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

Physical therapy for acute and sub-acute low back pain: A systematic review and expert consensus

OBJECTIVE

To review the effectiveness of different physical therapies for acute and sub-acute low back pain supported by evidence, and create clinical recommendations and expert consensus for physiotherapists on clinical prescriptions.

DATA SOURCES

A systematic search was conducted in PubMed and the Cochrane Library for studies published within the previous 15 years.

REVIEW METHODS

Systematic review and meta-analysis, randomized controlled trials assessing patients with acute and sub-acute low back pain were included. Two reviewers independently screened relevant studies using the same inclusion criteria. The Physiotherapy Evidence Database and the Assessment of Multiple Systematic Reviews tool were used to grade the quality assessment of randomized controlled trials and systematic reviews, respectively. The final recommendation grades were based on the consensus discussion results of the Delphi of 22 international experts.

RESULTS

Twenty-one systematic reviews and 21 randomized controlled trials were included. Spinal manipulative therapy and low-level laser therapy are recommended for acute low back pain. Core stability exercise/motor control, spinal manipulative therapy, and massage can be used to treat sub-acute low back pain.

CONCLUSIONS

The consensus statements provided medical staff with appliable recommendations of physical therapy for acute and sub-acute low back pain. This consensus statement will require regular updates after 5-10 years.

Low socioeconomic status is associated with worse treatment outcomes in patients with Achilles tendinopathy

OBJECTIVE

To assess whether there is a difference in symptom severity at baseline and 24 weeks follow-up between conservatively managed patients with Achilles tendinopathy (AT) with low socioeconomic status (SES) compared with those with high SES.

METHODS

In this prospective cohort study, 200 patients with AT were included and treated according to current guidelines. We linked a neighbourhood SES indicator based on income, employment and education level and divided the patient population into quintiles, with Q1 being the highest SES and Q5 the lowest. Symptom severity at baseline and follow-up was assessed using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Treatment adherence was not measured. We used a general linear model and the mean VISA-A scores at baseline and at 6, 12 and 24 weeks follow-up were compared between Q1 (n=45) and Q5 (n=39), while adjusting for age, sex, body mass index (BMI), Ankle Activity Score, symptom duration and baseline VISA-A score.

RESULTS

Patients had a median age of 51 years and median BMI of 25.4, 40% were female. 74%, 70% and 58% of the participants completed the VISA-A at 6, 12 and 24 weeks, respectively. VISA-A scores at baseline were similar for Q1 and Q5 (43.9 and 41.8, p=0.591). At 24 weeks, there was a mean (95% CI) difference of 11.2 (1.0 to 21.3, p=0.032) points in favour of Q1 on the VISA-A score.

CONCLUSION

AT patients with low SES may have worse outcomes when treated using the current guidelines. The difference in VISA-A score at 24 weeks is larger than the minimal clinically important difference and might be clinically relevant, but comes with uncertainty due to the large dispersion in the data. Clinicians need to consider the impact of social inequality when developing and implementing treatment plans.

Efficacy of heel lifts for mid-portion Achilles tendinopathy (the LIFT trial): study protocol for a randomised controlled trial

BACKGROUND

Mid-portion Achilles tendinopathy is a common condition, characterised by localised Achilles tendon load-related pain and dysfunction. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. Heel lifts have also been advocated as a treatment for Achilles tendinopathy, but the efficacy and mechanism of action of this intervention is unclear. This proposal describes a randomised controlled trial comparing the effectiveness of heel lifts versus sham heel lifts for reducing pain associated with mid-portion Achilles tendinopathy, with an embedded biomechanical analysis.

METHODS

One hundred and eight men and women aged 18 to 65 years with mid-portion Achilles tendinopathy (who satisfy the inclusion and exclusion criteria) will be recruited. Participants will be randomised, using the website Sealed Envelope, to either a control group (sham heel lifts) or an experimental group (heel lifts). Both groups will be provided with education regarding acceptable pain levels to ensure all participants receive some form of treatment. The participants will be instructed to use their allocated intervention for at least 8 h every day for 12 weeks. The primary outcome measure will be pain intensity (numerical rating scale) at its worst over the previous week. The secondary outcome measures will be additional measures of Achilles tendon pain and disability, participant-perceived global ratings of change, function, level of physical activity and health-related quality of life. Data will be collected at baseline and the primary endpoint (week 12). Data will be analysed using the intention-to-treat principle. In addition, the acute kinetic and kinematic effects of the interventions will be examined at baseline in a subpopulation of the participants (n = 40) while walking and running using three-dimensional motion analysis.

DISCUSSION

The LIFT trial (efficacy of heeL lIfts For mid-portion Achilles Tendinopathy) will be the first randomised trial to compare the efficacy of heel lifts to a sham intervention in reducing pain and disability in people with Achilles tendinopathy. The biomechanical analysis will provide useful insights into the mechanism of action of heel lifts.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12623000627651 . Registered 7 June 2023.

Rearfoot Strike Run Retraining for Achilles Tendon Pain: A Two-patient Case Series

INTRODUCTION

Running-related injuries are prevalent in the military and are often related to physical fitness test training. Non-rearfoot striking while running is known to increase the risk of Achilles tendon injuries because of the high eccentric energy absorption by the elastic components of the planarflexor muscle-tendon complex. However, there is limited evidence to suggest benefits of converting runners with Achilles tendon pain to use a rearfoot strike.

METHODS

This is a case series of two active-duty Service members with chronic, running-related Achilles tendon pain that utilized a natural non-rearfoot strike pattern. Both patients were trained to utilize a rearfoot strike while running through the use of real-time visual feedback from wearable sensors.

RESULTS

The trained rearfoot strike pattern was retained for over one month after the intervention, and both patients reported improvements in pain and self-reported function.

CONCLUSIONS

This case series demonstrated the clinical utility of converting two non-rearfoot strike runners to a rearfoot strike pattern to decrease eccentric demands on the plantarflexors and reduce Achilles tendon pain while running.

Asymmetric running is associated with pain during outdoor running in individuals with Achilles tendinopathy in the return-to-sport phase

OBJECTIVES

To determine the relationships between (1) Achilles tendon pain and loading symmetry, and (2) number of running bouts and symptom severity, during two weeks of outdoor running in individuals with Achilles tendinopathy.

DESIGN

Prospective, observational study.

SETTING

Biomechanics laboratory and outdoors.

PARTICIPANTS

Seventeen runners with Achilles tendinopathy in the return-to-sport phase of rehabilitation.

MAIN OUTCOME MEASURES

Symptom severity was recorded with the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Running bouts and Achilles tendon pain during runs were recorded with daily training logs. Ground contact time was collected during runs with wearable sensors. Linear mixed modeling determined if the relationship between Achilles tendon pain and ground contact time symmetry during running was moderated by consecutive run days. Multiple regression determined the relationship between number of running bouts and change in VISA-A scores over two weeks, adjusted for run distance.

RESULTS

Greater ground contact time on the contralateral leg corresponded to increased ipsilateral tendon pain for each consecutive run day (b = -0.028, p < 0.001). Number of running bouts was not associated with 2-week changes in VISA-A scores (p = 0.672).

CONCLUSIONS

Pain during running is associated with injured leg off-loading patterns, and this relationship strengthened with greater number of consecutive run days. Number of running bouts was not related to short-term symptom severity.

