Effects of isometric training at different knee angles on the muscle-tendon complex in vivo

Neuromuscular Electrical Stimulation Superimposed on Movement Early after ACL Surgery

PURPOSE

Quadriceps weakness and asymmetrical loading of lower limbs are two major issues after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to evaluate the effectiveness of a 6-wk training protocol involving neuromuscular electrical stimulations (NMES) of the quadriceps muscle superimposed on repeated sit-to-stand-to-sit exercises (STSTS), as an additional treatment to standard rehabilitation, from the 15th to the 60th day after ACLR.

METHODS

Sixty-three ACLR patients were randomly allocated to one of the three treatment groups: NMES superimposed on STSTS (NMES + STSTS), STSTS only, or no additional treatment (NAT) to standard rehabilitation. Maximal isometric strength of the knee extensor and flexor muscles was measured 60 and 180 d after surgery. Asymmetry in lower extremity loading was measured during a sit-to-stand movement at 15, 30, 60, and 180 d after surgery and during a countermovement jump 180 d after surgery by means of two adjacent force platforms placed under each foot.

RESULTS

The NMES + STSTS participants showed higher muscle strength of the knee extensors, which was accompanied by lower perception of pain and higher symmetry in lower extremity loading compared with STSTS-only and NAT participants after both 60 and 180 d from surgery. Participants in the STSTS-only treatment group showed higher symmetry in lower extremity loading compared with those in the NAT group 60 d after surgery.

CONCLUSIONS

These results suggest that an early intervention based on NMES superimposed to repeated STSTS exercises is effective for recovering quadriceps strength and symmetry in lower extremity loading by the time of return to sport.

Effect of Accommodating Elastic Bands on Mechanical Power Output during Back Squats

The aim of this study was to investigate whether accommodating elastic bands with barbell back squats (BSQ) increase muscular force during the deceleration subphase. Ten healthy men (mean ± standard deviation: Age: 23 ± 2 years; height: 170.5 ± 3.7 cm; mass: 66.7 ± 5.4 kg; and BSQ one repetition maximum (RM): 105 ± 23.1 kg; BSQ 1RM/body mass: 1.6 ± 0.3) were recruited for this study. The subjects performed band-resisted parallel BSQ (accommodating elastic bands each sides of barbell) with five band conditions in random order. The duration of the deceleration subphase, mean mechanical power, and the force and velocity during the acceleration and deceleration subphases were calculated. BSQ with elastic bands elicited greater mechanical power output, velocity, and force during the deceleration subphase, in contrast to that elicited with traditional free weight (p < 0.05). BSQ with elastic bands also elicited greater mechanical power output and velocity during the acceleration subphase. However, the force output during the acceleration subphase using an elastic band was lesser than that using a traditional free weight (p < 0.05). This study suggests that BSQ with elastic band elicit greater power output during the acceleration and deceleration subphases.

Tendinous Tissue Adaptation to Explosive- vs. Sustained-Contraction Strength Training

The effect of different strength training regimes, and in particular training utilizing brief explosive contractions, on tendinous tissue properties is poorly understood. This study compared the efficacy of 12 weeks of knee extensor explosive-contraction (ECT; n = 14) vs. sustained-contraction (SCT; n = 15) strength training vs. a non-training control (n = 13) to induce changes in patellar tendon and knee extensor tendon-aponeurosis stiffness and size (patellar tendon, vastus-lateralis aponeurosis, quadriceps femoris muscle) in healthy young men. Training involved 40 isometric knee extension contractions (three times/week): gradually increasing to 75% of maximum voluntary torque (MVT) before holding for 3 s (SCT), or briefly contracting as fast as possible to ∼80% MVT (ECT). Changes in patellar tendon stiffness and Young's modulus, tendon-aponeurosis complex stiffness, as well as quadriceps femoris muscle volume, vastus-lateralis aponeurosis area and patellar tendon cross-sectional area were quantified with ultrasonography, dynamometry, and magnetic resonance imaging. ECT and SCT similarly increased patellar tendon stiffness (20% vs. 16%, both p < 0.05 vs. control) and Young's modulus (22% vs. 16%, both p < 0.05 vs. control). Tendon-aponeurosis complex high-force stiffness increased only after SCT (21%; p < 0.02), while ECT resulted in greater overall elongation of the tendon-aponeurosis complex. Quadriceps muscle volume only increased after sustained-contraction training (8%; p = 0.001), with unclear effects of strength training on aponeurosis area. The changes in patellar tendon cross-sectional area after strength training were not appreciably different to control. Our results suggest brief high force muscle contractions can induce increased free tendon stiffness, though SCT is needed to increase tendon-aponeurosis complex stiffness and muscle hypertrophy.

