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Kirwan PD, Duffy T, French HP. Topical glyceryl trinitrate (GTN) and eccentric exercises in the treatment of mid-portion achilles tendinopathy (the NEAT trial): a randomised double-blind placebo-controlled trial. Br J Sports Med 2024:bjsports-2023-108043. [PMID: 39013615 DOI: 10.1136/bjsports-2023-108043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES To investigate if daily treatment with glyceryl trinitrate (GTN) ointment, over 24 weeks combined with a 12-week eccentric exercise programme is more effective for chronic mid-portion Achilles tendinopathy than placebo ointment and eccentric exercise. METHODS This was a single-site randomised double-blind placebo-controlled trial at an acute hospital, Dublin, Ireland. Patients with chronic mid-portion Achilles tendinopathy were randomised to either 24 weeks of daily GTN ointment or placebo ointment. Both groups received an identical 12-week eccentric exercise programme. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 24 weeks, which measures pain, function and activity. Secondary outcomes included pain severity, self-reported physical function, calf muscle function, pressure pain thresholds and ultrasound changes. Statistical analyses were performed according to intention-to-treat principles. RESULTS 76 patients (30 women; 46 men, mean age±SD, 45.6±8.2 years) were recruited for the trial. Significant improvements in VISA-A scores occurred in both groups at 6-week, 12-week and 24-week follow-up. The increase was not significantly different between groups, adjusted mean between-group difference from baseline to week 6, -1.33 (95% CI -6.96 to 4.31); week 12, -1.25 (95% CI -8.0 to 5.49) and week 24, -3.8 (95% CI -10.6 to 3.0); negative values favour GTN. There was no significant between-group difference in any of the secondary outcome measures at 6, 12 and 24 weeks. CONCLUSIONS Adding daily GTN ointment over 24 weeks to a 12-week eccentric exercise programme did not improve pain, function and activity level in patients with chronic mid-portion Achilles tendinopathy when compared with placebo ointment.
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Affiliation(s)
- Paul D Kirwan
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Physiotherapy, Connolly Hospital Blanchardstown, Dublin, Ireland
| | - Trevor Duffy
- Rheumatology, Connolly Hospital Blanchardstown, Dublin, Ireland
| | - Helen P French
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
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2
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Seymore KD, Corrigan P, Sigurðsson HB, Pohlig RT, Grävare Silbernagel K. Asymmetric running is associated with pain during outdoor running in individuals with Achilles tendinopathy in the return-to-sport phase. Phys Ther Sport 2024; 67:25-30. [PMID: 38460486 PMCID: PMC11162939 DOI: 10.1016/j.ptsp.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES To determine the relationships between (1) Achilles tendon pain and loading symmetry, and (2) number of running bouts and symptom severity, during two weeks of outdoor running in individuals with Achilles tendinopathy. DESIGN Prospective, observational study. SETTING Biomechanics laboratory and outdoors. PARTICIPANTS Seventeen runners with Achilles tendinopathy in the return-to-sport phase of rehabilitation. MAIN OUTCOME MEASURES Symptom severity was recorded with the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Running bouts and Achilles tendon pain during runs were recorded with daily training logs. Ground contact time was collected during runs with wearable sensors. Linear mixed modeling determined if the relationship between Achilles tendon pain and ground contact time symmetry during running was moderated by consecutive run days. Multiple regression determined the relationship between number of running bouts and change in VISA-A scores over two weeks, adjusted for run distance. RESULTS Greater ground contact time on the contralateral leg corresponded to increased ipsilateral tendon pain for each consecutive run day (b = -0.028, p < 0.001). Number of running bouts was not associated with 2-week changes in VISA-A scores (p = 0.672). CONCLUSIONS Pain during running is associated with injured leg off-loading patterns, and this relationship strengthened with greater number of consecutive run days. Number of running bouts was not related to short-term symptom severity.
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Affiliation(s)
- Kayla D Seymore
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Patrick Corrigan
- Department of Physical Therapy and Athletic Training, Saint Louis University, St. Louis, MO, USA
| | | | - Ryan T Pohlig
- Department of Epidemiology, University of Delaware, Newark, DE, USA
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Murakawa YAB, Nunes ACL, Franco KFM, de Queiroz JHM, Bezerra MA, Oliveira RRD. Psychological factors show limited association with the severity of Achilles tendinopathy. Phys Ther Sport 2024; 67:118-124. [PMID: 38685174 DOI: 10.1016/j.ptsp.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/02/2024]
Abstract
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.
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Affiliation(s)
- Yanka Aparecida Bandeira Murakawa
- Tendon Research Group, Master Program in Physical Therapy and Functioning Physical Therapy Department, Federal University of Ceara, Fortaleza, CE, Brazil.
| | - Ana Carla Lima Nunes
- Master Program in Physical Therapy and Functioning Physical Therapy Department, Federal University of Ceara, Fortaleza, CE, Brazil.
| | | | - Jeffeson Hildo Medeiros de Queiroz
- Tendon Research Group, Master Program in Physical Therapy and Functioning Physical Therapy Department, Federal University of Ceara, Fortaleza, CE, Brazil.
| | - Márcio Almeida Bezerra
- Tendon Research Group, Master Program in Physical Therapy and Functioning Physical Therapy Department, Federal University of Ceara, Fortaleza, CE, Brazil.
| | - Rodrigo Ribeiro de Oliveira
- Tendon Research Group, Master Program in Physical Therapy and Functioning Physical Therapy Department, Federal University of Ceara, Fortaleza, CE, Brazil.
