A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper's knee in athletes: pilot study

Ultrasound-guided electrocoagulation of neovascularisation for persistent patellar tendinopathy in athletes: a cohort study of 25 patients with a mean follow-up of 5 years from the SANTI Study Group

Background

Patellar tendinopathy (PT) is a common condition characterised by persistent patellar tendon pain and dysfunction, particularly in athletes. Neovascularisation is frequently observed in the PT and is associated with increased pain. Ultrasound-guided electrocoagulation of neovascularisation has emerged as a minimally invasive alternative treatment for recalcitrant PT.

Hypothesis/purpose

The purpose of this study was to evaluate the clinical outcomes of ultrasound-guided electrocoagulation of neovascularisation in athletes with persistent PT.

Study design

Case series; level of evidence, IV.

Methods

A retrospective analysis of prospectively collected data was performed on 25 athletes who underwent ultrasound-guided electrocoagulation of neovascularisation for recalcitrant PT. Clinical outcomes including complications, reinterventions and patient-reported outcome measures were recorded. Comparisons between variables were assessed using χ2 test or Fisher's exact test for categorical variables and Student's t-test or Wilcoxon test for quantitative variables.

Results

25 patients were included in the final analysis. 96% returned to their preoperative activity level at a mean of 3.8 months. At a mean follow-up of 5 years 4% did not receive significant benefit from electrocoagulation therapy. Significant improvements were observed in outcome measures, including the Victorian Institute of Sport Assessment Questionnaire for Patients with Patellar Tendinopathy, Kujala score, modified Blazina score and Visual Analogue Scale for pain.

Conclusion

Ultrasound-guided electrocoagulation of neovascularisation for persistent PT in elite athletes resulted in a low complication rate, a high rate and rapid return to sport and a significant improvement in outcome measures.

Resistance Training Practices of Brazilian Olympic Sprint and Jump Coaches: Toward a Deeper Understanding of Their Choices and Insights (Part III)

In the final part of this three-article collection on the training strategies of Brazilian Olympic sprint and jump coaches, we provide a detailed description of the resistance training methods and exercises most commonly employed by these speed experts. Always with the objective of maximizing the sprint and jump capabilities of their athletes, these experienced coaches primarily utilize variable, eccentric, concentric, machine-based, isometric, complex, and isoinertial resistance training methods in their daily practices. Squats (in their different forms), Olympic weightlifting, ballistics, hip thrusts, lunges, calf raises, core exercises, leg curls, stiff-leg deadlifts, and leg extension are the most commonly prescribed exercises in their training programs, during both the preparatory and competitive periods. Therefore, the current manuscript comprehensively describes and examines these methods, with the additional aim of extrapolating their application to other sports, especially those where sprint speed is a key performance factor.

Patellar tendinopathy: an overview of prevalence, risk factors, screening, diagnosis, treatment and prevention

Patellar tendinopathy (PT), or jumper's knee, is an overuse injury that occurs in professional, as well as recreational, athletes. This condition is a noncontact injury, typically characterized by gradually increasing pain in the patellar tendon. It is prevalent in participants of several sports, but it occurs mostly in jumping sports. The diagnosis of PT is primarily clinical; however, imaging techniques can be useful as well. Risk factors differ between sexes, playing conditions, the kind of sport, playing level and personal characteristics. Screening is an essential tool to assess PT. This condition affects athletic performance and often persists for years. The use of preventative methods is imperative because of the persistence of this condition, especially in elite athletes who sometimes end their career after long and failed treatments. There are a wide variety of treatment and rehabilitation options available, the majority of which are non-operative, such as eccentric exercises, cryotherapy, platelet-rich plasma (PRP) injections, and anti-inflammatory strategies. If conservative treatment fails, surgery is the next most preferable step. Even though there are many surgical treatment methods, there is no clear evidence on what is the most effective approach to address PT. Taking this into consideration, as well as the extent of this clinical entity, novel therapeutic techniques, as well as screening and prevention methods, are expected to emerge in the near future.

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

Background

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

Review questions

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

Methods

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

Results

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

Limitations

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

Conclusion

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

Future work

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

Study registration

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

Funding

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

Changes After a Conventional vs. an Alternative Therapy Program on Physical, Psychological, and Injury-Related Parameters in Male Youth Soccer Players With Patellar Tendinopathy During Return to Competition

ABSTRACT

Niering, M and Muehlbauer, T. Changes after a conventional vs. an alternative therapy program on physical, psychological and injury-related parameters in male youth soccer players with patellar tendinopathy during return to competition. J Strength Cond Res 37(9): 1834-1843, 2023-Changes after a conventional (CON) vs. alternative (ALT) therapy program on physical, psychological, and injury-related or pain-related parameters in soccer players with patellar tendinopathy (PT) during return to competition were examined. Thirty-four male youth soccer players (15-16 years) with PT were randomly assigned to a CON ( n = 18) or ALT ( n = 16) program. The ALT program consisted of 60 minutes of balance training, eccentric and isometric exercises, static stretching, and a dual-task progression. The CON program consisted of 30 minutes of eccentric and isometric exercises and static stretching. Both programs were conducted until painlessness was reported during full training load. Assessments of muscle power (drop jump, jump and reach), change of direction speed (CODS) (acyclic sprint), speed (tapping, 30-m linear sprint), endurance (Yo-Yo intermittent recovery test level-1), the Achievement Motives Scale Sport, and injury-related or pain-related correlates were performed immediately, 6 weeks, 16 weeks, and 20 weeks after the respective therapy program. Players in the ALT group required a shorter program duration (ALT: 47.1 ± 15.6 days, CON: 58.2 ± 24.6 days) and achieved the same (muscle power, speed, endurance) or greater (CODS) improvements in physical performances, the same enhancements in psychological measures (achievement motives), and better values for injury-related or pain-related correlates (injury incidence, pain-related training interruptions). Results indicate that both programs effectively improve relevant outcome parameters in players with PT. The ALT therapy is more time efficient than the CON therapy. Therapists should consider this multimodal training program for effective treatment of athletes to shorten their return to competition time and minimize the risk of secondary 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.

