How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials

Current and future advances in practice: tendinopathies of the hip

Tendinopathy describes persistent tendon pain and loss of function related to mechanical loading. Two common hip tendinopathies seen in practice are gluteal tendinopathy and proximal hamstring tendinopathy. Both conditions can be frustrating for patients and clinicians due to the delay in diagnosis, significant disability caused and lack of response to common treatments. Tendinopathy is a clinical diagnosis and can most often be made using findings from the patient interview and pain provocation tests, without the need for imaging. Specific education and progressive exercise offer a low-risk and effective option for gluteal tendinopathy and result in greater rates of treatment success than corticosteroid injection, both in the short term (8 weeks) and at 1 year. Proximal hamstring tendinopathy is a common, but less researched, and under-recognized cause of persistent ischial pain. As research on proximal hamstring tendinopathy is limited, this review summarizes the available evidence on diagnosis and treatment following similar principles to other well-researched tendinopathies.

Cell Sheet Technology: An Emerging Approach for Tendon and Ligament Tissue Engineering

Tendon and ligament injuries account for a substantial proportion of disorders in the musculoskeletal system. While non-operative and operative treatment strategies have advanced, the restoration of native tendon and ligament structures after injury is still challenging due to its innate limited regenerative ability. Cell sheet technology is an innovative tool for tissue fabrication and cell transplantation in regenerative medicine. In this review, we first summarize different harvesting procedures and advantages of cell sheet technology, which preserves intact cell-to-cell connections and extracellular matrix. We then describe the recent progress of cell sheet technology from preclinical studies, focusing on the application of stem cell-derived sheets in treating tendon and ligament injuries, as well as highlighting its effects on mitigating inflammation and promoting tendon/graft-bone interface healing. Finally, we discuss several prerequisites for future clinical translation including the selection of appropriate cell source, optimization of preparation process, establishment of suitable animal model, and the fabrication of vascularized complex tissue. We believe this review could potentially provoke new ideas and drive the development of more functional biomimetic tissues using cell sheet technology to meet the needs of clinical patients.

There is a Lack of Clinical Homogeneity in Lower-Limb Tendinopathy Trials: A Scoping Review

OBJECTIVE: It is unclear if clinical trials of treatments for lower-limb tendinopathies include clinically homogeneous participant populations (an assumption for pooling in meta-analyses). We assessed the recruitment setting and participant characteristics used in randomized controlled trials (RCTs) that were investigating any treatment for lower-limb tendinopathies. DESIGN: Scoping review. METHODS: We conducted a systematic literature search in the PubMed, Embase, Cochrane CENTRAL, and Web of Science databases. All RCTs that were investigating treatments for lower-limb tendinopathies in an adult population (≥18 years) were eligible for inclusion. At least 2 authors conducted independent screening and selection of full-text papers, and extracted data from included studies. RESULTS: Of 18 341 records, 342 RCTs (21 897 participants) were eligible for inclusion and data extraction. The most common diagnoses were plantar fasciopathy (n = 195, 57%), Achilles tendinopathy (n = 82, 24%), and patellar tendinopathy (n = 41, 12%). Secondary care (n = 144, 42%) was the most reported recruitment setting, followed by an open setting (n = 44, 13%). In 93 (27%) RCTs, the recruitment setting was not described. We found high heterogeneity in participant characteristics (eg, symptom duration, age, body mass index, and the Victorian Institute of Sport Assessment [VISA] questionnaire score) within and between recruitment settings. CONCLUSION: Our results question whether clinical homogeneity can be adequately assumed in clinical trials of lower-limb tendinopathies due to the lack of clear reporting of the recruitment setting and the variability within and between recruitment settings of key participant characteristics. These findings threaten assumptions for meta-analyses in lower-limb tendinopathies. J Orthop Sports Phys Ther 2024;54(1):1-10. Epub 5 December 2023. doi:10.2519/jospt.2023.11722.

