A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy

Widespread Vascularization and Correlation of Glycosaminoglycan Accumulation to Tendon Pain in Human Plantar Fascia Tendinopathy

BACKGROUND

Plantar fasciitis is a painful tendinous condition (tendinopathy) with a high prevalence in athletes. While a healthy tendon has limited blood flow, ultrasound has indicated elevated blood flow in tendinopathy, but it is unknown if this is related to a de facto increase in the tendon vasculature. Likewise, an accumulation of glycosaminoglycans (GAGs) is observed in tendinopathy, but its relationship to clinical pain is unknown.

PURPOSE

To explore to what extent vascularization, inflammation, and fat infiltration were present in patients with plantar fasciitis and if they were related to clinical symptoms.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Biopsy specimens from tendinopathic plantar fascia tissue were obtained per-operatively from both the primary site of tendon pain and tissue swelling ("proximal") and a region that appeared macroscopically healthy at 1 to 2 cm away from the primary site ("distal") in 22 patients. Biopsy specimens were examined with immunofluorescence for markers of blood vessels, tissue cell density, fat infiltration, and macrophage level. In addition, pain during the first step in the morning (registered during an earlier study) was correlated with the content of collagen and GAGs in tissue.

RESULTS

High vascularization (and cellularity) was present in both the proximal (0.89%) and the distal (0.96%) plantar fascia samples, whereas inconsistent but not significantly different fat infiltration and macrophage levels were observed. The collagen content was similar in the 2 plantar fascia regions, whereas the GAG content was higher in the proximal region (3.2% in proximal and 2.8% in distal; P = .027). The GAG content in the proximal region was positively correlated with the subjective morning pain score in the patients with tendinopathy (n = 17).

CONCLUSION

In patients with plantar fasciitis, marked tissue vascularization was present in both the painful focal region and a neighboring nonsymptomatic area. In contrast, the accumulation of hydrophilic GAGs was greater in the symptomatic region and was positively correlated with increased clinical pain levels in daily life.

CLINICAL RELEVANCE

The accumulation of GAGs in tissue rather than the extent of vascularization appears to be linked with the clinical degree of pain symptoms of the disease.

Efficacy of heel lifts for mid-portion Achilles tendinopathy (the LIFT trial): study protocol for a randomised controlled trial

BACKGROUND

Mid-portion Achilles tendinopathy is a common condition, characterised by localised Achilles tendon load-related pain and dysfunction. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. Heel lifts have also been advocated as a treatment for Achilles tendinopathy, but the efficacy and mechanism of action of this intervention is unclear. This proposal describes a randomised controlled trial comparing the effectiveness of heel lifts versus sham heel lifts for reducing pain associated with mid-portion Achilles tendinopathy, with an embedded biomechanical analysis.

METHODS

One hundred and eight men and women aged 18 to 65 years with mid-portion Achilles tendinopathy (who satisfy the inclusion and exclusion criteria) will be recruited. Participants will be randomised, using the website Sealed Envelope, to either a control group (sham heel lifts) or an experimental group (heel lifts). Both groups will be provided with education regarding acceptable pain levels to ensure all participants receive some form of treatment. The participants will be instructed to use their allocated intervention for at least 8 h every day for 12 weeks. The primary outcome measure will be pain intensity (numerical rating scale) at its worst over the previous week. The secondary outcome measures will be additional measures of Achilles tendon pain and disability, participant-perceived global ratings of change, function, level of physical activity and health-related quality of life. Data will be collected at baseline and the primary endpoint (week 12). Data will be analysed using the intention-to-treat principle. In addition, the acute kinetic and kinematic effects of the interventions will be examined at baseline in a subpopulation of the participants (n = 40) while walking and running using three-dimensional motion analysis.

DISCUSSION

The LIFT trial (efficacy of heeL lIfts For mid-portion Achilles Tendinopathy) will be the first randomised trial to compare the efficacy of heel lifts to a sham intervention in reducing pain and disability in people with Achilles tendinopathy. The biomechanical analysis will provide useful insights into the mechanism of action of heel lifts.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12623000627651 . Registered 7 June 2023.

Psychological factors show limited association with the severity of Achilles tendinopathy

BACKGROUND

This study aimed to investigate the association between psychosocial factors and the severity of Achilles tendinopathy, along with exploring their potential link to the pain's duration.

METHODS

A cross-sectional study involving 111 individuals with Achilles tendon pain was conducted.

METHODS

A cross-sectional study involving 111 individuals with Achilles tendon pain was conducted. Various psychological factors were assessed using the Pain Catastrophizing Scale, Chronic Pain Self-Efficacy Scale (CPSS), Tampa Scale for Kinesiophobia, and Hospital Anxiety and Depression Scale (HAD). Additionally, the severity of Achilles tendon pain was evaluated using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-Br). Regression analyses were employed to determine the association of these psychosocial factors with pain severity and duration.

RESULTS

Self-efficacy for chronic pain showed a slight association with Achilles tendon pain severity (β = 0.42 [95% CI: 0.06 to 0.16], p = 0.001), explaining only 19% of the dependent variable. The other variables, including anxiety, depression, pain catastrophizing, and fear of movement, did not exhibit significant associations.

CONCLUSION

The study suggests that psychological factors demonstrate limited association with the severity of Achilles tendinopathy. While self-efficacy for chronic pain was weakly associated, its clinical relevance remains uncertain. Future research, particularly longitudinal studies, should explore the influence of psychosocial factors on treatment adherence and response to enhance management strategies for Achilles tendon pain.

Platelet-rich plasma in chronic Achilles tendinopathy

INTRODUCTION

Achilles tendinopathy [AT] is a functional problem characterised by swelling and pain above the Achilles tendon insertion region. In individuals with AT, PRP or platelet-rich plasma can be used as an alternative modality of treatment with an aim to lessen the discomfort and enhance functional recovery. We assessed the available data supporting the effectiveness of PRP in treating chronic AT.

MATERIALS AND METHODS

We did a literature search for randomised controlled trials [RCTs] that contrasted the effectiveness of PRP with that of eccentric exercise and placebo injections as treatment for AT in databases such as the Cochrane Library, Web of Science, PubMed, and EMBASE. The Visual analogue scale [VAS] score, Victorian Institute of Sports Assessment-Achilles [VISA-A] score, and Achilles tendon thickness were used to measure the results. We used the RevMan 5.3.5 software for statistical analysis.

RESULTS

We included five RCTs in this meta-analysis. There was no significant difference in the VISA-A between the PRP and placebo groups at 12 weeks, 24 weeks and 1 year after treatment. However, at 6 weeks after treatment, PRP exhibited better efficacy than the placebo treatment. Two studies in our meta-analysis included VAS scores and tendon thickness. There was no significant difference in VAS scores at 6 weeks and 24 weeks after treatment. However, VAS scores at 12 weeks and tendon thickness were significantly different.

CONCLUSION

PRP injection is an effective treatment for chronic AT. It has a unique potential for increasing function and reducing discomfort in AT patients.

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.

Prognostic value of ultrasound tissue characterisation for a recurrence of mid-portion Achilles tendinopathy in military service members: a prospective cohort study

INTRODUCTION

Tendon structure in mid-portion Achilles tendinopathy (mid-AT) appears poorly associated with symptoms. Yet, degenerative tendon changes on imaging have been associated with an increased risk of mid-AT. We aimed to investigate the prognostic value of ultrasound tissue characterisation (UTC) for a mid-AT recurrence in service members reporting to be recovered following standard care.

METHODS

Mid-portion aligned fibrillar structure was quantified post-treatment in 37 participants. Recurrences were determined after 1 year of follow-up, based on self-perceived recurrence (yes/no) combined with a decrease in post-treatment Victorian Institute of Sports Assessment-Achilles score of at least the minimal important change of 7 points. Receiver operating characteristic curve analyses were used to determine a threshold for dichotomisation of outcomes for aligned fibrillar structure (normal representation/under-representation). Using multivariable logistic regression, the association between a mid-AT recurrence (yes/no) and the dichotomised aligned fibrillar structure was determined.

RESULTS

Eight participants (22%) experienced a recurrence. The threshold for aligned fibrillar structure was set at 73.2% (95% CI: 69.4% to 77.8%) according to Youden's index. Values below this threshold were significantly associated with a mid-AT recurrence (odds ratio (OR) 9.7, 95% CI: 1.007 to 93.185). The OR for a mid-AT recurrence was 1.1 (95% CI: 1.002 to 1.150) for each additional month of symptom duration. The explained variance of our multivariable logistic regression model was 0.423; symptom duration appeared to be a better predictor than aligned fibrillar structure.

CONCLUSIONS

This study identified mid-portion aligned fibrillar structure and symptom duration as potential prognostic factors for a mid-AT recurrence in military service members. The threshold for aligned fibrillar structure of 73.2% can guide preventative interventions (eg, training load adjustments or additional tendon load programmes) aiming to improve tendon structure to minimise the future recurrence risk.

