Psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy: a cross-sectional study

Objectiveto examine psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy as well as the association between psychological factors and tendinopathy severity, sport participation, and satisfaction with activity level and tendon function.Designcross-sectional study. Setting: online survey platform.Participants119 patients (mean age: 44 years (SD 14)) diagnosed with Achilles or patellar tendinopathy.Main outcome measuresA range of patient-reported psychological and outcome measures were recorded. Multivariate regression analyses were performed to establish the association between each psychological factor and outcome measures, adjusted for relevant confounders.ResultsPsychological readiness and confidence to return to sports (I-PRRS) and pain catastrophizing (PCS) were significantly associated with tendinopathy severity (modified VISA), sport participation(OSTRC-O), and satisfaction. Kinesiophobia (TSK) and the importance to patients of returning to pre-injury activity level were significantly associated with sports participation and satisfaction.ConclusionThe current study provides evidence of impairments in psychological factors during rehabilitation of patients with Achilles and patellar tendinopathy. Most investigated psychological factors were associated with tendinopathy severity, function, participation, and satisfaction. Physical therapists should recognize patients with lack of psychological readiness to return to sports and also patients with kinesiophobia or catastrophizing thoughts when experiencing pain.     

Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow up study

OBJECTIVE: To prospectively assess the early results of surgical treatment of chronic Achilles tendinopathy. METHODS: This seven month prospective follow up study assessed the short term results of surgical treatment of chronic Achilles tendinopathy and compared the subjective and functional outcome of patients with Achilles tendinopathy without a local intratendinous lesion (group A) with that of similar patients with such a lesion (group B). Forty two of the initial 50 patients were examined before surgery and after the seven month follow up. Evaluation included an interview, subjective evaluation, clinical tests, and a performance test. RESULTS: At the follow up, physical activity was fully restored in 28 of the 42 patients (67%), and 35 patients (83%) were asymptomatic or had only mild pain during strenuous exercise. In clinical tests, significant improvements were observed in climbing up and down stairs and the rising on the toes test. Surgical treatment also seemed to be successful from the total test score, which was excellent or good in 35 patients, compared with before surgery when it was excellent or good in one patient only. Patients in group A fared better than those in group B, whether evaluated by recovery of physical activity after surgery (88% v 54%) or the complication rate (6% v 27%). CONCLUSIONS: Surgical treatment of chronic Achilles tendinopathy gives good and acceptable short term results. A lower complication rate and a trend to better recovery was observed in patients with peritendinous adhesions only than in those with peritendinous adhesions combined with an intratendinous lesion.     

Eccentric exercise in treatment of Achilles tendinopathy

AIM: Prognosis and treatment of Achilles tendon pain (achillodynia) has been insufficiently studied. The purpose of the present study was to examine the long-term effect of eccentric exercises compared with stretching exercises on patients with achillodynia. METHODS: Patients with achillodynia for at least 3 months were randomly allocated to one of two exercise regimens. Exercise was performed daily for a 3-month period. Symptom severity was evaluated by tendon tenderness, ultrasonography, a questionnaire on pain and other symptoms, and a global assessment of improvement. Follow-up was performed at time points 3, 6, 9, 12 weeks and 1 year. RESULTS: Of 53 patients with achillodynia 45 patients were randomized to either eccentric exercises or stretching exercises. Symptoms gradually improved during the 1-year follow-up period and were significantly better assessed by pain and symptoms after 3 weeks and all later visits. However, no significant differences could be observed between the two groups. Women and patients with symptoms from the distal part of the tendon had significantly less improvement. CONCLUSIONS: Marked improvement in symptoms and findings could be gradually observed in both groups during the 1-year follow-up period. To that extent this is due to effect of both regimens or the spontaneous improvement is unsettled.     

A 2-year follow-up of rehabilitation after ACL reconstruction using patellar tendon or hamstring tendon grafts: a prospective randomised outcome study

