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Sara LK, Gutsch SB, Bement MH, Hunter SK. Plantar Flexor Weakness and Pain Sensitivity Cannot Be Assumed in Midportion Achilles Tendinopathy. EXERCISE, SPORT, & MOVEMENT 2023; 1:1-7. [PMID: 38222444 PMCID: PMC10786321 DOI: 10.1249/esm.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Introduction/Purpose The purpose of this study was to determine the following in persons with midportion Achilles tendinopathy (AT): 1) maximal strength and power; 2) neural drive during maximal contractions and contractile function during electrically evoked resting contractions; and 3) whether pain, neural drive, and contractile mechanisms contribute to differences in maximal strength. Methods Twenty-eight volunteers (14 AT, 14 controls) completed isometric, concentric, and eccentric maximal voluntary contractions (MVCs) of the plantar flexors in a Biodex™ dynamometer. Supramaximal electrical stimulation of the tibial nerve was performed to quantify neural drive and contractile properties of the plantar flexors. Pain sensitivity was quantified as the pressure-pain thresholds of the Achilles tendon, medial gastrocnemius, and upper trapezius. Results There were no differences in plantar flexion strength or power between AT and controls (isometric MVC: P = 0.95; dynamic MVC: P = 0.99; power: P = 0.98), nor were there differences in neural drive and contractile function (P = 0.55 and P = 0.06, respectively). However, the mechanisms predicting maximal strength differed between groups: neural drive predicted maximal strength in controls (P = 0.02) and contractile function predicted maximal strength in AT (P = 0.001). Although pain did not mediate these relationships (i.e., between maximal strength and its contributing mechanisms), pressure-pain thresholds at the upper trapezius were higher in AT (P = 0.02), despite being similar at the calf (P = 0.24) and Achilles tendon (P = 0.40). Conclusions There were no deficits in plantar flexion strength or power in persons with AT, whether evaluated isometrically, concentrically, or eccentrically. However, the mechanisms predicting maximal plantar flexor strength differed between groups, and systemic pain sensitivity was diminished in AT.
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Affiliation(s)
- Lauren K Sara
- Harvard Medical School, Cambridge, MA, USA
- Department of Physical Therapy, Marquette University, Milwaukee, WI, USA
| | - Savannah B Gutsch
- Department of Physical Therapy, Marquette University, Milwaukee, WI, USA
| | | | - Sandra K Hunter
- Department of Physical Therapy, Marquette University, Milwaukee, WI, USA
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Janowski AJ, Post AA, Heredia-Rizo AM, Mosby H, Dao M, Law LF, Bayman EO, Wilken JM, Sluka KA, Chimenti RL. Patterns of movement-evoked pain during tendon loading and stretching tasks in Achilles tendinopathy: A secondary analysis of a randomized controlled trial. Clin Biomech (Bristol, Avon) 2023; 109:106073. [PMID: 37657267 PMCID: PMC10543613 DOI: 10.1016/j.clinbiomech.2023.106073] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND This study aimed to characterize movement-evoked pain during tendon loading and stretching tasks in individuals with Achilles tendinopathy, and to examine the association between movement-evoked pain with the Achilles tendinopathy type (insertional and midportion), biomechanical, and psychological variables. METHODS In this laboratory-based, cross-sectional study, 37 individuals with chronic Achilles tendinopathy participated. Movement-evoked pain intensity (Numeric Rating Scale: 0 to 10) and sagittal-plane ankle biomechanics were collected simultaneously during standing, fast walking, single-leg heel raises, and weight-bearing calf stretch. Description of symptoms, including location of Achilles tendon pain and duration of tendon morning stiffness, as well as pain-related psychological measures, including the Tampa Scale of Kinesiophobia were collected. Linear mixed effects models were built around two paradigms of movement-evoked pain (tendon loading and stretching tasks) with each model anchored with pain at rest. FINDINGS Movement-evoked pain intensity increased as task demand increased in both models. Lower peak dorsiflexion with walking (β = -0.187, 95% CI: -0.305, -0.069), higher fear of movement (β = 0.082, 95% CI: 0.018, 0.145), and longer duration of tendon morning stiffness (β = 0.183, 95% CI: 0.07, 0.296) were associated with greater pain across tendon loading tasks (R2 = 0.47). Lower peak dorsiflexion with walking (β = -0.27, 95% CI: -0.41, -0.14), higher dorsiflexion with the calf stretch (β = 0.095, 95% CI: 0.02, 0.16), and insertional Achilles tendinopathy (β = -0.93, 95% CI: -1.65, -0.21) were associated with higher pain across tendon stretching tasks (R2 = 0.53). INTERPRETATION In addition to exercise, the ideal management of Achilles tendinopathy may require adjunct treatments to address the multifactorial aspects of movement-evoked pain.
