THE EFFECTS OF CONVENTIONAL PHYSICAL THERAPY AND ECCENTRIC STRENGTHENING FOR INSERTIONAL ACHILLES TENDINOPATHY

Study Design:

Single‐blind, randomized, clinical trial.

Background:

The effect of eccentric training for mid‐portion Achilles tendinopathy is well documented; however, its effect on insertional Achilles tendinopathy is inconclusive. The primary purpose of this study was to investigate the effect of eccentric training on pain and function for individuals with insertional Achilles tendinopathy.

Methods:

All patients received a 12‐week conventional strengthening protocol. Patients who were randomly assigned to the experimental group received additional eccentric exercises. Patients completed the Short Form‐36 Health and Bodily Pain Surveys, the Foot and Ankle Outcomes Questionnaire, and the Visual Analog Scale at initial evaluation, after 6 weeks of therapy, and at 12 weeks after therapy.

Results:

Thirty‐six patients (20 control and 16 experimental; average age 54 years; 72% women) completed the study. Both groups experienced statistically significant decreases in pain and improvements in function. No statistically significant differences were noted between the groups for any of the outcome measures.

Conclusion:

Conventional physical therapy consisting of gastrocnemius, soleus and hamstring stretches, ice massage on the Achilles tendon, and use of heel lifts and night splints with or without eccentric training is effective for treating insertional Achilles tendinopathy.

Level of Evidence:

Level 2     

OBSERVER RATING VERSUS THREE‐DIMENSIONAL MOTION ANALYSIS OF LOWER EXTREMITY KINEMATICS DURING FUNCTIONAL SCREENING TESTS: A SYSTEMATIC REVIEW

Background

Functional assessments are conducted in both clinical and athletic settings in an attempt to identify those individuals who exhibit movement patterns that may increase their risk of non‐contact injury. In place of highly sophisticated three‐dimensional motion analysis, functional testing can be completed through observation.

Hypothesis/purpose

To evaluate the validity of movement observation assessments by summarizing the results of articles comparing human observation in real‐time or video play‐back and three‐dimensional motion analysis of lower extremity kinematics during functional screening tests.

Study Design

Systematic review

Methods

A computerized systematic search was conducted through Medline, SPORTSdiscus, Scopus, Cinhal, and Cochrane health databases between February and April of 2014. Validity studies comparing human observation (real‐time or video play‐back) to three‐dimensional motion analysis of functional tasks were selected. Only studies comprising uninjured, healthy subjects conducting lower extremity functional assessments were appropriate for review. Eligible observers were certified health practitioners or qualified members of sports and athletic training teams that conduct athlete screening. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS‐2) was used to appraise the literature. Results are presented in terms of functional tasks.

Results

Six studies met the inclusion criteria. Across these studies, two‐legged squats, single‐leg squats, drop‐jumps, and running and cutting manoeuvres were the functional tasks analysed. When compared to three‐dimensional motion analysis, observer ratings of lower extremity kinematics, such as knee position in relation to the foot, demonstrated mixed results. Single‐leg squats achieved target sensitivity values (≥ 80%) but not specificity values (≥ 50%>%). Drop‐jump task agreement ranged from poor (< 50%) to excellent (> 80%). Two‐legged squats achieved 88% sensitivity and 85% specificity. Mean underestimations as large as 198 (peak knee flexion) were found in the results of those assessing running and side‐step cutting manoeuvres. Variables such as the speed of movement, the methods of rating, the profiles of participants and the experience levels of observers may have influenced the outcomes of functional testing.

Limitations

The small number of studies used limits generalizability. Furthermore, this review used two dimensional video‐playback for the majority of observations. If the movements had been rated in real‐time three dimensional video, the results may have been different.

Conclusions

Slower, speed controlled movements using dichotomous ratings reach target sensitivity and demonstrate higher overall levels of agreement. As a result, their utilization in functional screening is advocated.

