Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis

The Victorian Institute of Sport Assessment - Achilles is fundamentally flawed and unfit for clinical practice or research: A Rasch Measurement Theory Analysis using COSMIN recommendations

OBJECTIVES

Evaluate structural validity, hypothesis testing and measurement invariance of the Victorian Institute of Sport Assessment-Achilles (VISA-A) using Rasch analysis to determine if it can be recommended to measure Achilles tendinopathy severity.

METHODS

We performed an evaluation of the VISA-A measurement properties using Rasch Measurement Theory by pooling individual participant data from previously conducted studies (n = 217). Structural validity was assessed via threshold/category mean order; adequate item fit; unidimensionality; local dependence; internal consistency. Hypothesis testing was assessed via divergent validity. Measurement invariance assessed via differential item functioning.

RESULTS

The VISA-A has inadequate construct validity. This is evident from issues with item 8 and insufficient threshold order, item fit, borderline internal consistency and measurement invariance, with item response being influenced by both age and BMI.

CONCLUSION

The VISA-A has inadequate structural validity, borderline internal consistency and poor measurement invariance. Thus, the VISA-A does not meet with COSMIN criteria for construct validity due to issues with structural validity and measurement invariance. Thus, the VISA-A cannot be recommended for use, and should not be used in clinical practice or research. However, if the VISA-A has been used, analysis using only items 1-6, with responses collapsed into a 4-point scale provides the best structural validity.

Can quantitative sensory testing predict treatment outcomes in hip and knee osteoarthritis? A systematic review and meta-analysis of individual participant data

ABSTRACT

An individual participant data (IPD) meta-analysis can assess the predictive value of data on outcomes at the individual level, offering a potential tool for developing personalized pain management. Pretreatment quantitative sensory testing (QST) may stratify patient groups, which are then linked to treatment outcomes. Our objective was to determine if measures of QST at baseline are related to treatment outcomes (at any time point) for pain and disability in lower-limb osteoarthritis. We performed a systematic review with an IPD meta-analysis. Searches were conducted in 9 databases until May 5, 2023 for intervention studies that measured baseline QST and longitudinal measures of participant-reported pain and disability. We performed a 2-stage approach to analyse longitudinal data. Individual models were fitted to each study and combined using random effects multivariate meta-analytic models. Study quality was assessed using the Joanna Briggs Institute checklist, and certainty of the evidence was assessed using GRADE. We identified 3082 records and included 1 hip and 28 knee datasets consisting of 2522 participants from 40 studies. Local warm detection thresholds (P = 0.024) predicted knee osteoarthritis pain outcomes (very-low certainty). Local warm detection thresholds (P = 0.030), remote cold detection thresholds (P = 0.05), and remote pressure tolerance thresholds (P = 0.007) predicted knee osteoarthritis disability outcomes (very-low certainty). Other QST variables were associated with hip and knee osteoarthritis pain and disability levels (eg, pressure pain thresholds), but this relationship did not change over time. This review finds that mechanism-based, QST methodologies do not consistently predict pain or disability on an individual level in hip or knee osteoarthritis.

Reduced Achilles tendinopathy symptoms (e.g. stiffness), but not pain, relate to patient-perceived resolution of Achilles tendinopathy: a cross-sectional study

We aimed to determine whether pain, symptoms and/or physical function are associated with perceived recovery in people with current or resolved Achilles tendinopathy. We performed a cross-sectional cohort study, including people who reported having either "current" or "resolved" Achilles tendinopathy. Participants completed an online survey, including the Tendinopathy Severity Assessment- Achilles (TENDINS-A). We used multivariable binary logistic regression and reported odds ratio (OR) to quantify the strength of the association. We included 100 cases (n = 63 current, n = 37 resolved). There were no associations of age, sex, BMI, TENDINS-A (Pain) or TENDINS-A (Physical Function) with whether participants reported having current or resolved Achilles tendinopathy. However, for every 1% greater the TENDINS-A (Symptoms) there was 0.28 lower odds of a participant reporting their tendinopathy has resolved (OR = 0.972, 95% CI = 0.953 to 0.992, p = 0.007). We demonstrated a lower "symptom" severity but not "pain" severity was associated with greater patient-reported resolution of Achilles tendinopathy.

Achilles Tendon Mechanical but Not Morphological Properties Change with Rehabilitation in Patients with Chronic Midportion Achilles Tendinopathy

PURPOSE

Achilles tendinopathy is associated with altered tendon's morphological and mechanical properties, yet it is unclear whether these properties are reversed upon mechanical loading to promote tendon healing. This study aims to determine the extent to which pathological tendon's morphological and mechanical properties adapt throughout a 12-wk eccentric rehabilitation protocol.

METHODS

Forty participants with midportion Achilles tendinopathy were recruited and participated in a 12-wk eccentric rehabilitation program. Function and symptoms were recorded through the Victorian Institute of Sports Assessment-Achilles (VISA-A) and hopping. The tendon's morphological (i.e., volume, midportion cross-sectional area (CSA) and anteroposterior (AP) diameter) and mechanical (i.e., stiffness, Young's modulus, and tendon nonuniform displacement) properties were measured at baseline and at 6 and 12-wk of the intervention.

RESULTS

Significant functional improvements were observed, with VISA-A scores and hopping results showing marked improvements ( P < 0.001). Morphologically, no significant changes in volume, midportion CSA, or AP diameter were found, although a trend toward decreased CSA between 30% and 70% of tendon length was noted. Mechanically, significant increases in Achilles tendon stiffness ( P = 0.001) and Young's modulus ( P < 0.001) were observed over the course of the rehabilitation program. No differences in tendon nonuniform displacement were found after a 12-wk rehabilitation program.

CONCLUSIONS

These findings suggest that tendon adaptation in response to mechanical loading primarily involves changes in mechanical properties rather than morphology, highlighting the complexity and variability in tendon adaptation. Clinically, these mechanical properties could be considered in the load progression throughout rehabilitation as potentially higher strains will be induced when clinical improvements precede mechanical adaptations.

Physical and psychological factors related to injury, illness and tactical performance in law enforcement recruits: a systematic review

OBJECTIVE

There are inconsistent reports of factors relating to injury, illness and tactical performance in law enforcement recruits. Our objectives were to: (1) report physical and psychological risk factors and protective factors for injury and illness and (2) report physical and psychological risk factors and protective factors for tactical performance success.

DESIGN

Systematic epidemiological review.

METHODS

Searches of six databases were conducted on 13 December 2022. We included cohorts that assessed physical and psychological factors for injury, illness and tactical performance success. Study quality was assessed using the Joanna Briggs Institute Quality Assessment Checklist for Prevalence Studies and certainty assessed using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

30 studies were included, and quality assessment was performed. Very low certainty of evidence exists for physical variables related to injury risk, and we found no studies that investigated psychological variables as a risk factor for injury. Low-certainty evidence found older age, poorer performance with push-up reps to failure, poorer arm ergometer revolutions, poorer beep test, poorer 75-yard pursuit and the 1.5 miles run tests to be associated with reduced tactical performance. Very low certainty of evidence exists that the psychological variables of intelligence and anger are associated with tactical performance.

CONCLUSIONS

We identified a lack of high-level evidence for factors associated with injury, illness and performance. Interventions based on this research will be suboptimal. We suggest context-specific factors related to injury, illness and performance in law enforcement populations are used to inform current practice while further, high-quality research into risk factors is performed.

PROSPERO REGISTRATION NUMBER

CRD42022381973.