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Affiliation(s)
- Adam J Janowski
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA.
| | - Andrew A Post
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Alberto M Heredia-Rizo
- Department of Physiotherapy, Faculty of Nursing, Physiotherapy, and Podiatry, University of Seville, Spain; Uncertainty, Mindfulness, Self, and Spirituality (UMSS) Research Group, Spain
| | - Hadley Mosby
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Megan Dao
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Laura Frey Law
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Emine O Bayman
- Department of Biostatistics and Department of Anesthesia, University of Iowa, Iowa City, IA, USA
| | - Jason M Wilken
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Kathleen A Sluka
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Ruth L Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
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Stania M, Pawłowski M, Marszałek W, Juras G, Słomka KJ, Król P. A preliminary investigation into the impact of shock wave therapy and sonotherapy on postural control of stepping tasks in patients with Achilles tendinopathy. Front Neurol 2023; 14:1157335. [PMID: 37332988 PMCID: PMC10272772 DOI: 10.3389/fneur.2023.1157335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
Objective The outcomes of physical therapy are commonly assessed with subjective scales and questionnaires. Hence, a continuous search to identify diagnostic tests that would facilitate objective assessment of symptom reduction in those patients with Achilles tendinopathy who undergo mechanotherapy. The main aim of this study was to evaluate and compare the effectiveness of shock wave and ultrasound treatments, using objective posturographic assessment during step-up and step-down initiation. Materials and methods The patients with non-insertional Achilles tendinopathy and pain lasting for more than 3 months were randomly assigned to one of the experimental groups, i.e., radial shock wave therapy (RSWT), ultrasound therapy, or placebo ultrasound. All groups also received deep friction massage as the primary therapy. The transitional locomotor task was performed with the affected and unaffected limb in random order, on two force platforms under two conditions (step-up and step-down). The recording of center of foot pressure displacements was divided into three phases: quiet standing before step-up/step-down, transit, and quiet standing until measurement completion. Pre-intervention measurements were performed and then short-term follow-ups at weeks 1 and 6 post-therapy. Results The three-way repeated measures ANOVA showed few statistically significant two-factor interactions between therapy type, time point of measurement and the type of the locomotor task. Significant increases in postural sway were observed in the entire study population throughout the follow-up period. Three-way ANOVAs revealed a group effect (shock wave vs. ultrasound) on almost all variables of the quiet standing phase prior to step-up/step-down initiation. Overall, postural stability before the step-up and step-down tasks appeared to be more efficient in patients who had undergone RSWT compared to the ultrasound group. Conclusion Objective posturographic assessment during step-up and step-down initiation did not demonstrate therapeutic superiority of any of the three therapeutic interventions used in patients with non-insertional Achilles tendinopathy.Clinical Trial Registration: The trial was prospectively registered in the Australian and New Zealand Clinical Trials Registry (no. ACTRN12617000860369; registration date: 9.06.2017).
