Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (the HEALTHY trial): study protocol for a randomised trial

The current status of various preclinical therapeutic approaches for tendon repair

Tendons are fibroblastic structures that link muscle and bone. There are two kinds of tendon injuries, including acute and chronic. Each form of injury or deterioration can result in significant pain and loss of tendon function. The recovery of tendon damage is a complex and time-consuming recovery process. Depending on the anatomical location of the tendon tissue, the clinical outcomes are not the same. The healing of the wound process is divided into three stages that overlap: inflammation, proliferation, and tissue remodeling. Furthermore, the curing tendon has a high re-tear rate. Faced with the challenges, tendon injury management is still a clinical issue that must be resolved as soon as possible. Several newer directions and breakthroughs in tendon recovery have emerged in recent years. This article describes tendon injury and summarizes recent advances in tendon recovery, along with stem cell therapy, gene therapy, Platelet-rich plasma remedy, growth factors, drug treatment, and tissue engineering. Despite the recent fast-growing research in tendon recovery treatment, still, none of them translated to the clinical setting. This review provides a detailed overview of tendon injuries and potential preclinical approaches for treating tendon injuries.

Where is Your Pain? Achilles Tendinopathy Pain Location on Loading Is Different to Palpation, Imaging and Recall Location

OBJECTIVE: To describe and compare pain maps reported during Achilles tendon loading exercises with recall pain location, in people with pain on palpation in their Achilles tendon and tendon pathology on imaging. DESIGN: Cross-sectional analysis of baseline RCT. METHOD: Participants were recruited from a larger Achilles tendinopathy clinical trial. Inclusion criteria were at least 2-month self-reported history of Achilles tendinopathy, midtendon palpation pain, and pathology on ultrasound tissue characterization. Participants were asked to identify their Achilles tendon pain location on a pain map with 8 prespecified locations while at rest prior to loading (recall pain), and subsequently during tendon loading exercises (loading pain). Participants could select multiple locations or select "other" if the locations did not represent their pain. RESULTS: Ninety-three participants were included (93% of participants from a clinical trial). The locations of pain on loading were diverse; all 8 pain locations (and an "other" option) were represented within this sample. Twenty-five percent of participants did not report pain with loading (n = 23 of 93). Of the 70 participants with loading pain, recall pain location differed to loading pain location in 40% (n = 28 of 70) of the participants. CONCLUSION: Palpation pain location, recall pain location, or location of pathology on imaging were not valid proxies for load-related pain in the Achilles tendon. How different pain locations respond to treatment is unknown. Some pathologies (eg, plantaris) have clear pain locations (eg, medial tendon), and assessing pain location may assist differential diagnosis. J Orthop Sports Phys Ther 2024;54(1):1-9. Epub 7 December 2023. doi:10.2519/jospt.2023.12131.

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.

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

OBJECTIVES

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (registration number: CRD42020149970).

Ultrasound-Guided Percutaneous Needle Electrolysis Combined With Therapeutic Exercise May Add Benefit in the Management of Soleus Injury in Female Soccer Players: A Pilot Study

CONTEXT

The performance of sprints during male soccer matches usually is slow medium paced, where the soleus and gastrocnemius (ankle plantar flexors) play a very important role. As in male soccer, soleus injuries should be considered in female soccer; but the scientific evidence is very limited in this case.

DESIGN

Pilot clinical trial study.

OBJECTIVE

To determine whether adding an ultrasound-guided percutaneous needle electrolysis (US-guided PNE) technique to a specific exercise program improved perceived pain at stretching and at palpation, ankle dorsiflexion range of motion, muscle fatigue, and sport performance in women soccer players with soleus injury.

METHODS

This pilot study recruited 20 female players with chronic soleus injury (type 1, characterized by hypoechoic image) who were assigned to one of 2 groups: an experimental group (exercise program + US-guided PNE; n = 10) or a control group (exercise program + sham stimulation; n = 10). Pain intensity, dorsiflexion range of motion, knee-flexion heel raise test, curve sprint test, and the global rating of change scale were analyzed at baseline and after treatment (4 wk) and there was no further follow-up.

RESULTS

Pain intensity at palpation and at stretching, dorsiflexion range of motion, and heel raise test values showed significant improvements (P < .05) between pretreatment and posttreatment for both groups, however, no significant differences were observed between groups. Curve sprint tests did not show significant differences between pretreatment and posttreatment for either group or between groups. However, the percentage of changes always revealed better values in favor of the PNE group. Both groups showed good player satisfaction with the therapies.

CONCLUSION

The application of the US-guided PNE combined with a specific exercise program may cause clinical benefits in the treatment of female soccer players with soleus injury.

Evaluating lower limb tendinopathy with Victorian Institute of Sport Assessment (VISA) questionnaires: a systematic review shows very-low-quality evidence for their content and structural validity-part I

PURPOSE

The Victorian Institute of Sport Assessment (Achilles tendon-VISA-A, greater trochanteric pain syndrome-VISA-G, proximal hamstring tendinopathy-VISA-H, patellar tendon-VISA-P) questionnaires are widely used in research and clinical practice; however, no systematic reviews have formally evaluated their content, structural, and cross-cultural validity evidence. The measurement properties referring to content, structural and cross-cultural validity of the VISA questionnaires were appraised and synthesized.

METHODS

The systematic review was conducted according to Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology. PubMed, Cochrane, CINAHL, EMBASE, Web of Science, SportsDiscus, grey literature, and reference lists were searched. Development studies and cross-cultural adaptations (12 languages) assessing content or structural validity of the VISA questionnaires were included and two reviewers assessed their methodological quality. Evidence for content (relevance, comprehensiveness, and comprehensibility), structural, and cross-cultural validity was synthesized. A modified Grading of Recommendations Assessment Development and Evaluation (GRADE) approach was applied to evidence synthesis.

RESULTS

The VISA-A presented very-low-quality evidence of sufficient relevance, insufficient comprehensiveness, and inconsistent comprehensibility. VISA-G displayed moderate-quality evidence for sufficient comprehensibility and very-low-quality evidence of sufficient relevance and comprehensiveness. The VISA-P presented very-low-quality evidence of sufficient relevance, insufficient comprehensiveness, and inconsistent comprehensibility, while VISA-H presented very-low evidence of insufficient content validity. VISA-A displayed low-quality evidence for structural validity concerning unidimensionality and internal structure, while VISA-H presented low-quality evidence of insufficient unidimensionality. The structural validity of VISA-G and VISA-P were indeterminate and inconsistent, respectively. Internal consistency for VISA-G, VISA-H, and VISA-P was indeterminate. No studies evaluated cross-cultural validity, while measurement invariance across sexes was assessed in one study.

CONCLUSIONS

Only very-low-quality evidence exists for the content and structural validity of VISA questionnaires when assessing the severity of symptoms and disability in patients with lower limb tendinopathies.

LEVEL OF EVIDENCE

IV.

REGISTRATION

PROSPERO reference-CRD42019126595.

Management of Achilles and patellar tendinopathy: what we know, what we can do

Tendinopathies are challenging conditions frequent in athletes and in middle-aged overweight patients with no history of increased physical activity. The term “tendinopathy” refers to a clinical condition characterised by pain, swelling, and functional limitations of tendons and nearby structures, the effect of chronic failure of healing response. Tendinopathies give rise to significant morbidity, and, at present, only limited scientifically proven management modalities exist. Achilles and patellar tendons are among the most vulnerable tendons, and among the most frequent lower extremity overuse injuries. Achilles and patellar tendinopathies can be managed primarily conservatively, obtaining good results and clinical outcomes, but, when this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions, and, if performed well, they lead to a relatively high rate of success with few complications. The purpose of this narrative review is to critically examine the recent available scientific literature to provide evidence-based opinions on these two common and troublesome conditions.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial

OBJECTIVES

To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy.

METHODS

This was a parallel-group randomised superiority trial at a single centre (La Trobe University Health Sciences Clinic, Discipline of Podiatry, Melbourne, Victoria, Australia). One hundred participants (52 women and 48 men, mean age 45.9, SD 9.4 years) with clinically diagnosed and ultrasonographically confirmed mid-portion Achilles tendinopathy were randomly allocated to either a (1) heel lifts (n=50) or (2) eccentric exercise (n=50) group. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 12 weeks. Differences between groups were analysed using intention to treat with analysis of covariance.

RESULTS

There was 80% follow-up of participants (n=40 per group) at 12 weeks. The mean VISA-A score improved by 26.0 points (95% CI 19.6 to 32.4) in the heel lifts group and by 17.4 points (95% CI 9.5 to 25.3) in the eccentric exercise group. On average, there was a between-group difference in favour of the heel lifts for the VISA-A (adjusted mean difference 9.6, 95% CI 1.8 to 17.4, p=0.016), which approximated, but did not meet our predetermined minimum important difference of 10 points.

CONCLUSION

In adults with mid-portion Achilles tendinopathy, heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks. However, there is uncertainty in the estimate of effect for this outcome and patients may not experience a clinically worthwhile difference between interventions.

TRIAL REGISTRATION NUMBER

ACTRN12617001225303.

Ultrasound-Guided Percutaneous Needle Electrolysis in Dancers with Chronic Soleus Injury: A Randomized Clinical Trial

Damage to intramuscular tendons is very common in sports injuries, specifically in soleus muscle injuries. This study sought to compare the effects of applying ultrasound- (US-) guided percutaneous needle electrolysis (PNE) in combination with an eccentric exercise program on pain and functionality in dancers with chronic soleus injury, located in the central tendon. Thirty dancers with injured central tendon of the soleus muscle were randomly allocated to a PNE group (n = 10), an eccentric exercise group (n = 10), or a combined group (n = 10). Pain, ankle dorsiflexion range of motion (DROM), endurance, the heel raise test, the DFOS questionnaire, and the minimal clinically important difference (MCID) were analyzed at baseline and after treatment (four weeks). Over half (52%) of the dancers had a chronic soleus muscle injury. Variables for pain, DROM, the heel rise test, ADL, technique, DFOS total, and DFOS-subjective variables showed significant differences (P < 0.05) in pretreatment and posttreatment in all groups, whereas no significant differences were observed between intervention groups. However, the combined group showed a higher percentage of changes compared to the other groups, and these dancers had greater perceived changes (MCID = 4.70 ± 1.42). The conclusion of the study was that dancers with chronic soleus injury, located in the central tendon, treated with a combination of US-guided PNE and an eccentric exercise program displayed improved outcomes compared to the application of PNE therapy or eccentric exercise alone. The US-guided PNE, combined with an eccentric exercise program, is a useful therapeutic tool for the treatment of chronic soleus injury, located in the central tendon. The trial is registered with NCT04042012.