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Sleeswijk Visser TSO, O'Neill S, Colaris JW, Eygendaal D, de Vos RJ. Normative ultrasound values for Achilles tendon thickness in the general population and patients with Achilles tendinopathy: A large international cross-sectional study. Scand J Med Sci Sports 2024; 34:e14665. [PMID: 38773808 DOI: 10.1111/sms.14665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 05/24/2024]
Abstract
The objective of the study was to obtain adjusted ultrasonographic reference values of the Achilles tendon thickness (maximum anterior-posterior distance) in adults without (previous) Achilles tendinopathy (AT) and to compare these reference values with AT patients. Six hundred participants were consecutively included, comprising 500 asymptomatic individuals and 100 patients with clinically diagnosed chronic AT. The maximum tendon thickness was assessed using Ultrasound Tissue Characterization. A multiple quantile regression model was developed, incorporating covariates (personal characteristics) that were found to have a significant impact on the maximum anterior-posterior distance of the Achilles tendon. A 95% reference interval (RI) was derived (50th, 2.5th-97.5th percentile). In asymptomatic participants median (95% RI) tendon thickness was 4.9 (3.8-6.9) mm for the midportion region and 3.7 (2.8-4.8) mm for the insertional region. Age, height, body mass index, and sex had a significant correlation with maximum tendon thickness. Median tendon thickness for the midportion region was calculated with the normative equation -2.1 + AGE × 0.021 + HEIGHT × 0.032+ BMI × 0.028 + SEX × 0.05. For the insertional region, the normative equation was -0.34 + AGE × 0.010+ HEIGHT × 0.018 + BMI × 0.022 + SEX × -0.05. In the equations, SEX is defined as 0 for males and 1 for females. Mean (95% CI) difference in tendon thickness compared to AT patients was 2.7 mm (2.3-3.2, p < 0.001) for the midportion and 1.4 mm (1.1-1.7, p < 0.001) for the insertional region. Compared to the asymptomatic population 73/100 (73%) AT patients exhibited increased tendon thickening, with values exceeding the 95% RI. This study presents novel reference values for the thickness of midportion and insertional region of the Achilles tendon, which were adjusted for personal characteristics. Our novel web-based openly accessible calculator for determining normative Achilles tendon thickness (www.achillestendontool.com) will be a useful resource in the diagnostic process. Trial registration number: This trial is registered in the Netherlands Trial Register (NL9010).
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Affiliation(s)
- Tjerk S O Sleeswijk Visser
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Seth O'Neill
- Department of Life Sciences, School of Allied Health, University of Leicester, Leicester, UK
| | - Joost W Colaris
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Denise Eygendaal
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Merry K, MacPherson M, Vis-Dunbar M, Whittaker JL, Grävare Silbernagel K, Scott A. Identifying characteristics of resistance-based therapeutic exercise interventions for Achilles tendinopathy: A scoping review. Phys Ther Sport 2023; 63:73-94. [PMID: 37536026 DOI: 10.1016/j.ptsp.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE This scoping review describes resistance-based therapeutic exercise intervention characteristics for Achilles tendinopathy (AT) treatment (e.g., therapeutic dose, underlying mechanisms targeted by exercise) and assesses participant reporting characteristics. METHODS Seven electronic databases were searched; studies delivering a resistance exercise-focused treatment for individuals with AT were included. The Template for Intervention Description and Replication (TIDieR) and the ICON 2019 'Recommended standards for reporting participant characteristics in tendinopathy research' checklists framed data extraction, and study quality was assessed using the Mixed Methods Appraisal Tool 2018 version. RESULTS 68 publications (describing 59 studies and 72 exercise programs) were included. Results demonstrate that therapeutic exercise interventions for AT are well reported according to the TIDieR checklist, and participant characteristics are well reported according to the ICON checklist. Various underlying therapeutic mechanisms were proposed, with the most common being increasing tendon strength, increasing calf muscle strength, and enhancing collagen synthesis. CONCLUSIONS While evidence suggests that resistance-based therapeutic exercise interventions are effective in treating AT, more reporting on program fidelity, adherence, and compliance is needed. By summarizing currently published AT exercise programs and reporting key intervention characteristics in a single location, this review can assist clinicians in developing individualized resistance training programs for people with AT.
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Affiliation(s)
- Kohle Merry
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Megan MacPherson
- Virtual Health Team, Fraser Health Authority, Surrey, BC, Canada.
| | - Mathew Vis-Dunbar
- Library, The University of British Columbia, Kelowna, British Columbia, Canada.
| | - Jackie L Whittaker
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada; Arthritis Research Canada, Vancouver, BC, Canada.
| | | | - Alex Scott
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada.