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The Effects of Increasing Trunk Flexion During Stair Ascent on the Rate and Magnitude of Achilles Tendon Force in Asymptomatic Females. J Appl Biomech 2023; 39:10-14. [PMID: 36513076 DOI: 10.1123/jab.2022-0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/07/2022] [Accepted: 10/20/2022] [Indexed: 12/15/2022]
Abstract
Research indicates that increasing trunk flexion may optimize patellofemoral joint loading. However, this postural change could cause an excessive Achilles tendon force (ATF) and injury risk during movement. This study aimed to examine the effects of increasing trunk flexion during stair ascent on ATF, ankle biomechanics, and vertical ground reaction force in females. Twenty asymptomatic females (age: 23.4 [2.5] y; height: 1.6 [0.8] m; mass: 63.0 [12.2] kg) ascended stairs using their self-selected and flexed trunk postures. Compared with the self-selected trunk condition, decreases were observed for peak ATF (mean differences [MD] = 0.14 N/kg; 95% confidence interval [CI], 0.06 to 0.23; Cohen d = -1.2; P = .003), average rate of ATF development (MD = 0.25 N/kg/s; 95% CI, 0.07 to 0.43; Cohen d = -0.9; P = .010), ankle plantar flexion moment (MD = 0.08 N·m/kg; 95% CI, 0.03 to 0.13; Cohen d = -1.1; P = .005), and vertical ground reaction force (MD = 38.6 N/kg; 95% CI, 20.3 to 56.90; Cohen d = -1.8; P < .001). Increasing trunk flexion did not increase ATF. Instead, this postural change was associated with a decreased ATF rate and magnitude and may benefit individuals with painful Achilles tendinopathy.
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Plantarflexor neuromuscular performance in Insertional Achilles tendinopathy. Musculoskelet Sci Pract 2022; 62:102671. [PMID: 36219920 DOI: 10.1016/j.msksp.2022.102671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/08/2022] [Accepted: 09/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Insertional Achilles tendinopathy (IAT) is a common and painful musculoskeletal condition. The management of IAT commonly involves strengthening of the plantarflexors, although there is currently a paucity of research investigating plantarflexor neuromuscular performance specific to people with IAT. OBJECTIVES To compare plantarflexor neuromuscular performance between men with IAT and controls, and to investigate the relationship between plantarflexor neuromuscular performance and patient reported outcome measures for men with IAT. DESIGN Case control. METHOD 34 men with IAT (age 43.7 years [SD 10.02], weight 89.6 kg [16.3]) were matched with 34 healthy men (age 42.8 years [SD 8.9], weight 87.2 kg [9.7]). Participants underwent a plantarflexion maximal voluntary isometric contraction (MVIC) task, and a target force matching task. Neuromuscular variables from these tasks include; MVIC, rate of torque development (RTD), electromechanical delay (EMD), and muscle force steadiness. Participants also completed questionnaires regarding; pain and function, and psychological factors. RESULTS The IAT group had reduced MVIC (p < 0.01) and RTD, (p < 0.01) compared to controls, however no significant difference in plantarflexor force steadiness (p = 0.08), or EMD (p = 0.71) was observed. Low strength correlations were detected between the VISA-A and RTD (r = 0.37, p = 0.04), kinesiophobia and EMD (r = 0.45, p = 0.03). CONCLUSIONS This study established impairments in plantarflexor strength and RTD among people with IAT. Plantarflexor force steadiness and EMD is not altered in IAT, which is in contrast to evidence from mid-portion Achilles tendinopathy. Plantarflexor RTD was the only neuromuscular outcome measure linked to symptom severity, which may indicate it is an important rehabilitation finding.