Physical Function Following Total Knee Arthroplasty for Osteoarthritis: A Longitudinal Systematic Review With Meta-analysis

OBJECTIVES: To explore the extent of functional improvement following primary total knee arthroplasty for knee osteoarthritis and to compare the trajectories of self-reported and performance-based measures of physical function. DESIGN: Longitudinal systematic review with meta-analysis METHODS: We searched 3 electronic databases from January 2005 to February 2023 for longitudinal cohort studies involving adults with knee osteoarthritis undergoing primary total knee arthroplasty. Estimates of self-reported and performance-based physical function were extracted presurgery and up to 5 years postsurgery. Risk of bias was assessed using a 6-item checklist. Self-reported function scores were converted to a 0-100 scale (higher scores indicate worse function). Mixed models provided pooled estimates after excluding low-quality studies. RESULTS: Out of 230 relevant studies, 72 (n = 19 063) of high quality were included in meta-analyses. Self-reported function significantly improved from presurgery (55.6/100; 95% confidence interval [CI], 53.1 to 58.1) to 3-6 months postsurgery (21.1; 95% CI, 17.9 to 24.3; P<.001). A small decline in self-reported function occurred at 6-12 months (31.0; 95% CI, 25.8 to 36.2; P<.001), with no further change at 12-24 months (30.9; 95% CI, 23.2 to 38.6; P = .919). Performance-based measures exhibited variable trajectories, with most estimates indicating no clinically meaningful improvement following total knee arthroplasty. CONCLUSION: Total knee arthroplasty resulted in clinically meaningful improvements in self-reported function at 3-6 months postoperatively. There was some deterioration in function after 6 months, and at no other time point did the estimate reach a clinically important change. There was limited evidence of clinically meaningful improvements in performance-based measures of physical function at any time point. J Orthop Sports Phys Ther 2025;55(1):1-11. Epub 26 November 2024. doi:10.2519/jospt.2024.12570.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

NL69527.028.19.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024

The Academy of Orthopaedic Physical Therapy (AOPT) has an ongoing effort to create evidence-based clinical practice guidelines (CPG) for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The 2024 Achilles Pain, Stiffness, and Muscle Power Deficit: Midportion Achilles Tendinopathy Clinical Practice Guideline (CPG) is a revision of the 2018 CPG and represents the third CPG from AOPT on this topic. The goals of the revision were to provide a concise summary of the contemporary evidence and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers prevalence, pathoanatomical features, risk factors, clinical course, diagnosis, examination, imaging, and physical therapy interventions for the management of midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2024;54(12):CPG1-CPG32. Epub 27 November 2024. doi:10.2519/jospt.2024.0302.

Mitochondrial destabilization in tendinopathy and potential therapeutic strategies

Tendinopathy is a prevalent aging-related disorder characterized by pain, swelling, and impaired function, often resulting from micro-scarring and degeneration caused by overuse or trauma. Current interventions for tendinopathy have limited efficacy, highlighting the need for innovative therapies. Mitochondria play an underappreciated and yet crucial role in tenocytes function, including energy production, redox homeostasis, autophagy, and calcium regulation. Abnormalities in mitochondrial function may lead to cellular senescence. Within this context, this review provides an overview of the physiological functions of mitochondria in tendons and presents current insights into mitochondrial dysfunction in tendinopathy. It also proposes potential therapeutic strategies that focus on targeting mitochondrial health in tenocytes. These strategies include: (1) utilizing reactive oxygen species (ROS) scavengers to mitigate the detrimental effects of aberrant mitochondria, (2) employing mitochondria-protecting agents to reduce the production of dysfunctional mitochondria, and (3) supplementing with exogenous normal mitochondria. In conclusion, mitochondria-targeted therapies hold great promise for restoring mitochondrial function and improving outcomes in patients with tendinopathy. The translational potential of this article: Tendinopathy is challenging to treat effectively due to its poorly understood pathogenesis. This review thoroughly analyzes the role of mitochondria in tenocytes and proposes potential strategies for the mitochondrial treatment of tendinopathy. These findings establish a theoretical basis for future research and the clinical translation of mitochondrial therapy for tendinopathy.

Poor association between tendon structure and self-reported symptoms following conservative management in active soldiers with mid-portion Achilles tendinopathy

INTRODUCTION

Mid-portion Achilles tendinopathy (mid-AT) is currently the preferred term for persistent Achilles tendon pain, defined as located 2-7 cm proximal to the calcaneus, and with loss of function related to mechanical loading. Histologically, mid-AT is considered to represent a degenerative condition. Therefore, monitoring of tendon structure additional to pain and function may be warranted, to prevent progression of degeneration or even tendon rupture. The aim of this study was to determine the association between pain and function, relative to the Achilles tendon structure, in soldiers treated with a conservative programme for mid-AT.

METHODS

A total of 40 soldiers (40 unilateral symptomatic tendons) were included in this study. Pain and function were evaluated with the Victorian Institute of Sports Assessment -Achilles (VISA-A) questionnaire. Tendon structure was quantified using ultrasound tissue characterisation (UTC). We quantified both the Achilles tendon mid-portion (2-7 cm) and the area of maximum degeneration (AoMD) within the tendon mid-portion. VISA-A and UTC measurements were taken at baseline and after 26 weeks of follow-up. Spearman's rho was used to determine the correlation between VISA-A and UTC. Correlations were calculated for baseline, follow-up and change score values.

RESULTS

Negligible correlations were found for all analyses, ranging from -0.173 to 0.166 between mid-portion tendon structure and VISA-A, and from -0.137 to 0.150 between AoMD and VISA-A. While VISA-A scores improved, on average, from 59.4 points at baseline to 93.5 points at follow-up, no detectable improvement in aligned fibrillar structure was observed in our population.

CONCLUSION

Pain and function are poorly associated with Achilles tendon structure in soldiers treated with a conservative programme for mid-AT. Therefore, we advise clinicians to use great caution in communicating relationships between both clinical entities.

TRIAL REGISTRATION NUMBER

NL69527.028.19.

TENDINopathy Severity assessment-Achilles (TENDINS-A): evaluation of reliability and validity in accordance with COSMIN recommendations

OBJECTIVE

To evaluate the construct validity (structural validity and hypothesis testing), reliability (test-retest reliability, measurement error and internal consistency) and minimal important change (MIC) of the 13-item TENDINopathy Severity assessment-Achilles (TENDINS-A).

METHODS

Participants with Achilles pain completed an online survey including: demographics, TENDINS-A, Foot and Ankle Outcome Score (FAOS) and Victorian Institute of Sport Assessment-Achilles (VISA-A). Exploratory factor analysis (EFA) assessed dimensionality. Confirmatory factor analysis (CFA) assessed structural validity (root mean square error of approximation (RMSEA); Comparative Fit Index (CFI); Tucker-Lewis Index (TLI); standardised root measure square (SRMS)). Correlations between TENDINS-A and the FAOS or VISA-A assessed hypothesis testing. Intraclass correlation (ICC) assessed test-retest reliability. Cronbach's alpha assessed internal consistency. SE of the measurement (SEM) assessed measurement error. A distribution-based approach assessed MIC.

RESULTS

79 participants (51% female) with a mean (SD) age=42.6 (13.0) years, height=175.0 (11.7) cm and body mass=82.0 (19.1) kg were included. EFA identified three meaningful factors, proposed as pain, symptoms and function. The best model identified using CFA for TENDINS-A had structural validity (RMSEA=0.101, CFI=0.959, TLI=0.947, SRMS=0.068), which included three factors (pain, symptoms and function), but excluded three items from the original TENDINS-A. TENDINS-A exhibited moderate positive correlation with FAOS (r=0.598, p<0.001) and a moderate negative correlation with VISA-A (r=-0.639, p<0.001). Reliability of the TENDINS-A was excellent (ICC=0.930; Cronbach's α=0.808; SEM=6.54 units), with an MIC of 12 units.

CONCLUSIONS

Our evaluation of the revised 10-item TENDINS-A determined it has construct validity and excellent reliability, compared with the VISA-A and FAOS which lack content and construct validity. The TENDINS-A is recommended as the preferred patient-reported outcome measure to assess disability in people with Achilles tendinopathy.