Psychological factors show limited association with the severity of Achilles tendinopathy

BACKGROUND

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

METHODS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Normative ultrasound values for Achilles tendon thickness in the general population and patients with Achilles tendinopathy: A large international cross-sectional study

The objective of the study was to obtain adjusted ultrasonographic reference values of the Achilles tendon thickness (maximum anterior-posterior distance) in adults without (previous) Achilles tendinopathy (AT) and to compare these reference values with AT patients. Six hundred participants were consecutively included, comprising 500 asymptomatic individuals and 100 patients with clinically diagnosed chronic AT. The maximum tendon thickness was assessed using Ultrasound Tissue Characterization. A multiple quantile regression model was developed, incorporating covariates (personal characteristics) that were found to have a significant impact on the maximum anterior-posterior distance of the Achilles tendon. A 95% reference interval (RI) was derived (50th, 2.5th-97.5th percentile). In asymptomatic participants median (95% RI) tendon thickness was 4.9 (3.8-6.9) mm for the midportion region and 3.7 (2.8-4.8) mm for the insertional region. Age, height, body mass index, and sex had a significant correlation with maximum tendon thickness. Median tendon thickness for the midportion region was calculated with the normative equation -2.1 + AGE × 0.021 + HEIGHT × 0.032+ BMI × 0.028 + SEX × 0.05. For the insertional region, the normative equation was -0.34 + AGE × 0.010+ HEIGHT × 0.018 + BMI × 0.022 + SEX × -0.05. In the equations, SEX is defined as 0 for males and 1 for females. Mean (95% CI) difference in tendon thickness compared to AT patients was 2.7 mm (2.3-3.2, p < 0.001) for the midportion and 1.4 mm (1.1-1.7, p < 0.001) for the insertional region. Compared to the asymptomatic population 73/100 (73%) AT patients exhibited increased tendon thickening, with values exceeding the 95% RI. This study presents novel reference values for the thickness of midportion and insertional region of the Achilles tendon, which were adjusted for personal characteristics. Our novel web-based openly accessible calculator for determining normative Achilles tendon thickness (www.achillestendontool.com) will be a useful resource in the diagnostic process. Trial registration number: This trial is registered in the Netherlands Trial Register (NL9010).

Effects of high frequency strengthening on pain sensitivity and function in female runners with chronic patellofemoral pain

OBJECTIVE

To investigate the effects of a high frequency strengthening program on function, pain, and pain sensitization in female runners with chronic patellofemoral pain (PFP).

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Thirty female runners (mean age 32 ± 8.1 years) with chronic PFP completed an 8-week home strengthening program.

MAIN OUTCOME MEASURES

Variables assessed at baseline, 8-weeks, and 12 weeks included single leg step down test (SLSD), pain, Anterior Knee Pain Scale (AKPS), University of Wisconsin Running Injury and Recovery Index (UWRI), and quantitative sensory testing.

RESULTS

There was large and statistically significant improvement at 8 and 12 weeks for average knee pain (ηp2 = 0.334, p < 0.001), worst knee pain (ηp2 = 0.351, p < 0.001), SLSD (ηp2 = 0.161, p = 0.001), AKPS (ηp2 = 0.463, p < 0.001), and UWRI (ηp2 = 0.366, p < 0.001). A medium to large effect and statistically significant improvement in pressure pain threshold testing was found for all local and remote structures (ηp2 range, 0.110 to 0.293, range p < 0.001 to p = 0.009) at 8 and 12 weeks.

CONCLUSIONS

There was a significant decrease in local and remote hyperalgesia via mechanical and thermal pain sensitivity testing in female runners with chronic PFP. There was a large effect and significant improvement in self-reported pain and function.

Exercise induced hypoalgesia during different intensities of a dynamic resistance exercise: A randomized controlled trial

INTRODUCTION

Exercise produces an immediate lessening of pain sensitivity (Exercise-Induced Hypoalgesia (EIH)) in healthy individuals at local and distant sites, possibly through a shared mechanism with conditioned pain modulation (CPM). Dynamic resistance exercise is a recommended type of exercise to reduce pain, yet limited research has examined the effects of intensity on EIH during this type of exercise. Therefore, the primary purpose of this study is to compare changes in PPT at a local and distant site during a leg extension exercise at a high intensity, a low intensity, or a quiet rest condition. A secondary purpose is to examine if CPM changes after each intervention. The final purpose is to examine if baseline pain sensitivity measures are correlated with response to each intervention.

METHODS

In a randomized controlled trial of 60 healthy participants, participants completed baseline pain sensitivity testing (heat pain threshold, temporal summation, a cold pressor test as measure of CPM) and were randomly assigned to complete a knee extension exercise at: 1) high intensity (75% of a 1 Repetition Maximum (RM), 2) low intensity (30% 1RM), or 3) Quiet Rest. PPT was measured between each set at a local (quadriceps) and distant (trapezius) site during the intervention. CPM was then repeated after the intervention. To test the first purpose of the study, a three-way ANOVA examined for time x site x intervention interaction effects. To examine for changes in CPM by group, a mixed-model ANOVA was performed. Finally, a Pearson Correlation examined the association between baseline pain sensitivity and response to each intervention.

RESULTS

Time x site x intervention interaction effects were not significant (F(5.3, 150.97) = 0.87, p = 0.51, partial eta2 = 0.03). CPM did not significantly change after the interventions (time x intervention F(1,38) = 0.81, p = 0.37, partial eta2 = 0.02. EIH effects at the quadriceps displayed a significant, positive moderate association with baseline HPT applied over the trapezius (r = 0.61, p<0.01) and TS (r = 0.46, p = 0.04).

DISCUSSION

In healthy participants, PPT and CPM did not significantly differ after a leg extension exercise performed at a high intensity, low intensity, or quiet rest condition. It is possible pre-intervention CPM testing with a noxious stimuli may have impaired inhibitory effects frequently observed during exercise but future research would need to examine this hypothesis.

Evaluating and Characterizing the Scope of Care for Interventions Labeled as Manual Therapy in Low Back Pain Trials: A Scoping Review

OBJECTIVE

The purpose of this scoping review was to evaluate and characterize the scope of care for low back pain that falls under the specific label of manual therapy.

METHODS

PubMed database, Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and SPORTDiscus were searched from journal inception through May 2022 for randomized controlled trials that investigated the treatment of low back pain using manual therapy. Terminology used to define manual therapy was extracted and categorized by using only the words included in the description of the intervention. An expert consultation phase was undertaken to gather feedback.

RESULTS

One hundred seventy-six trials met final inclusion criteria, and 169 unique terms labeled as manual therapy for the treatment of low back pain were found. The most frequent terms were mobilization (29.0%), manipulation (16.0%), and thrust (6.4%). Eight percent of trials did not define or specify what type of manual therapy was used in the study. After removing duplicates, 169 unique terms emerged within 18 categories.

CONCLUSIONS

Manual therapy intervention labels used in low back pain trials are highly variable. With such variation, the heterogeneity of the intervention in trials is likely large, and the likelihood that different trials are comparing the same interventions is low. Researchers should consider being more judicious with the use of the term manual therapy and provide greater detail in titles, methods, and supplementary appendices in order to improve clarity, clinical applicability, and usefulness of future research.

IMPACT

The ability to interpret and apply findings from manual therapy-related research for low back pain is challenging due to the heterogeneity of interventions under this umbrella term. A clear use of terminology and description of interventions by researchers will allow for improved understanding for the role of manual therapy in managing back pain.