Sixty-eight patients were clinically evaluated preoperatively, 3, 5, 7, 9 months, 1 and 2 years after ACL reconstruction, 34 with patellar tendon graft, 34 with hamstring graft. Outcome regarding graft choice and anterior knee laxity (P = 0.04) was in favour of patellar tendon graft. Hamstring graft led to a larger laxity, 2.4 mm compared with patellar tendon graft, 1.3 mm at 1 year and 2.5 mm and 1.5 mm, respectively, at 2 years (P = 0.05). There was a significant difference in rotational knee stability in favour of the patellar tendon graft at all test occasions but 9 months. A general effect regarding graft choice and muscle torque was found at 90°/s for quadriceps (P = 0.03) and hamstrings (P ≤ 0.0001) and at 230°/s for hamstrings (P ≤ 0.0001). No treatment effect regarding graft choice and one-leg hop test, postural sway or knee function was found. No group differences in anterior knee pain were found at any of the test occasions but 2 years in favour of hamstring graft compared to patellar tendon graft (P = 0.04). Patellar tendon graft resulted in higher activity level than hamstring graft at all test occasions but 1 year (P = 0.01). Patellar tendon ACL reconstruction led to more stable knees with less anterior knee laxity and less rotational instability than hamstring ACL reconstruction. Hamstring graft patients had not reached preoperative level in hamstring torque even 2 years after ACL reconstruction. Athletes with patellar tendon graft returned to sports earlier and at a higher level than those with hamstring graft.     

Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols

Background

The use of cryotherapy in the management of acute soft tissue injury is largely based on anecdotal evidence. Preliminary evidence suggests that intermittent cryotherapy applications are most effective at reducing tissue temperature to optimal therapeutic levels. However, its efficacy in treating injured human subjects is not yet known.

Objective

: To compare the efficacy of an intermittent cryotherapy treatment protocol with a standard cryotherapy treatment protocol in the management of acute ankle sprains.

Subjects

Sportsmen (n  =  44) and members of the general public (n  =  45) with mild/moderate acute ankle sprains.

Methods

Subjects were randomly allocated, under strictly controlled double blind conditions, to one of two treatment groups: standard ice application (n  =  46) or intermittent ice application (n  =  43). The mode of cryotherapy was standardised across groups and consisted of melting iced water (0°C) in a standardised pack. Function, pain, and swelling were recorded at baseline and one, two, three, four, and six weeks after injury.

Results

Subjects treated with the intermittent protocol had significantly (p<0.05) less ankle pain on activity than those using a standard 20 minute protocol; however, one week after ankle injury, there were no significant differences between groups in terms of function, swelling, or pain at rest.

Conclusion

Intermittent applications may enhance the therapeutic effect of ice in pain relief after acute soft tissue injury.     

Risk factors for patellar tendinopathy in basketball and volleyball players: a cross-sectional study

Patellar tendinopathy (PT) has a multifactorial etiology, and many possible risk factors have been described in the literature. The findings are conflicting, though, and most research has been conducted on elite athletes. The aim of the current study is to determine the risk factors for PT in a large representative sample of basketball and volleyball players. Separate risk factors for men and women, basketball and volleyball players, and athletes with unilateral and bilateral PT were identified. All basketball and volleyball players between ages 18 and 35 from the Dutch Basketball Association and the Dutch Volleyball Association were invited to complete an online questionnaire on knee complaints and risk factors for PT. The logistic regression analyses included 2224 subjects. The risk factors for PT were age, playing at the national level, being male and playing volleyball (compared with playing basketball). The risk factors for men and women were comparable. Among volleyball players, outside hitters and middle blockers/hitters had an increased risk compared with setters. For basketball players, no risk factors could be identified. No differences in the risk factors were found between athletes with unilateral and bilateral PT. These findings should be taken into account for prevention and rehabilitation purposes.     

Efficacy of a platelet-rich plasma injection for the treatment of proximal hamstring tendinopathy: A pilot study

Objectives

To determine the efficacy of an ultrasound-guided platelet-rich plasma (PRP) injection in the treatment of patients with proximal hamstring tendinopathy (PHT).

A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy

Objectives: This non-randomised pilot study investigated the effect of eccentric quadriceps training on 17 patients (22 tendons) with painful chronic patellar tendinopathy.

Methods: Two different eccentric exercise regimens were used by subjects with a long duration of pain with activity (more than six months). (a) Nine consecutive patients (10 tendons; eight men, one woman; mean age 22 years) performed eccentric exercise with the ankle joint in a standard (foot flat) position. (b) Eight patients (12 tendons; five men, three women; mean age 28 years) performed eccentric training standing on a 25° decline board, designed to increase load on the knee extensor mechanism. The eccentric training was performed twice daily, with three sets of 15 repetitions, for 12 weeks. Primary outcome measures were (a) 100 mm visual analogue scale (VAS), where the subject recorded the amount of pain during activity, and (b) return to previous activity. Follow up was at 12 weeks, with a further limited follow up at 15 months.