Maximising neuromuscular performance in people with pain and injury: moving beyond reps and sets to understand the challenges and embrace the complexity

Rehabilitative practice is often criticised for being non-individualised, monotonous and not well aligned with foundational principles that drive continued physiological adaptation(s). However, our understanding of neuromuscular physiology is rapidly increasing and the way we programme rehabilitation is improving. This viewpoint highlights some of the potential considerations around why the adaptations achieved during rehabilitation programmes may be suboptimal. We provide basic, clinician-focused discussion about potential confounding physiological factors, and put forward several exercise-based programming recommendations and novel approaches to consider in contemporary rehabilitative practice. Specifically, we outline several potential mechanisms contributing to poor muscle activation and function that might be present following musculoskeletal injury. However, clinicians require strategies capable of attenuating these impairments to restore proper function. Therefore, we also provide an overview of recommended strength and conditioning guidelines, and novel strategies (such as external pacing and electrical stimulation techniques) that clinicians can consider to potentially improve the efficacy of musculoskeletal rehabilitation.

Cardiorespiratory fitness is a risk factor for lower-limb and back injury in law enforcement officers commencing their basic training: a prospective cohort study

We aimed to report the epidemiology of lower-limb and lumbosacral injuries in Police Force recruits. We performed a cohort study of Police Force recruits undergoing a six-month training program with prospective injury data collected between 2018 and 2021. Cardiorespiratory fitness was quantified by the beep-test and police-specific-functional-capacity was quantified using a specifically designed physical performance evaluation (PPE) tool. Injury frequency and prevalence were reported. Fifteen percent (n = 180) of study Police Force recruits (n = 1,181) sustained a lower-limb or lumbosacral injury. The six-month training program significantly improved cardiorespiratory fitness (p < 0.001) and functional capacity (p < 0.001). Increased cardiorespiratory fitness at baseline decreased injury risk (OR = 0.8, 95%CI: 0.66-0.97, p = 0.019). Injury rates decreased over time and females were injured significantly earlier than males (HR = 0.70, 95%CI: 0.52 to 0.95, p = 0.021). Interventions that can pre-condition Police Force recruits prior to the commencement of their basic physical training may reduce the number of lower-limb and lumbosacral injuries.

Effects of exercise-based interventions on gluteal tendinopathy. Systematic review with meta-analysis

The objective of this review was to evaluate the effect of exercise on pain intensity, function, and quality of life in individuals with gluteal tendinopathy. Searches were carried out in PUBMED, EMBASE, CINAHL, Cochrane Library, and PEDro databases. Randomized or quasi-randomized controlled trials were included. Five studies met the eligibility criteria, comparing exercise-based interventions with minimal interventions and/or corticosteroid injections. Three studies, involving 383 participants, were included in the quantitative analysis. Meta-analyses showed that exercise is superior to minimal intervention for function in short-term [mean difference (MD) = 10.24; 95% confidence interval (95%CI) = 5.98, 14.50) and long-term (MD = 6.54; 95%CI = 1.88, 11.21]). However, no difference was observed for quality of life in the short [standardized mean difference (SMD) = 0.33; 95%CI = -0.29, 0.94] and long-term (SMD = 0.11; 95%CI = -0.16, 0.37). The effect of exercise was no different from that of corticosteroid injections for pain intensity in the short (MD = 1.25; 95%CI = -3.56, 6.05) and long-term (MD = -1.37; 95%CI = -3.72, 0.98]). In conclusion, exercise is superior to minimal interventions for function in the short- and long-term in individuals with gluteal tendinopathy. Exercise and corticosteroid injections had similar effects on pain intensity, however, exercise showed a higher treatment success rate when compared to corticosteroid injections in this population. The GRADE analysis revealed that the certainty of the evidence ranges from low to very low, therefore, large high-quality randomized controlled trials are recommended.PROSPERO registration number: CRD42021242853.

TENDINopathy Severity Assessment - Achilles (TENDINS-A): Development and Content Validity Assessment of a New Patient-Reported Outcome Measure for Achilles Tendinopathy

OBJECTIVE: To develop a new patient-reported outcome measure (PROM) assessing TENDINopathy Severity of the Achilles (TENDINS-Achilles) and evaluate its content validity. DESIGN: Mixed-methods, modified Delphi. METHODS: We performed 1 round of semistructured one-on-one interview responses with professionals and patients, for initial item generation. This was followed by 1 round of survey responses for professionals and a final round of semistructured one-on-one interviews with patients. The work culminated in a PROM to quantify Achilles tendinopathy severity under the core health domain of disability. Participants identified 3 subdomains contributing to the severity of disability of Achilles tendinopathy: pain, symptoms, and functional capacity. RESULTS: All 8 patient participants invited to participate were enrolled. Forty professional participants (50% women, six different continents) were invited to participate and 30 were enrolled (75% response rate). Therefore, a total of 30 professionals and 8 patients were included within this study. Following 3 rounds of qualitative or quantitative feedback, this study has established the content validity of TENDINS-A (good relevance, comprehensibility, and comprehensiveness) as a new PROM to assess the severity of Achilles tendinopathy, which assesses aspects of pain, symptoms, and functional capacity. CONCLUSION: TENDINS-A has established content validity and is appropriate for use with clinical and research populations. We recommend users interpret TENDINS-A results cautiously, until further testing evaluates the most appropriate scoring scale, reliability, construct validity, criterion validity, and responsiveness of TENDINS-A. Until these psychometric properties are established, we suggest using TENDINS-A alongside existing tools. J Orthop Sports Phys Ther 2023;53(11):1-16. Epub: 24 August 2023. doi:10.2519/jospt.2023.11964.

Conditioned Pain Modulation Does Not Differ Between People With Lower-Limb Tendinopathy and Nontendinopathy Controls: A Systematic Review With Individual Participant Data Meta-analysis

OBJECTIVE: To explore whether people with lower-limb tendinopathy have reduced relative conditioned pain modulation (CPM) when compared to nontendinopathy controls. DESIGN: Systematic review with individual participant data (IPD) meta-analysis. LITERATURE SEARCH: Eight databases were searched until August 29, 2022. STUDY SELECTION CRITERIA: Cross-sectional studies comparing the magnitude of the CPM effect in people with lower-limb tendinopathy to nontendinopathy controls in a case-control design. DATA SYNTHESIS: Included studies provided IPD, which was reported using descriptive statistics. Generalized estimating equations (GEEs) determined between-group differences in the relative CPM effect, when adjusting for co-variables. Study quality was assessed using a Joanna Briggs Institute checklist, and certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluations. RESULTS: Five records were included, IPD were provided for 4 studies (n = 219 with tendinopathy, n = 226 controls). The principal GEE (model 1) found no significant relative CPM effects for tendinopathy versus controls (B = -1.73, P = .481). Sex (B = 4.11, P = .160), age (B = -0.20, P = .109), and body mass index (B = 0.28, P = .442) did not influence relative CPM effect. The Achilles region had a reduced CPM effect (B = -22.01, P = .009). In model 2 (adjusting for temperature), temperature (B = -2.86, P = .035) and female sex (B = 21.01, P = .047) were associated with the size of the relative CPM effect. All studies were low-quality, and the certainty of the evidence was moderate. CONCLUSION: There were no between-group differences in the magnitude of the CPM effect, suggesting clinicians should manage lower-limb tendinopathy using interventions appropriate for peripherally dominant pain (eg, tendon loading exercises such as heavy slow resistance). Based on the "moderate"-certainty evidence, future studies are unlikely to substantially change these findings. J Orthop Sports Phys Ther 2023;54(1):1-10. Epub 19 October 2023. doi:10.2519/jospt.2023.11940.

