The challenge of managing tendinopathy in competing athletes

Incidence of lower limb tendinopathy: A 3-year prospective study of a youth elite athletes in a Brazilian sport club

INTRODUCTION

The purpose of this study was to investigate lower limb tendinopathy incidence over 3 seasons in Brazilian youth elite athletes.

DESIGN

Prospective epidemiological study.

METHODS

A prospective study was performed during 2015, 2016 and 2017 seasons, with a total of 1553 Brazilian youth athletes (1.195 male and 358 female) out of 6 sports (volleyball, basketball, judo, gymnastics, tennis and futsal). The mean age was 14.1 (11.2; 17.0) years, mean height was 1.75 (1.55; 1.95) meters and mean body mass was 59.4 (42.0; 76.4) kilograms. The diagnosis of lower limb tendinopathy (LLT) was made by an experienced sports physician based on a detailed history and clinical exam. The incidence of LLT was determined by number of injuries/total exposure hours x 1000.

RESULTS

In total, 100 LLT were recorded during the 3 seasons. The most frequent type of LLT was patellar (79%), adductor (12%) and Achilles (9%). The frequency of patellar tendinopathy was higher in male's volleyball, basketball and female volleyball (41%, 25%, 13%, respectively) and the frequency of Achilles tendinopathy was higher in basketball and female volleyball (33%,22%). The LLT incidence was 2.5/1000h in 2015, 4.2/1000h in 2016 and 2.1/1000h in 2017.

CONCLUSION

Lower limb tendinopathies are relatively common in youth elite athletes. In 3-season, the most frequent type was patellar tendinopathy. A higher LLT incidence was observed in male volleyball athletes when compared to female volleyball athletes. Basketball athletes presented a higher frequency of patellar, adductor and Achilles tendinopathies in 3-seasons when compared to other sports.

The Biomechanics of Musculoskeletal Tissues during Activities of Daily Living: Dynamic Assessment Using Quantitative Transmission-Mode Ultrasound Techniques

The measurement of musculoskeletal tissue properties and loading patterns during physical activity is important for understanding the adaptation mechanisms of tissues such as bone, tendon, and muscle tissues, particularly with injury and repair. Although the properties and loading of these connective tissues have been quantified using direct measurement techniques, these methods are highly invasive and often prevent or interfere with normal activity patterns. Indirect biomechanical methods, such as estimates based on electromyography, ultrasound, and inverse dynamics, are used more widely but are known to yield different parameter values than direct measurements. Through a series of literature searches of electronic databases, including Pubmed, Embase, Web of Science, and IEEE Explore, this paper reviews current methods used for the in vivo measurement of human musculoskeletal tissue and describes the operating principals, application, and emerging research findings gained from the use of quantitative transmission-mode ultrasound measurement techniques to non-invasively characterize human bone, tendon, and muscle properties at rest and during activities of daily living. In contrast to standard ultrasound imaging approaches, these techniques assess the interaction between ultrasound compression waves and connective tissues to provide quantifiable parameters associated with the structure, instantaneous elastic modulus, and density of tissues. By taking advantage of the physical relationship between the axial velocity of ultrasound compression waves and the instantaneous modulus of the propagation material, these techniques can also be used to estimate the in vivo loading environment of relatively superficial soft connective tissues during sports and activities of daily living. This paper highlights key findings from clinical studies in which quantitative transmission-mode ultrasound has been used to measure the properties and loading of bone, tendon, and muscle tissue during common physical activities in healthy and pathological populations.

Staying in the Game: Interventions for Managing Achilles Tendinopathy in the In-Season Athlete

ABSTRACT

Achilles tendinopathy is a common overuse injury that is traditionally managed with activity modification and a progressive eccentric strengthening program. This narrative review describes the available evidence for adjunctive procedural interventions in the management of midportion and insertional AT, specifically in the athletic population. Safety and efficacy data from available literature on extracorporeal shockwave therapy, platelet-rich plasma, high-volume injectate with or without tendon scraping, and percutaneous needle tenotomy are used to propose an algorithm for treatment of Achilles tendinopathy for the in-season athlete.

Use of extracorporeal shockwave therapies for athletes and physically active individuals: a systematic review

OBJECTIVE

To determine the efficacy of extracorporeal shockwave therapy (ESWT) and investigate outcomes following the use of ESWT for athletes and physically active individuals.

DESIGN

Systematic review.

DATA SOURCES

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and searched four databases: PubMed (NLM), Embase (Elsevier), CINAHL Complete (EBSCO) and Web of Science (Clarivate).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies were randomised controlled trials, cohort and case-control studies, cases series and reports that evaluated outcomes following ESWT for athletes, physically active individuals and occupational groups requiring regular physical activity such as military cadets.

RESULTS

56 studies with 1874 athletes or physically active individuals were included. Using the Oxford level of evidence rating, included studies were 18 level I (32.1%), 3 level II (5.4%), 10 level III (17.9%), 13 level IV (23.2%) and 12 level V (21.4%). Based on the level I studies, ESWT may be effective alone in plantar fasciitis, lateral epicondylitis and proximal hamstring tendinopathy and as an adjunct to exercise treatment in medial tibial stress syndrome and osteitis pubis in athletes or physically active individuals. In most studies, athletes were allowed to continue activities and training and tolerated ESWT with minimal side effects.

CONCLUSION

ESWT may offer an efficacious treatment alone or as an adjunct to concurrent exercise therapy in selected sports-related injuries and without major adverse events. Further high-level research is needed to better define the role and clinical outcomes of ESWT.

Rehabilitation of Annular Pulley Injuries of the Fingers in Climbers: A Clinical Commentary

ABSTRACT

The annular pulley ligaments of the fingers are one of the most injured anatomical structures in those who participate in climbing. Despite this, there is a paucity of guidance clearly describing the rehabilitation and physical preparation parameters to return to sport following such injuries. The foundation of effective rehabilitation is the judicious application of progressive loading to increase the morphological and material properties of the damaged tissues. We maintain the optimal management of the climbing athlete after a traumatic annular flexor pulley system rupture should be grounded in the principles of strength and conditioning.

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.

Utilizing Extracorporeal Shockwave Therapy for in-Season Athletes

An athlete’s health and availability to train and compete at an optimal performance level is a growing focus for professional sports organizations [...]

Rehabilitation of anterior knee pain in the pregnant athlete: Considerations and modifications by trimester

BACKGROUND

Anterior knee pain is a common symptom many females experience during pregnancy. There are several musculoskeletal changes that occur in anatomy and physiology throughout the course of pregnancy that impact the lower extremity kinetic chain. Pregnant athletes, recreational through competitive, who attempt to maintain a high activity level through each trimester may be at increased risk for anterior knee pain due to a greater demand for lumbopelvic and hip stabilization.

CLINICAL QUESTION

What are the evidence-driven rehabilitation guidelines and specific modifications needed to treat anterior knee pain in the female athlete during each trimester of pregnancy?

KEY RESULTS

We aim to provide an overview of rehabilitation treatment guidelines for pregnant females with anterior knee pain, presenting specific physiological changes and rationale for modifications, discussed by trimester. We recommend our program be conducted under the supervision of a physical therapist working closely with the athlete's obstetrics and sports medicine team.

CLINICAL APPLICATION

The number of women who are active during pregnancy is increasing. We provide an overview of the guidelines and considerations for treating women with anterior knee pain during a healthy and uneventful pregnancy.