Comparison of the movement behaviour of experienced and novice performers during the Cat exercise

Two previous studies showed kinematic differences between novice and experienced performers during unchoreographed movements executed in standing position. However, no study explores if these kinematic differences holds during unchoreographed movements executed in quadrupedal position. The aim of this study is to compare the movement behaviour of experienced and novice performers during an exercise wherein they are challenged to use dynamic and largely unchoreographed movement patterns executed in quadrupedal position. The exercise studied was the Cat exercise, in which participants were asked to behave like a feline for 10 minutes. An inventory of the chosen movements and the assessment of their average and coefficient of variation of the ground contact temporal parameters, computed by analysing the tri-dimensional whole-body kinematics of 25 performers (n = 13 novices and n = 12 experienced), was compared according to their experience level. No significant difference was found between the groups for the number of chosen movements, and median or coefficient of variation of ground contact temporal parameters, except for a greater foot/ knee swing coefficient of variation in experienced performers. This suggests that biomechanical constraints induced by quadrupedal position "prevent" a different selection of motor strategies by experienced performers, although the latter can be more variable in their movements.

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

OBJECTIVES

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation

The objectives of this scoping review were as follows: (1) to describe what exercises and intervention variables are used in resistance training interventions for lower limb tendinopathy,  (2) to assess the completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework, and (3) to assess the implementation of scientific resistance training principles. We searched MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, and Cochrane Library databases. Randomized controlled trials, cohort studies, case series, case reports, and observational studies that reported using resistance exercises for lower limb tendinopathies were considered for inclusion, with 194 studies meeting the inclusion criteria. Completeness of the reporting of exercise descriptors and programme variables was assessed by the CERT and the Toigo and Boutellier framework. Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0 to 13, with an average score of 9/13, with only 9 studies achieving a full 13/13. Reporting of items from the CERT ranged from 0 to 18, with an average score of 13/19. No study achieved a full 19/19; however, 8 achieved 18/19. Scoring for resistance training principles ranged from 1 to 10, with only 14 studies achieving 10/10. Eccentric heel-drops were the most common exercise (75 studies), followed by isotonic heel raises (38), and single-leg eccentric decline squats (27). The reporting of exercise descriptors and intervention content was high across studies, with most allowing exercise replication, particularly for Achilles and patellar tendinopathy. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies

Objectives

We performed a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) to provide insights into the effectiveness of available treatment modalities in patellar tendinopathy(PT).

Methods

Several databases were searched in May 2021 for RCTs assessing the effectiveness of any intervention compared with any other intervention, placebo or no treatment for pain and/or function in PT. The risk of bias and strength of evidence were assessed with the Cochrane Collaboration and GRADE (Grading of Recommendations, Assessment, Development and Evaluations)/GRADE-NMA tools.

Results

A total of 37 RCTs were eligible that assessed 33 different interventions and their combinations, most represented by single studies. Based on pairwise meta-analyses of two RCTs, extracorporeal shockwave therapy (ESWT) does not appear to be superior to sham ESWT (eccentric exercise in both groups) for short-term pain (mean differences (MD) +0.1, 95% CI (−0.8 to 1), p=0.84) or function (MD −1.8, 95% CI (–8 to 4.4), p=0.57). Based on a pairwise meta-analysis of three RCTs, isometric exercise appears as effective as isotonic exercise for immediate postintervention pain relief (MD −1.03, 95% CI (−2.6 to 0.5), p=0.19). Our NMA showed that topical glyceryl trinitrate (GTN) and hyaluronic acid injection, both combined with eccentric exercise and moderate, slow resistance exercise had the highest probability of being the most effective interventions (low/very low strength of evidence).

Conclusions

Promising interventions with inadequate evidence, such as topical GTN, hyaluronic acid injections and isometric and slow resistance exercise, should be further investigated through high-quality RCTs. Meanwhile, eccentric loading with or without adjuncts should remain the first-line treatment for all individuals with patellar tendinopathy.

Foot and Lower Limb Clinical and Structural Changes in Overuse Injured Recreational Runners Using Floating Heel Shoes: Preliminary Results of a Randomised Control Trial

Foot-strike and the associated load rate are factors related to overuse injuries in runners. The purpose of this study was to analyse structural and functional changes in runners using floating heel running shoes, compared with runners using conventional footwear. A randomised control trial was conducted. Twenty runners with overuse injuries were followed over a 12-week gait retraining programme using floating heel running shoes or their conventional footwear. Pain was measured with pressure pain thresholds (PPTs), structural changes were measured with ultrasonography, and severity and impact of injury was scored on the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O). Statistical differences were found between groups after the intervention (p < 0.001), with a medium size effect SE = 0.8, and the floating heel running shoes group reached higher PPTs values. Participants using floating heel running shoes showed higher OSTRC-O scores than those using their conventional footwear (p < 0.05), with higher scores after the intervention (p < 0.05). A 12-week gait retraining programme using floating heel running shoes had positive effects on the injury recovery process when compared to the use of conventional footwear, with significant differences in terms of pain and impact on sports activity.