Epidemiology of musculoskeletal injury in military recruits: a systematic review and meta-analysis

BACKGROUND

Injuries are a common occurrence in military recruit training, however due to differences in the capture of training exposure, injury incidence rates are rarely reported. Our aim was to determine the musculoskeletal injury epidemiology of military recruits, including a standardised injury incidence rate.

METHODS

Epidemiological systematic review following the PRISMA 2020 guidelines. Five online databases were searched from database inception to 5th May 2021. Prospective and retrospective studies that reported data on musculoskeletal injuries sustained by military recruits after the year 2000 were included. We reported on the frequency, prevalence and injury incidence rate. Incidence rate per 1000 training days (Exact 95% CI) was calculated using meta-analysis to allow comparisons between studies. Observed heterogeneity (e.g., training duration) precluded pooling of results across countries. The Joanna Briggs Institute Quality Assessment Checklist for Prevalence Studies assessed study quality.

RESULTS

This review identified 41 studies comprising 451,782 recruits. Most studies (n = 26; 63%) reported the number of injured recruits, and the majority of studies (n = 27; 66%) reported the number of injuries to recruits. The prevalence of recruits with medical attention injuries or time-loss injuries was 22.8% and 31.4%, respectively. Meta-analysis revealed the injury incidence rate for recruits with a medical attention injury may be as high as 19.52 injuries per 1000 training days; and time-loss injury may be as high as 3.97 injuries per 1000 training days. Longer recruit training programs were associated with a reduced injury incidence rate (p = 0.003). The overall certainty of the evidence was low per a modified GRADE approach.

CONCLUSION

This systematic review with meta-analysis highlights a high musculoskeletal injury prevalence and injury incidence rate within military recruits undergoing basic training with minimal improvement observed over the past 20 years. Longer training program, which may decrease the degree of overload experienced by recruit, may reduce injury incidence rates. Unfortunately, reporting standards and reporting consistency remain a barrier to generalisability.

TRIAL REGISTRATION

PROSPERO (Registration number: CRD42021251080).

Achilles tendon disorders: An overview of diagnosis and conservative treatment

ABSTRACT

Achilles tendon-related pain affects up to 6% of the US population during their lifetime and is commonly encountered by primary care providers. An accurate diagnosis and early conservative management can improve patient quality of life and reduce unnecessary surgical consultations, saving healthcare dollars. Achilles tendon pathologies can be categorized into acute (pain lasting less than 6 weeks), chronic (pain lasting more than 6 weeks), and acute on chronic (worsening of pain with preexisting chronic Achilles tendon pathology). This article describes the diagnosis, conservative management, indications for imaging, and indications for surgical referral for acute and chronic Achilles tendon rupture, Achilles tendinitis, gastrocnemius strain, plantaris rupture, insertional Achilles tendinopathy, Haglund deformity, and noninsertional Achilles tendinopathy.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

DESIGN

A feasibility prospective cohort study SETTING: A community setting.

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

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

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

Biomimetic Scaffolds for Tendon Tissue Regeneration

Tendon tissue connects muscle to bone and plays crucial roles in stress transfer. Tendon injury remains a significant clinical challenge due to its complicated biological structure and poor self-healing capacity. The treatments for tendon injury have advanced significantly with the development of technology, including the use of sophisticated biomaterials, bioactive growth factors, and numerous stem cells. Among these, biomaterials that the mimic extracellular matrix (ECM) of tendon tissue would provide a resembling microenvironment to improve efficacy in tendon repair and regeneration. In this review, we will begin with a description of the constituents and structural features of tendon tissue, followed by a focus on the available biomimetic scaffolds of natural or synthetic origin for tendon tissue engineering. Finally, we will discuss novel strategies and present challenges in tendon regeneration and repair.

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

OBJECTIVES

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

DESIGN

Cross-sectional.

SETTING

Laboratory.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Injury Profiles of Police Recruits Undergoing Basic Physical Training: A Prospective Cohort Study

Purpose A lack of published epidemiological data among police recruits presents a major challenge when designing appropriate prevention programs to reduce injury burden. We aimed to report the injury epidemiology of Western Australian (WA) Police Force recruits and examine sex and age as injury risk factors. Methods Retrospective analyses were conducted of prospectively collected injury data from WA Police Force recruits between 2018-2021. Injury was defined as 'time-loss' and injury incidence rate per 1000 training days (Poisson exact 95% confidence intervals) was calculated. For each region and type of injury, the incidence, severity, and burden were calculated. The association between age, sex, and injury occurrence were assessed using Cox regression time-to-event analysis. Results A total of 1316 WA Police Force recruits were included, of whom 264 recruits sustained 304 injuries. Injury prevalence was 20.1% and the incidence rate was 2.00 (95%CI 1.78-2.24) injuries per 1000 training days. Lower limb injuries accounted for most of the injury burden. Ligament/ joint injuries had the highest injury tissue/pathology burden. The most common activity injuring recruits was physical training (31.8% of all injuries). Older age (Hazard Ratio = 1.5, 95%CI = 1.2 to 1.9, p = 0.002) and female sex (Hazard Ratio = 1.4, 95%CI = 1.3 to 1.6, p < 0.001) increased risk of injury. Conclusion Prevention programs targeting muscle/tendon and ligament/joint injuries to the lower limb and shoulder should be prioritised to reduce the WA Police Force injury burden. Injury prevention programs should also prioritise recruits who are over 30 years of age or of female sex, given they are a higher risk population.

Can we really say getting stronger makes your tendon feel better? No current evidence of a relationship between change in Achilles tendinopathy pain or disability and changes in triceps Surae structure or function when completing rehabilitation: a systematic review

OBJECTIVES

Determine if improvements in pain and disability in patients with mid-portion Achilles tendinopathy relate to changes in muscle structure and function whilst completing exercise rehabilitation.

DESIGN

A systematic review exploring the relationship between changes in pain/disability and muscle structure/function over time, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

Six online databases and the grey literature were searched from database inception to 16th December 2022 whereas clinical trial registries were searched from database inception to 11th February 2020. We included clinical studies where participants received exercise rehabilitation (±placebo interventions) for mid-portion Achilles tendinopathy if pain/disability and Triceps Surae structure/function were measured. We calculated Cohen's d (95 % confidence intervals) for changes in muscle structure/function over time for individual studies. Data were not pooled due to heterogeneity. Study quality was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

Seventeen studies were included for synthesis. No studies reported the relationship between muscle structure/function and pain/disability changes. Twelve studies reported muscle structure/function outcome measures at baseline and at least one follow-up time-point. Three studies reported improvements in force output after treatment; eight studies demonstrated no change in structure or function; one study did not provide a variation measure, precluding within group change over time calculation. All studies were low quality.

CONCLUSIONS

No studies explored the relationship between changes in tendon pain and disability and changes in muscle structure and function. It is unclear whether current exercise-based rehabilitation protocols for mid-portion Achilles tendinopathy improve muscle structure or function.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (registration number: CRD42020149970).

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

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

The Benefits to Bone Health in Children and Pre-School Children with Additional Exercise Interventions: A Systematic Review and Meta-Analysis

OBJECTIVE

Determine if exercise interventions, beyond what is already provided to children and preschool children, improve bone health and reduce fracture incidence.

DESIGN

Systematic review and meta-analysis reported using the PRISMA guidelines. Certainty of evidence was assessed using GRADE recommendations.

DATA SOURCES

Five electronic databases were searched for records: PUBMED; CINAHL; CENTRAL; SPORTDiscus; Web of Science.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised, quasi-randomised and non-randomised controlled trials (including cluster-randomised) assessing the impact of additional exercise interventions (e.g., increased physical education classes or specific jumping programs) on bone health in children (6-12 years) and pre-school children (2-5 years) without dietary intervention.

