The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up

A 7-item Tampa Scale for Kinesiophobia in people with femoroacetabular impingement syndrome: evaluation of structural validity, hypothesis testing, internal consistency and minimally important change

BACKGROUND

The 17-item Tampa Scale for Kinesiophobia (TSK) is a commonly used patient-reported outcome measure (PROM) to assess kinesiophobia, but the measurement properties of the TSK in people with femoroacetabular impingement syndrome (FAIS) are unknown.

OBJECTIVES

1) Revise the existing TSK by removing items, as needed, with inadequate functioning to optimise the TSK for people with FAIS, and 2) evaluate construct validity (both structural validity and hypothesis testing), internal consistency, and minimal important change.

METHODS

Cross-sectional cohort study including 153 young adults with FAIS. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to evaluate structural validity and the TSK was revised to remove items with poor function, improving CFA model fit. Hypothesis testing, internal consistency (Cronbach's α) and minimal important change (distribution-based method) were also evaluated.

RESULTS

A 7-item version of the TSK provided the best CFA model fit with 10-items functioning poorly and needing to be removed. The 7-item TSK was uni-dimensional (single factor in EFA) and had adequate structural validity (Standardised Root Measure Square = 0.0771). The 7-item TSK had insufficient hypothesis testing with moderate correlations to 8/14 PROMs measuring different constructs. The 7-item TSK had adequate internal consistency (α = 0.783). The minimal important change of the 7-item TSK was 6.00 points (0-100 point scale).

CONCLUSION

We found that the '7-item TSK for FAIS', had superior structural validity to the original 17-item scale, suggesting that it may be more appropriate for use in this population. Further studies should evaluate other measurement properties of the 7-item scale.

Whipping or tearing? The biomechanics of Achilles tendinopathy in rearfoot strike runners

BACKGROUND

Two biomechanical mechanisms for the development of Achilles tendinopathy in runners have been proposed: A whipping mechanism characterized by prolonged and excessive rearfoot eversion, and a tearing mechanism characterized by high eccentric plantar flexor forces. The purpose of this pilot study was to determine if runners with and without a history of Achilles tendinopathy exhibited gait biomechanics consistent with either of these mechanisms.

METHODS

Seven male runners with previous or current Achilles tendinopathy and seven healthy male control runners were evaluated by three-dimensional gait analysis. Peak rearfoot eversion angle, rearfoot eversion excursion, duration of rearfoot eversion, and peak rearfoot inversion angle were compared between groups to evaluate the whipping mechanism of injury. Peak dorsiflexion angle, peak dorsiflexion velocity, and peak ankle power absorption were compared between groups to evaluate the tearing mechanism. Additionally, rearfoot eversion angle and sagittal plane ankle power waveforms were compared between groups using statistical parametric mapping.

FINDINGS

There were no differences in any rearfoot eversion, inversion, or dorsiflexion variables or waveforms during running in the Achilles tendinopathy group compared to controls.

INTERPRETATION

Rearfoot strike runners with Achilles tendinopathy do not exhibit running biomechanics consistent with either the whipping or tearing mechanisms of injury.

Psychological factors show limited association with the severity of Achilles tendinopathy

BACKGROUND

This study aimed to investigate the association between psychosocial factors and the severity of Achilles tendinopathy, along with exploring their potential link to the pain's duration.

METHODS

A cross-sectional study involving 111 individuals with Achilles tendon pain was conducted.

METHODS

A cross-sectional study involving 111 individuals with Achilles tendon pain was conducted. Various psychological factors were assessed using the Pain Catastrophizing Scale, Chronic Pain Self-Efficacy Scale (CPSS), Tampa Scale for Kinesiophobia, and Hospital Anxiety and Depression Scale (HAD). Additionally, the severity of Achilles tendon pain was evaluated using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-Br). Regression analyses were employed to determine the association of these psychosocial factors with pain severity and duration.

RESULTS

Self-efficacy for chronic pain showed a slight association with Achilles tendon pain severity (β = 0.42 [95% CI: 0.06 to 0.16], p = 0.001), explaining only 19% of the dependent variable. The other variables, including anxiety, depression, pain catastrophizing, and fear of movement, did not exhibit significant associations.

CONCLUSION

The study suggests that psychological factors demonstrate limited association with the severity of Achilles tendinopathy. While self-efficacy for chronic pain was weakly associated, its clinical relevance remains uncertain. Future research, particularly longitudinal studies, should explore the influence of psychosocial factors on treatment adherence and response to enhance management strategies for Achilles tendon pain.

Individuals with a ventral hernia who report moderate to high fear have worse functional performance than those with low fear

PURPOSE

Ventral hernia repairs (VHR) are performed to restore the integrity of the abdominal wall. Fear of movement, or kinesiophobia, may develop in patients with ventral hernia due to pain and functional impairments, however it has not yet been objectively measured in this patient population. The purpose of this study was to test the hypothesis that in patients with ventral hernia awaiting surgical repair, higher levels of kinesiophobia would be associated with poorer mobility, abdominal core function, and quality of life.

METHODS

Seventy-seven participants scheduled for ventral hernia repair were enrolled as part of an ongoing randomized controlled trial (NCT05142618). The Tampa Scale of Kinesiophobia (TSK-11) is an 11-item questionnaire that asks about fear of movement and physical activity restriction. Participants were split into groups based on their TSK-11 score (minimal, low, moderate to high). Primary outcome measures included the five-time sit-to-stand (5xSTS), Quiet Unstable Sitting Test (QUeST), and the Hernia-Related Quality-of-Life (HerQLeS) survey. A one-way ANOVA with a Bonferroni correction compared QUeST, 5xSTS, and HerQLes results between groups.

RESULTS

Groups were significantly different on 5xSTS (minimal: 11.4 ± 2.6 s, low: 13.8 ± 3.1 s, moderate to high: 17.8 ± 9.8 s; p = 0.001) and HerQLes (minimal: 58.0 ± 27.8, low: 49.4 ± 22.0, moderate to high: 30.6 ± 25.3; p = 0.003) but not QUeST (minimal: - 2.8 ± 2.5, low: - 6.8 ± 10.0, moderate to high: - 5.5 ± 5.0; p = 0.16).

CONCLUSION

Individuals with moderate to high kinesiophobia have worse pre-operative performance-based (5xSTS) and self-reported (HerQLes) function and quality of life than those with minimal and low kinesiophobia. Future research should examine the influence of kinesiophobia on post-operative outcomes as it may be a potent target for rehabilitation.

