Is heavy eccentric calf training superior to wait-and-see, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy?

Background: Mid-portion Achilles tendinopathy (AT) is prevalent amongst athletic and non-athletic populations with pain, stiffness and impaired function typically reported. While different management options exist, loading protocols remain the best available intervention and have been shown to be effective in the management of AT. Trials investigating loading in AT have used a variety of different protocols, and recent narrative reviews suggest that no protocol is superior to another when comparing outcomes in pain and function. However, there has been no systematic review or meta-analysis completed to determine this. Furthermore, the narrative review did not consider wait-and-see or sham interventions, thus a systematic review and met-analysis which includes wait-and see or sham interventions is warranted. Methods: A systematic review and meta-analyses will be conducted as per the PRISMA guidelines. The databases PUBMED, CINAHL (Ovid) and CINAHL (EBSCO) will be searched for articles published from inception to 31 December 2017. Our search focuses on studies examining the improvement of pain and function when completing a loading program for mid-portion AT. Only randomised/ quasi-randomised trials will be included while case reports and case series will be excluded. The primary outcome assessing pain and function will be the Victorian Institute Sports Assessment - Achilles (VISA-A). Two reviewers will screen articles, extract data and assess the risk of bias independently with a third reviewer resolving any disagreements between the two reviewers. A meta-analysis will then be performed on the data (if appropriate) to determine if the traditional heavy load calf training protocol described by Alfredson is superior to wait-and-see, sham intervention, traditional physiotherapy, and other forms of exercise rehabilitation. Discussion: This systematic review and meta-analysis will allow us to investigate if there are difference in pain and function when comparing wait-and-see, sham interventions, traditional physiotherapy and different exercise interventions to the traditional heavy eccentric calf training protocol for mid-portion Achilles tendon pain. Systematic review registration: PROSPERO registration number CRD42018084493

Engineering tendon and ligament tissues : present developments towards successful clinical products

Musculoskeletal diseases are one of the leading causes of disability worldwide. Among them, tendon and ligament injuries represent an important aspect to consider in both athletes and active working people. Tendon and ligament damage is an important cause of joint instability, and progresses into early onset of osteoarthritis, pain, disability and eventually the need for joint replacement surgery. The social and economical burden associated with these medical conditions presents a compelling argument for greater understanding and expanding research on this issue. The particular physiology of tendons and ligaments (avascular, hypocellular and overall structural mechanical features) makes it difficult for currently available treatments to reach a complete and long-term functional repair of the damaged tissue, especially when complete tear occurs. Despite the effort, the treatmentmodalities for tendon and ligament are suboptimal, which have led to the development of alternative therapies, such as the delivery of growth factors, development of engineered scaffolds or the application of stem cells, which have been approached in this review

A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow)

<p>Abstract</p> <p>Background</p> <p>Recent reviews have indicated that low level level laser therapy (LLLT) is ineffective in lateral elbow tendinopathy (LET) without assessing validity of treatment procedures and doses or the influence of prior steroid injections.</p> <p>Methods</p> <p>Systematic review with meta-analysis, with primary outcome measures of pain relief and/or global improvement and subgroup analyses of methodological quality, wavelengths and treatment procedures.</p> <p>Results</p> <p>18 randomised placebo-controlled trials (RCTs) were identified with 13 RCTs (730 patients) meeting the criteria for meta-analysis. 12 RCTs satisfied half or more of the methodological criteria. Publication bias was detected by Egger's graphical test, which showed a negative direction of bias. Ten of the trials included patients with poor prognosis caused by failed steroid injections or other treatment failures, or long symptom duration or severe baseline pain. The weighted mean difference (WMD) for pain relief was 10.2 mm [95% CI: 3.0 to 17.5] and the RR for global improvement was 1.36 [1.16 to 1.60]. Trials which targeted acupuncture points reported negative results, as did trials with wavelengths 820, 830 and 1064 nm. In a subgroup of five trials with 904 nm lasers and one trial with 632 nm wavelength where the lateral elbow tendon insertions were directly irradiated, WMD for pain relief was 17.2 mm [95% CI: 8.5 to 25.9] and 14.0 mm [95% CI: 7.4 to 20.6] respectively, while RR for global pain improvement was only reported for 904 nm at 1.53 [95% CI: 1.28 to 1.83]. LLLT doses in this subgroup ranged between 0.5 and 7.2 Joules. Secondary outcome measures of painfree grip strength, pain pressure threshold, sick leave and follow-up data from 3 to 8 weeks after the end of treatment, showed consistently significant results in favour of the same LLLT subgroup (p < 0.02). No serious side-effects were reported.</p> <p>Conclusion</p> <p>LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses.</p