Subject-Specific 3D Models to Investigate the Influence of Rehabilitation Exercises and the Twisted Structure on Achilles Tendon Strains

The Achilles tendon (AT) is the largest tendon of the human body and has a primary role in locomotor activities. The complex structure of the AT includes twisting of three sub-tendons, non-uniform tissue deformations and differential triceps surae muscle forces. The main aim of this study was to investigate the impact of commonly used rehabilitation exercises (walking on heels, walking on toes, unilateral heel rise, heel drop with extended knee and heel drop with the knee bent) and different twists on AT strains. 3D freehand ultrasound based subject-specific geometry and subject-specific muscle forces during different types of rehabilitation exercises were used to determine tendon strains magnitudes and differences in strains between the sub-tendons. In addition, three Finite Element models were developed to investigate the impact of AT twist. While walking on heels developed the lowest average strain, heel drop with knee bent exhibited the highest average strain. The eccentric heel drop resulted in higher peak and average strain, compared to concentric heel rise for all the three models. The isolated exercises (heel rise and heel drop) presented higher average strains compared to the functional exercises (walking tasks). The amount of twist influences the peak strains but not the average. Type I consistently showed highest peak strains among the five rehabilitation exercises. The ranking of the exercises based on the AT strains was independent of AT twist. These findings might help clinicians to prescribe rehabilitation exercises for Achilles tendinopathy based on their impact on the AT strains.

Rehabilitation After Gluteus Medius and Minimus Treatment

We reviewed the current literature regarding rehabilitation after gluteus medius and minimus tears as part of a conservative management or postoperative protocol. The greater trochanteric pain syndrome includes a constellation of pathologies that generate pain in the greater trochanteric region and may be accompanied by varying degrees of hip abductor disfunction. It may be related to tendinitis of the gluteus medius and minimus, greater trochanteric bursitis, or even formal tears of the hip abductor tendons. The initial management strategy of the hip abductor tears is conservative, including different anti-inflammatory therapies such as physical therapy and cortisone and platelet-rich plasma injections. The clearest indication for surgical management is failure of conservative management and loss of abductor muscle power. Surgical management has been performed both open and endoscopic with good reported clinical results. More severe tears typically require a more rigid and complex type of fixation. Exorcise intervention seem to improve symptoms after 4 months to a year of therapy therefore a very close supervision of the rehabilitation protocol is mandatory. Gluteus medius and minimus tears are frequent and may be not diagnosed timely. Treatment of these of lesions is based on the knowledge of pathomechanics involved and the extent of injury to the tendon and muscle tissue. Conservative management is based on protecting the hip abductor tendons from excessive tensile and compression stresses while applying progressive load in conjunction with physical and medical anti-inflammatory measures. Surgical treatment is indicated when conservative management fails or an abductor power deficit is associated with pain. Similar physical therapy protocols to those used in conservative management are used postoperatively.

Level of Evidence

Level V, expert opinion.

Management of Patellar Tendinopathy Through Monitoring, Load Control, and Therapeutic Exercise: A Systematic Review

CONTEXT

Patellar tendinopathy presents with persistent tendon pain located in the lower pole of the patella and loss of function related to mechanical load. Although its pathogenesis is not completely clear, conservative treatment including exercise is the main intervention of patellar tendinopathy treatment.

OBJECTIVE

To describe the efficacy of patellar tendinopathy management through therapeutic exercise, and control and monitoring of loads.

EVIDENCE ACQUISITION

MEDLINE, WoS, Cochrane Plus, PEDro, and the gray literature were searched from inception to July 2021. Based on the PICO strategy, the inclusion criteria were clinical trials published in English or Spanish; outcomes of function, pain, and strength; patients with patellar tendinopathy with no age or gender limitations; using an active intervention; and at least a methodological quality equal to or greater than 3 points on the Jadad scale. All data were analyzed by 2 independent reviewers (P.N.-M. and D.H.-G.). Studies were qualitatively synthesized using a descriptive synthesis. The methodological quality and risk of bias assessment were performed with the PEDro and Jadad scale, respectively.

EVIDENCE SYNTHESIS

A total of 136 articles were identified, of which 12 met the eligibility criteria. All of them were regarded as presenting a moderate risk of bias and their methodological quality was considered acceptable to good. Recovering patellar tendinopathy with therapeutic exercise seems to significantly improve function, pain, and strength after intervention and even lasted over time.

CONCLUSION

A treatment based on load monitoring and physical exercise has proven to be effective in rehabilitating patellar tendinopathy, with positive results in the short and medium term.

Preventive effect of tailored exercises on patellar tendinopathy in elite youth athletes: A cohort study

OBJECTIVE

To investigate the effects of an intervention with tailored exercises on the incidence of patellar tendinopathy (PT) in elite youth jumping athletes.

DESIGN

Prospective crossover cohort.

SETTING

One sport club facility.

PARTICIPANTS

271 elite youth basketball and volleyball player were followed in the first year of the study (Observation year) and 270 athletes were followed in the second year (intervention year).

MAIN OUTCOME MEASURE

Incidence rates of PT per 1,000h of exposure. Cox survival analysis was used to verify the effects of the intervention (exercises implemented according to the findings of a preseason assessment) on PT incidence.

RESULTS

The exercise prevention program significantly reduced the number of cases of PT, with athletes submitted to the intervention showing 51% less risk of developing PT. The overall PT incidence in the Observation year (5.9 per 1,000h of exposure) was significantly higher than that in the intervention year (2.8 per 1,000h of exposure) (P = .037). Twenty-six athletes developed PT in the observation year, whereas 13 athletes developed PT in the intervention year.

CONCLUSIONS

A tailored preventive program may be able to reduce the incidence of patellar tendinopathy, especially in male youth volleyball athletes. Randomized controlled trials are encouraged to confirm these findings.

Effects of and Response to Mechanical Loading on the Knee

Mechanical loading to the knee joint results in a differential response based on the local capacity of the tissues (ligament, tendon, meniscus, cartilage, and bone) and how those tissues subsequently adapt to that load at the molecular and cellular level. Participation in cutting, pivoting, and jumping sports predisposes the knee to the risk of injury. In this narrative review, we describe different mechanisms of loading that can result in excessive loads to the knee, leading to ligamentous, musculotendinous, meniscal, and chondral injuries or maladaptations. Following injury (or surgery) to structures around the knee, the primary goal of rehabilitation is to maximize the patient's response to exercise at the current level of function, while minimizing the risk of re-injury to the healing tissue. Clinicians should have a clear understanding of the specific injured tissue(s), and rehabilitation should be driven by knowledge of tissue-healing constraints, knee complex and lower extremity biomechanics, neuromuscular physiology, task-specific activities involving weight-bearing and non-weight-bearing conditions, and training principles. We provide a practical application for prescribing loading progressions of exercises, functional activities, and mobility tasks based on their mechanical load profile to knee-specific structures during the rehabilitation process. Various loading interventions can be used by clinicians to produce physical stress to address body function, physical impairments, activity limitations, and participation restrictions. By modifying the mechanical load elements, clinicians can alter the tissue adaptations, facilitate motor learning, and resolve corresponding physical impairments. Providing different loads that create variable tensile, compressive, and shear deformation on the tissue through mechanotransduction and specificity can promote the appropriate stress adaptations to increase tissue capacity and injury tolerance. Tools for monitoring rehabilitation training loads to the knee are proposed to assess the reactivity of the knee joint to mechanical loading to monitor excessive mechanical loads and facilitate optimal rehabilitation.

Equine flexor tendon imaging part 1: Recent developments in ultrasonography, with focus on the superficial digital flexor tendon

Flexor tendon injuries are a major cause of lameness in performance horses and have considerable impact on equine welfare and the wider horse industry. Ageing and repetitive strain frequently cause varying degrees of tendon micro-damage prior to the recognition of clinical tendinopathy. Whilst B-mode ultrasonography is most commonly utilised for detection and monitoring of tendon lesions at the metacarpal/metatarsal level, the emphasis of recent research has focused on the identification of subclinical tendon damage in order to prevent further tendon injury and improve outcomes. The introduction of elastography, acoustoelastography and ultrasound tissue characterisation in the field of equine orthopaedics shows promising results and might find wider use in equine practice as clinical development continues. Based on the substantial number of research studies on tendon imaging published over the past decade this literature review aims to examine the currently used ultrasonographic imaging techniques and their limitations, and to introduce and critically appraise new modalities that could potentially change the clinical approach to equine flexor tendon imaging.