Effect of a Novel Training Program in Patients With Chronic Shoulder Pain Based on Implicit Motor Learning: Pilot and Feasibility Study

Background

Implicit motor learning has been shown to be effective for learning sports-related motor skills. It facilitates automaticity of movements and thereby improves performance in multitasking and high-pressure environments. Motor learning to develop motor skills and neuroplastic capacities is not sufficiently incorporated in musculoskeletal rehabilitation. Especially in patients with chronic pain conditions like shoulder pain this approach might benefit over traditional exercise programs.

Purpose/hypothesis

The aim of this study was to investigate the feasibility and clinical outcome of a new implicit motor learning exercise program in a group of patients with chronic shoulder pain.

Study design

Pilot and feasibility cohort study.

Methods

Twenty-six patients with chronic shoulder pain performed a 6-week home exercise program with weekly remote follow up by a physiotherapist. The program comprised five exercises designed to challenge overall body balance, simultaneously engaging the upper limbs in a range of reaching tasks. The tasks included reaching above the head, at and below waist level, in various directions. No instructions on correct performance were provided to foster external focus. Feasibility was assessed by (1) recruitment rate, (2) follow up rate, (3) subjective experience, (4) self-reported adverse events and (5) self-reported adherence of subjects. Clinical effects of the program were assessed with (1) the Shoulder Pain and Disability Index (SPADI), (2) the Auto-Constant score, (3) the numeric rating scale (NRS) at rest and at night, (4) the patient specific functional scale (PSFS), (5) the avoidance endurance questionnaire (AEQ), (6) patient acceptable symptom state (PASS) and (7) a global rating of change (GROC).

Results

The study protocol was feasible in terms of follow up rate (16w for 28 patients), exercise adherence (77.1%± 29.41), and adverse events (no serious, 5 light adverse events). Statistically significant improvements were observed for SPADI (p<0.001), NRS at rest (p=0.033), at night (p=0.29), PSFS (p<0.001) and PASS (p<0.001) after only six weeks training.

Conclusion

This study reveals promising results of another way of looking at exercise for patients with chronic shoulder pain. Both feasibility and clinical effects of the program on pain and function was acceptable. Future studies should incorporate a control group, provide longer follow up and include objective measurements.

Level of evidence

2b.

Triceps surae muscle forces during dynamic exercises in patients with Achilles tendinopathy: A cross-sectional study

PURPOSE

The aim of this study was to investigate the individual triceps surae muscle forces during the execution of six different functional movements and rehabilitation exercises in patients with Achilles tendinopathy compared to a control group.

METHODS

Triceps surae muscle forces of 15 participants with Achilles tendinopathy (AT) and 15 healthy controls were estimated through a combination of experimental data and musculo-skeletal modeling. Three-dimensional motion capture and force plates were used to collect the ankle and knee joint angles and moments during three functional movements (walking, heel walking, and toe walking) and three rehabilitation exercises (bilateral heel drop, unilateral heel drop with extended knee and with flexed knee). A dynamic optimization method was used to obtain the modeled triceps surae muscle forces. Force-sharing strategies were calculated at the peak triceps surae muscle force and compared between groups.

RESULTS

Lower peak triceps surae forces were obtained for the AT group during dynamic exercises. Across all exercises, the average contribution of the soleus (SOL) to the total triceps surae muscle force was the largest (60.83 ± 13.89% [AT] > 56.90 ± 16.18% [healthy]), followed by the gastrocnemius medialis (29.87 ± 10.67% [AT] < 32.19 ± 12.90% [healthy]) and the gastrocnemius lateralis (9.30 ± 4.31% [AT] < 10.91 ± 4.66% [healthy]). The triceps surae force-sharing strategy was different for the toe walking, heel walking, and the bilateral and unilateral heel drop with extended knee.

CONCLUSION

This study provides evidence for altered triceps surae muscle force-sharing strategies during dynamic tasks in patients with AT. The influence of altered muscle force-sharing on the subtendon nonuniformity and/or the tendon loading should be explored in future work.

Kinesiophobia contributes to worse functional and patient-reported outcome measures in Achilles tendinopathy: a systematic review

PURPOSE

To assess the effect of kinesiophobia or fear of reinjury on patient-reported outcome measures and physical performance measures in patients with chronic Achilles tendinopathy (AT).

METHODS

Three databases were systematically screened for studies from inception to May 22nd, 2023 for literature investigating the impact of kinesiophobia on PROMs or physical performance metrics in AT. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, pain, level of activity, self-reported injury severity, quality of life, single-leg hop performance, and heel-raise performance were recorded. Data was presented primarily in a narrative summary fashion. The MINORS score was used for all studies to perform a quality assessment of included studies.

RESULTS

Six studies comprising 705 patients were included in this review. Variations of the Tampa Scale of Kinesiophobia (TSK-11 or TSK-17) were used in all studies. TSK scores were strongly correlated with the Pain Catastrophizing Score (PCS) and Visual Analogue Scale (VAS) scores and were correlated with decreased Victorian Institute of Sports Assessment Achilles (VISA-A) and Foot and Ankle Outcome Scores Quality of Life (FAOS-QoL) subscale scores. Kinesiophobia was associated with heel raise completion with conflicting evidence on correlations with hop test performance.

CONCLUSION

Increased kinesiophobia scores (> 35 points), measured by TSK are associated with worse PROMs, including increased pain, decreased quality of life, increased self-reported severity, and is also associated with poorer physical performance measures in patients with AT.

LEVEL OF EVIDENCE

IV.

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.

Identifying characteristics of resistance-based therapeutic exercise interventions for Achilles tendinopathy: A scoping review

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.

Pain neuroscience education in persistent painful tendinopathies: A scoping review from the Tendon PNE Network

OBJECTIVE

to conduct and report a scoping review of the available evidence of the effects and content of pain neuroscience education for patients with persistent painful tendinopathies.

METHODS

PubMed, Embase, Web of Science, CINAHL, SPORTDiscus, and grey literature databases were searched from database inception to May 2022. Randomised and non-randomised controlled trials, non-controlled clinical trials, cohort studies, case series, case studies including people with persistent painful tendinopathy aged ≥18 years, a pain education intervention, and in English were included. Studies were excluded if they were cross-sectional studies, reviews, editorials, abstracts, or full-text not available or if included heterogeneous study cohorts, patients with tendon rupture, or patients with systemic diseases.