Measuring Ultrasonographic Thickness of the Achilles Tendon Insertion Is Less Reliable Than the Midportion in Healthy Tendons and Patients With Tendinopathy

INTRODUCTION

Ultrasound is the preferred imaging method in the diagnostic process of Achilles tendinopathy (AT). Ultrasound tissue characterization (UTC) is a frequently used, standardized and valid method to assess tendon geometry in AT patients. It is unknown whether UTC is reliable for measuring Achilles tendon thickness. The aim of the study was to assess intra- and inter-rater reliability of Achilles tendon thickness measurements using UTC in both asymptomatic individuals and patients with AT, and to evaluate if the reliability of thickness measurements differs between the midportion and insertional area.

METHODS

Exactly 50 patients with AT and 50 asymptomatic individuals were included. Using the conventional US and standardized UTC procedure maximum thickness was measured in the midportion and insertion region. To determine inter- and intra-rater reliabilities, the intraclass correlation coefficient (ICC) was used.

RESULTS

The ICC values for inter- and intra-rater reliability were classified as "excellent," for the AT group (0.93 [95% CI: 0.88-0.96] and 0.95 [0.92-0.97]) and asymptomatic participants (0.91 [0.87-0.94] and 0.94 [0.92-0.96]). The reliability of measuring tendon thickness in the midportion region was "excellent," with both inter-rater (0.97 [0.95-0.98]) and intra-rater (0.98 [0.96-0.99]) ICC values indicating high levels of agreement. In the insertional region, ICC values for inter-rater (0.79 [0.69-0.87]) and intra-rater (0.89 [0.84-0.93]) reliability were "moderate to good."

CONCLUSION

We showed excellent reliability for measuring the US thickness of the midportion and good reliability of measuring the insertional region in patients with AT. Significantly lower ICCs were observed for the reliability of thickness measurements in the insertional region when compared with the midportion.

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

Behaviour change and rehabilitation adherence in adults with tendinopathy: a scoping review

PURPOSE

This scoping review aimed to identify behaviour change strategies influencing rehabilitation adherence in adults with tendinopathy, a common musculoskeletal condition requiring prolonged rehabilitation with poor adherence and variable outcomes.

METHODS

Following the Joanna Briggs Institute (JBI) methodology, seven databases were searched until April 2023. Records included reviews, intervention, and qualitative studies published in English. Behaviour change strategies were deductively coded and mapped to the capability, opportunity, and motivation model of behaviour (COM-B).

RESULTS

Eighty-six articles were retained. The primary behaviour change strategies in tendinopathy rehabilitation reports addressed Psychological Capability; from knowledge through education, instruction, and self-monitoring using exercise diaries. Also, Social Opportunity involves demonstration and monitoring of rehabilitation behaviour, and Physical Opportunity focuses on time-efficient programs with access to equipment and health professionals. Few reports addressed Automatic Motivation (positive reinforcement and habit formation). Barriers identified in the reports were Reflective Motivation (negative beliefs and fears), Physical Opportunity (time-constraints), and Physical Capability (pain and comorbidities).

CONCLUSIONS

Further research should explore the impact of education on beliefs, fears, and pain-management, as well as the effectiveness of teaching habit formation for improved time-management. Implementing these behaviour change strategies may enhance tendinopathy rehabilitation adherence, improving clinical trial efficacy, guiding clinical practice, and impacting patient outcomes.

Current practice, guideline adherence, and barriers to implementation for Achilles tendinopathy rehabilitation: a survey of physical therapists and people with Achilles tendinopathy

Objective

To explore clinical practice patterns of physical therapists (PTs) who treat people with Achilles tendinopathy (AT), and identify perceived barriers and facilitators for prescribing and engaging with therapeutic exercise among PTs and people with AT.

Methods

Two cross-sectional surveys were electronically distributed between November 2021 and May 2022; one survey was designed for PTs while the second was for people with AT. Survey respondents answered questions regarding their physical therapy training and current practice (PTs), injury history and management (people with AT), and perceived barriers and facilitators (PTs and people with AT).

Results

341 PTs and 74 people with AT completed the surveys. In alignment with clinical practice guidelines, more than 94% of PTs surveyed (97% of whom had some form of advanced musculoskeletal training) prioritise patient education and therapeutic exercise. Patient compliance, patient knowledge, and the slow nature of recovery were barriers to prescribing therapeutic exercise reported by PTs, while time, physical resources, and a perceived lack of short-term treatment effectiveness were barriers for people with AT.

Conclusions

Consistent with clinical practice guidelines, PTs with advanced training reported prioritising therapeutic exercise and education for managing AT. However, both PTs and people with AT identified many barriers to prescribing or engaging with therapeutic exercise. By addressing misconceptions about the time burden and ineffectiveness of exercise, and by overcoming access issues to exercise space and equipment, PTs may be able to improve intervention adherence and subsequently outcomes for people with AT.

Assessing calf exercise fidelity among people with Achilles tendinopathy using videos recorded via Zoom®: an observational study

PURPOSE

Exercise fidelity is a fundamental aspect of exercise prescription by physiotherapists. Assessing exercise fidelity via telehealth (videoconference) is potentially useful but its reproducibility has not been assessed. The objective was to evaluate agreement (reproducibility) of video rating of calf exercise fidelity within (over four weeks) and between telehealth raters and compared with live rating.

METHODS

Nineteen videos of participants with AT undertaking calf exercises were rated by physiotherapists in person (live) and by watching pre-recorded videos (replicating telehealth). Three forms of agreement were assessed: (i) between live assessment and recorded video (telehealth) assessment; (ii) between telehealth raters (inter-rater); (iii) agreement within telehealth raters over four weeks (intra-rater).

RESULTS

There was weak to almost perfect agreement (Kappa = 0.65 to 1.00, rater 1, Kappa = 0.57 to 1.00, rater 2) between the telehealth and live raters. There was moderate to almost perfect agreement (Kappa = 0.65 to 1.00) when assessing intra-rater reliability, aside from one of the six criteria (quality of movement).

CONCLUSION

Assessing calf exercise fidelity via videos recorded on Zoom® appears to demonstrate weak or greater agreement versus live rating and over time. Inter-rater agreement was lower, suggesting that the criteria developed may be better suited to use by individual raters over time.Implications for rehabilitationTelehealth assessment (when compared with live, in person assessment) shows a moderate or greater agreement for the majority of assessment criteria when assessing calf exercise fidelity.The calf exercise fidelity criteria developed can be used as an adjunct to assessment and management of people with Achilles Tendinopathy.Intra-rater assessment was shown to be moderately or more consistent over a four-week period when assessing calf exercise fidelity.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Effects of a 12-week gait retraining program on the Achilles tendon adaptation of habitually shod runners

PURPOSE

This study investigated the effects of a 12-week gait retraining program on the morphological and mechanical properties of the Achilles tendon (AT) during running on the basis of real-time dynamic ultrasound imaging.

METHODS

A total of 30 male recreational runners who were used to wearing cushioned shoes with a rearfoot strike (RFS) pattern were recruited. They were randomized into a retraining group (RG, n = 15) and a control group (CG, n = 15). The RG group was asked to run in five-fingered minimalist shoes with a forefoot strike (FFS) pattern, and the CG group was asked to keep their strike pattern. Three training sessions were performed per week. All the participants in RG uploaded running tracks obtained through a mobile application (.jpg) after each session for training supervision. The ground reaction force, kinematics, and kinetics of the ankle joint at 10 km/h were collected using an instrumented split-belt treadmill and a motion capture system. The morphological (length and cross-sectional area) and mechanical characteristics (force, stress, strain, etc.) of AT in vivo were recorded and calculated with a synchronous ultrasonic imaging instrument before and after the intervention. Repeated two-way ANOVA was used to compare the aforementioned parameters.