Does long-term passive stretching alter muscle-tendon unit mechanics in children with spastic cerebral palsy?

Background: Cerebral palsy causes motor impairments during development and many children may experience excessive neural and mechanical muscle stiffness. The clinical assumption is that excessive stiffness is thought to be one of the main reasons for functional impairments in cerebral palsy. As such, passive stretching is widely used to reduce stiffness, with a view to improving function. However, current research evidence on passive stretching in cerebral palsy is not adequate to support or refute the effectiveness of stretching as a management strategy to reduce stiffness and/or improve function. The purpose was to identify the effect of six weeks passive ankle stretching on muscle–tendon unit parameters in children with spastic cerebral palsy. Methods: Thirteen children (8–14 y) with quadriplegic/diplegic cerebral palsy were randomly assigned to either an experimental group (n=7) or a control group (n=6). The experimental group underwent an additional six weeks of passive ankle dorsiflexion stretching for 15 min (per leg), four days per week, whilst the control group continued with their normal routine, which was similar for the two groups. Measures of muscle and tendon stiffness, strain and resting length were acquired pre- and post-intervention. Findings: The experimental group demonstrated a 3° increase in maximum ankle dorsiflexion. This was accompanied by a 13% reduction in triceps surae muscle stiffness, with no change in tendon stiffness. Additionally, there was an increase in fascicle strain with no changes in resting length, suggesting muscle stiffness reductions were a result of alterations in intra/extra-muscular connective tissue. Interpretation: The results demonstrate that stretching can reduce muscle stiffness by altering fascicle strain but not resting fascicle length

Patellar tendon properties distinguish elite from non-elite soccer players and are related to peak horizontal but not vertical power

Purpose: The aims of our study were to investigate differences in tendon properties between elite and non-elite soccer players, and to establish whether tendon properties were related to power assessed during unilateral jumps in different directions. Methods: Elite (n=16; age, 18.1 ± 1.0yrs) and non-elite (n=13; age, 22.3 ± 2.7yrs) soccer players performed three repetitions of each type (unilateral vertical, unilateral horizontal-forward and unilateral medial) of countermovement jump (CMJ) on a force plate. Patellar tendon (PT) cross-sectional area (CSA), elongation, stiffness and Young’s modulus (measured at the highest common force interval) were assessed with ultrasonography and isokinetic dynamometry. Results: Elite soccer players demonstrated greater PT elongation (6.83±1.87 vs. 4.92±1.88 mm, P=0.011) and strain (11.73±3.25 vs. 8.38±3.06 %, P=0.009) than non-elite. Projectile range and peak horizontal power during unilateral horizontal-forward CMJ correlated positively with tendon elongation (r=0.657 and 0.693, P<0.001) but inversely with Young’s modulus (r=-0.376 and -0.402, P=0.044 and 0.031). Peak medial power during unilateral medial CMJ correlated positively with tendon elongation (r=0.658, P=<0.001) but inversely with tendon stiffness (r=-0.368, P=0.050). No tendon property correlated with unilateral vertical CMJ performance (r≤0.168; P≥0.204). Conclusions: Patellar tendon strain was greater in elite vs. non-elite soccer players and can therefore be considered an indicator of elite soccer playing status. Moreover, a more compliant patellar tendon appears to facilitate unilateral horizontal-forward and medial, but not vertical CMJ performance in soccer players. These findings should be considered when prescribing the detail of talent selection and development protocols related to direction-specific power in elite soccer players