RESULTS

five studies (n = 164) were included. Pain neuroscience education entailed face-to-face discussion sessions or educational materials including videos, brochures, paper drawings, and review questions. All studies used pain neuroscience education in conjunction with other interventions, obtaining significant benefits in outcomes related to pain, physical performance, or self-reported function, among others.

CONCLUSIONS

The application of pain neuroscience education in conjunction with other interventions seemed to improve several outcomes. However, considering the current knowledge about tendon pain and the scarcity of well-designed trials studying pain neuroscience education in tendinopathy, additional research is needed.

Putting the fear-avoidance model into practice - what can patients with chronic low back pain learn from patients with Achilles tendinopathy and vice versa?

BACKGROUND

Fear-avoidance variables are present in patients with musculoskeletal pain conditions, such as chronic low back pain (CLBP) and Achilles tendinopathy (AT) and can lead to reduced function and recovery. It is unknown how these variables relate in populations with different etiologies but similar pain provocation mechanisms.

OBJECTIVE

To compare kinesiophobia, pain catastrophizing, and disability between these two groups.

METHODS

Patients with CLBP and those with AT were included. Tampa Scale of Kinesiophobia (TSK-17) and Pain Catastrophizing Scale (PCS-13) were evaluated in both groups. The CLBP group completed the Oswestry Disability Index (ODI) and the AT group completed the PROMIS-29 questionnaire. Gait speed was calculated for each group. Disability outcomes were normalized between groups.

RESULTS

119 patients in the CLBP group (64 female, 46 ± 8 years) and 83 patients in the AT group (42 female, 48 ± 12 years) were included. Both groups (CLBP, AT) presented with high prevalence of kinesiophobia (67%, 55%) but the CLBP group presented with higher prevalence of pain catastrophizing (22%, 2%). The CLBP group demonstrated higher levels of disability via normalized ODI (MD= 12.4, 95% CI: 9.2, 15.5) but the AT group demonstrated slower gait speed (MD= 0.1 m/s, 95% CI: 0.0, 0.2).

CONCLUSION

Similarly high prevalence of kinesiophobia was found in patients with CLBP and patients with AT. While the CLBP group reported greater prevalence of catastrophizing thoughts and greater disability, the AT group had slower gait speed. Overall, these findings demonstrate that CLBP and AT have similarities that may allow clinicians to learn from one to inform treatment of the other.

CLINICAL TRIAL REGISTRATION NUMBERS

NCT03523325, ISRCTN17115599.

Comparability of the Effectiveness of Different Types of Exercise in the Treatment of Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy (AT) is a common condition both in athletes and the general population. The purpose of this study is to highlight the most effective form of exercise in managing pain-related symptoms and functional capacity as well as in a return to life activities, ensuring the quality of life of patients with AT, and creating a protocol to be used in rehabilitation. We conducted a systematic review of the published literature in Pubmed, Scopus, Science Direct, and PEDro for Randomised Controlled Trials concerning interventions that were based exclusively on exercise and delivered in patients 18-65 years old, athletes and non-athletes. An amount of 5235 research articles generated from our search. Five met our inclusion criteria and were included in the review. Research evidence supports the effectiveness of a progressive loading eccentric exercise program based on Alfredson's protocol, which could be modified in intensity and pace to fit the needs of each patient with AT. Future research may focus on the optimal dosage and load of exercise in eccentric training and confirm the effectiveness of other type of exercise, such as a combination of eccentric-concentric training or heavy slow resistance exercise. Pilates could be applied as an alternative, useful, and friendly tool in the rehabilitation of AT.

Efficacy of Telehealth for Movement-Evoked Pain in People With Chronic Achilles Tendinopathy: A Noninferiority Analysis

OBJECTIVE

The purpose of this study was to compare the efficacy of physical therapy delivered via an all telehealth or hybrid format with an all in-person format on movement-evoked pain for individuals with chronic Achilles tendinopathy (AT).

METHODS

Sixty-six individuals with chronic AT participated (age, 43.4 [SD = 15.4] years; 56% female; body mass index, 29.9 [SD = 7.7] kg/m2). Participants completed all in-person visits from the initiation of recruitment in September 2019 to March 16, 2020 (in-person group). From March 17 to July 15, 2020, participants completed all telehealth visits (telehealth group). From July 16, 2020, to enrollment completion in December 2020, participants could complete visits all in-person, all telehealth, or a combination of in-person and telehealth (hybrid group) based on their preference. A physical therapist provided 6 to 7 visits, including an exercise program and patient education. Noninferiority analyses of the telehealth and hybrid groups compared with the in-person group were completed for the primary outcome of movement-evoked pain during single-limb heel raises.

RESULTS

All groups demonstrated decreases in movement-evoked pain beyond the minimal clinically important difference from baseline to 8 weeks (2 out of 10 on a numeric pain rating scale). Lower bounds of the 95% CIs for mean differences between groups did not surpass the preestablished noninferiority margin (2 out of 10) for movement-evoked pain in both the telehealth and hybrid groups (telehealth vs in-person: 0.45 [-1.1 to 2.0]; hybrid vs in-person: 0.48 [-1.0 to 1.9]).

CONCLUSION

Individuals with chronic AT who completed a tendon-loading program with patient education through a telehealth or hybrid format had no worse outcomes for pain than those who received the same intervention through in-person visits.

IMPACT

Physical therapist-directed patient care delivered via telehealth may enhance accessibility to best practice AT rehabilitation, including exercise and education. Use of telehealth technology may also provide an opportunity to prioritize patient preference for physical therapy visit format.

LAY SUMMARY

If you are a patient with chronic AT, physical therapist-directed patient care delivered via telehealth may improve your accessibility to best practice AT rehabilitation, including exercise and education. Use of telehealth technology may also prioritize your preferences regarding the format of the physical therapy visit.

Achilles tendon forces and pain during common rehabilitation exercises in male runners with Achilles tendinopathy. A laboratory study

OBJECTIVES

To estimate Achilles tendon forces and their relationship with self-reported pain in runners with Achilles tendinopathy (AT) during common rehabilitation exercises.

DESIGN

Cross-sectional.

SETTING

Laboratory.

PARTICIPANTS

24 recreational male runners (45.92 (8.24) years old; 78.20 (8.01) kg; 177.17 (6.69) cm) with symptomatic AT.

MAIN OUTCOME MEASURES

Kinematic and kinetic data were collected to estimate Achilles tendon forces during 12 commonly prescribed exercises. Achilles tendon forces were estimated from biomechanical data and normalised to the participant's bodyweight. The secondary aim was to investigate the relationship between Achilles tendon forces and pain during these exercises.