RESULTS

A total of 28 participants completed the training. The strike angle of RG after training was significantly smaller than that before training and significantly smaller than that of CG after training (F (1, 13)  = 23.068, p < 0.001, partial η2  = 0.640). The length (F (1, 13)  = 10.086, p = 0.007, partial η2  = 0.437) and CSA (F (1, 13)  = 7.475, p = 0.017, partial η2  = 0.365) of AT in RG increased after training. A significant main effect for time was observed for the time-to-peak AT force (F (1, 13)  = 5.225, p = 0.040, partial η2  = 0.287), average (F (1, 13)  = 7.228, p = 0.019, partial η2  = 0.357), and peak AT loading rate (F (1, 13)  = 11.687, p = 0.005, partial η2  = 0.473).

CONCLUSION

Preliminary evidence indicated that a 12-week gait retraining program could exert a beneficial effect on AT. 57% (8/14) runners in RG shifted from RFS to FFS pattern. Although not all runners were categorized as FFS pattern after the intervention, their foot strike angle was reduced. Retraining primarily positively promoted AT morphological properties (i.e., CSA and length) to strengthen AT capability for mechanical loading.

Which Psychological and Psychosocial Constructs Are Important to Measure in Future Tendinopathy Clinical Trials? A Modified International Delphi Study With Expert Clinician/Researchers and People With Tendinopathy

OBJECTIVE: To identify which psychological and psychosocial constructs to include in a core outcome set to guide future clinical trials in the tendinopathy field. DESIGN: Modified International Delphi study. METHODS: In 3 online Delphi rounds, we presented 35 psychological and psychosocial constructs to an international panel of 38 clinician/researchers and people with tendinopathy. Using a 9-point Likert scale (1 = not important to include, 9 = critical to include), consensus for construct inclusion required ≥70% of respondents rating "extremely critical to include" (score ≥7) and ≤15% rating "not important to include" (score ≤3). Consensus for exclusion required ≥70% of respondents rating "not important to include" (score ≤3) and ≤15% of rating "critical to include" (score ≥7). RESULTS: Thirty-six participants (95% of 38) completed round 1, 90% (n = 34) completed round 2, and 87% (n = 33) completed round 3. Four constructs were deemed important to include as part of a core outcome set: kinesiophobia (82%, median: 8, interquartile range [IQR]: 1.0), pain beliefs (76%, median: -7, IQR: 1.0), pain-related self-efficacy (71%, median: 7, IQR: 2.0), and fear-avoidance beliefs (73%, median: -7, IQR: 1.0). Six constructs were deemed not important to include: perceived injustice (82%), individual attitudes of family members (74%), social isolation and loneliness (73%), job satisfaction (73%), coping (70%), and educational attainment (70%). Clinician/researchers and people with tendinopathy reached consensus that kinesiophobia, pain beliefs, pain self-efficacy, and fear-avoidance beliefs were important psychological constructs to measure in tendinopathy clinical trials. J Orthop Sports Phys Ther 2024;54(1):1-12. Epub 20 September 2023. doi:10.2519/jospt.2023.11903.

Hip and knee kinematics, center of pressure position, and ground reaction force are associated with Achilles tendon force during jump landing

PURPOSE

Jump-landing exercises are often performed during the rehabilitation of Achilles tendon (AT) injuries. However, the factors that affect the AT force (ATF) during landing are unclear. This study aimed to determine the kinematics and ground reaction force (GRF) variables associated with the peak ATF during a drop vertical jump (DVJ).

METHODS

The landing phase of DVJ was evaluated in 101 healthy participants (46 males, age: 21.2 ± 1.4 years old) using a three-dimensional motion analysis system with two force plates. ATF was estimated from the ankle flexion angle and moment. Univariate and multivariate regression analyses were performed with the peak ATF as the dependent variable. The vertical GRF (VGRF), center of pressure (COP), forward trunk leaning, hip/knee/ankle joint angles at peak ATF, and sex were used as independent variables.

RESULTS

In the univariate regression analysis, larger VGRF (β = 0.813), more anterior COP position (β = 0.214), smaller knee flexion (β = -0.251) and adduction (β = -0.252), smaller hip flexion (β = -0.407), smaller forward trunk lean (β = -0.492), and male sex (β = -0.282) were significantly associated with a larger peak ATF. Multivariate analysis revealed that larger VGRF (β = 1.018), more anterior COP position (β = 0.320), a larger knee (β = 0.442), and smaller hip flexion (β = -0.205) were associated with the larger peak ATF.

CONCLUSIONS

The VGRF, COP position, and knee and hip flexion were independently associated with ATF. Modifying these factors may be useful in managing tendon loading during jump-landing exercises.

Diagnostic Imaging for Achilles Tendinopathy: Unnecessary Scans? Valuable Insights? Multidisciplinary Clinician-Scientists Present a Nuanced View

SYNOPSIS: Clinical practice guidelines for Achilles tendinopathy do not recommend imaging to inform diagnosis. However, there is considerable variation in how imaging is used, particularly in research and sports. Early imaging risks that people who see the images presume that what they "see" as pathology is the primary cause of pain; patients might end up receiving invasive treatments on the basis of the image when rehabilitation may suffice. On the other hand, imaging can help rule out Achilles tendinopathy and identify differential diagnoses. As more rehabilitation clinicians are direct access practitioners and take on expanded roles as primary health practitioners, ultrasound imaging might serve as a valuable point-of-care tool for diagnosis, identifying conditions that warrant referral and managing conditions like Achilles tendinopathy. We argue that the value of ultrasound imaging to diagnose tendinopathy outweighs the potential limitations. J Orthop Sports Phys Ther 2024;54(1):1-4. Epub 16 November 2023. doi:10.2519/jospt.2023.12255.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Dynamic Ankle Orthosis Reduces Tibial Compressive Force and Increases Ankle Motion Compared With a Walking Boot

PURPOSE

Tibial bone stress injuries are a common overuse injury among runners and military cadets. Current treatment involves wearing an orthopedic walking boot for 3 to 12 wk, which limits ankle motion and leads to lower limb muscle atrophy. A dynamic ankle orthosis (DAO) was designed to provide a distractive force that offloads in-shoe vertical force and retains sagittal ankle motion during walking. It remains unclear how tibial compressive force is altered by the DAO. This study compared tibial compressive force and ankle motion during walking between the DAO and an orthopedic walking boot.

METHODS

Twenty young adults walked on an instrumented treadmill at 1.0 m·s -1 in two brace conditions: DAO and walking boot. Three-dimensional kinematic, ground reaction forces, and in-shoe vertical force data were collected to calculate peak tibial compressive force. Paired t -tests and Cohen's d effect sizes were used to assess mean differences between conditions.

RESULTS

Peak tibial compressive force ( P = 0.023; d = 0.5) and Achilles tendon force ( P = 0.017; d = 0.5) were moderately lower in the DAO compared with the walking boot. Sagittal ankle excursion was 54.9% greater in the DAO compared with the walking boot ( P = 0.05; d = 3.1).

CONCLUSIONS

The findings from this study indicated that the DAO moderately reduced tibial compressive force and Achilles tendon force and allowed more sagittal ankle excursion during treadmill walking compared with an orthopedic walking boot.

Plantar Flexor Weakness and Pain Sensitivity Cannot Be Assumed in Midportion Achilles Tendinopathy

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.