TRIAL REGISTRATION NUMBER

https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm, file number ToetsingOnline NL69527.028.19.

Monitoring physical activity using wearable technology in people with Achilles tendinopathy undergoing physiotherapy treatment: A feasibility prospective cohort study

OBJECTIVES

Physical activity modification is an important part of the management of Achilles tendinopathy. However, to our knowledge, there is a lack of evidence on objective physical activity assessment in Achilles tendinopathy. The purpose of this study is to (1) assess feasibility of using an inertial measurement unit (IMU) to monitor physical activity and IMU-derived biomechanical measures over 12-week treatment course by a physiotherapist; (2) conduct a preliminary analysis of changes in physical activity over 12-weeks.

DESIGN

A feasibility prospective cohort study SETTING: A community setting.

PARTICIPANTS

People with Achilles tendinopathy who had recently commenced (≤2 sessions), or were about to commence, treatment with a physiotherapist MAIN OUTCOME MEASURES: Participants wore a shank-mounted IMU on the affected side for one week at baseline, 6-, and 12-week follow-ups. The outcomes were pain/symptom severity, IMU-derived physical activity and biomechanical measures (stride rate, peak shank angular velocity, and peak shank acceleration).

RESULTS

Thirty participants were recruited. There was a high retention rate (97%), response rate (97%), and IMU wear compliance at each timepoint (>93%). For pain/symptom severity, a significant time effect was observed between baseline and 12-week follow-up. Physical activity and IMU-derived biomechanical measures did not change over 12 weeks. Physical activity decreased at the 6-week follow-up but only returned to the baseline level at 12-week follow-up.

CONCLUSIONS

A larger-scale cohort study assessing clinical outcomes and physical activity appears feasible. Preliminary data indicate that physical activity may not change significantly over 12-weeks in people undergoing physiotherapy management for Achilles tendinopathy. CONTRIBUTION OF THE PAPER.

Pain neuroscience education in persistent painful tendinopathies: A scoping review from the Tendon PNE Network

OBJECTIVE

to conduct and report a scoping review of the available evidence of the effects and content of pain neuroscience education for patients with persistent painful tendinopathies.

METHODS

PubMed, Embase, Web of Science, CINAHL, SPORTDiscus, and grey literature databases were searched from database inception to May 2022. Randomised and non-randomised controlled trials, non-controlled clinical trials, cohort studies, case series, case studies including people with persistent painful tendinopathy aged ≥18 years, a pain education intervention, and in English were included. Studies were excluded if they were cross-sectional studies, reviews, editorials, abstracts, or full-text not available or if included heterogeneous study cohorts, patients with tendon rupture, or patients with systemic diseases.

RESULTS

five studies (n = 164) were included. Pain neuroscience education entailed face-to-face discussion sessions or educational materials including videos, brochures, paper drawings, and review questions. All studies used pain neuroscience education in conjunction with other interventions, obtaining significant benefits in outcomes related to pain, physical performance, or self-reported function, among others.

CONCLUSIONS

The application of pain neuroscience education in conjunction with other interventions seemed to improve several outcomes. However, considering the current knowledge about tendon pain and the scarcity of well-designed trials studying pain neuroscience education in tendinopathy, additional research is needed.

Comparability of the Effectiveness of Different Types of Exercise in the Treatment of Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy (AT) is a common condition both in athletes and the general population. The purpose of this study is to highlight the most effective form of exercise in managing pain-related symptoms and functional capacity as well as in a return to life activities, ensuring the quality of life of patients with AT, and creating a protocol to be used in rehabilitation. We conducted a systematic review of the published literature in Pubmed, Scopus, Science Direct, and PEDro for Randomised Controlled Trials concerning interventions that were based exclusively on exercise and delivered in patients 18-65 years old, athletes and non-athletes. An amount of 5235 research articles generated from our search. Five met our inclusion criteria and were included in the review. Research evidence supports the effectiveness of a progressive loading eccentric exercise program based on Alfredson's protocol, which could be modified in intensity and pace to fit the needs of each patient with AT. Future research may focus on the optimal dosage and load of exercise in eccentric training and confirm the effectiveness of other type of exercise, such as a combination of eccentric-concentric training or heavy slow resistance exercise. Pilates could be applied as an alternative, useful, and friendly tool in the rehabilitation of AT.

Exploring the role of intratendinous pressure in the pathogenesis of tendon pathology: a narrative review and conceptual framework

Despite the high prevalence of tendon pathology in athletes, the underlying pathogenesis is still poorly understood. Various aetiological theories have been presented and rejected in the past, but the tendon cell response model still holds true. This model describes how the tendon cell is the key regulator of the extracellular matrix and how pathology is induced by a failed adaptation to a disturbance of tissue homeostasis. Such failure has been attributed to various kinds of stressors (eg, mechanical, thermal and ischaemic), but crucial elements seem to be missing to fully understand the pathogenesis. Importantly, a disturbance of tissue pressure homeostasis has not yet been considered a possible factor, despite it being associated with numerous pathologies. Therefore, we conducted an extensive narrative literature review on the possible role of intratendinous pressure in the pathogenesis of tendon pathology. This review explores the current understanding of pressure dynamics and the role of tissue pressure in the pathogenesis of other disorders with structural similarities to tendons. By bridging these insights with known structural changes that occur in tendon pathology, a conceptual model was constituted. This model provides an overview of the possible mechanism of how an increase in intratendinous pressure might be involved in the development and progression of tendon pathology and contribute to tendon pain. In addition, some therapies that could reduce intratendinous pressure and accelerate tendon healing are proposed. Further experimental research is encouraged to investigate our hypotheses and to initiate debate on the relevance of intratendinous pressure in tendon pathology.

Exercise for rotator cuff tendinopathy: Proposed mechanisms of recovery

Rotator cuff (RC) tendinopathy is a common recurrent cause of shoulder pain, and resistance exercise is the first-line recommended intervention. Proposed causal mechanisms of resistance exercise for patients with RC tendinopathy consist of four domains: tendon structure, neuromuscular factors, pain and sensorimotor processing, and psychosocial factors. Tendon structure plays a role in RC tendinopathy, with decreased stiffness, increased thickness, and collagen disorganization. Neuromuscular performance deficits of altered kinematics, muscle activation, and force are present in RC tendinopathy, but advanced methods of assessing muscle performance are needed to fully assess these factors. Psychological factors of depression, anxiety, pain catastrophizing, treatment expectations, and self-efficacy are present and predict patient-reported outcomes. Central nervous system dysfunctions also exist, specifically altered pain and sensorimotor processing. Resisted exercise may normalize these factors, but limited evidence exists to explain the relationship of the four proposed domains to trajectory of recovery and defining persistent deficits limiting outcomes. Clinicians and researchers can use this model to understand how exercise mediates change in patient outcomes, develop subgroups to deliver patient-specific approach for treatment and define metrics to track recovery over time. Supporting evidence is limited, indicating the need for future studies characterizing mechanisms of recovery with exercise for RC tendinopathy.

"I've got a spring in my step" participants experience of action observation therapy and eccentric exercises, a telehealth study for mid-portion Achilles Tendinopathy: a qualitative study

BACKGROUND

Quantitative research has dominated the field of Achilles Tendinopathy. The use of qualitative research allows in-depth exploration of participants' perspectives, offering great insight in the evaluation of a trial's processes, particularly when exploring a novel intervention such as Action Observation Therapy combined with eccentric exercises which has not been previously researched. This study aimed to qualitatively explore participants' experiences of partaking in a telehealth study including the acceptability of the intervention, motivators for participation, and perspectives on the trial processes.

METHOD

A thematic analysis as guided by Braun and Clarke was used to analyse the semi-structured interviews conducted on a purposive sample of participants with mid-portion Achilles Tendinopathy who recently completed a pilot feasibility study. The study adhered to the criteria for reporting qualitative research guidelines (COREQ).

RESULTS/DISCUSSION

Sixteen participants were interviewed. The five themes identified were: (i) The impact of Achilles Tendinopathy is commonly not prioritised with 'The acceptance and minimisation of pain' as a sub-theme (ii) Therapeutic alliance has the greatest impact on support (iii) Factors which influenced adherence (iv) Action Observation Therapy is valued and recommended (v) Recommendations for future interventions.

CONCLUSION

This study provides insightful recommendations around; exploring the use of Action Observation Therapy in Achilles Tendinopathy, the relative importance of therapeutic alliance rather than mode of therapy delivery, and that sufferers of Achilles Tendinopathy may not prioritise health seeking for this condition.