Level of Evidence

1A     

THE EFFICACY OF TAPING FOR ROTATOR CUFF TENDINOPATHY: A SYSTEMATIC REVIEW AND META‐ANALYSIS

Background

Rotator cuff (RC) tendinopathy is a highly prevalent musculoskeletal disorder. Non‐elastic taping (NET) and kinesiology taping (KT) are common interventions used by physiotherapists. However, evidence regarding their efficacy is inconclusive.

Objective

To examine the current evidence on the clinical efficacy of taping, either NET or KT, for the treatment of individuals with RC tendinopathy.

Study Design

Systematic review and meta‐analysis

Methods

A literature search was conducted in four bibliographical databases to identify randomized controlled trials (RCT) that compared NET or KT to any other intervention or placebo for treatment of RC tendinopathy. Internal validity of RCTs was assessed with the Cochrane Risk of Bias tool. A qualitative or quantitative synthesis of evidence was performed.

Results

Ten trials were included in the present review on overall pain reduction or improvement in function. Most RCTs had a high risk of bias. There is inconclusive evidence for NET, either used alone or in conjunction with another intervention. Based on pooled results of two studies (n=72), KT used alone resulted in significant gain in pain free flexion (MD: 8.7 ° 95%CI 8.0 ° to 9.5 °) and in pain free abduction (MD: 10.3 ° 95%CI 9.1 ° to 11.4 °). Based on qualitative analyses, there is inconclusive evidence on the efficacy of KT when used alone or in conjunction with other interventions on overall pain reduction or improvement in function.

Conclusion

Although KT significantly improved pain free range of motion, there is insufficient evidence to formally conclude on the efficacy of KT or NET used alone or in conjunction with other interventions in patients with RC tendinopathy.

Level of Evidence

Therapy, level 1a     

EFFECTS OF WEARING ATHLETIC SHOES,FIVE‐TOED SHOES,AND STANDING BAREFOOT ON BALANCE PERFORMANCE IN YOUNG ADULTS

Background/Purpose

Almost all research using participants wearing barefoot‐style shoes study elite runners or have participants with a history of barefoot style shoe training run on a treadmill when shod or barefoot. Wearing barefoot‐style shoes is suggested as a method of transition between shod and barefoot running. Static and dynamic balance exercises also are recommended. However, little information is available on the effects five‐toed barefoot style shoes have on static balance. The purpose of this study was to examine balance of subjects barefoot, wearing Vibram FiveFingers™ barefoot‐style shoes, and regular athletic shoes with eyes closed when using the Biodex Balance System‐SD™.

Study Design

This was a repeated measures study.

Methods

Forty nine participants aged 18‐30 years without lower extremity injury or experience wearing barefoot‐style shoes were tested for static balance on the Biodex Stability System™ with their eyes closed while wearing Vibram FiveFingers™, athletic shoes, or barefoot. Three trials of 10 seconds for each footwear type were completed. Repeated measures analysis of variance with Bonferroni''s correction was used to analyze the degrees of sway in the anterior‐posterior and medial lateral directions. An overall stability index was also calculated by the Biodex.

Results

For anterior‐posterior and overall indices, differences were found between all conditions. Participants wearing athletic shoes demonstrated the smallest anterior‐posterior stability index (least sway) and spent the most time in the innermost concentric circular zone. Medial‐lateral indices were not different for any condition.

Conclusions

Wearing Vibram FiveFingers™ provided better overall and anterior‐posterior static balance than going barefoot. While differences between Vibram FiveFingers™ and barefoot are significant, results may reflect statistical significance rather than any clinical difference in young, uninjured individuals.

Clinical relevance

It would appear that Vibram FiveFingers™ mimic going barefoot and may be a bridge for exercising in preparation for barefoot exercise.

Level of Evidence

3B     

THE MINIMUM CLINICALLY IMPORTANT DIFFERENCE ON THE VISA‐A AND LEFS FOR PATIENTS WITH INSERTIONAL ACHILLES TENDINOPATHY

Study Design

Cohort study of subjects with insertional Achilles tendinopathy (IAT).

Objectives

The purpose of this study was to establish the minimum clinically important difference (MCID) on the Victorian Institute of Sport Assessment ‐ Achilles Questionnaire (VISA‐A) and the Lower Extremity Functional Scale (LEFS) for patients with IAT.

