Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players

Background: Conservative treatment of patellar tendinopathy has been minimally investigated. Effective validated treatment protocols are required.

Methods: This was a prospective randomised controlled trial of 17 elite volleyball players with clinically diagnosed and imaging confirmed patellar tendinopathy. Participants were randomly assigned to one of two treatment groups: a decline group and a step group. The decline group were required to perform single leg squats on a 25° decline board, exercising into tendon pain and progressing their exercises with load. The step group performed single leg squats on a 10 cm step, exercising without tendon pain and progressing their exercises with speed then load. All participants completed a 12 week intervention programme during their preseason. Outcome measures used were the Victorian Institute of Sport Assessment (VISA) score for knee function and 100 mm visual analogue scale (VAS) for tendon pain with activity. Measures were taken throughout the intervention period and at 12 months.

Results: Both groups had improved significantly from baseline at 12 weeks and 12 months. Analysis of the likelihood of a 20 point improvement in VISA score at 12 months revealed a greater likelihood of clinical improvements in the decline group than the step group. VAS scores at 12 months did not differ between the groups.

Conclusions: Both exercise protocols improved pain and sporting function in volleyball players over 12 months. This study indicates that the decline squat protocol offers greater clinical gains during a rehabilitation programme for patellar tendinopathy in athletes who continue to train and play with pain.

     

Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study

Background: A recent study reported promising clinical results using eccentric quadriceps training on a decline board to treat jumper''s knee (patellar tendinosis). Methods: In this prospective study, athletes (mean age 25 years) with jumper''s knee were randomised to treatment with either painful eccentric or painful concentric quadriceps training on a decline board. Fifteen exercises were repeated three times, twice daily, 7 days/week, for 12 weeks. All patients ceased sporting activities for the first 6 weeks. Age, height, weight, and duration of symptoms were similar between groups. Visual analogue scales (VAS; patient estimation of pain during exercise) and Victorian Institute of Sport Assessment (VISA) scores, before and after treatment, and patient satisfaction, were used for evaluation. Results: In the eccentric group, for 9/10 tendons patients were satisfied with treatment, VAS decreased from 73 to 23 (p<0.005), and VISA score increased from 41 to 83 (p<0.005). In the concentric group, for 9/9 tendons patients were not satisfied, and there were no significant differences in VAS (from 74 to 68, p<0.34) and VISA score (from 41 to 37, p<0.34). At follow up (mean 32.6 months), patients in the eccentric group were still satisfied and sports active, but all patients in the concentric group had been treated surgically or by sclerosing injections. Conclusions: In conclusion, eccentric, but not concentric, quadriceps training on a decline board, seems to reduce pain in jumper''s knee. The study aimed to include 20 patients in each group, but was stopped at the half time control because of poor results achieved in the concentric group.     

No effect of eccentric training on jumper's knee in volleyball players during the competitive season: a randomized clinical trial.

BACKGROUND: The effect of surgery on patellar tendinopathy (jumper's knee) is questionable, and conservative treatment protocols have not been properly documented. PURPOSE:: The aim of this study was to investigate the effect of a newly developed eccentric training program for patellar tendinopathy in volleyball players during the competitive season. STUDY DESIGN: Randomized clinical trial. METHODS: Patients were recruited from male and female elite volleyball teams in Norway, and the diagnosis was based on clinical examination alone. Of 51 players diagnosed with patellar tendinopathy, 29 could be included in the study. The training group (n = 13) performed squats on a 25 degrees decline board as a home exercise program (3 x 15 repetitions twice daily) for a 12-week intervention period during the final half of the competitive season. The eccentric (downward) component was done on the affected leg. The control group (n = 16) trained as usual. The primary outcome was a symptom-based questionnaire developed specifically for patellar tendinopathy (Victorian Institute of Sport Assessment score), and patients were followed up before and after the intervention period, as well as after 6 and 30 weeks. All subjects self-recorded training to document their activity level (eccentric training, volleyball training, matches, other training). RESULTS: There was no change in Victorian Institute of Sport Assessment score during the intervention period in the training (pre, 71.1 +/- 11.3; post, 70.2 +/- 15.4) or control group (pre, 76.4 +/- 12.1; post, 75.4 +/- 16.7), nor was there any change during the follow-up period at 6 weeks or 6 months. The training group completed 8.2 +/- 4.6 weekly sessions of eccentric training during the intervention period (59% of the recommended volume), and there was no difference between groups in training or competition load. CONCLUSION: There was no effect on knee function from a 12-week program with eccentric training among a group of volleyball players with patellar tendinopathy who continued to train and compete during the treatment period. Whether the training would be effective if the patients did not participate in sports activity is not known.     

Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized,single blinded,clinical trial

Purpose

To investigate the effectiveness of isolated eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy.

Methods

Thirty-six patients with rotator cuff tendinopathy, diagnosed by an orthopaedic surgeon, were included and randomly allocated to an isolated eccentric exercise (EE) group (n = 20, mean age = 50.2 ± 10.8 years) or a conventional exercise (CG) group (n = 16, mean age = 48.6 ± 12.3 years). Both groups fulfilled a 12-week daily home-based exercise programme and received a total amount of nine treatment sessions. The Constant Murley score was used to evaluate both objective (e.g. range of motion and strength) and subjective measures (e.g. pain and activities of daily living). A visual analogue scale (VAS) was used to evaluate pain during daily activities. As secondary outcomes, shoulder range of motion and isometric abduction strength in 45° in the scapular plane were evaluated. All measurements were taken at baseline, at 6, 12 and 26 weeks.

Results

After 26 weeks, both groups showed a significant increase in the Constant Murley score and a significant decrease in VAS scores. No difference was found between the groups, for any of the evaluated outcome measures.

Conclusion

A 12-week-isolated eccentric training programme of the rotator cuff is beneficial for shoulder function and pain after 26 weeks in patients with rotator cuff tendinopathy. However, it is no more beneficial than a conventional exercise programme for the rotator cuff and scapular muscles. Based on the results, clinicians should take into account that performing two eccentric exercises twice a day is as effective as performing six concentric/eccentric exercises once a day in patients with rotator cuff tendinopathy.

     

Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols

Objective

To compare the efficacy and safety of two eccentric rehabilitation protocols for patients with symptomatic patellar tendinopathy. A new eccentric overload training device was compared with the present standard eccentric rehabilitation programme on a decline board.

Design

Prospective, randomised clinical trial.

Setting

Sports rehabilitation clinic, university sports laboratory, supplemented with home exercises.

Patients

20 competitive and recreational athletes, all with clinical diagnosis of patellar tendinopathy, verified by MRI or ultrasound imaging.

Interventions

A 12‐week rehabilitation period, either with bilateral eccentric overload strength training using the Bromsman device twice a week or with unilateral eccentric body load training using a decline board twice a week, supplemented with daily home exercises.

Outcome measures

The primary outcome was pain and function, assessed by the Swedish Victorian Institute of Sport Assessment for Patella (VISA‐P) score. Secondary outcome measures were isokinetic muscle torque, dynamic function and muscle flexibility, as well as pain level estimations using visual analogue scale (VAS). Side effects were registered.

Results

Both treatment groups improved in the short term according to the VISA‐P scores during the 12‐week rehabilitation period. However, there were no significant differences between the groups in terms of pain and function. After a 3‐month rehabilitation period, most patients could be regarded as improved enough to be able to return to training and sports. No serious side effects were detected in either group.

Conclusion

In patients with patellar tendinopathy pain, two‐legged eccentric overload training twice per week, using the new device (Bromsman), was as efficient and safe as the present standard daily eccentric one‐legged rehabilitation‐training regimen using a decline board.Proximal patellar tendon pain (patellar tendinopathy) occurs typically in sports characterised by high demands on force and power of the leg extensor muscles, such as basketball, volleyball, tennis and soccer. Controlled eccentric strengthening of the muscle–tendon complexes involved seems to be important for successful rehabilitation.^1,2,3,4,5 Eccentric squat training on a decline board has been shown to have a superior therapeutic effect in reduction of pain compared with squatting on a flat surface.⁶ One‐legged squatting, using the decline board, resulted in encouraging results with, for example, earlier return to a functional level of sport.^7,8 By contrast, Visnes et al⁹ showed no significant improvements of eccentric training on patellar tendinopathy among volleyball players when instituted during the playing season.Previous research suggests that the efficacy of eccentric squatting rehabilitation may be correlated with the load applied to the quadriceps muscle. The aim of the present prospective randomised short‐term study was to evaluate and compare clinical outcomes in terms of knee pain and function after eccentric training, using either a novel eccentric overload training device (Bromsman, Lidingö, Sweden)¹⁰ or the current standard programme of one‐leg squatting exercises.¹¹     

