Rat tendon morphologic and functional changes resulting from soft tissue mobilization

Astym treatment vs. eccentric exercise for lateral elbow tendinopathy: a randomized controlled clinical trial

Introduction. Patients with chronic lateral elbow (LE) tendinopathy, commonly known as tennis elbow, often experience prolonged symptoms and frequent relapses. Astym treatment, evidenced in animal studies to promote the healing and regeneration of soft tissues, is hypothesized to improve outcomes in LE tendinopathy patients. This study had two objectives: (1) to compare the efficacy of Astym treatment to an evidence-based eccentric exercise program (EE) for patients with chronic LE tendinopathy, and (2) to quantify outcomes of subjects non-responsive to EE who were subsequently treated with Astym treatment.

Study Design. Prospective, two group, parallel, randomized controlled trial completed at a large orthopedic center in Indiana. Inclusion criteria: age range of 18–65 years old, with clinical indications of LE tendinopathy greater than 12 weeks, with no recent corticosteriod injection or disease altering comorbidities.

Methods. Subjects with chronic LE tendinopathy (107 subjects with 113 affected elbows) were randomly assigned using computer-generated random number tables to 4 weeks of Astym treatment (57 elbows) or EE treatment (56 elbows). Data collected at baseline, 4, 8, 12 weeks, 6 and 12 months. Primary outcome measure: DASH; secondary outcome measures: pain with activity, maximum grip strength and function. The treating physicians and the rater were blinded; subjects and treating clinicians could not be blinded due to the nature of the treatments.

Results. Resolution response rates were 78.3% for the Astym group and 40.9% for the EE group. Astym subjects showed greater gains in DASH scores (p = 0.047) and in maximum grip strength (p = 0.008) than EE subjects. Astym therapy also resolved 20/21 (95.7%) of the EE non-responders, who showed improvements in DASH scores (p < 0.005), pain with activity (p = 0.002), and function (p = 0.004) following Astym treatment. Gains continued at 6 and 12 months. No adverse effects were reported.

Conclusion. This study suggests Astym therapy is an effective treatment option for patients with LE tendinopathy, as an initial treatment, and after an eccentric exercise program has failed.

Registration/Funding. Ball Memorial Hospital provided limited funding. Trial registration was not required by FDAAA 801.

Known about the Subject. Under the new paradigm of degenerative tendinopathy, eccentric exercise (EE) is emerging as a first line conservative treatment for LE tendinopathy. EE and Astym treatment are among the few treatment options aiming to improve the degenerative pathophysiology of the tendon. In this trial, Astym therapy, which has shown success in the treatment of tendinopathy, is compared to EE, which has also shown success in the treatment of tendinopathy.

Clinical Relevance. There is a need for more effective, conservative treatment options. Based on the current efficacy study, Astym therapy appears to be a promising, non-invasive treatment option.

Feasibility of using the patient-reported outcomes measurement information system in academic health centers: case series design on pain reduction after chiropractic care

OBJECTIVE

The purpose of this study was to test the utility of Patient-Reported Outcomes Measurement Information System (PROMIS) as a resource for collecting data on patient-reported outcomes (PRO) within academic health centers at a chiropractic college; and, to describe changes in PRO following pragmatic chiropractic care incorporating instrument-assisted soft tissue mobilization (IASTM) on pain symptoms.

METHODS

This was a pre-post intervention design without a control group (case series) involving 25 patients (14 females and 11 males; 40.5 ± 16.39 years, range 20-70 years) who completed their chiropractic care and their baseline and post-treatment pain assessments. The pragmatic chiropractic care intervention included both spinal manipulation and IASTM to treat pain symptoms. PRO's were collected using PROMIS to measure pain behavior, pain interference and pain intensity.

RESULTS

The average pre-post assessment interval was 33 ± 22.5 days (95% CI, 23-42 days). The durations of treatments ranged from one week to 10 weeks. The median number of IASTM treatments was six. Pre-post decreases in T-scores for pain behavior and pain interference were 55.5 to 48.4 and 57.7 to 48.4, respectively (P < .05). Only 12 patients had a baseline T-score for pain intensity greater than 50. The pre-post decrease in pain intensity T-scores for these 12 patients was from 53.4 to 40.9.

CONCLUSION

Within the limitations of a case series design, these data provide initial evidence on the utility of PROMIS instruments for clinical and research outcomes in chiropractic patients.

Effects of synergistic massage and physical exercise on the expression of angiogenic markers in rat tendons

Physical exercise and massage are regarded as key factors in regulating tendon structure. However, information on the mechanism through which massage influences the structure and biology of a tendon is scarce. In this study, we attempted to define the impact of these two activities on rat tendons by using morphological and molecular techniques, determining the expression of VEGF-A, FGF-2, and CD34 in the tendons of rats subjected to 10 weeks of physical exercise (running) with massage of varied duration. The group of rats that was trained and massaged during the entire study was characterized by the highest expression of these markers, compared to the rats subjected to massage before training and to the control group subjected to physical exercises only. The greatest significant differences, compared to the control, were noted in the expression of all the studied markers at mRNA level, and in the case of VEGF-A, at protein level, in the third and fifth weeks of the experiment. The results of this study could point to the synergistic impact of simultaneous massage and physical exercise on the expression of angiogenesis markers in rat tendons.