Current Clinical Concepts: Clinical Management of Patellar Tendinopathy

Patellar tendinopathy is a common, yet misunderstood pathoetiology afflicting a variety of patient populations. This lack of unified understanding affects the capability of clinicians to provide effective treatment interventions. Patients with tendinopathy often report long-term and low to moderate levels of pain, diminished flexibility, and strength, as well as decreased physical function. Load-management strategies combined with exercise regimens focused on progressive tendon loading are the most effective treatment option for patients with patellar tendinopathy. This review will provide an evidence-based approach to patellar tendinopathy, including its pathoetiology, evaluation, and treatment strategies.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of Physical Training on Physical and Psychological Parameters in Individuals with Patella Tendon Myopathy: A Systematic Review and Meta-Analysis

The effectiveness of physical training on physical and psychological parameters in individuals with patella tendinopathy has not been investigated in a systematic review and meta-analysis. The aim of the present study was to determine the effects of physical exercise interventions for measures of physical and psychological performance in subjects with patella tendinopathy. A computerised systematic literature search was conducted in the electronic databases PubMed, Medline, and Web of Science from January 1960 to July 2020. Initially, 506 articles were identified for review of which eleven articles met the inclusion criteria. Our results revealed a small effect (weighted mean standardized mean difference (SMD) = 0.12; nine studies) of physical training on the psychological measure Victorian Institute of Sport Assessment–Patellar tendon scale and a medium effect (weighted mean SMD = 0.61; five studies) on the psychological measure visual analogue scale—both in favour of the intervention group. In contrast, a small effect (weighted mean SMD = −0.05; two studies) in favour of the control group was detected for the physical measure muscle power. Compared to the control condition, physical training seems to be an effective means to improve psychological but not physical parameters in individuals with patella tendinopathy; although conclusions on the latter could have been biased by the small amount of eligible studies (n = 2). In addition, the predetermined cut-off value of ≥6 for the Physiotherapy Evidence Database scale score (i.e., assessment of methodological quality) was only achieved by six out of eleven studies. Thus, further research of high methodological quality is needed to verify whether there is or is not an effect of physical training on physical parameters in persons with patella tendinopathy.

Rehabilitation of patellar tendinopathy

Patellar tendinopathy is a common musculoskeletal disorder characterized by progressive activity-related anterior knee pain and patellar tendon dysfunction. It is highly prevalent in sports which involve running and jumping. Various treatment methods are used in the management of PT including rest, activity modification, anti-inflammatory medication, injection therapies, taping, eccentric exercises, extra corporeal shock wave therapy, percutaneous electrolysis, and surgery. Even though various treatment options are available for patellar tendinopathy, no single method has proven to result in a consistent and near complete recovery in patients. Conservative management is considered to be the first line of treatment. This study presents an overview of the current practice about the management of patellar tendinopathy with an emphasis on rehabilitation. This review can act as a guide to sports medicine and rehabilitation professionals' decision making in the management of this disorder.

Load progression criteria in exercise programmes in lower limb tendinopathy: a systematic review

OBJECTIVE

The objective of this study is to summarise and analyse the current literature about what progression criteria are applied in loading exercise programmes in lower limb tendinopathies and their evidence and effectiveness.

DESIGN

Systematic review.

METHODS

PubMed, Embase, Scopus and PEDro were searched from inception to 24 September 2020. The inclusion criteria were randomised controlled trials that included patients with midportion Achilles, patellar or gluteal tendinopathy; assessed function, pain or performance; included at least one group where progressive physical exercise was administered as monotherapy; included at least a control group. We excluded studies that included subjects with previous tendon surgical treatment; studies with control group that conducted a supplemented modality of the exercise performed in the intervention group. A narrative synthesis was conducted. Cohen's d and the percentage of change of main clinical and performance outcomes were obtained. Methodological quality was assessed using the PEDro scale.

RESULTS

Thirty studies that described progression criteria were included. Six types of criteria grouped in two categories were identified and included in a new classification proposal: pain as a primary criterion (evoking and avoid-pain based), and pain and symptom control as a secondary criterion (conditioning stages, fatigue-based, subjective perception and temporary linear increase). Most of the studies applied a pain-based criterion. Criteria based on conditioning stages were also commonly applied. Other criteria such as fatigue, a temporary linear increase, or the subjective perception of the patient's abilities were occasionally applied.

CONCLUSIONS

There is a predominant use of pain-based criteria, but the utilisation of these criteria is not supported by strong evidence. This review evidences the need for studies that compare the same exercise programme using different progression criteria. A new classification of the existing progression criteria is proposed based on the use of pain as the primary or secondary criterion.

PROSPERO REGISTRATION NUMBER

CRD42018110997.

Changes on Tendon Stiffness and Clinical Outcomes in Athletes Are Associated With Patellar Tendinopathy After Eccentric Exercise

OBJECTIVE

Eccentric exercise is commonly used as a form of loading exercise for individuals with patellar tendinopathy. This study investigated the change of mechanical properties and clinical outcomes and their interrelationships after a 12-week single-legged decline-board exercise with and without extracorporeal shockwave therapy (ESWT).

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinic of a university.

PARTICIPANTS

Thirty-four male in-season athletes with patellar tendinopathy for more than 3 months were randomized into exercise and combined groups.

INTERVENTIONS

The exercise group received a 12-week single-legged decline-squat exercise, and the combined group performed an identical exercise program in addition to a weekly session of ESWT in the initial 6 weeks.

MAIN OUTCOME MEASURES

Tendon stiffness and strain were examined using ultrasonography and dynamometry. Visual analog scale and Victoria Institute of Sports Assessment-patella (VISA-p) score were used to assess pain and dysfunction. These parameters were measured at preintervention and postintervention.

RESULTS

Significant time effect but no significant group effect on the outcome measures; significant reduction in tendon stiffness (P = 0.02) and increase in tendon strain (P = 0.00); and reduction of intensity of pain (P = 0.00) and dysfunction (P = 0.00) were observed. Significant correlations between changes in tendon stiffness and VISA-p score (ρ = -0.58, P = 0.05); alteration in tendon strain, pain intensity (ρ = -0.63, P = 0.03); and VISA-p score (ρ = 0.60, P = 0.04) were detected after the exercise program.