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Grävare Silbernagel K, Malliaras P, de Vos RJ, Hanlon S, Molenaar M, Alfredson H, van den Akker-Scheek I, Antflick J, van Ark M, Färnqvist K, Haleem Z, Kaux JF, Kirwan P, Kumar B, Lewis T, Mallows A, Masci L, Morrissey D, Murphy M, Newsham-West R, Norris R, O'Neill S, Peers K, Sancho I, Seymore K, Vallance P, van der Vlist A, Vicenzino B. ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy. Sports Med 2022; 52:613-641. [PMID: 34797533 PMCID: PMC8891092 DOI: 10.1007/s40279-021-01588-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated. OBJECTIVE To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains. DESIGN Systematic review. DATA SOURCES Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series. RESULTS 9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain. CONCLUSION 233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures. PROSPERO REGISTRATION CRD42020156763.
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Affiliation(s)
- Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA.
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Robert-Jan de Vos
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Zuid-Holland, The Netherlands
| | - Shawn Hanlon
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Mitchel Molenaar
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jarrod Antflick
- Department of Bioengineering, School of Engineering, Imperial College, London, UK
| | - Mathijs van Ark
- Department of Physiotherapy, School of Health Care Studies, Hanze University of Applied Sciences and Peescentrum, Centre of Expertise Primary Care Groningen (ECEZG), Groningen, The Netherlands
| | | | - Zubair Haleem
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Arsenal Football Club, London, UK
| | - Jean-Francois Kaux
- Department of Physical and Rehabilitation Medicine and Sports Traumatology, University and University Hospital of Liège, Liège, Belgium
| | - Paul Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bhavesh Kumar
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Trevor Lewis
- Aintree University Hospital, Liverpool Foundation Trust, Liverpool, UK
| | - Adrian Mallows
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, UK
| | - Lorenzo Masci
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
| | - Myles Murphy
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Richard Newsham-West
- School of Allied Health, Department of Physiotherapy, La Trobe University, Melbourne, VIC, Australia
| | - Richard Norris
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- Liverpool University Hospitals, NHS Foundation Trust, Liverpool, UK
| | - Seth O'Neill
- School of Allied Health, University of Leicester, Leicester, UK
| | - Koen Peers
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Igor Sancho
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, University of Deusto, San Sebastian, Spain
| | - Kayla Seymore
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Patrick Vallance
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Clayton, VIC, Australia
| | - Arco van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, QLD, Australia
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Foot and Lower Limb Clinical and Structural Changes in Overuse Injured Recreational Runners Using Floating Heel Shoes: Preliminary Results of a Randomised Control Trial. SENSORS 2021; 21:s21237814. [PMID: 34883818 PMCID: PMC8659959 DOI: 10.3390/s21237814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/19/2021] [Accepted: 11/21/2021] [Indexed: 11/29/2022]
Abstract
Foot-strike and the associated load rate are factors related to overuse injuries in runners. The purpose of this study was to analyse structural and functional changes in runners using floating heel running shoes, compared with runners using conventional footwear. A randomised control trial was conducted. Twenty runners with overuse injuries were followed over a 12-week gait retraining programme using floating heel running shoes or their conventional footwear. Pain was measured with pressure pain thresholds (PPTs), structural changes were measured with ultrasonography, and severity and impact of injury was scored on the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O). Statistical differences were found between groups after the intervention (p < 0.001), with a medium size effect SE = 0.8, and the floating heel running shoes group reached higher PPTs values. Participants using floating heel running shoes showed higher OSTRC-O scores than those using their conventional footwear (p < 0.05), with higher scores after the intervention (p < 0.05). A 12-week gait retraining programme using floating heel running shoes had positive effects on the injury recovery process when compared to the use of conventional footwear, with significant differences in terms of pain and impact on sports activity.
