Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial

High School Girls' Volleyball Athletes' Self-Reported Management of Pain, Intentions to Report Overuse Injuries, and Intentions to Adhere to Medical Advice for Treating Overuse Injuries

CONTEXT

Girls' high school volleyball is a popular sport with a high rate of overuse injuries and sport specialization. Health professionals perceive that high school athletes are reluctant to follow treatment plans involving sport activity reduction. This study's purpose was to describe high school girls' volleyball athletes' self-reported shoulder and knee pain, the likelihood of adhering to medical advice, and the association of factors that influence the likelihood of reporting overuse injuries and sport specialization.

STUDY DESIGN

Cross-sectional.

METHODS

Participants completed an online survey (demographics, sport participation measures, shoulder and knee pain information, medical adherence likelihood [4-point Likert: not at all likely to extremely likely], and factors influencing overuse injury reporting intentions). A 2 × 2 chi-square analysis compared factors that influence athletes' intentions to "not report an overuse injury" (eg, I thought my coach would get mad; yes/no) and sport specialization (nonhighly specialized/highly specialized athletes).

RESULTS

There were 150 participants (highly specialized = 56%, grade: ninth = 33%, 10th = 28%, 11th = 22%, 12th = 17%). At least 60% reported shoulder and knee pain related to an overuse mechanism. Most reportedly did not seek rehabilitation led by a medical provider (shoulder pain = 66%, knee pain = 60%). Only 11% of athletes reported they were "extremely likely" to rest from sporting activity during the regular season if advised by a medical professional. Highly specialized athletes were more likely to report the pursuit of a college scholarship as a factor that influences their intention to report an overuse injury compared to nonhighly specialized athletes (13% vs 3%, respectively, P = .04).

CONCLUSIONS

Most girls' volleyball athletes did not treat their pain with guided rehabilitation, which may increase their risk of a worse overuse injury or even acute injury. Clinicians, athletes, parents, and coaches need to work together to create a sport culture that empowers athletes to discuss their pain and overuse injuries with medical professionals.

Is radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses more effective than advice plus customised foot orthoses alone in the treatment of plantar fasciopathy? A double-blind, randomised, sham-controlled trial

OBJECTIVES

To assess whether radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses is more effective than advice plus customised foot orthoses alone in alleviating heel pain in patients with plantar fasciopathy.

METHODS

200 patients with plantar fasciopathy were included in a four-arm, parallel-group, sham-controlled, observer-blinded, partly patient-blinded trial. At baseline, before randomisation, all patients received advice plus customised foot orthoses. Patients were randomised to rESWT (n=50), sham-rESWT (n=50), exercise (n=50) or advice plus customised foot orthoses alone (n=50). Patients in the rESWT and sham-rESWT groups received three treatments. The exercise programme comprised two exercises performed three times a week for 12 weeks, including eight supervised sessions with a physiotherapist. Patients allocated to advice plus customised foot orthoses did not receive additional treatment. The primary outcome was change in heel pain during activity in the previous week per Numeric Rating Scale (0-10) from baseline to 6-month follow-up. The outcome was collected at baseline, and 3, 6 and 12 months.

RESULTS

The primary analysis showed no statistically significant between-group differences in mean change in heel pain during activity for rESWT versus advice plus customised foot orthoses (-0.02, 95% CI -1.01 to 0.96), sham-rESWT versus advice plus customised foot orthoses (0.52, 95% CI -0.49 to 1.53) and exercise versus advice plus customised foot orthoses (-0.11, 95% CI -1.11 to 0.89) at 6 months.

CONCLUSION

In patients with plantar fasciopathy, there was no additional benefit of rESWT, sham-rESWT or a standardised exercise programme over advice plus customised foot orthoses in alleviating heel pain.

TRIAL REGISTRATION NUMBER

NCT03472989.

The emerging role of Piezo1 in the musculoskeletal system and disease

Piezo1, a mechanosensitive ion channel, has emerged as a key player in translating mechanical stimuli into biological signaling. Its involvement extends beyond physiological and pathological processes such as lymphatic vessel development, axon growth, vascular development, immunoregulation, and blood pressure regulation. The musculoskeletal system, responsible for structural support, movement, and homeostasis, has recently attracted attention regarding the significance of Piezo1. This review aims to provide a comprehensive summary of the current research on Piezo1 in the musculoskeletal system, highlighting its impact on bone formation, myogenesis, chondrogenesis, intervertebral disc homeostasis, tendon matrix cross-linking, and physical activity. Additionally, we explore the potential of targeting Piezo1 as a therapeutic approach for musculoskeletal disorders, including osteoporosis, muscle atrophy, intervertebral disc degeneration, and osteoarthritis.

Advanced MRI Approaches for Evaluating Common Lower Extremity Injuries in Basketball Players: Current and Emerging Techniques

Magnetic resonance imaging (MRI) can provide accurate and non-invasive diagnoses of lower extremity injuries in athletes. Sport-related injuries commonly occur in and around the knee and can affect the articular cartilage, patellar tendon, hamstring muscles, and bone. Sports medicine physicians utilize MRI to evaluate and diagnose injury, track recovery, estimate return to sport timelines, and assess the risk of recurrent injury. This article reviews the current literature and describes novel developments of quantitative MRI tools that can further advance our understanding of sports injury diagnosis, prevention, and treatment while minimizing injury risk and rehabilitation time. Innovative approaches for enhancing the early diagnosis and treatment of musculoskeletal injuries in basketball players span a spectrum of techniques. These encompass the utilization of T2, T1ρ, and T2* quantitative MRI, along with dGEMRIC and Na-MRI to assess articular cartilage injuries, 3D-Ultrashort echo time MRI for patellar tendon injuries, diffusion tensor imaging for acute myotendinous injuries, and sagittal short tau inversion recovery and axial long-axis T1-weighted, and 3D Cube sequences for bone stress imaging. Future studies should further refine and validate these MR-based quantitative techniques while exploring the lifelong cumulative impact of basketball on players' knees. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 2.

Intermittent blood flow restriction with low-load resistance training for older adults with knee osteoarthritis: a randomized, controlled, non-inferiority trial protocol

BACKGROUND

Knee osteoarthritis (KOA) is a chronic musculoskeletal disorder characterized by pain and functional impairment. Blood flow restriction (BFR) with low-load resistance training (LLRT) demonstrates a similar improvement in clinical outcomes to high-load resistance training (HLRT) in treating KOA. It has not been established whether intermittent blood flow restriction (iBFR) with LLRT can lead to clinical outcomes that are comparable to those produced by continuous blood flow restriction (cBFR) with LLRT and HLRT. The aim of the proposed study is to evaluate the efficacy of iBFR with LLRT on pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), muscle strength, muscle mass, physical function, perceptions of discomfort and effort, and adherence in KOA patients.