CONCLUSIONS

Eccentric exercise-induced modulation on tendon mechanical properties and clinical symptoms are associated in athletes with patellar tendinopathy.

Comparison of the Effect of 5 Different Treatment Options for Managing Patellar Tendinopathy: A Secondary Analysis

OBJECTIVE

Currently, no treatments exist for patellar tendinopathy (PT) that guarantee quick and full recovery. Our objective was to assess which treatment option provides the best chance of clinical improvement and to assess the influence of patient and injury characteristics on the clinical effect of these treatments.

DESIGN

A secondary analysis was performed on the combined databases of 3 previously performed double-blind randomized controlled trials.

PATIENTS

In total, 138 patients with PT were included in the analysis.

INTERVENTIONS

Participants were divided into 5 groups, based on the treatment they received: Extracorporeal shockwave therapy (ESWT) (n = 31), ESWT plus eccentric training (n = 43), eccentric training (n = 17), topical glyceryl trinitrate patch plus eccentric training (n = 16), and placebo treatment (n = 31).

MAIN OUTCOME MEASURES

Clinical improvement (increase of ≥13 points on the Victorian Institute of Sport Assessment-Patella score) after 3 months of treatment.

RESULTS

Fifty-two patients (37.7%) improved clinically after 3 months of treatment. Odds ratios (ORs) for clinical improvement were significantly higher in the eccentric training group (OR 6.68, P = 0.009) and the ESWT plus eccentric training group (OR 5.42, P = 0.015) compared with the other groups. We found evidence that a high training volume, a longer duration of symptoms, and older age negatively influence a treatment's clinical outcome (trend toward significance).

CONCLUSIONS

Our study confirmed the importance of exercise, and eccentric training in particular, in the management of PT. The role of ESWT remains uncertain. Further research focusing on the identified prognostic factors is needed to be able to design patient-specific treatment protocols for the management of PT.

Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis

BACKGROUND

Patellar tendinopathy is a condition characterized by anterior knee activity-related pain. It has a high incidence among athletes engaged in jumping sports and may become a chronic condition. Nonoperative management is the first choice in these patients, and several nonsurgical treatment options have been proposed. Nonetheless, clear indications on the most effective approach to address patellar tendinopathy are still lacking.

PURPOSE

To analyze the evidence on nonoperative options to treat chronic patellar tendinopathy through a systematic review of the literature and to perform a meta-analysis to identify the most effective nonsurgical option.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The search was conducted with the PubMed and Cochrane databases on January 4, 2017. All clinical English-language reports of any level of evidence on nonsurgical treatment of patellar tendinopathy were included. The quality of each article was assessed by use of the Coleman score. A meta-analysis was performed on all articles reporting the Victorian Institute of Sport Assessment scale for patellar tendinopathy to evaluate the results of the most described treatments.

RESULTS

A total of 70 studies involving 2530 patients were included in the qualitative data synthesis. The Coleman score showed an overall poor study quality. The most described treatment groups that could be included in the meta-analysis were reported in 22 studies on eccentric exercise, extracorporeal shockwave therapy (ESWT), and platelet-rich plasma (PRP). Single and multiple PRP injections were evaluated separately. Eccentric exercise therapies obtained the best results ( P < .05) at short-term (<6 months, mean 2.7 ± 0.7 months). However, multiple injections of PRP obtained the best results ( P < .05), followed by ESWT and eccentric exercise, at long-term follow-up (≥6 months, mean 15.1 ± 11.3 months).

CONCLUSION

The literature documents several nonsurgical approaches for the treatment of chronic patellar tendinopathy with important limitations in terms of study quality. The available evidence showed an overall positive outcome, but some differences have been highlighted. Eccentric exercises may seem the strategy of choice in the short-term, but multiple PRP injections may offer more satisfactory results at long-term follow-up and can be therefore considered a suitable option for the treatment of patellar tendinopathy.

Effects of long-term respiratory muscle endurance training on respiratory and functional outcomes in patients with Myasthenia gravis

BACKGROUND

Myasthenia gravis (MG) is characterized by reduced muscle endurance and often leads to respiratory complications.

OBJECTIVE

A long-term respiratory muscle endurance training (RMET) based on normocapnic hyperpnea was introduced for the first time in MG patients. We investigated RMET effects on respiratory endurance (RE), MG symptoms, lung function and physical fitness and compared the results with a control group (CG).

METHODS

The training period consisted of four weeks intensive training (IT; five 30-min training sessions per week) followed by twelve months maintenance training (MT; five 30-min training sessions over two weeks). Eighteen patients with mild to moderate MG participated as the training group (TG), six patients served as CG. RE, lung function, MG score and physical fitness were tested before and after IT and after three to twelve months of MT.

RESULTS

Only 12 TG patients completed the entire training period. Thirteen months of training significantly increased RE measured as time until exhaustion (T_lim) to 412% of baseline (P < 0.001). The MG score improved from 0.67±0.09 to 0.41 ± 0.1 (p = 0.004), and the number of squats per minute as a measure of physical fitness increased in the TG to 160% of baseline (p = 0.015). While lung function did not change during the training period, we observed a modulation in the breathing pattern at rest with prolonged expiration (122% of baseline, p = 0.028). In addition, TG reported subjective improvements in MG symptoms, respiratory symptoms and physical fitness by 49%, 58% and 64%, respectively (P < 0.001). No significant changes were observed in the CG.

CONCLUSION AND SIGNIFICANCE

This is the first controlled long-term RMET study in MG patients. The results demonstrated that this normocapnic hyperpnea training is feasible and beneficial for patients with mild to moderate MG and is a valuable supplement to conventional drug treatment.

Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review

Objective

Evaluate effectiveness and harms of interventions for patellar tendon related pain in children and adolescents.

Design

Systematic review and meta-analysis.

Data sources

Medline via Pubmed, Embase via OVID, CINAHL via Ebsco, SportDiscus up until 24 November 2017 were searched.

Eligibility criteria for selecting studies

Inclusion criteria were (1) controlled or randomised controlled clinical trials (RCTs), (2) participants with diagnosis of patellar tendon related disorder, (3) participants≤18 years of age at enrolment and (4) published in a peer-reviewed English or Scandinavian language journal.

Results

Of 530 studies identified, eight were included after screening, with three included in data synthesis. To be included in data synthesis, we required studies to have included (and have data available for) a minimum of 10 participants under 18 years. All studies were rated as being at high risk of bias. For adolescents with patellar tendinopathy, one RCT compared eccentric exercises to usual care and found no difference between groups. In adolescents with Osgood-Schlatter disease (OSD), injection of local anaesthetic with dextrose proved superior to either usual care or local anaesthetic alone (three armed RCTs). In a retrospective case controlled study in adolescents with OSD, surgery provided no benefit over conservative management in terms of persistent symptoms and had a higher complication rate.

Conclusion

There is weak evidence to support the use of dextrose injection with local anaesthetic and no evidence to support the use of specific types of exercises to treat children/adolescents with OSD/patellar tendinopathy. Until further evidence arises, clinicians should include load modification and advise on a return to sport based on symptoms.

Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review

BACKGROUND AND PURPOSE

The purpose of this study is to evaluate current evidence and provide a review on the effects of isometric, eccentric, or heavy slow resistance (HSR) exercises on pain and function in individuals with patellar tendinopathy (PT).

METHODS

Academic journals from CINAHL, Embase, MEDLINE, Scopus, SPORTDiscus™, and The Cochrane Library were searched from inception to August 2017. Screening of reference lists was also performed. Human interventional studies investigating outcomes of pain and function in PT using either isometric, eccentric, or HSR training exercises were included. The McMaster Critical Review Form-Quantitative Studies was used to assess for risk of bias. Levels of evidence were obtained using the National Health and Medical Research Council (NHMRC) evidence hierarchy. The NHMRC Body of Evidence Framework was utilized to formulate recommendations for clinical practice. Extraction of data was performed by two independent reviewers according to predefined data criterion, data were then tabulated, and a descriptive, qualitative data synthesis was performed.

RESULTS

Fifteen studies (3 isometric, 2 HSR, and 10 eccentric) were included for this review. Mean quality score across all studies was 81.6% (range 70% to 93%). Nine studies were of high quality, whereas six studies were of moderate quality. Nine studies were randomized controlled trials, which provided good Level II evidence; four studies were of satisfactory Level III evidence; and two studies were case series (Level IV evidence).

CONCLUSIONS

Findings from isometric exercises can be trusted to guide clinical practice (Grade A), whereas eccentric exercises can be trusted to guide clinical practice in most clinical situations (Grade B). It is recommended that HSR exercises should be applied carefully to individual clinical circumstances (Grade C) and interpreted with care. Isometric exercises appear to be more effective during competitive seasons for short-term pain relief, whereas HSR or eccentric exercises are more suitable for long-term pain reduction and improvement in knee function.

Arthroscopic patellar release for treatment of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population

BACKGROUND

Arthroscopic patellar release (APR) is utilized for minimally invasive surgical treatment of patellar tendinopathy. Evidence regarding long-term success following the procedure is limited. Also, the influence of age and preoperative performance level, are incompletely understood. The aim of this study was to investigate whether APR translates into sustained pain relief over a long-term follow-up in athletes undergoing APR. Furthermore, we analyzed if age influences clinical and functional outcome measures in APR.

METHODS

Between 1998 and 2010, 30 competitive and recreational athletes were treated with APR due to chronic refractory patellar tendinopathy. All data were analyzed retrospectively. Demographic data, such as age or level of performance prior to injury were extracted. Clinical as well as functional outcome measures (Swedish Victorian Institute of sport assessment for patella (VISA-P), the modified Blazina score, pain level following exercise, return to sports, and subjective knee function were assessed pre- and postoperatively.

RESULTS

In total, 30 athletes were included in this study. At follow-up (8.8 ± 2.82 years), clinical and functional outcome measures such as the mean Blazina score, VISA-P, VAS, and subjective knee function revealed significant improvement compared to before surgery (P < 0.001). The mean time required for return to sports was 4.03 ± 3.18 months. After stratification by age, patients younger than 30 years of age yielded superior outcome in the mean Blazina score and pain level when compared to patients ≥30 years (P = 0.0448). At 8 years of follow-up, patients yielded equivalent clinical and functional outcome scores compared to our previous investigation after four years following APR.

CONCLUSION

In summary, APR can be regarded a successful, minimally invasive, and sustained surgical technique for the treatment of patella tendinopathy in athletes. Younger age at surgery may be associated with improved clinical and functional outcome following APR.

Revision Surgery for Failed Patellar Tendinopathy Exploration

Chronic patellar tendinopathy affects athletes, with a higher incidence in high-impact sporting activities. It can seriously impair sports activities. Many patients respond well to conservative treatment, but about 10% of them are refractory to conservative treatment. In these cases, surgery is indicated. Multiple surgical techniques have been reported, including both open and arthroscopic procedures with good results. However, in a small percentage of patients surgery is unsuccessful. This group of patients presents a major challenge, as options are limited. We describe our surgical approach in the management of recalcitrant patellar tendinopathy.

Patellar tendon straps decrease pre-landing quadriceps activation in males with patellar tendinopathy

OBJECTIVE

To determine if patellar tendon straps altered quadriceps' muscle activity during a drop-jump landing in males with and without patellar tendinopathy.

