Physical Activity and Investigation With Magnetic Resonance Imaging Partly Explain Variability in the Prevalence of Patellar Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals

UK defence rehabilitation review of Achilles and patellar tendinopathy conservative management: a systematic review

INTRODUCTION

Tendinopathy is a common condition affecting physically active populations, such as the military. Diagnosis is clinical, with no gold-standard tests. The role of imaging and functional assessment in subdiagnosis is an active area of research with the hope of delivering more nuanced and clinically effective management. A vast array of injectable and adjunctive therapies have been proposed with varying, and at times, conflicting evidence. Multiple methods for exercise therapy exist, but increasingly tendinopathy is recognised as a heterogeneous condition not suited to a one-size-fits-all approach. The aim was to complete a systematic review, to appraise the recent evidence for conservative management of Achilles and patellar tendinopathy.

METHODS

A multidisciplinary team from across defence rehabilitation searched PubMed for literature dating from May 2017 to July 2023. Four key areas were searched: diagnosis and outcome measures, medical, exercise and adjuncts.

RESULTS

A total of 840 articles were identified. Articles were screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Following screening and abstract review, a total of 143 were included for full review. Due to the breadth of literature and large heterogeneity of studies, meta-analysis of results was not feasible. Articles were assessed against the Oxford Centre for Evidence Based Medicine criteria.

CONCLUSIONS

The literature review found the strongest evidence for exercise-based rehabilitation as first-line treatment, with limited evidence for medical interventions and adjuncts. The primacy of stand-alone loading modalities is challenged by developing literature supporting a progressive tendon loading exercise protocol (PTLE). PTLE represents a framework where various exercise modalities are prescribed based on the individual's capacity and function. Novel interventions should be practised with caution and not conducted as monotherapy.

Tendon structure, clinical tests, and pain during-loading in young female competitive gymnasts

To examine the relationship between Achilles-tendon (AT) and patellar-tendon (PT) structure, clinical-examination and tendon pain in young gymnasts; and, to explore the associations between these factors and age, maturation, and training-load. Two hundred and seventy-four female gymnasts (aged 12.1±1.9 yrs) were assessed for anthropometric measures, pubertal-stage, and training-load. They had clinical-tests (pain-on-palpation for AT and pain-on-palpation and Royal-London Hospital-Test for PT), were asked about tendon-pain during-loading and were assessed for tendon-structure. Gymnasts with positive clinical-tests (with and without pain during-loading) presented a significantly higher prevalence of disorganized AT and PT compared to gymnasts with negative clinical-tests (with and without pain during-loading) (p<0.05). A significant pubertyXpositive clinical-test interaction was found for disorganized PT structure, whereby a disorganized structure was more prevalent among post-pubertal gymnasts with positive clinical-tests compared to pre-pubertal participants with negative clinical-tests (F(1, 263)=9.436, p=0.002). In gymnasts with positive clinical-tests, significant correlations were found between disorganized AT and PT structures and age, and training-load (p<0.05). An increased prevalence of disorganized tendon structure (regardless of pain during-loading) was seen in participants with positive clinical-tests. This disorganized tendon-structure was found to be significantly related to increased age, post-pubertal stage, and higher training hours in gymnasts with positive clinical-tests.

Epidemiology of Patellar Tendinopathy in Athletes and the General Population: A Systematic Review and Meta-analysis

Background

Patellar tendinopathy (PT) mainly affects athletes who use the tendon for repeated energy storage and release activities. It can have a striking impact on athletes' careers, although data on its real prevalence and incidence are sparse. Research efforts should start from the results of reliable and updated epidemiological research to help better understand the impact of PT and underpin preventative measures.

Purpose

To determine the prevalence and incidence of PT in athletes and the general population.

Design

Systematic review; Level of evidence, 3.

Methods

A systematic review of the literature was performed on January 17, 2022, and conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, Web of Science, and Wiley Cochrane Library databases were searched for epidemiological reports of any evidence level and clinical studies reporting data on the incidence or prevalence of PT for the 11,488 retrieved records. The primary endpoint was the prevalence and incidence of PT in sport-active patients. The secondary endpoints were PT prevalence and incidence in subgroups of athletes based on sex, age, sport type, and sport level played, as well as the same epidemiological measures in the general population.

Results

A total of 28 studies, with 28,171 participants, were selected and used for the qualitative and quantitative analysis. The general and athletes' populations reported an overall PT prevalence of 0.1% and 18.3%, respectively. In athletes, the prevalence of PT was 11.2% in women and 17% in men (P = .070). The prevalence of PT in athletes <18 years was 10.1%, while it was 21.3% in athletes ≥18 years (P = .004). The prevalence of PT was 6.1% in soccer players, 20.8% in basketball players, and 24.8% in volleyball players. Heterogeneous PT diagnostic approaches were observed. Higher prevalence values were found when PT diagnoses were made using patient-reported outcomes versus clinical evaluations (P = .004).

Conclusion

This review demonstrated that PT is a common problem in the male and female sport-active populations. There are twice as many athletes aged ≥18 years than there are <18 years. Volleyball and basketball players are most affected by PT.

Proximal patellar tendon abnormalities on ultrasound can develop in male adolescent basketball players: A longitudinal study

INTRODUCTION

Adolescent patellar tendinopathy is reported but the pubertal-stage of onset of abnormal tendon structure has not been investigated with grayscale ultrasound.

AIMS

To investigate abnormal tendon structure using grayscale ultrasound and its association with pubertal-stage and pain.

METHODS

Forty-three male basketball players aged 13.7 years (SD 1.0) had patellar tendon ultrasound scans every 6 months for 2.5 years. Pubertal-stage (peak height velocity) was calculated using the Mirwauld equation. Tendon thickness, hypoechogenicity and pain during single leg decline squat (SLDS) were recorded. Tendons were classified: hypoechoic, normal or immature.

RESULTS

Two tendons were hypoechoic at baseline. Six developed hypoechogenicity over 2.5 years (eight tendons [9%], six participants [14%]), all in peri and post-PHV players. Twenty-six tendons (17 participants) were classified as immature during the study. Hypoechoic tendons were thicker (5.3 mm SD 1.2) than normal (3.9 mm SD 0.7) tendons (p < 0.001). There was no difference in the proportion of participants reporting pain during SLDS in the hypoechoic (N = 3) and normal (N = 11) groups (p = 0.33), or in hypoechoic tendon thickness between those reporting pain (6.5 mm, SD 1.7) or not (5.2 mm, SD 0.9, p = 0.17).

DISCUSSION

This study using grayscale ultrasound found that basketball players with hypoechogenicity were peri or post-PHV. Abnormal structure was not always associated with pain.