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Oskouei ST, Malliaras P, Hill KD, Clark R, Perraton L. Monitoring physical activity using wearable technology in people with Achilles tendinopathy undergoing physiotherapy treatment: A feasibility prospective cohort study. Physiotherapy 2023; 120:38-46. [PMID: 37364446 DOI: 10.1016/j.physio.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/07/2023] [Accepted: 04/17/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Physical activity modification is an important part of the management of Achilles tendinopathy. However, to our knowledge, there is a lack of evidence on objective physical activity assessment in Achilles tendinopathy. The purpose of this study is to (1) assess feasibility of using an inertial measurement unit (IMU) to monitor physical activity and IMU-derived biomechanical measures over 12-week treatment course by a physiotherapist; (2) conduct a preliminary analysis of changes in physical activity over 12-weeks. DESIGN A feasibility prospective cohort study SETTING: A community setting. PARTICIPANTS People with Achilles tendinopathy who had recently commenced (≤2 sessions), or were about to commence, treatment with a physiotherapist MAIN OUTCOME MEASURES: Participants wore a shank-mounted IMU on the affected side for one week at baseline, 6-, and 12-week follow-ups. The outcomes were pain/symptom severity, IMU-derived physical activity and biomechanical measures (stride rate, peak shank angular velocity, and peak shank acceleration). RESULTS Thirty participants were recruited. There was a high retention rate (97%), response rate (97%), and IMU wear compliance at each timepoint (>93%). For pain/symptom severity, a significant time effect was observed between baseline and 12-week follow-up. Physical activity and IMU-derived biomechanical measures did not change over 12 weeks. Physical activity decreased at the 6-week follow-up but only returned to the baseline level at 12-week follow-up. CONCLUSIONS A larger-scale cohort study assessing clinical outcomes and physical activity appears feasible. Preliminary data indicate that physical activity may not change significantly over 12-weeks in people undergoing physiotherapy management for Achilles tendinopathy. CONTRIBUTION OF THE PAPER.
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Affiliation(s)
- Sanam Tavakkoli Oskouei
- Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
| | - Peter Malliaras
- Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
| | - Keith D Hill
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, Monash University, Victoria, Australia.
| | - Ross Clark
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Queensland, Australia.
| | - Luke Perraton
- Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
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7
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Dosal GC, Schroeder JD, Oh RC. Low-volume Hydrodissection for the Treatment of Chronic Achilles Tendinopathy. Mil Med 2023; 188:e3269-e3272. [PMID: 36515159 DOI: 10.1093/milmed/usac384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/03/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Chronic Achilles tendinopathy (AT) is a common ailment for many active duty service members that adversely affects readiness. Patients present with pain, swelling, and limited functional ability. Kager's fat pad is a mass of adipose tissue that protects the blood vessels supplying the Achilles tendon and preserves its function. A popular hypothesis is that scarring, tethering, and neovascularization play a significant role in the pathogenesis of AT. Current literature supports the effectiveness of high-volume (40-50 mL) hydrodissection, a procedure in which fluid is injected under ultrasound guidance into the tissues surrounding the Achilles tendon to mechanically separate the paratenon from the underlying Kager's fat pad. There may also be a beneficial effect of scar tissue and neoneurovascular breakdown. However, high-volume injections result in short-term discomfort and decreased mobility. Lowering injection volume (2-10 mL) may reduce this morbidity and facilitate use in limited-resource environments. This case report presents a 29-year-old active duty male with recalcitrant post-traumatic AT who achieved significant pain reduction and faster return to full service using low-volume hydrodissection. The use of 10 mL volume has not been described previously and provides additional support for using lower volumes in chronic AT. This technique is a direct adjunctive treatment option with rehabilitation at a military treatment facility or in the operational environment.
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Affiliation(s)
- Gerardo Capo Dosal
- Department of Family Medicine,Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Jeremy D Schroeder
- Department of Family Medicine,Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Robert C Oh
- Department of Education, US Department of Veterans Affairs,VA Puget Sound Health System, Seattle, WA 98108, USA
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8
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Paantjens MA, Helmhout PH, Backx FJG, Bakker EWP. Victorian Institute of Sport Assessment-Achilles thresholds for minimal important change and return to presymptom activity level in active soldiers with mid-portion Achilles tendinopathy. BMJ Mil Health 2023:e002326. [PMID: 36889820 DOI: 10.1136/military-2022-002326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Mid-portion Achilles tendinopathy (mid-AT) is common in soldiers, significantly impacting activity levels and operational readiness. Currently, Victorian Institute of Sport Assessment-Achilles (VISA-A) represents the gold standard to evaluate pain and function in mid-AT. Our objective was to estimate VISA-A thresholds for minimal important change (MIC) and patient-acceptable symptom state for return to the presymptom activity level (PASS-RTA), in soldiers treated with a conservative programme for mid-AT. METHODS A total of 40 soldiers (40 unilateral symptomatic Achilles tendons) were included in this prospective cohort study. Pain and function were evaluated using VISA-A. Self-perceived recovery was assessed with the Global Perceived Effect scale. The predictive modelling method (MIC-predict) was used to estimate MIC VISA-A post-treatment (after 26 weeks) and after 1 year of follow-up. The post-treatment PASS-RTA VISA-A was estimated using receiver operating characteristic statistics. The PASS-RTA was determined by calculating Youden's index value closest to 1. RESULTS The adjusted MIC-predict was 6.97 points (95% CI 4.18 to 9.76) after 26 weeks and 7.37 points (95% CI 4.58 to 10.2) after 1 year of follow-up post-treatment.The post-treatment PASS-RTA was 95.5 points (95% CI 92.2 to 97.8). CONCLUSIONS A VISA-A change score of 7 points, post-treatment and at 1 year of follow-up, can be considered a minimal within-person change over time, above which soldiers with mid-AT perceive themselves importantly changed. Soldiers consider their symptoms to be acceptable for return to their presymptom activity level at a post-treatment VISA-A score of 96 points or higher. TRIAL REGISTRATION NUMBER NL69527.028.19.