Sharp pain in a normal Achilles tendon of a professional female football player was related to a plantaris tendon in a rare position: a case report

BACKGROUND

Plantaris tendinopathy and plantaris-associated Achilles tendinopathy can be responsible for chronic pain in the Achilles tendon midportion, often accompanied by medial tenderness. As conservative treatments are less successful for this patient group, proper diagnosis is important for decision making. This report presents a case with plantaris tendinopathy in a rare (superficial) location.

CASE PRESENTATION

This article describes a pain history and treatment timeline of a professional Swedish female soccer player (32 years old, Northern European ethnicity, white) who suffered from sharp pain in the Achilles tendon midportion and tenderness on the medial and superficial side for about 2 years. Conservative treatments, including eccentric exercises, were not successful and, to some extent, even caused additional irritation in that region. Ultrasound showed a wide and thick plantaris tendon located on the superficial side of the Achilles tendon midportion. The patient was surgically treated with local removal of the plantaris tendon. After surgery there was a relatively quick (4-6 weeks) rehabilitation, with immediate weight bearing, gradual increased loading, and return to running activities after 4 weeks. At follow-up at 8 weeks, the patient was running and had not experienced any further episodes of sharp pain during change of direction or sprinting.

CONCLUSIONS

The plantaris tendon should be considered as a possible source of Achilles tendon pain. This case study demonstrates that the plantaris tendon can be found in unexpected (superficial) positions and needs to be carefully visualized during clinical and imaging examinations.

Running-related injury: How long does it take? Feasibility, preliminary evaluation, and German translation of the University of Wisconsin running and recovery index

OBJECTIVE

The University of Wisconsin Running Injury and Recovery Index (UWRI) was developed as an evaluative patient-reported outcome measure of perceived running ability and recovery after running-related injuries. To date, the questionnaire was not translated into German language and studies on its clinical feasibility and validity are sparse.

DESIGN

Prospective cohort study.

SETTING

Outpatient sports medicine clinic.

PARTICIPANTS

The UWRI questionnaire was translated to German language using a state-of-the art back-translation method including three translators and two back-translators. Clinical feasibility and validation were assessed in 14 injured runners.

MAIN OUTCOME MEASURES

UWRI total score, running volume.

RESULTS

The translation process was completed without major discrepancies. Feasibility and preliminary evaluation were demonstrated in a cohort of 14 injured runners. The UWRI total score significantly improved throughout 12 weeks of recovering from running-related injuries (p < 0.001). Relative running volume significantly correlated with UWRI score (p < 0.001).

CONCLUSION

The University of Wisconsin Running Injury and Recovery Index was successfully translated into the German language. Its usage may hold promise for better rehabilitation surveillance following running-related injuries.

Despite maintaining a high daily training availability, a quarter of athletes start the season injured and three quarters experience injury in an Australian State Academy of Sport

OBJECTIVES

To 1) investigate the incidence, prevalence, burden and characteristics of injuries; and 2) explore the frequency of physiotherapy and medical servicing for elite sports academy athletes over a 12-month season.

DESIGN

Prospective cohort study.

METHODS

Medical attention and time-loss injuries were prospectively recorded by Physiotherapy and Medical (Sports Physician) staff for 94 athletes (72.3% females). The number of linked physiotherapy and medical servicing appointments was also recorded. Injury incidence rates (IIR), point and period prevalence, and injury burden were calculated and compared by athlete gender, sport, and categorisation (performance level) using incidence rate ratios (IRR).

RESULTS

The number of injuries reported was 193 in 71 (75.5%) athletes. The IIR was 2.1 (95%CI: 1.8 to 2.4) injuries per 365 days, with no gender difference observed (IRR: 1.1, 0.8 to 1.4). The injury burden was 43.5 (95%CI: 37.8 to 50.1) days absent per 365 days. More than one-quarter (point prevalence, 26.6%) of athletes commenced the season with an injury. In-season injury risk was 2.5 fold greater in athletes who started the season with an injury compared to athletes who started the season without an injury (IRR: 2.5, 1.9 to 3.4). The majority (81.2%) of the 1164 appointments recorded were physiotherapy, with an overall 4.3:1.0 physiotherapy to medical appointment ratio.

CONCLUSIONS

One in four athletes began the elite pathway season with a pre-existing injury, while also demonstrating a 2.5 fold greater risk of subsequent injury in the scholarship period. Sports should not assume their athletes are uninjured at the beginning of their scholarship. Injury profiles, and physiotherapy and medical servicing varied across sports. To reduce health as a barrier in the successful transition of talented young athletes to elite athletes, injury management strategies at the commencement of recruitment and throughout the scholarship should be prioritised in the development pathway.

The Burden and Risk Factors of Patellar and Achilles Tendinopathy in Youth Basketball: A Cohort Study

This study aimed at evaluating the burden and risk factors of patellar and Achilles tendinopathy among youth basketball players. Patellar and Achilles tendinopathy were prospectively monitored in 515 eligible male and female youth basketball players (11–18 years) through a competitive season. Overall, the season prevalence of patellar tendinopathy was 19.0% (95% CI: 15.7–22.7%), 23.2% (95% CI: 18.6–28.2%) in males and 12.5% (95% CI: 8.3–17.9%) in females. The season prevalence of Achilles tendinopathy was 4.3% (95% CI: 2.7–6.4%), 4.1% (95% CI: 2.2–7.0%) in males and 4.5% (95% CI: 2.1–8.4%) in females. Median proportion of symptoms duration was 83% of average total weeks of basketball exposure for patellar tendinopathy and 75% for Achilles tendinopathy. Median time to patellar tendinopathy onset was 8 weeks for male players and 6 weeks for female players. Higher odds of patellar tendinopathy risk were seen in males (OR: 2.23, 95% CI: 1.10–4.69) and players with previous anterior knee pain had significantly elevated odds (OR: 8.5, 95% CI: 4.58–16.89). The burden and risk of patellar tendinopathy is high among competitive youth basketball players. Risk factors include sex and previous anterior knee pain. These findings provide directions for practice and future research.

Comprehensive Return to Competitive Distance Running: A Clinical Commentary

Running injuries are very common, and there are well-established protocols for clinicians to manage specific musculoskeletal conditions in runners. However, competitive and elite runners may experience different injuries than the average recreational runner, due to differences in training load, biomechanics, and running experience. Additionally, injury-specific rehabilitation protocols do not consider the broader goal of return to competitive running, including the unique psychosocial and cardiorespiratory fitness needs of elite athletes. This review aims to suggest a guideline for running-specific progression as part of a comprehensive rehabilitation program for injured competitive runners. Tools to evaluate an athlete's psychosocial preparedness to return to competition are presented. Recommendations are also provided for monitoring cardiorespiratory fitness of injured runners, including the nuances of interpreting these data. Finally, a six-phase training paradigm is proposed to guide clinicians as they help competitive runners transition from the early stages of injury through a full return to competition.

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.

A criteria-based rehabilitation program for chronic mid-portion Achilles tendinopathy: study protocol for a randomised controlled trial

BACKGROUND

Achilles tendinopathy (AT) is a common overuse injury in running-related sports where patients experience pain and impaired function which can persist. A graded rehabilitation program has been successful in reducing pain and improving function to enable a return to sport. The aim of this study is to compare the effectiveness of a criteria-based rehabilitation program including strength and reactive strength targets, with a previously successful rehabilitation program on changes in pain and function using the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Secondary aims will be to assess changes in calf strength, reactive strength, and lower limb running and forward hop biomechanics over the course of a 12-week rehabilitation program, and long-term follow-up investigations.