RESULTS

Two exercise clusters were identified based on Achilles tendon forces. Cluster1 included various exercises including double heel raises, single heel raises, and walking (range: 1.10-2.76 BWs). Cluster2 included running, jumping and hopping exercises (range: 5.13-6.35 BWs). Correlation between tendon forces and pain was at best low for each exercise (range: -0.43 - 0.20). Higher force exercises lead to more tendon load for a given amount of pain (R² = 0.7505; y = 0.2367x + 0.6191).

CONCLUSION

This study proposes a hierarchical exercise progression based on Achilles tendon forces to guide treatment of runners with AT. Achilles tendon forces and pain are not correlated in runners with AT.

Longitudinal Validation of a Specific Measure of Fear Avoidance in Athletes: Predicting Time from Injury to Return to Sports Competition

Purpose

We developed the Athlete Fear Avoidance Questionnaire (AFAQ) to measure fear avoidance in athletes. Previous fear avoidance scales were developed for the general population and have demonstrated significant predictive capabilities regarding rehabilitation. No research to date has examined the association between athlete fear avoidance as measured by the AFAQ and the rehabilitation time in athletes.

Patients and Methods

Fifty-nine athletes who were injured during sport season participated in the study (40 males and 19 females). At injury onset, all participants completed self-report functional questionnaires. In addition, we measured multiple aspects of fear avoidance including athlete fear avoidance (AFAQ), kinesiophobia (TSK), and pain catastrophizing (PCS). Finally, we assessed pain severity and interference, as well as depression. Once the athletes were able to return to competition all participants answered the questionnaires again. Pearson correlations and a regression analysis were used to identify relationships between function, psychological variables, pain, and return to competition time.

Results

The AFAQ yielded the strongest correlation with return to competition time (r=0.544, p<0.001). In addition, function at initial injury time and pain interference were also significantly correlated with return to competition time (r=0.442, p<0.001 and r=0.356, p=0.006 respectively). Athlete fear-avoidance combined with function at the time of injury explained 34% of the variance of return to competition time in the multivariate regression model (p<0.001).

Conclusion

Athlete fear-avoidance as measured by the AFAQ is associated with rehabilitation time and returning to competition in injured athletes. Psychosocial factors including athlete fear avoidance may explain why some athletes take longer to rehabilitate than others and should be evaluated in athletes who are taking longer than anticipated to complete their rehabilitation. Reducing athlete fear avoidance may facilitate rehabilitation in future studies.

Eccentric exercise is more effective than other exercises in the treatment of mid-portion Achilles tendinopathy: systematic review and meta-analysis

Achilles tendinopathy (AT) is one of the most frequent overuse injuries in the ankle. The evidence base for its conservative management AT continues to evolve, but there is still a gap in the evidence for the efficacy of any modality of treatment in high-quality studies. This systematic review and meta-analysis investigated the efficacy of EE in improving pain and function in adult patients with mid-portion Achilles tendinopathy compared to other forms of exercise. A search was performed in PubMed, BIREME, SportDiscus, Cinahl, Web of Science and PEDro, in November 2022. The methodological quality was evaluated using the Risk of Bias 2 tool (RoB2) of the Cochrane collaboration, and the meta-analysis was performed using the Review Manager 5.1 program. 2024 articles were identified and eight fulfilled the inclusion criteria. RoB2 presented a final score with 62.5% of the studies presented "some concerns", and 37.5% (five and three articles, respectively) presenting "high risk" of bias. EE was effective for the managment of AT. The only variable for which a meta-analysis was possible was pain (five articles), analysed with the visual analogue scale/numerical visual scale. The mean difference (MD) in treatment effect using EE was - 1.21 (- 2.72 to - 0.30) with a 95% of confidence interval (CI), thus identifying a significant positive effect for the improvement of pain in patients with AT in whom EE was used. EE is effective in the management of AT. The meta-analysis shows the need for appropriately powered randomized controlled trials with better design, the use of standard outcome measures and well-planned protocols for conservative management of AT.Level of evidence: Level 1.Registration: CRD42018118016.

One fifth of patients with Achilles tendinopathy have symptoms after 10 years: A prospective cohort study

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).

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

ABSTRACT

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

Validity, reliability, and normative data on calf muscle function in rugby union players from the Calf Raise application

We examined the validity and reliability of biomechanical outcomes extracted using the Calf Raise application of three calf muscle tests. We then established normative calf muscle function values for male rugby union players accounting for rugby-related factors (position, level) alone and together with clinical factors (age, leg dominance, BMI, previous injury). In total, 120 athletes performed three single-leg calf muscle tests. Twenty athletes participated in application validation; 18 in test-retest reliability; and all in establishing normative equations. Validity of application outcomes against 3D motion and force plate data was good-to-excellent (CV ≤ 6.6%, ICC ≥0.84). Test-retest reliability was good across outcomes following familiarisation (CV < 10%, ICC ≥0.83). Forwards produced superior power than backs during the bodyweight (59 W, p = 0.007) and weighted (73 W, p < 0.001) power tests. Playing level influenced power outcomes (p < 0.009). Super Rugby players were more powerful than Club (both power tests), Provincial (both power tests), and International (bodyweight power). Backs completed more repetitions (3 repetitions, p = 0.001) and positive displacement (30 cm, p = 0.001) than forwards during endurance testing. When accounting for clinical factors; BMI, age, and previous injury explained some of the differences observed between positions and levels. This study provides initial benchmark values of calf muscle function in rugby union.

Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol

Calcaneal apophysitis and Achilles tendinopathy are common overuse injuries characterised by insidious posterior heel pain with activity. Calcaneal apophysitis is commonly diagnosed in adolescents, although Achilles tendinopathy is understudied in the adolescent population and is therefore rarely considered until adulthood. Exercise therapy and activity modification have the highest level of evidence for treating Achilles tendinopathy, while calcaneal apophysitis is treated with anecdotal and passive treatment or complete rest. It remains unknown whether exercise therapy is effective for adolescents with heel pain related to either diagnosis.

This is a pilot and feasibility study. Thirty participants between the ages of 7 years and 17 years with posterior heel pain will be recruited from the local community and club sports team and local physicians, school nurses, and athletic trainers through flyers and social media. Participants will be asked to complete evaluations and treatment sessions every 4 weeks with three virtual visits every 2 weeks in between for 12 weeks. All participants will receive standardised treatment consisting of daily Achilles tendon loading exercises and education on pain-guided activity modification. Feasibility outcomes will include recruitment, enrolment, retention and compliance. Clinical outcomes will include the measures of symptom severity, quality of life, tendon morphology and lower extremity function.