Background

The VISA‐A and LEFS are two measures commonly utilized for patients with IAT. Previous authors have estimated the MCID for the VISA‐A, but a MCID has not been formally established. The MCID for the LEFS has been established for patients with lower extremity conditions in general, but it is not clear if this MCID is applicable to patients with IAT.

Methods

Fifteen subjects participating in a randomized controlled trial studying the effectiveness of intervention for IAT over a 12‐week period were included in this study. Subjects completed the VISA‐A and LEFS forms at baseline and 12 weeks after the initiation of treatment. All subjects also completed a 15‐point global rating of change (GROC) questionnaire at 12 weeks after the initiation of treatment. Subjects were classified as improved or stable based on their GROC scores.

Results

The area under the curve (AUC) for the VISA‐A was 0.97 and a MCID of 6.5 points was identified. The AUC for the LEFS was 0.97 and a MCID of 12 points was identified.

Conclusion

The VISA‐A and LEFS are both useful outcome measures to assess response in patients with IAT.

Level of Evidence

3     

ASSOCIATIONS BETWEEN THE FEMALE ATHLETE TRIAD AND INJURY AMONG HIGH SCHOOL RUNNERS

Purpose/Background:

During the 2013‐14 school year, over 763,000 female athletes participated in interscholastic running sports in the United States. Recent studies have indicated associations between the female athlete triad (Triad) and stress fracture or other musculoskeletal injuries in elite or collegiate female running populations. Little is known about these relationships in an adolescent interscholastic running population. The purpose of this study was to determine the associations between Triad and risk of lower extremity musculoskeletal injury among adolescent runners.

Methods:

Eighty‐nine female athletes competing in interscholastic cross‐country and track in southern California were followed, prospectively. The runners were monitored throughout their respective sport season for lower extremity musculoskeletal injuries. Data collected included daily injury reports, Eating Disorder Examination Questionnaire (EDE‐Q) that assessed disordered eating attitudes/behaviors, a questionnaire on menstrual history and demographic characteristics, a dual‐energy x‐ray absorptiometry scan that measured whole‐body bone mineral density (BMD) and body composition (lean tissue and fat mass), and anthropometric measurements.

Results:

Thirty‐eight runners (42.7%) incurred at least one lower extremity musculoskeletal injury. In the BMD Z‐score ≤ ‐1 standard deviation (SD) adjusted model, low BMD relative to age (BMD Z‐score of ≤ ‐1SD) was significantly associated (Odds Ratio [OR]=4.6, 95% confidence interval [CI]: 1.5‐13.3) with an increased occurrence of musculoskeletal injury during the interscholastic sport season. In the BMD Z‐score ≤ ‐2 SDs adjusted model, a history of oligo/amenorrhea was significantly associated (OR=4.1, 95% CI: 1.2‐13.5) with increased musculoskeletal injury occurrence.

Conclusion:

Oligo/amenorrhea and low BMD were associated with musculoskeletal injuries among the female interscholastic cross‐country and track runners.

Clinical Relevance:

Regular, close monitoring of adolescent female runners during seasonal and off‐season training may be warranted, so that potential problems can be recognized and addressed promptly in order to minimize the risk of running injury.

Level Of Evidence:

2     

CHANGES IN LOWER EXTREMITY MOVEMENT AND POWER ABSORPTION DURING FOREFOOT STRIKING AND BAREFOOT RUNNING

Purpose/Background:

Both forefoot strike shod (FFS) and barefoot (BF) running styles result in different mechanics when compared to rearfoot strike (RFS) shod running. Additionally, running mechanics of FFS and BF running are similar to one another. Comparing the mechanical changes occurring in each of these patterns is necessary to understand potential benefits and risks of these running styles. The authors hypothesized that FFS and BF conditions would result in increased sagittal plane joint angles at initial contact and that FFS and BF conditions would demonstrate a shift in sagittal plane joint power from the knee to the ankle when compared to the RFS condition. Finally, total lower extremity power absorption will be least in BF and greatest in the RFS shod condition.

