Disrupted Tactile Acuity in People With Achilles Tendinopathy: A Preliminary Case-Control Investigation

Effects of Tempo-Controlled Resistance Training on Corticospinal Tract Plasticity in Healthy Controls: A Systematic Review

After musculoskeletal injuries, there is often a loss of corticospinal control. Current tendon rehabilitation may not adequately address the corticospinal control of the muscle which may contribute to the recalcitrance of symptom recurrence. This review provides a summary of the current literature regarding the effectiveness of tempo-controlled resistance training (TCRT) in (1) promoting corticospinal plasticity, (2) improving physical performance, and (3) improving strength outcomes in healthy adults. A comprehensive literature search was conducted using electronic databases (PubMed, CINAHL, Embase, and Google Scholar) to identify relevant studies published between 2010 and 2023. Randomized control (RCT) studies that included recreationally trained and untrained healthy adults between 18 and 60 years of age and that compared a TCRT intervention to a control condition were included. Twelve of the 1255 studies identified in the initial search were included in the final analysis. Throughout all included studies, TCRT was shown to elicit greater neural adaptations compared to traditional resistance training methods (i.e., self-paced strength training). These results indicate that TCRT holds promise as an effective method for modulating corticospinal plasticity in healthy adults and may enhance neuromuscular adaptations, including improvements in CSE, decreased SICI, enhanced motor unit synchronization, and voluntary muscle activation.

Comparison of tactile acuity between patients with chronic patellofemoral pain with central sensitization and healthy persons: A cross-sectional study

BACKGROUND

Patellofemoral pain (PFP) is a common multifactorial condition in young and physically active people.

OBJECTIVE

The occurrence of central sensitization may play an important role in sensory disturbance. This study was designed to investigate, in patients with chronic PFP, the presence of disturbances in tactile acuity with central sensitization.

METHODS

Thirty patients with chronic PFP and 30 matched healthy controls entered this cross-sectional study. Graphesthesia (numerical score), two-point discrimination (mm), and point-to-point sensation (mm) were assessed in all participants.

RESULTS

The results of between-group comparisons showed that there were significant differences between the involved knee in patients with chronic PFP and healthy participants in graphesthesia (median = 13 [case], 19 [control]; p < .001), two-point discrimination (median = 25.8 [case], 20.3 [control]; p < .001), and point-to-point sensation (median = 14.5 [case], 6.2 [control]; p < .001). There was also a significant difference in graphesthesia between the non-involved knee in patients with chronic PFP and healthy participants (median = 17 [case], 19 [control]; p = .003). The results of within-group comparisons revealed a significant difference in graphesthesia, two-point discrimination, and point-to-point sensation between the involved and non-involved knee in patients with chronic PFP (p < .001). Moreover, there was a positive correlation between two-point discrimination and pain in patients with chronic PFP (r = 0.446, p = .014).

CONCLUSION

The findings of this study reveal that there is a sensory deficit in patients with chronic PFP. Because sensory information is necessary for motor control and pain perception, we can assume that clinical symptoms in these patients are related to sensory deficits.

Effects of pain associated with orthodontic tooth movement on tactile sensation of periodontal ligaments

OBJECTIVES

Pain associated with orthodontic tooth movement reportedly reduces periodontal ligament tactile sensation. However, the mechanism associated with the central nervous system remains unclear. This study was conducted by measuring somatosensory evoked magnetic fields (SEFs) during mechanical stimulation of teeth as they were being moved by separator elastics. Findings clarified the effects of pain on periodontal ligament tactile sensation during orthodontic tooth movement.

MATERIALS AND METHODS

Using magnetoencephalography, SEFs were measured during the application of mechanical stimuli to the mandibular right first molars of 23 right-handed healthy participants (0 h). Separator elastics were subsequently inserted into the mesial and distal interdental portions of the mandibular right first molars. The same mechanical stimuli were applied again 24 h later while the SEFs were measured (24 h). After each SEF measurements, pain was also evaluated using the Visual Analog Scale (VAS).