METHODS

Sixty eligible participants with chronic mid-portion AT who train in running-based sports will be included in this study. They will be randomly assigned to a group that will follow an evidence-based rehabilitation program of daily exercises with progression guided by symptoms or a group performing 3 high-intensity rehabilitation sessions per week with individualised load targets progressing to reactive strength exercises. Testing will take place at baseline, week 6 and 12. Plantar flexor peak torque will be measured using isokinetic dynamometry, reactive strength will be measured using a drop jump and lower limb biomechanical variables will be measured during a single leg forward hurdle hop test and treadmill running using 3D motion analysis. Follow-up interviews will take place at 6, 12 and 24 months after beginning the program which will assess patient participation in sport and possible re-injury.

DISCUSSION

This is the first study to propose an individualised criteria-based graded rehabilitation program in patients in with chronic mid-portion Achilles tendinopathy where progression is guided by strength and reactive strength outcome measures. This study will provide a comprehensive assessment of plantar flexor strength, reactive strength and lower limb biomechanical variables in running and forward hopping with the VISA-A questionnaire as the primary outcome measure and long term post-intervention follow-up assessments performed.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT04384874 ). Registered retrospectively on April 23rd 2020.

Non-surgical treatment as the first step to manage peritrochanteric space disorders

PURPOSE

Greater trochanter pain syndrome (GTPS) or lateral hip pain terms include external snapping hip, trochanteric bursitis and gluteus medius or minimus pathology. The aim of this review is to update the most recent knowledge about non-surgical management of peritrochanteric disorders.

METHODS

A literature review was performed including articles most relevant in the last years that were focused in non-surgical treatment of peritrochanteric disorders.

RESULTS

Conservative treatment still has a place and includes activity modification, NSAIDs, analgesics, physiotherapy, home training, local corticosteroid injection (CSI) and shock wave therapy (SWT). These non-surgical alternatives have demonstrated good clinical results with low rate of complications.

CONCLUSION

Most patients tend to resolve GTPS or lateral hip pain with non-surgical management in the mid-term but when everything failed, surgical options should be evaluated. The next frontier that will be a game changer is to determine an individualized treatment plan based on the exact pathology.

LEVEL OF EVIDENCE

V.

Effect of Autologous Expanded Bone Marrow Mesenchymal Stem Cells or Leukocyte-Poor Platelet-Rich Plasma in Chronic Patellar Tendinopathy (With Gap >3 mm): Preliminary Outcomes After 6 Months of a Double-Blind, Randomized, Prospective Study

BACKGROUND

Patellar tendinopathy is common. The success of traditional management, including isometric or eccentric exercises combined with shockwave therapy and even surgery, is limited. Therefore, it is important to determine whether biological treatments such as ultrasound-guided intratendinous and peritendinous injections of autologous expanded bone marrow mesenchymal stem cells (BM-MSCs) or leukocyte-poor platelet-rich plasma (Lp-PRP) improve clinical outcomes in athletic patients with patellar tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A prospective, double-blinded, randomized, 2-arm parallel group, active controlled, phase 1/2 single-center clinical study was performed in patients who had proximal patellar tendinopathy with a lesion >3 mm. A total of 20 participants (age 18-48 years) with pain for >4 months (mean, 23.6 months) and unresponsive to nonoperative treatments were randomized into 2 groups. Of these, 10 participants were treated with BM-MSC (20 × 10⁶ cells) and 10 with Lp-PRP. Both groups performed the same postintervention rehabilitation protocol. Outcomes included the Victorian Institute of Sport Assessment for pain (VISA-P), self-reported tendon pain during activity (visual analog scale [VAS]), muscle function by dynamometry, tendon thickness and intratendinous vascularity by ultrasonographic imaging and Doppler signal, ultrasound tissue characterization (UTC) echo type changes, and magnetic resonance imaging (MRI) T2-weighted mapping changes. Participants were followed longitudinally for 6 months.

RESULTS

The average VAS scores improved in both groups at all time points, and there was a significant reduction in pain during sporting activities (P < .05). In both groups, the average mean VISA-P scores at 6 months were significantly increased compared with baseline (66 BM-MSC group and 72.90 Lp-PRP group), with no significant differences in VAS or VISA-P scores between the groups. There were statistically significant greater improvements in tendon structure on 2-dimensional ultrasound and UTC in the BM-MSC group compared with the Lp-PRP group at 6 months. Similarly, the BM-MSC group demonstrated significant evidence of restoration of tendon structure on MRI compared with the Lp-PRP group at 6 months. Only the participants in the BM-MSC group showed evidence of normalization of tendon structure, with statistically significant differences between the groups on T2-weighted, fat-saturated sagittal and coronal scans and hypersignal in T2-weighted on spin-echo T2-weighted coronal MRI scan. Both treatments were safe, and no significant adverse events were reported in either group.

CONCLUSION

Treatment with BM-MSC or Lp-PRP in combination with rehabilitation in chronic patellar tendinopathy is effective in reducing pain and improving activity levels in active participants. Participants who received BM-MSC treatment demonstrated greater improvement in tendon structure compared with those who received Lp-PRP.

REGISTRATION

2016-001262-28 (EudraCT identifier); NCT03454737 (ClinicalTrials.gov identifier).

The Bonar Score in the Histopathological Assessment of Tendinopathy and Its Clinical Relevance-A Systematic Review

This study aimed to perform a comprehensive systematic review, which reports the role of the Bonar score in the histopathological assessment of tendinopathy and its clinical relevance. To identify all of the studies that reported relevant information on the Bonar scoring system and tendinopathy, an extensive search of the major and the most significant electronic databases (PubMed, Cochrane Central, ScienceDirect, SciELO, Web of Science) was performed. A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The extracted data included—year of study, geographical location, type of the study, radiological modifications, gender, number of patients, region of tendinopathy, mean age, control group, characteristics of the Bonar score and alterations in the scale, mean Bonar score, number of investigators, area of tendon investigation, clinical and radiological implications. An extensive search of the databases and other sources yielded a total of 807 articles. Eighteen papers were finally included in this systematic review, and of these, 13 original papers included the clinical and radiological implications of tendinopathy. Radiological evaluation was present in eight studies (both magnetic resonance imaging (MRI) and ultrasound (US)). The clinical implications were more frequent and present in 10 studies. Using the Bonar score, it is easy to quantify the pathological changes in tendinous tissue. However, its connection with clinical and radiological evaluation is much more complicated. Based on the current state of knowledge, we concluded that the neovascularization variable in the Bonar system should be reconsidered. Ideally, the microscopic assessment score should follow the established classification scale with the radiological and clinical agreement and should have a prognostic value.

Clinical Outcomes, Structure, and Function Improve With Both Heavy and Moderate Loads in the Treatment of Patellar Tendinopathy: A Randomized Clinical Trial

BACKGROUND

Loading interventions have become a predominant treatment strategy for tendinopathy, and positive clinical outcomes and tendon tissue responses may depend on the exercise dose and load magnitude.

PURPOSE/HYPOTHESIS

The purpose was to investigate if the load magnitude influenced the effect of a 12-week loading intervention for patellar tendinopathy in the short term (12 weeks) and long term (52 weeks). We hypothesized that a greater load magnitude of 90% of 1 repetition maximum (RM) would yield a more positive clinical outcome, tendon structure, and tendon function compared with a lower load magnitude of 55% of 1 RM when the total exercise volume was kept equal in both groups.

STUDY DESIGN

Randomized clinical trial; Level of evidence, 1.