Update on evidence-based treatments for plantar fasciopathy

Plantar fasciopathy, a common, painful condition of the foot, is often diagnosed by a musculoskeletal physiatrist in an outpatient practice setting. This focused review examines the most recent recommendations for the management of plantar fasciopathy in acute, subacute, and chronic phases. The evidence for treatment with various interventions is discussed, and suggestions for clinical care (along with the respective rationales for those therapies) are provided. The purpose of this review is to enable clinicians to make informed evidence-based decisions about the best available treatments for patients with any phase of plantar fasciopathy. Emerging technologies for the treatment of the condition are also addressed.

Instrument-assisted cross fiber massage increases tissue perfusion and alters microvascular morphology in the vicinity of healing knee ligaments

Background

Ligament injuries are common clinical problems for which there are few established interventions. Instrument-assisted cross fiber massage (IACFM) was recently shown to accelerate the restoration of biomechanical properties in injured rodent knee medial collateral ligaments (MCL). The current study aimed to investigate the influence of IACFM on regional perfusion and vascularity in the vicinity of healing rodent knee MCL injuries.

Methods

Bilateral knee MCL injuries were induced in female Sprague–Dawley rats. Commencing 1 week post-injury, 1 minute of IACFM was introduced unilaterally 3 times/week for 3 weeks. The contralateral injured MCL served as an internal control. Regional tissue perfusion was assessed in vivo throughout healing using laser Doppler imaging, whereas regional microvascular morphology was assessed ex vivo via micro-computed tomography of vessels filled with contrast.

Results

IACFM had no effect on tissue perfusion when assessed immediately, or at 5, 10, 15 or 20 min following intervention (all p > 0.05). However, IACFM-treated hindlimbs had enhanced tissue perfusion when assessed 1 day following the 4th and 9th (last) treatment sessions (all p < 0.05). IACFM-treated hindlimbs also had greater perfusion when assessed 1 wk following the final treatment session (32 days post-injury) (p < 0.05). Subsequent investigation of microvascular morphology found IACFM to increase the proportion of arteriole-sized blood vessels (5.9 to <41.2 μm) in the tibial third of the ligament (p < 0.05).

Conclusions

These findings suggest IACFM alters regional perfusion and vascularity in the vicinity of healing rodent knee MCL injuries. This effect may contribute to the beneficial effect of IACFM observed on the recovery of knee ligament biomechanical properties following injury.

Augmenting tendon and ligament repair with platelet-rich plasma (PRP)

Tendon and ligament injuries (TLI) commonly occur in athletes and non-athletes alike, and remarkably debilitate patients' athletic and personal abilities. Current clinical treatments, such as reconstruction surgeries, do not adequately heal these injuries and often result in the formation of scar tissue that is prone to re-injury. Platelet-rich plasma (PRP) is a widely used alternative option that is also safe because of its autologous nature. PRP contains a number of growth factors that are responsible for its potential to heal TLIs effectively. In this review, we provide a comprehensive report on PRP. While basic science studies in general indicate the potential of PRP to treat TLIs effectively, a review of existing literature on the clinical use of PRP for the treatment of TLIs indicates a lack of consensus due to varied treatment outcomes. This suggests that current PRP treatment protocols for TLIs may not be optimal, and that not all TLIs may be effectively treated with PRP. Certainly, additional basic science studies are needed to develop optimal treatment protocols and determine those TLI conditions that can be treated effectively.

The management of bilateral high hamstring tendinopathy with ASTYM® treatment and eccentric exercise: a case report

High hamstring tendinopathy (HHT) is an overuse injury that occurs most commonly in runners. The management of HHT is often challenging and the research supporting many interventions is limited. Eccentric exercise has been proven effective in the treatment of various tendinopathies but has not been thoroughly studied with HHT. Soft tissue mobilization, including ASTYM, is often utilized in the treatment of tendinopathies, though there is limited evidence supporting this approach. The purpose of this paper is to present the case of a patient referred to physical therapy with bilateral HHT. The patient was a 41-year-old recreational runner that had an insidious onset of right buttock pain 12 months prior to initiating therapy and left buttock pain 9 months prior. Her primary complaints included an inability to run, pain with prolonged or brisk walking, and pain with sitting on hard surfaces. The patient was treated in physical therapy two times per week for 16 visits with treatment focused on eccentric hamstring strengthening and ASTYM. By her eighth visit, the patient was able to walk 2·5 miles without pain and by her 12 visit, she was able to jog 1 mile before the onset of pain. After 16 visits, the patient reported that she was approximately 95% improved, was able to run 2·5 miles without pain, and had no pain with sitting on hard surfaces. This case suggests that eccentric exercise combined with ASTYM may be an effective treatment for HHT.

Overuse injuries

Tendinopathy and chronic tendon issues related to tendinosis are conditions difficult to treat. These conditions often lead to patients' quality of life declining because of the inability to participate in exercise, occupation-related activities, and activities of daily living. By better understanding the pathophysiology related to the development of tendinosis, clinicians will be better able to understand the treatment options available and their limitations while allowing novel therapies to be developed. Conservative treatment of tendinosis starting with a sound rehabilitation program seems to be the best place to start while reserving surgical approaches for cases that have failed conservative management.