RESULTS

The VAS values were significantly higher at 24 h than at 0 h (p < 0.05). No significant difference in the peak latencies was found between those obtained at 0 h and 24 h, but the intensities around 40.0 ms in the contralateral hemisphere were significantly lower at 24 h than at 0 h (p < 0.01).

CONCLUSIONS

Pain associated with orthodontic tooth movement might suppress periodontal ligament tactile sensation in the primary somatosensory cortex.

CLINICAL RELEVANCE

Pain associated with orthodontic tooth movement might affect periodontal ligament sensation, consequently causing discomfort during occlusion.

Efficacy of Transcutaneous Electrical Nerve Stimulation and Interferential Current on Tactile Acuity of Individuals With Nonspecific Chronic Low Back Pain

OBJECTIVES

Transcutaneous electrical nerve stimulation (TENS) and interferential currents (IFC) are pain electrotherapies with questioned efficacy. Studies of their effects on tactile acuity of individuals with nonspecific chronic low back pain (NSCLBP) are limited, hence, this study.

MATERIALS AND METHODS

Thirty-three individuals with NSCLBP randomly allocated into three groups completed this study. Data collected from participants included age, gender, and anthropometric characteristics of height, weight, body mass index, and percentage body fat measured with standard instruments. Also, participants' tactile acuity, pain intensity, and disability were assessed before and after interventions with digital caliper, numerical pain rating scale, and Roland-Morris Disability Questionnaire, respectively. Interventions consisted of stretching, strengthening, and stabilization exercises to all three groups in addition of TENS to group 1 and IFC to group 2, respectively, for five weeks. Descriptive statistics of mean and standard deviation summarized the data. Inferential statistics of paired t-test, independent t-test, and analysis of variance tested the level of significance among variables at p ≤ 0.05.

RESULTS

Tactile acuity was significantly (p < 0.05) increased after TENS intervention only, while pain intensity was significantly (p < 0.05) reduced after the three interventions. The result showed no gender difference in tactile acuity values among the participants.

CONCLUSIONS

TENS increases the tactile acuity of individuals with NSCLBP, whereas IFC demonstrated no significant change in tactile acuity.

The effect of combined Action Observation Therapy with eccentric exercises in the treatment of mid-portion Achilles-tendinopathy: a feasibility pilot randomised controlled trial

BACKGROUND

Mid-portion Achilles Tendinopathy (AT) is a common musculoskeletal condition with varying rehabilitation success rates. Despite the prevalence of this condition, a considerable proportion of individuals experience persisting pain and functional deficits. Current treatment approaches bias the biomedical model which emphasises physically treating and loading the tendon. Overall, there is a lack of consideration for the central nervous system that is commonly implicated in chronic injuries. The aim of this pilot study was to explore the feasibility of combining Action Observation Therapy (AOT), a treatment technique which targets central changes and influences motor learning, with eccentric exercises in the treatment of mid-portion AT. AOT involves the observation of movements and is commonly followed by the physical performance of these same movements.

METHODOLOGY

This was a double-blinded randomised controlled pilot feasibility study. All participants underwent the 12-week Alfredson eccentric training protocol. The intervention group watched videos of the exercises prior to performing these exercises, whilst the control group watched nature videos before performing the same exercises. Study feasibility was the primary outcome measure, with the Victorian Institute of Sports Assessment- Achilles (VISA-A) selected as the primary clinical outcome measure.

RESULTS

Thirty participants were recruited, reflecting a 75% eligibility rate and 100% of eligible participants enrolled in the study. The retention rate at week 12 was 80%. At week six the mean VISA-A score improved by 18.1 (95% CI 10.2-26.0) in the intervention group and 7.7 (95% CI 0.3-14.9) in the control group, and 75% and 33% of participants in the intervention and control group respectively exceeded the minimal clinically important difference (MCID). At week 12 the mean VISA-A score from baseline improved by 22.25 (95% CI 12.52-31.98) in the intervention group and 16.5-(95% CI 8.47-24.53) in the control group, equating to 75% and 58% in each group respectively exceeding the MCID.