METHODS

A total of 44 adult participants with chronic patellar tendinopathy were included and randomized to undergo moderate slow resistance (MSR group; 55% of 1 RM) or heavy slow resistance (HSR group; 90% of 1 RM). Function and symptoms (Victorian Institute of Sport Assessment-Patella questionnaire [VISA-P]), tendon pain during activity (numeric rating scale [NRS]), and ultrasound findings (tendon vascularization and swelling) were assessed before the intervention, at 6 and 12 weeks during the intervention, and at 52 weeks from baseline. Tendon function (functional tests) and tendon structure (ultrasound and magnetic resonance imaging) were investigated before and after the intervention period.

RESULTS

The HSR and MSR interventions both yielded significant clinical improvements in the VISA-P score (mean ± SEM) (HSR: 0 weeks, 58.8 ± 4.3; 12 weeks, 70.5 ± 4.4; 52 weeks, 79.7 ± 4.6) (MSR: 0 weeks, 59.9 ± 2.5; 12 weeks, 72.5 ± 2.9; 52 weeks, 82.6 ± 2.5), NRS score for running, NRS score for squats, NRS score for preferred sport, single-leg decline squat, and patient satisfaction after 12 weeks, and these were maintained after 52 weeks. HSR loading was not superior to MSR loading for any of the measured clinical outcomes. Similarly, there were no differences in functional (strength and jumping ability) or structural (tendon thickness, power Doppler area, and cross-sectional area) improvements between the groups undergoing HSR and MSR loading.

CONCLUSION

There was no superior effect of exercising with a high load magnitude (HSR) compared with a moderate load magnitude (MSR) for the clinical outcome, tendon structure, or tendon function in the treatment of patellar tendinopathy in the short term. Both HSR and MSR showed equally good, continued improvements in outcomes in the long term but did not reach normal values for healthy tendons.

REGISTRATION

NCT03096067 (ClinicalTrials.gov identifier).

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

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

Self-reported pain with single leg heel raise or single leg hop offer distinct information as measures of severity in men with midportion and insertional Achilles tendinopathy: An observational cross-sectional study

OBJECTIVES

To investigate if self-reported pain with single leg heel raise (SLHR) or single leg hop (SLH) are concurrently valid to assess midportion (MPAT) or insertional Achilles tendinopathy (IAT) symptom severity, compared to the VISA-A. Additionally, if SLHR or SLH pain accounts for VISA-A variability, and if they are associated with psychological factors.

PARTICIPANTS

60 men with MPAT, 26 men with IAT.

MAIN OUTCOMES

Participants rated SLHR and SLH pain on a numerical rating scale (0 = none, 10 = worst). We investigated relationships between loading task pain, VISA-A, VISA-A constructs, and psychological outcomes (Pearson's correlation coefficients). Linear regression determined best model accounting for VISA-A variability.

RESULTS

In MPAT, load tests shared fair-negative relationship with VISA-A, and VISA-A function. In IAT, SLHR had moderately strong-negative relationship with VISA-A, and pain and function constructs, and SLH shared fair-negative relationship with VISA-A, and pain and function constructs. Relationships were negligible between load tests and VISA-A activity in both conditions, and VISA-A pain in MPAT. In IAT, there was fair-positive relationship between pain catastrophising and load tests. Remaining psychological outcome relationships were negligible. Best model accounting for VISA-A included SLH in MPAT, and SLHR in IAT.

CONCLUSIONS

Despite VISA-A and selected VISA-A construct associations, self-reported SLHR and SLH pain appears to provide distinct information.

Landing biomechanics are not immediately altered by a single-dose patellar tendon isometric exercise protocol in male athletes with patellar tendinopathy: A single-blinded randomized cross-over trial

OBJECTIVES

To a) determine the acute effects of a single-dose patellar tendon isometric exercise protocol on involved limb landing biomechanics in individuals with patellar tendinopathy and asymptomatic patellar tendon pathology, and b) determine if individuals with patellar tendinopathy demonstrated changes in pain following a single-dose patellar tendon isometric exercise protocol.

DESIGN

Single-blinded randomized cross-over trial.

SETTING

Laboratory; PARTICIPANTS: 28 young male athletes with symptomatic (n = 13, age: 19.62 ± 1.61) and asymptomatic (n = 15, age: 21.13 ± 1.88) patellar tendinopathy.

MAIN OUTCOME MEASURES

Participants completed a single-dose patellar tendon isometric exercise protocol and a sham-TENS protocol, randomized and separated by 7-10 days. Pain-levels during a single-limb decline squat (SLDS) and three-dimensional biomechanics were collected during a double-limb jump-landing task before and after each intervention protocol. A mixed-model repeated measures ANOVA was conducted to compare change scores for all dependent variables.

RESULTS

There were no group × intervention interactions for change in pain (F_{(1, 26)} = 0.555, p = 0.463). There was one significant group × intervention interaction for vertical ground reaction force (VGRF) (F_{(1, 26)} = 5.33, p = 0.029). However, post-hoc testing with Bonferroni correction demonstrated no statistical significance for group (SYM: t = -1.679, p = 0.119; ASYM: t = -1.7, p = 0.107) or intervention condition (isometric: t = -2.58, p = 0.016; sham-TENS: 0.72, p = 0.460). There were no further significant group × intervention interactions (p > 0.05).

CONCLUSIONS

A single-dose patellar tendon isometric exercise protocol did not have acute effects on landing biomechanics or pain levels in male athletes with patellar tendinopathy or asymptomatic patellar tendon pathology.

A 2-year prospective study of injuries and illness in an elite national junior tennis program

Objectives: Injury and illness in elite national tennis programs can limit players' current and future performance. This study aimed to prospectively examine injuries and illnesses in an Irish elite national junior tennis program over 2 years. Methods: All injuries and illnesses that led to missed tennis training and match play in the Irish national junior tennis program (n = 82) over 2 years were collected in a prospective cohort study. Injury and illness prevalence and rates were calculated and reported with respect to gender and age group. Descriptive statistics were calculated for the type of illness and the region, location, type, nature, mechanism, and severity of injury. Results: Over the course of the study, 54% of players became injured, with 9.0% receiving more than one injury. Injuries were most frequent in the under-16 age group (12.93 injuries per 1,000 athletic exposures), compared to younger age groups (4.13 [U10], 3.43 [U12], 4.63 [U14] injuries per 1,000 athletic exposures) and seniors (1.98 injuries per 1,000 athletic exposures). Lower (49.5%) and upper limb (35.9%) injuries were frequent and mostly occurred due to overextension (35.9%). No significant differences in males and females injury rates were noted. However, females received a greater proportion of shoulder injuries (23.5% vs 10.9%), with more knee injuries in males (29.1% vs 7.8%). 0.52 illnesses per 1,000 athletic exposures were reported, with respiratory/cardiorespiratory (43.5%) most frequent. Injuries lead to greater average sessions lost (6.77 ± 11.56) than illness (1.83 ± 1.11). Conclusion: These findings can inform injury and illness preventative strategies to minimize absence from tennis play and should be prioritized in the under-16 group. Due to the different injury profiles between males and females, tailored preventative programs should be developed for males and females individually.

Multimodal management of patellar tendinopathy in basketball players: A retrospective chart review pilot study

BACKGROUND

The aim of this observational study was to document changes in pain, dysfunction, and fear of movement in basketball players using a multimodal rehabilitation approach for managing patellar tendinopathy.

METHODS

A multimodal treatment approach was utilized with basketball athletes during a competitive season. Numeric pain rating scale (NPRS), Victorian Institute of Sport Assessment Patellar (VISA-P) questionnaire, and a Tampa Scale of Kinesiophobia were used as outcome measures to assess for patellar tendon pain and knee function. A single group, pre-test/post-test, de-identified, retrospective chart review was performed at the end of the season.