The VISA-A (sedentary) should be used for sedentary patients with Achilles tendinopathy: a modified version of the VISA-A developed and evaluated in accordance with the COSMIN checklist

OBJECTIVE

To develop and evaluate a modified version of the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire, for use in sedentary patients with Achilles tendinopathy, using the Consensus-based Standards for the selection of health Measurement Instruments recommendations.

METHODS

Twenty-two sedentary patients with Achilles tendinopathy completed the VISA-A and provided feedback regarding the relevance, comprehensiveness and comprehensibility of each item, response options and instructions. Patient and professional feedback was used to develop the VISA-A (sedentary) questionnaire. Reliability, validity and responsiveness of the VISA-A (sedentary) was evaluated in 51 sedentary patients with Achilles tendinopathy: 47.1% women, mean age 64.8 (SD 11.24).

RESULTS

Factor analysis identified two dimensions (symptoms and activity) for the VISA-A (sedentary). Test-retest reliability was excellent for symptoms (intraclass correlation coefficient, ICC=0.991) and activity (ICC=0.999). Repeatability was 1.647 for symptoms and 0.549 for activity. There was a significant difference between the VISA-A and VISA-A (sedentary) scores both pretreatment and post-treatment. There was stronger correlation between the pretreatment to post-treatment change in the VISA-A (sedentary) scores (r=0.420 for symptoms, r=0.407 for activity) and the global rating of change than the VISA-A scores (r=0.253 for symptoms, r=0.186 for activity).

CONCLUSION

The VISA-A (sedentary) demonstrates adequate reliability, validity and responsiveness in sedentary patients with Achilles tendinopathy. The VISA-A (sedentary) is a more appropriate measure than the VISA-A for this cohort and is recommended for clinical and research purposes.

Growth factors in the treatment of Achilles tendon injury

Achilles tendon (AT) injury is one of the most common tendon injuries, especially in athletes, the elderly, and working-age people. In AT injury, the biomechanical properties of the tendon are severely affected, leading to abnormal function. In recent years, many efforts have been underway to develop effective treatments for AT injuries to enable patients to return to sports faster. For instance, several new techniques for tissue-engineered biological augmentation for tendon healing, growth factors (GFs), gene therapy, and mesenchymal stem cells were introduced. Increasing evidence has suggested that GFs can reduce inflammation, promote extracellular matrix production, and accelerate AT repair. In this review, we highlighted some recent investigations regarding the role of GFs, such as transforming GF-β(TGF-β), bone morphogenetic proteins (BMP), fibroblast GF (FGF), vascular endothelial GF (VEGF), platelet-derived GF (PDGF), and insulin-like GF (IGF), in tendon healing. In addition, we summarized the clinical trials and animal experiments on the efficacy of GFs in AT repair. We also highlighted the advantages and disadvantages of the different isoforms of TGF-β and BMPs, including GFs combined with stem cells, scaffolds, or other GFs. The strategies discussed in this review are currently in the early stages of development. It is noteworthy that although these emerging technologies may potentially develop into substantial clinical treatment options for AT injury, definitive conclusions on the use of these techniques for routine management of tendon ailments could not be drawn due to the lack of data.

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

OBJECTIVE

This scoping review describes resistance-based therapeutic exercise intervention characteristics for Achilles tendinopathy (AT) treatment (e.g., therapeutic dose, underlying mechanisms targeted by exercise) and assesses participant reporting characteristics.

METHODS

Seven electronic databases were searched; studies delivering a resistance exercise-focused treatment for individuals with AT were included. The Template for Intervention Description and Replication (TIDieR) and the ICON 2019 'Recommended standards for reporting participant characteristics in tendinopathy research' checklists framed data extraction, and study quality was assessed using the Mixed Methods Appraisal Tool 2018 version.

RESULTS

68 publications (describing 59 studies and 72 exercise programs) were included. Results demonstrate that therapeutic exercise interventions for AT are well reported according to the TIDieR checklist, and participant characteristics are well reported according to the ICON checklist. Various underlying therapeutic mechanisms were proposed, with the most common being increasing tendon strength, increasing calf muscle strength, and enhancing collagen synthesis.

CONCLUSIONS

While evidence suggests that resistance-based therapeutic exercise interventions are effective in treating AT, more reporting on program fidelity, adherence, and compliance is needed. By summarizing currently published AT exercise programs and reporting key intervention characteristics in a single location, this review can assist clinicians in developing individualized resistance training programs for people with AT.

Monitoring physical activity using wearable technology in people with Achilles tendinopathy undergoing physiotherapy treatment: A feasibility prospective cohort study

OBJECTIVES

Physical activity modification is an important part of the management of Achilles tendinopathy. However, to our knowledge, there is a lack of evidence on objective physical activity assessment in Achilles tendinopathy. The purpose of this study is to (1) assess feasibility of using an inertial measurement unit (IMU) to monitor physical activity and IMU-derived biomechanical measures over 12-week treatment course by a physiotherapist; (2) conduct a preliminary analysis of changes in physical activity over 12-weeks.

DESIGN

A feasibility prospective cohort study SETTING: A community setting.

PARTICIPANTS

People with Achilles tendinopathy who had recently commenced (≤2 sessions), or were about to commence, treatment with a physiotherapist MAIN OUTCOME MEASURES: Participants wore a shank-mounted IMU on the affected side for one week at baseline, 6-, and 12-week follow-ups. The outcomes were pain/symptom severity, IMU-derived physical activity and biomechanical measures (stride rate, peak shank angular velocity, and peak shank acceleration).

RESULTS

Thirty participants were recruited. There was a high retention rate (97%), response rate (97%), and IMU wear compliance at each timepoint (>93%). For pain/symptom severity, a significant time effect was observed between baseline and 12-week follow-up. Physical activity and IMU-derived biomechanical measures did not change over 12 weeks. Physical activity decreased at the 6-week follow-up but only returned to the baseline level at 12-week follow-up.

CONCLUSIONS

A larger-scale cohort study assessing clinical outcomes and physical activity appears feasible. Preliminary data indicate that physical activity may not change significantly over 12-weeks in people undergoing physiotherapy management for Achilles tendinopathy. CONTRIBUTION OF THE PAPER.

Validation of a bluetooth-enabled load cell for objective and accessible assessment of lower extremity strength

High magnitude loading from performing resistance-based exercise has been found to improve tendon strength and reduce symptoms of Achilles tendinopathy (AT) but is difficult to quantify without specialist equipment. Here, we assess the validity and reliability of a novel AT rehabilitation tool (the "PhysViz" system) compared to a "gold-standard" dynamometer for assessing plantarflexion maximal voluntary isometric contractions (MVIC). 41 participants aged 18-60 completed the study. A within-subject test-retest study design was used to examine and compare the validity and reliability of the two systems during plantarflexion MVICs. Test - retest reliability of the two methods were determined by calculating intra-class correlation coefficients (ICCs) and 95% confidence intervals. Method agreement was assessed with Bland - Altman Limits of Agreement (LoA) analysis. The PhysViz demonstrated excellent test-retest reliability; ICC, SEM and MDC were numerically comparable to the dynamometer (ICC 0.93 vs. 0.92; SEM 2.01 vs. 2.95 kg and MDC 5.58 vs. 8.18 kg, respectively), indicating that the novel system is valid and reliable for measuring plantarflexor MVICs. Future studies should address its utility in monitoring AT rehabilitative loading remotely over time.

