In vivo biological response to extracorporeal shockwave therapy in human tendinopathy:Response of tendinopathy to shockwave therapy

Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment for chronic tendinopathies, however little is known about the in-vivo biological mechanisms of ESWT. Using microdialysis, we examined the real-time biological response of healthy and pathological tendons to ESWT. A single session of ESWT was administered to the mid-portion of the Achilles tendon in thirteen healthy individuals (aged 25.7±7.0 years) and patellar or Achilles tendon of six patients with tendinopathies (aged 39.0±14.9 years). Dialysate samples from the surrounding peri-tendon were collected before and immediately after ESWT. Interleukins (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17A, vascular endothelial growth factor (VEGF) and interferon (IFN)-γ were quantified using a cytometric bead array while gelatinase activity (MMP-2 and -9) was examined using zymography. There were no statistical differences between the biological tissue response to ESWT in healthy and pathological tendons. IL-1β, IL-2, IL-6 and IL-8 were the cytokines predominantly detected in the tendon dialysate. IL-1β and IL-2 did not change significantly with ESWT. IL-6 and IL-8 concentrations were elevated immediately after ESWT and remained significantly elevated for four hours post-ESWT (p<0.001). Pro forms of MMP-2 and -9 activity also increased after ESWT (p<0.003), whereas there were no significant changes in active MMP forms. In addition, the biological response to ESWT treatment could be differentiated between possible responders and non-responders based on a minimum 5-fold increase in any inflammatory marker or MMP from pre- to post-ESWT. Our findings provide novel evidence of the biological mechanisms underpinning ESWT in humans in vivo. They suggest that the mechanical stimulus provided by ESWT might aid tendon remodelling in tendinopathy by promoting the inflammatory and catabolic processes that are associated with removing damaged matrix constituents. The non-response of some individuals may help to explain why ESWT does not improve symptoms in all patients and provides a potential focus for future research

Exercise therapy for the treatment of tendinopathies: a scoping review protocol.

Objective: The aim of the review is to provide a map of exercise interventions and outcomes that have been reported for the treatment of any tendinopathy. Introduction: Tendinopathy is a common condition that affects athletic and non-athletic populations. Exercise is the mainstay of conservative management of tendinopathy, and a range of different exercise types are recommended. There is a significant body of literature on exercise for tendinopathy, but to date no scoping review has provided a clear map of interventions used and outcomes reported in the literature. Inclusion criteria: We will include people of any age or gender with a diagnosis of tendinopathy of any severity or duration at any anatomical location. We will exclude full-thickness/massive tears and plantar fasciitis. The exercise therapy may take place at any location, including hospital, community, or people's homes, and may be supervised or unsupervised. We will include systematic reviews, quantitative, qualitative, and mixed-methods studies conducted in any developed nation. Methods: We will search MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, Cochrane (controlled trials; systematic reviews), JBI Evidence Synthesis, Epistemonikos, four trial registries, and six gray literature databases. We will use Scopus to search for cited/citing articles from included studies and will perform hand searching where relevant. We will include literature from 1998 to 2020 in any language for which we can access translation. Studies will be screened by two independent reviewers at title/abstract and full-text screening stages; a third reviewer will resolve conflicts. Data will be extracted into a bespoke charting form and will be presented as figure/tables with accompanying narrative

Lived experience and attitudes of people with plantar heel pain:a qualitative exploration

BACKGROUND: Plantar heel pain is a common source of pain and disability. Evidence-based treatment decisions for people with plantar heel pain should be guided by the best available evidence, expert clinical reasoning, and consider the needs of the patient. Education is a key component of care for any patient and needs to be tailored to the patient and their condition. However, no previous work has identified, far less evaluated, the approaches and content required for optimal education for people with plantar heel pain. The aim of this study was to gather the patients' perspective regarding their lived experience, attitudes and educational needs in order to inform the content and provision of meaningful education delivery approaches. METHODS: Using a qualitative descriptive design, semi-structured interviews were conducted with participants with a clinical diagnosis of plantar heel pain. A topic guide was utilised that focused on the experience of living with plantar heel pain and attitudes regarding treatment and educational needs. Interviews were audio recorded, transcribed verbatim and analysed using the Framework approach. Each transcription, and the initial findings, were reported back to participants to invite respondent validation. RESULTS: Eighteen people with plantar heel pain were interviewed. Descriptive analysis revealed eight themes including perceptions of plantar heel pain, impact on self, dealing with plantar heel pain, source of information, patient needs, patient unmet needs, advice to others and interest in online education. Participants revealed doubt about the cause, treatment and prognosis of plantar heel pain. They also expressed a desire to have their pain eliminated and education individually tailored to their condition and needs. Respondent validation revealed that the transcripts were accurate, and participants were able to recognise their own experiences in the synthesised themes. CONCLUSION: Plantar heel pain has a negative impact on health-related quality of life. Participants wanted their pain eliminated and reported that their expectations and needs were frequently unmet. Health professionals have an important role to be responsive to the needs of the patient to improve their knowledge and influence pain and behaviour. Our study informs the content needed to help educate people with plantar heel pain