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Affiliation(s)
- M A Paantjens
- Sports Medicine Centre, Training Medicine and Training Physiology, Royal Netherlands Army, Utrecht, The Netherlands
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P H Helmhout
- Centre of Excellence, Training Medicine and Training Physiology, Royal Netherlands Army, Utrecht, The Netherlands
| | - F J G Backx
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - E W P Bakker
- Department Epidemiology and Data Science, Division EPM, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
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9
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Lagas IF, Tol JL, Weir A, de Jonge S, van Veldhoven PLJ, Bierma-Zeinstra SMA, Verhaar JAN, de Vos RJ. One fifth of patients with Achilles tendinopathy have symptoms after 10 years: A prospective cohort study. J Sports Sci 2023; 40:2475-2483. [PMID: 36617848 DOI: 10.1080/02640414.2022.2163537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients with midportion Achilles tendinopathy (AT) are thought to experience a gradual symptomatic improvement over time. The aim of this study was to prospectively investigate if patients with midportion AT have symptoms at 10-year follow-up. Patients withmidportion AT were invited to complete an online questionnaire 10 years after inclusion in an intervention trial. The primary outcomewas the presence of AT symptoms. Secondary outcomes were: the Victorian Institute of Sports Assessment-Achilles tendinopathy (VISA-A, 0-100) score and sports activity level. Of the 54 patientsincluded, 43 (80%) completed the questionnaire at an average follow-up of 10.4 years. Persisting symptoms were reported by 19%. The mean (standard deviation-SD) VISA-A score improved from 52 (17) at baseline to 79 (21) at 10-years follow-up with a mean change of 27 points (95% confidence interval: 21; 35, p < 0.001). Of the 38 active patients, 16 (42%) returned to their pre-injury level sports,of whom 14 (37%) performed them pain free. One-fifth of patients with conservatively treated midportion AT still have symptoms after 10years. One-third of patients were able to perform sports pain-free atpre-injury level. Patients should be adequately counselled to giverealistic expectations. Trial registration number: clinicaltrials.gov (identifier: NCT00761423).
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Affiliation(s)
- Iris F Lagas
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johannes L Tol
- Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,Amsterdam University Medical Center, Academic Medical Center, Amsterdam Movement Sciences, Academic Center for Evidence-based Sports Medicine (ACES), Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
| | - Adam Weir
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,Sports Medicine and Exercise Clinic Haarlem (SBK), IJsbaanlaan 4B, 2024 AV Haarlem, The Netherlands
| | - Suzan de Jonge
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Sita M A Bierma-Zeinstra
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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10
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Corrigan P, Hornsby S, Pohlig RT, Willy RW, Cortes DH, Silbernagel KG. Tendon loading in runners with Achilles tendinopathy: Relations to pain, structure, and function during return-to-sport. Scand J Med Sci Sports 2022; 32:1201-1212. [PMID: 35488734 PMCID: PMC9972464 DOI: 10.1111/sms.14178] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/11/2022] [Accepted: 04/25/2022] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Patrick Corrigan
- Department of Physical Therapy and Athletic Training, Saint Louis University, St. Louis, Missouri, USA,Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Samantha Hornsby
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont, USA
| | - Ryan T. Pohlig
- College of Health Sciences Biostatistics Core Facility, University of Delaware, Burlington, Vermont, USA
| | - Richard W. Willy
- School of Physical Therapy and Rehabilitation Science, University of Montana, Missoula, Montana, USA
| | - Daniel H. Cortes
- Department of Mechanical Engineering, Penn State University, State College, Pennsylvania, USA
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11
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Grävare Silbernagel K, Malliaras P, de Vos RJ, Hanlon S, Molenaar M, Alfredson H, van den Akker-Scheek I, Antflick J, van Ark M, Färnqvist K, Haleem Z, Kaux JF, Kirwan P, Kumar B, Lewis T, Mallows A, Masci L, Morrissey D, Murphy M, Newsham-West R, Norris R, O'Neill S, Peers K, Sancho I, Seymore K, Vallance P, van der Vlist A, Vicenzino B. ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy. Sports Med 2022; 52:613-641. [PMID: 34797533 PMCID: PMC8891092 DOI: 10.1007/s40279-021-01588-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated. OBJECTIVE To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains. DESIGN Systematic review. DATA SOURCES Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series. RESULTS 9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain. CONCLUSION 233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures. PROSPERO REGISTRATION CRD42020156763.
