Patellar and Achilles tendinopathies are predominantly peripheral pain states: a blinded case control study of somatosensory and psychological profiles

There is more to the knee joint than just the quadriceps: A systematic review with meta-analysis and evidence gap map of hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders

BACKGROUND

Impairments in hamstring strength, flexibility, and morphology have been associated with altered knee biomechanics, pain, and function. Determining the presence of these impairments in individuals with gradual-onset knee disorders is important and may indicate targets for assessment and rehabilitation. This systematic review aimed to synthesize the literature to determine the presence of impairments in hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders.

METHODS

Five databases (MEDLINE, Embase, CINAHL, SPORTDiscus, and Web of Science) were searched from inception to September 2022. Only studies comparing hamstring outcomes (e.g., strength, flexibility, and/or morphology) between individuals with gradual-onset knee disorders and their unaffected limbs or pain-free controls were included. Meta-analyses for each knee disorder were performed. Outcome-level certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation, and evidence gap maps were created.

RESULTS

Seventy-nine studies across 4 different gradual-onset knee disorders (i.e., knee osteoarthritis (OA), patellofemoral pain (PFP), chondromalacia patellae, and patellar tendinopathy) were included. Individuals with knee OA presented with reduced hamstring strength compared to pain-free controls during isometric (standard mean difference (SMD) = -0.76, 95% confidence interval (95%CI) : -1.32 to -0.21) and concentric contractions (SMD = -0.97, 95%CI : -1.49 to -0.45). Individuals with PFP presented with reduced hamstring strength compared to pain-free controls during isometric (SMD = -0.48, 95%CI : -0.82 to -0.14), concentric (SMD = -1.07, 95%CI : -2.08 to -0.06), and eccentric contractions (SMD = -0.59, 95%CI : -0.97 to -0.21). No differences were observed in individuals with patellar tendinopathy. Individuals with PFP presented with reduced hamstring flexibility when compared to pain-free controls (SMD = -0.76, 95%CI : -1.15 to -0.36). Evidence gap maps identified insufficient evidence for chondromalacia patellae and hamstring morphology across all gradual-onset knee disorders.

CONCLUSION

Our findings suggest that assessing and targeting impairments in hamstring strength and flexibility during rehabilitation may be recommended for individuals with knee OA or PFP.

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.

Conditioned Pain Modulation Does Not Differ Between People With Lower-Limb Tendinopathy and Nontendinopathy Controls: A Systematic Review With Individual Participant Data Meta-analysis

OBJECTIVE: To explore whether people with lower-limb tendinopathy have reduced relative conditioned pain modulation (CPM) when compared to nontendinopathy controls. DESIGN: Systematic review with individual participant data (IPD) meta-analysis. LITERATURE SEARCH: Eight databases were searched until August 29, 2022. STUDY SELECTION CRITERIA: Cross-sectional studies comparing the magnitude of the CPM effect in people with lower-limb tendinopathy to nontendinopathy controls in a case-control design. DATA SYNTHESIS: Included studies provided IPD, which was reported using descriptive statistics. Generalized estimating equations (GEEs) determined between-group differences in the relative CPM effect, when adjusting for co-variables. Study quality was assessed using a Joanna Briggs Institute checklist, and certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluations. RESULTS: Five records were included, IPD were provided for 4 studies (n = 219 with tendinopathy, n = 226 controls). The principal GEE (model 1) found no significant relative CPM effects for tendinopathy versus controls (B = -1.73, P = .481). Sex (B = 4.11, P = .160), age (B = -0.20, P = .109), and body mass index (B = 0.28, P = .442) did not influence relative CPM effect. The Achilles region had a reduced CPM effect (B = -22.01, P = .009). In model 2 (adjusting for temperature), temperature (B = -2.86, P = .035) and female sex (B = 21.01, P = .047) were associated with the size of the relative CPM effect. All studies were low-quality, and the certainty of the evidence was moderate. CONCLUSION: There were no between-group differences in the magnitude of the CPM effect, suggesting clinicians should manage lower-limb tendinopathy using interventions appropriate for peripherally dominant pain (eg, tendon loading exercises such as heavy slow resistance). Based on the "moderate"-certainty evidence, future studies are unlikely to substantially change these findings. J Orthop Sports Phys Ther 2023;54(1):1-10. Epub 19 October 2023. doi:10.2519/jospt.2023.11940.

Plantar Flexor Weakness and Pain Sensitivity Cannot Be Assumed in Midportion Achilles Tendinopathy

Introduction/Purpose

The purpose of this study was to determine the following in persons with midportion Achilles tendinopathy (AT): 1) maximal strength and power; 2) neural drive during maximal contractions and contractile function during electrically evoked resting contractions; and 3) whether pain, neural drive, and contractile mechanisms contribute to differences in maximal strength.

Methods

Twenty-eight volunteers (14 AT, 14 controls) completed isometric, concentric, and eccentric maximal voluntary contractions (MVCs) of the plantar flexors in a Biodex™ dynamometer. Supramaximal electrical stimulation of the tibial nerve was performed to quantify neural drive and contractile properties of the plantar flexors. Pain sensitivity was quantified as the pressure-pain thresholds of the Achilles tendon, medial gastrocnemius, and upper trapezius.

Results

There were no differences in plantar flexion strength or power between AT and controls (isometric MVC: P = 0.95; dynamic MVC: P = 0.99; power: P = 0.98), nor were there differences in neural drive and contractile function (P = 0.55 and P = 0.06, respectively). However, the mechanisms predicting maximal strength differed between groups: neural drive predicted maximal strength in controls (P = 0.02) and contractile function predicted maximal strength in AT (P = 0.001). Although pain did not mediate these relationships (i.e., between maximal strength and its contributing mechanisms), pressure-pain thresholds at the upper trapezius were higher in AT (P = 0.02), despite being similar at the calf (P = 0.24) and Achilles tendon (P = 0.40).

Conclusions

There were no deficits in plantar flexion strength or power in persons with AT, whether evaluated isometrically, concentrically, or eccentrically. However, the mechanisms predicting maximal plantar flexor strength differed between groups, and systemic pain sensitivity was diminished in AT.

The VISA-A (sedentary) should be used for sedentary patients with Achilles tendinopathy: a modified version of the VISA-A developed and evaluated in accordance with the COSMIN checklist

OBJECTIVE

To develop and evaluate a modified version of the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire, for use in sedentary patients with Achilles tendinopathy, using the Consensus-based Standards for the selection of health Measurement Instruments recommendations.

METHODS

Twenty-two sedentary patients with Achilles tendinopathy completed the VISA-A and provided feedback regarding the relevance, comprehensiveness and comprehensibility of each item, response options and instructions. Patient and professional feedback was used to develop the VISA-A (sedentary) questionnaire. Reliability, validity and responsiveness of the VISA-A (sedentary) was evaluated in 51 sedentary patients with Achilles tendinopathy: 47.1% women, mean age 64.8 (SD 11.24).

RESULTS

Factor analysis identified two dimensions (symptoms and activity) for the VISA-A (sedentary). Test-retest reliability was excellent for symptoms (intraclass correlation coefficient, ICC=0.991) and activity (ICC=0.999). Repeatability was 1.647 for symptoms and 0.549 for activity. There was a significant difference between the VISA-A and VISA-A (sedentary) scores both pretreatment and post-treatment. There was stronger correlation between the pretreatment to post-treatment change in the VISA-A (sedentary) scores (r=0.420 for symptoms, r=0.407 for activity) and the global rating of change than the VISA-A scores (r=0.253 for symptoms, r=0.186 for activity).