"Restoring That Faith in My Shoulder": A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff-Related Shoulder Pain

OBJECTIVE

Rotator cuff-related shoulder pain (RCRSP) is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for RCRSP. However, the causal mechanisms underpinning the benefits of exercise for RCRSP are not well understood. Moreover, how individuals with lived experience of RCRSP believe exercise helped or did not help them is unknown. This study aimed to gain insights into how individuals with RCRSP believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs.

METHODS

This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semi-structured interview. The data were coded by 2 members of the research team (J.K.P. and N.C.) and verified by a third (B.S.). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations.

RESULTS

Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psychoemotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress.

CONCLUSION

Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with RCRSP was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself.

IMPACT

Exercise is a recommended first-line intervention to manage RCRSP. The results of this study suggest that a positive experience and outcome with exercise for RCRSP is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context that an exercise program is prescribed and delivered within should be considered by clinicians.

Mechanisms and therapeutic prospects of mesenchymal stem cells-derived exosomes for tendinopathy

Tendinopathy is a debilitating and crippling syndrome resulting from the degeneration of tendon tissue, leading to loss of mechanical properties and function, and eventual tendon rupture. Unfortunately, there is currently no treatment for tendinopathy that can prevent or delay its progression. Exosomes are small extracellular vesicles that transport bioactive substances produced by cells, such as proteins, lipids, mRNAs, non-coding RNAs, and DNA. They can generate by mesenchymal stem cells (MSCs) throughout the body and play a role in intercellular communication and regulation of homeostasis. Recent research suggests that MSCs-derived exosomes (MSCs-exos) may serve as useful therapeutic candidates for promoting tendon healing. This review focuses on the function and mechanisms of MSCs-exos in tendinopathy treatment and discusses their potential application for treating this condition.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Elbow Artery Embolization for Lateral Epicondylitis

Lateral epicondylitis, also known as tennis elbow, is characterized by a low-grade inflammatory process in the lateral aspect of the elbow. Symptoms are typically treated conservatively, and most patients show resolution or improvement of symptoms within a few months. For those with refractory symptoms, treatment options are limited with questionable benefit. Embolization of the arteries supplying the elbow decreases the neo-vascularity seen in epicondylitis. The procedure may result in marked improvement in pain and function, which has shown to be durable.

Tendon Aging

Tendons are mechanosensitive connective tissues responsible for the connection between muscles and bones by transmitting forces that allow the movement of the body, yet, with advancing age, tendons become more prone to degeneration followed by injuries. Tendon diseases are one of the main causes of incapacity worldwide, leading to changes in tendon composition, structure, and biomechanical properties, as well as a decline in regenerative potential. There is still a great lack of knowledge regarding tendon cellular and molecular biology, interplay between biochemistry and biomechanics, and the complex pathomechanisms involved in tendon diseases. Consequently, this reflects a huge need for basic and clinical research to better elucidate the nature of healthy tendon tissue and also tendon aging process and associated diseases. This chapter concisely describes the effects that the aging process has on tendons at the tissue, cellular, and molecular levels and briefly reviews potential biological predictors of tendon aging. Recent research findings that are herein reviewed and discussed might contribute to the development of precision tendon therapies targeting the elderly population.

Efficacy of percutaneous electrolysis for the treatment of tendinopathies: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of percutaneous electrolysis for the treatment of patients with tendinopathies.

DATA SOURCES

A systematic search of publications was conducted in Pubmed, Cinahl, Medline, Scopus and Web of Science.

METHODS

The Oxford 2011 Levels of Evidence and the Jadad scale were used to assess the quality of studies. The mean and standard deviation were obtained for each study group and used to calculate the effect size. The DerSimonian and Laird method was used to develop a random-effects model.

RESULTS

Of the 14 articles, four applied percutaneous electrolysis to the knee, three to the shoulder, three to the elbow, two to the hip and two to the ankle and foot. A meta-analysis on intensity of pain (evaluated with algometer and the Visual Analogue Scale) was performed on studies comparing percutaneous electrolysis with a control group, indicating that the groups treated with percutaneous electrolysis had better results (p = 0.01). Although percutaneous electrolysis did not overcome the analgesic effect achieved by corticosteroid injections.