CONCLUSION

The positive feasibility outcomes and exploratory data from the clinical outcome measures suggest that a larger scaled RCT is warranted to further investigate the impact of AOT in the rehabilitation of mid-portion AT. Trial registration ISRCTN58161116, first registered on the 23/12/2020.

Tendinopathies and Pain Sensitisation: A Meta-Analysis with Meta-Regression

The presence of pain sensitisation has been documented and reported as being a possible cause of treatment failure and pain chronicity in several musculoskeletal conditions, such as tendinopathies. The aim of the present study is to analyse existing evidence on pain sensitisation in tendinopathies comparing the local and distant pain thresholds of healthy and affected subjects with distinct analysis for different tendinopathies. PubMed, Cochrane Central Register, Scopus, and Web Of Science were systematically searched after registration on PROSPERO (CRD42020164124). Level I to level IV studies evaluating the presence of pain sensitisation in patients with symptomatic tendinopathies, documented through a validated method, were included. A meta-analysis was performed to compare local, contralateral, and distant pain thresholds between patients and healthy controls with sub-analyses for different tendinopathies. Meta-regressions were conducted to evaluate the influence of age, activity level, and duration of symptoms on results. Thirty-four studies out of 2868 were included. The overall meta-analysis of local pressure pain thresholds (PPT) documented an increased sensitivity in affected subjects (p < 0.001). The analyses on contralateral PPTs (p < 0.001) and distant PPTs (p = 0.009) documented increased sensitivity in the affected group. The results of the sub-analyses on different tendinopathies were conflicting, except for those on lateral epicondylalgia. Patients’ activity level (p = 0.02) and age (p = 0.05) significantly influenced local PPT results. Tendinopathies are characterized by pain sensitisation, but, while features of both central and peripheral sensitisation can be constantly detected in lateral epicondylalgia, results on other tendinopathies were more conflicting. Patients’ characteristics are possible confounders that should be taken into account when addressing pain sensitisation.

The sensorimotor theory of pathological pain revisited

Harris (1999) proposed that pain can arise in the absence of tissue damage because changes in the cortical representation of the painful body part lead to incongruences between motor intention and sensory feedback. This idea, subsequently termed the sensorimotor theory of pain, has formed the basis for novel treatments for pathological pain. Here we review the evidence that people with pathological pain have changes to processes contributing to sensorimotor function: motor function, sensory feedback, cognitive representations of the body and its surrounding space, multisensory processing, and sensorimotor integration. Changes to sensorimotor processing are most evident in the form of motor deficits, sensory changes, and body representations distortions, and for Complex Regional Pain Syndrome (CRPS), fibromyalgia, and low back pain. Many sensorimotor changes are related to cortical processing, pain, and other clinical characteristics. However, there is very limited evidence that changes in sensorimotor processing actually lead to pain. We therefore propose that the theory is more appropriate for understanding why pain persists rather than how it arises.

Patient perspectives on participation in exercise-based rehabilitation for Achilles tendinopathy: A qualitative study

BACKGROUND

Achilles tendinopathy (AT) is common, and can be traumatic or insidious in onset and short-lasting or persistent in nature. Factors influencing the experience of pain are poorly understood; little is known about mechanisms driving pain and the response (or lack of) to rehabilitation. Despite this, there is a growing body of evidence supporting the use of exercise to manage AT. Interestingly, variation in exercise approach does not appear to significantly impact outcome. Patients' perceptions of factors related to rehabilitation that may influence outcome could provide a valuable addition to help guide future research and practice.

OBJECTIVES

The aim of this study is to gain an insight into patients' experiences of participating in an exercise-based rehabilitation programme for AT.

METHOD

A qualitative interpretive description design. Data generated from semi-structured interviews were analysed thematically using the guidelines set out by Braun and Clarke.

FINDINGS

This is the first study to use a qualitative method of inquiry to gain data on the experiences of people undertaking exercise-based rehabilitation for AT. The four major themes that were identified from the data were: (1) 'understanding the impact' (2) 'expectations' (3) 'what matters' and (4) 'the burden of exercise'.