Manual Physical Therapy for Non-Surgical Treatment of Adhesion-Related Small Bowel Obstructions: Two Case Reports

Background: Adhesion formation is a widely acknowledged risk following abdominal or pelvic surgery. Adhesions in the abdomen or pelvis can cause or contribute to partial or total small bowel obstruction (SBO). These adhesions deter or prevent the passage of nutrients through the digestive tract, and may bind the bowel to the peritoneum, or other organs. Small bowel obstructions can quickly become life-threatening, requiring immediate surgery to resect the bowel, or lyse any adhesions the surgeon can safely access. Bowel repair is an invasive surgery, with risks including bowel rupture, infection, and peritonitis. An additional risk includes the formation of new adhesions during the healing process, creating the potential for subsequent adhesiolysis or SBO surgeries. Objective: Report the use of manual soft tissue physical therapy for the reversal of adhesion-related partial SBOs, and create an initial inquiry into the possibility of nonsurgical lysis of adhesions. Case Reports: Two patients presenting with SBO symptoms due to abdominal adhesions secondary to abdominal and pelvic surgery were treated with manual soft tissue physical therapy focused on decreasing adhesions. Conclusions: Successful treatment with resolution of symptom presentation of partial SBO and sustained results were observed in both patients treated.

Treatment of a patient with post-natal chronic calf pain utilizing instrument-assisted soft tissue mobilization: a case study

Musculoskeletal pain is commonly reported by pre- and postnatal women, with the most common complaint being low back pain. However, lower leg pain is also frequently reported by women particularly in the third trimester. The purpose of the case study is to illustrate how instrument-assisted soft tissue mobilization (ISTM) can be used to treat a patient with a 2-year history of chronic calf pain. The subject was a 35-year-old female who developed calf pain during the last trimester of her pregnancy following severe lower leg edema. The calf pain was present for the 2 years following delivery and was described as a dull ache, typically aggravated by direct pressure on the calf, prolonged standing, and stairs. An X-ray, magnetic resonance imaging (MRI) with contrast, and ultrasound Doppler study prior to referral ruled out tumors, vascular, lymphatic, or skeletal bone abnormalities. However, her MRI did show a dense superficial venous tissue asymmetry in the same location of her symptoms. Impairments were minimal; the only asymmetrical objective findings were calf length, strength, and soft tissue restrictions detected on palpation. After nine treatments incorporating an ISTM approach, soft tissue mobility, pain, calf strength, and lower extremity functional scale score all improved and her symptoms were abolished.

Management of chronic ankle pain using joint mobilization and ASTYM® treatment: a case report

Treatment of ankle sprains predominately focuses on the acute management of this condition; less emphasis is placed on the treatment of ankle sprains in the chronic phase of recovery. Manual therapy, in the form of joint mobilization and manipulation, has been shown to be effective in the management of this condition, but the combination of joint mobilization and manipulation in tandem with ASTYM® treatment has not been explored. The purpose of this case report is to chronicle the management of a patient with chronic ankle pain who was treated with manual therapy including manipulation and ASTYM treatment. As a result of a fall down stairs 6 months previously, the patient sustained a severe ankle sprain. The soft tissue damage was accompanied by bony disruptions which warranted the patient spending 3 weeks in a walking boot. At the initial evaluation, the patient reported difficulty with descending stairs reciprocally and not being able to run more than 4 minutes on the treadmill before the pain escalated to the level that she had to stop running. After five sessions of therapy consisting of joint mobilization, manipulation and ASTYM, the patient was able to descend stairs and run 40 minutes without pain.

The morphology of the healing tendon: a comparison of the effects of intrasound therapy and therapeutic pulsed ultrasound

BACKGROUND AND PURPOSE

This study investigated the effects of low- and high-intensity intrasound therapy (LITR and HITR) and low-intensity pulsed ultrasound (LIPUS) on the morphology of the healing tendon.

METHODS

Forty-five male Sprague-Dawley albino rats, randomized into five groups, were further subdivided into groups A and B except Group 1. Groups 2-5 underwent an induced crush injury to the Achilles tendon. The groups were allocated to serve as controls (Group 1), received no treatment (Group 2), LIPUS once daily (Group 3), LITR twice daily (Group 4), and HITR twice daily (Group 5). Treatment commenced 24 hr post-injury over the first 14 days. Subgroup A animals were killed on day 15 and those in subgroup B were killed on day 31. The tendons were excised and processed for histological studies.

RESULTS

LITR and HITR given twice daily caused a significant (p < 0.05) proliferation of tenoblasts in the proliferative phase and enhanced their terminal differentiation to tenocytes in the remodeling phase compared with the untreated and LIPUS-treated groups. LITR and HITR also resulted in a significant increase in the volume fraction of collagen fibers compared with LIPUS.

CONCLUSION

Intrasound therapy has a better morphological effect on the healing tendon than LIPUS and may be an option to consider in the treatment of acute tendon injuries.

Chiropractic management of pediatric plantar fasciitis: a case report

OBJECTIVE

The purpose of this report is to present the case of a 10-year-old football player with bilateral plantar fasciitis who improved with a multimodal conservative approach using chiropractic treatment.

CLINICAL FEATURES

The patient presented with bilateral plantar heel pain at the origin of the plantar fascia with a duration of 3 weeks.

INTERVENTION AND OUTCOME

Treatment was provided for 6 visits over a 6-week period. Chiropractic care consisted of manipulative therapy, soft tissue therapy, and home rehabilitation exercises. The soft tissue technique (Graston Technique) was performed to the origin of the plantar fascia and the triceps surae bilaterally. High-velocity, low-amplitude manipulation was applied to the restricted ankle mortise joint. After 6 treatments, the patient reported resolution of foot pain bilaterally and improvements in activities of daily livings. Three months later, the patient reported no further complications and the absence of pain.

CONCLUSION

This patient with bilateral plantar fasciitis improved after a course of a multimodal treatment approach using chiropractic manipulation and soft tissue therapy in addition to exercise and stretching therapies.