Victorian Institute of Sport Assessment-Achilles thresholds for minimal important change and return to presymptom activity level in active soldiers with mid-portion Achilles tendinopathy

INTRODUCTION

Mid-portion Achilles tendinopathy (mid-AT) is common in soldiers, significantly impacting activity levels and operational readiness. Currently, Victorian Institute of Sport Assessment-Achilles (VISA-A) represents the gold standard to evaluate pain and function in mid-AT. Our objective was to estimate VISA-A thresholds for minimal important change (MIC) and patient-acceptable symptom state for return to the presymptom activity level (PASS-RTA), in soldiers treated with a conservative programme for mid-AT.

METHODS

A total of 40 soldiers (40 unilateral symptomatic Achilles tendons) were included in this prospective cohort study. Pain and function were evaluated using VISA-A. Self-perceived recovery was assessed with the Global Perceived Effect scale. The predictive modelling method (MIC-predict) was used to estimate MIC VISA-A post-treatment (after 26 weeks) and after 1 year of follow-up. The post-treatment PASS-RTA VISA-A was estimated using receiver operating characteristic statistics. The PASS-RTA was determined by calculating Youden's index value closest to 1.

RESULTS

The adjusted MIC-predict was 6.97 points (95% CI 4.18 to 9.76) after 26 weeks and 7.37 points (95% CI 4.58 to 10.2) after 1 year of follow-up post-treatment.The post-treatment PASS-RTA was 95.5 points (95% CI 92.2 to 97.8).

CONCLUSIONS

A VISA-A change score of 7 points, post-treatment and at 1 year of follow-up, can be considered a minimal within-person change over time, above which soldiers with mid-AT perceive themselves importantly changed. Soldiers consider their symptoms to be acceptable for return to their presymptom activity level at a post-treatment VISA-A score of 96 points or higher.

TRIAL REGISTRATION NUMBER

NL69527.028.19.

What are small, medium and large effect sizes for exercise treatments of tendinopathy? A systematic review and meta-analysis

Objective

To quantify and describe effect size distributions from exercise therapies across a range of tendinopathies and outcome domains to inform future research and clinical practice through conducting a systematic review with meta-analysis.

Design

Systematic review with meta-analysis exploring moderating effects and context-specific small, medium and large thresholds.

Eligibility criteria

Randomised and quasi-randomised controlled trials involving any persons with a diagnosis of rotator cuff, lateral elbow, patellar, Achilles or gluteal tendinopathy of any severity or duration.

Methods

Common databases, six trial registries and six grey literature databases were searched on 18 January 2021 (PROSPERO: CRD42020168187). Standardised mean difference (SMD_pre) effect sizes were used with Bayesian hierarchical meta-analysis models to calculate the 0.25 (small), 0.5 (medium) and 0.75 quantiles (large) and compare pooled means across potential moderators. Risk of bias was assessed with Cochrane's Risk of Bias tool.

Results

Data were obtained from 114 studies comprising 171 treatment arms 4104 participants. SMD_pre effect sizes were similar across tendinopathies but varied across outcome domains. Greater threshold values were obtained for self-reported measures of pain (small=0.5, medium=0.9 and large=1.4), disability (small=0.6, medium=1.0 and large=1.5) and function (small=0.6, medium=1.1 and large=1.8) and lower threshold values obtained for quality of life (small=-0.2, medium=0.3 and large=0.7) and objective measures of physical function (small=0.2, medium=0.4 and large=0.7). Potential moderating effects of assessment duration, exercise supervision and symptom duration were also identified, with greater pooled mean effect sizes estimated for longer assessment durations, supervised therapies and studies comprising patients with shorter symptom durations.

Conclusion

The effect size of exercise on tendinopathy is dependent on the type of outcome measure assessed. Threshold values presented here can be used to guide interpretation and assist with further research better establishing minimal important change.

The Efficacy of Platelet-Rich Plasma Injection Therapy in the Treatment of Patients with Achilles Tendinopathy: A Systematic Review and Meta-Analysis

BACKGROUND

Over the past few years, many studies have been conducted to evaluate the effectiveness of platelet-rich plasma (PRP) in treating musculoskeletal conditions. However, there is controversy about its benefits for patients with Achilles tendinopathy.

OBJECTIVE

This study aimed to investigate whether platelet-rich plasma injections can improve outcomes in patients with Achilles tendinopathy.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, Web of Science, China Biomedical CD-ROM, and Chinese Science and Technology Journal databases to identify randomised controlled clinical trials that compared the efficacy of PRP injection in patients with Achilles tendinopathy (AT) versus placebo, published between 1 January 1966 and 1 December 2022. Review Manager 5.4.1 software was used for the statistical analysis, and the Jadad score was used to assess the included literature. Only 8 of the 288 articles found met the inclusion criteria.

RESULTS

Our work suggests that: The PRP treatment group had a slightly higher VISA-A score than the placebo group at 6 weeks [MD = 1.92, 95% CI (-0.54, 4.38), I² = 34%], at 12 weeks [MD = 0.20, 95% CI (-2.65 3.05), I² = 60%], and 24 weeks [MD = 2.75, 95% CI (-2.76, 8.26), I² = 87%]). However, the difference was not statistically significant. The Achilles tendon thickness was higher at 12 weeks of treatment in the PRP treatment group compared to the control group [MD = 0.34, 95% CI (-0.04, 0.71), p = 0.08], but the difference was not statistically significant. The VAS-improvement results showed no significant difference at 6 and 24 weeks between the two groups, respectively (MD = 6.75, 95% CI = (-6.12, 19.62), I² = 69%, p = 0.30), and (MD = 10.46, 95% CI = (-2.44 to 23.37), I² = 69%, p = 0.11). However, at 12 weeks of treatment, the PRP injection group showed a substantial VAS improvement compared to the control group (MD = 11.30, 95% CI = (7.33 to 15.27), I² = 0%, p < 0.00001). The difference was statistically significant. The return to exercise rate results showed a higher return to exercise rate in the PRP treatment group than the placebo group [RR = 1.11, 95% CI (0.87, 1.42), p = 0.40]; the difference was not statistically significant.

CONCLUSION

There is no proof that PRP injections can enhance patient functional and clinical outcomes for Achilles tendinopathy. Augmenting the frequency of PRP injections may boost the outcomes, and additionally, more rigorous designs and standardised clinical randomised controlled trials are needed to produce more reliable and accurate results.

Eccentric exercise is more effective than other exercises in the treatment of mid-portion Achilles tendinopathy: systematic review and meta-analysis

Achilles tendinopathy (AT) is one of the most frequent overuse injuries in the ankle. The evidence base for its conservative management AT continues to evolve, but there is still a gap in the evidence for the efficacy of any modality of treatment in high-quality studies. This systematic review and meta-analysis investigated the efficacy of EE in improving pain and function in adult patients with mid-portion Achilles tendinopathy compared to other forms of exercise. A search was performed in PubMed, BIREME, SportDiscus, Cinahl, Web of Science and PEDro, in November 2022. The methodological quality was evaluated using the Risk of Bias 2 tool (RoB2) of the Cochrane collaboration, and the meta-analysis was performed using the Review Manager 5.1 program. 2024 articles were identified and eight fulfilled the inclusion criteria. RoB2 presented a final score with 62.5% of the studies presented "some concerns", and 37.5% (five and three articles, respectively) presenting "high risk" of bias. EE was effective for the managment of AT. The only variable for which a meta-analysis was possible was pain (five articles), analysed with the visual analogue scale/numerical visual scale. The mean difference (MD) in treatment effect using EE was - 1.21 (- 2.72 to - 0.30) with a 95% of confidence interval (CI), thus identifying a significant positive effect for the improvement of pain in patients with AT in whom EE was used. EE is effective in the management of AT. The meta-analysis shows the need for appropriately powered randomized controlled trials with better design, the use of standard outcome measures and well-planned protocols for conservative management of AT.Level of evidence: Level 1.Registration: CRD42018118016.

One fifth of patients with Achilles tendinopathy have symptoms after 10 years: A prospective cohort study

Patients with midportion Achilles tendinopathy (AT) are thought to experience a gradual symptomatic improvement over time. The aim of this study was to prospectively investigate if patients with midportion AT have symptoms at 10-year follow-up. Patients withmidportion AT were invited to complete an online questionnaire 10 years after inclusion in an intervention trial. The primary outcomewas the presence of AT symptoms. Secondary outcomes were: the Victorian Institute of Sports Assessment-Achilles tendinopathy (VISA-A, 0-100) score and sports activity level. Of the 54 patientsincluded, 43 (80%) completed the questionnaire at an average follow-up of 10.4 years. Persisting symptoms were reported by 19%. The mean (standard deviation-SD) VISA-A score improved from 52 (17) at baseline to 79 (21) at 10-years follow-up with a mean change of 27 points (95% confidence interval: 21; 35, p < 0.001). Of the 38 active patients, 16 (42%) returned to their pre-injury level sports,of whom 14 (37%) performed them pain free. One-fifth of patients with conservatively treated midportion AT still have symptoms after 10years. One-third of patients were able to perform sports pain-free atpre-injury level. Patients should be adequately counselled to giverealistic expectations. Trial registration number: clinicaltrials.gov (identifier: NCT00761423).

Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials

Background

Extracorporeal shockwave therapy (ESWT) is used commonly to treat pain and function in Achilles tendinopathy (AT). The aim of this study was to synthesize the evidence from (non-) randomized controlled trials, to determine the clinical effectiveness of ESWT for mid-portion Achilles tendinopathy (mid-AT) and insertional Achilles tendinopathy (ins-AT) separately.

Methods

We searched PubMed/Medline, Embase (Ovid), and Cochrane Central, up to January 2021. Unpublished studies and gray literature were searched in trial registers (ACTRN, ChiCTR, ChiCtr, CTRI, DRKS, EUCTR, IRCT, ISRCTN, JPRN UMIN, ClinicalTrials.gov, NTR, TCTR) and databases (OpenGrey.eu, NARCIS.nl, DART-Europe.org, OATD.org). Randomized controlled trials (RCTs) and non-randomized controlled clinical trials (CCTs) were eligible when investigating the clinical effectiveness of ESWT for chronic mid-AT or chronic ins-AT. We excluded studies that focused on treating individuals with systemic conditions, and studies investigating mixed cohorts of mid-AT and ins-AT, when it was not possible to perform a subgroup analysis for both clinical entities separately. Two reviewers independently performed the study selection, quality assessment, data extraction, and grading of the evidence levels. Discrepancies were resolved through discussion or by consulting a third reviewer when necessary.

Results

We included three RCTs on mid-AT and four RCTs on ins-AT. For mid-AT, moderate quality of evidence was found for the overall effectiveness of ESWT compared to standard care, with a pooled mean difference (MD) on the VISA-A of 9.08 points (95% CI 6.35–11.81). Subgroup analysis on the effects of ESWT additional to standard care for mid-AT resulted in a pooled MD on the VISA-A of 10.28 points (95% CI 7.43–13.12). For ins-AT, we found very low quality of evidence, indicating that, overall, ESWT has no additional value over standard care, with a standardized mean difference (SMD) of − 0.02 (95% CI − 0.27 to 0.23). Subgroup analysis to determine the effect of ESWT additional to standard care for ins-AT showed a negative effect (SMD − 0.29; 95% CI − 0.56 to − 0.01) compared to standard care alone.

Conclusions

There is moderate evidence supporting the effectiveness of ESWT additional to a tendon loading program in mid-AT. Evidence supporting the effectiveness of ESWT for ins-AT is lacking.

Trial Registration: PROSPERO Database; No. CRD42021236107.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00456-5.

Poor association between tendon structure and self-reported symptoms following conservative management in active soldiers with mid-portion Achilles tendinopathy

Introduction

Mid-portion Achilles tendinopathy (mid-AT) is currently the preferred term for persistent Achilles tendon pain, defined as located 2–7 cm proximal to the calcaneus, and with loss of function related to mechanical loading. Histologically, mid-AT is considered to represent a degenerative condition. Therefore, monitoring of tendon structure additional to pain and function may be warranted, to prevent progression of degeneration or even tendon rupture. The aim of this study was to determine the association between pain and function, relative to the Achilles tendon structure, in soldiers treated with a conservative programme for mid-AT.

Methods

A total of 40 soldiers (40 unilateral symptomatic tendons) were included in this study. Pain and function were evaluated with the Victorian Institute of Sports Assessment -Achilles (VISA-A) questionnaire. Tendon structure was quantified using ultrasound tissue characterisation (UTC). We quantified both the Achilles tendon mid-portion (2–7 cm) and the area of maximum degeneration (AoMD) within the tendon mid-portion. VISA-A and UTC measurements were taken at baseline and after 26 weeks of follow-up. Spearman’s rho was used to determine the correlation between VISA-A and UTC. Correlations were calculated for baseline, follow-up and change score values.

Results

Negligible correlations were found for all analyses, ranging from −0.173 to 0.166 between mid-portion tendon structure and VISA-A, and from −0.137 to 0.150 between AoMD and VISA-A. While VISA-A scores improved, on average, from 59.4 points at baseline to 93.5 points at follow-up, no detectable improvement in aligned fibrillar structure was observed in our population.

Conclusion

Pain and function are poorly associated with Achilles tendon structure in soldiers treated with a conservative programme for mid-AT. Therefore, we advise clinicians to use great caution in communicating relationships between both clinical entities.

Trial registration number

NL69527.028.19.

A comparison between the efficacy of eccentric exercise and extracorporeal shock wave therapy on tendon thickness, vascularity, and elasticity in Achilles tendinopathy: A randomized controlled trial

Objectives: This study aims to compare the efficacy of the eccentric exercise (EE) and extracorporeal shock wave therapy (ESWT) on chronic midportion Achilles tendinopathy and evaluate the efficacy of these treatment modalities on tendon thickness, vascularity, and elasticity.

Patients and methods: In this randomized controlled trial, a total of 63 patients (40 females, 23 males; mean age: 37.3±12.2; range, 18 to 55 years) with chronic midportion Achilles tendinopathy were enrolled between April 2017 and December 2019. The patients were allocated randomly to two groups: the first group was treated with EE every day for three months with the Alfredson protocol, and the second group received four sessions of ESWT at weekly intervals. The study was terminated at the end of three months. Visual Analog Scales (VAS), Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaires, and ultrasonography measurements were assessed before and after treatment. Patient pain was evaluated at the two-year follow-up.

Results: At the three-month follow up, VAS scores decreased, and VISA-A scores increased in both groups (p<0.001). At the two-year-follow-up, VAS scores significantly decreased in the EE group (p<0.001), but the difference was statistically insignificant in the ESWT group (p=0.095). Tendon thickness and stiffness increased in the EE group (p=0.003 and p=0.03, respectively) while the difference was statistically insignificant in the ESWT group after treatment (p=0.173 and p=0.702, respectively).

Conclusion: Eccentric exercise and ESWT are efficient in the short term, whereas EE is efficient on tendon pain in the long term. While EE increases tendon thickness and stiffness, ESWT has no effect on these measures.

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.

Evaluating daily physical activity and biomechanical measures using wearable technology in people with Achilles tendinopathy: A descriptive exploratory study

BACKGROUND

Load management is considered an important factor for prevention and treatment of Achilles tendinopathy. However, little attention has been given to monitoring daily load objectively in this population.

OBJECTIVES

We aimed to explore patterns in proxies of daily load derived from a six-axis inertial measurement unit (IMU) over a one-week period and the concordance between day-to-day fluctuation in pain intensity and IMU measures.

DESIGN

Descriptive exploratory study.

METHOD

Ten participants with Achilles tendinopathy (age: 53.00 ± 12.37) wore an IMU on the affected ankle for one week. Participants were contacted via text message three times daily to rate their worst pain intensity. Physical activity and biomechanical measures derived from the IMU signals including daily number of steps, peak stride rate, peak shank acceleration, and peak shank angular velocity were calculated.

RESULTS

The relationship between weekly worst pain and physical activity levels appeared modest; with increased steps not seeming to be linked to increased or reduced pain levels. According to the daily pain and daily IMU measures, a concordant pattern was evident in younger, highly active participants. However, in the middle-aged/older less active participants, there was either a fluctuation in pain intensity without fluctuation in the IMU measures, or a stable pattern of both pain and IMU measures.

CONCLUSIONS

Our exploratory study results suggest that continuous monitoring of proxies of daily load measures in parallel with pain may provide information about load management strategies in people with Achilles tendinopathy. Monitoring of these proxies may ultimately have a role in improving Achilles tendinopathy management.

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.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

The Reliability and Validity of a Novel Ankle Isometric Plantar Flexion Strength Test

CONTEXT

Strengthening of ankle plantar flexor muscles is one of the important components in the rehabilitation of many lower limb injuries and disorders. However, there are few simple methods to evaluate ankle plantar flexor strength in clinical situations without using equipment. The purpose of this study was to verify the intraexaminer and interexaminer reliability and the concurrent validity of a novel ankle isometric plantar flexion (PF) strength test (PF break test [PFBT]).

DESIGN

Case-control study.

METHODS

The intraexaminer and interexaminer reliabilities of the PFBT were evaluated in 57 orthopedic patients and 30 healthy adults. The range of motion of the ankle joint and the number of heel raises were compared between positive and negative PFBT cases. Then, isometric ankle PF torque (ankle PF of 0°, 15°, and 30°) was compared in knee extension and in the 50° flexion position between positive and negative PFBT cases in 30 healthy adults.