Muscle strength and stiffness in resistance exercise: Force transmission in tissues

Physical therapists and osteopaths want to know the quantitative force transmitted in the tissues during resistance exercise and also the relationship between tissue strength and the specific type of resistance exercise of the skeletal muscles. This paper uses the strain energy function for large deformations associated with the active and passive response of transversely isotropic skeletal muscle tissue to evaluate muscle strength and force transmitted in tissues during resistance exercises for the quadriceps muscle at the knee during isometric training exercise at different knee angles in vivo. It is found that after an exercise program, the muscle stiffness is halved when the bending angle of the knee increases from 50° to 100°. The muscle strength generated is marginally greater at 100° than at 50°. The stress transmitted in the lateral direction for 100° bending is double that for 50°.

Age and Sex Effects on the Active Stiffness of Vastus Intermedius under Isometric Contraction

Previously, a novel technique was proposed to quantify the relationship between the muscle stiffness and its nonfatigue contraction intensity. The method extended the measured range of isometric contraction to 100% maximum voluntary contraction (MVC) using an ultrasonic shear wave measurement setup. Yet, it has not been revealed how this relationship could be affected by factors like age or sex. To clarify these questions, vastus intermedius (VI) stiffness of 40 healthy subjects was assessed under 11 step levels of isometric contraction. The subjects were divided into four groups: young males, young females, elderly males, and elderly females (n = 10 for each). In a relaxed state, no significant difference was observed between the male and female subjects (p = 0.156) nor between the young and elderly subjects (p = 0.221). However, when performing isometric contraction, the VI stiffness of males was found to be significantly higher than that of females at the same level (p < 0.001), and that of the young was higher than the elderly (p < 0.001). Meanwhile, for two knee joint angles used, the stiffness measured at a 90° knee joint angle was always significantly larger than that measured at 60° (p < 0.001). Recognizing the active muscle stiffness of VI contributes to body stability, and these results may provide insight into the age and sex bias in musculoskeletal studies, such as those on fall risks.

Inter- and intramuscular differences in training-induced hypertrophy of the quadriceps femoris: association with muscle activation during the first training session

The purpose of this study was to examine whether inter- and intramuscular differences in hypertrophy induced by resistance training correspond to differences in muscle activation during the first training session. Eleven young men completed 12 weeks of training intervention for knee extension. Before and after the intervention, T1-weighted magnetic resonance (MR) images were recorded to determine the volume and anatomical cross-sectional area (CSA) along the length of the individual muscles of the quadriceps femoris. The T2-weighted MR images were also acquired before and immediately after the first training session. The T2 was calculated for each pixel within the quadriceps femoris, from which the muscle activation was evaluated as %activated volume and area. The results showed that the %activated volume after the first training session was significantly higher in the vastus intermedius than the vastus medialis. However, the relative change in muscle volume after the training intervention was significantly greater in the rectus femoris than the vasti muscles (vastus lateralis, intermedius and medialis). Within the rectus femoris, both the %activated area and relative increase in CSA were significantly greater in the distal region than the proximal region. In contrast, the %activated area and relative increase in CSA of the vasti were nearly uniform along each muscle. These results suggest that the muscle activation during the first training session is associated with the intramuscular difference in hypertrophy induced by training intervention, but not with the intermuscular difference.

Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults

BACKGROUND

The present article systematically reviews recent literature on the in vivo adaptation of asymptomatic human tendons following increased chronic mechanical loading, and meta-analyzes the loading conditions, intervention outcomes, as well as methodological aspects.

METHODS

The search was performed in the databases PubMed, Web of Knowledge, and Scopus as well as in the reference lists of the eligible articles. A study was included if it conducted (a) a longitudinal exercise intervention (≥8 weeks) on (b) healthy humans (18 to 50 years), (c) investigating the effects on mechanical (i.e., stiffness), material (i.e., Young's modulus) and/or morphological properties (i.e., cross-sectional area (CSA)) of tendons in vivo, and was reported (d) in English language. Weighted average effect sizes (SMD, random-effects) and heterogeneity (Q and I ² statistics) of the intervention-induced changes of tendon stiffness, Young's modulus, and CSA were calculated. A subgroup analysis was conducted regarding the applied loading intensity, muscle contraction type, and intervention duration. Further, the methodological study quality and the risk of bias were assessed.

RESULTS

The review process yielded 27 studies with 37 separate interventions on either the Achilles or patellar tendon (264 participants). SMD was 0.70 (confidence interval: 0.51, 0.88) for tendon stiffness (N=37), 0.69 (0.36, 1.03) for Young's modulus (N=17), and 0.24 (0.07, 0.42) for CSA (N=33), with significant overall intervention effects (p<0.05). The heterogeneity analysis (stiffness: I ² =30%; Young's modulus: I ² =57%; CSA: I ² =21%) indicated that differences in the loading conditions may affect the adaptive responses. The subgroup analysis confirmed that stiffness adaptation significantly (p<0.05) depends on loading intensity (I ² =0%), but not on muscle contraction type. Although not significantly different, SMD was higher for interventions with longer duration (≥12 weeks). The average score of 71±9% in methodological quality assessment indicated an appropriate quality of most studies.

CONCLUSIONS

The present meta-analysis provides elaborate statistical evidence that tendons are highly responsive to diverse loading regimens. However, the data strongly suggests that loading magnitude in particular plays a key role for tendon adaptation in contrast to muscle contraction type. Furthermore, intervention-induced changes in tendon stiffness seem to be more attributed to adaptations of the material rather than morphological properties.