CONCLUSIONS

The percutaneous electrolysis is effective for the treatment of tendinopathies. The combination of this technique with eccentric training has proven to be one of the most effective treatments to date for improving pain. PROSPERO Registration: CRD42021230005.

The tendon microenvironment: Engineered in vitro models to study cellular crosstalk

Tendinopathy is a multi-faceted pathology characterized by alterations in tendon microstructure, cellularity and collagen composition. Challenged by the possibility of regenerating pathological or ruptured tendons, the healing mechanisms of this tissue have been widely researched over the past decades. However, so far, most of the cellular players and processes influencing tendon repair remain unknown, which emphasizes the need for developing relevant in vitro models enabling to study the complex multicellular crosstalk occurring in tendon microenvironments. In this review, we critically discuss the insights on the interaction between tenocytes and the other tendon resident cells that have been devised through different types of existing in vitro models. Building on the generated knowledge, we stress the need for advanced models able to mimic the hierarchical architecture, cellularity and physiological signaling of tendon niche under dynamic culture conditions, along with the recreation of the integrated gradients of its tissue interfaces. In a forward-looking vision of the field, we discuss how the convergence of multiple bioengineering technologies can be leveraged as potential platforms to develop the next generation of relevant in vitro models that can contribute for a deeper fundamental knowledge to develop more effective treatments.

Surgeon Ratings of the Severity of Idiopathic Median Neuropathy at the Carpal Tunnel Are Not Influenced by Magnitude of Incapability

BACKGROUND

Accurately distinguishing the severity of pathophysiology from the level of symptom intensity and incapability is a foundation of effective treatment strategies under the biopsychosocial paradigm of illness. With respect to idiopathic median neuropathy at the carpal tunnel (the symptoms and signs of which are referred to as carpal tunnel syndrome), surgeons who are more likely to recommend surgery based on the magnitude of symptoms and incapability rather than the severity of neuropathy may be underappreciating and undertreating mental health opportunities and overtreating mild, and on occasion unmeasurable, disease. A survey-based experiment that randomizes elements of the patient presentation can help determine the relative influence of magnitude of incapability on ratings of pathology severity.

QUESTION/PURPOSE

What factors are associated with severity rating of idiopathic median neuropathy at the carpal tunnel on an 11-point ordinal scale?

METHODS

One hundred eight hand and wrist members of the Science of Variation Group (among approximately 200 participants who complete at least one survey-experiment a year related to the upper extremity on average) reviewed seven scenarios of fictional median neuropathy with seven randomized variables: age, gender, limitations of daily activity (incapability), Tinel and Phalen test results, duration of numbness episodes, prevention of numbness with nocturnal splint immobilization, constant numbness, and weakness of palmar abduction. Participants had a mean age of 51 ± 10 years, 90% (97 of 108) were men, and 74% (80 of 108) were subspecialized in hand surgery. Surgeons were asked to rate the severity of idiopathic median neuropathy at the carpal tunnel on a on an 11-point ordinal scale. Factors associated with rated severity were sought in multilevel ordered logistic regression models. Fifteen surgeons did not complete all of their assigned randomized scenarios, resulting in a total of 675 ratings.

RESULTS

After controlling for potentially confounding variables such as magnitude of incapability, factors associated with severity rating on the 11-point ordinal scale included palmar abduction weakness (odds ratio 11 [95% confidence interval 7.7 to 15]), longer duration of symptom episodes (OR 4.5 [95% CI 3.3 to 6.2]), nocturnal numbness in spite of splint immobilization (OR 3.2 [95% CI 2.3 to 4.3]), constant numbness (OR 2.5 [95% CI 1.9 to 3.4]), positive Tinel and positive Phalen test results (OR 2.2 [95% CI 1.6 to 2.9]), and older age (OR 1.6 [95% CI 1.2 to 2.1]).

CONCLUSION

Our results suggest that surgeons rate the severity of idiopathic median neuropathy at the carpal tunnel based on evidence of worse pathophysiology and are not distracted by greater incapability.