RESULTS

The intraexaminer reliability (κ) of the PFBT was .81 to .94, and the interexaminer reliability (κ) was .37 to .74. The PFBT positive group had a significantly smaller range of motion in the ankle joint (P < .05) and a significantly lower number of heel raises (P < .001) than the PFBT negative group in orthopedic patients, but no significant differences in healthy adults. The PFBT positive group had less ankle PF torque than the PFBT negative group at all ankle PF angles (P < .01). The isometric PF torque in the end range of ankle PF in knee extension could predict the results of the PFBT and correctly classified 90.0% of cases (P < .001).

CONCLUSION

The PFBT is considered a simple and valid method to evaluate isometric ankle PF strength in the clinical setting.

Runners with mid-portion Achilles tendinopathy have greater triceps surae intracortical inhibition than healthy controls

OBJECTIVES

This study aimed to investigate short-interval intracortical inhibition (SICI) and muscle function in the triceps surae of runners with mid-portion Achilles tendinopathy (AT).

METHODS

Runners with (n = 11) and without (n = 13) AT were recruited. Plantar flexor isometric peak torque and rate of torque development (RTD) were measured using an isokinetic dynamometer. Triceps surae endurance was measured as single-leg heel raise (SLHR) to failure test. SICI was assessed using paired-pulse transcranial magnetic stimulation during a sustained contraction at 10% of plantar flexor isometric peak torque.

RESULTS

Triceps surae SICI was 14.3% (95% CI: -2.1 to 26.4) higher in AT than in the control group (57.9%, 95% CI: 36.2 to 79.6; and 43.6% 95% CI: 16.2 to 71.1, p = 0.032) irrespective of the tested muscle. AT performed 16 (95% CI: 7.9 to 23.3, p < 0.001) fewer SLHR repetitions on the symptomatic side compared with controls, and 14 (95% CI: 5.8 to 22.0, p = 0.004), fewer SLHR repetitions on the non-symptomatic compared with controls. We found no between-groups differences in isometric peak torque (p = 0.971) or RTD (p = 0.815).

PERSPECTIVE

Our data suggest greater intracortical inhibition for the triceps surae muscles for the AT group accompanied by reduced SLHR endurance, without deficits in isometric peak torque or RTD. The increased SICI observed in the AT group could be negatively influencing triceps surae endurance; thus, rehabilitation aiming to reduce intracortical inhibition should be considered to improve patient outcomes. Furthermore, SLHR is a useful clinical tool to assess plantar flexor function in AT patients.

Efficacy of high-volume injections with and without corticosteroid compared with sham for Achilles tendinopathy: a protocol for a randomised controlled trial

Introduction

Achilles tendinopathy (AT) is a common and disabling musculoskeletal condition. First-line management involving Achilles tendon loading exercise with, or without, other modalities may not resolve the problem in up to 44% of cases. Many people receive injections. Yet there are no injection treatments with demonstrated long-term efficacy. The aim of the trial is to examine the 12-month efficacy of high-volume injection (HVI) with corticosteroid and HVI without corticosteroid versus sham injection among individuals with AT.

Methods and analysis

The trial is a three-arm, parallel group, double-blind, superiority randomised controlled trial that will assess the efficacy of HVI with and without corticosteroid versus sham up to 12 months. We will block-randomise 192 participants to one of the three groups with a 1:1:1 ratio, and both participants and outcome assessors will be blinded to treatment allocation. All participants will receive an identical evidence-based education and exercise intervention. The primary outcome measure will be the Victorian Institute of Sport Assessment - Achilles (VISA-A) at 12 months post-randomisation, a validated, reliable and disease-specific measure of pain and function. Choice of secondary outcomes was informed by core outcome domains for tendinopathy. Data will be analysed using the intention-to-treat principle.

Ethics and dissemination

Ethics approval was obtained via the Monash University Human Ethics Committee (no: 13138). The study is expected to be completed in 2024 and disseminated via peer review publication and conference presentations.

Trial registration number

Australia and New Zealand Clinical trials registry (ACTRN12619001455156).

No Difference in Clinical Effects When Comparing Alfredson Eccentric and Silbernagel Combined Concentric-Eccentric Loading in Achilles Tendinopathy: A Randomized Controlled Trial

Background:

Alfredson isolated eccentric loading and Silbernagel concentric–eccentric loading have both shown beneficial effects on clinical symptoms in midportion Achilles tendinopathy (AT), but they have never been compared directly.

Purpose:

To test for differences in clinical effects at 1-year follow-up between Alfredson and Silbernagel loading in midportion AT.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

A total of 40 recreational athletes were allocated to the Alfredson group (AG) or the Silbernagel group (SG). The primary outcome was the difference in the Victorian Institute of Sports Assessment–Achilles (VISA-A) at 1-year follow-up. Secondary outcomes were the visual analog scale for pain during activities of daily living (VAS-ADL) and sports activities (VAS–sports), the EuroQol 5 Dimensions instrument (EQ-5D), and global perceived effect score. Measurements were performed at baseline and 12-week, 26-week, and 1-year follow-up. Analysis was performed using a linear mixed-regression model with intervention (AG vs SG), time (12 weeks, 26 weeks, and 1 year postoperatively), and intervention-by-time interaction.

Results:

The VISA-A score improved for both AG and SG, from 60.7 ± 17.1 at baseline to 89.4 ± 13.0 at 1-year follow-up and from 59.8 ± 22.2 to 83.2 ± 22.4, respectively (P < .001 for both). Because the interaction term did not significantly improve the model, we reported a treatment effect without interaction term, indicating a constant difference at each follow-up. The linear mixed model with correction for baseline VISA-A and confounders revealed a nonsignificant treatment effect (2.4 [95% CI, –8.5 to 13.3]; P = .656). In addition, after adjustment for the respective baseline values and confounders, nonsignificant treatment effects were found for the VAS-ADL (–2.0 [95% CI, –11.3 to 7.3]; P = .665) and VAS-sports (1.3 [95% CI, –12.8 to 15.3], P = .858). The EQ-5D subscales improved in both groups. After 1 year, significantly more SG participants considered themselves improved (77.3% [SG] vs 50.0% [AG]; P = .04).

Conclusion:

No differences in clinical effects were found between Alfredson and Silbernagel loading at up to 1-year follow-up. Both programs significantly improved clinical symptoms, and given their high adherence rates, offering either of them as a home-based program with limited supervision appears to be an effective treatment strategy for midportion AT.

Registration:

NTR5638 (Netherlands Trial Register number).

Ultrasound evaluation of the patellar tendon and Achilles tendon and its association with future pain in distance runners

Objectives: To examine whether asymptomatic ultrasonographic abnormalities in the Achilles and patellar tendons in runners are associated with an increased risk of pain development.Methods: This is a longitudinal, prospective cohort study with 139 runners recruited at a half and full marathon race. Ultrasound examination of the Achilles and patellar tendons was performed bilaterally the day prior to the race. Self-reported injury data were collected at 1, 3, 6 and 12 months. 104 (74.8%) runners were included in the data analysis.Results: Ultrasonographic tendon abnormalities were found in 24.1% of the Achilles and in 23.1% of the patellar tendons prior to the race. Runners with tendon abnormality were 2-3 times more likely to develop pain within 12 months than those without (relative risk = 3.14, p = 0.010 for Achilles; relative risk = 2.52, p = 0.008 for patellar tendon). After adjusting for gender, age, years of running, average miles per week of running over a year, and pre-race pain, runners with ultrasound abnormality were about 3 times (hazard ratio = 2.89, p = 0.039 for Achilles; hazard ratio = 2.73, p = 0.030 for patellar tendon) more likely to develop pain after the race. Tendon delamination was most strongly associated with pain in both the Achilles (relative risk = 6.00; p = 0.001) and patellar tendons (relative risk = 3.81; p = 0.001).Conclusions: Structural changes in asymptomatic tendons were found in almost 25% of runners. Presence of structural changes was associated with increased development of Achilles and patellar tendon pain within one year.

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.

Autoregulation in Resistance Training for Lower Limb Tendinopathy: A Potential Method for Addressing Individual Factors, Intervention Issues, and Inadequate Outcomes

Musculoskeletal disorders, such as tendinopathy, are placing an increasing burden on society and health systems. Tendinopathy accounts for up to 30% of musculoskeletal disorders, with a high incidence in athletes and the general population. Although resistance training has shown short-term effectiveness in the treatment of lower limb tendinopathy, more comprehensive exercise protocols and progression methods are required due to poor long-term outcomes. The most common resistance training protocols are predetermined and standardized, which presents significant limitations. Current standardized protocols do not adhere to scientific resistance training principles, consider individual factors, or take the importance of individualized training into account. Resistance training programs in case of tendinopathy are currently not achieving the required intensity and dosage, leading to high recurrence rates. Therefore, better methods for individualizing and progressing resistance training are required to improve outcomes. One potential method is autoregulation, which allows individuals to progress training at their own rate, taking individual factors into account. Despite the finding of their effectiveness in increasing the strength of healthy athletes, autoregulation methods have not been investigated in case of tendinopathy. The purpose of this narrative review was 3-fold: firstly, to give an overview and a critical analysis of the individual factors involved in tendinopathy and current resistance training protocols and their limitations. Secondly, to give an overview of the history, methods, and application of autoregulation strategies both in sports performance and physiotherapy. Finally, a theoretical adaptation of a current tendinopathy resistance training protocol using autoregulation methods is presented, providing an example of how the method could be implemented in clinical practice or future research.