Neuromuscular adaptations associated with knee joint angle-specific force change

PURPOSE

Neuromuscular adaptations to joint angle-specific force increases after isometric training have not yet been fully elucidated. This study examined angle-specific neuromuscular adaptations in response to isometric knee extension training at short (SL, joint angle 38.1° ± 3.7°) versus long (LL, 87.5° ± 6.0°) muscle lengths.

METHODS

Sixteen men trained three times a week for 6 wk either at SL (n = 8) or LL (n = 8). Voluntary maximal isometric knee extensor (MVC) force, doublet twitch force, EMG amplitudes (EMG/Mmax), and voluntary activation during MVC force (VA%) were measured at eight knee joint angles (30°-100°) at weeks 0, 3, and 6. Muscle volume and cross-sectional area (CSA) were measured from magnetic resonance imaging scans, and fascicle length (Lf) was assessed using ultrasonography before and after training.

RESULTS

Clear joint angle specificity of force increase was seen in SL but not in LL. The 13.4% ± 9.7% (P = 0.01) force increase around the training angle in SL was related to changes in vastus lateralis and vastus medialis EMG/Mmax around the training angle (r = 0.84-0.88, P < 0.05), without changes in the doublet twitch force-angle relation or muscle size. In LL, muscle volume and CSA increased and the changes in CSA at specific muscle regions were correlated with changes in MVC force. A 5.4% ± 4.9% (P = 0.001) increase in Lf found in both groups was not associated with angle-specific force changes. There were no angle-specific changes in VA%.

CONCLUSION

The EMG/Mmax, although not VA%, results suggest that neural adaptations underpinned training-related changes at short quadriceps lengths, but hypertrophic changes predominated after training at long lengths. The findings of this study should contribute to the development of more effective and evidence-based rehabilitation and strength training protocols.

Impact of range of motion during ecologically valid resistance training protocols on muscle size, subcutaneous fat, and strength

The impact of using different resistance training (RT) kinematics, which therefore alters RT mechanics, and their subsequent effect on adaptations remain largely unreported. The aim of this study was to identify the differences to training at a longer (LR) compared with a shorter (SR) range of motion (ROM) and the time course of any changes during detraining. Recreationally active participants in LR (aged 19 ± 2.6 years; n = 8) and SR (aged 19 ± 3.4 years; n = 8) groups undertook 8 weeks of RT and 4 weeks of detraining. Muscle size, architecture, subcutaneous fat, and strength were measured at weeks 0, 8, 10, and 12 (repeated measures). A control group (aged 23 ± 2.4 years; n = 10) was also monitored during this period. Significant (p > 0.05) posttraining differences existed in strength (on average 4 ± 2 vs. 18 ± 2%), distal anatomical cross-sectional area (59 ± 15 vs. 16 ± 10%), fascicle length (23 ± 5 vs. 10 ± 2%), and subcutaneous fat (22 ± 8 vs. 5 ± 2%), with LR exhibiting greater adaptations than SR. Detraining resulted in significant (p > 0.05) deteriorations in all muscle parameters measured in both groups, with the SR group experiencing a more rapid relative loss of postexercise increases in strength than that experienced by the LR group (p > 0.05). Greater morphological and architectural RT adaptations in the LR (owing to higher mechanical stress) result in a more significant increase in strength compared with that of the SR. The practical implications for this body of work follow that LR should be observed in RT where increased muscle strength and size are the objective, because we demonstrate here that ROM should not be compromised for greater external loading.

Hamstrings stiffness and landing biomechanics linked to anterior cruciate ligament loading

CONTEXT

Greater hamstrings stiffness is associated with less anterior tibial translation during controlled perturbations. However, it is unclear how hamstrings stiffness influences anterior cruciate ligament (ACL) loading mechanisms during dynamic tasks.

OBJECTIVE

To evaluate the influence of hamstrings stiffness on landing biomechanics related to ACL injury.

DESIGN

Cross-sectional study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 36 healthy, physically active volunteers (18 men, 18 women; age = 23 ± 3 years, height = 1.8 ± 0.1 m, mass = 73.1 ± 16.6 kg).

INTERVENTION(S)

Hamstrings stiffness was quantified via the damped oscillatory technique. Three-dimensional lower extremity kinematics and kinetics were captured during a double-legged jump-landing task via a 3-dimensional motion-capture system interfaced with a force plate. Landing biomechanics were compared between groups displaying high and low hamstrings stiffness via independent-samples t tests.

MAIN OUTCOME MEASURE(S)

Hamstrings stiffness was normalized to body mass (N/m·kg(-1)). Peak knee-flexion and -valgus angles, vertical and posterior ground reaction forces, anterior tibial shear force, internal knee-extension and -varus moments, and knee-flexion angles at the instants of each peak kinetic variable were identified during the landing task. Forces were normalized to body weight, whereas moments were normalized to the product of weight and height.