CONCLUSION

The VISA-A (sedentary) demonstrates adequate reliability, validity and responsiveness in sedentary patients with Achilles tendinopathy. The VISA-A (sedentary) is a more appropriate measure than the VISA-A for this cohort and is recommended for clinical and research purposes.

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.

Do adolescents with Osgood-Schlatter display nociplastic pain manifestations compared to controls: A cross-sectional study

OBJECTIVES

Osgood-Schlatter disease is an overuse musculoskeletal pain condition. The pain mechanism is considered nociceptive, but no studies have investigated nociplastic manifestations. This study investigated pain sensitivity and inhibition evaluated through exercise-induced hypoalgesia in adolescents with and without Osgood-Schlatter.

DESIGN

Cross-sectional study.

METHODS

Adolescents underwent a baseline assessment comprising clinical history, demographics, sports participation, and pain severity rated (0-10) during a 45-second anterior knee pain provocation test, consisting of an isometric single leg squat. Pressure pain thresholds were assessed bilaterally at the quadriceps, tibialis anterior muscle, and the patella tendon before and after a three-minute wall squat.

RESULTS

Forty-nine adolescents (27 Osgood-Schlatter, 22 controls) were included. There were no differences in the exercise-induced hypoalgesia effect between Osgood-Schlatter and controls. Overall, an exercise-induced hypoalgesia effect was detected at the tendon only in both groups with a 48 kPa (95 % confidence interval 14 to 82) increase in pressure pain thresholds from before to after exercise. Controls had higher pressure pain thresholds at the patellar tendon (mean difference 184 kPa 95 % confidence interval 55 to 313), tibialis anterior (mean difference 139 kPa 95 % confidence interval 24 to 254), and rectus femoris (mean difference 149 kPa 95 % confidence interval 33 to 265). Higher anterior knee pain provocation severity was associated with lower exercise-induced hypoalgesia at the tendon (Pearson correlation = 0.48; p = 0.011) in participants with Osgood-Schlatter.

CONCLUSIONS

Adolescents with Osgood-Schlatter display increased pain sensitivity locally, proximally, and distally but similar endogenous pain modulation compared to healthy controls. Greater Osgood-Schlatter severity appears to be associated with less efficient pain inhibition during the exercise-induced hypoalgesia paradigm.

Can we really say getting stronger makes your tendon feel better? No current evidence of a relationship between change in Achilles tendinopathy pain or disability and changes in triceps Surae structure or function when completing rehabilitation: a systematic review

OBJECTIVES

Determine if improvements in pain and disability in patients with mid-portion Achilles tendinopathy relate to changes in muscle structure and function whilst completing exercise rehabilitation.

DESIGN

A systematic review exploring the relationship between changes in pain/disability and muscle structure/function over time, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

Six online databases and the grey literature were searched from database inception to 16th December 2022 whereas clinical trial registries were searched from database inception to 11th February 2020. We included clinical studies where participants received exercise rehabilitation (±placebo interventions) for mid-portion Achilles tendinopathy if pain/disability and Triceps Surae structure/function were measured. We calculated Cohen's d (95 % confidence intervals) for changes in muscle structure/function over time for individual studies. Data were not pooled due to heterogeneity. Study quality was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

Seventeen studies were included for synthesis. No studies reported the relationship between muscle structure/function and pain/disability changes. Twelve studies reported muscle structure/function outcome measures at baseline and at least one follow-up time-point. Three studies reported improvements in force output after treatment; eight studies demonstrated no change in structure or function; one study did not provide a variation measure, precluding within group change over time calculation. All studies were low quality.

CONCLUSIONS

No studies explored the relationship between changes in tendon pain and disability and changes in muscle structure and function. It is unclear whether current exercise-based rehabilitation protocols for mid-portion Achilles tendinopathy improve muscle structure or function.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (registration number: CRD42020149970).

The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial

ABSTRACT

Exercise is the standard of care for Achilles tendinopathy (AT), but 20% to 50% of patients continue to have pain following rehabilitation. The addition of pain science education (PSE) to an exercise program may enhance clinical outcomes, yet this has not been examined in patients with AT. Furthermore, little is known about how rehabilitation for AT alters the fear of movement and central nervous system nociceptive processing. Participants with chronic AT (N = 66) were randomized to receive education about AT either from a biopsychosocial (PSE) or from a biomedical (pathoanatomical education [PAE]) perspective. Simultaneously, all participants completed an exercise program over 8 weeks. Linear mixed models indicated that there were no differences between groups in (1) movement-evoked pain with both groups achieving a clinically meaningful reduction (mean change [95% CI], PSE: -3.0 [-3.8 to -2.2], PAE = -3.6 [-4.4 to -2.8]) and (2) self-reported function, with neither group achieving a clinically meaningful improvement (Patient-Reported Outcomes Measurement Information System Physical Function-PSE: 1.8 [0.3-3.4], PAE: 2.5 [0.8-4.2]). After rehabilitation, performance-based function improved (number of heel raises: 5.2 [1.6-8.8]), central nervous system nociceptive processing remained the same (conditioned pain modulation: -11.4% [0.2 to -17.3]), and fear of movement decreased (Tampa Scale of Kinesiophobia, TSK-17: -6.5 [-4.4 to -8.6]). Linear regression models indicated that baseline levels of pain and function along with improvements in self-efficacy and knowledge gain were associated with a greater improvement in pain and function, respectively. Thus, acquiring skills for symptom self-management and the process of learning may be more important than the specific educational approach for short-term clinical outcomes in patients with AT.

Psychosocial and individual factors affecting Quality of Life (QoL) in patients suffering from Achilles tendinopathy: a systematic review

BACKGROUND

Achilles tendinopathy (AT) is a joint condition that causes functional restrictions and pain. This condition negatively impacts patients' social connectedness and psychological well-being, reducing their quality of life (QoL). This review aims to summarise the current information on QoL in patients suffering from AT from different angles: compared to a healthy population, reported individual factors that influence it and the effects of some AT interventions on QoL.

METHODS

A systematic review was conducted at PubMed, Cochrane, Google Scholar, and PsycINFO using tendinopathy and QoL-related keywords up to November 2021. Articles were included if they compared QoL to demographic factors such as age or gender, lifestyle factors (physical activity levels), comorbidity factors (diabetes, obesity), and/or a control group.

RESULTS

Three hundred twenty-nine articles were reviewed; 23 met the inclusion criteria. SF-36, EQ-5D, and VISA-A were the most common instrument used. Patients with AT reported low QoL when compared to no AT population. When women were compared to men, women reported worse QoL. The patients who participated in different exercise programs (strengthening and stretching) showed improvements in QoL. Surgical AT intervention improved QoL, although results varied by age.

CONCLUSION

AT has a substantial impact on QoL. In AT patients, QoL is also influenced by specific individual factors, including gender and physical activity. Exercise, education, and surgical treatment improve QoL. We suggest more research on AT patients to better understand the aspects leading to poor QoL.

A Closer Look at Localized and Distant Pressure Pain Hypersensitivity in People With Lower Extremity Overuse Soft-Tissue Painful Conditions: A Systematic Review and Meta-Analysis

OBJECTIVE

The nociceptive pain processing of soft-tissue overuse conditions is under debate because no consensus currently exists. The purpose of this meta-analysis was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas in 2 groups: participants with symptomatic lower extremity overuse soft-tissue conditions and controls who were pain free.

METHODS

Five databases were searched from inception to December 1, 2021, for case-control studies comparing PPTs between individuals presenting with symptomatic lower extremity tendinopathy/overuse injury and controls who were pain free. Data extraction included population, diagnosis, sample size, outcome, type of algometer, and results. The methodological quality (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development, and Evaluation) were assessed. Meta-analyses of symptomatic, segmental related, and distant pain-free areas were compared.