DESIGN

Case-control.

SETTINGS

Biomechanics Research Laboratory.

PARTICIPANTS

Twenty recreationally-active males participated: ten (age = 21.3 ± 2.4 years, height = 182.8 ± 5.3 cm, mass = 81.7 ± 8.6 kg) with patellar tendinopathy; ten (age = 22.0 ± 1.6 years, height = 185.7 ± 4.5 cm, mass = 82.2 ± 9.8 kg) were healthy with no history of tendinopathy.

MAIN OUTCOME MEASURES

Electromyography (EMG) data for the vastus medialis (VM), rectus femoris (RF), and vastus lateralis (VL) muscles were collected. Five 2-legged 40 cm drop-jumps were performed wearing a patellar tendon strap and 5 with no-strap in a counterbalanced order. Root-mean square EMG (REMG) values of the VM, RF, and VL were averaged for a pre-landing and post-landing interval. Multiple mixed-model two-way ANOVAs were performed to determine the effect of tendinopathy and strapping condition on REMG values for each muscle.

RESULTS

For the pre-landing interval, all participants displayed lesser VL EMG activation (0.44 ± 0.19%, 0.53 ± 0.27%, respectively; p = 0.007, d = 0.39) in the no-strap compared with the strap condition.

CONCLUSIONS

When wearing a strap, all participants demonstrated lower VL activation prior to landing which may be helpful in reducing tensile stress at the tendon. These effects may be clinically important in modulating pain in those with patellar tendinopathy.

CURRENT CONCEPTS IN THE TREATMENT OF PATELLAR TENDINOPATHY

Patellar tendon pain is a significant problem in athletes who participate in jumping and running sports and can interfere with athletic participation. This clinical commentary reviews patellar tendon anatomy and histopathology, the language used to describe patellar tendon pathology, risk factors for patellar tendinopathy and common interventions used to address patellar tendon pain. Evidence is presented to guide clinicians in their decision-making regarding the treatment of athletes with patellar tendon pain.

LEVEL OF EVIDENCE

5.

Patellar Tendinopathy: Diagnosis and Treatment

Patellar tendinopathy is a common cause of pain in athletes' knees. Historically, it has been related to jumping sports, such as volleyball and basketball. Repetitive jumping generates a considerable load of energy in the extensor mechanism, leading to symptoms. The main pathophysiologic phenomenon in patellar tendinopathy is tendinosis, which is a degenerative disorder rather than an inflammatory disorder; therefore, the other popular term for this disease, tendinitis, is not appropriate. The nonsurgical treatment of patellar tendinopathy is focused on eccentric exercises and often has good results. Other experimental options, with variable levels of evidence, are available for recalcitrant cases. Surgical treatment is indicated for cases that are refractory to nonsurgical treatment. Open or arthroscopic surgery can be performed; the two methods are comparable, but arthroscopic surgery results in a faster recovery time.

The effect of different decline angles on the biomechanics of double limb squats and the implications to clinical and training practice

Bilateral decline squatting has been well documented as a rehabilitation exercise, however, little information exists on the optimum angle of decline. The aim of this study was to determine the ankle and knee angle, moments, the patellofemoral joint load, patellar tendon load and associated muscle activity while performing a double limb squat at different decline angles and the implications to rehabilitation. Eighteen healthy subjects performed double limb squats at 6 angles of declination: 0, 5, 10, 15, 20 and 25 degrees. The range of motion of the knee and ankle joints, external moments, the patellofemoral/patellar tendon load and integrated EMG of gastrocnemius, tibialis anterior, rectus femoris and biceps femoris were evaluated. As the decline angle increased up to 20 degrees, the range of motion possible at the ankle and knee increased. The joint moments showed a decrease at the ankle up to 15 degrees and an increase at the knee up to 25 degrees, indicating a progressive reduction in loading around the ankle with a corresponding increase of the load in the patellar tendon and patellofemoral joint. These trends were supported by a decrease in tibialis anterior activity and an increase in the rectus femoris activity up to 15 degrees declination. However, gastrocnemius and biceps femoris activity increased as the decline angle increased above 15 degrees. The action of gastrocnemius and biceps femoris stabilises the knee against an anterior displacement of the femur on the tibia. These findings would suggest that there is little benefit in using a decline angle greater than 15-20 degrees unless the purpose is to offer an additional stability challenge to the knee joint.

Lateral elbow tendinopathy: Evidence of physiotherapy management

Lateral elbow tendinopathy (LET) is a common musculoskeletal/sports injury. A plethora of physiotherapy techniques has been proposed in the management of LET. The exercise programme is the most common treatment in the management of LET. The optimal protocol of exercise programme is still unknown. The effectiveness of the exercise programme is low when it is applied as monotherapy. Therefore, exercise programme is combined with other physiotherapy modalities such as soft tissue techniques, external support, acupuncture, manual therapy and electrotherapy, in the treatment of LET. Future research is needed to determine which treatment strategy combined with exercise programme will provide the best results in LET rehabilitation.

Eccentric or Concentric Exercises for the Treatment of Tendinopathies?

Synopsis Tendinopathy is a very common disorder in both recreational and elite athletes. Many individuals have recurrent symptoms that lead to chronic conditions and termination of sports activity. Exercise has become a popular and somewhat efficacious treatment regime, and isolated eccentric exercise has been particularly promoted. In this clinical commentary, we review the relevant evidence for different exercise regimes in tendinopathy rehabilitation, with particular focus on the applied loads that are experienced by the tendon and how the exercise regime may affect these applied loads. There is no convincing clinical evidence to demonstrate that isolated eccentric loading exercise improves clinical outcomes more than other loading therapies. However, the great variation and sometimes insufficient reporting of the details of treatment protocols may hamper the interpretation of what may be the optimal exercise regime with respect to parameters such as load magnitude, speed of movement, and recovery period between exercise sessions. Future studies should control for these loading parameters, evaluate various exercise dosages, and think beyond isolated eccentric exercises to arrive at firm recommendations regarding rehabilitation of individuals with tendinopathies. J Orthop Sports Phys Ther 2015;45(11):853-863. Epub 14 Oct 2015. doi:10.2519/jospt.2015.5910.