This protocol will provide preliminary data to inform a larger clinical trial based on the feasibility of the proposed intervention and methodology. Additionally, the results will provide preliminary evidence on whether Achilles tendon injury occurs in the adolescent population.

The trial is registered with clinicaltrials.gov (ID:1652996).

Data driven model of midportion achilles tendinopathy health created with factor analysis

Background

Achilles tendinopathy is a complex injury and the clinical presentation spans multiple different domains: physical and psychological symptoms, lower extremity function and tendon structure. A conceptual model of Achilles tendon health comprising these domains has been proposed in the literature. The aim of the study was to fit a model of Achilles tendinopathy using factor analysis and compare that to the conceptual model. An inclusive approach using a wide range of variables spanning multiple potential domains were included.

Methods

Participants (N = 99) with midportion Achilles tendinopathy were assessed with variables representing symptoms, physical function, tendon structure, metabolic syndrome, and psychologic symptoms. A Kaiser-Mayer-Olkin index was used to determine suitable variables for a subsequent exploratory factor analysis.

Results

A model emerged with an acceptable fit to the data (standardized root mean square of residuals = 0.078). Five uncorrelated factors emerged from the model and were labelled as biopsychosocial, lower extremity function, body size, load tolerance, and tendon structure. The total explained variance was 0.51 with the five factors explaining 0.14, 0.12, 0.10, 0.08, and 0.07 respectively. The results differed from the conceptual model as the factors of psychological variables and metabolic variables did not emerge from the analysis.

Conclusion

A data driven model of Achilles tendon health supports assessment of the clinical presentation over multiple domains. As the factors are uncorrelated, the results of assessment of, for example, tendon structure should not be expected to be associated with lower extremity function or biopsychosocial limitations. The results suggest that the Patient Reported Outcomes Measurement Information System, counter-movement jump height, body mass index, pain with hopping, and the tendon cross-sectional area can evaluate the five factors, respectively.

Trial registration

Registered on clinicaltrials.gov (Medicine NL of. ClinicalTrials.gov [Internet], 2018), ID number NCT03523325.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05702-1.

Biopsychosocial approach to tendinopathy

Tendinopathy describes a spectrum of changes that occur in damaged tendons, leading to pain and reduced function that remains extremely challenging for all clinicians. There is an increasing awareness of the influence that psychological and psychosocial components, such as self-efficacy and fear-avoidance, have on rehabilitation outcomes in musculoskeletal medicine. Although it is widely accepted that psychological/psychosocial factors exist in tendinopathy, there is currently a distinct lack of trials measuring how these factors affect clinical outcomes. Biopsychosocial treatments acknowledge and address the biological, psychological and social contributions to pain and disability are currently seen as the most efficacious approach to chronic pain. Addressing and modulating these factors are crucial in the pathway of personalised treatments in tendinopathy and offer a real opportunity to drive positive outcomes in patients. In this education review, we also provide the current evidence-based guidance on psychological and psychosocial developments in musculoskeletal medicine and how these may be translated to treating tendinopathy using a biopsychosocial model.

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

OBJECTIVE

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

DESIGN

Scoping review.

LITERATURE SEARCH

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

STUDY SELECTION

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

DATA SYNTHESIS

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

RESULTS

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

CONCLUSION

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

An Isometric and Functionally Based 4-Stage Progressive Loading Program in Achilles Tendinopathy: A 12-Month Pilot Study

Background

Achilles tendinopathy (AT) is a common musculoskeletal disorder, and its management remains challenging. Hypothesis/Purpose. By conducting a pilot study, we aimed to assess the feasibility, safety, and clinical improvement of a new home-based 4-stage rehabilitation program with progressive loading including isometric exercises on a small scale prior to setting up a randomized controlled trial.

Methods

Ten recreational athletes with chronic midportion AT were included. The primary outcome was change in VISA-A score after 1, 2, 3, 6, and 12 months. Secondary outcomes included tenderness on palpation of the tendon and ultrasonographic changes after 6 months.

Results

Average VISA-A improvements of 26.9 points (P=0.004) and 35.4 points (P=0.006) were observed at 6- and 12-month follow-up, respectively. Tenderness on palpation of the tendon (0-10) was reduced from 5.5 to 2.5 (P < 0.001). Color Doppler ultrasound activity (0-4) was reduced by 50%, from an average of grade 2 to grade 1 (P=0.023). The hypoechoic cross-sectional area of the Achilles tendon was reduced from an average of 29.1% to 8.5% (P=0.001). Tendon thickness showed no statistically significant change (P=0.415).

Conclusion

Following the 4-stage rehabilitation program for AT based on isometric training and progressive loading, we observed improvement in both VISA-A score and ultrasonography in a group of athletes who had previously failed to benefit from standard AT rehabilitation. The study was feasible in terms of high adherence to the program and with no observed safety issues. The results of this pilot study support a further assessment of this specific approach for rehabilitation in a future randomized controlled trial.

Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Extracorporeal shockwave therapy (ESWT) is used commonly to treat pain and function in Achilles tendinopathy (AT). The aim of this study was to synthesize the evidence from (non-) randomized controlled trials, to determine the clinical effectiveness of ESWT for mid-portion Achilles tendinopathy (mid-AT) and insertional Achilles tendinopathy (ins-AT) separately.

METHODS

We searched PubMed/Medline, Embase (Ovid), and Cochrane Central, up to January 2021. Unpublished studies and gray literature were searched in trial registers (ACTRN, ChiCTR, ChiCtr, CTRI, DRKS, EUCTR, IRCT, ISRCTN, JPRN UMIN, ClinicalTrials.gov, NTR, TCTR) and databases (OpenGrey.eu, NARCIS.nl, DART-Europe.org, OATD.org). Randomized controlled trials (RCTs) and non-randomized controlled clinical trials (CCTs) were eligible when investigating the clinical effectiveness of ESWT for chronic mid-AT or chronic ins-AT. We excluded studies that focused on treating individuals with systemic conditions, and studies investigating mixed cohorts of mid-AT and ins-AT, when it was not possible to perform a subgroup analysis for both clinical entities separately. Two reviewers independently performed the study selection, quality assessment, data extraction, and grading of the evidence levels. Discrepancies were resolved through discussion or by consulting a third reviewer when necessary.