RESULTS

After screening 730 titles and abstracts, a total of 19 studies evaluating lower extremity overuse conditions (Achilles or patellar tendinopathy, greater trochanteric pain syndrome, plantar fasciitis, and iliotibial band syndrome) were included. The methodological quality ranged from fair (32%) to good (68%). Participants with lower extremity overuse injury had lower PPTs in both the painful and nonpainful areas, mirrored test-site, compared with controls (affected side: mean difference [MD] = -262.92 kPa, 95% CI = 323.78 to -202.05 kPa; nonaffected side: MD = -216.47 kPa, 95% CI = -304.99 to -127.95 kPa). Furthermore, people with plantar fasciitis showed reduced PPTs in the affected and nonaffected sides at segmental-related (MD = -176.39 kPa, 95% CI = -306.11 to -46.68 kPa) and distant pain-free (MD = -97.27 kPa, 95% CI = 133.21 to -61.33 kPa) areas compared with controls.

CONCLUSION

Low- to moderate-quality evidence suggests a reduction of PPTs at the symptomatic area and a contralateral/mirror side in lower extremity tendinopathies and overuse conditions compared with pain-free controls, particularly in plantar fasciitis and greater trochanteric pain syndrome. Participants with plantar fasciitis showed a reduction of PPTs on the affected and non-affected sides at a segmental-related area (very low-quality evidence) and at a remote asymptomatic area (moderate-quality evidence).

IMPACT

Some overuse peripheral pain conditions may be more associated with pressure pain sensitivity than others. Accordingly, examination and identification of conditions more peripherally, centrally, or mixed mediated could potentially lead to more specific and different treatment strategies.

The effect of combined Action Observation Therapy with eccentric exercises in the treatment of mid-portion Achilles-tendinopathy: a feasibility pilot randomised controlled trial

BACKGROUND

Mid-portion Achilles Tendinopathy (AT) is a common musculoskeletal condition with varying rehabilitation success rates. Despite the prevalence of this condition, a considerable proportion of individuals experience persisting pain and functional deficits. Current treatment approaches bias the biomedical model which emphasises physically treating and loading the tendon. Overall, there is a lack of consideration for the central nervous system that is commonly implicated in chronic injuries. The aim of this pilot study was to explore the feasibility of combining Action Observation Therapy (AOT), a treatment technique which targets central changes and influences motor learning, with eccentric exercises in the treatment of mid-portion AT. AOT involves the observation of movements and is commonly followed by the physical performance of these same movements.

METHODOLOGY

This was a double-blinded randomised controlled pilot feasibility study. All participants underwent the 12-week Alfredson eccentric training protocol. The intervention group watched videos of the exercises prior to performing these exercises, whilst the control group watched nature videos before performing the same exercises. Study feasibility was the primary outcome measure, with the Victorian Institute of Sports Assessment- Achilles (VISA-A) selected as the primary clinical outcome measure.

RESULTS

Thirty participants were recruited, reflecting a 75% eligibility rate and 100% of eligible participants enrolled in the study. The retention rate at week 12 was 80%. At week six the mean VISA-A score improved by 18.1 (95% CI 10.2-26.0) in the intervention group and 7.7 (95% CI 0.3-14.9) in the control group, and 75% and 33% of participants in the intervention and control group respectively exceeded the minimal clinically important difference (MCID). At week 12 the mean VISA-A score from baseline improved by 22.25 (95% CI 12.52-31.98) in the intervention group and 16.5-(95% CI 8.47-24.53) in the control group, equating to 75% and 58% in each group respectively exceeding the MCID.

CONCLUSION

The positive feasibility outcomes and exploratory data from the clinical outcome measures suggest that a larger scaled RCT is warranted to further investigate the impact of AOT in the rehabilitation of mid-portion AT. Trial registration ISRCTN58161116, first registered on the 23/12/2020.

Tendon loading in runners with Achilles tendinopathy: Relations to pain, structure, and function during return-to-sport

We aimed to (1) compare pain, tendon structure, lower limb function, and Achilles tendon loads while running between limbs in runners with Achilles tendinopathy, and (2) explore the relations of pain, tendon structure, and lower limb function to Achilles tendon loads while running. Twenty runners with Achilles tendinopathy participated in this pilot study. Pain was assessed with questionnaires, quantitative sensory testing, and functional testing. Tendon morphology and mechanical properties were evaluated with ultrasound imaging, continuous shear wave elastography, and ultrasound imaging combined with dynamometry. Lower limb function was assessed with an established test battery. Achilles tendon loads were estimated from biomechanical data acquired during running. Compared to the least symptomatic limb, the most symptomatic limb had lower scores on the Victorian Institute of Sports Assessment - Achilles questionnaire and worse pain during drop countermovement jumping, hopping, and running. Tendon thickness and cross-sectional area were greater, and Young's modulus, drop countermovement jump height, and plyometric quotient during hopping were lower on the most symptomatic limb. Side-to-side differences in drop countermovement jump height were significantly associated with side-to-side differences in Achilles tendon peak forces and average loading rates during running. Various measures of pain, structure, and function differ between limbs in runners with Achilles tendinopathy during return-to-sport. Tendon forces, however, do not differ between limbs during comfortable running. In addition to measures that differ between limbs, measures of performance during drop countermovement jumping may aid in clinical decision-making during return-to-sport because they are associated with tendon forces while running.

Tendinopathies and Pain Sensitisation: A Meta-Analysis with Meta-Regression

The presence of pain sensitisation has been documented and reported as being a possible cause of treatment failure and pain chronicity in several musculoskeletal conditions, such as tendinopathies. The aim of the present study is to analyse existing evidence on pain sensitisation in tendinopathies comparing the local and distant pain thresholds of healthy and affected subjects with distinct analysis for different tendinopathies. PubMed, Cochrane Central Register, Scopus, and Web Of Science were systematically searched after registration on PROSPERO (CRD42020164124). Level I to level IV studies evaluating the presence of pain sensitisation in patients with symptomatic tendinopathies, documented through a validated method, were included. A meta-analysis was performed to compare local, contralateral, and distant pain thresholds between patients and healthy controls with sub-analyses for different tendinopathies. Meta-regressions were conducted to evaluate the influence of age, activity level, and duration of symptoms on results. Thirty-four studies out of 2868 were included. The overall meta-analysis of local pressure pain thresholds (PPT) documented an increased sensitivity in affected subjects (p < 0.001). The analyses on contralateral PPTs (p < 0.001) and distant PPTs (p = 0.009) documented increased sensitivity in the affected group. The results of the sub-analyses on different tendinopathies were conflicting, except for those on lateral epicondylalgia. Patients’ activity level (p = 0.02) and age (p = 0.05) significantly influenced local PPT results. Tendinopathies are characterized by pain sensitisation, but, while features of both central and peripheral sensitisation can be constantly detected in lateral epicondylalgia, results on other tendinopathies were more conflicting. Patients’ characteristics are possible confounders that should be taken into account when addressing pain sensitisation.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials

OBJECTIVE

To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors.

STUDY SELECTION

Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation.

DATA SYNTHESIS

We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field.

RESULTS

Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct.

CONCLUSION

There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

Kinesiophobia Severity Categories and Clinically Meaningful Symptom Change in Persons With Achilles Tendinopathy in a Cross-Sectional Study: Implications for Assessment and Willingness to Exercise

Objectives: (1) Validate thresholds for minimal, low, moderate, and high fear of movement on the 11-item Tampa Scale of Kinesiophobia (TSK-11), and (2) Establish a patient-driven minimal clinically important difference (MCID) for Achilles tendinopathy (AT) symptoms of pain with heel raises and tendon stiffness.