Methods:

The study included 10 male and 10 female RFS runners who completed 3‐dimensional running analysis in 3 conditions: shod with RFS, shod with FFS, and BF. Variables were the angles of plantarflexion, knee flexion, and hip flexion at initial contact and peak sagittal plane joint power at the hip, knee, and ankle during stance phase.

Results:

Running with a FFS pattern and BF resulted in significantly greater plantarflexion and significantly less negative knee power (absorption) when compared to shod RFS condition. FFS condition runners landed in the most plantarflexion and demonstrated the most peak ankle power absorption and lowest knee power absorption between the 3 conditions. BF and FFS conditions demonstrated decreased total lower extremity power absorption compared to the shod RFS condition but did not differ from one another.

Conclusions:

BF and FFS running result in reduced total lower extremity power, hip power and knee power and a shift of power absorption from the knee to the ankle.

Clinical Relevance:

Alterations associated with BF running patterns are present in a FFS pattern when wearing shoes. Additionally, both patterns result in increased demand at the foot and ankle as compared to the knee.     

PREVALENCE OF MUSCULOSKELETAL PAIN AMONG SWIMMERS IN AN ELITE NATIONAL TOURNAMENT

Background

Professional swimmers are often affected by a high number of injuries due to their large amount of training. The occurrence of musculoskeletal pain during an important tournament has not been investigated.

Objective

The objective of the study was to assess the prevalence of musculoskeletal pain and its characteristics in professional swimmers. Secondary objectives included evaluating the swimmers’ injury history over the previous 12 months, and examining the association of the presence of pain with personal and training characteristics of the swimmers.

Design

Observational, cross‐sectional study

Method

Two‐hundred and fifty‐seven swimmers who participated in the Brazilian Swimming Championship were included in the study and answered a questionnaire about personal and training characteristics, presence of pain, and injuries in the previous 12 months. The relative risk of presence of pain was calculated for the following variables: gender, BMI, stroke specialty, swimmer''s position, strength training, practice of another physical activity, and previous injuries.

Results

The prevalence of musculoskeletal pain was about 20%, with 60% of swimmers reporting at least one injury in the previous 12 months. The shoulder was the most commonly affected region and tendinopathy was the most common type of previous injury. No significant relationships were found between the presence of pain and personal or training characteristics.

Conclusions

The results demonstrated that the prevalence of musculoskeletal pain in professional swimmers participating in the most important Brazilian national tournament was approximately 20%, while the majority of participants reported previous injuries in many areas.

Level of Evidence

2c     

RELIABILITY OF VIDEO‐BASED QUANTIFICATION OF THE KNEE‐ AND HIP ANGLE AT FOOT STRIKE DURING RUNNING

Introduction:

In clinical practice, joint kinematics during running are primarily quantified by two‐dimensional (2D) video recordings and motion‐analysis software. The applicability of this approach depends on the clinicians’ ability to quantify kinematics in a reliable manner. The reliability of quantifying knee‐ and hip angles at foot strike is uninvestigated.

Objective:

To investigate the intra‐ and inter‐rater reliability within and between days of clinicians’ ability to quantify the knee‐ and hip angles at foot strike during running.

Methods:

Eighteen recreational runners were recorded twice using a clinical 2D video setup during treadmill running. Two blinded raters quantified joint angles on each video twice with freeware motion analysis software (Kinovea 0.8.15)

Results:

The range from the lower prediction limit to the upper prediction limit of the 95% prediction interval varied three to eight degrees (within day) and nine to 14 degrees (between day) for the knee angles. Similarly, the hip angles varied three to seven degrees (within day) and nine to 11 degrees (between day).

Conclusion:

The intra‐ and inter rater reliability of within and between day quantifications of the knee‐ and hip angle based on a clinical 2D video setup is sufficient to encourage clinicians to keep using 2D motion analysis techniques in clinical practice to quantify the knee‐ and hip angles in healthy runners. However, the interpretation should include critical evaluation of the physical set‐up of the 2D motion analysis system prior to the recordings and conclusions should take measurement variations (3‐8 degrees and 9‐14 degrees for within and between day, respectively) into account.

Level of evidence:

3