METHODS

This is a three-arm, non-inferiority, randomized controlled trial utilizing blinded assessors. Two hundred thirteen participants will be randomly allocated to one of the following three groups: iBFR group-receiving 4 months of LLRT with iBFR, twice weekly (n = 71); cBFR group-receiving 4 months of LLRT with cBFR, twice weekly (n = 71); or HLRT group-receiving 4 months of HLRT without BFR, twice weekly (n = 71). The primary outcome is pain. The secondary outcomes include the WOMAC, muscle strength, muscle mass, physical function, perceptions of discomfort and effort, and adherence. Pain and WOMAC will be measured at the baseline and 4 and 12 months after randomizations. Muscle strength, muscle mass, and physical function will be measured at the baseline and 4 months after randomizations. The perceptions of discomfort and effort will be measured during the first and final sessions.

DISCUSSION

BFR with LLRT has a similar improvement in clinical outcomes as HLRT. However, cBFR may cause elevated ratings of perceived exertion and local discomfort, compromising patient tolerability and treatment adherence. If iBFR with LLRT could produce improvement in clinical outcomes analogous to those of HLRT and iBFR with LLRT, it could be considered an alternative approach for treating patients with KOA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300072820. Registered on June 26, 2023.

Feasibility of an early progressive resistance exercise program for acute Achilles tendon rupture

BACKGROUND

Long-term strength deficits are common after Achilles tendon ruptures. Early use of progressive resistance exercises may help reduce strength deficits, but the feasibility of this approach is unknown. The aim was to investigate the feasibility of early progressive resistance exercises regarding patient acceptability and compliance with the intervention.

METHODS

We recruited patients with an acute Achilles tendon rupture treated non-surgically. During 9 weeks of immobilisation with a walking boot, participants attended weekly supervised physiotherapy sessions of progressive resistance exercises and performed home exercises, consisting of isometric ankle plantarflexion, seated heel-rise, and elastic band exercises. Acceptability was evaluated using a 7-point Likert scale (1 = very unacceptable and 7 = very acceptable) with feasibility threshold at 80% of the participants rating ≥ 4. Adherence to the exercises was defined as 80% of the participants performing at least 50% of the home exercises. During the intervention, tendon healing and adverse events were monitored.

RESULTS

Sixteen participants (mean age 46 (range 28-61), male/female = 13/3) completed the intervention. Pre-injury Achilles tendon total rupture score was 98 (SD 8). All participants rated the acceptability of the exercises ≥ 5 (moderate acceptable to very acceptable) at 9- and 13-week follow-up and 9/16 rated 7 points (very acceptable). Participants performed 74% (range 4-117) of the total prescribed home exercises and 15/16 performed > 50%. One participant was not compliant with the home exercises due to feeling uncomfortable performing these independently. There were no re-ruptures, but one case of deep venous thrombosis.

CONCLUSIONS

The early progressive resistance exercise program for treatment of non-surgically treated Achilles tendon rupture was feasible. Future studies should investigate the efficacy of the progressive intervention.

TRIAL REGISTRATION

The study was registered at Clinical Trials (NCT04121377) on 29 September 2019.

CLINICALTRIALS

NCT04121377 .

Rehabilitation following ulnar collateral ligament injury of the elbow in a female acrobatic athlete: A case report

BACKGROUND

The mechanism of injury and the conservative rehabilitation of the ulnar collateral ligament of the elbow (UCL) are well studied and reported in overhead athletes, while research on gymnastic athletes is sparse. Evidence suggests exercise as the mainstay in UCL injury rehabilitation. With this report, we aimed to provide a complete rehabilitation protocol following a partial UCL tear of an acrobatic athlete, where exercise and adjunct treatments, such as manual therapy, were used in a progressive staged rehabilitation.

CASE DESCRIPTION

A 16-year-old female acrobatic athlete was diagnosed with partial tear of the anterior band of UCL. The rehabilitation included progressive exercise loading in conjunction with manual therapy for 10 sessions in 8 weeks. Pain, UCL special tests, the Disabilities of Arm, Shoulder and Hand Score Questionnaire (DASH), and the Upper Limb Functional Index (ULFI) were assessed and administered at baseline and at 3, 6, 10 weeks, and 3 months.

RESULTS

Improvement in all outcome measures was noted at the 3-month follow-up indicating a substantial reduction in pain and disability, and an increase in stability of the elbow joint. Return to training was achieved at 8 weeks from the initial visit, while return to sport at the pre-injury level was achieved at 3 months.

CONCLUSION

Progressive exercise loading along with the addition of manual therapy is an effective intervention for the rehabilitation and return to sport following a partial UCL tear. A progressive staged rehabilitation guideline for acrobatic athletes with UCL injuries has been provided to be used and guide clinical practice.

LEVEL OF EVIDENCE

Level IV.

Patellar Tendon Load Progression during Rehabilitation Exercises: Implications for the Treatment of Patellar Tendon Injuries

PURPOSE

This study aimed to evaluate patellar tendon loading profiles (loading index, based on loading peak, loading impulse, and loading rate) of rehabilitation exercises to develop clinical guidelines to incrementally increase the rate and magnitude of patellar tendon loading during rehabilitation.

METHODS

Twenty healthy adults (10 females/10 males, 25.9 ± 5.7 yr) performed 35 rehabilitation exercises, including different variations of squats, lunge, jumps, hops, landings, running, and sports specific tasks. Kinematic and kinetic data were collected, and a patellar tendon loading index was determined for each exercise using a weighted sum of loading peak, loading rate, and cumulative loading impulse. Then the exercises were ranked, according to the loading index, into tier 1 (loading index ≤0.33), tier 2 (0.33 < loading index <0.66), and tier 3 (loading index ≥0.66).

RESULTS

The single-leg decline squat showed the highest loading index (0.747). Other tier 3 exercises included single-leg forward hop (0.666), single-leg countermovement jump (0.711), and running cut (0.725). The Spanish squat was categorized as a tier 2 exercise (0.563), as was running (0.612), double-leg countermovement jump (0.610), single-leg drop vertical jump (0.599), single-leg full squat (0.580), double-leg drop vertical jump (0.563), lunge (0.471), double-leg full squat (0.428), single-leg 60° squat (0.411), and Bulgarian squat (0.406). Tier 1 exercises included 20 cm step up (0.187), 20 cm step down (0.288), 30 cm step up (0.321), and double-leg 60° squat (0.224).