RESULTS

Nine basketball players were diagnosed and treated for patellar tendinopathy during the course of a single season. VISA-P questionnaire scores were significantly higher at the end of the season, with a mean increase of 30 points (95% CI 22-38 p < 0.05). This magnitude of improvement exceeds the minimum clinically important difference of the VISA-P of 13 points. The NPRS during training over the previous week was significantly improved by 4.6 points (95% CI 2.6-6.6) from the start of treatment to the end of the season.

CONCLUSION

Dry needling, Extracorporeal Shockwave Therapy (ESWT), hands on manual therapy, and corrective exercise may be safe and effective strategies to reduce patellar tendon pain and improve knee function. Future research involving a larger sample size, control group, and randomization is indicated.

Immediate and Short-Term Effects of Short- and Long-Duration Isometric Contractions in Patellar Tendinopathy

OBJECTIVES

Isometric muscle contractions are used in the management of patellar tendinopathy to manage pain and improve function. Little is known about whether long- or short-duration contractions are optimal to improve pain. This study examined the immediate and short-term (4 weeks) effects of long- and short-duration isometric contraction on patellar tendon pain, and tendon adaptation.

DESIGN

Repeated measures within groups.

SETTING

Clinical primary care.

PATIENTS

Participants (n = 16, males) with patellar tendinopathy.

INTERVENTION

Short-duration (24 sets of 10 seconds) or long-duration (6 sets of 40 seconds) isometric knee extension loading (85% maximal voluntary contraction), for 4 weeks.

MAIN OUTCOME MEASURE

Immediate change in pain with single-leg decline squat (SLDS) and hop, as well as change in pain and tendon adaptation [within-session anterior-posterior (AP) strain] were assessed over 4 weeks.

RESULTS

Pain was significantly reduced after isometric loading on both SLDS (P < 0.01) and hop tests (P < 0.01). Pain and quadriceps function improved over the 4 weeks (P < 0.05). There was significant AP strain at each measurement occasion (P < 0.01). Although transverse strain increased across the training period from ∼14% to 22%, this was not significant (P = 0.08).

CONCLUSIONS

This is the first study to show that short-duration isometric contractions are as effective as longer duration contractions for relieving patellar tendon pain when total time under tension is equalized. This finding provides clinicians with greater options in prescription of isometric loading and may be particularly useful among patients who do not tolerate longer duration contractions. The trend for tendon adaptation over the short 4-week study period warrants further investigation.

Landing Biomechanics, But Not Physical Activity, Differ in Young Male Athletes With and Without Patellar Tendinopathy

OBJECTIVE

To examine differences in biomechanical and physical activity load in young male athletes with and without patellar tendinopathy.

DESIGN

Cross-sectional cohort study.

METHODS

Forty-one young male athletes (15-28 years of age) were categorized into 3 distinct groups: symptomatic athletes with patellar tendon abnormalities (PTA) (n = 13), asymptomatic athletes with PTA (n = 14), and a control group of asymptomatic athletes without PTA (n = 14). Participants underwent a laboratory biomechanical jump-landing assessment and wore an accelerometer for 1 week of physical activity monitoring.

RESULTS

The symptomatic group demonstrated significantly less patellar tendon force loading impulse in the involved limb compared with both the control and asymptomatic groups (P<.05), with large effects (d = 0.91-1.40). There were no differences in physical activity between the 3 groups (P>.05).

CONCLUSION

Young male athletes with symptomatic patellar tendinopathy demonstrated smaller magnitudes of patellar tendon force loading impulse during landing compared to both asymptomatic athletes with patellar tendinopathy and healthy control participants. However, these 3 distinct groups did not differ in general measures of physical activity. Future investigations should examine whether comprehensively monitoring various loading metrics may be valuable to avoid both underloading and overloading patterns in athletes with patellar tendinopathy. J Orthop Sports Phys Ther 2020;50(3):158-166. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9065.

How strong is the evidence that conservative treatment reduces pain and improves function in individuals with patellar tendinopathy? A systematic review of randomised controlled trials including GRADE recommendations

OBJECTIVE

To determine the effectiveness of conservative treatment (CT) on pain and function in patients with patellar tendinopathy (PT) compared with minimal intervention (MI) or other invasive intervention, or in addition to decline eccentric squat.

METHODS

Searches were performed in MEDLINE, Embase, Cochrane, PEDro, SPORTDiscus, CINAHL and AMED databases. All randomised trials that evaluated CT (any intervention not involving invasive procedures or medication) in individuals with PT were included. Two reviewers screened studies, extracted data and assessed risk of bias of all included studies. Where suitable, meta-analyses were conducted; we assessed certainty of the evidence using GRADE methodology.

RESULTS

When compared with MI, CT did not improve pain (weighted mean difference (WMD) -2.6, 95% CI -6.5 to 1.2) or function (WMD 1.8, 95% CI -2.4 to 6.1) in the short-term (up to 3 months) follow-up. When compared with invasive intervention, CT did not improve pain (WMD 0.7, 95% CI -0.1 to 1.4) or function (WMD -6.6, 95% CI -13.3 to 0.2) in the short-term follow-up. No overall effects were found for combined CT (when a conservative intervention was added to decline eccentric squat) on pain (WMD -0.5, 95% CI -1.4 to 0.4) or function (WMD -2.3, 95 % -9.1 to 4.6) at short-term follow-up. Single studies showed an effect on pain with iontophoresis at short-term follow-up (d = 2.42) or dry needling at medium/long-term follow-up (d = 1.17) and function with exercise intervention at medium/long-term follow-up (over 3 months) (d = 0.83).

SUMMARY/CONCLUSION

Our estimates of treatment effect have only low to very low certainty evidence to support them. This field of sports medicine/sports physiotherapy urgently needs larger, high-quality studies with pain and function among the potential primary outcomes.

Eccentric Exercise for Achilles Tendinopathy: A Narrative Review and Clinical Decision-Making Considerations

BACKGROUND

Achilles tendinopathy is a common health condition encountered in the orthopedic and sports medicine settings. Eccentric exercise is a common intervention in the management of pain and limited function for this patient population, although contemporary evidence suggests additional exercise methods may be effective as well.

STUDY DESIGN

Narrative review: Methods: A literature review was performed using the electronic databases Pubmed and PEDRO for articles through February 2019. Randomized clinical trials integrating eccentric exercise, with or without co-interventions, were evaluated. Outcomes related to pain and/or function were considered. A patient case is provided to highlight decision making processes related to clinical prescription of eccentrics for Achilles tendinopathy.

RESULTS

After screening titles and abstracts, seven studies were included for full review. Two articles compared eccentric exercise to a control group, four compared eccentrics to the use of modalities, while one used eccentric exercise as part of a multimodal intervention. In each case, eccentric exercise was effective in reducing pain and improving function. In comparison to other forms of exercise or additional interventions, eccentric exercise was frequently not more effective than other options.

DISCUSSION

Eccentric exercise has been associated with clinical benefit in improving pain and function for patients with Achilles tendinopathy. Despite the available evidence reporting effectiveness of eccentrics, other options may be equally useful. Appropriate load modification and exercise prescription for patients with Achilles tendinopathy requires systematic clinical reasoning and incorporation of patient values to optimize outcomes.

Cyriax Friction Massage-Suggestions for Improvements

Background and objectives: Cyriax friction massage is a widely known and used technique in the field of chronic pain management. Despite its frequent use in daily clinical practice, the technique lacks evidence to support its therapeutic value. While this might be due to various factors, the authors of this paper suggest that the technique might need to be improved and/or modernized according to the recent literature. The purpose of this letter is to further analyze our point of view. Materials and Methods: Using the most relevant methods to the subject literature, the authors intended to point out a few technical details that might need reconsideration and/or modernization. Results: An appropriate terminology is suggested in the text. Further, suggestions are made regarding the technique’s interval time, a possible addition of self-treatment, a discussion of the combination with Mill’s manipulation, tendon positioning and other parameters. Conclusions: As a therapeutic value has not yet been clearly documented, and since the modernization and/or improvement of the technique might be needed, we suggest that this technique should not be used as a first-line treatment for the management of chronic pain.