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Affiliation(s)
- Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA.
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Robert-Jan de Vos
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Zuid-Holland, The Netherlands
| | - Shawn Hanlon
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Mitchel Molenaar
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jarrod Antflick
- Department of Bioengineering, School of Engineering, Imperial College, London, UK
| | - Mathijs van Ark
- Department of Physiotherapy, School of Health Care Studies, Hanze University of Applied Sciences and Peescentrum, Centre of Expertise Primary Care Groningen (ECEZG), Groningen, The Netherlands
| | | | - Zubair Haleem
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Arsenal Football Club, London, UK
| | - Jean-Francois Kaux
- Department of Physical and Rehabilitation Medicine and Sports Traumatology, University and University Hospital of Liège, Liège, Belgium
| | - Paul Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bhavesh Kumar
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Trevor Lewis
- Aintree University Hospital, Liverpool Foundation Trust, Liverpool, UK
| | - Adrian Mallows
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, UK
| | - Lorenzo Masci
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
| | - Myles Murphy
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Richard Newsham-West
- School of Allied Health, Department of Physiotherapy, La Trobe University, Melbourne, VIC, Australia
| | - Richard Norris
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- Liverpool University Hospitals, NHS Foundation Trust, Liverpool, UK
| | - Seth O'Neill
- School of Allied Health, University of Leicester, Leicester, UK
| | - Koen Peers
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Igor Sancho
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, University of Deusto, San Sebastian, Spain
| | - Kayla Seymore
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Patrick Vallance
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Clayton, VIC, Australia
| | - Arco van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, QLD, Australia
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12
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Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy. J Orthop Sports Phys Ther 2021; 51:440-448. [PMID: 34074130 PMCID: PMC8410667 DOI: 10.2519/jospt.2021.10271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To identify latent subgroups among patients with Achilles tendinopathy, describe patient characteristics and clinical attributes that defined each subgroup, and develop a clinical classification model for subgroup membership. DESIGN Cross-sectional study. METHODS One hundred forty-five participants (men, n = 73; mean ± SD age, 51 ± 14 years) with clinically diagnosed Achilles tendinopathy completed a baseline evaluation, including demographics and medical history, patient-reported outcome measures, a clinical exam, tendon structure measures via ultrasound imaging and continuous shear-wave elastography, and a functional test battery. Subgroups were identified using mixture modeling. We compared the subgroups using a 1-way analysis-of-variance or chi-square test and the Tukey post hoc test to identify defining attributes. We developed a clinical classification model using logistic regression and receiver operating characteristic curves. RESULTS Three latent subgroups were identified and named by their distinctive patient characteristics and clinical attributes. The activity-dominant subgroup (n = 67), on average, had the highest physical activity level, function, and quality of life; reported mild symptoms; and was the youngest. The psychosocial-dominant subgroup (n = 56), on average, had the worst symptoms, impaired function, heightened psychological factors, the poorest quality of life, minimal tendon structural alterations, and was obese and predominantly female. The structure-dominant subgroup (n = 22), on average, had the most tendon structural alterations, severe functional deficits, moderate symptoms and psychological factors, reduced quality of life, and was the oldest, obese, and predominantly male. The clinical classification model correctly classified 85% (123/145) of participants. CONCLUSION Three Achilles tendinopathy subgroups (activity dominant, psychosocial dominant, and structure dominant) differed in patient characteristics and clinical attributes. J Orthop Sports Phys Ther 2021;51(9):440-448. Epub 1 Jun 2021. doi:10.2519/jospt.2021.10271.
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13
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Kakkos GA, Klontzas ME, Koltsakis E, Karantanas AH. US-guided high-volume injection for Achilles tendinopathy. J Ultrason 2021; 21:e127-e133. [PMID: 34258037 PMCID: PMC8264817 DOI: 10.15557/jou.2021.0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 11/22/2022] Open
Abstract
Achilles tendinopathy is a common overuse condition affecting the adult population. The incidence is on the rise because of greater participation of people in recreational or competitive sporting activities. Chronic Achilles tendinopathy occurs most commonly in the tendon’s mid-portion, and it is challenging to manage, leading to significant patient morbidity. Despite conservative management many patients still require surgical intervention. The mechanism underlying pain is not entirely understood; however, high-resolution color Doppler ultrasound has shown that neovascularisation could be involved. Minimally-invasive treatments for chronic Achilles tendinopathy may prevent the need for surgery when conservative methods have failed. Ultrasound provides an option to guide therapeutic interventions accurately, so that treatment is delivered to the desired site of pathology. High-volume image-guided injection is a relatively new technique where a high volume of liquid is injected between the anterior aspect of the Achilles tendon and the Kager’s fat pad, used to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases of Achilles tendinopathy. High-volume image-guided injection has shown promising results in terms of reducing pain and improving function in patients where conservative measures have failed. This review aims to describe the fundamental technical factors, and investigate the efficacy of high-volume image-guided injection with reference to the available literature.