Gagnon D. To What Extent Do Musculoskeletal Ultrasound Biomarkers Relate to Pain, Flexibility, Strength, and Function in Individuals With Chronic Symptomatic Achilles Tendinopathy?

Introduction: Achilles tendinopathy (AT) is a chronic musculoskeletal pathology best evaluated by ultrasound imaging. This cross-sectional study aimed at better understanding the relationship between musculoskeletal ultrasound biomarkers (MUBs) of Achilles tendon and localized pain, ankle flexibility, ankle strength, and functional abilities.

Method: Forty-one participants with unilateral midportion chronic AT had their tendon images analyzed bilaterally in the longitudinal and transverse planes. The Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) and Lower Extremity Functional Scale (LEFS) assessed pain and function, respectively, during standing and walking-related activities. Ankle flexibility was evaluated by weight-bearing lunge tests, while ankle isometric peak strength was measured using an instrumented dynamometer. Achilles tendon ultrasonographic images were analyzed using geometric (thickness), composition (echogenicity), and texture (homogeneity) MUBs. Discriminative validity was evaluated using paired Student's t-tests to compare MUBs between symptomatic and asymptomatic sides. Predictive validity was evaluated by computing the Pearson product-moment correlations coefficient between MUBs and pain, ankle flexibility, ankle strength, and function.

Results: Significant differences were found in MUBs between the symptomatic and asymptomatic sides, confirming the discriminative validity of the selected MUBs. On the symptomatic side, thickness was found 29.9% higher (p < 0.001), echogenicity 9.6% lower (p < 0.001), and homogeneity 3.8% higher (p = 0.001) when compared with the asymptomatic side. However, predictive validity was scarcely confirmed, as most of the correlation coefficients were found negligible for the associations investigated between MUBs with localized pain, ankle flexibility, strength, and function. Only 14 statistically significant low to moderate associations were found, with negative and positive correlations ranging between −0.31 and −0.55 and between 0.34 and 0.54, respectively.

Discussion: Musculoskeletal ultrasound biomarkers have a clinical utility in visualizing in vivo tendon integrity and diagnosing AT. MUBs should be valued as part of a comprehensive neuro-musculoskeletal assessment as they complement pain, flexibility, strength, and function measures. Altogether, they may inform the development and monitoring of a personalized rehabilitation treatment plan.

Dutch multidisciplinary guideline on Achilles tendinopathy

Objective

To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients.

Design

Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase.

Data sources

Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference.

Study eligibility criteria

Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module.

Data extraction and synthesis

To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations.

Primary outcome measure

The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions.

Results

Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy.

Summary/conclusion

Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice.

Achilles Scraping and Plantaris Tendon Removal Improves Pain and Tendon Structure in Patients with Mid-Portion Achilles Tendinopathy-A 24 Month Follow-Up Case Series

Background: Studies have demonstrated that a sub-group of patients with medial Achilles pain exhibit Achilles tendinopathy with plantaris tendon involvement. This clinical condition is characterised by structural relationships and functional interference between the two tendons, resulting in compressive or shearing forces. Surgical plantaris tendon removal together with an Achilles scraping procedure has demonstrated positive short-term clinical results. The aim of this case series was to determine the long-term outcomes on pain and Achilles tendon structure. Methods: 18 consecutive patients (13 males; 5 females; mean age 39 years; mean symptom duration 28 months), of which three were elites, were included. Clinical examination, b-mode ultrasound (US) and Ultrasound Tissue Characterisation (UTC) confirmed medial Achilles tendon pain and tenderness, medial Achilles tendinopathy plus a plantaris tendon located close to the medial side of the Achilles tendon. Patients underwent US-guided local Achilles scraping and plantaris tendon removal followed by a structured rehabilitation program. Outcomes were VISA-A score for pain and function and UTC for Achilles structure. Results: 16 of 18 patients completed the 24 months follow-up. Mean VISA-A scores increased from 58.2 (±15.9) to 92.0 (±9.2) (mean difference = 33.8, 95% CI 25.2, 42.8, p < 0.01). There was an improvement in Achilles structure with mean organised echo pixels (UTC type I+II, in %) increasing from 79.9 (±11.5) to 86.4 (±10.0) (mean difference = 6.5%, 95% CI 0.80, 13.80, p =0.01), exceeding the 3.4% minimum detectable change. All 16 patients reported satisfaction with the procedure and 14 returned to pre-injury activity levels. There were no reported complications. Conclusions: Improved pain, function and tendon structure were observed 24 months after treatment with Achilles scraping and plantaris excision. The improvement in structure on the medial side of the Achilles after plantaris removal indicates that compression from the plantaris tendon might be an important presenting factor in this sub-group.

Are pain coping strategies and neuropathic pain associated with a worse outcome after conservative treatment for Achilles tendinopathy? A prospective cohort study

OBJECTIVES

To analyse whether (1) passive or active pain coping strategies and (2) presence of neuropathic pain component influences the change of Achilles tendinopathy (AT) symptoms over a course of 24 weeks in conservatively-treated patients.

DESIGN

Prospective cohort study.

METHODS

Patients with clinically-diagnosed chronic midportion AT were conservatively treated. At baseline, the Pain Coping Inventory (PCI) was used to determine scores of coping, which consisted of two domains, active and passive (score ranging from 0 to 1; the higher, the more active or passive). Presence of neuropathic pain (PainDETECT questionnaire, -1 to 38 points) was categorized as (a) unlikely (≤12 points), (b) unclear (13-18 points) and (c) likely (≥19 points). The symptom severity was determined with the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire (0-100) at baseline, 6, 12 and 24 weeks. We analysed the correlation between (1) PCI and (2) PainDETECT baseline scores with change in VISA-A score using an adjusted Generalized Estimating Equations model.

RESULTS

Of 80 included patients, 76 (95%) completed the 24-weeks follow-up. The mean VISA-A score (standard deviation) increased from 43 (16) points at baseline to 63 (23) points at 24 weeks. Patients had a mean (standard deviation) active coping score of 0.53 (0.13) and a passive score of 0.43 (0.10). Twelve patients (15%) had a likely neuropathic pain component. Active and passive coping mechanisms and presence of neuropathic pain did not influence the change in AT symptoms (p=0.459, p=0.478 and p=0.420, respectively).

CONCLUSIONS

Contrary to widespread belief, coping strategy and presence of neuropathic pain are not associated with a worse clinical outcome in this homogeneous group of patients with clinically diagnosed AT.

Contralateral mechanical hyperalgesia and altered pain modulation in men who have unilateral insertional Achilles tendinopathy: A cross-sectional study

OBJECTIVE

The primary aim was to assess whether men who have insertional Achilles tendinopathy (IAT) have altered endogenous modulation of painful stimuli, and secondarily if they exhibit unaffected-side pressure hyperalgesia.

METHODS

Using a cross-sectional design, we recruited men with unilateral IAT and asymptomatic men as controls matched for age, body mass index (BMI) and activity history (participation in running, lower limb loading sport or sedentary). We collected pressure pain threshold (PPT) at the asymptomatic side Achilles tendon insertion for cases, and dominant side Achilles tendon insertion for controls. We compared PPT between groups before and after immersion of the hand in painful cold water.

RESULTS

Twenty men with unilateral IAT (45.4 years [SD 10.02], BMI 29.09 [SD 4.61], 60% sedentary) and 34 men without symptoms (43.2 years [SD 8.78], BMI 27.59 [SD 3.18], 50% sedentary) participated. An interaction effect was found for group x time (F (1,50) = 7.67, p = 0.008), with PPT increase after cold water immersion being 1.20 (95%CI 0.25 to 2.15) Kg greater in the control group (1.44 Kg [SD 1.79]) compared to IAT unaffected side (0.24 Kg [SD 1.47]). Before cold water immersion, PPT was 4.77 (CI 3.22 to 6.31; p < 0.001) Kg greater in the control group.

DISCUSSION

This study provides evidence men with IAT have altered endogenous modulation of a painful stimulus, and display pressure hyperalgesia at their unaffected side compared to men without symptoms. These findings infer alterations to pain processing in men with IAT, suggesting nociplastic mechanism(s) may contribute to pain.

Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials

OBJECTIVE

To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy.

DESIGN

Living systematic review and network meta-analysis.

DATA SOURCES

Multiple databases including grey literature sources were searched up to February 2019.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials examining the effectiveness of any treatment in patients with both insertional and/or midportion Achilles tendinopathy. We excluded trials with 10 or fewer participants per treatment arm or trials investigating tendon ruptures.

DATA EXTRACTION AND SYNTHESIS

Reviewers independently extracted data and assessed the risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation to appraise the certainty of evidence.

PRIMARY OUTCOME MEASURE

The validated patient-reported Victorian Institute of Sport Assessment-Achilles questionnaire.

RESULTS

29 trials investigating 42 different treatments were included. 22 trials (76%) were at high risk of bias and 7 (24%) had some concerns. Most trials included patients with midportion tendinopathy (86%). Any treatment class seemed superior to wait-and-see for midportion Achilles tendinopathy at 3 months (very low to low certainty of evidence). At 12 months, exercise therapy, exercise+injection therapy and exercise+night splint therapy were all comparable with injection therapy for midportion tendinopathy (very low to low certainty). No network meta-analysis could be performed for insertional Achilles tendinopathy.

SUMMARY/CONCLUSION

In our living network meta-analysis no trials were at low risk of bias and there was large uncertainty in the comparative estimates. For midportion Achilles tendinopathy, wait-and-see is not recommended as all active treatments seemed superior at 3-month follow-up. There seems to be no clinically relevant difference in effectiveness between different active treatments at either 3-month or 12-month follow-up. As exercise therapy is easy to prescribe, can be of low cost and has few harms, clinicians could consider starting treatment with a calf-muscle exercise programme.

PROSPERO REGISTRATION NUMBER

CRD42018086467.

A novel murine muscle loading model to investigate Achilles musculotendinous adaptation

Achilles tendinopathy is a debilitating condition affecting the entire spectrum of society and a condition that increases the risk of tendon rupture. Effective therapies remain elusive, as anti-inflammatory drugs and surgical interventions show poor long-term outcomes. Eccentric loading of the Achilles muscle-tendon unit is an effective physical therapy for treatment of symptomatic human tendinopathy. Here, we introduce a novel mouse model of hindlimb muscle loading designed to achieve a tissue-targeted therapeutic exercise. This model includes the application of tissue (muscle and tendon)-loading "doses," coupled with ankle dorsiflexion and plantarflexion, inspired by human clinical protocols. Under computer control, the foot was rotated through the entire ankle joint range of motion while the plantar flexors simultaneously contracted to simulate body mass loading, consistent with human therapeutic exercises. This approach achieved two key components of the heel drop and raise movement: ankle range of motion coupled with body mass loading. Model development entailed the tuning of parameters such as footplate speed, number of repetitions, number of sets of repetitions, treatment frequency, treatment duration, and treatment timing. Initial model development was carried out on uninjured mice to define a protocol that was well tolerated and nondeleterious to tendon biomechanical function. When applied to a murine Achilles tendinopathy model, muscle loading led to a significant improvement in biomechanical outcome measures, with a decrease in cross-sectional area and an increase in material properties, compared with untreated animals. Our model facilitates the future investigation of mechanisms whereby rehabilitative muscle loading promotes healing of Achilles tendon injuries.NEW & NOTEWORTHY We introduce a novel mouse model of hindlimb muscle loading designed to achieve a tissue-targeted therapeutic exercise. This innovative model allows for application of muscle loading "doses," coupled with ankle dorsiflexion and plantarflexion, inspired by human loading clinical treatment. Our model facilitates future investigation of mechanisms whereby rehabilitative muscle loading promotes healing of Achilles tendon injuries.

Telehealth sounds a bit challenging, but it has potential: participant and physiotherapist experiences of gym-based exercise intervention for Achilles tendinopathy monitored via telehealth

Background

Although telehealth is becoming more popular for delivery of care for individuals with musculoskeletal pain, to our knowledge telehealth has not been used to manage Achilles tendinopathy. This research aimed to explore the experience of participants and physiotherapists with gym-based exercise interventions for Achilles tendinopathy monitored via videoconference.

Methods

A qualitative, interpretive description design was performed using semi-structured interviews (8 participants) and a focus group (7 physiotherapists). Participants and physiotherapists were interviewed about their experiences of the use of telehealth during a gym-based exercise intervention incorporating different calf load parameters for Achilles tendinopathy. We employed an inductive thematic analysis approach to analyse the data.

Results

Three themes identified from both participants and physiotherapists included i) acceptability of telehealth; ii) enablers to adherence with telehealth; and iii) barriers to adherence with telehealth. Two extra themes arose from participants regarding adherence with gym-based exercise, including enablers to adherence with the exercise intervention, and barriers to adherence with the exercise intervention. Both participants and physiotherapists expressed overall satisfaction and acceptability of telehealth monitoring of gym-based exercise.

Conclusion

Gym-based exercise intervention for Achilles tendinopathy involving weekly telehealth monitoring was acceptable to both participants and physiotherapists. Potential enablers and barriers were identified that may improve adherence to this type of intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03907-w.

Participant characteristics are poorly reported in exercise trials in tendinopathy: A systematic review

OBJECTIVE

To evaluate the reporting of eligibility criteria and baseline participant characteristics in randomised controlled trials investigating the effects of exercise interventions in tendinopathy.

METHODS

Randomised controlled trials investigating the effects of exercise therapy compared to a non-exercising intervention in upper and lower limb tendinopathy were included. Data extraction was categorised into the following domains: participant demographics, tendinopathy descriptors, general health, participant recruitment and eligibility criteria.

RESULTS

The review included the following tendinopathies: Achilles (n = 9), gluteal (n = 2), lateral elbow tendinopathy (n = 15), patellar (n = 3) plantar (n = 3), and rotator cuff (n = 13). Age, sex, duration of symptoms and symptom severity were commonly reported across the review, while prior history of tendinopathy was poorly reported (6/45). Variables such as physical activity level (17/45), sleep (0/45), psychological factors (2/45), medication at baseline (8/45), co morbid health complaints (10/45) and sociodemographic factors (11/45) were poorly reported across the included studies. Substantial variation existed between studies in the specific eligibility criteria used.

CONCLUSION

The findings of this systematic review demonstrate that participant characteristics are poorly reported in exercise trials in tendinopathy. To improve effectiveness of exercise interventions in tendinopathy, improved reporting of participant characteristics may allow better comparisons and targeted interventions for specific subgroups.

How many runners with new-onset Achilles tendinopathy develop persisting symptoms? A large prospective cohort study

BACKGROUND

Achilles tendinopathy (AT) occurs in half of the elite runners. AT is a difficult-to-treat tendon disease, which may progress from new onset to a chronic state. It is unknown how many runners with new-onset AT develop persisting symptoms and which prognostic factors are associated with this course.

OBJECTIVE

To describe how many runners develop persisting symptoms 1 year after onset of reactive AT.

STUDY DESIGN

Prospective cohort study.

METHODS

Runners registering for a Dutch running event (5-42.2 km) were eligible for inclusion. Runners reporting new-onset AT between registration for the running event and 1 month after received a 1-year follow-up questionnaire. The 1-year follow-up questionnaire inquired about persisting symptoms (yes/no), running activity, and metabolic disorders. We calculated the percentage of runners with persisting symptoms and performed a multivariable logistic regression analysis to study the association between potential prognostic factors and persisting symptoms.

RESULTS

Of 1929 participants, 100 runners (5%) reported new-onset AT. A total of 62 runners (62%) filled in the 1-year follow-up questionnaire. Persisting symptoms were reported by 20 runners (32%). A higher running distance per week before new-onset AT was associated with a lower risk of developing persisting symptoms (odds ratio (OR): 0.9, 95% confidence interval (CI): [0.9;1.0]). There was a positive trend toward an association between metabolic disorders and persisting symptoms (OR: 5.7, 95% CI: [0.9;36.2]).

CONCLUSION

One third of runners develop persisting symptoms 1 year after new-onset AT. Interestingly, a higher running distance per week before new-onset AT potentially lowers the risk of developing persisting symptoms.