CONCLUSIONS

Given the uncertainty surrounding the mechanisms of effect of our treatments, the insights provide a platform from which researchers and clinicians can consider further in the management of people with Achilles tendinopathy. Specifically, it has highlighted that patients value a flexible, supportive approach embracing the biopsychosocial impact of AT on the individual.

"But it feels swollen!": the frequency and clinical characteristics of people with knee osteoarthritis who report subjective knee swelling in the absence of objective swelling

Supplemental Digital Content is Available in the Text.

The present results support the coexistence of altered body image (subjective without objective swelling) and pain, disability, and maladaptive beliefs in people with knee osteoarthritis.

Introduction:

There are complex interactions between pain and perceptions of the painful body part in musculoskeletal disorders, and disruption of various body representations in people with chronic pain.

Objectives:

The purpose of this study was to investigate how frequently people with knee osteoarthritis (OA) complain of swelling without objective evidence of swelling, and describe the clinical characteristics of this population.

Methods:

Forty-six people with knee OA (68.1 ± 8.8 years) participated in this cross-sectional study. Subjective and objective swelling was evaluated by knee-specific body perception questionnaire and ultrasonography, respectively. Pain intensity, disability, pain-related beliefs, 2-point discrimination threshold, and quadriceps muscle strength were also evaluated.

Results:

Approximately 1/3 of participants (n = 15) had subjective feelings of knee swelling in the absence of objective swelling (S only). Fifteen participants had both subjective and objective knee swelling (S + O group) and 16 had neither subjective nor objective knee swelling (No S/O group). Participants in the S only group had similar pain or disability as those in the S + O group but had more severe pain or disability than those with in the No S/O group. Those in the S only group also had larger 2-point discrimination distance threshold at the medial knee (impaired tactile acuity) than those in the S + O group and had more dysfunctional pain catastrophizing and pain-related self-efficacy than both other groups.

Conclusion:

Our results suggest that about 30% of people with knee OA perceive swelling of the knee in the absence of any objective swelling and that this is accompanied by severe pain and functional disability. Considering altered body image of the knee may reveal relevant treatment-based subgroups in people with knee OA.

Modernising tactile acuity assessment; clinimetrics of semi-automated tests and effects of age, sex and anthropometry on performance

Background

Reduced tactile acuity has been observed in several chronic pain conditions and has been proposed as a clinical indicator of somatosensory impairments related to the condition. As some interventions targeting these impairments have resulted in pain reduction, assessing tactile acuity may have significant clinical potential. While two-point discrimination threshold (TPDT) is a popular method of assessing tactile acuity, large measurement error has been observed (impeding responsiveness) and its validity has been questioned. The recently developed semi-automated ‘imprint Tactile Acuity Device’ (iTAD) may improve tactile acuity assessment, but clinimetric properties of its scores (accuracy score, response time and rate correct score) need further examination.

Aims

Experiment 1: To determine inter-rater reliability and measurement error of TPDT and iTAD assessments. Experiment 2: To determine internal consistencies and floor or ceiling effects of iTAD scores, and investigate effects of age, sex, and anthropometry on performance.

Methods

Experiment 1: To assess inter-rater reliability (ICC_(2,1)) and measurement error (coefficient of variation (CoV)), three assessors each performed TPDT and iTAD assessments at the neck in forty healthy participants. Experiment 2: To assess internal consistency (ICC_(2,k)) and floor or ceiling effects (skewness z-scores), one hundred healthy participants performed the iTAD’s localisation and orientation tests. Balanced for sex, participants were equally divided over five age brackets (18–30, 31–40, 41–50, 51–60 and 61–70). Age, sex, body mass index (BMI) and neck surface area were assessed to examine their direct (using multiple linear regression analysis) and indirect (using sequential mediation analysis) relationship with iTAD scores.

Results

Mean ICC_(2,1) was moderate for TPDT (0.70) and moderate-to-good for the various iTAD scores (0.65–0.86). The CoV was 25.3% for TPDT and ranged from 6.1% to 16.5% for iTAD scores. Internal consistency was high for both iTAD accuracy scores (ICC_(2,6) = 0.84; ICC_(2,4) = 0.86). No overt floor or ceiling effects were detected (all skewness z-scores < 3.29). Accuracy scores were only directly related to age (decreasing with increasing age) and sex (higher for men).

