Do physical tests have a prognostic value in chronic midportion Achilles tendinopathy?

OBJECTIVES

To determine whether baseline physical tests have a prognostic value on patient-reported outcomes in Achilles tendinopathy.

DESIGN

Prospective cohort study, secondary analysis of data from a randomized trial.

METHODS

Patients with chronic midportion Achilles tendinopathy performed a progressive calf muscle exercise program. At baseline and after 2, 6, 12 and 24 weeks, patients completed the Victorian Institute of Sports Assessment-Achilles questionnaire and performed the following physical tests: ankle dorsiflexion range of motion with a bent knee or an extended knee, calf muscle strength, jumping height and pain on palpation (Visual Analogue Scale; 0-100) and after 10 hops (Visual Analogue Scale-10-hops). Associations between baseline test results and improvement (Victorian Institute of Sports Assessment-Achilles scores) were determined using a Mixed Linear Model.

RESULTS

80 patients were included. The mean Victorian Institute of Sports Assessment-Achilles score improved 20 points (95 % confidence interval, 16-25, P < .001) after 24 weeks. There were significant associations between the baseline ankle dorsiflexion range of motion with a bent knee (β 0.2, 95 % confidence interval 0.001 to 0.3, P = .049), the baseline pain provocation tests (Visual Analogue Scale palpation: β -0.2; 95 % confidence interval: -0.4 to -0.1; P < .001, Visual Analogue Scale-10-hops: β -0.3; 95 % confidence interval: -0.4 to -0.2; P < .001) and the change in the Victorian Institute of Sports Assessment-Achilles score.

CONCLUSIONS

In patients with chronic midportion Achilles tendinopathy, easy-to-perform pain provocation tests have a clinically relevant prognostic value on patient-reported improvement. Patients with less pain during pain provocation tests at baseline have a better improvement in pain, function and activities after 24 weeks than patients with high baseline pain scores.

Dutch multidisciplinary guideline on Achilles tendinopathy

Objective

To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients.

Design

Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase.

Data sources

Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference.

Study eligibility criteria

Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module.

Data extraction and synthesis

To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations.

Primary outcome measure

The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions.

Results

Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy.

Summary/conclusion

Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice.

Impact of chronic Achilles tendinopathy on health-related quality of life, work performance, healthcare utilisation and costs

Objectives

To evaluate the impact of Achilles tendinopathy (AT) on quality of life (QoL), work performance, healthcare utilisation and costs in adults with conservatively treated chronic midportion AT.

Methods

This cross-sectional survey-based study included 80 patients and took place in a sports medicine department of a large regional hospital in the Netherlands. Data were collected before any intervention was given. Primary outcome was the EuroQol questionnaire (EQ-5D). The EQ-5D expresses the percentage of moderate/major problems on the domains self-care, anxiety/depression, mobility, usual activities and pain/discomfort. Secondary outcomes were the number of previous healthcare visits, work performance during the period of symptoms and estimated annual direct medical and indirect costs per patient as a result of AT.

Results

All 80 patients completed the questionnaires. The EQ-5D scores were low for the domains self-care (1%) and anxiety/depression (20%), and high for the domains mobility (66%), usual activities (50%) and pain/discomfort (89%). Patients with AT mainly reported an impact on work productivity (38%). Work absenteeism due to AT was present in 9%. The total median (IQR) number of annual healthcare visits was 9 (3-11). The total mean (SD) estimated annual costs were €840 (1420) per patient with AT (mean (SD) US$991 (1675)).

Conclusions

This study shows the large impact of AT on QoL and work productivity. This study also provides new information about the socioeconomic impact of AT, which emphasises that this common and longstanding disease causes substantial costs. These findings stress the need for optimised treatment and improved preventive interventions for AT.

Trial registration number

NCT02996409.

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.

Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial

OBJECTIVE

To study whether a high volume injection without corticosteroids improves clinical outcome in addition to usual care for adults with chronic midportion Achilles tendinopathy.

DESIGN

Patient and assessor blinded, placebo controlled randomised clinical trial.

SETTING

Sports medicine department of a large district general hospital, the Netherlands.

PARTICIPANTS

80 adults (aged 18-70 years) with clinically diagnosed chronic midportion Achilles tendinopathy and neovascularisation on ultrasonography. 39 were randomised to a high volume injection without corticosteroids and 41 to placebo.

INTERVENTIONS

Participants were instructed to perform an exercise programme for 24 weeks (usual care) combined with one 50 mL high volume injection of saline and lidocaine (intervention group) or one 2 mL placebo injection of saline and lidocaine (placebo group) at baseline.

MAIN OUTCOME MEASURES

Primary outcome was pain and function assessed using the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire at 24 weeks (analysed using a generalised estimation equations model). Secondary outcomes were patient satisfaction, return to sport, degree of ultrasonographic Doppler flow, visual analogue scale on 10 hop test, power and flexibility of the gastrocnemius and soleus muscles, pain detect questionnaire for neuropathic pain, and pain coping inventory. Participants were evaluated at baseline and at 2, 6, 12, and 24 weeks.

RESULTS

Only one participant (1%) was lost to follow-up. The estimated mean VISA-A score improved significantly, from 40.4 (95% confidence interval 32.0 to 48.7) at baseline to 59.1 (50.4 to 67.8) at 24 weeks in the high volume injection group and from 36.9 (27.1 to 46.8) to 58.5 (47.9 to 69.1) in the placebo group. The VISA-A score over time did not differ between the groups (adjusted between group difference at 24 weeks 0.5 points, 95% confidence interval -17.8 to 18.8). No significant between group differences were found for patient satisfaction (21/37 (57%) v 19/39 (49%) patients, P=0.50) and return to desired sport (15/29 (52%) v 19/31 (61%) patients active in sports, P=0.65) at 24 weeks. None of the other secondary outcomes differed between the two groups.