RESULTS

We included three RCTs on mid-AT and four RCTs on ins-AT. For mid-AT, moderate quality of evidence was found for the overall effectiveness of ESWT compared to standard care, with a pooled mean difference (MD) on the VISA-A of 9.08 points (95% CI 6.35-11.81). Subgroup analysis on the effects of ESWT additional to standard care for mid-AT resulted in a pooled MD on the VISA-A of 10.28 points (95% CI 7.43-13.12). For ins-AT, we found very low quality of evidence, indicating that, overall, ESWT has no additional value over standard care, with a standardized mean difference (SMD) of - 0.02 (95% CI - 0.27 to 0.23). Subgroup analysis to determine the effect of ESWT additional to standard care for ins-AT showed a negative effect (SMD - 0.29; 95% CI - 0.56 to - 0.01) compared to standard care alone.

CONCLUSIONS

There is moderate evidence supporting the effectiveness of ESWT additional to a tendon loading program in mid-AT. Evidence supporting the effectiveness of ESWT for ins-AT is lacking.

TRIAL REGISTRATION

PROSPERO Database; No. CRD42021236107.

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

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

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

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

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

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

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

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

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.

Psychological factors associated with foot and ankle pain: a mixed methods systematic review

BACKGROUND

Foot and ankle pain is common, and generally viewed through a biomedical lens rather than applying a biopsychosocial model. The objectives of this review were to evaluate: (1) the psychosocial characteristics of participants with foot/ankle pain compared to participants without foot/ankle pain; (2) the association between psychosocial factors with pain and function in people with foot/ankle pain; and (3) understand the psychosocial factors associated with the lived experience of foot/ankle pain.

METHODS

A mixed methods systematic review was conducted according to the PRISMA guidelines and guided by the Joanna Briggs Institute methodology for mixed methods systematic reviews. The databases MEDLINE, Embase, CINAHL, SPORTDiscus, PsychInfo, and Scopus were searched. The Mixed Methods Assessment Tool was used to evaluate study quality. A convergent segregated approach was used to synthesise and integrate quantitative and qualitative data.

RESULTS

Eighteen studies were included, consisting of 13 quantitative, 4 qualitative and 1 mixed methods study. The overall quality of the studies was considered high. Integration of the quantitative and qualitative data were not possible due to the disparate nature of the included studies. A narrative synthesis of the quantitative data revealed that negative emotional and cognitive factors were more common in people with foot/ankle pain compared to those without foot/ankle pain. A significant association was also found between emotional distress with foot pain and foot function in some people with plantar heel pain. In addition, kinesiophobia and pain catastrophising were significantly associated with impaired foot function, and pain catastrophising was significantly associated with first step pain in people with plantar heel pain. The qualitative data revealed emotional impacts, physical challenges, and a loss of self which was individual and unpredictable.

CONCLUSIONS

This review provides evidence that negative psychological constructs are greater in participants with foot/ankle pain compared to those without foot/ankle pain, although the cross-sectional nature of the study designs included in this review reduces the certainty of the evidence. These findings indicate that psychological constructs are associated with foot/ankle pain. Further research should evaluate the predictive ability of multidimensional screening tools to identify patients at risk of developing persistent foot/ankle pain.

Fear of Movement and Reinjury in Sports Medicine: Relevance for Rehabilitation and Return to Sport

Athletes are defined by their ability to move and are often accustomed to pain as it relates to their sports and exercise regime. The forced movement restriction and pain associated with an acute or overuse injury has a profound effect not only on their physical abilities but also on their psychological well-being and social context. With the goal of returning to sport, the rehabilitation focus historically has been on recovery of physical attributes, but more recent research is addressing the psychological factors. This Perspective proposes that-according to the current evidence in sports medicine-the fear that affects choice of treatment, rehabilitation, and return to sports is intertwined with physical capacity and recovery of function. Past injury is also 1 of the main risk factors for a sports injury; therefore, fear of reinjury is not irrational. For an athlete, the fear related to a sports injury encompasses the fear of reinjury along with fear of not being able to return to the sport at their highest performance level-and the fear of having lifelong debilitating pain and symptoms. This Perspective reviews the evidence for the influence of fear of movement and reinjury on choice of treatment, rehabilitation, and return to sport and provides suggestions on how to address this fear during the continuum of treatment and return to sports.

Application of the 4-Element Movement System Model to Sports Physical Therapy Practice and Education

The 4-Element Movement System Model describes primary elements (motion, force, motor control, and energy) essential to the performance of all movements. The model provides a framework or scaffolding which allows for consistent processes to be used in examination and intervention decisions. The process starts with task identification followed by a systematic observation of control, amount, speed, symmetry, and symptoms during movement. Testable hypotheses are generated from the observations which inform the examination and the interventions. This commentary describes the use of the 4-Element Movement System Model in entry level and post-graduate residency educational programs and in clinical care with three common sports-related diagnoses.

LEVEL OF EVIDENCE

5.

The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Clinical results and a radiographic analysis to explain its efficacy

Local debridement or decompression of the posterior heel in Haglund's syndrome yields variable results. This condition is sometimes due to an excessively long calcaneus rather than simply a large posterosuperior bony prominence. Failure to address this abnormality may explain the poor results in some series. We recently published a new measurement (the X/Y ratio) which, combined with the calcaneal pitch angle, assesses the abnormality of the shape of the calcaneus. The Zadek osteotomy strongly modifies that shape. We retrospectively reviewed 50 patients treated by a Zadek osteotomy at a mean 7 years follow-up using the AOFAS ankle-hindfoot score, the VISA-A score and Tegner scale. We measured only the X/Y ratio and the calcaneal inclination angle, as the classically described radiographic measurements in Haglund's syndrome are unreliable. We then assessed the condition of the distal end of the Achilles tendon with an MRI. Our results demonstrate excellent outcomes(40/50, 80%) following Zadek osteotomy and correspond to the change in pre- and post-operative measurements, especially the X/Y ratio. An algorithm using those geometrical measurements of the calcaneus is proposed for decision making in Haglund's syndrome. Level of clinical evidence: Level 3.

Runners with mid-portion Achilles tendinopathy have greater triceps surae intracortical inhibition than healthy controls

OBJECTIVES

This study aimed to investigate short-interval intracortical inhibition (SICI) and muscle function in the triceps surae of runners with mid-portion Achilles tendinopathy (AT).