Results: Good clinical results were obtained in the group who trained on the decline board, with six patients (nine tendons) returning to sport and showing a significantly reduced amount of pain over the 12 week period. Mean VAS scores fell from 74.2 to 28.5 (p = 0.004). At 15 months, four patients (five tendons) reported satisfactory results (mean VAS 26.2). In the standard squat group the results were poor, with only one athlete returning to previous activity. Mean VAS scores in this group were 79.0 at baseline and 72.3 at 12 weeks (p = 0.144).

Conclusion: In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced encouraging results in terms of pain reduction and return to function in the short term. Eccentric exercise using standard single leg squats in a similar sized group appeared to be a less effective form of rehabilitation in reducing pain and returning subjects to previous levels of activity.

     

Risk factors for patellar tendinopathy in volleyball and basketball players: A survey‐based prospective cohort study

Patellar tendinopathy (PT) is a common overuse injury of the patellar tendon in jumping athletes. In a recent large cross‐sectional study from 2008 several factors were identified that may be associated with the etiology of PT. However, because of the study design no conclusions could be drawn about causal relations. The primary aim of the current study is to investigate whether the factors identified in the previous 2008 study can also be prospectively recognized as predictors of symptomatic PT in 2011. Nine hundred twenty‐six Dutch elite and non‐elite basketball and volleyball players from the previous study were invited again to complete an online survey about knee complaints and risk factors for PT in 2011. The logistic regression included 385 athletes of which 51 (13%) developed PT since 2008. Male gender [odds ratio (OR) 2.0, 95% confidence interval (CI) 1.1–3.5] was found to be a risk factor for developing PT. No sports‐related variables could be identified to increase the risk of developing PT, but some evidence was found for performing heavy physically demanding work, like being a nurse or a physical education teacher (OR 2.3, 95% CI 0.9–6.3). These findings indicate that, when considering preventive measures, it is important to take into account the total tendon load.     

Risk factors for patellar tendinopathy: a systematic review of the literature

Patellar tendinopathy (PT) is an injury with a high prevalence in sports. Knowledge of risk factors is essential for developing preventive measures and rehabilitation programmes. However, risk factors associated with PT have not yet been systematically studied. This review was undertaken to identify risk factors associated with PT. The literature was systematically searched to identify articles that investigated risk factors for PT. There was no strong or moderate evidence that any investigated risk factor was associated with PT. For nine risk factors there was some evidence: weight, body mass index, waist-to-hip ratio, leg-length difference, arch height of the foot, quadriceps flexibility, hamstring flexibility, quadriceps strength and vertical jump performance. Based on the present evidence, reducing body weight, increasing upper-leg flexibility and quadriceps strength and the use of orthotics may be beneficial treatment options. However, it should be stressed that the evidence for the nine identified risk factors was only limited. Therefore, there is a clear need for high-quality studies in order to identify the exact risk factors associated with PT.     

Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid injections in a clinical setting

In published efficacy studies on Achilles tendinopathy (AT) exercise alone results in improvement in 60–90% of the cases. However, this high success rate cannot be expected in usual clinical practice. We prospectively investigated the effectiveness of a treatment regimen consisting of home‐based exercises (concentric, eccentric, and stretching) and optional glucocorticosteroid (GCS) injections in patients with (AT) in a usual clinical setting. Patients unable to commence or progress in exercise were offered GCS, hypothesizing that the GCS would facilitate exercise. Ninety‐three consecutive patients with AT referred to two outpatient rheumatology clinics were registered, and seen at five visits over a 6‐month period. Exercises seemed to have a slow, but long‐lasting effect with GCS having a dramatic short‐term effect on symptoms. Twenty‐six percent of the patients could proceed with training alone, the remainder received one to three supplementary GCS. There were significant improvements on all outcome variables over time (P ≤ 0.001). At follow‐up, 42 had no more symptoms, 29 good result, 16 slightly improved, 4 unchanged, and 2 slightly worse. Overall, 94% of the patients had improved, and we thus recommend the use of GCS injections in AT patients if training alone does not lead to improvement.     