RESULTS

Internal knee-varus moment was 3.6 times smaller in the high-stiffness group (t22 = 2.221, P = .02). A trend in the data also indicated that peak anterior tibial shear force was 1.1 times smaller in the high-stiffness group (t22 = 1.537, P = .07). The high-stiffness group also demonstrated greater knee flexion at the instants of peak anterior tibial shear force and internal knee-extension and -varus moments (t22 range = 1.729-2.224, P < .05).

CONCLUSIONS

Greater hamstrings stiffness was associated with landing biomechanics consistent with less ACL loading and injury risk. Musculotendinous stiffness is a modifiable characteristic; thus exercises that enhance hamstrings stiffness may be important additions to ACL injury-prevention programs.

Effects of isometric training on the knee extensor moment-angle relationship and vastus lateralis muscle architecture

PURPOSE

To analyse the muscle adaptations induced by two protocols of isometric training performed at different muscle lengths.

METHODS

Twenty-eight subjects were divided into three groups: one (K90) performed isometric training of the knee extensors at long muscle lengths (90° of knee flexion) for 8 weeks, and the second group (K50) at short muscle lengths (50°). The subjects of the third group acted as controls. Isokinetic dynamometry was utilized to analyse the net moment-angle relationship and vastus lateralis muscle thickness at three different locations, and pennation angles and fascicle length at 50 % of thigh length were measured at rest with ultrasonography.

RESULTS

Only subjects from K90 group showed significant increases in isokinetic strength (23.5%, P < 0.001), while K50 group showed no increases in isokinetic strength: (10%, P > 0.05). There was a shift in the angle of peak torque of the K90 group to longer muscle lengths (+14.6%, P = 0.002) with greater increases in isokinetic strength, while the K50 angle shifted to shorter muscle lengths (-7.3%, P = 0.039). Both training groups showed significant increases in muscle thickness, (K90 9-14% vs. K50 5-9%) but only K90 significantly increased their pennation angles (11.7%, P = 0.038). Fascicle lengths remained unchanged.

CONCLUSIONS

Isometric training at specific knee angles led to significant shifts of peak torque in the direction of the training muscle lengths. The greater strength gains and the architectural changes with training at long muscle lengths probably come from a combination of different factors, such as the different mechanical stresses placed upon the muscle-tendon complex.

Task-specific neural adaptations to isoinertial resistance training

This study aimed to delineate the contribution of adaptations in agonist, antagonist, and stabilizer muscle activation to changes in isometric and isoinertial lifting strength after short-term isoinertial resistance training (RT). Following familiarization, 45 men (23.2 ± 2.8 years) performed maximal isometric and isoinertial strength tests of the elbow flexors of their dominant arms before and after 3 weeks of isoinertial RT. During these tasks, surface electromyography (EMG) amplitude was recorded from the agonist (biceps brachii short and long heads), antagonist (triceps brachii lateral head), and stabilizer (anterior deltoid, pectoralis major) muscles and normalized to either Mmax (agonists) or to maximum EMG during relevant reference tasks (antagonist, stabilizers). After training, there was more than a twofold greater increase in training task-specific isoinertial than isometric strength (17% vs 7%). There were also task-specific adaptations in agonist EMG, with greater increases during the isoinertial than isometric strength task [analysis of variance (ANOVA), training × task, P = 0.005]. A novel finding of this study was that training increased stabilizer muscle activation during all the elbow flexion strength tasks (P < 0.001), although these were not task-specific training effects. RT elicited specific neural adaptations to the training task that appeared to explain the greater increase in isoinertial than isometric strength.

Acute effects of different stretching durations on passive torque, mobility, and isometric muscle force

Static stretching is widely applied in various disciplines. However, the acute effects of different durations of stretching are unclear. Therefore, this study was designed to investigate the acute effects of different stretching durations on muscle function and flexibility, and provide an insight into the optimal duration of static stretching. This randomized crossover trial included 24 healthy students (17 men and 7 women) who stretched their right hamstrings for durations of 20, 60, 180, and 300 seconds in a random order. The following outcomes were assessed using an isokinetic dynamometer as markers of lower-limb function and flexibility: static passive torque (SPT), dynamic passive torque (DPT), stiffness, straight leg raise (SLR), and isometric muscle force. Static passive torque was significantly decreased after all stretching durations (p < 0.05). Static passive torque was significantly lower after 60, 180, and 300 seconds of stretching compared with that after 20-second stretching, and stiffness decreased significantly after 180- and 300-second stretching (p < 0.05). In addition, DPT and stiffness were significantly lower after 300 seconds than after 20-second stretching (p < 0.05), and SLR increased significantly after all stretching durations (p < 0.05). Straight leg raise was higher after 180- and 300-second stretching than after 20-second stretching and higher after 300-second stretching than after 60-second stretching (p < 0.05). Isometric muscle force significantly decreased after all stretching durations (p < 0.05). Therefore, increased duration of stretching is associated with a decrease in SPT but an increase in SLR. Over 180 seconds of stretching was required to decrease DPT and stiffness, but isometric muscle force decreased regardless of the stretching duration. In conclusion, these results indicate that longer durations of stretching are needed to provide better flexibility.