Methods: Four hundred and forty-two adults with chronic AT responded to an online survey, including psychosocial questionnaires and symptom-related questions (severity and willingness to complete heel raises and hops). Kinesiophobia subgroups (Minimal ≤ 22, Low 23–28, Moderate 29–35, High ≥ 36 scores on the TSK-11), pain MCID subgroups (10-, 20-, 30-, >30-points on a 0- to 100-point scale), and stiffness MCID subgroups (5, 10, 20, >20 min) were described as median [interquartile range] and compared using non-parametric statistics.

Results: Subgroups with higher kinesiophobia reported were less likely to complete three heel raises (Minimal = 93%, Low = 74%, Moderate = 58%, High = 24%). Higher kinesiophobia was associated with higher expected pain (Minimal = 20.0 [9.3–40.0], Low = 43.0 [20.0–60.0], Moderate = 50.0 [24.0–64.0], High = 60.5 [41.3–71.0]) yet not with movement-evoked pain (Minimal = 25.0 [5.0–43.0], Low = 31.0 [18.0–59.0], Moderate = 35.0 [20.0–60.0], High = 43.0 [24.0–65.3]). The most common pain MCID was 10 points (39% of respondents). Half of respondents considered a 5-min (35% of sample) or 10-min (16%) decrease in morning stiffness as clinically meaningful.

Conclusions: Convergent validity of TSK-11 thresholds was supported by association with pain catastrophizing, severity of expected pain with movement, and willingness to complete tendon loading exercises. Most participants indicated that reducing their pain severity to the mild range would be clinically meaningful.

Evidence of Widespread Mechanical Hyperalgesia but Not Exercise-Induced Analgesia in Athletes With Mild Patellar Tendinopathy Compared With Pain-Free Matched Controls: A Blinded Exploratory Study

OBJECTIVE

The aim of the study was to assess centrally induced pain processing with pressure pain thresholds bilaterally and remotely in active volleyball and basketball athletes with mild patellar tendinopathy compared with asymptomatic control athletes. Secondary objective was to explore the role of exercise-induced analgesia during a training session in athletes with patellar tendinopathy.

DESIGN

In this exploratory study, pressure pain thresholds of 21 patellar tendinopathy athletes and 16 age- and sex-matched asymptomatic team members were measured by a blinded assessor bilaterally on the patellar tendon and unilaterally on the elbow extensor tendon with a pressure algometer before, during, and after a regular training session.

RESULTS

Patellar tendinopathy athletes had a significantly higher average body mass index compared with asymptomatic athletes (mean difference 1.75 kg/m2; 95% confidence interval = 0.35-3.15, P = 0.02). At baseline, athletes with patellar tendinopathy showed lowered pressure pain thresholds in the affected knee (P = 0.001), unaffected knee (P < 0.001), and elbow (P = 0.01) compared with controls. No clear patterns were identified to explain between-group differences in pressure pain thresholds before, during, and after exercise.

CONCLUSIONS

This exploratory study found primary and secondary mechanical hyperalgesia in athletes with patellar tendinopathy compared with asymptomatic athletes. Further research is required on the effects of an acute exercise bout on pain thresholds in this population.

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

OBJECTIVE

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

DESIGN

Multi site case-control study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Left/right discrimination is not impaired in people with unilateral chronic Achilles tendinopathy

OBJECTIVE

Impaired left/right discrimination of an affected body part has been observed in various chronic pain states. This study aimed to examine whether people with unilateral chronic Achilles tendinopathy also present with impaired left/right discrimination.

DESIGN

Cross-sectional study.

METHODS

Nineteen runners with persistent unilateral Achilles tendinopathy and 19 matched healthy volunteers performed a left/right discrimination task in a laboratory setting. Participants were shown pictures of feet, hands and Shepard-Metzler figures and were asked to decide as accurately and as fast as possible whether the body part belonged to the left or right side of the body, or whether the Shepard-Metzler figures were rotated or mirrored. Performance was evaluated in terms of accuracy and response time. Data were analysed with mixed-design ANOVAs.

RESULTS

The decline in left/right discrimination ability at group level, if present, between affected and unaffected side, or compared to healthy participants, was negligible for both accuracy (<1.5%) and response time (<50 ms). There was no significant effect of side (affected versus unaffected side) or group (people with Achilles tendinopathy versus healthy) for accuracy (p > 0.36) or response time (p > 0.69).

CONCLUSIONS

People with Achilles tendinopathy recognised the affected side as accurately and as fast as the non-affected side and their performance was comparable to healthy participants. The absence of impaired left/right discrimination despite the chronicity of the condition may be attributable to the typical intermittent nature of Achilles tendinopathy pain and/or maintained sports activity.

The Impact of the Degree of Kinesiophobia on Recovery in Patients With Achilles Tendinopathy

OBJECTIVE

Kinesiophobia has been proposed to influence recovery in individuals with Achilles tendinopathy. However, whether there are differences in outcomes in individuals with different levels of kinesiophobia is unknown. The purpose of this study was to compare the characteristics of patients at baseline and recovery over time in individuals with Achilles tendinopathy and various levels of kinesiophobia.

METHODS

This study was a secondary analysis of a prospective observational cohort study of 59 individuals with Achilles tendinopathy. The participants were divided into 3 groups on the basis of scores on the Tampa Scale for Kinesiophobia (TSK) (those with low TSK scores [≤33; low TSK group], those with medium TSK scores [34-41; medium TSK group], and those with high TSK scores [≥42; high TSK group]). All participants were evaluated with self-reported outcomes, clinical evaluation, tendon morphology, viscoelastic property measurements, and a calf muscle endurance test at baseline, 6 months, and 12 months. No treatment was provided throughout the study period.

RESULTS

There were 16 participants (8 women) in the low TSK group (age = 51.9 [SD = 15.3] years, body mass index [BMI] = 24.3 [22.3-25.4]), 28 participants (13 women) in the medium TSK group (age = 52.7 [SD = 15.2] years, BMI = 26.4 [22.5-30.8]), and 15 participants (8 women) in the high TSK group (age = 61.1 [SD = 11.1] years, BMI = 28.1 [25.2-33.6]). Among the groups at baseline, the high TSK group had significantly greater BMI and symptom severity and lower quality of life. All groups showed significant improvement over time for all outcomes except tendon viscoelastic properties and tendon thickening when there was an adjustment for baseline BMI. The high and medium TSK groups saw decreases in kinesiophobia at 6 months, but there was no change for the low TSK group.

CONCLUSION

Despite the high TSK group having the highest BMI and the worse symptom severity and quality of life at baseline, members of this group showed improvements in all of the outcome domains similar to those of the other groups over 12 months.

IMPACT

Evaluating the degree of kinesiophobia in individuals with Achilles tendinopathy might be of benefit for understanding how they are affected by the injury. However, the degree of kinesiophobia at baseline does not seem to affect recovery; this finding could be due to the patients receiving education about the injury and expectations of recovery.