METHODS

Runners with (n = 11) and without (n = 13) AT were recruited. Plantar flexor isometric peak torque and rate of torque development (RTD) were measured using an isokinetic dynamometer. Triceps surae endurance was measured as single-leg heel raise (SLHR) to failure test. SICI was assessed using paired-pulse transcranial magnetic stimulation during a sustained contraction at 10% of plantar flexor isometric peak torque.

RESULTS

Triceps surae SICI was 14.3% (95% CI: -2.1 to 26.4) higher in AT than in the control group (57.9%, 95% CI: 36.2 to 79.6; and 43.6% 95% CI: 16.2 to 71.1, p = 0.032) irrespective of the tested muscle. AT performed 16 (95% CI: 7.9 to 23.3, p < 0.001) fewer SLHR repetitions on the symptomatic side compared with controls, and 14 (95% CI: 5.8 to 22.0, p = 0.004), fewer SLHR repetitions on the non-symptomatic compared with controls. We found no between-groups differences in isometric peak torque (p = 0.971) or RTD (p = 0.815).

PERSPECTIVE

Our data suggest greater intracortical inhibition for the triceps surae muscles for the AT group accompanied by reduced SLHR endurance, without deficits in isometric peak torque or RTD. The increased SICI observed in the AT group could be negatively influencing triceps surae endurance; thus, rehabilitation aiming to reduce intracortical inhibition should be considered to improve patient outcomes. Furthermore, SLHR is a useful clinical tool to assess plantar flexor function in AT patients.

No Difference in Clinical Effects When Comparing Alfredson Eccentric and Silbernagel Combined Concentric-Eccentric Loading in Achilles Tendinopathy: A Randomized Controlled Trial

Background:

Alfredson isolated eccentric loading and Silbernagel concentric–eccentric loading have both shown beneficial effects on clinical symptoms in midportion Achilles tendinopathy (AT), but they have never been compared directly.

Purpose:

To test for differences in clinical effects at 1-year follow-up between Alfredson and Silbernagel loading in midportion AT.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

A total of 40 recreational athletes were allocated to the Alfredson group (AG) or the Silbernagel group (SG). The primary outcome was the difference in the Victorian Institute of Sports Assessment–Achilles (VISA-A) at 1-year follow-up. Secondary outcomes were the visual analog scale for pain during activities of daily living (VAS-ADL) and sports activities (VAS–sports), the EuroQol 5 Dimensions instrument (EQ-5D), and global perceived effect score. Measurements were performed at baseline and 12-week, 26-week, and 1-year follow-up. Analysis was performed using a linear mixed-regression model with intervention (AG vs SG), time (12 weeks, 26 weeks, and 1 year postoperatively), and intervention-by-time interaction.

Results:

The VISA-A score improved for both AG and SG, from 60.7 ± 17.1 at baseline to 89.4 ± 13.0 at 1-year follow-up and from 59.8 ± 22.2 to 83.2 ± 22.4, respectively (P < .001 for both). Because the interaction term did not significantly improve the model, we reported a treatment effect without interaction term, indicating a constant difference at each follow-up. The linear mixed model with correction for baseline VISA-A and confounders revealed a nonsignificant treatment effect (2.4 [95% CI, –8.5 to 13.3]; P = .656). In addition, after adjustment for the respective baseline values and confounders, nonsignificant treatment effects were found for the VAS-ADL (–2.0 [95% CI, –11.3 to 7.3]; P = .665) and VAS-sports (1.3 [95% CI, –12.8 to 15.3], P = .858). The EQ-5D subscales improved in both groups. After 1 year, significantly more SG participants considered themselves improved (77.3% [SG] vs 50.0% [AG]; P = .04).

Conclusion:

No differences in clinical effects were found between Alfredson and Silbernagel loading at up to 1-year follow-up. Both programs significantly improved clinical symptoms, and given their high adherence rates, offering either of them as a home-based program with limited supervision appears to be an effective treatment strategy for midportion AT.

Registration:

NTR5638 (Netherlands Trial Register number).

Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: A narrative review

Tendinopathy is a chronic degenerative musculoskeletal disorder that is common in both athletes and the general population. Exercise and extracorporeal shockwave therapy (ESWT) is among the most common treatments used to mediate tendon healing and regeneration. The review presents the current understanding of mechanisms of action of ESWT and exercise in isolation and briefly synthesises evidence of their effectiveness for various tendinopathies. The central purpose of the review is to synthesize research findings investigating the combination of ESWT and exercise for five common tendinopathies (plantar heel pain, rotator cuff, lateral elbow, Achilles, and patellar tendinopathy) and provide recommendations on clinical applicability. Collectively, the available evidence indicates that ESWT combined with exercise in the form of eccentric training, tissue-specific stretching, or heavy slow resistance training are effective for specific tendinopathies and can therefore be recommended in treatment. Whilst there are at present a limited number of studies investigating combined EWST and exercise approaches, there is evidence to suggest that the combination improves outcomes in the treatment of plantar heel pain, Achilles, lateral elbow, and rotator cuff tendinopathy. However, despite overall positive outcomes in patellar tendinopathy, the combined treatment has not been shown at present to offer additional benefit over eccentric exercise alone.

Psychological Factors Change During the Rehabilitation of an Achilles Tendon Rupture: A Multicenter Prospective Cohort Study

OBJECTIVE

The authors sought to gain insight into the changes in psychological factors during rehabilitation after Achilles tendon rupture (ATR) and to explore the association between psychological factors during rehabilitation and functional outcome 12 months after ATR.

METHODS

Fifty patients clinically diagnosed with ATR were invited to visit the hospital 3, 6, and 12 months after injury for data collection. They completed questionnaires assessing psychological factors: psychological readiness to return to sport (Injury Psychological Readiness to Return to Sport Questionnaire); kinesiophobia (Tampa Scale for Kinesiophobia); expectations, motivation, and outcome measures related to symptoms and physical activity (Achilles Tendon Total Rupture Score); and sports participation and performance (Oslo Sports Trauma Research Centre Overuse Injury Questionnaire). To determine whether psychological factors changed over time, generalized estimating equation analyses were performed. Multivariate regression analyses were used to study the association between psychological factors at 3, 6, and 12 months and outcome measures at 12 months after ATR.

RESULTS

Psychological readiness to return to sport improved, and kinesiophobia decreased significantly during rehabilitation. Psychological readiness at 6 and 12 months showed significant associations with sports participation and performance. Kinesiophobia at 6 months was significantly associated with symptoms and physical activity. Motivation remained high during rehabilitation and was highly associated with symptoms and physical activity, sports participation, and performance.