CONCLUSIONS

Three patellar tendon loading tiers were established based on a combination of loading peak, loading impulse, and loading rate. Clinicians may use these loading tiers as a guide to progressively increase patellar tendon loading during the rehabilitation of patients with patellar tendon disorders and after anterior cruciate ligament reconstruction using the bone-patellar tendon-bone graft.

Effects of exercise-based interventions on gluteal tendinopathy. Systematic review with meta-analysis

The objective of this review was to evaluate the effect of exercise on pain intensity, function, and quality of life in individuals with gluteal tendinopathy. Searches were carried out in PUBMED, EMBASE, CINAHL, Cochrane Library, and PEDro databases. Randomized or quasi-randomized controlled trials were included. Five studies met the eligibility criteria, comparing exercise-based interventions with minimal interventions and/or corticosteroid injections. Three studies, involving 383 participants, were included in the quantitative analysis. Meta-analyses showed that exercise is superior to minimal intervention for function in short-term [mean difference (MD) = 10.24; 95% confidence interval (95%CI) = 5.98, 14.50) and long-term (MD = 6.54; 95%CI = 1.88, 11.21]). However, no difference was observed for quality of life in the short [standardized mean difference (SMD) = 0.33; 95%CI = -0.29, 0.94] and long-term (SMD = 0.11; 95%CI = -0.16, 0.37). The effect of exercise was no different from that of corticosteroid injections for pain intensity in the short (MD = 1.25; 95%CI = -3.56, 6.05) and long-term (MD = -1.37; 95%CI = -3.72, 0.98]). In conclusion, exercise is superior to minimal interventions for function in the short- and long-term in individuals with gluteal tendinopathy. Exercise and corticosteroid injections had similar effects on pain intensity, however, exercise showed a higher treatment success rate when compared to corticosteroid injections in this population. The GRADE analysis revealed that the certainty of the evidence ranges from low to very low, therefore, large high-quality randomized controlled trials are recommended.PROSPERO registration number: CRD42021242853.

Maximal Lower Limb Strength in Patellar Tendinopathy: A Systematic Review With Meta-Analysis

OBJECTIVE

To investigate whether lower limb strength is reduced in people with patellar tendinopathy (PT) compared with asymptomatic control individuals or the asymptomatic contralateral limb.

DATA SOURCES

MEDLINE, PubMed, Scopus, and Web of Science.

STUDY SELECTION

To be included in the systematic review and meta-analysis, studies were required to be peer reviewed, published in the English language, and case control investigations; include participants with a clinical diagnosis of PT and an asymptomatic control or contralateral limb group; and include an objective measure of lower limb maximal strength.

DATA EXTRACTION

We extracted descriptive statistics for maximal strength for the symptomatic and asymptomatic limbs of individuals with PT and the limb(s) of the asymptomatic control group, inferential statistics for between-groups differences, participant characteristics, and details of the strength-testing protocol. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for analytical cross-sectional studies.

DATA SYNTHESIS

Of the 23 included studies, 21 reported knee strength, 3 reported hip strength, and 1 reported ankle strength. Random-effects models (Hedges g) were used to calculate the pooled effect sizes (ESs) of muscle strength according to the direction of joint movement and type of contraction. The pooled ESs (95% CI) for maximal voluntary isometric contraction knee-extension strength, concentric knee-extension strength, and concentric knee-flexion strength were 0.54 (0.27, 0.80), 0.78 (0.30, 1.33), and 0.41 (0.04, 0.78), respectively, with all favoring greater strength in the asymptomatic control group. Researchers of 2 studies described maximal eccentric knee-extensor strength with no differences between the PT and asymptomatic control groups. In 3 studies, researchers measured maximal hip strength (abduction, extension, and external rotation), and all within-study ESs favored greater strength in the asymptomatic control group.

CONCLUSIONS

Isometric and concentric knee-extensor strength are reduced in people with PT compared with asymptomatic control individuals. In contrast, evidence for reduced eccentric knee-extension strength in people with PT compared with asymptomatic control individuals is limited and inconsistent. Although evidence is emerging that both knee-flexion and hip strength may be reduced in people with PT, more examination is needed to confirm this observation.

Peak patellar tendon force progressions during heavy load single-leg squats on level ground and decline board

BACKGROUND

Progressive tendon loading programs for patellar tendinopathy typically include single-leg squats with heavy weights either on level ground or on a decline board. Changes in patellar tendon force due to variations of the heavy load single-leg squat have not yet been objectively quantified. The objective of this study was to investigate the influence of the mass of an external weight and the use of a decline board on the peak patellar tendon force during a heavy load single-leg squat.

METHODS

Twelve healthy participants performed single-leg back squats on a decline board and level ground at 70%, 80% and 90% of their one repetition maximum. Three-dimensional kinematics and ground reaction forces were measured and the peak patellar tendon force was calculated using musculoskeletal modelling. A two-way repeated measures ANOVA determined the main effects for the mass of the external weights and the use of a decline board as well as their interaction effect.

FINDINGS

Peak patellar tendon forces were significantly higher on the decline board compared to level ground (p < 0.05). Neither on the decline board, nor on level ground did the peak patellar tendon force increase significantly when increasing the external weights (p > 0.05).

INTERPRETATION

Progression in peak patellar tendon forces during a heavy load single-leg squat can only be obtained with a decline board. Increasing the mass of the external weight from 70% to 90% of the one repetition maximum does not result in a progressively higher peak patellar tendon force.

Efficacy of ultrasound-guided galvanic electrolysis technique and physical therapy in patients with Achilles' tendinopathy: A pilot randomised controlled trial

BACKGROUND

Ultrasound-guided galvanic electrolysis technique (USGET) is an innovative mini-invasive intervention with the potential to optimise outcomes in the treatment of Achille's tendinopathy (AT).

OBJECTIVE

The aim of this pilot study is to evaluate the efficacy of adding USGET to conventional eccentric exercise treatment in patients with chronic AT.

METHODS

Inclusion criteria were patients with unilateral non-insertional AT, pain lasting > 3 months, aged 25-60 years. Patients were randomised in two groups receiving the same physiotherapy treatment (2 sessions per week for 8 weeks). In addition, the experimental group received three USGET stimulations, one every 15 days. Outcome measures were assessment of Achilles tendinopathy severity using the Victorian Institute of Sport Assessment-Achilles (VISA-A) and pain intensity using the Visual Analogue Scale (VAS). Assessment points occurred at the onset of treatment (T0), its conclusion (T1), and subsequent follow-ups at one (T2) and two months (T3).