Local hyperalgesia, normal endogenous modulation with pain report beyond its origin: a pilot study prompting further exploration into plantar fasciopathy

Background and aims Persistent tendinopathies were previously considered solely as peripheral conditions affecting the local tendinous tissue until quantitative sensory testing identified involvement of altered pain processing. In similar fashion, pain in patients with persistent plantar fasciopathy may also involve more than local tissue. The aim of this pilot study was to investigate potential differences in conditioned pain modulation and pressure and thermal pain thresholds, between individuals with PF and healthy pain-free controls, as a precursor to a larger-scale study. Methods We assessed 16 individuals with plantar fasciopathy and 11 pain-free controls. Plantar fasciopathy diagnosis was: palpation pain of the medial calcaneal tubercle or the proximal plantar fascia, duration ≥3 months, pain intensity ≥2/10, and ultrasound-measured plantar fascia thickness ≥4 mm. Quantitative sensory tests were performed locally at the plantar heel and remotely on the ipsilateral elbow. Assessments included pain thresholds for pressure, heat and cold, and conditioned pain modulation measured as change in local resting pressure pain threshold with cold water hand immersion. Participants rated pain intensity at pain threshold. Additionally, the area and distribution of plantar fasciopathy pain was drawn on a digital body chart of the lower limbs. Descriptive analyses were performed and between-group differences/effects expressed as standardised mean differences (d). Results There was no conditioned pain modulation difference between participants with plantar fasciopathy and controls (d = 0.1). Largest effects were on local pressure pain threshold and reported pain intensity on pressure pain threshold (d > 1.8) followed by pain intensity for heat and cold pain thresholds (d = 0.3-1.5). According to the digital body chart, pain area extended beyond the plantar heel. Conclusions The unlikelihood of a difference in conditioned pain modulation yet a pain area extending beyond the plantar heel provide a basis for exploring altered pain processing in a larger-scale study. Implications This was the first study to investigate the presence of altered pain processing in individuals with plantar fasciopathy using a conditioned pain modulation paradigm and thermal pain thresholds. We found no indication of an altered pain processing based on these measures, however, patients rated pain higher on thresholds compared to controls which may be important to clinical practice and warrants further exploration in the future.

Individuals with Persistent Greater Trochanteric Pain Syndrome Exhibit Impaired Pain Modulation, as well as Poorer Physical and Psychological Health, Compared with Pain-Free Individuals: A Cross-Sectional Study

OBJECTIVES

To compare physical, sensory, and psychosocial factors between individuals with greater trochanteric pain syndrome and controls and to explore factors associated with pain and disability.

DESIGN

Cross-sectional study.

SETTING

General community.

SUBJECTS

Patients with persistent, clinically diagnosed greater trochanteric pain syndrome and healthy controls.

METHODS

Participants completed tests of thermal and pressure pain threshold, conditioned pain modulation, temporal summation, muscle strength, physical function, physical activity, psychological factors, and health-related quality of life. Standardized mean differences between groups were calculated, and multiple linear regression identified factors associated with pain and disability.

RESULTS

Forty patients (95% female, average [SD] age = 51 [9] years) and 58 controls (95% female, average [SD] age = 53 [11] years) were included. Heat pain threshold, temporal summation, and pain catastrophizing were not different between groups. Compared with controls, patients displayed significantly poorer quality of life (standardized mean difference = -2.66), lower pressure pain threshold locally (-1.47, remotely = -0.57), poorer health status (-1.22), impaired physical function (range = 0.64-1.20), less conditioned pain modulation (-1.01), weaker hip abductor/extensor strength (-1.01 and -0.59), higher depression (0.72) and anxiety (0.61) levels, lower cold pain threshold locally (-0.47, remotely = -0.39), and less time spent in (vigorous) physical activity (range = -0.43 to -0.39). Twenty-six percent of pain and disability was explained by depression, hip abductor strength, and time to complete stairs.

CONCLUSIONS

Patients with greater trochanteric pain syndrome exhibited poorer health-related quality of life, physical impairments, widespread hyperalgesia, and greater psychological distress than healthy controls. Physical and psychological factors were associated with pain and disability.

Psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy: a cross-sectional study

OBJECTIVE

to examine psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy as well as the association between psychological factors and tendinopathy severity, sport participation, and satisfaction with activity level and tendon function.

DESIGN

cross-sectional study.

SETTING

online survey platform.

PARTICIPANTS

119 patients (mean age: 44 years (SD 14)) diagnosed with Achilles or patellar tendinopathy.

MAIN OUTCOME MEASURES

A range of patient-reported psychological and outcome measures were recorded. Multivariate regression analyses were performed to establish the association between each psychological factor and outcome measures, adjusted for relevant confounders.

RESULTS

Psychological readiness and confidence to return to sports (I-PRRS) and pain catastrophizing (PCS) were significantly associated with tendinopathy severity (modified VISA), sport participation(OSTRC-O), and satisfaction. Kinesiophobia (TSK) and the importance to patients of returning to pre-injury activity level were significantly associated with sports participation and satisfaction.

CONCLUSION

The current study provides evidence of impairments in psychological factors during rehabilitation of patients with Achilles and patellar tendinopathy. Most investigated psychological factors were associated with tendinopathy severity, function, participation, and satisfaction. Physical therapists should recognize patients with lack of psychological readiness to return to sports and also patients with kinesiophobia or catastrophizing thoughts when experiencing pain.

Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine

Chronic pain is a leading cause of disability globally and associated with enormous health-care costs. The discrepancy between the extent of tissue damage and the magnitude of pain, disability, and associated symptoms represents a diagnostic challenge for rheumatology specialists. Central sensitisation, defined as an amplification of neural signalling within the CNS that elicits pain hypersensitivity, has been investigated as a reason for this discrepancy. Features of central sensitisation have been documented in various pain conditions common in rheumatology practice, including fibromyalgia, osteoarthritis, rheumatoid arthritis, Ehlers-Danlos syndrome, upper extremity tendinopathies, headache, and spinal pain. Within individual pain conditions, there is substantial variation among patients in terms of presence and magnitude of central sensitisation, stressing the importance of individual assessment. Central sensitisation predicts poor treatment outcomes in multiple patient populations. The available evidence supports various pharmacological and non-pharmacological strategies to reduce central sensitisation and to improve patient outcomes in several conditions commonly seen in rheumatology practice. These data open up new treatment perspectives, with the possibility for precision pain medicine treatment according to pain phenotyping as a logical next step. With this view, studies suggest the possibility of matching non-pharmacological approaches, or medications, or both to the central sensitisation pain phenotypes.

The utilization and effects of filiform dry needling in the management of tendinopathy: a systematic review

Background: Tendinopathy is frequently associated with pain, soft tissue impairments and muscle performance limitations. Dry needling (DN) incorporates a fine filiform needle to penetrate the skin and underlying soft tissue in an effort to decrease pain and improve function. While injectable interventions and gauged-needle tendon fenestration for tendinopathy has been reviewed, DN for tendinopathy has yet to be synthesized.Objective: To systematically review the utilization and effects of DN for tendinopathy.Methods: Six electronic databases (PubMed, CINAHL, Scopus, SportDiscus, PEDro and the Cochrane Library) were searched from inception through August 15, 2020, using appropriate keywords and relevant synonyms.Results: After screening 462 articles, 10 studies met inclusion criteria. Study designs included case reports, case series, and randomized clinical trials. DN was used in isolation in 3/10 studies and as part of a multimodal approach in 7/10 studies. DN was associated with improved pain, function, muscle performance and perceived improvement in each study evaluating the relevant outcome. Conflicting results were found in comparative studies evaluating DN.Conclusions: DN may be a useful adjunctive treatment in the conservative management of tendinopathy, although its discrete effect is unclear. Very Low-quality evidence and methodological limitations suggest further investigation is warranted.

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.

Topical diclofenac vs placebo for the treatment of chronic Achilles tendinopathy: A randomized controlled clinical trial

INTRODUCTION

The application of topical diclofenac has been suggested as a possible treatment for Achilles tendinopathy. Our aim was to answer the question, is topical diclofenac more effective than placebo for the treatment of Achilles tendinopathy?.