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Are Plantarflexor Muscle Impairments Present Among Individuals with Achilles Tendinopathy and Do They Change with Exercise? A Systematic Review with Meta-analysis. SPORTS MEDICINE-OPEN 2021; 7:18. [PMID: 33689050 PMCID: PMC7947084 DOI: 10.1186/s40798-021-00308-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 02/14/2021] [Indexed: 01/22/2023]
Abstract
Background Understanding plantarflexor muscle impairments among individuals with Achilles tendinopathy (AT) may help to guide future research and inform clinical management of AT. Therefore, the aim of this review is to evaluate plantarflexor muscle impairments among individuals with AT and whether plantarflexor muscle function changes following resistance training interventions. Methods We searched relevant databases including Cochrane Central Register of Controlled Trials, Ovid (MEDLINE, EMBASE, AMED) and EBSCO (CINAHL Plus and SPORTDiscus) up to September 2020. Studies investigating plantarflexor muscle function were included if they met the following criteria: (1) any study design enabled comparison of plantarflexor muscle function between individuals with and without AT, or the affected and unaffected side of individuals with unilateral AT, and (2) any studies enabled investigation of change in plantarflexion muscle function over time with use of resistance training intervention. We included studies that recruited adults with either insertional or mid-portion AT of any duration. Study selection, quality assessment and data extraction were undertaken independently by two reviewers. Discrepancies were resolved via discussion, or by consulting a third reviewer where necessary. The Joanna Briggs Institute (JBI) critical appraisal tools specific to each study design were used to assess the methodological quality of included studies. Grading the strength of evidence for each outcome was determined according to the quality and number of studies. Results A total of 25 studies (545 participants) met inclusion. Participants’ mean age was 40 ± 7 years old. Six studies were high quality for all domains, while the remaining were susceptible to the risk of bias (e.g. selection criteria, reporting findings). This review identified moderate evidence that individuals with AT have impairment in maximal plantarflexor torque (seven studies including one with a mixed population) on their affected side, compared with the unaffected side. Impairments were modest (9% and 13% [pooled effect divided by mean of the unaffected side scores]) and of uncertain clinical importance. The remaining evidence, primarily among individuals with mid-portion AT, showed conflicting impairments for plantarflexor function (i.e. explosive strength and endurance) between sides. There was limited to very limited evidence for improvement in plantarflexor endurance (7% and 23%) but not power or strength (five studies including one with a mixed population for strength) over time, despite individuals undertaking several weeks of resistance training. Conclusions Plantarflexor impairments appear more common between sides than compared with control groups but given limitations in the literature further exploration of these relationships is needed. Registration PROSPERO Database; number CRD42019100747. Supplementary Information The online version contains supplementary material available at 10.1186/s40798-021-00308-8.
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Post AA, Rio EK, Sluka KA, Moseley GL, Bayman EO, Hall MM, de Cesar Netto C, Wilken JM, Danielson JF, Chimenti R. Effect of Pain Education and Exercise on Pain and Function in Chronic Achilles Tendinopathy: Protocol for a Double-Blind, Placebo-Controlled Randomized Trial. JMIR Res Protoc 2020; 9:e19111. [PMID: 33141102 PMCID: PMC7678911 DOI: 10.2196/19111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Achilles tendinopathy (AT) rehabilitation traditionally includes progressive tendon loading exercises. Recent evidence suggests a biopsychosocial approach that incorporates patient education on psychosocial factors and mechanisms of pain can reduce pain and disability in individuals with chronic pain. This is yet to be examined in individuals with AT. OBJECTIVE This study aims to compare the effects on movement-evoked pain and self-reported function of pain education as part of a biopsychosocial approach with pathoanatomical education for people with AT when combined with a progressive tendon loading exercise program. METHODS A single-site, randomized, double-blind, placebo-controlled clinical trial will be conducted in a university-based hospital in a laboratory setting and/or by telehealth. A total of 66 participants with chronic (>3 months) midportion or insertional AT will be randomized for the Tendinopathy Education of the Achilles (TEAch) study. All participants will complete progressive Achilles tendon loading exercises over 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. All participants will complete 6-7 one-to-one sessions with a physical therapist to progress exercises in a standardized manner over 8 weeks. During the last 4 weeks of the intervention, participants will be encouraged to maintain their home exercise program. Participants will be randomized to 1 of 2 types of education (pain education or pathoanatomic), in addition to exercise. Pain education will focus on the biological and psychological mechanisms of pain within a biopsychosocial framing of AT. Pathoanatomic education will focus on biological processes within a more traditional biomedical framework of AT. Evaluation sessions will be completed at baseline and 8-week follow-up, and self-reported outcome measures will be completed at the 12-week follow-up. Both groups will complete progressive Achilles loading exercises in 4 phases throughout the 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. Primary outcomes are movement-evoked pain during heel raises and self-reported function (patient-reported outcome measure information system-Physical Function). Secondary outcomes assess central nervous system nociceptive processing, psychological factors, motor function, and feasibility. RESULTS Institutional review board approval was obtained on April 15, 2019, and study funding began in July 2019. As of March 2020, we randomized 23 out of 66 participants. In September 2020, we screened 267 individuals, consented 68 participants, and randomized 51 participants. We anticipate completing the primary data analysis by March 2022. CONCLUSIONS The TEAch study will evaluate the utility of pain education for those with AT and the effects of improved patient knowledge on pain, physical function, and clinical outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/19111.