RESULTS

Out of the 52 patients who met the study inclusion criteria, two participants withdrew from the study, resulting in a total of 50 subjects who completed the research. None of the parameters showed a different distribution at T1 (p> 0.337). At T2, there was a statistical difference in VISA-A (p= 0.010) and its subscales and VAS (p= 0.002) in the USGET group. At T3, both groups improved with a statistical difference observed in VISA-A (p< 0.001) and its subscales Pain (p= 0.004), Function (p= 0.003) and Sport (p= 0.002), but the EG patients showed a greater improvement. No adverse events were reported.

CONCLUSION

The effect of USGET combined with eccentric exercise appears to be a safe and effective technique for achieving pain relief and functional recovery in the medium term, supporting the integrated use of USGET as a rehabilitative treatment option for patients with chronic AT.

The Tendinopathy Game Changers: Five Papers From the Last 5 Years That Might Change How You Manage Tendons

SYNOPSIS: The clinical and scientific understanding of tendinopathy has substantially advanced since the Fifth International Scientific Tendinopathy Symposium in 2019. This editorial aims to highlight some of the fantastic tendinopathy research from the past 5 years. We have selected what we consider the "best paper" for each year from 2019 to 2023, which might change how you treat tendons. Selecting only 5 papers was not easy. Did your favorite papers make the cut? Or do you think we missed some key studies? We encourage you to tell us what you think using the social media hashtag #JOSPTtendon. J Orthop Sports Phys Ther 2024;54(1):1-3. Epub 16 November 2023. doi:10.2519/jospt.2023.12372.

S.P.O.R.R.T.-A Comprehensive Approach to the Assessment and Non-Operative Management of Overuse Knee Conditions in Youth Athletes

PURPOSE OF REVIEW

The evaluation of a young athlete with an overuse injury to the knee involves a comprehensive approach. There are a number of elements to consider including assessments of skeletal maturity (biologic maturation), workload (training load + competition load), sport specialization status, and biomechanics. The type of injury and treatment, as well as future prognosis, may be influenced by these and other factors.

RECENT FINDINGS

Calculating the percentage of predicted adult height (PPAH) is a valuable tool in assessing overuse injury patterns and diagnoses in youth athletes. Modifiable and non-modifiable overuse injury risk factors require monitoring from clinicians as young athletes mature and develop over time. Training and rehabilitation programs should be adapted to account for these. In this manuscript, we seek to introduce a novel, comprehensive approach: S.P.O.R.R.T. (Skeletal Maturity, Prior Injury Risk, One Sport Specialization, Rehabilitation, Return to Play, Training Recommendations) (Fig. 1). Overuse, non-traumatic injuries to the knee in youth athletes will be presented in a case-based and evidence-based model to provide a framework for a comprehensive approach to the assessment and treatment of youth athletes with overuse injuries.

The JUMPFOOD study: additional effect of hydrolyzed collagen and vitamin C to exercise treatment for patellar tendinopathy (jumper's knee) in athletes-study protocol for a double-blind randomized controlled trial

BACKGROUND

Patellar tendinopathy (PT) is a common problem in jumping athletes. Management can be challenging and treatment outcome is not always successful. In combination with tendon loading exercises, hydrolyzed collagen/vitamin C supplementation appears to have a promising effect on the recovery of tendinopathy. The aim of this study is to evaluate whether the use of oral supplementation of hydrolyzed collagen and vitamin C in combination with progressive tendon loading exercises (PTLE) is superior to PTLE and placebo on VISA-P score (which rates pain, function, sports participation) after 24 weeks for athletes with PT.

METHODS

The JUMPFOOD study is a double-blinded, two-armed randomized controlled trial, in which the effectiveness of oral supplementation of hydrolyzed collagen/vitamin C combined with PTLE compared to PTLE with placebo on pain and recovery of function in athletes with PT will be investigated. Seventy-six athletes aged 16-40 years, with symptoms of PT for at least 12 weeks, who play sports at least once a week will be included. All participants will receive education, advice with regard to load management and a PTLE program according to the Dutch guidelines for anterior knee pain. In addition, the intervention group will receive daily 10 g hydrolyzed collagen and 40 mg vitamin C supplementation for 24 weeks whereas the control group receives 10 g maltodextrin placebo supplementation. Measurements will take place at baseline and at 12 and 24 weeks' follow-up. Primary outcome is the VISA-P score, which evaluates pain, function, and sports participation. For secondary outcome measures, data with regard to pain during functional tests, flexibility measurements, blood withdrawals, imaging characteristics of the tendon, and health questionnaires will be collected. During the follow-up period, participants will register sports participation, amount of training and tendon load, pain during sports, co-medication, and side-effects in a digital weekly diary.

DISCUSSION

The JUMPFOOD study is the first large RCT to study the effectiveness of hydrolyzed collagen/vitamin C supplementation in combination with the PTLE program in athletes with patellar tendinopathy. If supplementation of collagen/vitamin C appears to be effective, this treatment can be implemented in daily sports medicine practice to improve the treatment outcome of patients with PT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05407194. Registered on 7 June 2022.

Home-based exercise program and Health education in patients with patellofemoral pain: a randomized controlled trial

BACKGROUND

Patellofemoral pain (PFP) is one of the most common disorders of the knee joint. Home-based exercise is an effective intervention to achieve self-management for chronic diseases. This study evaluated the effects of home-based exercise and health education in patients with PFP.

METHODS

Patients who had PFP were randomly allocated to an intervention group (IG) or control group (CG). Patients in the IG received a 6-week tailored home-based exercise program with health education via remote support, while patients in the CG group only received health education. Clinical outcomes were compared using the Anterior Knee Pain Scale (AKPS) to measure function and the Visual Analog Scale (VAS) to measure "worst pain" and "pain with daily activity". Muscle strength was measured according to the peak torque of the knee muscles using an isokinetic system.

RESULTS

Among a total of 112 participants screened for eligibility, 38 were randomized and analyzed, including 19 participants in the intervention group and 19 participants in the control group. There were no significant differences in baseline characteristics between the groups. At 6-week follow-up, the intervention group showed a greater worst pain reduction (between-group difference, -19.3 [95%CI, -23.2 to -15.5]; P < 0.01) and pain with daily activity (between-group difference, -22.9 [95%CI, -28.3 to -17.4]; P < 0.01) than the control group. Similarly, the intervention group had better improvements in AKPS (between-group difference, 9.0 [95%CI, 4.1 to 13.9]; P < 0.01) and knee extensor strength (between-group difference, 20.1 [95%CI, 14.5 to 25.8]; P < 0.01), compared to the control group. No adverse events were reported.