METHODS

67 participants with persistent midportion or insertional Achilles tendinopathy were randomly assigned to receive a 4 week course of 10% topical diclofenac (n = 32) or placebo (n = 35). The a priori primary outcome measure was change in severity of Achilles tendinopathy (VISA-A score) at 4 and 12 weeks. Secondary outcome measures included numeric pain rating, and patient-reported change in symptoms using a 7 point scale, from substantially worse to substantially better. Pressure pain threshold (N) and transverse tendon stiffness (N/m) were measured over the site of maximum Achilles tendon pathology at baseline and 4 weeks.

RESULTS

There were no statistically or clinically significant differences between the diclofenac and placebo groups in any of the primary or secondary outcome measures at any timepoint. Average VISA-A score improved in both groups (p<0.0001), but the improvements were marginal: at 4 weeks, the improvements in VISA-A were 9 (SD 11) in the diclofenac group and 8 (SD 12) in the placebo group, and at 12 weeks the improvements were 9 (SD 16) and 11 (SD13) respectively-these average changes are smaller than the minimum clinically important difference of the VISA-A.

CONCLUSION

The regular application of topical diclofenac for Achilles tendinopathy over a 4 week period was not associated with superior clinical outcomes to that achieved with placebo.

Sensory Processing in People With and Without Tendinopathy: A Systematic Review With Meta-analysis of Local, Regional, and Remote Sites in Upper- and Lower-Limb Conditions

OBJECTIVE

To synthesize results of somatosensory processing tests in people with upper- and lower-limb tendinopathy, compared to controls.

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

Four electronic databases (MEDLINE, CINAHL Plus, SPORTDiscus, and Embase) were searched.

STUDY SELECTION CRITERIA

Included studies measured a domain of sensory processing and compared a tendinopathy group to a healthy control group.

DATA SYNTHESIS

Meta-analysis was conducted for outcomes with homogeneous data from at least 2 studies. Upper- and lower-limb conditions were compared and outcomes were examined by measurement site (local, regional, or remote to location of pain).

RESULTS

Of the 30 studies included, 18 investigated lateral elbow tendinopathy. The most commonly assessed outcome measures were pressure pain threshold (PPT) and thermal pain threshold. There was moderate evidence for local and regional reduction of PPT in upper-limb tendinopathies, but not at remote sites. In lower-limb tendinopathies, there was conflicting evidence regarding reduced PPT at local sites and limited evidence of normal PPT at remote sites. There was moderate evidence of sensitization of thermal pain threshold at local sites in upper-limb tendinopathies and limited evidence of no difference in thermal pain threshold in lower-limb tendinopathies. Findings across other domains were variable.

CONCLUSION

Sensory processing was different between upper-limb tendinopathy and lower-limb tendinopathy. Upper-limb tendinopathies showed signs consistent with primary and secondary hyperalgesia, but lower-limb tendinopathies did not. There was mixed evidence for primary hyperalgesia and limited evidence against secondary hyperalgesia. J Orthop Sports Phys Ther 2021;51(1):12-26. doi:10.2519/jospt.2021.9417.

Stretching and relaxing the plantar fascia may change plantar fascia thickness but not pressure pain thresholds: a cross-sectional study of patients with plantar fasciopathy

Background

Despite the established relevance of ultrasonography and assessment of pressure pain thresholds in patients with plantar fasciopathy, patient and probe positioning has been mostly ignored and are not necessarily reported in research. The primary aim of this study was to compare plantar fascia thickness in stretched and relaxed positions in patients with plantar fasciopathy. The secondary aim was to compare plantar heel pressure pain thresholds in these positions.

Methods

In this cross-sectional study, we measured the plantar fascia thickness with ultrasonography, and localised pressure pain thresholds using pressure algometry of 20 patients with plantar fasciopathy. These were assessed bilaterally, with the plantar fascia in both a stretched and relaxed position. In the stretched position, toes were maximally dorsiflexed, while in the relaxed position participants’ feet were hanging freely over the end of the table.

Results

The plantar fascia of the most symptomatic foot was significantly thicker when stretched compared with the relaxed position (sagittal: mean difference 0.2 mm, 95%CI: 0.1–0.4, P = 0.013; frontal: mean difference − 0.27, 95%CI: − 0.49 to − 0.06, P = 0.014). The plantar fascia was significantly thinner in the frontal plane compared with the sagittal plane in both positions (stretched: mean difference − 0.2 mm, 95%CI: − 0.42 to − 0.03, P = 0.025; relaxed: mean difference − 0.3 mm, 95%CI:-0.49 to − 0.08, P = 0.008). There was no difference between pressure pain thresholds in stretched or relaxed positions in either foot (P > 0.4).

Conclusions

The plantar fascia was significantly thicker in a stretched compared with a relaxed position and in the sagittal compared with the frontal plane, but differences were smaller than the standard deviation. Pressure pain thresholds were not different between the positions. These results highlight the importance of how ultrasonography is performed and reported in research to allow for replication.

Trial registration

The study was pre-registered September 25th, 2017 on ClinicalTrials.gov (NCT03291665).

Effect of Pain Education and Exercise on Pain and Function in Chronic Achilles Tendinopathy: Protocol for a Double-Blind, Placebo-Controlled Randomized Trial

BACKGROUND

Achilles tendinopathy (AT) rehabilitation traditionally includes progressive tendon loading exercises. Recent evidence suggests a biopsychosocial approach that incorporates patient education on psychosocial factors and mechanisms of pain can reduce pain and disability in individuals with chronic pain. This is yet to be examined in individuals with AT.

OBJECTIVE

This study aims to compare the effects on movement-evoked pain and self-reported function of pain education as part of a biopsychosocial approach with pathoanatomical education for people with AT when combined with a progressive tendon loading exercise program.

METHODS

A single-site, randomized, double-blind, placebo-controlled clinical trial will be conducted in a university-based hospital in a laboratory setting and/or by telehealth. A total of 66 participants with chronic (>3 months) midportion or insertional AT will be randomized for the Tendinopathy Education of the Achilles (TEAch) study. All participants will complete progressive Achilles tendon loading exercises over 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. All participants will complete 6-7 one-to-one sessions with a physical therapist to progress exercises in a standardized manner over 8 weeks. During the last 4 weeks of the intervention, participants will be encouraged to maintain their home exercise program. Participants will be randomized to 1 of 2 types of education (pain education or pathoanatomic), in addition to exercise. Pain education will focus on the biological and psychological mechanisms of pain within a biopsychosocial framing of AT. Pathoanatomic education will focus on biological processes within a more traditional biomedical framework of AT. Evaluation sessions will be completed at baseline and 8-week follow-up, and self-reported outcome measures will be completed at the 12-week follow-up. Both groups will complete progressive Achilles loading exercises in 4 phases throughout the 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. Primary outcomes are movement-evoked pain during heel raises and self-reported function (patient-reported outcome measure information system-Physical Function). Secondary outcomes assess central nervous system nociceptive processing, psychological factors, motor function, and feasibility.

RESULTS

Institutional review board approval was obtained on April 15, 2019, and study funding began in July 2019. As of March 2020, we randomized 23 out of 66 participants. In September 2020, we screened 267 individuals, consented 68 participants, and randomized 51 participants. We anticipate completing the primary data analysis by March 2022.

CONCLUSIONS

The TEAch study will evaluate the utility of pain education for those with AT and the effects of improved patient knowledge on pain, physical function, and clinical outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19111.