CONCLUSION

Psychological factors change during rehabilitation after ATR. Patients with lower motivation levels during rehabilitation, low psychological readiness to return to sports, and/or high levels of kinesiophobia at 6 months after ATR need to be identified.

IMPACT

According to these results, psychological factors can affect the rehabilitation of patients with ATR. Physical therapists can play an important role in recognizing patients with low motivation levels and low psychological readiness for return to sport and patients with high levels of kinesiophobia at 6 months post-ATR. Physical therapist interventions to enhance motivation and psychological readiness to return to sport and to reduce kinesiophobia need to be developed and studied in the post-ATR population.

LAY SUMMARY

With Achilles tendon rupture, level of motivation, psychological readiness for return to sport, and fear of movement can affect rehabilitation outcome. A physical therapist can help recognize these factors.

Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy

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.

Autoregulation in Resistance Training for Lower Limb Tendinopathy: A Potential Method for Addressing Individual Factors, Intervention Issues, and Inadequate Outcomes

Musculoskeletal disorders, such as tendinopathy, are placing an increasing burden on society and health systems. Tendinopathy accounts for up to 30% of musculoskeletal disorders, with a high incidence in athletes and the general population. Although resistance training has shown short-term effectiveness in the treatment of lower limb tendinopathy, more comprehensive exercise protocols and progression methods are required due to poor long-term outcomes. The most common resistance training protocols are predetermined and standardized, which presents significant limitations. Current standardized protocols do not adhere to scientific resistance training principles, consider individual factors, or take the importance of individualized training into account. Resistance training programs in case of tendinopathy are currently not achieving the required intensity and dosage, leading to high recurrence rates. Therefore, better methods for individualizing and progressing resistance training are required to improve outcomes. One potential method is autoregulation, which allows individuals to progress training at their own rate, taking individual factors into account. Despite the finding of their effectiveness in increasing the strength of healthy athletes, autoregulation methods have not been investigated in case of tendinopathy. The purpose of this narrative review was 3-fold: firstly, to give an overview and a critical analysis of the individual factors involved in tendinopathy and current resistance training protocols and their limitations. Secondly, to give an overview of the history, methods, and application of autoregulation strategies both in sports performance and physiotherapy. Finally, a theoretical adaptation of a current tendinopathy resistance training protocol using autoregulation methods is presented, providing an example of how the method could be implemented in clinical practice or future research.

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

OBJECTIVE

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

DESIGN

Cross-sectional study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Achilles Scraping and Plantaris Tendon Removal Improves Pain and Tendon Structure in Patients with Mid-Portion Achilles Tendinopathy-A 24 Month Follow-Up Case Series

Background: Studies have demonstrated that a sub-group of patients with medial Achilles pain exhibit Achilles tendinopathy with plantaris tendon involvement. This clinical condition is characterised by structural relationships and functional interference between the two tendons, resulting in compressive or shearing forces. Surgical plantaris tendon removal together with an Achilles scraping procedure has demonstrated positive short-term clinical results. The aim of this case series was to determine the long-term outcomes on pain and Achilles tendon structure. Methods: 18 consecutive patients (13 males; 5 females; mean age 39 years; mean symptom duration 28 months), of which three were elites, were included. Clinical examination, b-mode ultrasound (US) and Ultrasound Tissue Characterisation (UTC) confirmed medial Achilles tendon pain and tenderness, medial Achilles tendinopathy plus a plantaris tendon located close to the medial side of the Achilles tendon. Patients underwent US-guided local Achilles scraping and plantaris tendon removal followed by a structured rehabilitation program. Outcomes were VISA-A score for pain and function and UTC for Achilles structure. Results: 16 of 18 patients completed the 24 months follow-up. Mean VISA-A scores increased from 58.2 (±15.9) to 92.0 (±9.2) (mean difference = 33.8, 95% CI 25.2, 42.8, p < 0.01). There was an improvement in Achilles structure with mean organised echo pixels (UTC type I+II, in %) increasing from 79.9 (±11.5) to 86.4 (±10.0) (mean difference = 6.5%, 95% CI 0.80, 13.80, p =0.01), exceeding the 3.4% minimum detectable change. All 16 patients reported satisfaction with the procedure and 14 returned to pre-injury activity levels. There were no reported complications. Conclusions: Improved pain, function and tendon structure were observed 24 months after treatment with Achilles scraping and plantaris excision. The improvement in structure on the medial side of the Achilles after plantaris removal indicates that compression from the plantaris tendon might be an important presenting factor in this sub-group.

Effects of kinesiophobia and pain on performance and willingness to perform jumping tests in Achilles tendinopathy: A cross-sectional study

OBJECTIVES

Fear of movement may be a source of systemic bias in studies reporting functional deficits in patients with Achilles tendinopathy. The purpose of this study was to assess the effects of kinesiophobia on completion rate and performance on tests evaluating lower extremity function, while controlling for self-reported pain.

DESIGN

Cross-sectional study; SETTING: Tendon research laboratory.

PARTICIPANTS

Ninety-four participants with Achilles tendinopathy.

MAIN OUTCOME MEASURES

Completion (yes/no) and performance (cm) on the counter-movement jump, hopping, and drop counter-movement jump.

RESULTS

The models fit the data (R^2 = 0.81, both models). TSK score did not predict completion (beta = -0.01, 95% CI = -0.13 - 0.09, P = 0.74) but pain did (beta = -0.36, 95% CI = -0.53 to -0.19, P < 0.0001). TSK score did not predict performance (beta = -0.06, 95% CI = -0.14 - 0.003, P = 0.07), but pain did (beta = -0.15, 95% CI = -0.22 to -0.07, P < 0.0001).

CONCLUSIONS

Kinesiophobia did not affect the physical performance tests in patients with Achilles tendinopathy. Measures of physical performance should be interpreted alongside self-reported pain.

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

OBJECTIVE

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

DESIGN

cross-sectional study.

SETTING

online survey platform.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Are pain coping strategies and neuropathic pain associated with a worse outcome after conservative treatment for Achilles tendinopathy? A prospective cohort study

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.

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

BACKGROUND

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

PURPOSE/HYPOTHESIS

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

STUDY DESIGN

Randomized clinical trial; Level of evidence, 1.

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

NCT03096067 (ClinicalTrials.gov identifier).