Impact of decline-board squat exercises and knee joint angles on the muscle activity of the lower limbs

[Purpose] This study aims to investigate how squat exercises on a decline board and how the knee joint angles affect the muscle activity of the lower limbs. [Subjects] The subjects were 26 normal adults. [Methods] A Tumble Forms wedge device was used as the decline board, and the knee joint angles were measured with a goniometer. To examine the muscle activity of the biceps femoris, rectus femoris, gastrocnemius lateralis, and tibialis anterior of the lower limbs, a comparison analysis with electromyography was conducted. [Results] The muscle activity of the biceps femoris, rectus femoris, gastrocnemius lateralis, and tibialis anterior increased with increased knee joint angles, both for squat exercises on the decline board and on a flat floor. When the knee joint angle was 45°, 60°, and 90°, the muscle activity of the rectus femoris was significantly higher and that of the tibialis anterior was significantly lower during squat exercises on the decline board than on the flat floor. When the knee joint angle was 90°, the muscle activity of the gastrocnemius lateralis was significantly lower. [Conclusion] Squat exercises on a decline board are an effective intervention to increase the muscle activity of the rectus femoris with increased knee joint angles.

Clinical results after ultrasound-guided intratissue percutaneous electrolysis (EPI®) and eccentric exercise in the treatment of patellar tendinopathy

PURPOSE

To investigate the outcome of ultrasound (US)-guided intratissue percutaneous electrolysis (EPI(®)) and eccentric exercise in the treatment of patellar tendinopathy during a long-term follow-up.

METHODS

Forty patients with patellar tendinopathy were prospectively evaluated over a 10-year follow-up period. Pain and function were evaluated before treatment, at 3 months and at 2, 5 and 10 years using the Victorian Institute of Sport Assessment-Patella (VISA-P) score, the Tegner score and Blazina's classification. According to VISA-P score at baseline, patients were also dichotomized into Group 1 (<50 points) and Group 2 (≥50 points). There were 21 patients in Group 1 and 19 in Group 2. Patient satisfaction was measured according to the Roles and Maudsley score.

RESULTS

The VISA-P score improved globally by 41.2 points (p < 0.01) after a mean 4.1 procedures. In Group 1, VISA-P score improved from 33.1 ± 13 to 78.9 ± 14.4 at 3-month and to 88.8 ± 10.1 at 10-year follow-up (p < 0.001). In Group 2, VISA-P score improved from 69.3 ± 10.5 to 84.9 ± 9 at 3-month and to 96.0 ± 4.3 at 10-year follow-up (p < 0.001). After 10 years, 91.2 % of the patients had a VISA-P score >80 points. The same level (80 % of patients) or the Tegner score at no more than one level lower (20 % of patients) was restored, and 97.5 % of the patients were satisfied with the procedure.

CONCLUSION

Treatment with the US-guided EPI(®) technique and eccentric exercises in patellar tendinopathy resulted in a great improvement in knee function and a rapid return to the previous level of activity after few sessions. The procedure has proved to be safe with no recurrences on a long-term basis.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Region-specific tendon properties and patellar tendinopathy: a wider understanding

Patellar tendinopathy is a common painful musculoskeletal disorder with a very high prevalence in the athletic population that can severely limit or even end an athletic career. To date, the underlying pathophysiology leading to the condition remains poorly understood, although reports suggesting that patellar tendinopathy most frequently concerns the proximal posterior region of the tendon has prompted some researchers to examine region-specific tendon properties for a better understanding of the etiology and potential risk factors associated with the condition. However, to date, research concerning the in vivo region-specific tendon properties in relation to patellar tendinopathy is very scarce, perhaps due to the lack of validated techniques that can determine such properties in vivo. In recent years, a technique has been developed involving an automated tendon-tracking program that appears to be very useful in the determination of region-specific tendon properties in vivo. In terms of regional variations in tendon properties, previous research has demonstrated differences in structural, mechanical, and biochemical properties between the discrete regions of the patellar tendon, but the extent to which these regional variations contribute to patellar tendinopathy remains elusive. In addition, with respect to treatment strategies for patellar tendinopathy, previous research has utilized a wide range of interventions, but the use of eccentric exercise (EE) and/or heavy-slow resistance (HSR) training appear to be most promising. However, the optimal program design variables of EE and HSR training that induce the most favorable effects are yet to be determined. This review article provides a detailed discussion of all of the above to allow a better understanding of the etiology and potential risk factors associated with the condition as well as the most effective treatment strategies. First, a comprehensive literature review is provided with respect to region-specific structural, mechanical, and biochemical properties, in association with patellar tendinopathy. Second, the automated tendon-tracking methodology is outlined to assist future researchers in the determination of region-specific tendon properties. Finally, potential treatment strategies are discussed, particularly with regards to the use of EE and HSR training for the management of patellar tendinopathy.

The role of eccentric exercise in sport injuries rehabilitation

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.

Eccentric exercise: acute and chronic effects on healthy and diseased tendons

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.

Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness

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.

Heated lidocaine/tetracaine patch for treatment of patellar tendinopathy pain

INTRODUCTION

The pain of patellar tendinopathy (PT) may be mediated by neuronal glutamate and sodium channels. Lidocaine and tetracaine block both of these channels. This study tested the self-heated lidocaine-tetracaine patch (HLT patch) in patients with PT confirmed by physical examination to determine if the HLT patch might relieve pain and improve function.