Corticosteroid injections,eccentric decline squat training and heavy slow resistance training in patellar tendinopathy

A randomized‐controlled single‐blind trial was conducted to investigate the clinical, structural and functional effects of peritendinous corticosteroid injections (CORT), eccentric decline squat training (ECC) and heavy slow resistance training (HSR) in patellar tendinopathy. Thirty‐nine male patients were randomized to CORT, ECC or HSR for 12 weeks. We assessed function and symptoms (VISA‐p questionnaire), tendon pain during activity (VAS), treatment satisfaction, tendon swelling, tendon vascularization, tendon mechanical properties and collagen crosslink properties. Assessments were made at 0 weeks, 12 weeks and at follow‐up (half‐year). All groups improved in VISA‐p and VAS from 0 to 12 weeks (P<0.05). VISA‐p and VAS improvements were maintained at follow‐up in ECC and HSR but deteriorated in CORT (P<0.05). In CORT and HSR, tendon swelling decreased (?13±9% and ?12±13%, P<0.05) and so did vascularization (?52±49% and ?45±23%, P<0.01) at 12 weeks. Tendon mechanical properties were similar in healthy and injured tendons and were unaffected by treatment. HSR yielded an elevated collagen network turnover. At the half‐year follow‐up, treatment satisfaction differed between groups, with HSR being most satisfied. Conclusively, CORT has good short‐term but poor long‐term clinical effects, in patellar tendinopathy. HSR has good short‐ and long‐term clinical effects accompanied by pathology improvement and increased collagen turnover.     

Non-surgical treatment of patellar tendinopathy: A systematic review of randomized controlled trials

Study designSystematic review of randomized controlled trials.ObjectivesTo determine the most effective non-surgical treatment interventions for reducing pain and improving function for patients with patellar tendinopathy.MethodsStudies considered for this systematic review were from peer-reviewed journals published between January 2012 and September 2017. All included studies used a visual analogue scale (VAS) to evaluate the participant’s pain. The majority of the included studies also used the Victorian Institute of Sport Assessment Patellar Tendinopathy (VISA-P questionnaire) to assess participant’s symptoms and function.ResultsNine randomized controlled trials fit the inclusion criteria and were analyzed. The results of three studies supported the use of isometric exercise to reduce pain immediately. One study found patellar strapping and sports taping to be effective for reduction in pain during sport and immediately after. Eccentric exercise, Dry Needling (DN) (2 studies), injections with Platelet Rich Plasma (PRP), Autologous Blood Injection (ABI), and saline were found to have a more sustained effect on reducing pain and improving knee function.ConclusionIsometric exercise, patellar strapping, sports taping, eccentric exercise, injections with PRP, ABI, and saline and DN demonstrated a short-term pain relieving and functional improvement effect in subjects with patellar tendinopathy. Longer term follow up on interventions involving eccentric exercise, DN, and injections with PRP, ABI and saline showed sustained pain reduction and improvement in knee function.Level of evidenceLevel 1.     

The role of eccentric training in the management of Achilles tendinopathy: A pilot study

ObjectiveTo investigate the effect of different types of treatment on Achilles tendinopathy, one proposed to increase tensile strength of the tendon, the other a more traditional treatment used in a clinical setting.DesignRepeated measures trial comparing two interventions.SettingSports injury clinic.ParticipantsTwenty-five participants were randomly allocated to the eccentric group (n=13) or the control group (n=12).Main outcome measuresThe VISA-A questionnaire was used to determine outcomes and was administered to all participants at 0, 4, 8, and 12 weeks.ResultsAll subjects significantly improved over the 12-week period (p=0.0001), but the eccentric group demonstrated significantly higher (p=0.014) VISA-A scores at 12 weeks.ConclusionThe study suggests that the addition of a 12-week eccentric exercise programme to conventional treatment of ultrasound and deep transverse frictions is more effective in treating Achilles tendinopathy than conventional treatment alone.     