Inertial flywheel vs heavy slow resistance training among athletes with patellar tendinopathy: A randomised trial

ObjectivesTo compare the efficacy of inertial flywheel and heavy slow resistance training in reducing pain and improving function in patellar tendinopathy.DesignRandomised clinical trial.MethodsFourty two participants (1 woman, 41 men) with longstanding (>3 months) patellar tendinopathy were randomised into inertial flywheel resistance (N = 21) or heavy slow resistance (N = 21) group. Both programmes consisted of three supervised inertial flywheel or heavy slow resistance exercise sessions per week in a fitness center during 12 weeks. Primary outcome was pain and function, assessed by the Spanish Victorian Institute of Sport Assessment for Patella (VISA-P) score at 6 and 12 weeks. Secondary outcomes were activity limitation using Patient Specific Functional Scale (PSFS), health status (EuroQol-5D), patient impression of change on pain and function, adherence, adverse events, pain provocation test for the patellar tendon (numerical rating score of pain between 0 and 10), physical test, patellar tendon thickness and doppler signal on ultrasound. Secondary outcomes were taken at 0 and 12 weeks.ResultsBoth groups showed significant improvements in VISA-P scores from 0 to 12 weeks but there was not statistically significant between-group difference (P = 0.506). No adverse events or side effects occurred in any of the groups during the intervention period.ConclusionsInertial flywheel resistance three times a week during 12 weeks resulted in similar pain and function benefit at 12 weeks compared with the heavy slow resistance training among people with patellar tendinopathy. Flywheel training is another exercise option for managing people with patellar tendinopathy.ClinicalTrials.gov RegistryNCT03917849.     

Short-term effectiveness of hyperthermia for supraspinatus tendinopathy in athletes: a short-term randomized controlled study

BACKGROUND: Hyperthermia has been introduced as a physical therapy modality for soft tissue injuries. HYPOTHESIS: The authors tested the null hypothesis that there are no short-term differences after the use of hyperthermia, ultrasound, and exercises for tendinopathy of the supraspinatus tendon. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: The authors studied 37 athletes (29 men, 8 women; mean age, 26.7 +/- 5.8 years; range, 19-43 years) with supraspinatus tendinopathy who had had symptoms between 3 and 6 months. Subjects were randomly assigned to 3 groups. Group A (n = 14) received hyperthermia at 434 MHz. Group B (n = 12) received continuous ultrasound at 1 MHz at an intensity of 2.0 w/cm(2) 3 times a week. Group C (n = 11) undertook exercises, consisting of pendular swinging and stretching exercises 5 minutes twice a day every day. All interventions were undertaken for 4 weeks. Subjects were evaluated at baseline, immediately on completion of treatment, and at 6 weeks after the end of the intervention using mean pain score for pain at night, during movement, and at rest on a visual analog scale; pain on resisted movement and painful arc on active abduction between 40 degrees and 120 degrees on a 4-point scale; and Constant score. RESULTS: Patients who received hyperthermia experienced significantly better pain relief than did patients receiving ultrasound or exercises: group A, 5.96 to 1.2 (P = .03); group B, 6.3 to 5.15 (P = .10); group C, 6.1 to 4.9 (P = .09). CONCLUSION: Hyperthermia at 434 MHz appears safe and effective in the short term for the management of supraspinatus tendinopathy.     

No beneficial effect of Polidocanol treatment in Achilles tendinopathy: a randomised controlled trial

Purpose

Polidocanol injections have been used to treat chronic Achilles tendinopathy in clinical settings, but the few studies published show inconsistent results. The aim of this study was to evaluate the mid-term effect of Polidocanol in patients with chronic Achilles tendinopathy. It was hypothesised that patients treated with Polidocanol would have significant improvements in the outcome measures investigated compared to patients treated with a placebo treatment at mid-term follow-up.

Methods

This randomised controlled trial included forty-eight patients aged 32–77 years with a history of Achilles tendinopathy for at least 3 months and with neovascularisation demonstrated by ultrasonography was included. A minimum of 3 months of eccentric exercise treatment was required before participating. The patients were allocated to a maximum of two injection of either Polidocanol or Lidocaine (placebo). The primary outcome measure was pain during walking reported on a visual analogue scale. Secondary outcome measures were Foot and Ankle Outcome Score (FAOS), patient satisfaction with treatment and, shortly after inclusion, the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A) was also included. Follow-up examinations were performed after 3 and 6 months.

Results

Pain during walking decreased during the 6-month follow-up period, but no significant differences were seen between the two groups. The same tendency was seen for FAOS and VISA-A in which both groups showed an improvement at 3- and 6-month follow-up, but no mid-term differences between the groups were seen. An equal number of patients in the two groups were satisfied with the treatment at follow-up.

Conclusions

The results indicate that Polidocanol is a safe treatment, but the mid-term effects are the same as a placebo treatment. This further questions the use of Polidocanol in the treatment of chronic Achilles tendinopathy.

Level of evidence

I.