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Affiliation(s)
- George A Kakkos
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece
| | - Michail E Klontzas
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece.,Advanced Hybrid Imaging Systems, Institute of Computer Science, FORTH, Crete, Greece.,Department of Radiology, School of Medicine, University of Crete, Greece
| | - Emmanouil Koltsakis
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece
| | - Apostolos H Karantanas
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece.,Advanced Hybrid Imaging Systems, Institute of Computer Science, FORTH, Crete, Greece.,Department of Radiology, School of Medicine, University of Crete, Greece
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14
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Are pain coping strategies and neuropathic pain associated with a worse outcome after conservative treatment for Achilles tendinopathy? A prospective cohort study. J Sci Med Sport 2021; 24:871-875. [PMID: 33934973 DOI: 10.1016/j.jsams.2021.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 03/27/2021] [Accepted: 04/08/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To analyse whether (1) passive or active pain coping strategies and (2) presence of neuropathic pain component influences the change of Achilles tendinopathy (AT) symptoms over a course of 24 weeks in conservatively-treated patients. DESIGN Prospective cohort study. METHODS Patients with clinically-diagnosed chronic midportion AT were conservatively treated. At baseline, the Pain Coping Inventory (PCI) was used to determine scores of coping, which consisted of two domains, active and passive (score ranging from 0 to 1; the higher, the more active or passive). Presence of neuropathic pain (PainDETECT questionnaire, -1 to 38 points) was categorized as (a) unlikely (≤12 points), (b) unclear (13-18 points) and (c) likely (≥19 points). The symptom severity was determined with the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire (0-100) at baseline, 6, 12 and 24 weeks. We analysed the correlation between (1) PCI and (2) PainDETECT baseline scores with change in VISA-A score using an adjusted Generalized Estimating Equations model. RESULTS Of 80 included patients, 76 (95%) completed the 24-weeks follow-up. The mean VISA-A score (standard deviation) increased from 43 (16) points at baseline to 63 (23) points at 24 weeks. Patients had a mean (standard deviation) active coping score of 0.53 (0.13) and a passive score of 0.43 (0.10). Twelve patients (15%) had a likely neuropathic pain component. Active and passive coping mechanisms and presence of neuropathic pain did not influence the change in AT symptoms (p=0.459, p=0.478 and p=0.420, respectively). CONCLUSIONS Contrary to widespread belief, coping strategy and presence of neuropathic pain are not associated with a worse clinical outcome in this homogeneous group of patients with clinically diagnosed AT.
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15
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Sleeswijk Visser TSO, van der Vlist AC, van Oosterom RF, van Veldhoven P, Verhaar JAN, de Vos RJ. Impact of chronic Achilles tendinopathy on health-related quality of life, work performance, healthcare utilisation and costs. BMJ Open Sport Exerc Med 2021; 7:e001023. [PMID: 33868707 PMCID: PMC8006822 DOI: 10.1136/bmjsem-2020-001023] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives To evaluate the impact of Achilles tendinopathy (AT) on quality of life (QoL), work performance, healthcare utilisation and costs in adults with conservatively treated chronic midportion AT. Methods This cross-sectional survey-based study included 80 patients and took place in a sports medicine department of a large regional hospital in the Netherlands. Data were collected before any intervention was given. Primary outcome was the EuroQol questionnaire (EQ-5D). The EQ-5D expresses the percentage of moderate/major problems on the domains self-care, anxiety/depression, mobility, usual activities and pain/discomfort. Secondary outcomes were the number of previous healthcare visits, work performance during the period of symptoms and estimated annual direct medical and indirect costs per patient as a result of AT. Results All 80 patients completed the questionnaires. The EQ-5D scores were low for the domains self-care (1%) and anxiety/depression (20%), and high for the domains mobility (66%), usual activities (50%) and pain/discomfort (89%). Patients with AT mainly reported an impact on work productivity (38%). Work absenteeism due to AT was present in 9%. The total median (IQR) number of annual healthcare visits was 9 (3-11). The total mean (SD) estimated annual costs were €840 (1420) per patient with AT (mean (SD) US$991 (1675)). Conclusions This study shows the large impact of AT on QoL and work productivity. This study also provides new information about the socioeconomic impact of AT, which emphasises that this common and longstanding disease causes substantial costs. These findings stress the need for optimised treatment and improved preventive interventions for AT. Trial registration number NCT02996409.