Relationship between neovascularization and clinical severity in Achilles tendinopathy in 556 paired measurements

Neovascularization is frequently observed in tendinopathy. Previous studies have focused on the role of neovascularization in Achilles tendinopathy, but have been conducted in small series. It is still unclear whether the degree of neovascularization is related to severity of symptoms. The purpose was to study the relationship between ultrasonographic neovascularization and clinical severity in patients with Achilles tendinopathy. In this prospective cohort study, data on 127 patients (141 tendons) were assembled from databases of three clinical trials. All patients followed an eccentric exercise program. The Öhberg neovascularization score (0–4+) and Victorian Institute of Sports Assessment‐Achilles (VISA‐A) score (split into domains: pain, function and activity) were collected during baseline and follow‐up. The relationship between neovascularization and VISA‐A score was calculated. At baseline, 107 tendons (76%) showed some degree of neovascularization. In 556 coupled measurements, neovascularization was weakly related to the VISA‐A score [Exp (B) 1.017, 95% confidence interval (CI), 1.007–1.026]. No significant relationship was found between neovascularization and the pain domain (P = 0.277) and the activity domain (P = 0.283), but there was between neovascularization and the function domain of the VISA‐A score [Exp (B) = 1.067, 95% CI 1.018–1.119]. In conclusion, neovascularization in Achilles tendinopathy is weakly related to clinical severity, mainly based on the function domain of the VISA‐A score.     

Are unilateral and bilateral patellar tendinopathy distinguished by differences in anthropometry, body composition, or muscle strength in elite female basketball players?

Background: Overuse injury to the patellar tendon (patellar tendinopathy) is a major reason for interrupted training and competition for elite athletes. In both sexes, the prevalence of unilateral and bilateral tendinopathy has been shown to differ. It has been proposed that bilateral pathology may have a different aetiology from unilateral pathology. Investigation of risk factors that may be unique to unilateral and bilateral patellar tendinopathy in female athletes may reveal insights into the aetiology of this condition.

Objectives: To examine whether anthropometry, body composition, or muscle strength distinguished elite female basketball players with unilateral or bilateral patellar tendinopathy.

Methods: Body composition, anthropometry, and muscle strength were compared in elite female basketball players with unilateral (n = 8), bilateral (n = 7), or no (n = 24) patellar tendinopathy. Body composition was analysed using a dual energy x ray absorptiometer. Anthropometric measures were assessed using standard techniques. Knee extensor strength was measured at 180°/s using an isokinetic dynamometer. z scores were calculated for the unilateral and bilateral groups (using the no tendinopathy group as controls). z scores were tested against zero.

Results: The tibia length to stature ratio was approximately 1.3 (1.3) SDs above zero in both the affected and non-affected legs in the unilateral group (p<0.05). The waist to hip ratio was 0.66 (0.78) SD above zero in the unilateral group (p<0.05). In the unilateral group, leg lean to total lean ratio was 0.42 (0.55) SD above zero (p<0.07), the trunk lean to total lean ratio was 0.63 (0.68) SD below zero (p<0.05), and leg fat relative to total fat was 0.47 (0.65) SD below zero (p<0.09). In the unilateral group, the leg with pathology was 0.78 (1.03) SD weaker during eccentric contractions (p<0.07).

Conclusions: Unilateral patellar tendinopathy has identifiable risk factors whereas bilateral patellar tendinopathy may not. This suggests that the aetiology of these conditions may be different. However, interpretation must respect the limitation of small subject numbers.