CONCLUSION

Home-based exercise and health education resulted in less pain, better function, and higher knee muscle strength compared with no exercise in patients with PFP. A large randomized controlled trial with long-term follow-up is required to confirm these findings.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200056224 ( https://www.chictr.org.cn/showproj.aspx?proj=135506 ). Registered on February 1, 2022.

Effectiveness and Safety of Progressive Loading-Motion Style Acupuncture Treatment for Acute Low Back Pain after Traffic Accidents: A Randomized Controlled Trial

BACKGROUND

Traffic injuries include acute low back pain (LBP) needing active treatment to prevent chronicity. This two-armed, parallel, assessor-blinded, randomized controlled trial evaluated the effectiveness and safety of progressive loading-motion style acupuncture treatment (PL-MSAT) for acute LBP following traffic accidents.

METHODS

Based on an effect size of 1.03, 104 participants were recruited and divided in a 1:1 ratio into PL-MAST and control groups using block randomization. Both groups underwent integrative Korean medicine treatment (IKMT) daily; only the PL-MSAT group underwent three PL-MSAT sessions. The outcomes were assessed before and after the treatment sessions and at 1 and 3 months post-discharge. The primary outcome was the difference in the numeric rating scale (NRS) for LBP. The secondary outcomes included a visual analog scale for LBP, leg pain status, the Oswestry disability index, lumbar active range of motion (ROM), quality of life, Patient Global Impression of Change, and Post-Traumatic Stress Disorder Checklist adverse events.

RESULTS

In the modified intention-to-treat analysis, 50 and 51 participants were included in the PL-MSAT and control groups. On Day 4, the mean LBP NRS score was 3.67 (3.44-3.90) in the PL-MSAT group, indicating a significantly lower NRS 0.77 (0.44-1.11) compared to 4.44 (4.20-4.68) for the control group (p < 0.001). The PL-MSAT group exhibited greater ROM flexion (-5.31; -8.15 to -2.48) and extension (-2.09; -3.39 to -0.80). No significant differences were found for the secondary outcomes and follow-ups.

CONCLUSIONS

Compared with IKMT alone, PL-MSAT plus IKMT showed significantly better outcomes for reducing pain and increasing the ROM in acute LBP.

Association Between Physical Tests and Patients-Reported Outcomes in Athletes Performing Exercise Therapy for Patellar Tendinopathy: A Secondary Analysis of the JUMPER Study

BACKGROUND

Physical tests are commonly used in patellar tendinopathy to aid the clinical diagnosis, assess the prognosis, and monitor treatment. However, it is still unknown whether these physical measures are associated with patient-reported outcomes after exercise therapy.

PURPOSE

To identify the prognostic value of baseline physical test results and to determine the association between physical response after exercise therapy and clinical improvement over 24 weeks.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This study recruited 76 consecutive athletes with patellar tendinopathy who were randomized to 2 different programs of exercise therapy for 24 weeks. Athletes underwent a range of physical tests before and during exercise therapy (12 and 24 weeks), including isometric muscle strength (quadriceps and hip abductors), muscle flexibility (quadriceps, hamstrings, soleus, and gastrocnemius), vertical jump height, and visual analog scale (VAS) scores by palpation, after 3 jump trials, and after single-leg squat (VAS-SLS). The Victorian Institute of Sports Assessment-Patella (VISA-P) questionnaire was used as the primary patient-reported outcome. Linear mixed-effect models were used to assess the prognostic value of baseline physical tests. The change in VISA-P score was further dichotomized into clinical responsiveness (≥14 points) and nonresponsiveness (<14 points). Multiple linear and logistic regression models were performed to evaluate associations between physical response and clinical improvement.

RESULTS

Of the 76 included patients, 67 (88%) had complete follow-ups. The estimated mean VISA-P score increased by 23 points (95% CI, 19-28 points) after 24 weeks. No association was found between any baseline physical test results and a 24-week change in VISA-P score (all Pinteraction > .2, using the likelihood ratio test). Improvement in VAS-SLS after exercise therapy was not associated with VISA-P improvement after adjustment (β = -1.76; P = .01; Bonferroni-corrected P = .10; R2 = 36.3%). No associations were found between changes in other physical test results and clinical improvement (all P > .05).

CONCLUSION

In patients with patellar tendinopathy, physical test results including strength and flexibility in the lower limb, jump performance, and pain levels during pain-provoking tests were not identified as prognostic factors for patient-reported outcomes after exercise therapy. Similarly, changes in physical test results were not associated with changes in patient-reported outcomes after adjustments. These results do not support using physical test results to estimate prognosis or monitor treatment response.

REGISTRATION

NCT02938143 (ClinicalTrials.gov identifier).

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

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

A Review of Patellar Tendinopathy in Athletes Involved in Jumping Sports

This review article discusses the anatomy and histopathology of the patellar tendon, as well as the risk factors and common interventions for patellar tendinopathy (PT) with a view to guide clinicians in treating athletes with patellar tendon pain. PT, or jumper's knee, refers to a chronic injury to the patellar tendon that affects athletes who engage in jumping and explosive movements. The condition is characterized by degeneration and disorganization of the collagen fibers in the tendon, an increase in mucoid ground substance, and fibroblast proliferation. Risk factors for patellar tendinopathy include participation in jumping sports, a greater counter-movement jump height, and training on hard surfaces. Nonoperative treatments for patellar tendinopathy include relative rest, stretching and strengthening exercises, and correction of biomechanical abnormalities. Surgery and other procedures, such as extracorporeal shockwave therapy (ESWT) and injection therapies, may be considered for patients who do not respond to conservative measures.

Evidence for exercise therapy in patients with hand and wrist tendinopathy is limited: A systematic review

BACKGROUND

Several studies reported the efficacy of exercise therapy in hand and wrist tendinopathy. However, no systematic review synthesized the effect of exercise therapy on these patients.

PURPOSE

This study aimed to perform a systematic review to summarize evidence if exercise therapy may be considered an effective treatment in conservative management for patients with hand and wrist tendinopathy.

STUDY DESIGN

This was a systematic review.

METHODS

A literature search in MEDLINE, Cochrane Library, PEDro, and Embase was conducted from their inception until April 10, 2022. Two independent reviewers included the studies administering exercise therapy in patients with hand and/or wrist tendinopathy in the review and extrapolated the data. Methodological quality was assessed using the framework developed by Murad et al for case reports and case series and the PEDro score for clinical trials.