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Affiliation(s)
- Tjerk S O Sleeswijk Visser
- Department of Orthopedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands.,Department of Orthopedic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Arco C van der Vlist
- Department of Orthopedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Robert F van Oosterom
- Department of Sports Medicine, Haaglanden Medical Centre, Leidschendam, The Netherlands
| | - Peter van Veldhoven
- Department of Sports Medicine, Haaglanden Medical Centre, Leidschendam, The Netherlands
| | - Jan A N Verhaar
- Department of Orthopedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Robert-Jan de Vos
- Department of Orthopedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
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16
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Auliffe SM, Korakakis V, Hilfiker R, Whiteley R, O'Sullivan K. Participant characteristics are poorly reported in exercise trials in tendinopathy: A systematic review. Phys Ther Sport 2020; 48:43-53. [PMID: 33360409 DOI: 10.1016/j.ptsp.2020.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the reporting of eligibility criteria and baseline participant characteristics in randomised controlled trials investigating the effects of exercise interventions in tendinopathy. METHODS Randomised controlled trials investigating the effects of exercise therapy compared to a non-exercising intervention in upper and lower limb tendinopathy were included. Data extraction was categorised into the following domains: participant demographics, tendinopathy descriptors, general health, participant recruitment and eligibility criteria. RESULTS The review included the following tendinopathies: Achilles (n = 9), gluteal (n = 2), lateral elbow tendinopathy (n = 15), patellar (n = 3) plantar (n = 3), and rotator cuff (n = 13). Age, sex, duration of symptoms and symptom severity were commonly reported across the review, while prior history of tendinopathy was poorly reported (6/45). Variables such as physical activity level (17/45), sleep (0/45), psychological factors (2/45), medication at baseline (8/45), co morbid health complaints (10/45) and sociodemographic factors (11/45) were poorly reported across the included studies. Substantial variation existed between studies in the specific eligibility criteria used. CONCLUSION The findings of this systematic review demonstrate that participant characteristics are poorly reported in exercise trials in tendinopathy. To improve effectiveness of exercise interventions in tendinopathy, improved reporting of participant characteristics may allow better comparisons and targeted interventions for specific subgroups.
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Affiliation(s)
- Seán Mc Auliffe
- Department of Physical Therapy & Rehabilitation Science, College of Health Sciences, Qatar University, Doha, Qatar.
| | | | - Roger Hilfiker
- School of Health Sciences, HES-SO Valais-Wallis, University of Applied Sciences and Arts Western Switzerland Valais, Leukerbad, Switzerland
| | - Rodney Whiteley
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Kieran O'Sullivan
- School of Allied Health, University of Limerick, Limerick, Ireland; Ageing Research Centre, University of Limerick, Limerick, Ireland
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17
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van der Vlist AC, van Oosterom RF, van Veldhoven PLJ, Bierma-Zeinstra SMA, Waarsing JH, Verhaar JAN, de Vos RJ. Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial. BMJ 2020; 370:m3027. [PMID: 33315586 PMCID: PMC7479639 DOI: 10.1136/bmj.m3027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To study whether a high volume injection without corticosteroids improves clinical outcome in addition to usual care for adults with chronic midportion Achilles tendinopathy. DESIGN Patient and assessor blinded, placebo controlled randomised clinical trial. SETTING Sports medicine department of a large district general hospital, the Netherlands. PARTICIPANTS 80 adults (aged 18-70 years) with clinically diagnosed chronic midportion Achilles tendinopathy and neovascularisation on ultrasonography. 39 were randomised to a high volume injection without corticosteroids and 41 to placebo. INTERVENTIONS Participants were instructed to perform an exercise programme for 24 weeks (usual care) combined with one 50 mL high volume injection of saline and lidocaine (intervention group) or one 2 mL placebo injection of saline and lidocaine (placebo group) at baseline. MAIN OUTCOME MEASURES Primary outcome was pain and function assessed using the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire at 24 weeks (analysed using a generalised estimation equations model). Secondary outcomes were patient satisfaction, return to sport, degree of ultrasonographic Doppler flow, visual analogue scale on 10 hop test, power and flexibility of the gastrocnemius and soleus muscles, pain detect questionnaire for neuropathic pain, and pain coping inventory. Participants were evaluated at baseline and at 2, 6, 12, and 24 weeks. RESULTS Only one participant (1%) was lost to follow-up. The estimated mean VISA-A score improved significantly, from 40.4 (95% confidence interval 32.0 to 48.7) at baseline to 59.1 (50.4 to 67.8) at 24 weeks in the high volume injection group and from 36.9 (27.1 to 46.8) to 58.5 (47.9 to 69.1) in the placebo group. The VISA-A score over time did not differ between the groups (adjusted between group difference at 24 weeks 0.5 points, 95% confidence interval -17.8 to 18.8). No significant between group differences were found for patient satisfaction (21/37 (57%) v 19/39 (49%) patients, P=0.50) and return to desired sport (15/29 (52%) v 19/31 (61%) patients active in sports, P=0.65) at 24 weeks. None of the other secondary outcomes differed between the two groups. CONCLUSIONS A high volume injection without corticosteroids in addition to usual care is not effective for symptom reduction in patients with chronic midportion Achilles tendinopathy. On the basis of our findings, we cannot recommend the use of a high volume injection in this patient group. TRIAL REGISTRATION ClinicalTrials.gov NCT02996409.