CONCLUSIONS

A high volume injection without corticosteroids in addition to usual care is not effective for symptom reduction in patients with chronic midportion Achilles tendinopathy. On the basis of our findings, we cannot recommend the use of a high volume injection in this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02996409.

Isometric exercises do not provide immediate pain relief in Achilles tendinopathy: A quasi-randomized clinical trial

Background

Isometric exercises may provide an immediate analgesic effect in patients with lower‐limb tendinopathy and have been proposed as initial treatment and for immediate pain relief. Current evidence is conflicting, and previous studies were small.

Objective

To study whether isometric exercises result in an immediate analgesic effect in patients with chronic midportion Achilles tendinopathy.

Methods

Patients with clinically diagnosed chronic midportion Achilles tendinopathy were quasi‐randomized to one of four arms: isometric calf‐muscle exercises (tiptoes), isometric calf‐muscle exercises (dorsiflexed ankle position), isotonic calf‐muscle exercises, or rest. The primary outcome was pain measured on a visual analogue scale (VAS) score (0‐100) during a functional task (10 unilateral hops) both before and after the intervention. Between‐group differences were analyzed using a generalized estimation equations model.

Results

We included 91 patients. There was no significant reduction in pain on the 10 hop test after performing any of the four interventions: isometric (tiptoes) group 0.2, 95%CI −11.2 to 11.5; isometric (dorsiflexed) group −1.9, 95%CI −13.6 to 9.7; isotonic group 1.4, 95%CI −8.3 to 11.1; and rest group 7.2, 95%CI −2.4 to 16.7. There were also no between‐group differences after the interventions.

Conclusion

The isometric exercises investigated in this study did not result in immediate analgesic benefit in patients with chronic midportion Achilles tendinopathy. We do not recommend isometric exercises if the aim is providing immediate pain relief. Future research should focus on the use of isometric or isotonic exercise therapy as initial treatment as all exercise protocols used in this study were well‐tolerated.

Ultrasound Doppler Flow in Patients With Chronic Midportion Achilles Tendinopathy: Is Surface Area Quantification a Reliable Method?

OBJECTIVES

Ultrasound assessments of patients with chronic midportion Achilles tendinopathy include determining the degree of neovascularization using Doppler flow. A frequently used measure to quantify neovascularization is the modified Öhberg score. It is unknown whether the semiquantitative modified Öhberg score (0-4+) has higher reliability than a quantified measure of Doppler flow (0-100%). The purpose of this cross-sectional study was to evaluate the interobserver reliability of the modified Öhberg score and a surface area quantification (SAQ) method for Doppler flow in patients with chronic midportion Achilles tendinopathy.

METHODS

Two observers examined the degree of Doppler flow independently using SAQ and the modified Öhberg score during a single consultation. The intraclass correlation coefficient, standard error of measurement, and minimal detectable difference were determined to evaluate the reliability and measurement properties of the SAQ method and the modified Öhberg score.

RESULTS

In total, 28 consecutive patients with chronic midportion Achilles tendinopathy participated. The intraclass correlation coefficient for interobserver reliability of the SAQ method was 0.81 (95% confidence interval, 0.58-0.91), compared to 0.64 (95% confidence interval, 0.45-0.81) for the modified Öhberg score. The standard error of measurement and minimal detectable difference values for the SAQ method were 2.9% and 8.0%, respectively, and for the modified Öhberg score, they were 0.55 and 1.53 points.

CONCLUSIONS

The SAQ method shows good reliability to evaluate the degree of Doppler flow in patients with chronic midportion Achilles tendinopathy, and it overcomes the ceiling effect of the modified Öhberg score. Future research should focus on the relationship between the SAQ method and clinical outcomes and use this method to monitor treatment responses.

Clinical risk factors for Achilles tendinopathy: a systematic review

Background

Achilles tendinopathy is a common problem, but its exact aetiology remains unclear.

Objective

To evaluate the association between potential clinical risk factors and Achilles tendinopathy.

Design

Systematic review.

Data sources

The databases Embase, MEDLINE Ovid, Web of Science, Cochrane Library and Google Scholar were searched up to February 2018.

Eligibility criteria

To answer our research question, cohort studies investigating risk factors for Achilles tendinopathy in humans were included. We restricted our search to potential clinical risk factors (imaging studies were excluded).

Results

We included 10 cohort studies, all with a high risk of bias, from 5111 publications identified. There is limited evidence for nine risk factors: (1) prior lower limb tendinopathy or fracture, (2) use of ofloxacin (quinolone) antibiotics, (3) an increased time between heart transplantation and initiation of quinolone treatment for infectious disease, (4) moderate alcohol use, (5) training during cold weather, (6) decreased isokinetic plantar flexor strength, (7) abnormal gait pattern with decreased forward progression of propulsion, (8) more lateral foot roll-over at the forefoot flat phase and (9) creatinine clearance of <60 mL/min in heart transplant patients. Twenty-six other putative risk factors were not associated with Achilles tendinopathy, including being overweight, static foot posture and physical activity level.

Conclusion

From an ocean of studies with high levels of bias, we extracted nine clinical risk factors that may increase a person’s risk of Achilles tendinopathy. Clinicians may consider ofloxacin use, alcohol consumption and a reduced plantar flexor strength as modifiable risk factors when treating patients with Achilles tendinopathy.

Trial registration number

CRD42017053258.