Achilles tendon morphology in ballet dancers

Achilles tendinopathy is the most frequent foot overuse injury in ballet dancers and knowledge of clinically modifiable factors related to tendon structure in a population at risk, such as ballet dancers, would be important for the development of preventive programs. Therefore, the present study aimed to assess relationships of gastrocnemius muscle architecture and ankle plantar flexors function with Achilles tendon morphology in ballet dancers. Fifty-four measures from 27 ballet dancers were collected. Tendon morphology (thickness, echogenicity, hypoechoic areas and neovascularisation) and muscle architecture (thickness, pennation angle and fascicle length) were evaluated using ultrasonography; ankle plantar flexors torque was evaluated using hand-held dynamometry, flexibility was evaluated in maximal weight-bearing ankle dorsiflexion position using inclinometer, and endurance was evaluated using the heel rise test. Ankle plantar flexors torque and medial gastrocnemius muscle architecture (thickness, pennation angle and fascicle length) are associated with Achilles tendon thickness in ballet dancers (r² = 0.24, p = 0.008). Ankle plantar flexors torque and medial gastrocnemius muscle fascicle length are also associated with the echogenicity of the Achilles tendon (r² = 0.13, p = 0.03). These findings call attention to the potential importance of ankle plantar flexors muscle force in healthy ballet dancers for the prevention of alterations in Achilles tendon structure.

Extracorporeal Shock Wave Therapy Plus Rehabilitation for Insertionaland Noninsertional Achilles Tendinopathy Shows Good Results Across a Range of Domains of Function

Achilles tendinopathy, both insertional and noninsertional, is a common cause of posterior ankle pain. Although the condition of most patients improves with simple conservative measures, a proportion will go on develop chronic symptoms. This study examines the outcomes of patients following extracorporeal shock wave therapy plus a home exercise program. This prospective case series study involves a total of 39 patients, with a mean follow-up duration of 163 (range 65 to 385) days. This has demonstrated significant benefits in pain, stiffness, and a range of measures of local and global function. Median (interquartile range [IQR]) values for average self-reported pain improved from 6.5 of 10 (IQR 5.0 to 7.8) at baseline to 3.5 of 10 (IQR 2.0 to 5.1) at 3 months and to 2.0 of 10 (IQR 0.6 to 4.8) at 6 months for patients with insertional Achilles tendinopathy. This compares to improvements from 7.0 of 10 (IQR 7.0 to 8.0) at baseline to 6.0 of 10 (IQR 5.6 to 6.8) at 3 months and to 6.0 of 10 (IQR 3.0 to 7.0) at 6 months for patients with noninsertional Achilles tendinopathy. Statistically significant improvements were seen in insertional tendinopathy across a range of outcome measures; however, these were less apparent for patients with noninsertional tendinopathy. Despite these figures, no significant differences were seen in the outcomes for patients with insertional and noninsertional tendinopathy. Despite the improvements seen in the aspects of pain and function, physical activity levels had not increased following the treatment.