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Affiliation(s)
- Arco C van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Robert F van Oosterom
- Department of Sports Medicine, Haaglanden Medical Centre, 2262 BA Leidschendam, Netherlands
| | | | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC University Medical Centre, 3000 CA Rotterdam, Netherlands
| | - Jan H Waarsing
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, Netherlands
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18
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Lagas IF, Fokkema T, Bierma-Zeinstra SMA, Verhaar JAN, van Middelkoop M, de Vos RJ. How many runners with new-onset Achilles tendinopathy develop persisting symptoms? A large prospective cohort study. Scand J Med Sci Sports 2020; 30:1939-1948. [PMID: 32615645 PMCID: PMC7540273 DOI: 10.1111/sms.13760] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Achilles tendinopathy (AT) occurs in half of the elite runners. AT is a difficult-to-treat tendon disease, which may progress from new onset to a chronic state. It is unknown how many runners with new-onset AT develop persisting symptoms and which prognostic factors are associated with this course. OBJECTIVE To describe how many runners develop persisting symptoms 1 year after onset of reactive AT. STUDY DESIGN Prospective cohort study. METHODS Runners registering for a Dutch running event (5-42.2 km) were eligible for inclusion. Runners reporting new-onset AT between registration for the running event and 1 month after received a 1-year follow-up questionnaire. The 1-year follow-up questionnaire inquired about persisting symptoms (yes/no), running activity, and metabolic disorders. We calculated the percentage of runners with persisting symptoms and performed a multivariable logistic regression analysis to study the association between potential prognostic factors and persisting symptoms. RESULTS Of 1929 participants, 100 runners (5%) reported new-onset AT. A total of 62 runners (62%) filled in the 1-year follow-up questionnaire. Persisting symptoms were reported by 20 runners (32%). A higher running distance per week before new-onset AT was associated with a lower risk of developing persisting symptoms (odds ratio (OR): 0.9, 95% confidence interval (CI): [0.9;1.0]). There was a positive trend toward an association between metabolic disorders and persisting symptoms (OR: 5.7, 95% CI: [0.9;36.2]). CONCLUSION One third of runners develop persisting symptoms 1 year after new-onset AT. Interestingly, a higher running distance per week before new-onset AT potentially lowers the risk of developing persisting symptoms.
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Affiliation(s)
- Iris F Lagas
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Zuid-Holland, The Netherlands
| | - Tryntsje Fokkema
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Zuid-Holland, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Zuid-Holland, The Netherlands.,Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Zuid-Holland, The Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Zuid-Holland, The Netherlands
| | - Marienke van Middelkoop
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Zuid-Holland, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Zuid-Holland, The Netherlands
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von Wehren L, Pokorny K, Blanke F, Sailer J, Majewski M. Injection with autologous conditioned serum has better clinical results than eccentric training for chronic Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 2019; 27:2744-2753. [PMID: 30900032 DOI: 10.1007/s00167-019-05465-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/04/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Chronic Achilles tendinopathy is one of the most common causes of malfunction and pain, which can lead to a significant reduction of the quality of life. The hypothesis of this study argues that autologous conditioned serum (i.e. Orthokine) injections in chronic midportion Achilles tendinopathy have a better outcome than eccentric training. METHODS This study investigates, retrospectively, the effects of peritendinous autologous conditioned serum injections as compared to standard eccentric training in 50 patients with chronic Achilles tendinopathy between 2012 and 2015. Before injection or eccentric training and 6 weeks, 12 weeks and 6 months thereafter, the patients were assessed by means of the VISA-A-G score (Victorian Institute of Sport Assessment-Achilles questionnaire-German). An MRI was also performed before and 6 months after injection and eccentric training. RESULTS Both patient groups had statistically significant better VISA-A-G scores after injection or eccentric training compared to the baseline before injection (90 vs 40, respectively, P < 0.001) or eccentric training (81 vs 47, respectively, P < 0.001). Comparing the baseline corrected VISA-A-G scores, patients in the autologous-conditioned-serum-group had significantly higher changes in VISA-A-G scores than the eccentric-training-group after 12 weeks (40 vs 36, P = 0.018) and 6 months (50 vs 34, P = 0.034). Both patient groups had statistically significant (P < 0.001) reduction of tendon thickness (autologous conditioned serum: 0.32; eccentric training: 0.24) and length of bursa (autologous conditioned serum: 0.24; eccentric training: 0.21) as well as significant (P < 0.001) improvement of tendon quality in MRI (autologous conditioned serum: 14 vs 1; eccentric training: 14 vs 2). There were no statistical differences in MRI-findings between the two groups. CONCLUSION Both therapies led to improvement of MRI-findings, including reduction of tendon thickness and tendon quality. Autologous-conditioned-serum-injections show greater clinical long-term benefit as compared to eccentric training and, therefore, offers a good alternative to eccentric training. LEVEL OF EVIDENCE Therapeutic studies, Level III.
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Affiliation(s)
- Lutz von Wehren
- Schön Klinik Bad Aibling, Kolbermoorerstrasse 72, 83043, Bad Aibling, Germany.
| | - Kerstin Pokorny
- Medical Park Chiemsee, Birkenallee 41, 83233, Bernau-Felden, Germany
| | - Fabian Blanke
- Hessing Stiftung, Abteilung für Sportorthopädie und arthroskopische Chirurgie, Hessingstraße 17, 86199, Augsburg, Germany
| | - Jannis Sailer
- Kantonsspital Nidwalden, Ennetmooserstrasse 19, 6370, Stans, Switzerland
| | - Martin Majewski
- Orthopädische Gemeinschaftspraxis Schützenmatt, Schützenmattstrasse 41, 4051, Basel, Switzerland
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