Added mass increases Achilles tendon stress in female runners

CONTEXT

Achilles tendon (AT) injuries are common in female runners and military personnel where increased AT loading may be a contributing factor. Few studies have examined AT stress during running with added mass. The purpose was to examine the stress, strain, and force placed on the AT, kinematics and temporospatial variable in running with different amounts of added mass.

DESIGN

Repeated measure design METHODS: Twenty-three female runners with a rear-foot strike pattern were participants. AT stress, strain, and force were measured during running using a musculoskeletal model that used kinematic (180 Hz) and kinetic data (1800 Hz) as input. Ultrasound data were used to measure AT cross sectional area. A repeated measures multivariate analysis of variance (α = 0.05) was used on AT loading variables, kinematics and temporospatial variables.

RESULTS

Peak AT stress, strain, and force were greatest during the 9.0 kg added load running condition (p < .0001). There was a 4.3% and 8.8% increase in AT stress and strain during the 4.5 kg and 9.0 kg added load conditions, respectively, compared to baseline. Kinematics at the hip and knee changed with added load but not at the ankle. Small changes in temporospatial variables were seen.

CONCLUSION

Added load increased stress on the AT during running. There may be an increased risk for AT injury with added load. Individuals may consider slowly progressing training with added load to allow for increased AT loading.

The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis

Background

Tendinopathy is a growing global concern affecting many people, like athletes, workers, and the elderly. Despite its commonality among the sporting population, there is no practical clinical guideline for patellar tendinopathy (PT). Furthermore, there is conflicting evidence between clinical guidelines on shockwave therapy's application and clinical utility for Achilles tendinopathy (AT) and plantar fasciitis (PF). Thus, our aim of this study is to evaluate the evidence for shockwave therapy; to provide a Grading of Recommendation, Assessment, Development and Evaluation (GRADE) level of the evidence and effectiveness of shockwave therapy for patellar tendinopathy, Achilles tendinopathy, and Plantar fasciitis.

Method

Medical Literature Analysis and Retrieval System Online (Medline), Embase, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro) and China National Knowledge Infrastructure database (CNKI) were searched to find relevant studies published before December 14th, 2022.

Results

Our study showed that for PT in the short term, extracorporeal shockwave therapy (ESWT) or ESWT + eccentric exercise (EE) has a negligible effect on pain and function compared to a placebo or placebo + EE. On the contrary, ESWT significantly affects pain compared to conservative treatment (CT). For AT, ESWT has a small inconclusive effect on pain and function in the short term compared to EE. On the other hand, a placebo outperformed ESWT in improving function for AT but not pain outcomes. PF showed that ESWT significantly affects short- and long-term pain and function. When ESWT was compared to other interventions such as low laser therapy (LLLT), corticosteroid injection (CSI), or CT, there was a small inconclusive effect on pain and function in the short term.

Conclusion

There is low-moderate evidence that ESWT has a negligible effect on pain and function for PT and AT. However, high-quality evidence suggests ESWT has a large effect on pain and function for PF.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023396835, identifier CRD42023396835.

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

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

Reliability and validity of two-dimensional motion capture to assess ankle dorsiflexion motion and heel raise work

OBJECTIVES

To determine the inter-rater reliability and criterion validity of two-dimensional (2D) measures of ankle function in the sagittal plane for participants with Achilles tendinopathy (AT).

DESIGN

Cohort study.

SETTING

University Laboratory, Participants, Adults with AT (N = 18, Women: 72.2%, Age = 43.4 ± 15.8 years, BMI = 28.7 ± 8.9 kg/m2) MAIN OUTCOME MEASURES: Reliability and validity were determined with intra-class correlation coefficients (ICC), standard error of the measurement (SEM), minimal detectable change (MDC), and Bland-Altman plots for ankle dorsiflexion and positive work during heel raises.

RESULTS

Inter-rater reliability between three raters for all 2D motion analysis tasks was good to excellent (ICC = 0.88 to 0.99). Criterion validity between 2D and 3D motion analyses for all tasks was good to excellent (ICC = 0.76 to 0.98). 2D motion analysis overestimated ankle dorsiflexion motion by 1.0-1.7° (3% of mean sample value) and positive ankle joint work by 76.8 J (9% of mean) compared to 3D motion analysis.

CONCLUSION

Although 2D and 3D measures are not interchangeable, the good to excellent reliability and validity of 2D measures in the sagittal plane support the use of video analysis to quantify ankle function for individuals with foot and ankle pain.

Effect of Symptom Duration on Injury Severity and Recovery in Patients With Achilles Tendinopathy

Background

Achilles tendinopathy is a common overuse condition. Distinguishing between early- and late-stage tendinopathy may have implications on treatment decisions and recovery expectations.

Purpose

To compare the effects of time and baseline measures of tendon health on outcomes among patients with varying symptom durations after 16 weeks of comprehensive exercise treatment.

Study Design

Cohort study; Level of evidence, 3.

Methods

Participants (N = 127) were categorized into 4 groups based on the number of months since symptom onset: ≤3 months (n = 24); between >3 and ≤6 months (n = 25); between >6 and ≤12 months (n = 18); or >12 months (n = 60). All participants received 16 weeks of standardized exercise therapy and pain-guided activity modification. Outcomes representing symptoms, lower extremity function, tendon structure, mechanical properties, psychological factors, and patient-related factors were assessed at baseline and at 8 and 16 weeks after the initiation of exercise therapy. Chi-square tests and 1-way analysis of variance were used to compare baseline measures between groups.Time, group, and interaction effects were evaluated using linear mixed models.

Results

The mean age of the participants was 47.8 ± 12.6 years, 62 participants were women, and symptoms ranged from 2 weeks to 274 months. No significant differences were found among symptom duration groups at baseline for any measure of tendon health. At 16 weeks, all groups demonstrated improvements in symptoms, psychological factors, lower extremity function, and tendon structure, with no significant differences among the groups (P > .05).

Conclusion

Symptom duration did not influence baseline measures of tendon health. Additionally, no differences were observed among the different symptom duration groups in response to 16 weeks of exercise therapy and pain-guided activity modification.

Return to Sports and Functional Outcomes after Autologous Platelet-Rich Fibrin Matrix (PRFM) and Debridement in Midportion Achilles Tendinopathy: A Case Series with 24-Month Follow-Up

(1) Background: Achilles tendinopathy (AT) is characterized by load-induced tendon pain, stiffness, and functional impairment that may affect the tendon midportion or insertion. Platelet-rich fibrin matrix (PRFM) is a promising adjunctive therapy for AT. We analyzed 24-month pain and functional outcomes in a cohort of patients managed by tendon debridement and autologous PRFM application to determine whether the combined treatment ensured an early return to sports/work and satisfactory clinical outcomes and functional scores. (2) Methods: The 24-month outcomes of 32 sport-practicing patients with chronic midportion AT treated with debridement and autologous PRFM were evaluated in terms of time to return to sports/work. The AOFAS and VISA-A were computed preoperatively and at 6 and 24 months. Blazina scores were evaluated preoperatively and at 6 months; ankle range of motion was assessed at 1, 6, 12, 24 months; and patient satisfaction was assessed at 24 months. (3) Results: Altogether, all patients had resumed their sport(s) activity, at the same or higher level, after 25.41 days (±5.37). Regarding work, all patients were able to return to their jobs after 16.41 days (±2.43). Ankle dorsiflexion and plantarflexion increased significantly: the AOFAS rose from 54.56 (±6.47) to 97.06 (±4.06) and 98.88 (±2.21) at 6 and 12 months, respectively, and the mean VISA-A score rose from 69.16 (±7.35) preoperatively to 95.03 (±4.67) and 97.28 (±2.43) at 6 and 12 months, respectively, after treatment. There were no complications. Most (90.62%) patients were very satisfied. (4) Conclusions: In symptomatic midportion AT, surgical debridement and autologous PRFM ensured a fast return to sports/work (4 weeks), significantly improving AOFAS and VISA-A and Blazina scores already at 6 months and providing excellent clinical outcomes at 24 months.