Short- and Long-Term Exercise Results in a Differential Achilles Tendon Mechanical Response

The study was conducted to define the biomechanical response of rat Achilles tendon after a single bout of exercise and a short or long duration of daily exercise. We hypothesized that a single bout or a short duration of exercise would cause a transient decrease in Achilles tendon mechanical properties and a long duration of daily exercise would improve these properties. One hundred and thirty-six Sprague-Dawley rats were divided into cage activity (CA) or exercise (EX) groups for a single bout, short-term, or long-term exercise. Animals in single bout EX groups were euthanized, 3, 12, 24, or 48 h upon completion of a single bout of exercise (10 m/min, 1 h) on a flat treadmill. Animals in short-term EX groups ran on a flat treadmill for 3 days, 1, or 2 weeks while animals in long-term EX groups ran for 8 weeks. Tendon quasi-static and viscoelastic response was evaluated for all Achilles tendons. A single bout of exercise increased tendon stiffness after 48 h of recovery. Short-term exercise up to 1 week decreased cross-sectional area, stiffness, modulus, and dynamic modulus of the Achilles tendon. In contrast, 8 weeks of daily exercise increased stiffness, modulus, and dynamic modulus of the tendon. This study highlights the response of Achilles tendons to single and sustained bouts of exercise. Adequate time intervals are important to allow for tendon adaptations when initiating a new training regimen and overall beneficial effects to the Achilles tendon.

Isometric exercises do not provide immediate pain relief in Achilles tendinopathy: A quasi-randomized clinical trial

Background

Isometric exercises may provide an immediate analgesic effect in patients with lower‐limb tendinopathy and have been proposed as initial treatment and for immediate pain relief. Current evidence is conflicting, and previous studies were small.

Objective

To study whether isometric exercises result in an immediate analgesic effect in patients with chronic midportion Achilles tendinopathy.

Methods

Patients with clinically diagnosed chronic midportion Achilles tendinopathy were quasi‐randomized to one of four arms: isometric calf‐muscle exercises (tiptoes), isometric calf‐muscle exercises (dorsiflexed ankle position), isotonic calf‐muscle exercises, or rest. The primary outcome was pain measured on a visual analogue scale (VAS) score (0‐100) during a functional task (10 unilateral hops) both before and after the intervention. Between‐group differences were analyzed using a generalized estimation equations model.

Results

We included 91 patients. There was no significant reduction in pain on the 10 hop test after performing any of the four interventions: isometric (tiptoes) group 0.2, 95%CI −11.2 to 11.5; isometric (dorsiflexed) group −1.9, 95%CI −13.6 to 9.7; isotonic group 1.4, 95%CI −8.3 to 11.1; and rest group 7.2, 95%CI −2.4 to 16.7. There were also no between‐group differences after the interventions.

Conclusion

The isometric exercises investigated in this study did not result in immediate analgesic benefit in patients with chronic midportion Achilles tendinopathy. We do not recommend isometric exercises if the aim is providing immediate pain relief. Future research should focus on the use of isometric or isotonic exercise therapy as initial treatment as all exercise protocols used in this study were well‐tolerated.

Meta-analysis of Noninsertional Achilles Tendinopathy

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional. A variety of treatment methods have been described, although little consensus exists on an optimal method or methods. We sought to investigate the current evidence on different treatment methods for noninsertional Achilles tendinopathy, with a focus on functional outcomes.

METHODS

We performed a review of the available literature in PubMed and the Cochrane Central Register of Controlled Trials. Data from included studies were categorized according to treatment method and analyzed with respect to functional outcome and complication rate.

RESULTS

In total, 1420 abstracts were reviewed, of which 72 articles containing 3523 patients met inclusion criteria. Within the 72 studies included, 6 operative techniques and 19 nonoperative treatments were evaluated.

CONCLUSION

A wide variety of treatments are available for noninsertional Achilles tendinopathy, although newer treatments and most operative methods lack high-level evidence. Eccentric exercise is the most thoroughly studied and supported nonoperative treatment, while tenotomy and debridement is the operative procedure with the most evidence of efficacy. Platelet-rich plasma injections and extracorporeal shockwave therapy have proven to be viable second-line nonoperative treatments. Gastrocnemius recession and flexor hallucis longus transfer have shown benefit in case series.

LEVEL OF EVIDENCE

Level II, systematic review.

"It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away." A qualitative study exploring individuals' beliefs and experiences of Achilles tendinopathy

Background

Achilles tendinopathy (AT) is a common and often persistent musculoskeletal disorder affecting both athletic and non-athletic populations. Despite the relatively high incidence there is little insight into the impact and perceptions of tendinopathy from the individual’s perspective. Increased awareness of the impact and perceptions around individuals’ experiences with Achilles tendinopathy may provide crucial insights for the management of what is often a complex, persistent, and disabling MSK disorder.

Purpose

To qualitatively explore the lived experiences of individuals with AT.

Design

A qualitative, interpretive description design was performed using semi-structured telephone interviews.

Methods

Semi-structured interviews were conducted on 15 participants (8 male and 7 female) with AT. Thematic analysis was performed using the guidelines laid out by Braun and Clarke. The study has been reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Results

Four main themes were identified from the data: 1) beliefs and perceptions surrounding AT: “If I'm over training or something, I don't really know”, 2) the biopsychosocial impact of AT: “I think it restricts me in a lot of things that I would be able to do”, 3) individuals’ experiences with the management process: “You want it to happen now. You're doing all this stuff and it's just very slow progress”, and 4) future prognosis and outlook in individuals with AT: “I see myself better”.

Conclusions

This study offers a unique insight into the profound impact and consequences of Achilles tendinopathy in a mixed sample of both athletic and non-athletic individuals. The findings of this study have important clinical implications. Specifically, it highlights the need for clinicians to recognize and adopt treatment approaches to embrace a more biopsychosocial approach for the management of tendinopathy.

To Compare the Effect of Eccentric Exercises and Isometric Exercises for Achilles Tendinitis in Skaters

Background

Achilles tendinitis is one of the commonest injuries that happen to skaters. Roller skates traditionally have four wheels onto axles, one under the ball of the foot and one under the heel. Skaters have to maintain a closed kinematics chain which involves continuous trunk and hip flexion along with knee flexion and ankle dorsiflexion. It creates angular tension and strain in the muscles and tendons which can lead to different types of musculotendinous injuries. As not many studies has not been done on the prospect in India this study was done with a objective to compare the effect eccentric exercise and isometric exercise on Achilles tendinitis for skaters.

Methods

A Quasi-experimental study with 40 subjects of the age group between 15 and 25 was administered the VISA-A Questionnaire and VAS as outcome measures. A sample size of 40 was separated into two groups of 20 participants each into Group A (eccentric) and Group B (isometric). Pre-test and post-test were done using the VISA-A questionnaire and VAS Scale in the Study period- 4 weeks.

Results

There was a significant difference during the comparison between pre-test and post-test values (p < 0.005) of isometric exercise and eccentric exercise by VISA-A questionnaire and VAS scale but there was insignificance during the comparison of post-test values (p > 0.005) of the same.

Conclusion

The study concludes that there is a significant improvement in Achilles tendinitis when assessed with VISA-A questionnaire and VAS Scale for both the exercise; that is, eccentric and isometric, individually but it isn’t statistically significant enough to choose one method of intervention over the other.

Injection with autologous conditioned serum has better clinical results than eccentric training for chronic Achilles tendinopathy

PURPOSE

Chronic Achilles tendinopathy is one of the most common causes of malfunction and pain, which can lead to a significant reduction of the quality of life. The hypothesis of this study argues that autologous conditioned serum (i.e. Orthokine) injections in chronic midportion Achilles tendinopathy have a better outcome than eccentric training.

METHODS

This study investigates, retrospectively, the effects of peritendinous autologous conditioned serum injections as compared to standard eccentric training in 50 patients with chronic Achilles tendinopathy between 2012 and 2015. Before injection or eccentric training and 6 weeks, 12 weeks and 6 months thereafter, the patients were assessed by means of the VISA-A-G score (Victorian Institute of Sport Assessment-Achilles questionnaire-German). An MRI was also performed before and 6 months after injection and eccentric training.

RESULTS

Both patient groups had statistically significant better VISA-A-G scores after injection or eccentric training compared to the baseline before injection (90 vs 40, respectively, P < 0.001) or eccentric training (81 vs 47, respectively, P < 0.001). Comparing the baseline corrected VISA-A-G scores, patients in the autologous-conditioned-serum-group had significantly higher changes in VISA-A-G scores than the eccentric-training-group after 12 weeks (40 vs 36, P = 0.018) and 6 months (50 vs 34, P = 0.034). Both patient groups had statistically significant (P < 0.001) reduction of tendon thickness (autologous conditioned serum: 0.32; eccentric training: 0.24) and length of bursa (autologous conditioned serum: 0.24; eccentric training: 0.21) as well as significant (P < 0.001) improvement of tendon quality in MRI (autologous conditioned serum: 14 vs 1; eccentric training: 14 vs 2). There were no statistical differences in MRI-findings between the two groups.

CONCLUSION

Both therapies led to improvement of MRI-findings, including reduction of tendon thickness and tendon quality. Autologous-conditioned-serum-injections show greater clinical long-term benefit as compared to eccentric training and, therefore, offers a good alternative to eccentric training.

LEVEL OF EVIDENCE

Therapeutic studies, Level III.