RESULTS

Thirty-one records representing 16 distinct clinical trials were included. Dual-energy X-ray Absorptiometry (DXA) and/or peripheral Quantitative Computed Tomography (pQCT) were used to quantify bone health. Increased femoral neck bone mineral content in children with additional exercise interventions (n = 790, SMD = 0.55, 95% CI = 0.01 to 1.09) was reported, however this was not significant following sensitivity analysis. Other DXA and pQCT measures, as well as fracture incidence, did not appear to significantly differ over time between intervention and control groups. No studies reported adverse events. Studies failed to report all domains within the TIDieR checklist. All studies were at high risk of bias using the Cochrane RoB Tool 2.0. The certainty of the evidence was very low.

CONCLUSIONS

The addition of exercise interventions, beyond what is provided to children, does not appear to improve DXA and pQCT measures of bone health. The effect of additional exercise interventions on bone health in pre-school children is largely unknown. Future trials should ensure adherence is clearly reported and controlled for within analysis as well as including reports of adverse events (e.g., apophysitis) that occur due to increased exercise interventions.

Plantarflexor neuromuscular performance in Insertional Achilles tendinopathy

BACKGROUND

Insertional Achilles tendinopathy (IAT) is a common and painful musculoskeletal condition. The management of IAT commonly involves strengthening of the plantarflexors, although there is currently a paucity of research investigating plantarflexor neuromuscular performance specific to people with IAT.

OBJECTIVES

To compare plantarflexor neuromuscular performance between men with IAT and controls, and to investigate the relationship between plantarflexor neuromuscular performance and patient reported outcome measures for men with IAT.

DESIGN

Case control.

METHOD

34 men with IAT (age 43.7 years [SD 10.02], weight 89.6 kg [16.3]) were matched with 34 healthy men (age 42.8 years [SD 8.9], weight 87.2 kg [9.7]). Participants underwent a plantarflexion maximal voluntary isometric contraction (MVIC) task, and a target force matching task. Neuromuscular variables from these tasks include; MVIC, rate of torque development (RTD), electromechanical delay (EMD), and muscle force steadiness. Participants also completed questionnaires regarding; pain and function, and psychological factors.

RESULTS

The IAT group had reduced MVIC (p < 0.01) and RTD, (p < 0.01) compared to controls, however no significant difference in plantarflexor force steadiness (p = 0.08), or EMD (p = 0.71) was observed. Low strength correlations were detected between the VISA-A and RTD (r = 0.37, p = 0.04), kinesiophobia and EMD (r = 0.45, p = 0.03).

CONCLUSIONS

This study established impairments in plantarflexor strength and RTD among people with IAT. Plantarflexor force steadiness and EMD is not altered in IAT, which is in contrast to evidence from mid-portion Achilles tendinopathy. Plantarflexor RTD was the only neuromuscular outcome measure linked to symptom severity, which may indicate it is an important rehabilitation finding.

Shear wave elastography imaging in a porcine tendinopathy model

OBJECTIVE

To quantify the effect of structural damage in an ex vivo animal tendinopathy model using shear wave elastography (SWE).

MATERIALS AND METHODS

Sixteen porcine flexor tendons were injected with a 0.05 mL bolus of 1.5% collagenase solution to induce focal structural damage without surfacing tears. Control tendons were injected with saline (n = 16). Eight tendons from each group were incubated at 37 °C for 3.5 h while the remaining 8 from each group were incubated for 7 h. Tendons were mechanically stretched to 0% and 1% strain. Simultaneously, SWE was acquired proximal to, at, and distal to the injection site using a clinical ultrasound scanner.

RESULTS

There were significant differences in SWS (saline > collagenase) at 1% strain and 7-h incubation for all three locations (PROX p = 0.0031, ROI p = 0.001, DIST p = 0.0043). There were also significant differences at 0% strain and 7 h, but only at (p = 0.0005), and distal to (p = 0.0035), the injection site. No statistically significant differences were observed for 3.5-h incubation, at 0% or 1% strain.

CONCLUSIONS

Collagenase-mediated structural damage does appear to convey decreased tissue elasticity on SWE when ex vivo tendons are incubated for 7 h. These findings suggest that SWE may be a useful tool for predicting ultimate tissue strength in tendinopathic tissues. Pull-to-failure testing should be performed in the future and are expected to show that tendons with decreased SWS, and, therefore, decreased elasticity, rupture at lower pulls forces.

Irisin promotes the proliferation and tenogenic differentiation of rat tendon-derived stem/progenitor cells via activating YAP/TAZ

Tendinopathy is a common tendon disorder characterized by pain, swelling, and dysfunction. Current evidence has demonstrated that the depletion of stem cell pool and non-tenogenic differentiation of tendon-derived stem/progenitor cells (TSPCs) might account for the pathogenesis of tendinopathy. FNDC5/Irisin, as a novel exercise-induced myokine, is proved to be involved in the exercise-induced protective effects on musculoskeletal disorders. However, whether irisin can affect TSPCs fate is still unknown. To ascertain the roles of irisin on the proliferation and tenogenic differentiation of TSPCs, rat TSPCs were isolated and incubated with irisin. Cell viability, phenotypic changes, and related signaling pathways were evaluated by CCK-8 assay, colony formation assay, real-time PCR, Western blot, immunofluorescence, and proteasome activity assay. We found that irisin treatment increased the proliferative and colony-forming abilities, and promoted the tenogenic differentiation of TSPCs by upregulating the expression of YAP/TAZ. In conclusion, our work showed for the first time that irisin promotes the proliferation and tenogenic differentiation of rat TSPCs in vitro by activating YAP/TAZ, and the process was associated with a ubiquitin-proteasome proteolytic pathway. In conclusion, irisin and agents targeting YAP/TAZ may be promising therapeutic options for tendinopathy.

Foundational Principles and Adaptation of the Healthy and Pathological Achilles Tendon in Response to Resistance Exercise: A Narrative Review and Clinical Implications

Therapeutic exercise is widely considered a first line fundamental treatment option for managing tendinopathies. As the Achilles tendon is critical for locomotion, chronic Achilles tendinopathy can have a substantial impact on an individual's ability to work and on their participation in physical activity or sport and overall quality of life. The recalcitrant nature of Achilles tendinopathy coupled with substantial variation in clinician-prescribed therapeutic exercises may contribute to suboptimal outcomes. Further, loading the Achilles tendon with sufficiently high loads to elicit positive tendon adaptation (and therefore promote symptom alleviation) is challenging, and few works have explored tissue loading optimization for individuals with tendinopathy. The mechanism of therapeutic benefit that exercise therapy exerts on Achilles tendinopathy is also a subject of ongoing debate. Resultingly, many factors that may contribute to an optimal therapeutic exercise protocol for Achilles tendinopathy are not well described. The aim of this narrative review is to explore the principles of tendon remodeling under resistance-based exercise in both healthy and pathologic tissues, and to review the biomechanical principles of Achilles tendon loading mechanics which may impact an optimized therapeutic exercise prescription for Achilles tendinopathy.

Assessment and monitoring of Achilles tendinopathy in clinical practice: a qualitative descriptive exploration of the barriers clinicians face

Our primary objective was to explore the barriers preventing clinicians from implementing what they think is ideal practice as it relates to using tools to aid diagnosis and monitor progress in mid-portion Achilles tendinopathy. Our secondary objectives were to describe the assessments employed by clinicians in their own practice to aid with (a) diagnosis and (b) monitoring progress in Achilles tendinopathy and explore the outcome measure domains clinicians believe to be the most and least important when managing patients with Achilles tendinopathy. We employed a qualitative descriptive study design. Thirteen participants (eight female, five male) from across Australia, consisting of two junior physiotherapists, five senior physiotherapists working in private practice, four senior physiotherapists working within elite sports organisations and two sport and exercise medicine doctors, were included and one-on-one interviews were performed. Audio was transcribed then entered into NVivo for coding and analysis. Four main themes were perceived as barriers to implementing ideal practice of assessment and monitoring in people with Achilles tendinopathy: financial constraints, time constraints, access to equipment and patient symptom severity. Assessments related to function, pain on loading, pain over a specified time frame and palpation are commonly used to assist diagnosis. Assessments related to disability, pain on loading, pain over a specified time frame and physical function capacity are used to monitor progress over time. Furthermore, pain on loading and pain over a specified time frame were considered the most important outcome measure domains for assisting diagnosis whereas pain on loading, patient rating of the condition and physical function capacity were the most important outcome measure domains for monitoring progress. A number of barriers exist that prevent clinicians from implementing what they view as ideal assessment and monitoring for Achilles tendinopathy. These barriers should be considered when developing new assessments and in clinical practice recommendations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

PROSPERO Database; No. CRD42021236107.