Muscular adaptations and insulin-like growth factor-1 responses to resistance training are stretch-mediated

INTRODUCTION

Modulation of muscle characteristics was attempted through altering muscle stretch during resistance training. We hypothesized that stretch would enhance muscle responses.

METHODS

Participants trained for 8 weeks, loading the quadriceps in a shortened (SL, 0-50° knee flexion; n=10) or lengthened (LL, 40-90°; n=11) position, followed by 4 weeks of detraining. Controls (CON; n=10) were untrained. Quadriceps strength, vastus lateralis architecture, anatomical cross-sectional area (aCSA), and serum insulin-like growth factor-1 (IGF-1) were measured at weeks 0, 8, 10, and 12.

RESULTS

Increases in fascicle length (29±4% vs. 14±4%), distal aCSA (53±12% vs. 18±8%), strength (26±6% vs. 7±3%), and IGF-1 (31±6% vs. 7±6%) were greater in LL compared with SL muscles (P<0.05). No changes occurred in CON. Detraining decrements in strength and aCSA were greater in SL than LL muscles (P<0.05).

CONCLUSIONS

Enhanced muscle in vivo (and somewhat IGF-1) adaptations to resistance training are concurrent with muscle stretch, which warrants its inclusion within training.

The effects of isometric and isotonic training on hamstring stiffness and anterior cruciate ligament loading mechanisms

Greater hamstring musculotendinous stiffness is associated with lesser ACL loading mechanisms. Stiffness is enhanced via training, but previous investigations evaluated tendon rather than musculotendinous stiffness, and none involved the hamstrings. We evaluated the effects of isometric and isotonic training on hamstring stiffness and ACL loading mechanisms. Thirty-six healthy volunteers were randomly assigned to isometric, isotonic, and control groups. Isometric and isotonic groups completed 6 weeks of training designed to enhance hamstring stiffness. Stiffness, anterior tibial translation, and landing biomechanics were measured prior to and following the interventions. Hamstring stiffness increased significantly with isometric training (15.7%; p=0.006), but not in the isotonic (13.5%; p=0.089) or control (0.4%; p=0.942) groups. ACL loading mechanisms changed in manners consistent with lesser loading, but these changes were not statistically significant. These findings suggest that isometric training may be an important addition to ACL injury prevention programs. The lack of significant changes in ACL loading mechanisms and effects of isotonic training were likely due to the small sample sizes per group and limited intervention duration. Future research using larger sample sizes and longer interventions is necessary to determine the effects of enhancing hamstring stiffness on ACL loading and injury risk.

The manipulation of strain, when stress is controlled, modulates in vivo tendon mechanical properties but not systemic TGF-β1 levels

Modulators of loading-induced in vivo adaptations in muscle–tendon complex (MTC) mechanical properties remain unclear. Similarly contentious, is whether changes in MTC characteristics are associated with growth factor levels. Four groups were subjected to varying magnitudes of stress/strain: Group 1 trained with the MTC at a shortened position (MTCS; n = 10); Group 2 at a lengthened position (MTCL; n = 11; stress levels matched to MTCS); Group 3 over a wide range of motion (MTCX; n = 11); and Group 4 (n = 10) was the control population (no training). Patella tendon Stiffness (P < 0.001), Young's modulus, and quadriceps torque (P < 0.05) increments (only seen in the training groups), showed MTCL and MTCX groups responses to be superior to those of MTCS (P < 0.05). In addition, MTCL and MTCX better maintained adaptations compared to MTCS (P < 0.05) following detraining, with a pattern of slower loss of improvements at the early phase of detraining in all training groups. There were no significant changes (P > 0.05) in antagonist cocontraction, patella tendon dimensions or circulating transforming growth factor beta (TGF-β1) levels following training or detraining in any of the groups. We conclude that chronically loading the MTC in a relatively lengthened position (which involves greater strains) enhances its mechanical properties, more so than loading in a shortened position. This is true even after normalizing for internal stress. The underlying endocrine mechanisms do not appear to be mediated via TGF-β1, at least not at the systemic level. Our findings have implications with regard to the effectiveness of eccentric loading on improved tendon structural and mechanical properties.

Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness

INTRODUCTION

Achilles and patellar tendinopathy are overuse injuries that are common among athletes. Isolated eccentric muscle training has become the dominant conservative management strategy for Achilles and patellar tendinopathy but, in some cases, up to 45 % of patients may not respond. Eccentric-concentric progressing to eccentric (Silbernagel combined) and eccentric-concentric isotonic (heavy-slow resistance; HSR) loading have also been investigated. In order for clinicians to make informed decisions, they need to be aware of the loading options and comparative evidence. The mechanisms of loading also need to be elucidated in order to focus treatment to patient deficits and refine loading programmes in future studies.

OBJECTIVES

The objectives of this review are to evaluate the evidence in studies that compare two or more loading programmes in Achilles and patellar tendinopathy, and to review the non-clinical outcomes (potential mechanisms), such as improved imaging outcomes, associated with clinical outcomes.