RESULTS

Seven case reports, 3 case series, and 2 randomized controlled studies were included and methodologically evaluated, obtaining a low score for all the analyzed studies. The total number of included patients in the analyzed studies was 106, of which 54 were female, 13 were male, and 39 were not specified. The type of exercise was widespread and often not really well described: it varies from eccentric forearm training to mobilization with movement, passing through strengthening exercises, grip proprioception training, and self-management exercises according to the McKenzie method. The dosage was often not precise, making it difficult to reproduce the therapeutic proposals. Exercise therapy was always administered together with different treatments; therefore, its efficacy alone is difficult to distinguish, although in some cases, the patients improved pain and functionality.

CONCLUSIONS

Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. Future research is strongly recommended to determine the appropriate dosage of the exercise therapy to determine clinical changes in these patients.

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

ABSTRACT

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

Safety and Efficacy of Bone Marrow-Derived Mesenchymal Stem Cells for Chronic Patellar Tendinopathy (With Gap >3 mm) in Patients: 12-Month Follow-up Results of a Phase 1/2 Clinical Trial

Background

In a previous study, the authors found that at 6 months after treatment with a 20 × 106 dose of bone marrow-derived mesenchymal stem cells (BM-MSCs), patients showed improved tendon structure and regeneration of the gap area when compared with treatment using leukocyte-poor platelet-rich plasma (Lp-PRP). The Lp-PRP group (n = 10), which had not seen tendon regeneration at the 6-month follow-up, was subsequently offered treatment with BM-MSCs to see if structural changes would occur. In addition, the 12-month follow-up outcomes of the original BM-MSC group (n = 10) were evaluated.

Purpose

To evaluate the outcomes of all patients (n = 20) at 12 months after BM-MSC treatment and observe if the Lp-PRP pretreated group experienced any type of advantage.

Study Design

Cohort study; Level of evidence, 2.

Methods

Both the BM-MSC and original Lp-PRP groups were assessed at 12 months after BM-MSC treatment with clinical examination, the visual analog scale (VAS) for pain during daily activities and sports activities, the Victorian Institute of Sport Assessment-Patella score for patellar tendinopathy, dynamometry, and magnetic resonance imaging (MRI). Differences between the 2 groups were compared with the Student t test.

Results

The 10 patients originally treated with BM-MSCs continued to show improvement in tendon structure in their MRI scans (P < .0001), as well as in the clinical assessment of their pain by means of scales (P < .05). Ten patients who were originally treated with Lp-PRP and then with BM-MSCs exhibited an improvement in tendon structure in their MRI scans, as well as a clinical pain improvement, but this was not significant on the VAS for sports (P = .139). Thus, applying Lp-PRP before BM-MScs did not yield any type of advantage.

Conclusion

The 12-month follow-up outcomes after both groups of patients (n = 20) received BM-MSC treatment indicated that biological treatment was safe, there were no adverse effects, and the participants showed a highly statistically significant clinical improvement (P < .0002), as well as an improvement in tendon structure on MRI (P < .0001). Preinjection of Lp-PRP yielded no advantages.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patellofemoral Joint Loading Progression Across 35 Weightbearing Rehabilitation Exercises and Activities of Daily Living

BACKGROUND

Exercises that provide progressive therapeutic loading are a central component of patellofemoral pain rehabilitation, but quantitative evidence on patellofemoral joint loading is scarce for a majority of common weightbearing rehabilitation exercises.

PURPOSE

To define a loading index to quantify, compare, rank, and categorize overall loading levels in the patellofemoral joint across 35 types of weightbearing rehabilitation exercises and activities of daily living.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Model-estimated knee flexion angles and extension moments based on motion capture and ground-reaction force data were used to quantify patellofemoral joint loading in 20 healthy participants who performed each exercise. A loading index was computed via a weighted sum of loading peak and cumulative loading impulse for each exercise. The 35 rehabilitation exercises and daily living activities were then ranked and categorized into low, moderate, and high "loading tiers" according to the loading index.

RESULTS

Overall patellofemoral loading levels varied substantially across the exercises and activities, with loading peak ranging from 0.6 times body weight during walking to 8.2 times body weight during single-leg decline squat. Most rehabilitation exercises generated a moderate level of patellofemoral joint loading. Few weightbearing exercises provided low-level loading that resembled walking or high-level loading with both high magnitude and duration. Exercises with high knee flexion tended to generate higher patellofemoral joint loading compared with high-intensity exercises.

CONCLUSION

This study quantified patellofemoral joint loading across a large collection of weightbearing exercises in the same cohort.

CLINICAL RELEVANCE

The visualized loading index ranks and modifiable worksheet may assist clinicians in planning patient-specific exercise programs for patellofemoral pain rehabilitation.

The use of physical function capacity measures in the management of lower limb tendinopathy: A scoping review of expert recommendations

BACKGROUND

Physical function capacity measures are recommended as outcome measures for people with lower limb tendinopathy.

OBJECTIVE

(i) Explore measures of physical function capacity recommended by experts in lower limb tendinopathy (ii) the context they were used, (ii) identify recommended criteria for exercise progression and return to sport or activity.

DESIGN

Scoping Review.

METHOD

Three databases were searched using keywords for lower limb tendinopathy and physical function capacity to identify studies that outlined a progressive exercise rehabilitation program. A 15-item tool was used for data extraction.

RESULTS

26 studies were included, only eight recommended a physical function capacity measure. There were 10 physical function capacity measures identified for a range of lower limb tendinopathies including patellar (50%), Achilles (13%), proximal hamstring (13%), gluteal (13%), combined patellar and Achilles (13%). Pain was the most common criterion that was used to determine the progression of rehabilitation (96%), with physical function capacity measures rarely used (12%).

CONCLUSION

Physical function capacity measures are used infrequently across expert recommended exercise rehabilitation programs. There remains a high reliance on pain as the criterion for progression of exercises during rehabilitation. There is a need to develop measures of physical function capacity to better inform and progress rehabilitation.

Evidence-Based High-Loading Tendon Exercise for 12 Weeks Leads to Increased Tendon Stiffness and Cross-Sectional Area in Achilles Tendinopathy: A Controlled Clinical Trial

BACKGROUND

Assuming that the mechanisms inducing adaptation in healthy tendons yield similar responses in tendinopathic tendons, we hypothesized that a high-loading exercise protocol that increases tendon stiffness and cross-sectional area in male healthy Achilles tendons may also induce comparable beneficial adaptations in male tendinopathic Achilles tendons in addition to improving pain and function.