Does Additional Dietary Supplementation Improve Physiotherapeutic Treatment Outcome in Tendinopathy? A Systematic Review and Meta-Analysis

A systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of dietary supplements in addition to physiotherapeutic treatment on pain and functional outcomes. PubMed, The Cochrane Library, Web of Science, and Embase were searched from inception to November 2021 (Prospero registration: CRD42021291951). Studies were eligible if the interventions consisted of physiotherapeutic approaches that were combined with dietary supplementation and if they reported measures of pain and/or function. Six studies were included in the meta-analysis. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated and analysed using a Review Manager software. Subgroup analysis was performed to explore possible associations between the study characteristics and the effectiveness of the intervention. Additional dietary supplementation during physiotherapeutic treatment significantly improved the reduction in pain score (SMD = −0.74, 95% CI, −1.37 to −0.10; p < 0.05), while it had no effect on functional outcomes (SMD = 0.29, 95% CI, 0.00 to 0.58; p > 0.05). This systematic review and meta-analysis suggests that additional nutritional interventions may improve physiotherapeutic treatment outcomes in the management of tendinopathies.

Treatment preferences and use of diagnostic imaging in midportion Achilles tendinopathy by Australian allied health professionals

OBJECTIVES

The objectives of this study were to examine the treatment preferences and use of diagnostic imaging by Australian allied health professionals in the management of midportion Achilles tendinopathy.

DESIGN

Cross-sectional survey of Australian allied health professionals.

METHODS

An online survey was distributed to registered Australian physiotherapists, podiatrists, myotherapists, exercise physiologists, osteopaths, and chiropractors between September 2018 and October 2019. This survey captured information on clinician demographic, treatment modalities, frequency of use and the reasons for their preferences. A descriptive analysis of the data was employed with nominal and ordinal data analysed using frequency counts.

RESULTS

Valid responses were captured from 283 respondents, the majority (229, 80.9%) being physiotherapists. Exercise-based therapy and education were the most commonly used treatments (98.6% and 92.6%, respectively), with the majority of respondents (91.8% and 89.3%) stating that they "always" provided these interventions. Respondents stated that they utilised a number of exercise modalities within the last three years (median = 3, IQR = 3 to 4). Other interventions used as adjunct treatments included heel lifts for shoes (70.0%), massage (59.4%), and taping (40.3%). The majority of respondents (76.7%) never or rarely used diagnostic imaging, citing its limited impact on treatment decision-making and potential for negative impact on patient outcomes.

CONCLUSIONS

Australian allied health professionals predominantly use exercise and education, but also use adjuncts such as heel lifts and massage, in the management of midportion Achilles tendinopathy. The results of this study may inform research priorities to generate high quality evidence that best reflects clinical practice.

Backward Running on a Negative Slope as a Treatment for Achilles Tendinopathy in Runners: A Feasibility Pilot Study

CONTEXT

Achilles tendinopathy (AT) is a common musculoskeletal injury among runners. Eccentric exercises are considered first-line treatment. However, during the early stages of rehabilitation, patients are usually instructed to stop running. Backward running (BR) on a negative slope provides a similar eccentric load while enabling ongoing physical activity; thus, it may be suggested as an alternative treatment.

OBJECTIVES

To determine the feasibility of a BR program as a treatment option for AT in runners.

DESIGN

Prospective, single-arm feasibility study.

SETTING

Outpatient clinic.

PATIENTS

Recreational runners diagnosed with AT and referred to the Meuhedet Health Services Physical Therapy Clinic in Jerusalem, Israel, from September 2019 to February 2020.

INTERVENTION

The patients completed a 5-week (9 sessions) rehabilitation program of supervised BR on a negatively inclined treadmill.

MAIN OUTCOME MEASURES

Compliance with the program was evaluated by calculating the percentage of patients who completed the full protocol with no adverse events. Personal running-related goals were set before the program and were assessed following rehabilitation using the goal attainment scaling method. Forward-running time until the onset of relevant Achilles tendon pain, and the Victorian Institute of Sports Assessment Scale-Achilles were measured at baseline (T0), before treatment session 6 (T1), and after the last session (T2).

RESULTS

Among the 15 patients recruited, 14 (93%), average age 48.8 (10.4) years (86% males), completed the full protocol with no adverse events. Almost all participants (85.7%) achieved their running-related functional goals. Postintervention, the median forward-running time increased from 52.5 (92.5) to 900 (522.5) seconds (P = .008, effect size = .858), and the median Victorian Institute of Sports Assessment Scale-Achilles score improved by 28 points (P = .003, effect size = .881).

CONCLUSIONS

BR on a negative slope may be a feasible treatment method for runners suffering from AT. Future randomized control trials are required to further validate the efficacy of this method.

Achilles Tendinopathy: Evaluation, Rehabilitation, and Prevention

ABSTRACT

Achilles tendinopathy is a common overuse condition that is characterized by degenerative, cumulative tissue microtrauma. It is largely a clinical diagnosis in which the patient typically presents with localized pain that is worse with tendon-loading activities. Imaging modalities may be helpful with the diagnosis of difficult cases or in the planning of interventional procedures. Midportion (noninsertional) and insertional tendinopathy have distinct features and differences for therapeutic paradigms. Overall, Achilles tendinopathy has a good clinical prognosis with most patients improving with activity modification and rehabilitation, with a focus on progressive tendon-loading. Recalcitrant cases may require adjuvant treatment with procedures (e.g., injections, shockwave therapy) and rarely surgical intervention.

A criteria-based rehabilitation program for chronic mid-portion Achilles tendinopathy: study protocol for a randomised controlled trial

BACKGROUND

Achilles tendinopathy (AT) is a common overuse injury in running-related sports where patients experience pain and impaired function which can persist. A graded rehabilitation program has been successful in reducing pain and improving function to enable a return to sport. The aim of this study is to compare the effectiveness of a criteria-based rehabilitation program including strength and reactive strength targets, with a previously successful rehabilitation program on changes in pain and function using the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Secondary aims will be to assess changes in calf strength, reactive strength, and lower limb running and forward hop biomechanics over the course of a 12-week rehabilitation program, and long-term follow-up investigations.

METHODS

Sixty eligible participants with chronic mid-portion AT who train in running-based sports will be included in this study. They will be randomly assigned to a group that will follow an evidence-based rehabilitation program of daily exercises with progression guided by symptoms or a group performing 3 high-intensity rehabilitation sessions per week with individualised load targets progressing to reactive strength exercises. Testing will take place at baseline, week 6 and 12. Plantar flexor peak torque will be measured using isokinetic dynamometry, reactive strength will be measured using a drop jump and lower limb biomechanical variables will be measured during a single leg forward hurdle hop test and treadmill running using 3D motion analysis. Follow-up interviews will take place at 6, 12 and 24 months after beginning the program which will assess patient participation in sport and possible re-injury.