Intramuscular stimulation vs sham needling for the treatment of chronic midportion Achilles tendinopathy: A randomized controlled clinical trial

Background

The insertion of filiform needles intramuscularly (a.k.a. intramuscular stimulation/dry needling) has been suggested as a possible treatment for various painful musculoskeletal conditions. Our aim was to answer the question, is intramuscular stimulation more effective than sham intramuscular stimulation/dry needling for the treatment of Achilles tendinopathy?

Methods

52 participants with persistent midportion Achilles tendinopathy began and 46 completed one of three treatment protocols which were randomly assigned: (G3) a 12-week rehabilitation program of progressive tendon loading plus intramuscular stimulation (n = 25), (G2) the same rehabilitation program but with sham intramuscular stimulation (n = 19), or (G1) a reference group of rehabilitation program alone (as an additional control) (n = 8). The a priori primary outcome measure was change in VISA-A score at 12 weeks–VISA-A was also measured at 6 weeks, and at 6 and 12 months. Secondary outcome measures include the proportion of patients who rated themselves as much or very much improved (%), dorsiflexion range of motion (degrees), and tendon thickness (mm).

Results

The study retention was 94% at 12 weeks and 88% at 1 year. VISA-A score improved in all three groups over time (p<0.0001), with no significant difference among the three groups in VISA-A score at the start of the study (mean ± SD: G3 59 ± 13, G2 57 ± 17, G1 56 ± 22), at 12 weeks (G3 76 ± 14, G2 76 ± 15, G1 82 ± 11) or at any other timepoint. The percentage of patients who rated themselves as much or very much improved (i.e. treatment success) was not different after 12 weeks (G3 70%, G2 89%, G1 86% p = 0.94), or at 26 (p = 0.62) or 52 weeks (p = 0.71). No clinically significant effects of intervention group were observed in any of the secondary outcome measures.

Conclusion

The addition of intramuscular stimulation to standard rehabilitation for Achilles tendinopathy did not result in any improvement over the expected clinical benefit achieved with exercise-based rehabilitation alone.

Local Anesthetic Injection Resolves Movement Pain, Motor Dysfunction, and Pain Catastrophizing in Individuals With Chronic Achilles Tendinopathy: A Nonrandomized Clinical Trial

OBJECTIVES

Peripherally directed treatments (targeted exercise, surgery) can reduce, but not fully eliminate, pain for up to 40% of patients with Achilles tendinopathy. The objectives of the present study were (1) to identify indicators of altered central processing in participants with Achilles tendinopathy compared to controls, and (2) to determine which indicators of altered central processing would persist after a local anesthetic injection in patients with Achilles tendinopathy.

DESIGN

Mechanistic clinical trial.

METHODS

Forty-six adults (23 with chronic Achilles tendinopathy, 23 matched controls) repeated (1) a movement-evoked pain rating, (2) motor performance assessment, (3) pain psychology questionnaires, and (4) quantitative sensory testing. Participants with Achilles tendinopathy received a local anesthetic injection before repeat testing and controls did not. Mixed-effects analyses of variance examined the effects of group, time, and group by time.

RESULTS

The Achilles tendinopathy group had movement-evoked pain, motor dysfunction, and higher pain psychological factors (pain catastrophizing, kinesiophobia) compared to controls (P<.05). The Achilles tendinopathy group did not have indicators of nociplastic pain with quantitative sensory testing (P>.05). In those with Achilles tendinopathy, local anesthetic injection eliminated pain and normalized the observed deficits in heel-raise performance and pain catastrophizing (group-by-time effect, P<.01), but not in kinesiophobia (P = .45). Injection did not affect measures of nociplastic pain (P>.05).

CONCLUSION

People with Achilles tendinopathy had elevated pain psychological factors and motor dysfunction but no signs of nociplastic pain with quantitative sensory testing. Removal of nociceptive input normalized movement-evoked pain and some indicators of altered central processing (motor dysfunction, pain catastrophizing), but not kinesiophobia. J Orthop Sports Phys Ther 2020;50(6):334-343. Epub 29 Apr 2020. doi:10.2519/jospt.2020.9242.

Characterisation of Achilles tendon pain in recreational runners using multidimensional pain scales

OBJECTIVES

The main assessment tool for Achilles tendinopathy (AT) is the VISA-A. However, the VISA-A only assesses the physical impairments that result from tendon pain. This study sought to describe and assess tendon pain using other multidimensional pain scales; the short forms of the McGill pain questionnaire (sf-MPQ) and the Brief Pain Inventory (sf-BPI).

DESIGN

Cross sectional observational study.

METHODS

124 recreational runners with clinically confirmed mid-portion Achilles tendinopathy for at least 3 months were recruited from Cape Town, South Africa. They described and rated their tendinopathy symptoms by completing the VISA-A, sf-BPI and sf-MPQ questionnaires.

RESULTS

Tendon pain was largely described as a sensory type of pain with minimal affective elements. Sixty percent described their pain as aching. Significant proportions described it as tender (52.9%), throbbing (33.9%), hot burning (24.8%) and 33.8% ranked it as discomfiting or worse on the pain intensity score of the sf-MPQ. Tendon pain interfered with mood in 50.8% of the participants as well as with walking ability (72.5%), sleep (34.8%) and enjoyment of life (54.2%).

CONCLUSIONS

Tendon pain was described using a variety of adjectives which may suggest that AT has clinical subtypes. Tendon pain interferes with more than just physical function. Therefore, the recommendation is to conduct further studies using various pain questionnaires to elicit more details and better understand the nature of Achilles tendon pain.

Minocycline microspheres did not significantly improve outcomes after collagenase injection of tendon

BACKGROUND

Tetracycline antibiotics inhibit matrix metalloproteinases and pro-inflammatory cytokines implicated in the pathogenesis of tendinopathy, while microsphere formulations allow sustained release of drug contents. The purpose of this study was to evaluate the ability of a local minocycline microsphere injection to restore normal tendon properties in a rat model of collagenase-induced patellar tendinopathy.

METHODS

A total of 22 rats were randomly assigned to the control (n = 11) or minocycline (n = 11) group and received bilateral patellar tendon injections of collagenase. After 7 days, the minocycline group received the minocycline microsphere treatment and the control group received phosphate buffered solution. Pain was assessed via activity monitors and Von Frey filament testing. At 4 weeks post-collagenase injections, animals were euthanized.

RESULTS

Cage crossings significantly decreased among all rats 2-3 days following each injection period, however, tactile allodynia measures did not reflect this injury response. Biomechanical properties, interleukin-1 beta levels, and glycosaminoglycan content did not differ between groups. While not statistically significant, levels of leukotriene B4 were lower in the minocycline group compared to controls (p = 0.061), suggesting a trend.

CONCLUSIONS

Our study further characterizes the collagenase model of tendinopathy by demonstrating no evidence of central sensitization with collagenase-induced injury. We found no adverse effect of intratendinous injections of minocycline-loaded poly-lactic-co-glycolic acid microspheres, although no therapeutic effect was observed. Future studies involving a more substantial tendon injury with a greater inflammatory component may be necessary to more thoroughly evaluate the effects of minocycline on tendon pathology.

Do features of central sensitisation exist in Greater Trochanteric Pain Syndrome (GTPS)? A case control study

BACKGROUND

Greater Trochanteric Pain Syndrome (GTPS), which is commonly due to Gluteal Tendinopathy, refers to pain over the lateral hip that can become persistent and disabling. Central nervous sensitisation has been implicated in upper limb tendinopathy, but no studies have investigated if it plays a role in GTPS.

OBJECTIVES

To investigate if features of central sensitisation were present in people with GTPS.