     

Chronic Achilles tendon pain treated with eccentric calf-muscle training

Injuries involving the Achilles tendon and manifested as chronic tendon pain are common, especially among recreational athletes. In a pilot study on a small group of patients with chronic painful mid-portion Achilles tendinosis, eccentric calf-muscle training was shown to give good clinical results. The aim of this prospective study was to investigate if the previously achieved good clinical results could be reproduced in a larger group of patients, and also to investigate the effects of eccentric calf-muscle training in patients with chronic insertional Achilles tendon pain. Seventy-eight consecutive patients, having chronic painful Achilles tendinosis at the mid-portion (2–6 cm level) in a total of 101 tendons (55 unilateral and 23 bilateral), and thirty consecutive patients with chronic insertional Achilles tendon pain in 31 tendons (29 unilateral and one bilateral) were treated with eccentric calf-muscle training for 12 weeks. Most patients were recreational athletes. Evaluation of the amount of tendon pain during activity was recorded on a visual analogue scale (VAS), before and after treatment. In 90 of the 101 Achilles tendons (89%) with chronic painful mid-portion Achilles tendinosis, treatment was satisfactory and the patients were back on their pre-injury activity level after the 12-week training regimen. In these patients, the amount of pain during activity, registered on the VAS-scale (mean±SD), decreased significantly from 66.8±19.4 to 10.2±13.7. On the contrary, in only ten of the tendons (32%) with chronic insertional Achilles tendon pain was treatment satisfactory, with a significant decrease on the VAS-scale (mean±SD), from 68.3±7.0 to 13.3±13.2. Our conclusion is that treatment with eccentric calf-muscle training produced good clinical results in patients with chronic painful mid-portion Achilles tendinosis, but not in patients with chronic insertional Achilles tendon pain.     

Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up

Achilles tendinopathy is common and treatment with eccentric exercises seems promising. We designed a prospective randomized clinical trial to test the hypothesis that eccentric calf muscle exercises reduce pain and improve function in patients with Achilles tendinopathy. Forty-four patients were recruited from primary care (mean age: 45 years; 23 women; 65% active in sports) and randomized to three treatment groups for 12 weeks: eccentric exercises, a night splint or a combination of both treatments. Pain and function were evaluated at 6, 12, 26 and 52 weeks by the Foot and Ankle Outcome Score. At 6 weeks, the eccentric group reported a significant pain reduction (27% compared with baseline, P = 0.007) which lasted for 1 year (42%, P = 0.001). The two groups treated with a night splint also reported significant but less pain reduction than the eccentric group. Differences between all the three groups were not significant. At 12 weeks, the eccentric group reported significantly less pain than the splint-only group (P = 0.04). More patients in the eccentric group than in the splint group returned to sport after 12 weeks. We conclude that eccentric exercises seem to reduce pain and improve function in patients with Achilles tendinopathy. Our results are in line with previous studies and strengthen the recommendation that patients should undergo an eccentric exercise program prior to considering other treatments such as surgery.     

A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy

Background

The use of ice as a supplement to an exercise programme has been recommended for the management of lateral elbow tendinopathy (LET). No studies have examined its effectiveness.

Objectives

To investigate whether an exercise programme supplemented with ice is more successful than the exercise programme alone in treating patients with LET.

Methods

Patients with unilateral LET for at least four weeks were included in this pilot study. They were sequentially allocated to receive five times a week for four weeks either an exercise programme with ice or the exercise programme alone. The exercise programme consisted of slow progressive eccentric exercises of wrist extensors and static stretching of the extensor carpi radialis brevis tendon. In the exercise programme/ice group, the ice was applied after the exercise programme for 10 minutes in the form of an ice bag to the facet of the lateral epicondyle. Patients were evaluated at baseline, at the end of treatment, and three months after the end of treatment. Outcome measures used were the pain visual analogue scale and the dropout rate.

Results

Forty patients met the inclusion criteria. At the end of treatment there was a decline in visual analogue scale of about 7 units in both groups compared with baseline (p<0.0005, paired t test). There were no significant differences in the magnitude of reduction between the groups at the end of treatment and at the three month follow up (p<0.0005, independent t test). There were no dropouts.

Conclusions

An exercise programme consisting of eccentric and static stretching exercises had reduced the pain in patients with LET at the end of the treatment and at the follow up whether or not ice was included. Further research to establish the relative, absolute, and cost effectiveness as well as the mechanism of action of the exercise programme is needed.     

High prevalence of jumper's knee and sonographic changes in Swedish elite junior volleyball players compared to matched controls

Background: Jumper's knee is a common and troublesome condition among senior volleyball players, but its prevalence among elite junior players compared to matched non-sports active controls is not known.