DISCUSSION

This is the first study to propose an individualised criteria-based graded rehabilitation program in patients in with chronic mid-portion Achilles tendinopathy where progression is guided by strength and reactive strength outcome measures. This study will provide a comprehensive assessment of plantar flexor strength, reactive strength and lower limb biomechanical variables in running and forward hopping with the VISA-A questionnaire as the primary outcome measure and long term post-intervention follow-up assessments performed.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT04384874 ). Registered retrospectively on April 23rd 2020.

The Impact of the Degree of Kinesiophobia on Recovery in Patients With Achilles Tendinopathy

OBJECTIVE

Kinesiophobia has been proposed to influence recovery in individuals with Achilles tendinopathy. However, whether there are differences in outcomes in individuals with different levels of kinesiophobia is unknown. The purpose of this study was to compare the characteristics of patients at baseline and recovery over time in individuals with Achilles tendinopathy and various levels of kinesiophobia.

METHODS

This study was a secondary analysis of a prospective observational cohort study of 59 individuals with Achilles tendinopathy. The participants were divided into 3 groups on the basis of scores on the Tampa Scale for Kinesiophobia (TSK) (those with low TSK scores [≤33; low TSK group], those with medium TSK scores [34-41; medium TSK group], and those with high TSK scores [≥42; high TSK group]). All participants were evaluated with self-reported outcomes, clinical evaluation, tendon morphology, viscoelastic property measurements, and a calf muscle endurance test at baseline, 6 months, and 12 months. No treatment was provided throughout the study period.

RESULTS

There were 16 participants (8 women) in the low TSK group (age = 51.9 [SD = 15.3] years, body mass index [BMI] = 24.3 [22.3-25.4]), 28 participants (13 women) in the medium TSK group (age = 52.7 [SD = 15.2] years, BMI = 26.4 [22.5-30.8]), and 15 participants (8 women) in the high TSK group (age = 61.1 [SD = 11.1] years, BMI = 28.1 [25.2-33.6]). Among the groups at baseline, the high TSK group had significantly greater BMI and symptom severity and lower quality of life. All groups showed significant improvement over time for all outcomes except tendon viscoelastic properties and tendon thickening when there was an adjustment for baseline BMI. The high and medium TSK groups saw decreases in kinesiophobia at 6 months, but there was no change for the low TSK group.

CONCLUSION

Despite the high TSK group having the highest BMI and the worse symptom severity and quality of life at baseline, members of this group showed improvements in all of the outcome domains similar to those of the other groups over 12 months.

IMPACT

Evaluating the degree of kinesiophobia in individuals with Achilles tendinopathy might be of benefit for understanding how they are affected by the injury. However, the degree of kinesiophobia at baseline does not seem to affect recovery; this finding could be due to the patients receiving education about the injury and expectations of recovery.

Achilles Scraping and Plantaris Tendon Removal Improves Pain and Tendon Structure in Patients with Mid-Portion Achilles Tendinopathy-A 24 Month Follow-Up Case Series

Background: Studies have demonstrated that a sub-group of patients with medial Achilles pain exhibit Achilles tendinopathy with plantaris tendon involvement. This clinical condition is characterised by structural relationships and functional interference between the two tendons, resulting in compressive or shearing forces. Surgical plantaris tendon removal together with an Achilles scraping procedure has demonstrated positive short-term clinical results. The aim of this case series was to determine the long-term outcomes on pain and Achilles tendon structure. Methods: 18 consecutive patients (13 males; 5 females; mean age 39 years; mean symptom duration 28 months), of which three were elites, were included. Clinical examination, b-mode ultrasound (US) and Ultrasound Tissue Characterisation (UTC) confirmed medial Achilles tendon pain and tenderness, medial Achilles tendinopathy plus a plantaris tendon located close to the medial side of the Achilles tendon. Patients underwent US-guided local Achilles scraping and plantaris tendon removal followed by a structured rehabilitation program. Outcomes were VISA-A score for pain and function and UTC for Achilles structure. Results: 16 of 18 patients completed the 24 months follow-up. Mean VISA-A scores increased from 58.2 (±15.9) to 92.0 (±9.2) (mean difference = 33.8, 95% CI 25.2, 42.8, p < 0.01). There was an improvement in Achilles structure with mean organised echo pixels (UTC type I+II, in %) increasing from 79.9 (±11.5) to 86.4 (±10.0) (mean difference = 6.5%, 95% CI 0.80, 13.80, p =0.01), exceeding the 3.4% minimum detectable change. All 16 patients reported satisfaction with the procedure and 14 returned to pre-injury activity levels. There were no reported complications. Conclusions: Improved pain, function and tendon structure were observed 24 months after treatment with Achilles scraping and plantaris excision. The improvement in structure on the medial side of the Achilles after plantaris removal indicates that compression from the plantaris tendon might be an important presenting factor in this sub-group.

LOAD-intensity and time-under-tension of exercises for men who have Achilles tendinopathy (the LOADIT trial): a randomised feasibility trial

BACKGROUND

One potential reason for disparate outcomes of exercise for Achilles tendinopathy is poor knowledge about whether exercise parameters (i.e. different exercise doses) influence outcome. Whether parameters that are important for tendon adaptation influence clinical outcomes in Achilles tendinopathy has not been investigated. Therefore, this research aimed to assess the feasibility of conducting a fully powered randomised trial to investigate the efficacy of different load-intensity and time-under-tension exercise parameters for Achilles tendinopathy.

METHODS

A factorial four-arm, randomised trial. Forty-eight male participants (18-70 years old) with mid-portion Achilles tendinopathy (≥ 3 months) were recruited. Participants were randomly allocated to high (6 repetition maximum) or low intensity (18 repetition maximum) exercise, performed with either high (6 s per cycle) or low (2 s per cycle) time-under-tension. Participants performed 12-weeks of standing and seated calf raise exercises three times per week in a gym setting using a Smith machine. One session per week was supervised (via videoconference). Primary feasibility outcomes (recruitment and retention rate, exercise adherence and fidelity [i.e. time-under-tension, volume, load intensity], incidence of adverse events, health care use and productivity cost) were collected weekly. Means and standard deviations were determined for parametric data, medians and interquartile range for non-parametric continuous data, and frequency counts for discrete data.

RESULTS

Total recruitment (76%) and retention (90%) rates were high. Exercise adherence ranged from 45 to 63% and fidelity ranged from 8 to 83% across the groups. Thirty-one participants reported 64 adverse events over the 3 months. Twenty-one participants (70%) reported mild events. Participants reported reduced presenteeism more than absenteeism.

CONCLUSIONS

A fully powered trial is feasible. The proposed trial design and interventions demonstrated acceptable recruitment and retention rates and safety profile. However, exercise fidelity and adherence to the gym-based intervention was not acceptable. Strategies to improve intervention adherence and fidelity should be considered in future trials.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618001315202 . Registered retrospectively on August 6th, 2018.

Management of recent onset tendon-related pain in a primary contact setting: A survey of practice

BACKGROUND

Tendon-related pain is a common and debilitating condition that affects a wide range of people. To inform future research, it is important to understand healthcare professional's current practice.

OBJECTIVES

To describe the practice of First Contact Practitioners (FCPs) and Other Clinicians (OCs) for recent onset tendon pain in a primary contact setting. The secondary aim was to understand if practice differed between the locations of pain.

DESIGN

Cross-sectional online survey METHOD: The online survey asked for responses relating to one scenario of shoulder pain and one of Achilles pain. Except location of pain, the scenarios were identical. Responses were collected over a four-week period to December 2020. The Chi-Square test was used to analyse the difference in proportion of responses between FCPs and OCs, and between locations of pain.

RESULTS

118 responses were received. Rotator Cuff Related Shoulder Pain (RCRSP) was preferred by 64/118 (54.2%) for the shoulder scenario. Achilles tendinopathy was the preferred term by 86/103 (83.5%) for the Achilles. FCPs were more likely to advise NSAIDs for both shoulder (p = 0.006) and Achilles (p = 0.046) scenarios than OCs. Amended duties were more likely to be advised for manual workers for the shoulder scenario compared to Achilles (p = <0.0001).