Orthopedic Injury Profiles in Adolescent Elite Athletes: A Retrospective Analysis From a Sports Medicine Department

Aim: The aim of the study was to identify common orthopedic sports injury profiles in adolescent elite athletes with respect to age, sex, and anthropometrics. Methods: A retrospective data analysis of 718 orthopedic presentations among 381 adolescent elite athletes from 16 different sports to a sports medical department was performed. Recorded data of history and clinical examination included area, cause and structure of acute and overuse injuries. Injury-events were analyzed in the whole cohort and stratified by age (11-14/15-17 years) and sex. Group differences were tested by chi-squared-tests. Logistic regression analysis was applied examining the influence of factors age, sex, and body mass index (BMI) on the outcome variables area and structure (α = 0.05). Results: Higher proportions of injury-events were reported for females (60%) and athletes of the older age group (66%) than males and younger athletes. The most frequently injured area was the lower extremity (47%) followed by the spine (30.5%) and the upper extremity (12.5%). Acute injuries were mainly located at the lower extremity (74.5%), while overuse injuries were predominantly observed at the lower extremity (41%) as well as the spine (36.5%). Joints (34%), muscles (22%), and tendons (21.5%) were found to be the most often affected structures. The injured structures were different between the age groups (p = 0.022), with the older age group presenting three times more frequent with ligament pathology events (5.5%/2%) and less frequent with bony problems (11%/20.5%) than athletes of the younger age group. The injured area differed between the sexes (p = 0.005), with males having fewer spine injury-events (25.5%/34%) but more upper extremity injuries (18%/9%) than females. Regression analysis showed statistically significant influence for BMI (p = 0.002) and age (p = 0.015) on structure, whereas the area was significantly influenced by sex (p = 0.005). Conclusion: Events of soft-tissue overuse injuries are the most common reasons resulting in orthopedic presentations of adolescent elite athletes. Mostly, the lower extremity and the spine are affected, while sex and age characteristics on affected area and structure must be considered. Therefore, prevention strategies addressing the injury-event profiles should already be implemented in early adolescence taking age, sex as well as injury entity into account.

Treatment of Lateral Epicondylitis With Autologous Blood, Platelet-Rich Plasma, or Corticosteroid Injections: A Systematic Review of Overlapping Meta-analyses

Background:

Previous meta-analyses have been conducted to compare outcomes of various treatment injections for lateral epicondylitis (LE), including corticosteroid injection (CSI) and autologous blood products such as autologous blood (AB) and platelet-rich plasma (PRP).

Purpose:

To conduct a systematic review of overlapping meta-analyses comparing different injection treatments (CSI, AB, PRP) for LE to determine which meta-analyses provide the best available evidence.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

A systematic review was performed by searching PubMed, Embase, and the Cochrane Library to locate meta-analyses that compared clinical outcomes of CSI, AB, and PRP for the treatment of LE. Search terms included “injection,” “corticosteroid,” “platelet-rich plasma,” “autologous blood,” “tennis elbow,” “lateral epicondylitis,” and “meta-analysis.” Results were reviewed to determine study eligibility. Patient outcomes were extracted from these meta-analyses. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence.

Results:

Nine meta-analyses (two level 1 studies, seven level 2 studies) containing 8656 patients met the eligibility criteria. Seven meta-analyses found that autologous blood products such as AB and PRP significantly improved pain and elbow function in the intermediate term (12-26 weeks), while 4 studies found that CSI effectively relieved pain and improved elbow function in the short term (<12 weeks). The study by Arirachakaran et al in 2016 received the highest QUOROM and Oxman-Guyatt scores; therefore, this meta-analysis appears to have the highest level of evidence. In addition, this study was rated the highest-quality study in this systematic review according to the Jadad decision algorithm. Lower-quality meta-analyses indicated that dosage, number of injections, and differences in therapeutic duration between CSI and autologous blood products may be essential factors in determining the appropriate treatment injection protocol for LE.

Conclusion:

The current best available evidence suggests that CSI improves functional outcomes and pain relief in the short term, while AB and PRP are the most effective treatments in the intermediate term.

Interventions used for Rehabilitation and Prevention of Patellar Tendinopathy in athletes: a survey of Brazilian Sports Physical Therapists

OBJECTIVES

(1) To identify the type and frequency of interventions used by Brazilian physical therapists to treat and prevent the occurrence of patellar tendinopathy in athletes and the criteria used to return to sport; (2) to compare the interventions used to the grade of recommendation of current evidence.

METHODS

Design: cross-sectional study.

SETTING

online survey throughout sports physical therapy association.

PARTICIPANTS

Physical therapists who were invited to complete a structured questionnaire.

MAIN OUTCOME MEASURES

Interventions more frequently used for treating and preventing PT in athletes and the criteria used to define return to sport.

RESULTS

One-hundred and twenty-one physical therapists participated in this study. Quadriceps eccentric strengthening (75.2%), education (61.2%) and lower limb joint/lumbo-pelvic stabilization/hamstrings stretching (59.5%) were more frequently cited for prevention purposes, while lower limb joint stabilization (81.8%), education (80.2%) and myofascial release (78.5%) were more frequently reported for treatment. The majority of the physical therapists based their decision of athlete discharge on a combination of pain intensity, function and functional test results (44.6%).

CONCLUSION

There was inconsistency between interventions used in clinical practice and interventions recommended by the best available evidence.

Surgical plantaris tendon removal for patients with plantaris tendon-related pain only and a normal Achilles tendon: a case series

Objectives

Surgical removal of the plantaris tendon can cure plantaris-associated Achilles tendinopathy, a condition in which Achilles and plantaris tendinopathy coexist. However, rare cases with plantaris tendinopathy alone are often misdiagnosed due to a normal Achilles tendon.

Design and setting

Prospective case series study at one centre.

Participants

Ten consecutive patients (9 men and one woman, mean age 35 years, range 19–67) with plantaris tendon-related pain alone in altogether 13 tendons were included. All had had a long duration (median 10 months, range 3 months to 10 years) of pain symptoms on the medial side of the Achilles tendon mid-portion. Preoperative ultrasound showed thickened plantaris tendon but a normal Achilles tendon.

Interventions

Operative treatment consisting of ultrasound-guided excision of the plantaris tendon.

Primary and secondary outcome measures

Scores from Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A)were taken preoperatively and postoperatively (median duration 10 months). Patient satisfaction and time until full return to sports activity level was asked by a questionnaire.

Results

The VISA-A scores increased from 61 (range 45–81) preoperatively to 97 (range 94–100) postoperatively (p<0.01). Follow-up results at 10 months (range 7–72 months) on 9/10 patients showed full satisfaction and return to their preinjury sports or recreational activity

Conclusion

The plantaris tendon should be kept in mind when evaluating painful conditions in the Achilles tendon region, especially when no Achilles tendinopathy is present. Excision of the plantaris tendon via a minor surgical procedure in local anaesthesia results in a good outcome.

Ultrasound examination and patellar tendinopathy scores in asymptomatic college jumpers

OBJECTIVE

To investigate the prevalence of hypoechoic areas by US and its' association with VISA-P scores among asymptomatic jumpers while highlighting sex comparisons.

DESIGN

Cross-sectional study.

SETTING

Pre-participation exam at a National Collegiate Athletic Association (NCAA) division I college.

PARTICIPANTS

Thirty-one college athletes who engage in jumping sports.

MAIN OUTCOME MEASURES

Hypoechoic images of patellar tendon captured by ultrasound examination were compared to a self-reported knee functional survey, the Victorian Institute of Sport Assessment for patellar tendinopathy (VISA-P) scale (0-100).