Victorian Institute of Sport Assessment-Achilles thresholds for minimal important change and return to presymptom activity level in active soldiers with mid-portion Achilles tendinopathy

INTRODUCTION

Mid-portion Achilles tendinopathy (mid-AT) is common in soldiers, significantly impacting activity levels and operational readiness. Currently, Victorian Institute of Sport Assessment-Achilles (VISA-A) represents the gold standard to evaluate pain and function in mid-AT. Our objective was to estimate VISA-A thresholds for minimal important change (MIC) and patient-acceptable symptom state for return to the presymptom activity level (PASS-RTA), in soldiers treated with a conservative programme for mid-AT.

METHODS

A total of 40 soldiers (40 unilateral symptomatic Achilles tendons) were included in this prospective cohort study. Pain and function were evaluated using VISA-A. Self-perceived recovery was assessed with the Global Perceived Effect scale. The predictive modelling method (MIC-predict) was used to estimate MIC VISA-A post-treatment (after 26 weeks) and after 1 year of follow-up. The post-treatment PASS-RTA VISA-A was estimated using receiver operating characteristic statistics. The PASS-RTA was determined by calculating Youden's index value closest to 1.

RESULTS

The adjusted MIC-predict was 6.97 points (95% CI 4.18 to 9.76) after 26 weeks and 7.37 points (95% CI 4.58 to 10.2) after 1 year of follow-up post-treatment.The post-treatment PASS-RTA was 95.5 points (95% CI 92.2 to 97.8).

CONCLUSIONS

A VISA-A change score of 7 points, post-treatment and at 1 year of follow-up, can be considered a minimal within-person change over time, above which soldiers with mid-AT perceive themselves importantly changed. Soldiers consider their symptoms to be acceptable for return to their presymptom activity level at a post-treatment VISA-A score of 96 points or higher.

TRIAL REGISTRATION NUMBER

NL69527.028.19.

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

OBJECTIVES

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

DESIGN

Cross-sectional.

SETTING

Laboratory.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

The relationship between psychological, cognitive, and contextual factors and rehabilitation outcomes in Achilles tendinopathy: A prospective feasibility cohort study

OBJECTIVES

This study aimed to investigate the feasibility of conducting a full-scale study investigating the influence of patient-related factors on rehabilitation outcomes in Achilles tendinopathy (AT). A secondary aim was to investigate preliminary relationships between patient-related factors and clinical outcomes at 12- and 26- weeks.

DESIGN

feasibility cohort.

SETTING

Australian healthcare settings.

METHODS

Participants with AT receiving physiotherapy in Australia were recruited via treating physiotherapists and online. Data were collected online at baseline, 12- and 26-weeks. Progression criteria for a full-scale study were recruitment rate of ≥10 per month, conversion rate ≥20%, and response rate to questionnaires ≥80%. The relationship between patient-related factors and clinical outcomes was investigated using Spearman's rho correlation coefficient.

RESULTS

The average recruitment rate was 5/month, conversion rate was 97%, and response rate to questionnaires was ≥97% at all timepoints. There was a fair to moderate correlation (rho = 0.225 to 0.683) between patient-related factors and clinical outcomes at the 12-week, but no to weak correlation at the 26-week (rho = 0.002 to 0.284).

CONCLUSIONS

Feasibility outcomes suggest a future full-scale cohort study is feasible with the caveat of utilizing strategies to improve recruitment rate. Preliminary bivariate correlations at 12-weeks warrant further investigations in larger studies.

What is the Incidence of Subsequent Adjacent Joint Injury After Patellofemoral Pain?

OBJECTIVE

To investigate the incidence of subsequent lumbar spine, hip, and ankle-foot injuries after a diagnosis of patellofemoral pain.

DESIGN

Retrospective cohort study.

SETTING

Military Health System.

PARTICIPANTS

Individuals (n = 92,319) ages 17-60 diagnosed with patellofemoral pain between 2010-2011.

INTERVENTIONS

Therapeutic exercise.

MAIN OUTCOME MEASURES

Frequency of adjacent joint injuries in the 2-year period after initial patellofemoral pain injury, and hazard ratios (HR) with 95% confidence interval (CI) and Kaplan-Meier survival curves for risk of adjacent joint injury based on receiving therapeutic exercise for the initial injury.

RESULTS

After initial patellofemoral pain diagnosis, 42,983 (46.6%) individuals sought care for an adjacent joint injury. Of these, 19,587 (21.2%) were subsequently diagnosed with a lumbar injury, 2837 (3.1%) a hip injury, and 10,166 (11.0%) an ankle-foot injury. One in five (19.5%; n = 17,966) received therapeutic exercise which reduced the risk of having a subsequent lumbar (HR = 0.78, 95% CI 0.76-0.81), hip (HR = 0.93, 95% CI 0.87-0.98) or ankle-foot (HR = 0.86, 95% CI 0.83-0.90) injury.

CONCLUSION

The results suggest that a high number of individuals with patellofemoral pain will sustain an adjacent joint injury within 2 years although causal relationships cannot be determined. Receiving therapeutic exercise for the initial knee injury reduced the risk of sustaining an adjacent joint injury. This study helps provide normative data for subsequent injury rates in this population and guide development of future studies designed to understand causal factors.

The load borne by the Achilles tendon during exercise: A systematic review of normative values

The Achilles tendon (AT) can be exposed to considerable stress during athletic activities and is often subject to pathologies such as tendinopathies. When designing a prevention or rehabilitation protocol, mechanical loading is a key factor to consider. This implies being able to accurately determine the load applied to the AT when performing exercises that stress this tendon. A systematic review was performed to synthesize the load borne by the AT during exercises/activities. Three databases (Pubmed, Embase and Cochrane) were searched for articles up to May 2021, and only the studies assessing the AT load in newtons relative to body-weight (BW) on humans during activities or exercises were included. Most of the 11 included studies assessed AT load when running or walking (N = 10), and only three tested exercises were usually performed during rehabilitation. The load on the tendon ranged from 2.7 to 3.95 BW when walking, from 4.15 to 7.71 BW when running, and from 0.41 to 7.3 BW according to the strengthening exercise performed. From the collected data, a progression of exercises progressively loading the Achilles tendon, as well as the possible connections with walking and running activities, could be defined. However, the trends highlighted in the relationship between tendon loading and walking or running speeds present some inconsistencies. Further research is still needed to clarify them, but also to complete the data set in healthy and injured people.

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

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

Meniscal procedures are not increased with delayed ACL reconstruction and rehabilitation: results from a randomised controlled trial

OBJECTIVE

To assess whether initial non-operative treatment of anterior cruciate ligament (ACL) ruptures with optional delayed ACL reconstruction leads to more meniscal procedures compared with early ACL reconstruction during the 2-year follow-up.