CONCLUSION

There were similarities in the management of recent onset tendon-related pain; the majority of respondents recommended against further investigations, steroid injections, and recommended exercise. Understanding whether these approaches are clinically effective requires further investigation.

Immediate Effects of two Isometric Calf Muscle Exercises on Mid-portion Achilles Tendon Pain

The objectives of this randomized, cross-over pilot study were to determine whether isometric plantarflexion exercises resulted in an immediate change in Achilles tendon pain during a loading task, and whether this differed in knee extension or flexion. Eleven participants with mid-portion Achilles tendinopathy were recruited from NHS community physiotherapy services and local running clubs. Participants were then randomized to complete an isometric calf muscle exercise with the knee fully extended or flexed to 80°. Participants switched to the alternate exercise after a minimum seven-day period. Achilles tendon pain during a specific, functional load test was measured on a 11-point numeric pain rating scale (NPRS) pre- and post-intervention. There was a small, immediate, mean reduction in pain following isometric plantar flexion performed in both knee extension (1.6, 95%CI 0.83 to 2.45, p=0.001) and knee flexion (1.3, 95%CI 0.31 to 2.19, p=0.015). There were no significant differences between the two positions. A non-significant, potentially clinically relevant finding was a 20% larger reduction in symptoms in knee extension versus flexion (p=0.110). In conclusion, isometric plantarflexion holds gave an approximately 50% immediate reduction in Achilles tendon pain with a functional load test. There were no significant differences between the two positions and both were well tolerated.

Are Plantarflexor Muscle Impairments Present Among Individuals with Achilles Tendinopathy and Do They Change with Exercise? A Systematic Review with Meta-analysis

Background

Understanding plantarflexor muscle impairments among individuals with Achilles tendinopathy (AT) may help to guide future research and inform clinical management of AT. Therefore, the aim of this review is to evaluate plantarflexor muscle impairments among individuals with AT and whether plantarflexor muscle function changes following resistance training interventions.

Methods

We searched relevant databases including Cochrane Central Register of Controlled Trials, Ovid (MEDLINE, EMBASE, AMED) and EBSCO (CINAHL Plus and SPORTDiscus) up to September 2020. Studies investigating plantarflexor muscle function were included if they met the following criteria: (1) any study design enabled comparison of plantarflexor muscle function between individuals with and without AT, or the affected and unaffected side of individuals with unilateral AT, and (2) any studies enabled investigation of change in plantarflexion muscle function over time with use of resistance training intervention. We included studies that recruited adults with either insertional or mid-portion AT of any duration. Study selection, quality assessment and data extraction were undertaken independently by two reviewers. Discrepancies were resolved via discussion, or by consulting a third reviewer where necessary. The Joanna Briggs Institute (JBI) critical appraisal tools specific to each study design were used to assess the methodological quality of included studies. Grading the strength of evidence for each outcome was determined according to the quality and number of studies.

Results

A total of 25 studies (545 participants) met inclusion. Participants’ mean age was 40 ± 7 years old. Six studies were high quality for all domains, while the remaining were susceptible to the risk of bias (e.g. selection criteria, reporting findings). This review identified moderate evidence that individuals with AT have impairment in maximal plantarflexor torque (seven studies including one with a mixed population) on their affected side, compared with the unaffected side. Impairments were modest (9% and 13% [pooled effect divided by mean of the unaffected side scores]) and of uncertain clinical importance. The remaining evidence, primarily among individuals with mid-portion AT, showed conflicting impairments for plantarflexor function (i.e. explosive strength and endurance) between sides. There was limited to very limited evidence for improvement in plantarflexor endurance (7% and 23%) but not power or strength (five studies including one with a mixed population for strength) over time, despite individuals undertaking several weeks of resistance training.

Conclusions

Plantarflexor impairments appear more common between sides than compared with control groups but given limitations in the literature further exploration of these relationships is needed.

Registration

PROSPERO Database; number CRD42019100747.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-021-00308-8.

The Benefits of Strength Training on Musculoskeletal System Health: Practical Applications for Interdisciplinary Care

Global health organizations have provided recommendations regarding exercise for the general population. Strength training has been included in several position statements due to its multi-systemic benefits. In this narrative review, we examine the available literature, first explaining how specific mechanical loading is converted into positive cellular responses. Secondly, benefits related to specific musculoskeletal tissues are discussed, with practical applications and training programmes clearly outlined for both common musculoskeletal disorders and primary prevention strategies.

Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials

OBJECTIVE

To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy.

DESIGN

Living systematic review and network meta-analysis.

DATA SOURCES

Multiple databases including grey literature sources were searched up to February 2019.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials examining the effectiveness of any treatment in patients with both insertional and/or midportion Achilles tendinopathy. We excluded trials with 10 or fewer participants per treatment arm or trials investigating tendon ruptures.

DATA EXTRACTION AND SYNTHESIS

Reviewers independently extracted data and assessed the risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation to appraise the certainty of evidence.

PRIMARY OUTCOME MEASURE

The validated patient-reported Victorian Institute of Sport Assessment-Achilles questionnaire.

RESULTS

29 trials investigating 42 different treatments were included. 22 trials (76%) were at high risk of bias and 7 (24%) had some concerns. Most trials included patients with midportion tendinopathy (86%). Any treatment class seemed superior to wait-and-see for midportion Achilles tendinopathy at 3 months (very low to low certainty of evidence). At 12 months, exercise therapy, exercise+injection therapy and exercise+night splint therapy were all comparable with injection therapy for midportion tendinopathy (very low to low certainty). No network meta-analysis could be performed for insertional Achilles tendinopathy.

SUMMARY/CONCLUSION

In our living network meta-analysis no trials were at low risk of bias and there was large uncertainty in the comparative estimates. For midportion Achilles tendinopathy, wait-and-see is not recommended as all active treatments seemed superior at 3-month follow-up. There seems to be no clinically relevant difference in effectiveness between different active treatments at either 3-month or 12-month follow-up. As exercise therapy is easy to prescribe, can be of low cost and has few harms, clinicians could consider starting treatment with a calf-muscle exercise programme.

PROSPERO REGISTRATION NUMBER

CRD42018086467.

Conservative management of acute lower limb tendinopathies: A systematic review

BACKGROUND

Most knowledge regarding conservative management for lower limb tendinopathy (LLT) is for persistent symptoms, with less known about conservative management of acute LLT. Sub-optimal management of acute LLT is detrimental in many regards, not least the likely conversion to persistent symptoms.

OBJECTIVES

To synthesise existing literature on conservative management of acute LLTs.

DESIGN

Systematic review of relevant literature (PROSPERO [ID: CRD42018117882]).

METHOD

A search was made of multiple databases (MEDLINE, CINAHL and EMBASE) using relevant search terms. Titles, abstracts and then full texts were filtered to find articles that met the strict inclusion/exclusion criteria. Searching, data extraction and quality assessment, using the Grading of Recommendations Assessment, Development and Evaluation, were done independently by two authors. To understand how the interventions impacted the duration of reported symptoms, results were split into three time points: short-term (<4 weeks), medium-term (4-12 weeks) and long-term (>12 weeks).

RESULTS

Thirteen studies (n = 534) met the criteria for inclusion. There was very low level of certainty for the effectiveness of interventions at short-term, medium-term and long-term follow ups. However, there were large effects seen across a number of different treatments on pain intensity and disability in LLTs.

CONCLUSIONS

This review demonstrates that limited evidence currently exists to guide the management of acute LLT, and the quality of the existing evidence is collectively low. These findings inform the discussion of different treatment options with patients in a shared decision-making process to empower and enable the patient.