METHODS

Comprehensive searching (MEDLINE, EMBASE, CINAHL, Current Contents and SPORTDiscus(™)) identified 403 studies. Two authors independently reviewed studies for inclusion and quality. The final yield included 32 studies; ten compared loading programmes and 28 investigated at least one potential mechanism (six studies compared loading programmes and investigated potential mechanisms).

RESULTS

This review has identified limited (Achilles) and conflicting (patellar) evidence that clinical outcomes are superior with eccentric loading compared with other loading programmes, questioning the currently entrenched clinical approach to these injuries. There is equivalent evidence for Silbernagel combined (Achilles) and greater evidence for HSR loading (patellar). The only potential mechanism that was consistently associated with improved clinical outcomes in both Achilles and patellar tendon rehabilitation was improved neuromuscular performance (e.g. torque, work, endurance), and Silbernagel-combined (Achilles) HSR loading (patellar) had an equivalent or higher level of evidence than isolated eccentric loading. In the Achilles tendon, a majority of studies did not find an association between improved imaging (e.g. reduced anteroposterior diameter, proportion of tendons with Doppler signal) and clinical outcomes, including all high-quality studies. In contrast, HSR loading in the patellar tendon was associated with reduced Doppler area and anteroposterior diameter, as well as greater evidence of collagen turnover, and this was not seen following eccentric loading. HSR seems more likely to lead to tendon adaptation and warrants further investigation. Improved jump performance was associated with Achilles but not patellar tendon clinical outcomes. The mechanisms associated with clinical benefit may vary between loading interventions and tendons.

CONCLUSION

There is little clinical or mechanistic evidence for isolating the eccentric component, although it should be made clear that there is a paucity of good quality evidence and several potential mechanisms have not been investigated, such as neural adaptation and central nervous system changes (e.g. cortical reorganization). Clinicians should consider eccentric-concentric loading alongside or instead of eccentric loading in Achilles and patellar tendinopathy. Good-quality studies comparing loading programmes and evaluating clinical and mechanistic outcomes are needed in both Achilles and patellar tendinopathy rehabilitation.

Reliability and effects of muscular pretension on isometric strength of older adults

There were two objectives to this study: (a) to determine the reliability of measuring isometric maximum torque (MT) and maximum rate of torque development (MRTD) of the knee extensor and flexor muscles and (b) to assess the effects of different muscular pretensions on MT and MRTD of older adults. Maximum strength of 35 untrained healthy older adults (aged 66.9 ± 6.6 years; height 1.72 ± 0.07 m; weight 75.2 ± 9.6 kg) was measured. Strength measurement was performed with the Dr. Wolff ISO Check using a piezo-electric force transducer. MT intra-day coefficient of variation (CV) was between 3.30 and 12.40 % for both measurement sessions. Intraclass correlation coefficients (ICC) ranging from 0.71 to 0.99 showed good relative reliability. MT test–retest reliability (between sessions 1 and 2) of knee extension reached a CV between 7.10 and 9.30 % and high ICC values. The measurement of the knee flexion achieved an acceptable CV (9.40 %) at 40 % muscular pretension. MRTD was negatively influenced by muscular pretension (p <0.05). In conclusion, MT could be measured reliably over different trials using isometric strength measurement. The test–retest reliability was acceptable at knee extension with 10 to 40 % muscular pretension and with 40 % muscular pretension at knee flexion. A higher muscular pretension has no impact on MT but decreases MRTD in older adults.

Patellar tendon adaptation in relation to load-intensity and contraction type

BACKGROUND

Loading leads to tendon adaptation but the influence of load-intensity and contraction type is unclear. Clinicians need to be aware of the type and intensity of loading required for tendon adaptation when prescribing exercise. The aim of this study was to investigate the influence of contraction type and load-intensity on patellar tendon mechanical properties.

METHOD

Load intensity was determined using the 1 repetition maximum (RM) on a resistance exercise device at baseline and fortnightly intervals in four randomly allocated groups of healthy, young males: (1) control (no training); (2) concentric (80% of concentric-eccentric 1RM, 4×7-8); (3) standard load eccentric only (80% of concentric-eccentric 1RM, 4×12-15 repetitions) and (4) high load eccentric (80% of eccentric 1RM, 4×7-8 repetitions). Participants exercised three times a week for 12 weeks on a leg extension machine. Knee extension maximum torque, patellar tendon CSA and length were measured with dynamometry and ultrasound imaging. Patellar tendon force, stress and strain were calculated at 25%, 50%, 75% and 100% of maximum torque during isometric knee extension contractions, and stiffness and modulus at torque intervals of 50-75% and 75-100%. Within group and between group differences in CSA, force, elongation, stress, strain, stiffness and modulus were investigated. The same day reliability of patellar tendon measures was established with a subset of eight participants.