OBJECTIVES

We investigated the effectiveness of high-loading exercise in Achilles tendinopathy in terms of inducing mechanical (tendon stiffness, maximum strain), material (Young's modulus), morphological (tendon cross-sectional area (CSA)), maximum voluntary isometric plantar flexor strength (MVC) as well as clinical adaptations (Victorian Institute of Sports Assessment-Achilles (VISA-A) score and pain (numerical rating scale (NRS))) as the primary outcomes. As secondary outcomes, drop (DJ) and counter-movement jump (CMJ) height and intratendinous vascularity were assessed.

METHODS

We conducted a controlled clinical trial with a 3-month intervention phase. Eligibility criteria were assessed by researchers and medical doctors. Inclusion criteria were male sex, aged between 20 and 55 years, chronic Achilles tendinopathy confirmed by a medical doctor via ultrasound-assisted assessment, and a severity level of less than 80 points on the VISA-A score. Thirty-nine patients were assigned by sequential allocation to one of three parallel arms: a high-loading intervention (training at ~ 90% of the MVC) (n = 15), eccentric exercise (according to the Alfredson protocol) as the standard therapy (n = 15) and passive therapy (n = 14). Parameters were assessed pre- and-post-intervention. Data analysis was blinded.

RESULTS

Primary outcomes: Plantar flexor MVC, tendon stiffness, mean CSA and maximum tendon strain improved only in the high-loading intervention group by 7.2 ± 9.9% (p = 0.045), 20.1 ± 20.5% (p = 0.049), 8.98 ± 5.8% (p < 0.001) and -12.4 ± 10.3% (p = 0.001), respectively. Stiffness decreased in the passive therapy group (-7.7 ± 21.2%; p = 0.042). There was no change in Young's modulus in either group (p > 0.05). The VISA-A score increased in all groups on average by 19.8 ± 15.3 points (p < 0.001), while pain (NRS) dropped by -0.55 ± 0.9 points (p < 0.001).

SECONDARY OUTCOMES

CMJ height decreased for all groups (-0.63 ± 4.07 cm; p = 0.005). There was no change in DJ height and vascularity (p > 0.05) in either group.

CONCLUSION

Despite an overall clinical improvement, it was exclusively the high-loading intervention that induced significant mechanical and morphological adaptations of the plantar flexor muscle-tendon unit. This might contribute to protecting the tendon from strain-induced injury. Thus, we recommend the high-loading intervention as an effective (alternative) therapeutic protocol in Achilles tendinopathy rehabilitation management in males.

CLINICAL TRIALS REGISTRATION NUMBER

NCT02732782.

The Influence of Different Modes of Exercise on Healthy and Injured Tendons

Tendons are essential components of the musculoskeletal system that links the skeletal muscle to the skeleton. This dense connective tissue exhibits great plasticity. Therefore, research on the influence of types of exercise, including acute and long-term training, on the structural and mechanical properties of tendons in athletic and sedentary populations is of critical importance in the design of scientific-based exercise plans and effective tendinopathy treatment. Here, we review recent studies on the relationship between exercise and tendon health and tendinopathy repair to provide a general understanding of how exercise may reshape tendons.

Ballet Rehabilitation: A Novel Return to Sport Protocol

Dance injuries and re-injuries are common but can be difficult to rehabilitate because of the unique demands and motor skills required. During tissue healing, pain resolves prior to tissue maturation and re-injury often occurs if the original injury is not properly rehabilitated.

The purpose of this narrative review is to analyze the existing literature addressing ballet injury, re-injury, and recovery, and to provide clinicians with timing guidelines for entering and implementing a Return to Sport (RTS) ballet rehabilitation protocol designed to prevent re-injury by progressive, sport-specific tissue loading. Thus far, a literature-based ballet-specific and body region-specific late-stage rehabilitation RTS protocol has not been established. The authors sought to address this literature gap by combining this comprehensive narrative review with our extensive clinical expertise to develop a late-stage rehabilitation RTS protocol to help guide medical clinicians treating injured ballet dancers.

Experience of physical activity in patients with COPD: A systematic review and qualitative meta-synthesis

OBJECTIVE

To systematically evaluate and integrate the qualitative research on physical activity (PA) experience of patients with chronic obstructive pulmonary disease (COPD).

METHODS

Web of Science, Cochrane Library, Embase, CINAHL and other databases were searched, and the qualitative research on PA experience of patients with COPD was collected. The systematic review was conducted in line with Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence.

RESULTS

12 studies were included and 3 themes were summarized, included: COPD patients experience more barriers while participating in physical activities than facilitators; COPD patients experience more positive effects post-physical activities than negative effects; Guaranteeing safety, goal setting, and establishing a professional support group improve compliance in COPD patients.

CONCLUSION

Health care professionals should help patients overcome the obstacles of PA, pay attention to the PA experience of patients, adopt diversified PA methods, improve PA participation and compliance, and make patients develop good PA habits.

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.

High-Volume Image-Guided Injections in Achilles and Patellar Tendinopathy in a Young Active Military Population: A Double-Blind Randomized Controlled Trial

Background:

Chronic Achilles and patellar tendinopathy are a significant burden in physically active populations. High-volume image-guided injection (HVIGI) proposes to strip away associated neovascularity, disrupt painful nerve ingrowth, and facilitate rehabilitation.

Purpose:

To investigate the efficacy of HVIGI with and without steroid relative to placebo.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 62 participants were recruited between May 25, 2016, and March 5, 2020. Participants were men aged 18 to 55 years with Achilles or patellar tendinopathy of at least 6-month chronicity that had not improved with nonoperative management (including physical therapy and shockwave therapy), with ultrasound evidence of neovascularization, tendon thickening, and echogenic changes. They were assigned to the following groups: control (3 mL of subcutaneous 0.5% bupivacaine), HVIGI (10 mL of 0.5% bupivacaine and 30 mL of normal saline, ultrasound-guided between tendon and underlying fat pad), or HVIGI with steroid (HVIGIwSteroid; 0.25 mL of 100 mg/mL hydrocortisone). Clinicians and assessors were blinded. All participants were supervised through a pain-guided progressive loading program for 6 months postinjection. The main outcome measures were the Victoria Institute of Sport Assessments (VISA) for Achilles and patellar tendinopathy and the visual analog scale (VAS) for pain at 6 months postinjection.