METHODS

We compared the number of meniscal procedures of 167 patients with an ACL rupture, who either received early ACL reconstruction (n=85) or rehabilitation therapy plus optional delayed ACL reconstruction (n=82), participating in the Conservative vs Operative Methods for Patients with ACL Rupture Evaluation trial. Patients were aged 18 to 65 years (mean 31.3, SD 10.5), 60% male sex (n=100). We evaluated the presence and location of meniscal tears by baseline MRI. We analysed and compared how many patients per randomisation group had a meniscal procedure during follow-up in the ACL injured knee, adjusted for sex, body mass index, age group and orthopaedic surgeon.

RESULTS

At baseline, 41% of the entire study population (69/167 patients) had a meniscal tear on MRI. During the 2-year follow-up, 25 patients randomised to early ACL reconstruction (29%, 25/85 patients) had a meniscal procedure, compared with 17 patients randomised to rehabilitation plus optional delayed reconstruction (21%, 17/82 patients) (risk ratio 0.67 with 95% CI 0.40 to 1.12, p=0.12). Of these patients who received early ACL reconstruction (n=82) and patients that received delayed ACL reconstruction (n=41), 5% of the patients had an additional isolated meniscal procedure after ACL reconstruction. In patients who received no ACL reconstruction (n=41), 10% (n=4) had an isolated surgical procedure for a meniscal tear during the 2-year follow-up period.

CONCLUSION

Initial non-surgical treatment of ACL ruptures followed by optional delayed ACL reconstruction does not lead to a higher number of meniscal procedures compared with early ACL reconstruction over a 2-year follow-up period.

TRIAL REGISTRATION NUMBER

NL 2618.

Lower motor unit discharge rates in gastrocnemius lateralis, but not in gastrocnemius medialis or soleus, in runners with Achilles tendinopathy: a pilot study

OBJECTIVES

Deficits in muscle performance could be a consequence of a reduced ability of a motor neuron to increase the rate in which it discharges. This study aimed to investigate motor unit (MU) discharge properties of each triceps surae muscle (TS) and TS torque steadiness during submaximal intensities in runners with Achilles tendinopathy (AT).

METHODS

We recruited runners with (n = 12) and without (n = 13) mid-portion AT. MU discharge rate was analysed for each of the TS muscles, using high-density surface electromyography during 10 and 20% isometric plantar flexor contractions.

RESULTS

MU mean discharge rate was lower in the gastrocnemius lateralis (GL) in AT compared to controls. In AT, GL MU mean discharge rate did not increase as torque increased from 10% peak torque, 8.24 pps (95% CI 7.08 to 9.41) to 20%, 8.52 pps (7.41 to 9.63, p = 0.540); however, in controls, MU discharge rate increased as torque increased from 10%, 8.39 pps (7.25-9.53) to 20%, 10.07 pps (8.89-11.25, p < 0.001). There were no between-group difference in gastrocnemius medialis (GM) or soleus (SOL) MU discharge rates. We found no between-group differences in coefficient of variation of MU discharge rate in any of the TS muscles nor in TS torque steadiness.

CONCLUSION

Our data demonstrate that runners with AT may have a lower neural drive to GL, failing to increase MU discharge rate to adjust for the increase in torque demand. Further research is needed to understand how interventions focussing on increasing neural drive to GL would affect muscle function in runners with AT.

The use of physical function capacity measures in the management of lower limb tendinopathy: A scoping review of expert recommendations

BACKGROUND

Physical function capacity measures are recommended as outcome measures for people with lower limb tendinopathy.

OBJECTIVE

(i) Explore measures of physical function capacity recommended by experts in lower limb tendinopathy (ii) the context they were used, (ii) identify recommended criteria for exercise progression and return to sport or activity.

DESIGN

Scoping Review.

METHOD

Three databases were searched using keywords for lower limb tendinopathy and physical function capacity to identify studies that outlined a progressive exercise rehabilitation program. A 15-item tool was used for data extraction.

RESULTS

26 studies were included, only eight recommended a physical function capacity measure. There were 10 physical function capacity measures identified for a range of lower limb tendinopathies including patellar (50%), Achilles (13%), proximal hamstring (13%), gluteal (13%), combined patellar and Achilles (13%). Pain was the most common criterion that was used to determine the progression of rehabilitation (96%), with physical function capacity measures rarely used (12%).

CONCLUSION

Physical function capacity measures are used infrequently across expert recommended exercise rehabilitation programs. There remains a high reliance on pain as the criterion for progression of exercises during rehabilitation. There is a need to develop measures of physical function capacity to better inform and progress rehabilitation.

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

ABSTRACT

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial Registration: PROSPERO Database; No. CRD42021236107.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00456-5.

Barriers and facilitators to the adoption and implementation of evidence-based injury prevention training programmes: a narrative review

While there is a multitude of evidence supporting the efficacy of injury prevention training programmes, the literature investigating the implementation of these programmes is, in contrast, rather limited. This narrative review sought to describe the commonly reported barriers and facilitators of the implementation of injury prevention training programmes among athletes in organised sport. We also aimed to identify necessary steps to promote the uptake and sustainable use of these programmes in non-elite athletic communities. We identified 24 publications that discussed implementing evidence-based injury prevention training programmes. Frequently reported barriers to implementation include the perceived time and financial cost of the programme, coaches lacking confidence in their ability to implement it, and the programme including exercises that were difficult or confusing to follow. Frequently reported facilitators to implementation include the coach being aware of programme efficacy, shared motivation to complete the programme from both coaches and athletes, and the ability to easily integrate the programme into practice schedules. The current literature is focused on high-income, high-resource settings. We recommend that future studies focus on understanding the best practices of programme dissemination in culturally and economically diverse regions. Programmes ought to be of no financial burden to the user, be simply adaptable to different sports and individual athletes and be available for use in easily accessible forms, such as in a mobile smartphone application.

Manual therapy should not be on the sideline in the game of treating tendinopathy

Tendinopathy is a common but difficult condition to manage in the orthopedic and sports settings. Despite strong evidence supporting exercise and load-management, a substantial proportion of individuals with the condition do not achieve a satisfactory long-term outcome. Tendinopathy can be associated with a number of impairments, including mobility deficits, muscle performance impairments, pain, and possible altered central pain processing - all of which are indications for manual therapy. Manual therapy has not been well described in the management of tendinopathy, even though its indications match the impairments associated with the condition. In this clinical perspective, the role of manual therapy in the management of tendinopathy is explored, with the intention of expanding possible treatment strategies for this challenging condition.

Effectiveness of Dry Needling of Myofascial Trigger Points in the Triceps Surae Muscles: Systematic Review

This study aims to analyze the effects of Dry Needling (DN) for the release of myofascial trigger points (MTrPs) in the triceps surae muscles (TSM). A systematic review was performed up to February 2022 in PubMed, PEDro, Scopus, CENTRAL, and Web of Science. Selection criteria were studies involving subjects older than 18 years presenting MTrPs in the TSM, without any concomitant acute or chronic musculoskeletal conditions; DN interventions applied to the MTrPs of the TSM; and results on pain, range of motion (ROM), muscle strength, muscle stiffness, and functional outcomes. The PEDro scale was used to assess the methodological quality of the studies, and the Risk of Bias Tool 2.0 to assess risk of bias. A total of 12 studies were included in the systematic review, involving 426 participants. These results suggest that DN of MTrPs in TSM could have a positive impact on muscle stiffness and functional outcomes. There are inconclusive findings on musculoskeletal pain, ROM, and muscle strength. Significant results were obtained in favor of the control groups on pressure pain thresholds. Despite the benefits obtained on muscle stiffness and functional performance, the evidence for the use of DN of MTrPs in the TSM remains inconclusive.