RESULTS

Patellar tendon modulus increased in all exercise groups compared with the control group (p<0.05) at 50-75% of maximal voluntary isometric contraction (MVIC), but only in the high eccentric group compared with the control group at 75-100% of MVIC (p<0.05). The only other group difference in tendon properties was a significantly greater increase in maximum force in the high eccentric compared with the control group (p<0.05). Five repetition maximum increased in all groups but the increase was significantly greater in the high load eccentric compared with the other exercise groups (p<0.05).

CONCLUSION

Load at different intensity levels and contraction types increased patellar tendon modulus whereas muscle strength seems to respond more to load-intensity. High load eccentric was, however, the only group to have significantly greater increase in force, stiffness and modulus (at the highest torque levels) compared with the control group. The effects and clinical applicability of high load interventions needs to be investigated further.

Effective therapeutic exercise prescription: the right exercise at the right dose

The prescription of an effective therapeutic exercise program requires the right dosage of the right exercise, at the right time for that patient. The therapist must understand and apply training principles effectively in the presence of pathology, injury, or otherwise unhealthy tissue. The intervention goal is to close the gap between current performance and the desired goal or capacity. Although there may be a preferred linear path from current performance to optimal outcome, complexities of the human body, internal factors, and external variables may create barriers to this direct path. Successful programs include key program design considerations such as ensuring a stable baseline before progression, treating the right impairments and activity limitations, understanding contextual factors, considering the principles of specificity and optimal loading, and applying dosing principles. Program progression can be achieved through increases in total exercise volume and/or through manipulation of exercise challenges at the same exercise volume. Effective application of these principles will guide patients toward their goals as quickly and efficiently as possible.

Specificity of training in the lingual musculature

PURPOSE

Training specificity for a number of exercise parameters has been demonstrated for the limb musculature. The current study is a Phase I exploration of training specificity in the lingual musculature.

METHOD

Twenty-five healthy participants were assigned to 1 of 5 training conditions. Four groups completed 4 weeks of lingual exercise targeting strength, endurance, power, or speed; a control group did not exercise. Performance measures of strength, endurance, power, and speed were obtained before and after training.

RESULTS

Although statistically significant group effects were not detected, specificity was observed with respect to effect size for the performance variables of strength, endurance, and power. Further evidence of specificity was provided by the finding that training isotonic endurance did not increase performance on an isometric endurance task. Speed training did not improve performance on any of the outcome measures, nor did speed increase following training with any of the exercises.

CONCLUSIONS

The findings provide initial evidence that training specificity may be observed in the lingual musculature. The reported effect sizes can inform future studies examining the benefit of training muscle functions underlying speech and swallowing.

A return-to-sport algorithm for acute hamstring injuries

Acute hamstring injuries are the most prevalent muscle injuries reported in sport. Despite a thorough and concentrated effort to prevent and rehabilitate hamstring injuries, injury occurrence and re-injury rates have not improved over the past 28 years. This failure is most likely due to the following: 1) an over-reliance on treating the symptoms of injury, such as subjective measures of "pain", with drugs and interventions; 2) the risk factors investigated for hamstring injuries have not been related to the actual movements that cause hamstring injuries i.e. not functional; and, 3) a multi-factorial approach to assessment and treatment has not been utilized. The purpose of this clinical commentary is to introduce a model for progression through a return-to-sport rehabilitation following an acute hamstring injury. This model is developed from objective and quantifiable tests (i.e. clinical and functional tests) that are structured into a step-by-step algorithm. In addition, each step in the algorithm includes a treatment protocol. These protocols are meant to help the athlete to improve through each phase safely so that they can achieve the desired goals and progress through the algorithm and back to their chosen sport. We hope that this algorithm can serve as a foundation for future evidence based research and aid in the development of new objective and quantifiable testing methods.

Relationship Between Muscle Strength, Power and Stiffness and Running Economy in Trained Male Runners

Purpose:

In this study, a comparison was made between muscle strength, power and muscle and tendon (km and kt respectively) stiffness of the triceps surae muscle group and running economy (RE) in trained male runners.

Methods:

Twelve well-trained male runners (age = 21 + 2.7 y, height = 178.1 ± 7.1 cm, body mass = 66.7 + 3.2 kg, VO2 max = 68.3 + 4.3 mLkg–1min–1, 5000-m time = 15:04 min:s) underwent passive stiffness testing using a free oscillation method. Muscle strength was determined via a maximal isometric squat test and power determined via a maximal countermovement jump (CMJ). On a separate day, subjects performed an incremental treadmill test and their RE, lactate threshold, and VO2 max were determined. Fingertip blood lactate was determined at the end of each 3-min stage. Lactate threshold was defined as a nonlinear increase in lactate accumulation.

Results:

A statistically significant correlation was found between k m and VO at stage 6 (r = -0.69, P = .01). In addition, statistically significant correlations were observed between CMJ peak force production and VO2 at stage 2 (r = .66, P = .02), stage 3 (r = .70, P = .01), and stage 4 (r = .58, P = .04). No other statistically significant correlations were observed.

Conclusion:

These data suggest that greater muscle stiffness and less power are associated with greater RE. Future study in this area should focus on determining the mechanisms behind this relationship and how to best apply them to a running population through training techniques.