METHODS

Eighteen people with GTPS were matched with 18 healthy controls in this cross-sectional study. The VISA-G and Central Sensitisation Inventory (CSI) self-report questionnaires were completed and pressure pain detection thresholds (PPDTs) at local and remote sites were measured in all participants. Data were analysed for between-group differences using Mann-Whitney U tests. Correlation between CSI and PPDTs were assessed using Pearson correlation co-efficients.

RESULTS

PPDT values were lower at local (symptomatic greater trochanter) and remote sites in the GTPS group, indicative of central sensitisation, resulting in statistically significant between-group differences. 44.4% of the GTPS group were classified as having symptoms of central sensitisation, based on the CSI.

CONCLUSION

There is preliminary evidence of central sensitisation in people with GTPS. Results need to be validated using other objective quantitative sensory testing measures in larger samples.

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.

Potential Nervous System Sensitization in Patients With Persistent Lower Extremity Tendinopathies: 3 Case Reports

BACKGROUND

Tendinopathy is a condition often associated with pain and functional and sport performance limitations. While targeted exercise prescriptions are often effective, many patients with tendinopathy develop persistent symptoms. Emerging evidence suggests a possible link between nervous system sensitization and tendinopathy. If so, identifying and treating specific pain mechanisms may improve outcomes.

CASE DESCRIPTION

Three patients were seen in physical therapy for complaints of ongoing chronic tendon pain and self-reported disability, despite being treated previously and receiving evidence-informed care. Upon examination, each patient demonstrated signs consistent with possible dysfunction of central pain mechanisms. Joint mobilization, pain neuroscience education, and aerobic exercise were primary interventions in each case to decrease pain and improve function.

OUTCOMES

The 3 patients were treated for 5 sessions over the course of 8 weeks. Clinically significant improvement was noted in measures of pain, self-reported function, and pressure pain thresholds. At discharge, all patients were able to run without symptoms, and improvement was maintained at 1-year follow-up.

DISCUSSION

Tendinopathy, while often described as local pain and dysfunction, may be associated with dysfunction of the nervous system. Identifying and treating pain mechanisms in addition to relevant impairments may be an appropriate intervention approach for individuals with tendinopathy.

LEVEL OF EVIDENCE

Therapy, level 4. J Orthop Sports Phys Ther 2019;49(4):272-279. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8600.

Clinical risk factors for Achilles tendinopathy: a systematic review

Background

Achilles tendinopathy is a common problem, but its exact aetiology remains unclear.

Objective

To evaluate the association between potential clinical risk factors and Achilles tendinopathy.

Design

Systematic review.

Data sources

The databases Embase, MEDLINE Ovid, Web of Science, Cochrane Library and Google Scholar were searched up to February 2018.

Eligibility criteria

To answer our research question, cohort studies investigating risk factors for Achilles tendinopathy in humans were included. We restricted our search to potential clinical risk factors (imaging studies were excluded).

Results

We included 10 cohort studies, all with a high risk of bias, from 5111 publications identified. There is limited evidence for nine risk factors: (1) prior lower limb tendinopathy or fracture, (2) use of ofloxacin (quinolone) antibiotics, (3) an increased time between heart transplantation and initiation of quinolone treatment for infectious disease, (4) moderate alcohol use, (5) training during cold weather, (6) decreased isokinetic plantar flexor strength, (7) abnormal gait pattern with decreased forward progression of propulsion, (8) more lateral foot roll-over at the forefoot flat phase and (9) creatinine clearance of <60 mL/min in heart transplant patients. Twenty-six other putative risk factors were not associated with Achilles tendinopathy, including being overweight, static foot posture and physical activity level.

Conclusion

From an ocean of studies with high levels of bias, we extracted nine clinical risk factors that may increase a person’s risk of Achilles tendinopathy. Clinicians may consider ofloxacin use, alcohol consumption and a reduced plantar flexor strength as modifiable risk factors when treating patients with Achilles tendinopathy.

Trial registration number

CRD42017053258.

Relationship between ultrasound detected tendon abnormalities, and sensory and clinical characteristics in people with chronic lateral epicondylalgia

Objective

To investigate the relationship between tendon structural changes determined by static ultrasound images (US) and sensory changes using quantitative sensory testing (QST), and clinical measures in lateral epicondylalgia.

Materials and methods

Both elbows of 66 adult participants with a clinical diagnosis of lateral epicondylalgia were investigated. Using a standardised ultrasound image rating scale, common extensor hypoechogenicity, heterogenicity, neovascularity, and bony abnormalities at the enthesis were scored, and tendon thickness (longitudinal and transverse plane) was measured by a trained assessor. Sensory measures of pressure, heat and cold pain thresholds and vibration detection threshold were recorded. Pain and function were assessed using the patient-rated tennis elbow (PRTEE), pain-free grip strength, pain visual analog scale (PVAS) and quality of life (EuroQoL EQ -5D). Univariate and multivariate linear regression analyses were used to explore the association between tendon structural, sensory and clinical variables which were adjusted for age, gender and duration of symptoms.

Results

A negative correlation was identified between the presence of neovascularity and cold pain threshold (P = 0.015). Multiple regression analyses revealed that a combination of female gender (P = 0.044) and transverse tendon thickness (P = 0.010) were significantly associated with vibration detection threshold in affected elbows, while gender (P = 0.012) and total ultrasound scale score (P = 0.024) were significantly associated with heat pain threshold and vibration detection threshold in unaffected elbows. Heat pain threshold and gender were significantly associated with pain and disability (PRTEE; P < 0.001), and pain-free grip strength (P < 0.001) respectively, in the affected elbows.

Conclusion

Generally, structural and sensory measures were weakly correlated. However, neovascularity and transverse tendon thickness may be related to sensory system changes in LE.

Widespread Pressure Pain Hypersensitivity in Musculoskeletal and Nerve Trunk Areas as a Sign of Altered Nociceptive Processing in Unilateral Plantar Heel Pain

Our aim was to investigate the differences in pressure sensitivity over musculoskeletal and nerve symptomatic and distant areas between individuals with plantar heel pain and healthy subjects and to determine the relationship between sensitivity to pressure pain, foot pain, and fascia thickness. Thirty-five patients with unilateral chronic plantar heel pain and 35 matched healthy controls participated. Pressure pain thresholds (PPTs) were assessed bilaterally over several nerve trunks (median, radial, ulnar, common peroneal, tibial, and sural nerve trunks) and musculoskeletal structures (calcaneus, medial gastrocnemius, tibialis anterior, and second metacarpal) by an assessor blinded to the subject's condition. Pain was assessed with a numerical pain rating scale (0-10), impact of foot pain was assessed with the Foot Function Index, and plantar fascia thickness was measured via ultrasound imaging. Analysis of covariance revealed lower widespread and bilateral PPTs over both nerve trunks and musculoskeletal structures in individuals with plantar heel pain (P < .001). Female patients showed lower PPT than male patients in almost all points (P < .001). PPT over the peripheral nerve trunks of the lower extremity were significantly associated with the intensity of pain at first step in the morning and with the foot function disability scale of the Foot Function Index (P < .05). This study found widespread pressure pain hypersensitivity over both nerve trunks and musculoskeletal structures in individuals with unilateral chronic plantar heel pain, suggesting the presence of a central altered central nociceptive pain processing. Pressure hypersensitivity over nerve trunks on the lower extremity was associated with higher pain intensity and related disability. PERSPECTIVES: This study found widespread pressure hypersensitivity over both nerve trunks and musculoskeletal structures in individuals with unilateral chronic plantar heel pain, as a manifestation of a centrally altered central nociceptive pain processing.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.