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Affiliation(s)
- Andrew A Post
- Department of Physical Therapy & Rehabilitation Science, University of Iowa, Iowa City, IA, United States
| | - Ebonie K Rio
- School of Allied Health, La Trobe University, Bundoora, Australia
| | - Kathleen A Sluka
- Department of Physical Therapy & Rehabilitation Science, University of Iowa, Iowa City, IA, United States
| | - G Lorimer Moseley
- IMPACT in Health, University of South Australia, Adelaide, Australia
| | - Emine O Bayman
- Departments of Biostatistics and Anesthesia, University of Iowa, Iowa City, IA, United States
| | - Mederic M Hall
- University of Iowa Sports Medicine, Department of Orthopaedics & Rehabilitation, University of Iowa, Iowa City, IA, United States
| | - Cesar de Cesar Netto
- Department of Orthopaedics & Rehabiliation, University of Iowa, Iowa City, IA, United States
| | - Jason M Wilken
- Department of Physical Therapy & Rehabilitation Science, University of Iowa, Iowa City, IA, United States
| | - Jessica F Danielson
- Department of Physical Therapy & Rehabilitation Science, University of Iowa, Iowa City, IA, United States.,Institute for Clinical and Translation Science, University of Iowa, Iowa City, IA, United States
| | - Ruth Chimenti
- Department of Physical Therapy & Rehabilitation Science, University of Iowa, Iowa City, IA, United States
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Local Anesthetic Injection Resolves Movement Pain, Motor Dysfunction, and Pain Catastrophizing in Individuals With Chronic Achilles Tendinopathy: A Nonrandomized Clinical Trial. J Orthop Sports Phys Ther 2020; 50:334-343. [PMID: 32349638 PMCID: PMC10016231 DOI: 10.2519/jospt.2020.9242] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Peripherally directed treatments (targeted exercise, surgery) can reduce, but not fully eliminate, pain for up to 40% of patients with Achilles tendinopathy. The objectives of the present study were (1) to identify indicators of altered central processing in participants with Achilles tendinopathy compared to controls, and (2) to determine which indicators of altered central processing would persist after a local anesthetic injection in patients with Achilles tendinopathy. DESIGN Mechanistic clinical trial. METHODS Forty-six adults (23 with chronic Achilles tendinopathy, 23 matched controls) repeated (1) a movement-evoked pain rating, (2) motor performance assessment, (3) pain psychology questionnaires, and (4) quantitative sensory testing. Participants with Achilles tendinopathy received a local anesthetic injection before repeat testing and controls did not. Mixed-effects analyses of variance examined the effects of group, time, and group by time. RESULTS The Achilles tendinopathy group had movement-evoked pain, motor dysfunction, and higher pain psychological factors (pain catastrophizing, kinesiophobia) compared to controls (P<.05). The Achilles tendinopathy group did not have indicators of nociplastic pain with quantitative sensory testing (P>.05). In those with Achilles tendinopathy, local anesthetic injection eliminated pain and normalized the observed deficits in heel-raise performance and pain catastrophizing (group-by-time effect, P<.01), but not in kinesiophobia (P = .45). Injection did not affect measures of nociplastic pain (P>.05). CONCLUSION People with Achilles tendinopathy had elevated pain psychological factors and motor dysfunction but no signs of nociplastic pain with quantitative sensory testing. Removal of nociceptive input normalized movement-evoked pain and some indicators of altered central processing (motor dysfunction, pain catastrophizing), but not kinesiophobia. J Orthop Sports Phys Ther 2020;50(6):334-343. Epub 29 Apr 2020. doi:10.2519/jospt.2020.9242.