Development and application of a newly designed massage instrument for deep cross-friction massage in chronic non-specific low back pain

Objective

To introduce a newly designed massage instrument, the Hand Grip T-bar (HT-bar) and use it to relieve chronic non-specific low back pain (nLBP) through deep cross-friction massage (roptrotherapy).

Method

22 subjects (9 males and 13 females, aged 51.6±6.7) with chronic nLBP were allocated randomly to a Roptrotherapy group (n=12) and a Transcutaneous Electrical Nerve Stimulation (TENS) group (n=10). The Roptrotherapy group received deep cross-friction massage with the HT-bar, which was made of metal and had a cylinder for increasing weight and grooves for an easy grip. It was applied across the middle and lower back for 20 minutes a day, 3 days a week for 2 weeks. The TENS group received TENS for 20 minutes a day, 5 days a week for 2 weeks. The outcome was measured on the pain numeric rating scale (PNRS), by the Oswestry disability index (ODI), and by the Roland & Morris Disability Questionnaire (RMDQ) at pre-treatment, at immediate post-treatment and 2 weeks later. The application of the HT-bar was assessed by a questionnaire to 19 therapists.

Results

At post-treatment, immediately and 2 weeks later, both groups showed significant improvement in PNRS, ODI and RMDQ. During the two weeks after post-treatment, however, the Roptrotherapy group improved in PNRS, ODI and RMDQ, but the TENS group did not. Over 80% of the therapists responded that the HT-bar was useful and comfortable.

Conclusion

This study suggests that deep cross-friction massage can be a beneficial therapeutic technique and that the HT-bar can be a useful instrument in deep cross-friction massage for chronic nLBP patients.

Chiropractic management of a postoperative complete anterior cruciate ligament rupture using a multimodal approach: a case report

OBJECTIVE

The purpose of this case report is to describe the chiropractic management of a patient who had postoperative reconstructive surgery for an anterior cruciate ligament (ACL) tear.

CLINICAL FEATURES

A 25-year-old man experienced a rupture of his left ACL, as well as a bucket-handle tear of the medial meniscus and full-thickness tear within the posterior horn of the lateral meniscus, following direct-contact trauma while playing basketball.

INTERVENTION AND OUTCOME

Postoperative care included a 12-week functional chiropractic rehabilitation program along with Active Release Technique, Graston Technique, and Kinesio Taping. Following treatment, the patient recorded a 0/10 on the Numeric Pain Scale, recorded improvement on the Patient Specific Functional and Pain Scales, returned to play with no complications, and had complete restoration of range of motion and lower extremity muscle strength. At 1-year follow-up, the patient reported no pain and was fully functional.

CONCLUSION

A multimodal approach to the treatment of a postsurgical ACL repair was successful in restoring functional ability, as well as complete subjective pain relief. Chiropractic care may be a beneficial addition to the care of postoperative patients.

Tendinopathy in athletes

Overuse related tendon pain is a significant problem in sport and can interfere with and, in some instances, end an athletic career. This article includes a consideration of the biology of tendon pain including a review of tendon anatomy and histopathology, risk factors for tendon pain, semantics of tendon pathology, and the pathogenesis of tendon pain. Evidence is presented to guide the physical therapist in clinical decision-making regarding the examination of and intervention strategies for athletes with tendon pain.

Graston instrument soft tissue mobilization and home stretching for the management of plantar heel pain: a case series

OBJECTIVE

The purpose of this prospective case series was to describe the outcome of a set of patients with plantar fasciitis treated with Graston Instrument Soft Tissue Mobilization techniques (GT) and a home stretching program.

METHODS

Ten patients with a primary report of plantar heel pain completed self-report questionnaires including the Global Rating of Change Scale (GRC), the Numeric Pain Rating Scale, and the Lower Extremity Functional Scale. Patients were treated with GT directed to the triceps surae, soleus, plantar fascia, and medial calcaneal tubercle. Participants received a maximum of 8 treatments over a time frame ranging from 3 to 8 weeks at a frequency of 1 to 2 sessions per week. Each patient was instructed to perform the stretching program at home 3 times daily. Patients completed all outcome measures at baseline, sixth visit (GRC), and at discharge or the eighth visit. The number of successful outcomes on the GRC was examined using a binomial test. Dependent t tests were used to examine if a significant difference existed in secondary outcome measures of pain and function.

RESULTS

The subjects had a mean duration of symptoms of 32.4 weeks (SD, 31.1). Patients were treated for an average of 6.9 visits (SD, 1.3). There was a statistically significant difference between the number of patients who did and did not achieve a successful outcome (P = .047). There was also a significant improvement from baseline to follow-up for the Numeric Pain Rating Scale (P = .002) and Lower Extremity Functional Scale (P = .017).

CONCLUSIONS

The group of patients selected for this case series who were treated with GT and home stretching experienced clinically meaningful improvement.

What are the validated animal models for tendinopathy?

Chronic tendinopathy refers to a broad spectrum of pathological conditions in tendons and their insertion, with symptoms including activity-related chronic pain. To study the pathogenesis and management strategies of chronic tendinopathy, studies in animal models are essential. The different animal models in the literature present advantages and limitations, and there is no consensus regarding the criteria of a universal tendinopathy animal model. Based on the review of literature and the discussion in the International Symposium on Ligaments and Tendons-X, we concluded that established clinical, histopathological and functional characteristics of human tendinopathy were all important and relevant criteria to be met, if possible, by animal models. As tendinopathy is a progressive, multifactorial tendon disorder affecting different anatomical structures, it may not be realistic to expect a single animal model to study all aspects of tendinopathy. Staging of tendinopathy over time and clearer definition of tendinopathies in relation to severity and type would enable realistic targets with any animal model. The existing animal models can be used for answering specific questions (horses for courses) but should not be used to conclude the general aspects of tendinopathy neither in animals nor in human.

Intrasound therapy in tendon healing: is intensity a factor?

OBJECTIVE

This study investigated the effects of low- and high-intensity intrasound therapy (LITR and HITR, respectively) given once daily and twice daily on the morphology and oxidative stress in healing tendon tissue following an acute injury.

METHODS

Eighty-five male rats, randomized into six groups were further subdivided into groups A, B, and C, except for Group 1 which was subdivided into A and B only. Groups 2-6 underwent an induced crush injury. The six groups were allocated to: serve as controls (Group 1), receive no treatment (Group 2), HITR twice daily (Group 3), HITR once daily (Group 4), LITR twice daily (Group 5), and LITR once daily (Group 6). Intrasound therapy (ITR) was commenced 24 hours postinjury and was given once daily or twice daily over the first 14 days postinjury. The animals in subgroups A and B were sacrificed on day 15 postinjury, and those in subgroup C were sacrificed on day 31 postinjury. The tendons were excised, and processed for histology and malondialdehyde (MDA) assay.

RESULTS

There was no significant difference in the tenocyte population between the HITR- and LITR-treated groups. However, twice-daily treatment in either the low- or high-intensity mode resulted in significant tenocyte proliferation compared with the once-daily treated groups, and also had the highest percentage of tenoblasts compared with the population of tenocytes in the proliferative phase of healing. All treatment protocols marginally lowered the MDA level.

CONCLUSION

The role of IRT in tendon healing is influenced more by the frequency of treatment rather than the intensity of the delivered dosage.

Transient decreases in forelimb gait and ground reaction forces following rotator cuff injury and repair in a rat model

Due to inadequate healing, surgical repairs of torn rotator cuff tendons often fail, limiting the recovery of upper extremity function. The rat is frequently used to study rotator cuff healing; however, there are few systems capable of quantifying forelimb function necessary to interpret the clinical significance of tissue level healing. We constructed a device to capture images, ground reaction forces and torques, as animals ambulated in a confined walkway, and used it to evaluate forelimb function in uninjured control and surgically injured/repaired animals. Ambulatory data were recorded before (D-1), and 3, 7, 14, 28 and 56 days after surgery. Speed as well as step width and length were determined by analyzing ventral images, and ground reaction forces were normalized to body weight. Speed averaged 22+/-6 cm/s and was not affected by repair or time. Step width and length of uninjured animals compared well to values measured with our previous system. Forelimbs were used primarily for braking (-1.6+/-1.5% vs +2.5+/-0.6%), bore less weight than hind limbs (49+/-5% vs 58+/-4%), and showed no differences between sides (49+/-5% vs 46+/-5%) for uninjured control animals. Step length and ground reaction forces of the repaired animals were significantly less than control initially (days 3, 7 and 14 post-surgery), but not by day 28. Our new device provided uninjured ambulatory data consistent with our previous system and available literature, and measured reductions in forelimb function consistent with the deficit expected by our surgical model.

Instrument-assisted cross-fiber massage accelerates knee ligament healing

STUDY DESIGN

Controlled laboratory study.

OBJECTIVES

To investigate the effects of instrument-assisted cross-fiber massage (IACFM) on tissue-level healing of knee medial collateral ligament (MCL) injuries.

BACKGROUND

Ligament injuries are common and significant clinical problems for which there are few established interventions. IACFM represents an intervention that may mediate tissue-level healing following ligament injury.

METHODS

Bilateral knee MCL injuries were created in 51 rodents, while 7 rodents were maintained as ligament-intact, control animals. IACFM was commenced 1 week following injury and introduced 3 sessions per week for 1 minute per session. IACFM was introduced unilaterally (IACFM-treated), with the contralateral, injured MCL serving as an internal control (nontreated). Thirty-one injured animals received 9 ACFM treatments, while the remaining 20 injured animals received 30 treatments. Ligament biomechanical properties and morphology were assessed at either 4 or 12 weeks postinjury.

RESULTS

IACFM-treated ligaments were 43.1% stronger (P<.05), 39.7% stiffer (P<.01), and could absorb 57.1% more energy before failure (P<.05) than contralateral, injured, nontreated ligaments at 4 weeks postinjury. On histological and scanning electron microscopy assessment, IACFM-treated ligaments appeared to have improved collagen fiber bundle formation and orientation within the scar region than nontreated ligaments. There were minimal differences between IACFM-treated and contralateral, nontreated ligaments at 12 weeks postinjury, although IACFM-treated ligaments were 15.4% stiffer (P<.05).

CONCLUSION

IACFM-accelerated ligament healing, possibly via favorable effects on collagen formation and organization, but had minimal effect on the final outcome of healing. These findings are clinically interesting, as there are few established interventions for ligament injuries, and IACFM is a simple and practical therapy technique. J Orthop Sports Phys Ther 2009;39(7):506-514, Epub 24 February 2009. doi:10.2519/jospt.2009.2997.

Animal models of tendinopathy

PURPOSE

The term tendinopathy describes non-ruptured tendon injuries. While several important studies have evaluated the aetiology, pathogenesis, and treatment of this common condition, further study is needed. Several animal models, which allow for full tissue evaluation on different organizational levels and stages of disease, have been used to investigate tendinopathy.

METHOD

A literature review was conducted to identify and evaluate animal models that have been developed and used to study the aetiology and pathology of tendinopathy.

RESULTS

Animal models of tendinopathy fit into two general categories based on the mode of injury application: (i) models that induce tendinopathy through a change in the mechanical environment, and (ii) models that induce tendinopathy through a chemical agent. The cost, difficulty, invasiveness, reproducibility and time required to induce injury in these models varies. Mechanically-induced models are beneficial since they induce injury through repetitive mechanical loading, similar to how tendinopathy is believed to develop in the human condition. Chemically-induced models are beneficial by allowing for the study of the interplay among inflammatory cells, mechanical loading and tissue healing.

CONCLUSION

Further work is needed to fully characterize and understand tendinopathy. Appropriate animal models provide a greater understanding of human tendinopathy, leading to better prevention and treatment.

Mid-portion Achilles tendinopathy--current options for treatment

PURPOSE

To report on the present option for management of tendinopathy of the main body of the Achilles tendon.

BACKGROUND

Tendinopathy of the main body of tendo Achillis affects athletic and sedentary patients. Mechanical loading is thought to be a major causative factor. However, the exact mechanical loading conditions which cause tendinopathy are poorly defined. Repetitive mechanical loading induces a non-inflammatory pathology, and repetitive microtrauma ultimately exceeds the healing response. The management of Achilles tendinopathy is primarily conservative. Although many non-operative options are available, few have been tested under controlled conditions. This review article specifically focuses on eccentric training, and on shock wave therapy. Surgical intervention can be successful in refractory cases. However, surgery does not usually completely eliminate symptoms and complications are not rare.

CONCLUSIONS

Further studies are needed to discern the optimal non-operative and surgical management of midsubstance Achilles tendinopathy.

Noninsertional Achilles tendinopathy

The treatment of noninsertional Achilles tendinopathy remains, to a large extent, empirical. Neither different operative techniques nor nonoperative regimes have been subjected to controlled trials. Rather, the condition is still treated on the basis of anecdotal evidence combined with personal experience. However, increased knowledge of the basic science of tendinopathy and tendon healing has directed therapeutic regimens and will continue to do so. Manipulation of proteolytic enzymes and control of neovascularization are probably the two areas that show most promise.

A treatment algorithm for managing Achilles tendinopathy: new treatment options

Achilles tendinopathy affects athletes, recreational exercisers and even inactive people. The pathology is not inflammatory; it is a failed healing response. The source of pain in tendinopathy could be related to the neurovascular ingrowth seen in the tendon's response to injury. The treatment of Achilles tendinopathy is primarily conservative with an array of effective treatment options now available to the primary care practitioner. If conservative treatment is not successful, then surgery relieves pain in the majority of cases. Directing a patient through the algorithm presented here will maximise positive treatment outcomes.

Early voluntary exercise does not promote healing in a rat model of Achilles tendon injury

Mechanical stress is an important modulator of connective tissue repair. However, the effects on tendon healing are very poorly defined, preventing optimal use of mechanical stress. We hypothesized that early voluntary exercise initially retards tendon repair but results in a faster recovery rate at longer term. Male Wistar rats were injured by a collagenase injection in the Achilles tendon, and exercise was voluntarily performed on a running wheel. We observed the persistent presence of neutrophils in injured tendons of rats that began exercise immediately after the trauma [injured + early exercise (Inj+EEx)]. Early exercise also increased the concentration of ED1(+) macrophages in injured tendons after 3 and 7 days compared with ambulatory injured rats (Inj). Similar results were obtained with the subset of ED2(+) macrophages in the tendon core 3 days after the collagenase injection. Furthermore, collagen content returned to normal values more rapidly in the Inj+EEx tendons than in the Inj group, but this was not associated with an increase in cell proliferation. Surprisingly, Inj+EEx tendons roughly displayed lower stiffness and force at rupture point relative to Inj tendons at day 28. Injured tendons of rats that began exercise only from day 7 had better mechanical properties than those of early-exercised rats 28 days postinjury. We speculate that the persistence of the inflammatory response and undue mechanical loading in the Inj+EEx tendons led to fibrosis and a loss of tendon function.

GFP chimeric models exhibited a biphasic pattern of mesenchymal cell invasion in tendon healing

The healing of an injured musculoskeletal system requires an influx of mesenchymal cells that can differentiate into osteoblasts, fibroblasts, chondroblasts, and skeletal myoblasts. However, whether these mesenchymal cells arise from the circulation (bone marrow) or the injured tissues themselves has been controversial. To reveal the spatiotemporal characteristics of the reparative mesenchymal cells, we investigated the healing process after patellar tendon injury using two types of green fluorescent protein (GFP) chimeric rats; one expressing GFP in the circulating cells, and the other expressing it in the patellar tendon. We analyzed the behavior of GFP-positive cells after experimental tendon injury in both chimeric rats to clarify the origin of reparative cells. At 24 h after the injury, the wound contained circulation-derived cells but not tendon-derived cells. Tendon-derived cells first appeared in the wounded area at 3 days after the injury, and had significantly increased in number with time and had maintained a high level of proliferative activity until 7 days after the injury, whereas the circulation-derived cells had decreased in number and had been replaced by the tendon-derived cells. These findings suggest that circulation-derived and tendon-derived cells contribute to the healing of tendons in different periods as part of a biphasic process.

Six sessions of manual therapy increase knee flexion and improve activity in people with anterior knee pain: a randomised controlled trial

QUESTION

What are the effects of manual therapy on pain, range of motion, and activity in patients with anterior knee pain?

DESIGN

Randomised controlled trial.

PARTICIPANTS

Thirty-eight ambulatory care patients (one dropout) with anterior knee pain.

INTERVENTION

The experimental intervention consisted of six sessions of manual therapy, while the control intervention was to remain on the waiting list for two weeks.

OUTCOME MEASURES

Pain was measured using the Patellofemoral Pain Severity Questionnaire. Active knee flexion and extension was measured from photographs. Activity was measured by having the participants step up and down a 15 cm step, leading with the painful leg as many times as they could in a 60 second period. Measurements were taken before and after intervention by a blinded assessor.

RESULTS

The experimental group decreased their pain by -8 mm (95% CI to 1 p =0.08) and pain on stairs by-10, (95% CI -22 to 2 p = 0.10) compared with the control group. They increased their active knee flexion by 10 deg (95% CI TO 16, p = 0.004) and and the number of steps in 60 seconds by 5 (95% CI 2 TO 8, p = 0.001) compared with the control group.

CONCLUSION

Manual therapy is effective improving knee flexion and stair climbing i patients with anterior knee pain. There is a trend towards a small improvement in pain.

Mechanobiology of tendon

Tendons are able to respond to mechanical forces by altering their structure, composition, and mechanical properties--a process called tissue mechanical adaptation. The fact that mechanical adaptation is effected by cells in tendons is clearly understood; however, how cells sense mechanical forces and convert them into biochemical signals that ultimately lead to tendon adaptive physiological or pathological changes is not well understood. Mechanobiology is an interdisciplinary study that can enhance our understanding of mechanotransduction mechanisms at the tissue, cellular, and molecular levels. The purpose of this article is to provide an overview of tendon mechanobiology. The discussion begins with the mechanical forces acting on tendons in vivo, tendon structure and composition, and its mechanical properties. Then the tendon's response to exercise, disuse, and overuse are presented, followed by a discussion of tendon healing and the role of mechanical loading and fibroblast contraction in tissue healing. Next, mechanobiological responses of tendon fibroblasts to repetitive mechanical loading conditions are presented, and major cellular mechanotransduction mechanisms are briefly reviewed. Finally, future research directions in tendon mechanobiology research are discussed.

Treatment of a Case of Subacute Lumbar Compartment Syndrome Using the Graston Technique

OBJECTIVE

To discuss subacute lumbar compartment syndrome and its treatment using a soft tissue mobilization technique.

CLINICAL FEATURES

A patient presented with low back pain related to exercise combined with prolonged flexion posture. The symptoms were relieved with rest and lumbar extension. The patient had restrictive lumbar fascia in flexion and rotation and no neurological deficits.

INTERVENTION AND OUTCOME

The restrictive lumbar posterior fascial layers and adjoining restrictive fascia (thoracic, gluteal, hamstring) were treated with a form of instrument-assisted soft tissue mobilization called the Graston technique. Restoration of fascial extensibility and resolution of the complaint occurred after 6 treatment visits.

CONCLUSIONS

The posterior spinal fascial compartments may be responsible for intermittent lower back pain. Functional clinical tests can be employed to determine whether the involved fascia is abnormally restrictive. Treatment directed at the restrictive fascia using this soft tissue technique may result in improved fascial functional testing and reduction of symptoms.

Immunohistochemical characterization of cells in adult human patellar tendons

Cells in tendons are conventionally identified as elongated tenocytes and ovoid tenoblasts, but specific markers for these cells are not available. The roles and interplay of these cells in tendon growth, remodeling, and healing are not well established. Therefore, we proposed to characterize these cells with respect to cell turnover, extracellular matrix metabolism, and expression of growth factors. Here we examined 14 healthy human patellar tendon samples for the expression of various proteins in tenocytes and tenoblasts, which were identified as elongated tendon cells and ovoid tendon cells, respectively. Matrix metalloproteinase 1 (MMP1), procollagen type I (procol I), heat shock protein 47 (hsp47), bone morphogenetic protein 12 (BMP12), 13 (BMP13), and transforming growth factor beta1 (TGFbeta1) were detected by immunohistochemistry (IHC). An image analysis of the IHC staining for proliferation cell nuclear antigen (PCNA) and apoptotic cells was performed to determine the proliferation index and the apoptosis index in elongated and ovoid tendon cells. The ovoid tendon cells expressed higher levels of procol I, hsp47, MMP1, BMP12, BMP13, and TGFbeta1 than the elongated tendon cells. Both the proliferation index and the apoptosis index of ovoid tendon cells were higher than those of the elongated tendon cells. The results suggested that ovoid tendon cells, conventionally recognized as tenoblasts, were more active in matrix remodeling. The expression of BMP 12, BMP13 and TGFbeta1 might be associated with the different cellular activities of tenoblasts and tenocytes.

Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression

Extracorporeal shock waves (ESW) have recently been used in resolving tendinitis. However, mechanisms by which ESW promote tendon repair is not fully understood. In this study, we reported that an optimal ESW treatment promoted healing of Achilles tendintis by inducing TGF-beta1 and IGF-I. Rats with the collagenease-induced Achilles tendinitis were given a single ESW treatment (0.16 mJ/mm(2) energy flux density) with 0, 200, 500 and 1000 impulses. Achilles tendons were subjected to biomechanical (load to failure and stiffness), biochemical properties (DNA, glycosaminoglycan and hydroxyproline content) and histological assessment. ESW with 200 impulses restored biomechanical and biochemical characteristics of healing tendons 12 weeks after treatment. However, ESW treatments with 500 and 1000 impulses elicited inhibitory effects on tendinitis repair. Histological observation demonstrated that ESW treatment resolved edema, swelling, and inflammatory cell infiltration in injured tendons. Lesion site underwent intensive tenocyte proliferation, neovascularization and progressive tendon tissue regeneration. Tenocytes at the hypertrophied cellular tissue and newly developed tendon tissue expressed strong proliferating cell nuclear antigen (PCNA) after ESW treatment, suggesting that physical ESW could increase the mitogenic responses of tendons. Moreover, the proliferation of tenocytes adjunct to hypertrophied cell aggregate and newly formed tendon tissue coincided with intensive TGF-beta1 and IGF-I expression. Increasing TGF-beta1 expression was noted in the early stage of tendon repair, and elevated IGF-I expression was persisted throughout the healing period. Together, low-energy shock wave effectively promoted tendon healing. TGF-beta1 and IGF-I played important roles in mediating ESW-stimulated cell proliferation and tissue regeneration of tendon.

Patellar tendinopathy

Patellar tendinopathy is a common and serious condition in athletes. Although there have been many advances in the understanding of the histopathology, imaging, and surgical outcomes in this condition in the past decade, successful management of athletes with patellar tendinopathy remains a major challenge for both the practitioner and patient. There is a definite need for further prospective studies into etiological factors and randomized controlled trials into treatment choices.

A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain

The purpose of this single blinded randomised controlled trial was to investigate the effects of soft tissue massage on range of motion, reported pain and reported function in patients with shoulder pain. Twenty-nine patients referred to physiotherapy for shoulder pain were randomly assigned to a treatment group that received six treatments of soft tissue massage around the shoulder (n = 15) or to a control group that received no treatment while on the waiting list for two weeks (n = 14). Measurements were taken both before and after the experimental period by a blinded assessor. Active range of motion was measured for flexion, abduction and hand-behind-back movements. Pain was assessed with the Short Form McGill Pain Questionnaire (SFMPQ) and functional ability was assessed with the Patient Specific Functional Disability Measure (PSFDM). The treatment group showed significant improvements in range of motion compared with the control group for abduction (mean 42.2 degrees, 95% CI 24.1 to 60.4 degrees), flexion (mean 22.6 degrees, 95% CI 12.4 to 32.8 degrees) and hand-behind-back (mean 11.0 cm improvement, 95% CI 6.3 to 15.6 cm). Massage reduced pain as reported on the descriptive section of the SFMPQ by a mean of 4.9 points (95% CI 2.5 to 7.2 points) and on the visual analogue scale by an average of 26.5 mm (95% CI 5.3 to 47.6 mm), and it improved reported function on the PSFDM by a mean of 8.6 points (95% CI 4.9 to 12.3 points). We conclude that soft tissue massage around the shoulder is effective in improving range of motion, pain and function in patients with shoulder pain. The mechanisms behind these effects remain unclear.

Rehabilitation of lower limb tendinopathies

Tendon rehabilitation requires an extensive assessment, and identification of deficits that impact on sporting performance. Rehabilitation must address all these deficits and may take several months. Return to sport may require short- or long-term load modification. Surgery also requires a long recovery time, and may not guarantee a return to sport.

Acute and Chronic Tendon Injuries: Factors Affecting the Healing Response and Treatment

Objective:

Tendons have biomechanical properties based on collaborative remodeling of all their cells through normal lysis and synthesis. This review assesses factors that affect the healing response and presents solutions for rehabilitating acute and chronic tendon injuries.

Data Sources:

MEDLINE (1970–2002) and SPORTDiscus (1970–2002). Key words searched weretendon, tendinitis, tendinosis, tendinopathy, rehabilitation, ultrasound, NSAIDs, exercise, mobilization, aging, immobilization,andhealing.

Data Synthesis:

The biomechanical roles tendons play change throughout one’s lifetime and are influenced by maturation and aging, injury and healing, immobilization, exercise, medications, and therapeutic modalities. Suggestions from animal, case, and clinical studies are varied but provide solutions in the treatment of acute and chronic tendon injuries.

Conclusions and Recommendations:

All factors that affect the tendon structure should be considered in a rehabilitation program. Therapeutic exercise, medications, or therapeutic modalities should never be used as a stand-alone therapy.

Toothbrushing promotes gingival fibroblast proliferation more effectively than removal of dental plaque

OBJECTIVES

Removal of dental plaque is an essential element of periodontal treatment. However, there have also been studies of the effects of the mechanical stimulation provided by toothbrushing on gingival host-defense mechanisms. The aim of the study was to evaluate the effects of toothbrushing on gingival fibroblast proliferation in dogs over time, compared to effects of plaque removal without brushing.

METHODS

The mouths of six mongrel dogs were divided into four quadrants: two for daily toothbrushing, and two for daily plaque removal with a curette. After 1, 3 and 5 weeks of treatment, histometrical analyses were performed to assess inflammatory cell infiltration, proliferating cell nuclear antigen (PCNA)-positive fibroblasts, procollagen type I-positive fibroblasts in the subepithelial connective tissue of junctional epithelium.

RESULTS

Toothbrushing increased the number of PCNA-positive fibroblasts in the first week, increased the number of type I procollagen-positive fibroblasts at the fifth week, and reduced inflammatory cell infiltration at the third week.

CONCLUSION

These findings suggest that mechanically stimulated fibroblasts begin proliferating within a week, and this cell division results in an increased number of fibroblasts at the third week. It takes 5 weeks before differences in collagen synthesis between brushing and plaque removal areas are detectable.