CLINICAL RELEVANCE

Surgeons who consider greater incapability as an indication of more severe pathology seem to be practicing outside the norm and may be underappreciating and undertreating the unhelpful thoughts and feelings of worry or despair that consistently account for a notable amount of the variation in symptom intensity and magnitude of incapability.

Tendinopatias do quadril: Uma atualização de conceitos e abordagens

The present update was based on new scientific evidence of major hip-related tendinopathies. Themes were addressed that involve the principles of the onset of tendinopathies through, mainly, the principle of capacity versus demand and the biomechanical aspects involved in its onset, its main characteristics, and clinical presentations. Associated with this, treatment-related updates were presented, with exercise therapy being the focus of conservative treatment and surgical approaches necessary for the control or resolution of these cases.

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 analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review

Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

The implementation of resistance training principles in exercise interventions for lower limb tendinopathy: A systematic review

OBJECTIVES

The primary purpose of this systematic review is to examine the literature on resistance training interventions for lower limb tendinopathy to evaluate the proportion of interventions that implemented key resistance training principles (specificity, progression, overload, individualisation) and reported relevant prescription components (frequency, intensity, sets, repetitions) and reported intervention adherence.

METHODS

Two reviewers performed a systematic review after screening titles and abstracts based on eligibility criteria. Identified papers were obtained in full text, with data extracted regarding the implementation of resistance training principles. Included articles were evaluated by the Cochrane risk of bias tool, with a scoring tool out of 10 used for implementation and reporting of the 5 key principles. Scientific databases were searched in November 2020 and included Medline, CINAHL, AMED, and Sportsdiscus.

RESULTS

52 randomised controlled trials investigating resistance training in five different lower limb tendinopathies were included. Although most studies considered the principles of progression (92%) and individualisation (88%), only 19 studies (37%) appropriately described how this progression in resistance was achieved, and only 18 studies (35%) reported specific instruction on how individualisation was applied. Adherence was considered in 27 studies (52%), with only 17 studies (33%) reporting the levels of adherence. In the scoring criteria, only 5 studies (10%) achieved a total maximum score of 10, with 17 studies (33%) achieving a maximum score of 8 for implementing and reporting the principles of specificity, overload, progression and individualisation.

CONCLUSION

There is meaningful variability and methodological concerns regarding the application and reporting of resistance training principles, particularly progression and individualisation, along with intervention adherence throughout studies. Collectively, these findings have important implications for the prescription of current resistance training interventions, including the design and implementation of future interventions for populations with lower limb tendinopathies.

Proximal Hamstring Tendinopathy: A Systematic Review of Interventions

BACKGROUND

Proximal hamstring tendinopathy affects athletic and non-athletic populations and is associated with longstanding buttock pain. The condition is common in track and field, long distance running and field-based sports. Management options need to be evaluated to direct appropriate clinical management.

PURPOSE/HYPOTHESIS

To evaluate surgical and non-surgical interventions used in managing proximal hamstring tendinopathy.

STUDY DESIGN

Systematic review.

METHODS

Electronic databases were searched to January 2019. Studies (all designs) investigating interventions for people with proximal hamstring tendinopathy were eligible. Outcomes included symptoms, physical function, quality of life and adverse events. Studies were screened for risk of bias. Reporting quality was assessed using the Cochrane Risk of Bias Tool (Randomized Controlled Trials [RCT]) and the Joanna Briggs Institute Checklist (Case Series). Effect sizes (Standard mean difference or Standard paired difference) of 0.2, 0.5 and 0.8 were considered as small, medium and large respectively. Overall quality of evidence was rated according to GRADE guidelines.