Discussion

Although reliability was similar, iTAD scores demonstrated less measurement error than TPDT indicating a potential for better responsiveness to treatment effects. Further, unlike previously reported for TPDT, iTAD scores appeared independent of anthropometry, which simplifies interpretation. Additionally, the iTAD assesses multiple aspects of tactile processing which may provide a more comprehensive evaluation of tactile acuity. Taken together, the iTAD shows promise in measuring tactile acuity, but patient studies are needed to verify clinical relevance.

Implicit motor imagery of the foot and hand in people with Achilles tendinopathy: a left right judgement study

OBJECTIVE

To determine if impairment in motor imagery processes is present in Achilles tendinopathy (AT), as demonstrated by a reduced ability to quickly and accurately identify the laterality (left-right judgement) of a pictured limb. Additionally, this study aimed to use a novel data pooling approach to combine data collected at 3 different sites via meta-analytical techniques that allow exploration of heterogeneity.

DESIGN

Multi site case-control study.

METHODS

Three independent studies with similar protocols were conducted by separate research groups. Each study-site evaluated left/right judgement performance for images of feet and hands using Recognise© software and compared performance between people with AT and healthy controls. Results from each study-site were independently collated, then combined in a meta-analysis.

RESULTS

126 participants (40 unilateral, 22 bilateral AT cases, 61 controls) were included. There were no differences between AT cases and controls for hand image accuracy and reaction time. Contrary to the hypothesis, there were no differences in performance between those with AT and controls for foot image reaction time, however there were conflicting findings for foot accuracy, based on four separate analyses. There were no differences between the affected and unaffected sides in people with unilateral AT.

CONCLUSIONS

Impairments in motor imagery performance for hands were not found in this study and we found inconsistent results for foot accuracy. This contrasts to studies in persistent pain of limbs, face and knee osteoarthritis, and suggests that differences in pathoaetiology or patient demographics may uniquely influence proprioceptive representation.

Sensory Processing in People With and Without Tendinopathy: A Systematic Review With Meta-analysis of Local, Regional, and Remote Sites in Upper- and Lower-Limb Conditions

OBJECTIVE

To synthesize results of somatosensory processing tests in people with upper- and lower-limb tendinopathy, compared to controls.

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

Four electronic databases (MEDLINE, CINAHL Plus, SPORTDiscus, and Embase) were searched.

STUDY SELECTION CRITERIA

Included studies measured a domain of sensory processing and compared a tendinopathy group to a healthy control group.

DATA SYNTHESIS

Meta-analysis was conducted for outcomes with homogeneous data from at least 2 studies. Upper- and lower-limb conditions were compared and outcomes were examined by measurement site (local, regional, or remote to location of pain).

RESULTS

Of the 30 studies included, 18 investigated lateral elbow tendinopathy. The most commonly assessed outcome measures were pressure pain threshold (PPT) and thermal pain threshold. There was moderate evidence for local and regional reduction of PPT in upper-limb tendinopathies, but not at remote sites. In lower-limb tendinopathies, there was conflicting evidence regarding reduced PPT at local sites and limited evidence of normal PPT at remote sites. There was moderate evidence of sensitization of thermal pain threshold at local sites in upper-limb tendinopathies and limited evidence of no difference in thermal pain threshold in lower-limb tendinopathies. Findings across other domains were variable.

CONCLUSION

Sensory processing was different between upper-limb tendinopathy and lower-limb tendinopathy. Upper-limb tendinopathies showed signs consistent with primary and secondary hyperalgesia, but lower-limb tendinopathies did not. There was mixed evidence for primary hyperalgesia and limited evidence against secondary hyperalgesia. J Orthop Sports Phys Ther 2021;51(1):12-26. doi:10.2519/jospt.2021.9417.

Potential Nervous System Sensitization in Patients With Persistent Lower Extremity Tendinopathies: 3 Case Reports

BACKGROUND

Tendinopathy is a condition often associated with pain and functional and sport performance limitations. While targeted exercise prescriptions are often effective, many patients with tendinopathy develop persistent symptoms. Emerging evidence suggests a possible link between nervous system sensitization and tendinopathy. If so, identifying and treating specific pain mechanisms may improve outcomes.