RESULTS

With a total of 31 athletes (13 males and 18 females), prevalence rate of the hypoechoic areas of patellar tendon was 19.4% (6/31) in the right knee and 29.0% (9/31) in the left knee. There was no proportional difference in a comparison of prevalence rate of hypoechoic area [(+) or (-)] by sex in either right or left knee. The VISA-P scores were significantly lower in US (+) than US (-) in the right knee (p = 0.003, Cohen's d = 1.675), but not the left knee (p = 0.250, Cohen's d = 0.512). The receiver operating characteristics curve analysis indicated the most sensitive and specific VISA-P values based on status [(+) or (-)] of hypoechoic area was 89.5 with 86.4% and 77.7% of sensitivity and specificity.

CONCLUSION

In short, hypoechoic areas were detected by US examination among self-reported asymptomatic jumpers. There was an association between hypoechoic areas and VISA-P scores in the right knee, but not in left knee. VISA-P scores may be used as a screening tool for the presence of hypoechoic areas.

Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines

Objective

To systematically review all randomised clinical trials to determine the efficacy of local strengthening exercises compared with other forms of conservative management for adults with posterior tibial tendon dysfunction.

Design

Systematic review.

Data sources

Four electronic databases (Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase and PubMed) were searched up to June 2018.

Eligibility criteria for selecting studies

The study included randomised clinical trials investigating individuals with posterior tibial tendon dysfunction where local strengthening was compared with other forms of conservative management with respect to pain, function and/or physical impairment outcome measures. Standardised mean differences (SMDs) were used to compare change scores between groups and descriptors of exercise prescription assessed according to the Template for Intervention Description and Replication and the Toigo and Boutellier recommendations.

Results

3 studies (n=93) were eligible for inclusion in the review. Varying strengthening exercises were compared with stretching and foot orthoses (n=2) or no intervention (n=1). Moderate effects (SMD 0.6-1.2) were found for reducing pain and disability with eccentric strengthening in conjunction with stretching and orthoses compared with concentric exercises, stretching and orthoses combined, and stretching and orthoses alone. Evaluation of exercise prescription parameters demonstrated minimal reporting, with the only consistent parameters being the number of sets and repetitions of the exercises, and the duration of the experimental period.

Conclusion

This review demonstrates the paucity of high-quality research for the conservative management of posterior tibial tendon dysfunction, and highlights the lack of exercise prescription parameters reported in clinical trials.

Trial registration number

CRD42017076156.

Nonpharmacological Management of Persistent Pain in Elite Athletes: Rationale and Recommendations

Persistent pain is common in elite athletes. The current review arose from a consensus initiative by the International Olympic Committee to advance the development of a standardized, scientific, and evidence-informed approach to management. We suggest that optimal management of persistent pain in elite athletes requires an understanding of contemporary pain science, including the rationale behind and implementation of a biopsychosocial approach to care. We argue that athletes and clinicians need to understand the biopsychosocial model because it applies to both pain and the impact of pain with special reference to the sport setting. Management relies on thorough and precise assessment that considers contributing factors across nociceptive, inflammatory, neuropathic, and centrally acting domains; these can include contextual and psychosocial factors. Pain management seeks to remove contributing factors wherever possible through targeted education; adjustment of mechanical loading, training, and performance schedules; psychological therapies; and management of inflammation.

Injectable Corticosteroids in Sport

OBJECTIVE

To review the literature guiding all aspects of the use of injectable corticosteroids for painful musculoskeletal conditions, with a focus on the treatment of athletes.

DATA SOURCES

An extensive search of the literature was completed including search terms of corticosteroid, steroid, athlete, and injection, among others. Additional articles were used after being identified from previously reviewed articles.

MAIN RESULTS

Injections of corticosteroids for a variety of painful conditions of the extremities and the axial spine have been described. Numerous minor and major complications have been reported, including those with a high degree of morbidity. There is a dearth of published research on the use of corticosteroid injections in athletes, with most of the research on this topic focused on older, nonathlete populations. Generally, these injections are well tolerated and can provide short-term pain improvement with little or no long-term benefits.

CONCLUSIONS

Corticosteroid injections should be used cautiously in athletes and only after a full consideration of the pharmacology, pathogenesis of disease, potential benefits, complications, factors specific to the athlete, and rules of athletic governing bodies. Corticosteroid injections are just one component of a comprehensive rehabilitation plan available to the physician providing care to athletes.

Association of Hip and Foot Factors With Patellar Tendinopathy (Jumper's Knee) in Athletes

Background Investigations on the causes of patellar tendinopathy should consider impairments at the hip and foot/ankle because they are known to influence movement patterns and affect patellar tendon loading. Objectives To investigate hip and foot/ankle impairments associated with patellar tendinopathy in volleyball and basketball athletes using classification and regression tree analysis. Methods In this clinical measurement, cross-sectional study, 192 athletes were assessed for impairments of the hip and foot/ankle, including shank-forefoot alignment, dorsiflexion range of motion (ROM), iliotibial band flexibility, passive hip internal rotation ROM, and hip external rotator and hip abductor isometric strength. Athletes with tenderness and/or pain at the inferior pole of the patella were considered to have patellar tendinopathy. Athletes with scores higher than 95 points on the Victorian Institute of Sport Assessment-patella (VISA-P), no pain during the single-leg decline squat, and no history of patellar tendon pain were considered not to have patellar tendinopathy. Classification and regression tree analyses were performed to identify interacting factors associated with patellar tendinopathy. Results Interactions among passive hip internal rotation ROM, shank-forefoot alignment, and hip external rotator and abductor strength identified athletes with and without patellar tendinopathy. The model achieved 71.2% sensitivity and 74.4% specificity. The area under the receiver operating characteristic curve was 0.77 (95% confidence interval: 0.70, 0.84; P<.001). Conclusion Impairments of the hip and foot/ankle are associated with the presence of patellar tendinopathy in volleyball and basketball athletes. Future studies should evaluate the role of these impairments in the etiology of patellar tendinopathy. J Orthop Sports Phys Ther 2018;48(9):676-684. Epub 23 May 2018. doi:10.2519/jospt.2018.7426.

Rehabilitation of symptomatic atraumatic degenerative rotator cuff tears: A clinical commentary on assessment and management

STUDY DESIGN

Clinical Commentary.

INTRODUCTION

Atraumatic rotator cuff (RC) disease, is one of the most common cause of shoulder pain, which encompasses a continuum from tendinopathy to full thickness cuff tears. Extrinsic, intrinsic and environmental factors have been implicated in the pathophysiology of this disorder, affecting the clinical presentation of symptoms including pain and irritability. Successful rehabilitation of symptomatic atraumatic degenerative rotator cuff (SADRC) tears must address the underlying mechanisms causing dysfunction and correct modifiable factors.

PURPOSE OF THE STUDY

The purpose of this paper is to review the shoulder complex anatomy, introduce atraumatic degenerative RC pathology, differentiate between symptomatic and asymptomatic degenerative RC tears, propose an assessment and introduce the Rotator Cuff Protocol 1 (RCP1) designed by the clinical reasoning of one of the lead authors (LW) as a rehabilitation management approach for those clients who present with SADRC tears.

METHODS/RESULTS/DISCUSSION

N/A for clinical commentary.

CONCLUSIONS

The ability to identify SADRC tears should consider shoulder anatomy, extrinsic, intrinsic and environmental factors, and the consideration for the natural history of atraumatic partial and full thickness tears in the general population. A thorough clinical history and examination, which includes shoulder symptom modification tests, allows the examiner to determine at what phase the patient may start their exercise program. The RCP1 is a program that has been used clinically by many therapists and clients over the years and research is underway to test this protocol in atraumatic rotator cuff disease including SADRC tears.

LEVEL OF EVIDENCE

5.