Objective: To clinically, and by sonography, examine the patellar tendons in elite junior volleyball players (15–19 years) at the Swedish National Centre for volleyball and in matched controls.

Methods: The patellar tendons in the 57 students at the Swedish National Centre for high school volleyball and in 55 age, height, and weight matched not regularly sports active controls were evaluated clinically and by grey scale ultrasonography (US) and power Doppler (PD) sonography.

Results: There were no significant differences in mean age, height, and weight between the volleyball players and the controls. In the volleyball group, jumper's knee was diagnosed clinically and by US in 12 patellar tendons (10 male and two female). In 12/12 tendons, PD sonography demonstrated a neovascularisation in the area with structural tendon changes. In another 10 pain free tendons, there were structural tendon changes and neovessels. In the control group, no individual had a clinical diagnosis of jumper's knee. US demonstrated structural tendon changes in 11 tendons, but there was no neovascularisation on PD sonography.

Conclusions: A clinical diagnosis of jumper's knee, together with structural tendon changes and neovascularisation visualised with sonography, was seen among Swedish elite junior volleyball players but not in matched not regularly sports active controls. Structural tendon change alone was seen in 10% of the control tendons.

     

Treatment for insertional Achilles tendinopathy: a systematic review

Purpose

Systematically search and analyse the results of surgical and non-surgical treatments for insertional Achilles tendinopathy.

Methods

A structured systematic review of the literature was performed to identify surgical and non-surgical therapeutic studies reporting on ten or more adults with insertional Achilles tendinopathy. MEDLINE, CINAHL, EMBASE (Classic) and the Cochrane database of controlled trials (1945–March 2011) were searched. The Coleman methodology score was used to assess the quality of included articles, and these were analysed with an emphasis on change in pain score, patient satisfaction and complication rate.

Results

Of 451 reviewed abstracts, 14 trials met our inclusion criteria evaluating 452 procedures in 433 patients. Five surgical techniques were evaluated; all had a good patient satisfaction (avg. 89 %). The complication ratio differed substantially between techniques. Two studies analysed injections showing significant decrease in visual analogue scale (VAS). Eccentric exercises showed a significant decrease in VAS, but a large group of patients was unsatisfied. Extracorporeal shockwave therapy (ESWT) was superior to both wait-and-see and an eccentric training regime. One study evaluated laser CO², TECAR and cryoultrasound, all with significant decrease in VAS.

Conclusions

Despite differences in outcome and complication ratio, the patient satisfaction is high in all surgical studies. It is not possible to draw conclusions regarding the best surgical treatment for insertional Achilles tendinopathy. ESWT seems effective in patients with non-calcified insertional Achilles tendinopathy. Although both eccentric exercises resulted in a decrease in VAS score, full range of motion eccentric exercises shows a low patient satisfaction compared to floor level exercises and other conservative treatment modalities.

Level of evidence

III.     

Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial

Local injections of the sclerosing substance Polidocanol has been demonstrated to give good clinical results in a pilot study on patients with chronic Achilles tendinopathy. In this study, 20 consecutive patients (9 men and 11 women, mean age 50 years) with chronic painful mid-portion Achilles tendinopathy were randomised to injection treatment with either Polidocanol (5 mg/ml) (group A) or Lidocaine hydro-chloride (5 mg/ml) + Adrenaline (5 g/ml) (group B). Both substances have a local anaesthetic effect, but Polidocanol also has a sclerosing effect. The patients and the treating physician were blinded to the substance injected. The short-term effects were evaluated after a maximum of two treatments, 3–6 weeks apart. Before treatment, all patients had structural tendon changes and neo-vascularisation demonstrated with US and colour doppler. Under US and colour doppler-guidance, the injections targeted the area of neo-vascularisation just outside the ventral part of the tendon. For evaluation, the patients recorded the severity of Achilles tendon pain during tendon loading activity, before and after treatment, on a VAS. Patients satisfaction with treatment was also assessed. At follow-up (mean 3 months) after a maximum of two treatments, 5/10 patients in group A were satisfied with the treatment and had a significantly reduced level of tendon pain (p<0.005). In group B, no patient was satisfied with treatment. In the pain-free tendons, but not in the painful tendons, neo-vascularisation was absent after treatment. After completion of the study, treatment with Polidocanol injections (Cross-over in group B and additional treatments in group A) resulted in 10/10 and 9/10 satisfied patients in group A and B, respectively. In summary, injections with the sclerosing substance Polidocanol have the potential to reduce tendon pain during activity in patients with chronic painful mid-portion Achilles tendinopathy.     

Jumper's knee in volleyball athletes: advancements in diagnosis and treatment

Jumper's knee, or patellar tendinopathy, affects nearly one half of elite volleyball athletes and causes significant morbidity. The diagnosis and treatment of jumper's knee is evolving with heavier reliance on the use of diagnostic ultrasound with and without color or power Doppler. Research suggests that conservative treatment is very effective using an eccentric exercise regimen and decline squats. Interventional treatments are expanding as well, with positive results seen using extracorporeal shock wave therapy and polidocanol sclerosing injections. Arthroscopic surgical approaches are being developed, some using intra-operative ultrasound guidance. The findings of several recent basic science studies imply that the future may lie in developing a greater understanding of, and then possibly modulating the balance of, the local neuronal, vascular, or biochemical factors associated with symptomatic patellar tendinopathy.     

Ultrasound guided injection in patellar tendinopathy; clinical outcomes of platelet-rich plasma compared to high-volume injection

Objectives

To assess the efficacy of ultrasound guided injection of platelet rich plasma versus high volume injection in treatment of patellar tendinopathy, in patients not responding to conservative treatment.

Vascularity and pain in the patellar tendon of adult jumping athletes: a 5 month longitudinal study

Background: This study investigated changes in tendon vascularity in 102 (67 men and 35 women) volleyball players over a 6 month competitive season.

Methods: Athletes were examined with both grey scale ultrasound and standardised colour Doppler settings. Vessel length and pain were measured each month on five separate occasions. Vascular tendons were divided into (i) those that were vascular on all occasions (persistent vascularity) and (ii) those that were vascular on more than two but less than five occasions (intermittent vascularity).

Results: A total of 41 of the 133 abnormal tendons were vascular on two or more occasions. Of these, 16 had persistent vascularity and 25 had intermittent vascularity. There was no significant difference in the prevalence of vascularity between men and women. None of the tendons had a pattern of vascularity over the season that could be clearly interpreted as the onset or resolution of vascularity. Subjects with changes in both tendons were more likely to have persistent vascularity (p = 0.045). Vessels were longer in tendons with persistent vascularity (p<0.000) and pain was significantly greater (p = 0.043) than in tendons with intermittent vascularity. Tendons with intermittent vascularity had similar pain scores on all days, whether or not they had detectable blood flow.

Conclusions: These data suggest that the presence of blood vessels is more likely to be the source of pain than the blood flow in them.

     

PRP improves short term clinical results in tendinopathy of Achilles tendon

BackgroundChronic Achilles tendinopathy is a common pathology and standardized treatment strategies are lacking. The purpose of this study is to evaluate the efficacy of Platelet Rich Plasma (PRP) injections in treatment of Achilles tendinopathy.Materials and MethodsTwenty tendons in seventeen patients were included. Mean age of participants was 52.6 years (range, 34-72 years). All patients were treated by one single PRP injection. American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score and pain level according to Visual Analogue Scale (VAS) were noted in all patients pre-treatment and at 2 weeks, 2 and 6 months post-treatment.ResultsThe average AOFAS Hindfoot Score increased from 37.95 points (range, 33 to 52 points) pre-treatment to 90.8 (range, 83 to 97 points) post-treatment at 6 months. The average pain level according to VAS decreased from 8.65 points pre-treatment to 1.15 points post-treatment at 6 month. All patients returned to daily activities after 2 weeks and to sports activities after 1 month. Two of the patients were able to practice sports after the 3 month post PRP injection due to pain. None of the patients showed complications or adverse effects after the PRP injection.ConclusionLocal PRP injections showed effective results in chronic Achilles tendinopathy without any complications and seems to be a good treatment alternative in this entity. Moreover it might have the ability to avoid surgical intervention.Level of EvidenceIV.