METHODS

Thirteen patients with PT pain of ≥14 days' duration and baseline average pain scores ≥4 (on a 0-10 scale) enrolled in and completed this prospective, single-center pilot study. Patients applied one HLT patch to the affected knee twice daily for 2-4 hours for a total of 14 days. Change in average pain intensity and interference (Victorian Institute of Sport Assessment [VISA]) scores from baseline to day 14 were assessed. No statistical inference testing was performed.

RESULTS

Average pain scores declined from 5.5 ± 1.3 (mean ± standard deviation) at baseline to 3.8 ± 2.5 on day 14. Similarly, VISA scores improved from 45.2 ± 14.4 at baseline to 54.3 ± 24.5 on day 14. A clinically important reduction in pain score (≥30%) was demonstrated by 54% of patients.

CONCLUSION

The results of this pilot study suggest that topical treatment that targets neuronal sodium and glutamate channels may be useful in the treatment of PT.

Patellar tendon adaptation in relation to load-intensity and contraction type

BACKGROUND

Loading leads to tendon adaptation but the influence of load-intensity and contraction type is unclear. Clinicians need to be aware of the type and intensity of loading required for tendon adaptation when prescribing exercise. The aim of this study was to investigate the influence of contraction type and load-intensity on patellar tendon mechanical properties.

METHOD

Load intensity was determined using the 1 repetition maximum (RM) on a resistance exercise device at baseline and fortnightly intervals in four randomly allocated groups of healthy, young males: (1) control (no training); (2) concentric (80% of concentric-eccentric 1RM, 4×7-8); (3) standard load eccentric only (80% of concentric-eccentric 1RM, 4×12-15 repetitions) and (4) high load eccentric (80% of eccentric 1RM, 4×7-8 repetitions). Participants exercised three times a week for 12 weeks on a leg extension machine. Knee extension maximum torque, patellar tendon CSA and length were measured with dynamometry and ultrasound imaging. Patellar tendon force, stress and strain were calculated at 25%, 50%, 75% and 100% of maximum torque during isometric knee extension contractions, and stiffness and modulus at torque intervals of 50-75% and 75-100%. Within group and between group differences in CSA, force, elongation, stress, strain, stiffness and modulus were investigated. The same day reliability of patellar tendon measures was established with a subset of eight participants.

RESULTS

Patellar tendon modulus increased in all exercise groups compared with the control group (p<0.05) at 50-75% of maximal voluntary isometric contraction (MVIC), but only in the high eccentric group compared with the control group at 75-100% of MVIC (p<0.05). The only other group difference in tendon properties was a significantly greater increase in maximum force in the high eccentric compared with the control group (p<0.05). Five repetition maximum increased in all groups but the increase was significantly greater in the high load eccentric compared with the other exercise groups (p<0.05).

CONCLUSION

Load at different intensity levels and contraction types increased patellar tendon modulus whereas muscle strength seems to respond more to load-intensity. High load eccentric was, however, the only group to have significantly greater increase in force, stiffness and modulus (at the highest torque levels) compared with the control group. The effects and clinical applicability of high load interventions needs to be investigated further.

Eccentric Exercise Protocols for Patella Tendinopathy: Should we Really be Withdrawing Athletes from Sport? A Systematic Review

The 2007 review by Visnes and Bahr concluded that athletes with patella tendinopathy should be withdrawn from sport whilst engaging in eccentric exercise (EE) rehabilitation programs. However, deprivation of sport is associated with a number of negative psychological and physiological effects. Withdrawal from sport is therefore a decision that warrants due consideration of the risk/benefit ratio. The aim of this study was to determine whether sufficient evidence exists to warrant withdrawal of athletes from sport during an eccentric exercise rehabilitation program. A systematic review of the literature was performed to identify relevant randomised trials. Data was extracted to determine whether athletes were withdrawn from sport, what evidence was presented to support the chosen strategy and whether this affected the clinical outcome. Seven studies were included. None of these reported high quality evidence to support withdrawal. In addition, three studies were identified in which athletes were not withdrawn from sport and still benefited from EE. This review has demonstrated that there is no high quality evidence to support a strategy of withdrawal from sport in the management of patella tendinopathy.

Eccentric strengthening for chronic lateral epicondylosis: a prospective randomized study

Background:

Effective treatments for chronic lateral epicondylosis have not been studied adequately. Eccentric overload exercises have been used with success for other chronic tendinopathy, mainly Achilles and patellar.

Hypothesis/Purpose:

To compare a wrist extensor eccentric strengthening exercise program with a wrist extensor stretching/modality program for the treatment of chronic lateral epicondylosis. The authors hypothesized that the eccentric strengthening program would produce more favorable results than a stretching/modality program.

Study Design:

Prospective randomized controlled trial.

Methods:

Twenty-eight adults with lateral epicondylosis of greater than 4 weeks’ duration were randomized to an eccentric strengthening group or a stretching group. Exercises were taught by a physical therapist, and participants performed most of the exercises on their own at home. Pain scores with visual analog scale from 0 to 100 were obtained at baseline and then at 4, 8, 12, 16, and 20 weeks after the start of the exercise program.

Results:

Both groups improved their pain scores from baseline to the 4-week time point, followed by nonsignificant further decreases in pain scores thereafter. No statistically significant differences were found between the eccentric strengthening group and stretching groups at any follow-up time point.

Conclusions:

Despite previous reports documenting favorable results with eccentric exercises for other tendinopathy, the authors were unable to show any statistical advantage to eccentric exercises for lateral epicondylosis during these periods compared with local modalities and stretching exercises.