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van der Vlist AC, Breda SJ, Oei EHG, Verhaar JAN, de Vos RJ. Clinical risk factors for Achilles tendinopathy: a systematic review. Br J Sports Med 2019; 53:1352-1361. [PMID: 30718234 PMCID: PMC6837257 DOI: 10.1136/bjsports-2018-099991] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2019] [Indexed: 01/04/2023]
Abstract
Background Achilles tendinopathy is a common problem, but its exact aetiology remains unclear. Objective To evaluate the association between potential clinical risk factors and Achilles tendinopathy. Design Systematic review. Data sources The databases Embase, MEDLINE Ovid, Web of Science, Cochrane Library and Google Scholar were searched up to February 2018. Eligibility criteria To answer our research question, cohort studies investigating risk factors for Achilles tendinopathy in humans were included. We restricted our search to potential clinical risk factors (imaging studies were excluded). Results We included 10 cohort studies, all with a high risk of bias, from 5111 publications identified. There is limited evidence for nine risk factors: (1) prior lower limb tendinopathy or fracture, (2) use of ofloxacin (quinolone) antibiotics, (3) an increased time between heart transplantation and initiation of quinolone treatment for infectious disease, (4) moderate alcohol use, (5) training during cold weather, (6) decreased isokinetic plantar flexor strength, (7) abnormal gait pattern with decreased forward progression of propulsion, (8) more lateral foot roll-over at the forefoot flat phase and (9) creatinine clearance of <60 mL/min in heart transplant patients. Twenty-six other putative risk factors were not associated with Achilles tendinopathy, including being overweight, static foot posture and physical activity level. Conclusion From an ocean of studies with high levels of bias, we extracted nine clinical risk factors that may increase a person’s risk of Achilles tendinopathy. Clinicians may consider ofloxacin use, alcohol consumption and a reduced plantar flexor strength as modifiable risk factors when treating patients with Achilles tendinopathy. Trial registration number CRD42017053258.
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Affiliation(s)
- Arco C van der Vlist
- Department of Orthopedic Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stephan J Breda
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Edwin H G Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan A N Verhaar
- Department of Orthopedic Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopedic Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Gheidi N, Kernozek TW, Willson JD, Revak A, Diers K. Achilles tendon loading during weight bearing exercises. Phys Ther Sport 2018; 32:260-268. [DOI: 10.1016/j.ptsp.2018.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 04/18/2018] [Accepted: 05/08/2018] [Indexed: 01/18/2023]
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Chimenti RL, Cychosz CC, Hall MM, Phisitkul P. Current Concepts Review Update: Insertional Achilles Tendinopathy. Foot Ankle Int 2017; 38:1160-1169. [PMID: 28789557 PMCID: PMC5956523 DOI: 10.1177/1071100717723127] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Ruth L. Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Chris C. Cychosz
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Mederic M. Hall
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA,Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
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Chimenti RL, Bucklin M, Kelly M, Ketz J, Flemister AS, Richards MS, Buckley MR. Insertional achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion. J Orthop Res 2017; 35:910-915. [PMID: 27306527 PMCID: PMC5738911 DOI: 10.1002/jor.23338] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/14/2016] [Indexed: 02/04/2023]
Abstract