RESULTS

Twelve studies (2 RCTs and 10 case series) were included (n=424; males 229). RCTs examined the following interventions: platelet-rich plasma injection (n=1), autologous whole-blood injection (n=1), shockwave therapy (n=1) and multi-modal intervention (n=1). Case series included evaluation of the following interventions: platelet-rich plasma injection (n=3), surgery (n=4), corticosteroid injection (n=2), multi-modal intervention + platelet-rich plasma injection (n=1). Very low-level evidence found shockwave therapy was more effective than a multi-modal intervention, by a large effect on improving symptoms (-3.22 SMD; 95% CI -4.28, -2.16) and physical function (-2.42 SMD; 95% CI-3.33, -1.50) in the long-term. There was very low-level evidence of no difference between autologous whole-blood injection and platelet-rich plasma injection on physical function (0.17 SMD; 95% CI -0.86, 1.21) to (0.24 SMD; 95% CI -0.76, 1.24) and quality of life (-0.04 SMD; 95%CI -1.05, 0.97) in the medium-term. There was very low-quality evidence that surgery resulted in a large reduction in symptoms (-1.89 SPD; 95% CI -2.36, -1.41) to (-6.02 SPD; 95% CI -8.10, -3.94) and physical function (-4.08 SPD; 95%CI -5.53, -2.63) in the long-term.

CONCLUSIONS

There is insufficient evidence to recommend any one intervention over another. A pragmatic approach would be to initially trial approaches proven successful in other tendinopathies.

LEVEL OF EVIDENCE

Level 2a.

Do we need to improve the reporting of evidence in tendinopathy management? A critical appraisal of systematic reviews with recommendations on strength of evidence assessment

Objective

To critically appraise the quality of published systematic reviews (SRs) of randomised controlled trials (RCTs) in tendinopathy with regard to handling and reporting of results with special emphasis on strength of evidence assessment.

Data sources

Medline from inception to June 2020.

Study eligibility

All SRs of RCTs assessing the effectiveness of any intervention(s) on any location of tendinopathy.

Data extraction and synthesis

Included SRs were appraised with the use of a 12-item tool devised by the authors arising from the Preferred Reporting Items in Systematic Reviews and Meta-Analyses statement and other relevant guidance. Subgroup analyses were performed based on impact factor (IF) of publishing journals and date of publication.

Results

A total of 57 SRs were included published in 38 journals between 2006 and 2020. The most commonly used risk-of-bias (RoB) assessment tool and strength of evidence assessment tool were the Cochrane Collaboration RoB tool and the Cochrane Collaboration Back Review Group tool, respectively. The mean score on the appraisal tool was 46.5% (range 0%–100%). SRs published in higher IF journals (>4.7) were associated with a higher mean score than those in lower IF journals (mean difference 26.4%±8.8%, p=0.004). The mean score of the 10 most recently published SRs was similar to that of the first 10 published SRs (mean difference 8.3%±13.7%, p=0.54). Only 23 SRs (40%) used the results of their RoB assessment in data synthesis and more than half (n=30; 50%) did not assess the strength of evidence of their results. Only 12 SRs (21%) assessed their strength of evidence appropriately.

Conclusions

In light of the poor presentation of evidence identified by our review, we provide recommendations to increase transparency and reproducibility in future SRs.

Discriminating the precision of inertial sensors between healthy and damaged shoulders during scaption movement: A cross-sectional study

BACKGROUND

Shoulder assessment in rehabilitation is focused on kinematic properties due to the variability of symptomatology and clinical expression of shoulder injuries.

AIM

To perform a receiver operating characteristic analysis of the kinematic variables involved in the functional mobility of the shoulder that allow the identification of discriminating variables between healthy and diseased shoulders during scaption motion.

METHOD

Analytical cross-sectional study of diagnostic effectiveness was performed in 27 subjects suffering from shoulder damage and 14 asymptomatic controls. Scaption kinematics were evaluated using four inertial sensors placed on the humerus, scapula, forearm and sternum. Three variables (mobility, velocity and acceleration) were obtained from each sensor and the norm of the resultant vector was calculated from each axis. A discriminatory receiver operating characteristic analysis was performed, obtaining the area under the curve, sensitivity and specificity.

FINDINGS

Significant differences from both the resultant vectors and the axis depended on the body segment analysed were observed. Greater movement velocity and acceleration were observed in the asymptomatic group. Receiver operating characteristic analysis, scapular protraction-retraction mobility distinguished with a diagnostic sensitivity of 83.3% and specificity of 90.9% between asymptomatic and shoulder-damaged patients. These diagnosis values were 83.3% and 72.7% for scapular anterior-posterior velocity. Scapular kinematics, in terms of mobility and velocity, are the key variables in shoulder assessment.