Results:

The VISA score improved by a mean of 22.8 points (95% CI, 10.4-35.3 points; effect size [ES], 1.51) in the control group (n = 21), 18.6 points (95% CI, 9.1-28.0 points; ES, 1.31) in the HVIGI group (n = 21), and 18.5 points (95% CI, 3.4-33.6 points; ES, 0.88) in the HVIGIwSteroid group (n = 20). VAS pain improved by a mean of 15 points (interquartile range [IQR], –38.75, 8 points; ES, 0.39) in controls, 13 points (IQR,–34.0, 3.75 points; ES, 0.47) in the HVIGI group, and 27 points (IQR,–38.0, –1.0 points; ES, 0.54) in the HVIGIwSteroid group. The main effects were significant for time (P < .001) but not group (P ≥ .48), with no group × time interaction (P = .71). One participant was lost to follow-up from each group, multiple imputation was used for missing data points. No adverse events occurred.

Conclusion:

Study findings did not demonstrate superiority of HVIGI over control injection.

Registration:

EU Clinical Trials Register (EudraCT: 2015-003587-36).

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

OBJECTIVES

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Patellar Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

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Patellar tendinopathy is an attritional injury of the patellar tendon that is frequently identified in jumping athletes. Through repetitive or explosive movements, considerable loads and high peak strains are generated across the patellar tendon.

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This leads to microinjury of tendon fibers, local mucoid degeneration, and loss of the fibrocartilaginous tissue that attaches tendon to bone.

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Management of patellar tendinopathy often begins with nonoperative modalities: progressive tendon loading and eccentric rehabilitative exercise programs are the most effective. While a variety of additional treatment modalities are available, the comparative efficacy of these supportive treatments is not well differentiated at this time.

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In this article, we analyze the existing literature regarding nonoperative treatment of patellar tendinopathy and provide additional insight on the effectiveness of current modalities.

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.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Standardized pain mapping for diagnosing Achilles tendinopathy

OBJECTIVES

To assess the level of agreement between patient-reported pain using a standardized pain map and the physician-determined clinical diagnosis of Achilles tendinopathy.

DESIGN

Cross-sectional study.

METHODS

Eligible patients were adults visiting a sports physician for symptoms in the Achilles tendon region. Patients completed a digital questionnaire and indicated one location on a pain map where they experienced their pain. The primary outcome measure was level of agreement (% and Kappa coefficient) between patient-reported pain on the pain map and the physician-determined clinical diagnosis (defined as localized pain associated with tendon-loading activities and pain on palpation with or without tendon thickening). The secondary outcome measure was the agreement between the location on the pain map (midportion/insertional region) with the clinical diagnosis of midportion/insertional Achilles tendinopathy.

RESULTS

110 patients (mean (SD) age 48 (13), 61% men) with pain in the Achilles region were included. In 102 (93%, Kappa = 0.86, CI 0.78-0.95) patients who indicated pain in the Achilles tendon region on the pain map, the clinical diagnosis of Achilles tendinopathy was made by the sports physician. 82% of the patients had the clinical diagnosis of tendinopathy in the specific region of the tendon they marked on the pain map (Kappa = 0.67, CI 0.54-0.79).

CONCLUSIONS

There is almost perfect agreement between patient-reported pain on a pain map and a physician-established clinical diagnosis of Achilles tendinopathy. There was substantial agreement between the localization of the pain that was selected by the patient and the diagnosis of insertional/midportion Achilles tendinopathy by the physician. This tool could potentially aid in adequate triage for specialized care and for researchers performing large epidemiological studies.

Current Clinical Concepts: Clinical Management of Patellar Tendinopathy

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

The 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.

The Epidemiology, Risk Factors, and Nonsurgical Treatment of Injuries Related to Endurance Running

ABSTRACT

Running is a popular form of exercise that is easily accessible to various populations; endurance running, defined as distances beyond 5 km, continues to grow within the sport. Endurance running-related injuries are common in the lower extremities and are primarily overuse related. A multitude of risk factors for injury exist, including extrinsic factors, such as running distance and frequency, and intrinsic factors, such as biomechanics and nutrition status. Training and rehabilitation techniques vary with a general focus on strengthening and gradual increase in activity, but evidence is mixed, and it is difficult to generalize programs across different running populations. Management of specific running groups, including youth runners, is an area in which additional research is needed. New treatments, such as orthobiologics and wearable technology, have promising potential to optimize performance and recovery and minimize injury. However, they need to be further evaluated with high-quality studies.

Association Between T2 * Relaxation Times Derived From Ultrashort Echo Time MRI and Symptoms During Exercise Therapy for Patellar Tendinopathy: A Large Prospective Study

Background

Exercise therapy is considered preferential treatment for patellar tendinopathy (PT). However, there is conflicting evidence for structural patellar tendon adaptation in response to exercise therapy and its association with symptoms is weak.

Purpose

To assess the association between 1) T₂^* relaxation times and symptom severity; 2) baseline T₂^* and clinical outcome; and 3) longitudinal T₂^* changes and clinical outcome in athletes with PT performing exercise therapy.

Study Type

Randomized controlled clinical trial.

Subjects

Seventy‐six athletes (18–35 years) with clinically diagnosed and ultrasound‐confirmed PT.

Field strength/Sequence

3D gradient echo sequence (3.0 T).

Assessment

Patients were enrolled in a randomized trial of progressive tendon‐loading exercises (PTLE) versus eccentric exercise therapy (EET). Symptoms were assessed using the Victorian Institute of Sports Assessment (VISA‐P) questionnaire. 3D‐Ultrashort echo time (UTE)‐MRI was acquired at baseline, 12 and 24 weeks. Voxel‐wise T₂^* relaxation times were quantified using mono‐exponential and bi‐exponential models. T₂^* analysis was performed in three patellar tendon tissue compartments representing: aligned collagen, degenerative tissue, and interface.

Statistical Tests

Adjusted general linear, mixed‐linear models, and generalized estimating equations.

Results

We included 76 patients with PT (58 men, mean age 24 ± 4 years); 38 in the PTLE‐group and 38 in the EET‐group, of which 57 subjects remained eligible for analysis. T₂^* relaxation times were significantly associated with VISA‐P in degenerative and interface tissues of the patellar tendon. No association was found between baseline T₂^* and VISA‐P after 24 weeks (P > 0.29). The estimated mean T₂^* in degenerative tissue decreased from 14 msec (95%CI: 12–16) at baseline to 13 msec (95%CI: 11–15) at 12 weeks and to 13 msec (95%CI: 10–15) at 24 weeks. The significant decrease in T₂^* from baseline to 24 weeks was associated with improved clinical outcome.

Data Conclusion

Tissue‐specific T₂^* relaxation times, identified with 3D‐UTE‐MRI, decreased significantly in athletes with patellar tendinopathy performing exercise therapy and this decrease was associated with improved clinical outcome.

Evidence Level

1

Technical Efficacy

Stage 4