CASE DESCRIPTION

Three patients were seen in physical therapy for complaints of ongoing chronic tendon pain and self-reported disability, despite being treated previously and receiving evidence-informed care. Upon examination, each patient demonstrated signs consistent with possible dysfunction of central pain mechanisms. Joint mobilization, pain neuroscience education, and aerobic exercise were primary interventions in each case to decrease pain and improve function.

OUTCOMES

The 3 patients were treated for 5 sessions over the course of 8 weeks. Clinically significant improvement was noted in measures of pain, self-reported function, and pressure pain thresholds. At discharge, all patients were able to run without symptoms, and improvement was maintained at 1-year follow-up.

DISCUSSION

Tendinopathy, while often described as local pain and dysfunction, may be associated with dysfunction of the nervous system. Identifying and treating pain mechanisms in addition to relevant impairments may be an appropriate intervention approach for individuals with tendinopathy.

LEVEL OF EVIDENCE

Therapy, level 4. J Orthop Sports Phys Ther 2019;49(4):272-279. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8600.

Clinical risk factors for Achilles tendinopathy: a systematic review

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.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.

Patellar and Achilles tendinopathies are predominantly peripheral pain states: a blinded case control study of somatosensory and psychological profiles

Study design

Case–control design.

Background

Tendinopathy is characterised by pain on tendon loading. In persistent cases of upper limb tendinopathy, it is frequently associated with central nervous system sensitisation, whereas less commonly linked in the case of persistent lower limb tendinopathies.

Objectives

Compare somatosensory and psychological profiles of participants with persistent patellar (PT) and Achilles tendinopathies (AT) with pain-free controls.

Methods

A comprehensive battery of Quantitative Sensory Testing (QST) was assessed at standardised sites of the affected tendon and remotely (lateral elbow) by a blinded assessor. Participants completed the Victorian Institute of Sports Assessment, a health-related quality of life questionnaire, the Hospital Anxiety and Depression Scale and the Active Australia Questionnaire. Independent t-test and analysis of covariance (sex-adjusted and age-adjusted) were performed to compare groups.

Results

Participants with PT and AT did not exhibit differences from controls for the QST at the remote site, but there were differences at the affected tendon site. Compared with controls, participants with PT displayed significantly lower pressure pain threshold locally at the tendon (p=0.012) and fewer single limb decline squats before pain onset, whereas participants with AT only displayed fewer single heel raises before pain onset, but this pain was of a higher intensity.

Conclusion

PT and AT appear to be predominantly local not widespread pain states related to loading of tendons without significant features of central sensitisation.

Level of evidence

Level 4.

Modern pain neuroscience in clinical practice: applied to post-cancer, paediatric and sports-related pain

•

Generalized hypersensitivity in post-cancer, sports-related and pediatric pain.

•

Rationale for pain education, stress management and cognition targeted exercises.

•

Need to change from a biomedical or psychosocial to an integrated approach.

In the last decade, evidence regarding chronic pain has developed exponentially. Numerous studies show that many chronic pain populations show specific neuroplastic changes in the peripheral and central nervous system. These changes are reflected in clinical manifestations, like a generalized hypersensitivity of the somatosensory system. Besides a hypersensitivity of bottom-up nociceptive transmission, there is also evidence for top-down facilitation of pain due to malfunctioning of the endogenous descending nociceptive modulatory systems. These and other aspects of modern pain neuroscience are starting to be applied within daily clinical practice. However, currently the application of this knowledge is mostly limited to the general adult population with musculoskeletal problems, while evidence is getting stronger that also in other chronic pain populations these neuroplastic processes may contribute to the occurrence and persistence of the pain problem. Therefore, this masterclass article aims at giving an overview of the current modern pain neuroscience knowledge and its potential application in post-cancer, paediatric and sports-related pain problems.

Nonsurgical Management of Midsubstance Achilles Tendinopathy

Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery.