The Acute Transverse Strain Response of the Patellar Tendon to Quadriceps Exercise

Effect of applied cadence in repeated sprint cycling on muscle characteristics

PURPOSE

This study aimed to investigate physiological responses, muscle-tendon unit properties of the quadriceps muscle, and mechanical performance after repeated sprint cycling at optimal and 70% of optimal cadence.

METHODS

Twenty recreational cyclists performed as first sprint performance cycling test and during subsequent sessions two repeated sprint cycling protocols at optimal and 70% of optimal cadence, in random order. The muscle-tendon unit outcome measures on the dominant leg included muscle thickness, fascicle length (Lf), pennation angle (θp), and stiffness for the rectus femoris (RF), vastus lateralis (VL), and vastus medialis muscle (VM) at baseline, immediately after repeated sprint cycling, and 1-h post-exercise.

RESULTS

The results showed an increase in muscle thickness and θp in RF, VL, and VM for both cadences from baseline to immediately after exercise. The Lf decreased in RF (both cadences), while stiffness decreased in RF, VL, and VM at optimal cadence, and in VL at 70% of optimal cadence from baseline to immediately after exercise.

CONCLUSION

The present study revealed that the alterations in muscle characteristics were more marked after repeated sprint cycling at optimal cadence compared with a lower cadence most likely as a result of higher load on the muscle-tendon unit at optimal cadence.

Exploring the role of intratendinous pressure in the pathogenesis of tendon pathology: a narrative review and conceptual framework

Despite the high prevalence of tendon pathology in athletes, the underlying pathogenesis is still poorly understood. Various aetiological theories have been presented and rejected in the past, but the tendon cell response model still holds true. This model describes how the tendon cell is the key regulator of the extracellular matrix and how pathology is induced by a failed adaptation to a disturbance of tissue homeostasis. Such failure has been attributed to various kinds of stressors (eg, mechanical, thermal and ischaemic), but crucial elements seem to be missing to fully understand the pathogenesis. Importantly, a disturbance of tissue pressure homeostasis has not yet been considered a possible factor, despite it being associated with numerous pathologies. Therefore, we conducted an extensive narrative literature review on the possible role of intratendinous pressure in the pathogenesis of tendon pathology. This review explores the current understanding of pressure dynamics and the role of tissue pressure in the pathogenesis of other disorders with structural similarities to tendons. By bridging these insights with known structural changes that occur in tendon pathology, a conceptual model was constituted. This model provides an overview of the possible mechanism of how an increase in intratendinous pressure might be involved in the development and progression of tendon pathology and contribute to tendon pain. In addition, some therapies that could reduce intratendinous pressure and accelerate tendon healing are proposed. Further experimental research is encouraged to investigate our hypotheses and to initiate debate on the relevance of intratendinous pressure in tendon pathology.

Quantitative Analysis of Patellar Tendon After Total Knee Arthroplasty Using Echo Intensity: A Nonrandomized Controlled Trial of Alpine Skiing

BACKGROUND

Despite the knee extensor weakness, less attention has been paid to the evaluation of patellar tendon after total knee arthroplasty (TKA). We previously observed patellar tendon hypertrophy after TKA. The purpose of this study is to reanalyze these ultrasound data to detect whether brightness mode ultrasound imaging reflects pathological changes of the patellar tendon after TKA.

METHODS

Twenty-eight participants with post unilateral TKA were assigned to an intervention group or control group. The intervention group underwent a 12-week skiing program. Patellar tendon mechanical properties were obtained by combining isometric dynamometry, ultrasound imaging, and electromyography in operated knee and nonoperated knee. Luminosity ratio (LR) was measured using echo intensity in a relaxed and maximally loaded phase.

RESULTS

Baseline comparisons revealed significant effects of the surgical side (P < .001) and loading phase (P = .017), but no interaction between leg and phase (P < .149). LR of the operated knee was significantly lower than LR of the nonoperated knee in relaxed (P < .001) and maximally loaded phases (P = .003). In addition, there was a significant correlation between LR of maximum phase and isometric knee extension torque (r² = 0.156, P = .038). However, LR was not related to patellar tendon stiffness, Young's modulus, or strain. There was a significant time effect in knee extension torque, but no time effects on LR and tendon force.

CONCLUSION

Patellar tendon LR is decreased along with degenerative change after TKA. Ultrasound imaging provides a promising metric to acquire in vivo patellar tendon pathological assessment after TKA.

Immediate and Short-Term Effects of Short- and Long-Duration Isometric Contractions in Patellar Tendinopathy

OBJECTIVES

Isometric muscle contractions are used in the management of patellar tendinopathy to manage pain and improve function. Little is known about whether long- or short-duration contractions are optimal to improve pain. This study examined the immediate and short-term (4 weeks) effects of long- and short-duration isometric contraction on patellar tendon pain, and tendon adaptation.

DESIGN

Repeated measures within groups.

SETTING

Clinical primary care.

PATIENTS

Participants (n = 16, males) with patellar tendinopathy.

INTERVENTION

Short-duration (24 sets of 10 seconds) or long-duration (6 sets of 40 seconds) isometric knee extension loading (85% maximal voluntary contraction), for 4 weeks.

MAIN OUTCOME MEASURE

Immediate change in pain with single-leg decline squat (SLDS) and hop, as well as change in pain and tendon adaptation [within-session anterior-posterior (AP) strain] were assessed over 4 weeks.

RESULTS

Pain was significantly reduced after isometric loading on both SLDS (P < 0.01) and hop tests (P < 0.01). Pain and quadriceps function improved over the 4 weeks (P < 0.05). There was significant AP strain at each measurement occasion (P < 0.01). Although transverse strain increased across the training period from ∼14% to 22%, this was not significant (P = 0.08).

CONCLUSIONS

This is the first study to show that short-duration isometric contractions are as effective as longer duration contractions for relieving patellar tendon pain when total time under tension is equalized. This finding provides clinicians with greater options in prescription of isometric loading and may be particularly useful among patients who do not tolerate longer duration contractions. The trend for tendon adaptation over the short 4-week study period warrants further investigation.

Tendon morphological changes after a prolonged ski race can be detected by ultrasound echo intensity

BACKGROUND

Ultrasound imaging techniques have been used to assess the characteristics of skeletal muscles and tendons. Such techniques (gray scale analysis) allow qualitative evaluation and have been used recently to assess the internal structure of muscles and tendons by computer-aided gray scale analysis. We hypothesized that changes in the internal structure of the Achilles and patellar tendons after a ski mountaineering race competition could be detected with ultrasound.

METHODS

Twenty athletes were recruited during the 19th Millet Tour du Rutor extreme, a three-day ski mountaineering competition. Ultrasound measurements of the Achilles and patellar tendons were carried out before the first race and immediately after each of the three competition days. Tendon thickness, cross-sectional area (CSA), and ultrasound gray scale analysis were calculated.

RESULTS

Significant differences (p < 0.05) were observed between the pre- and post-race measurements for the Achilles tendon thickness and CSA, while no significant differences were noted for the patellar tendon thickness and CSA. However, gray scale analysis of both the Achilles and patellar tendons showed significantly higher post-race values, than the pre-race values (p < 0.05).

CONCLUSIONS

Achilles and patellar tendons of healthy athletes are highly responsive to an acute increase in mechanical load. Those changes can be detected from classical (thickness and CSA) and innovative (gray scale) ultrasound-based parameters.

TRIAL REGISTRATION

This study was approved by the Azienda USL Valle d'Aosta Ethics Committee (protocol no. 23/03/2018.0026243.I).

Mechanical properties and collagen fiber orientation of tendon in young and elderly

BACKGROUND

The purpose of this study was to investigate differences in the mechanical properties and collagen fiber orientation of tendon structures between young and elderly groups.

METHODS

The mechanical properties of tendon structures in medial gastrocnemius muscle were measured using ultrasonography during ramp and ballistic contractions. Tendon collagen fiber orientation was estimated from coefficient of variation (CV) of echogenicity on transverse ultrasonic images of Achilles tendon.

FINDINGS

Differences in elongation between ramp and ballistic contractions of elderly were significantly smaller than those of young group at 20-80% of MVC. During ramp contraction, hysteresis of elderly was significantly higher than that of young, whereas no difference in hysteresis during ballistic contraction was found between the two groups. Difference in hysteresis between ramp and ballistic contractions of elderly tended to be lower than that of young group. Mean echogenicity of elderly was significantly higher than that of young group, whereas no difference in CV of echogenicity was found between the two groups.

INTERPRETATION

These results suggest that smaller differences in elongation and hysteresis between ramp and ballistic contractions of elderly may be related to decreased water content within tendons. Furthermore, no difference in collagen fiber orientation of tendons was noted between the two groups.

Does Magnetic Resonance Imaging Provide Superior Reliability for Achilles and Patellar Tendon Cross-Sectional Area Measurements Compared with Ultrasound Imaging?

This study investigated the reliability of Achilles and patellar tendon cross-sectional area (CSA) measurement using ultrasound imaging (USI) and magnetic resonance imaging (MRI). Fifteen healthy adults were imaged twice on two occasions, interrupted by a tendon loading protocol. Tendon CSA segmentations were conducted by an experienced and an inexperienced rater blinded to information regarding subject, session and loading status. USI provided good test-retest reliability (intra-class correlation coefficient [ICC] 2,1 > 0.85, standard error of measurement [SEM] 5%-6%), while with MRI it was excellent (ICC 2,1 > 0.92, SEM 4%) for the experienced rater. This study suggests that MRI provides superior reliability for tendon CSA measurements compared with USI. However, the difference in reliability between the methods was small, and the results were inconclusive regarding objectivity and sensitivity to change when assessed based on the effect of loading. We concluded that both methods can be used for reliable CSA measurements of the Achilles and patellar tendons when using a highly standardized measurement protocol and when conducted by an experienced rater.

Effects of static stretching on mechanical properties and collagen fiber orientation of the Achilles tendon in vivo

BACKGROUND

The study was designed to examine changes in tendon properties measured during ramp and ballistic contractions after static stretching and to elucidate the relationship between stretching-induced changes in tendon properties (particularly hysteresis) and collagen fiber orientation.

METHODS

Thirteen males performed static stretching, in which the ankle was passively flexed to 36° dorsiflexion and remained stationary for 10 min. Before and after stretching, the stiffness and hysteresis of tendon structures in the medial gastrocnemius muscle were measured using ultrasonography during ramp and ballistic contractions. Tendon collagen fiber orientation was also estimated from the coefficient of variation (CV) of echogenicity on transverse ultrasonic images of the Achilles tendon.

FINDINGS

The hysteresis of tendon structures significantly decreased by 15.5% (p = 0.005) during ramp contractions and by 15.3% (p = 0.003) during ballistic contractions after stretching, whereas stiffness did not. The mean echogenicity of the Achilles tendon significantly increased by 6.0% (p = 0.002) after stretching, whereas the CV of echogenicity did not (p = 0.148). Furthermore, the relative change in mean echogenicity, which reflected interstitial fluid movement within tendons, tended to be correlated to that in hysteresis measured during ballistic contractions (r = 0.439, p = 0.133).

INTERPRETATION

These results suggest that the hysteresis, but not stiffness, of tendon structures measured during ramp and ballistic contractions significantly decreased after stretching. Furthermore, a decline in the hysteresis of tendon structures after static stretching was associated with interstitial fluid movement within tendons, but not to changes in collagen fiber orientation.

Changes in tendon spatial frequency parameters with loading

To examine and compare the loading related changes in micro-morphology of the patellar tendon. Fifteen healthy young males (age 19±3yrs, body mass 83±5kg) were utilised in a within subjects matched pairs design. B mode ultrasound images were taken in the sagittal plane of the patellar tendon at rest with the knee at 90° flexion. Repeat images were taken whilst the subjects were carrying out maximal voluntary isometric contractions. Spatial frequency parameters related to the tendon morphology were determined within regions of interest (ROI) from the B mode images at rest and during isometric contractions. A number of spatial parameters were observed to be significantly different between resting and contracted images (Peak spatial frequency radius (PSFR), axis ratio, spatial Q-factor, PSFR amplitude ratio, and the sum). These spatial frequency parameters were indicative of acute alterations in the tendon micro-morphology with loading. Acute loading modifies the micro-morphology of the tendon, as observed via spatial frequency analysis. Further research is warranted to explore its utility with regard to different loading induced micro-morphological alterations, as these could give valuable insight not only to aid strengthening of this tissue but also optimization of recovery from injury and treatment of conditions such as tendinopathies.

Immediate effects of whole body vibration on patellar tendon properties and knee extension torque

PURPOSE

Reports about the immediate effects of whole body vibration (WBV) exposure upon torque production capacity are inconsistent. However, the changes in the torque-angle relationship observed by some authors after WBV may hinder the measurement of torque changes at a given angle. Acute changes in tendon mechanical properties do occur after certain types of exercise but this hypothesis has never been tested after a bout of WBV. The purpose of the present study was to investigate whether tendon compliance is altered immediately after WBV, effectively shifting the optimal angle of peak torque towards longer muscle length.

METHODS

Twenty-eight subjects were randomly assigned to either a WBV (n = 14) or a squatting control group (n = 14). Patellar tendon CSA, stiffness and Young's modulus and knee extension torque-angle relationship were measured using ultrasonography and dynamometry 1 day before and directly after the intervention. Tendon CSA was additionally measured 24 h after the intervention to check for possible delayed onset of swelling.

RESULTS

The vibration intervention had no effects on patellar tendon CSA, stiffness and Young's modulus or the torque-angle relationship. Peak torque was produced at ~70° knee angle in both groups at pre- and post-test. Additionally, the knee extension torque globally remained unaffected with the exception of a small (-6%) reduction in isometric torque at a joint angle of 60°.

CONCLUSION

The present results indicate that a single bout of vibration exposure does not substantially alter patellar tendon properties or the torque-angle relationship of knee extensors.

Tendinopathy alters ultrasound transmission in the patellar tendon during squatting

Measurement of loading patterns of the patellar tendon during activity is important in understanding tendon injury. We used transmission-mode ultrasonography to investigate patellar tendon loading during squatting in adults with and without tendinopathy. It was hypothesized that axial ultrasonic velocity, a surrogate measure of the elastic modulus of tendon, would be lower in tendinopathy. Ultrasound velocity was measured in both patellar tendons of adults with unilateral patellar tendinopathy (n = 9) and in healthy controls (n = 16) during a bilateral squat maneuver. Sagittal knee movement was measured simultaneously with an electrogoniometer. Statistical comparisons between healthy and injured tendons were made using two-way mixed-design ANOVAs. Axial ultrasound velocity in both symptomatic and asymptomatic patellar tendons in tendinopathy was approximately 15% higher than in healthy tendons at the commencement (F_1,23  = 5.2, P < 0.05) and completion (F_1,23  = 4.5, P < 0.05) of the squat. While peak velocity was ≈5% higher during both flexion (F_1,23  = 5.4, P < 0.05) and extension (F_1,23  = 5.3, P < 0.05) phases, there was no significant between-group difference at the midpoint of the movement. There were no significant differences in the rate and magnitude of knee movement between groups. Although further research is required, these findings suggest enhanced baseline muscle activity in patellar tendinopathy and highlight fresh avenues for its clinical management.

Achilles tendon structure improves on UTC imaging over a 5-month pre-season in elite Australian football players

Pre-season injuries are common and may be due to a reintroduction of training loads. Tendons are sensitive to changes in load, making them vulnerable to injury in the pre-season. This study investigated changes in Achilles tendon structure on ultrasound tissue characterization (UTC) over the course of a 5-month pre-season in elite male Australian football players. Eighteen elite male Australian football players with no history of Achilles tendinopathy and normal Achilles tendons were recruited. The left Achilles tendon was scanned with UTC to quantify the stability of the echopattern. Participants were scanned at the start and completion of a 5-month pre-season. Fifteen players remained asymptomatic over the course of the pre-season. All four echo-types were significantly different at the end of the pre-season, with the overall echopattern suggesting an improvement in Achilles tendon structure. Three of the 18 participants developed Achilles tendon pain that coincided with a change in the UTC echopattern. This study demonstrates that the UTC echopattern of the Achilles tendon improves over a 5-month pre-season training period, representing increased fibrillar alignment. However, further investigation is needed to elucidate with this alteration in the UTC echopattern results in improved tendon resilience and load capacity.