The purposes of this case-control study (N = 20) were to examine the effects of insertional Achilles tendinopathy (IAT) and tendon region on tendon strain in patients with IAT compared to a control group without tendinopathy. An ultrasound transducer was positioned over the Achilles tendon insertion during dorsiflexion tasks, which included standing and partial squat. A non-rigid image registration-based algorithm was used to estimate transverse compressive and axial tensile strains of the tendon from radiofrequency ultrasound images, which was segmented into two regions (superficial tendon and deep). For transverse compressive strain, two-way mixed effects ANOVAs demonstrated that there were interaction effects between group and tendon region for both dorsiflexion tasks (Heel lowering, p = 0.004; Partial squat, p = 0.008). For axial tensile strain, the IAT group demonstrated a main effect of lower tensile strain than the control group (Standing, p = 0.001; Partial squat, p = 0.033). There was also a main effect of greater tensile strain in the superficial region of the tendon compared to the deep during standing (p = 0.002), but not during partial squat (p = 0.603). Reduced transverse compressive and axial tensile strains in the IAT group indicate altered mechanical properties specific to the region of IAT pathology. Additionally, patterns of compressive strain are consistent with the theory of calcaneal impingement contributing to IAT pathology. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:910-915, 2017.
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Affiliation(s)
- Ruth L Chimenti
- Post-doctoral fellow, University of Iowa, Department of Physical Therapy and Rehabilitation Science
| | - Mary Bucklin
- Student, University of Rochester, Department of Biomedical Engineering
| | - Meghan Kelly
- Resident, University of Rochester, Department of Orthopaedic Surgery
| | - John Ketz
- Assistant Professor, University of Rochester, Department of Orthopaedic Surgery
| | - A. Samuel Flemister
- Associate Professor, University of Rochester, Department of Orthopaedic Surgery
| | - Michael S. Richards
- Research Assistant Professor, University of Rochester, Department of Surgery
| | - Mark R Buckley
- Assistant Professor, University of Rochester, Department of Biomedical Engineering
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Gaulke R, Krettek C. [Tendinopathies of the foot and ankle : Evidence for the origin, diagnostics and therapy]. Unfallchirurg 2017; 120:205-213. [PMID: 28120032 DOI: 10.1007/s00113-016-0301-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Tendinopathies of the foot and ankle result in substantial impairment of the mobility of patients and have a high clinical significance. Knowledge of the origin of these diseases has been accumulated over decades from the multitude of intrinsic and extrinsic triggering factors based on biomechanical considerations with an evidence-based medicine (EBM) level 5. A high correlation between tendinopathy and hypervascularization of the Achilles tendon was found in a double-blind randomized prospective study using Doppler ultrasound (EBM level 1) but these results were not reproducible; therefore, the importance of these findings is unclear. Inspection and clinical examination supplemented by ultrasound and magnetic resonance imaging (MRI) are essential to achieve the correct diagnosis. The varying extent of load-dependent irritation of tendons and the surrounding tissues and the individual variation in experience of investigators mean that the results of clinical examinations are difficult to collate or not reproducible and cannot be investigated in studies. The expression of the varying results is difficult to assess even by the use of sonography and magnetic resonance imaging (MRI). Conservative treatment of tendinopathy is based on medical experience (EBM level 5). The effectiveness of physiotherapeutic eccentric loading and extracorporal shock wave treatment (ESWT) for Achilles tendinopathy was demonstrated in several case control studies and series (EBM level 3). Due to the high rate of healing with physiotherapy, surgery should only be performed following a minimum of 6-12 weeks of unsuccessful conservative treatment, because formation of scar tissue on the foot can result in permanent complaints (EBM level 4).
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Affiliation(s)
- Ralph Gaulke
- Sektion Obere Extremität, Fuß- und Rheumachirurgie, Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Christian Krettek
- Sektion Obere Extremität, Fuß- und Rheumachirurgie, Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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