INTERPRETATION

This study discriminated between patients suffering from shoulder damage and asymptomatic subjects based on shoulder kinematics during scaption motion. Scapular mobility and velocity were found to be key variables in shoulder assessment, along with the humerus.

Tendinopathy

Tendinopathy describes a complex multifaceted pathology of the tendon, characterized by pain, decline in function and reduced exercise tolerance. The most common overuse tendinopathies involve the rotator cuff tendon, medial and lateral elbow epicondyles, patellar tendon, gluteal tendons and the Achilles tendon. The prominent histological and molecular features of tendinopathy include disorganization of collagen fibres, an increase in the microvasculature and sensory nerve innervation, dysregulated extracellular matrix homeostasis, increased immune cells and inflammatory mediators, and enhanced cellular apoptosis. Although diagnosis is mostly achieved based on clinical symptoms, in some cases, additional pain-provoking tests and imaging might be necessary. Management consists of different exercise and loading programmes, therapeutic modalities and surgical interventions; however, their effectiveness remains ambiguous. Future research should focus on elucidating the key functional pathways implicated in clinical disease and on improved rehabilitation protocols.

Effects of manual acupuncture and electroacupuncture for lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to evaluate the effect of acupuncture/electroacupuncture, alone or combined with other interventions, on pain intensity, pain-related disability, and strength in lateral epicondylalgia (LE) of musculoskeletal origin.

DATABASES AND DATA TREATMENT

Electronic databases were searched for randomized clinical trials, where at least one group received acupuncture or electroacupuncture for LE of musculoskeletal origin. To be eligible, trials had to include humans and collect outcomes on pain intensity or pain-related disability in LE. Data were extracted by two reviewers. The risk of bias (RoB) of the trials was assessed using the Cochrane RoB tool, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the level of evidence was summarized using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) using random effects were calculated.

RESULTS

A total of 14 trials (10 acupuncture) were included. The meta-analysis found a moderate effect size of acupuncture (SMD = -0.66, 95% confidence interval (CI) = -1.22 to -0.10), but not electroacupuncture (SMD = -0.08, 95% CI = -0.99 to 0.83), in the reduction of elbow pain as compared to a comparative group. Acupuncture exhibited a significant moderate effect size (SMD = -0.51, 95% CI = -0.91 to -0.11) in the improvement of related-disability. Acupuncture (SMD = 0.36, 95% CI = 0.16 to 0.57), but not electroacupuncture (SMD = 0.34, 95% CI = -0.29 to 0.98), exhibited a significant but small effect size on strength. Most significant effects were in the short term. The RoB was low but the heterogeneity of trial results led to a downgrading of the GRADE evidence level.

CONCLUSION

Low-level evidence suggests positive effects of acupuncture, but not electroacupuncture, for pain, related-disability, and strength, in LE of musculoskeletal origin, in the short term.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Recent advances in tendinopathy

Tendinopathy refers to the clinical diagnosis of activity-related pain resulting in a decline in tendon function. In the last few years, much has been published concerning the basic science and clinical investigation of tendinopathy and debates and discussions to new questions and points of view started many years ago. This advances review will discuss the current thinking on the basic science and clinical management of tendinopathy and in particular new findings in the tendon repair space that are relevant to the pathophysiology of tendinopathy. We will further discuss potential novel therapies on the horizon in human tendon disease.

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

Background

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

Methods

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

Results

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

Conclusion

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

Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis evaluated the effect of dry needling alone or combined with other treatment interventions on pain, related-disability, pressure pain sensitivity, and strength in people with lateral epicondylalgia of musculoskeletal origin.

DATA SOURCES

MEDLINE, CINAHL, PubMed, PEDro, Cochrane Library, SCOPUS and Web of Science databases from their inception to 5 April 2020.

REVIEW METHODS

Randomized controlled trials collecting outcomes on pain, related-disability, pressure pain thresholds, or strength where one group received dry needling for lateral epicondylalgia of musculoskeletal origin. The risk of bias was assessed by the Cochrane Guidelines, methodological quality was assessed with the PEDro score, and the quality of evidence by using the GRADE approach.