Effects of plyometric training on passive stiffness of gastrocnemii and the musculo-articular complex of the ankle joint

This study aimed to determine simultaneously the effects of plyometric training on the passive stiffness of the ankle joint musculo-articular complex, the gastrocnemii muscle-tendon complex (MTC) and the Achilles tendon in order to assess possible local adaptations of elastic properties. Seventeen subjects were divided into a trained (TG) group and a control (CG) group. They were tested before and after 8 weeks of a plyometric training period. The ankle joint range of motion (RoM), the global musculo-articular passive stiffness of the ankle joint, the maximal passive stiffness of gastrocnemii and the stiffness of the Achilles tendon during isometric plantar flexion were determined. A significant increase in the jump performances of TG relative to CG was found (squat jumps: +17.6%, P=0.008; reactive jumps: +19.8%, P=0.001). No significant effect of plyometric training was observed in the ankle joint RoM, musculo-articular passive stiffness of the ankle joint or Achilles tendon stiffness (P>0.05). In contrast, the maximal passive stiffness of gastrocnemii of TG increased after plyometric training relative to CG (+33.3%, P=0.001). Thus, a specific adaptation of the gastrocnemii MTC occurred after plyometric training, without affecting the global passive musculo-articular stiffness of the ankle joint.

Effects of static and dynamic training on the stiffness and blood volume of tendon in vivo

The purpose of this study was to investigate the effects of static and dynamic training on the stiffness and blood volume of the human tendon in vivo. Ten subjects completed 12 wk (4 days/wk) of a unilateral training program for knee extensors. They performed static training on one side [ST; 70% of maximum voluntary contraction (MVC)] and dynamic training on the other side (DT; 80% of one repetition maximum). Before and after training, MVC, neural activation level (by interpolated twitch), muscle volume (by magnetic resonance imaging), stiffness of tendon-aponeurosis complex and patella tendon (by ultrasonography), and blood volume of patella tendon (by red laser lights) were measured. Both protocols significantly increased MVC (49% for ST, 32% for DT; both P < 0.001), neural activation level (9.5% for ST, 7.6% for DT; both P < 0.01), and muscle volume (4.5% for ST, 5.6% for DT; both P < 0.01). The stiffness of tendon-aponeurosis complex increased significantly after ST (55%; P = 0.003) and DT (30%; P = 0.033), while the stiffness of patella tendon increased significantly after ST (83%; P < 0.001), but not for DT ( P = 0.110). The blood volume of patella tendon increased significantly after DT (47%; P = 0.016), but not for ST ( P = 0.205). These results implied that the changes in the blood volume of tendon would be related to differences in the effects of resistance training on the tendon properties.

The influence of frequency, intensity, volume and mode of strength training on whole muscle cross-sectional area in humans

Strength training is an important component in sports training and rehabilitation. Quantification of the dose-response relationships between training variables and the outcome is fundamental for the proper prescription of resistance training. The purpose of this comprehensive review was to identify dose-response relationships for the development of muscle hypertrophy by calculating the magnitudes and rates of increases in muscle cross-sectional area induced by varying levels of frequency, intensity and volume, as well as by different modes of strength training. Computer searches in the databases MEDLINE, SportDiscus and CINAHL were performed as well as hand searches of relevant journals, books and reference lists. The analysis was limited to the quadriceps femoris and the elbow flexors, since these were the only muscle groups that allowed for evaluations of dose-response trends. The modes of strength training were classified as dynamic external resistance (including free weights and weight machines), accommodating resistance (e.g. isokinetic and semi-isokinetic devices) and isometric resistance. The subcategories related to the types of muscle actions used. The results demonstrate that given sufficient frequency, intensity and volume of work, all three types of muscle actions can induce significant hypertrophy at an impressive rate and that, at present, there is insufficient evidence for the superiority of any mode and/or type of muscle action over other modes and types of training. Tentative dose-response relationships for each variable are outlined, based on the available evidence, and interactions between variables are discussed. In addition, recommendations for training and suggestions for further research are given.

Effects of 6 months of walking training on lower limb muscle and tendon in elderly

The purpose of this study was to investigate the effects of 6 months of walking training on muscle strength, muscle thickness and tendon stiffness on various parts of the lower limbs in the elderly. Subjects were assigned to training (n=35) and control (n=10) groups. Maximal isometric torque (MVC) and muscle thickness for knee extensors (KE), knee flexors (KF), dorsi flexors (DF) and plantar flexors (PF) were measured. Tendon stiffness for KE and PF was measured using ultrasonography while subjects performed isometric contraction. No significant changes occurred in any measured variables in the control group. In the training group, muscle thickness increased significantly for KF and DF, but not for PF. For KE, significant increases of muscle thickness at the proximal and medial sides were observed, although mean relative increase of the eight measured sites for KE was not significant. MVC increased significantly for KF, DF, and PF, but not for KE. In addition, tendon stiffness for KE and PF did not change after training. These results indicated that walking training brought about increments of muscle thickness and strength in most of the lower limbs in the elderly, but it did not result in any changes in tendon stiffness.