RESULTS

Seven studies including 320 patients with lateral epicondylalgia were included. The meta-analysis found that dry needling reduced pain intensity (SMD ‒1.13, 95%CI ‒1.64 to ‒0.62) and related-disability (SMD ‒2.17, 95%CI ‒3.34 to ‒1.01) with large effect sizes compared to a comparative group. Dry needling also increased pressure pain thresholds with a large effect size (SMD 0.98, 95%CI 0.30 to 1.67) and grip strength with a small size effect (SMD 0.48, 95%CI 0.16 to 0.81) when compared to a comparative group. The most significant effect was at short-term. The risk of bias was generally low, but the heterogenicity of the results downgraded the evidence level.

CONCLUSION

Low to moderate evidence suggests a positive effect of dry needling for pain, pain-related disability, pressure pain sensitivity and strength at short-term in patients with lateral epicondylalgia of musculoskeletal origin.

LEVEL OF EVIDENCE

Therapy, level 1a.

REGISTRATION NUMBER

OSF Registry - https://doi.org/10.17605/OSF.IO/ZY3E8.

Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments

While the pathoetiology is disputed, a wide array of treatments is available to treat tendinopathy. The most common treatments found in the literature include therapeutic modalities, exercise protocols, and surgical interventions; however, their effectiveness remains ambiguous. The purpose of this study was to perform a systematic review of systematic reviews to determine the ability of therapeutic interventions to improve pain and dysfunction in patients with tendinopathy regardless of type or location. Five databases were searched for systematic reviews containing only randomized control trials to determine the effectiveness of treatments for tendinopathies based on pain and patient-reported outcomes. Systematic reviews were assessed via the Assessment of Multiple Systematic Reviews (AMSTAR) for methodological quality. From the database search, 3,295 articles were found, 107 passed the initial inclusion criteria. After further review, 25 systematic reviews were included in the final qualitative analysis. The AMSTAR scores were relatively high (8.8 ± 1.0) across the 25 systematic reviews. Eccentric exercises were the most common and consistently effective treatment for tendinopathy across systematic reviews. Low-level laser therapy and extracorporeal shockwave therapy demonstrated moderate effectiveness, while platelet-rich plasma injections demonstrated inconclusive evidence on their ability to decrease tendinopathy-related pain and improve function. Corticosteroids also showed some effectiveness for short-term pain, but for the long-term use deemed ineffective and at times contraindicated. Regarding surgical options, minimally invasive procedures were more effective compared to open surgical interventions. When treating tendinopathy regardless of location, eccentric exercises were the best treatment option to improve tendinopathy-related pain and improve self-reported function.

Isometric versus isotonic exercise for greater trochanteric pain syndrome: a randomised controlled pilot study

Objectives

Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain. Limited evidence exists for the effectiveness of exercise for GTPS. This study aimed to compare the effectiveness of isometric and isotonic exercise for individuals with GTPS.

Methods

This randomised controlled pilot trial recruited 30 participants with GTPS. Both programmes consisted of daily, progressive home exercise for 12 weeks with 8 individual physiotherapy sessions over the trial period. The primary outcome measure was the Victorian Institute of Sport Assessment-Gluteal (VISA-G) and secondary outcome measures included the Numeric Pain Rating Scale (0–10) and an 11-point Global Rating of Change Scale. Outcome measures were assessed at baseline, 4 and 12 weeks.

Results

Twenty-three participants completed the trial. After 12 weeks, mean VISA-G scores improved in both groups; 55–65 in the isometric group and 62–72 in the isotonic group. 55% of the isometric group and 58% of the isotonic group achieved a reduction in pain of at least 2 points (minimally clinically important difference (MCID)) on the Numeric Pain Rating Scale. 64% of the isometric group and 75% of the isotonic group had improved by at least 2 points (MCID) on the Global Rating of Change Scale.

Conclusion

Isometric and isotonic exercise programmes appear to be effective for individuals with GTPS and should be considered in the loading management of patients with this condition.