An in vitro investigation into the effects of 10Hz cyclic loading on tenocyte metabolism

Tendinopathy is a prevalent, highly debilitating condition, with poorly defined aetiology. A wide range of clinical treatments have been proposed, with systematic reviews largely supporting shock wave therapy or eccentric exercise. Characterising these treatments has demonstrated both generate perturbations within tendon at a frequency of approximately 812Hz. Consequently, it is hypothesised that loading in this frequency range initiates increased anabolic tenocyte behaviour, promoting tendon repair. The primary aim of this study is to investigate the effects of 10Hz perturbations on tenocyte metabolism, comparing gene expression in response to a 10Hz and 1Hz loading profile. Tenocytes from healthy and tendinopathic human tendons were seeded into 3D collagen gels and subjected to 15 mins cyclic strain at 10Hz or 1Hz. Tenocytes from healthy tendon showed increased expression of all analysed genes in response to loading, with significantly increased expression of inflammatory and degradative genes with 10Hz, relative to 1Hz loading. By contrast, whilst the response of tenocytes from tendinopathy tendon also increased with 10Hz loading, the overall response profile was more varied and less intense, possibly indicative of an altered healing response. Through inhibition of the pathway, IL1 was shown to be involved in the degradative and catabolic response of cells to high frequency loading, abrogating the loading response. This study has demonstrated for the first time that loading at a frequency of 10Hz may enhance the metabolic response of tenocytes by initiating an immediate degradatory and inflammatory cell response through the IL1 pathway, perhaps as an initial stage of tendon healing

Feasibility and acceptability of exercise interventions for adults with tendinopathy: a mixed methods review.

This is a protocol for a review that aims to explore the feasibility and acceptability of any exercise intervention for the treatment of any tendinopathy. The first specific review question is: What is the current knowledge about the feasibility of delivering exercise interventions for tendinopathy from the perspective of those delivering and receiving interventions? Specifically: a) How feasible is the delivery of exercise therapy for tendinopathy in terms of rates (e.g. of adherence, attendance, fidelity); and b) What are patients' and healthcare professionals' perceptions of the feasibility of exercise therapy for tendinopathy? The second specific review question is: What is the current knowledge about acceptability of receiving exercise therapy for tendinopathy from the perspective of people with tendinopathy? Specifically: a) How acceptable is exercise therapy in terms of tolerability; and b) What are patients' and healthcare professionals' perceptions of the acceptability of exercise therapy for tendinopathy

Tears of the fascia cruris demonstrate characteristic sonographic features: a case series analysis

BACKGROUND: fascia cruris (FC) tears have recently been recognised in the literature, although little is known about their characteristic ultrasound findings. The aim was to describe the echo-graphic features of FC tears in order to improve recognition and diagnosis. METHODS: the ultrasound reports and images of >600 patients attending a specialist musculoskeletal clinic for Achilles tendon ultrasound scans between October 2010–May 2014 were reviewed. Any patient diagnosed with a FC tear had a structured data set extracted. All ultrasound images were performed by one consultant radiologist. Bilateral Achilles images were available for analysis. RESULTS: sixteen patients from >600 subjects were diagnosed with a FC tear. Fourteen subjects were male and two female (mean age 37.8; range 23–61), with seven elite level sports men. Nine tears were right sided and seven left, with eight situated laterally and seven medially. Seven of the tears were situated in the musculotendinous junction. Symptomatic Achilles tendinopathy co-existed in ten of sixteen subjects (average transverse diameter of Achilles tendon = 7.1±2.0 mm). CONCLUSION: FC tears should be considered in the differential diagnoses for Achillodynia, diagnosed using their characteristic ultrasound findings, with a hypoechoic area at the medial or lateral attachment to the Achilles tendon in the transverse plane

The effectiveness of exercise interventions for tendinopathy.

This is a protocol for a study that aimed to determine: 1) which exercise interventions are most effective across all tendinopathies; 2) does the type/location of the tendinopathy, or other specific covariates, affect which are the most effective exercise therapies. The protocol was intended to guide a scoping review, and was then meant to be updated for the effectiveness review

Online questionnaire, clinical and biomechanical measurements for outcome prediction of plantar heel pain: feasibility for a cohort study

BACKGROUND: Plantar heel pain (PHP) accounts for 11-15% of foot symptoms requiring professional care in adults. Recovery is variable, with no robust prognostic guides for sufferers, clinicians or researchers. Therefore, we aimed to determine the validity, reliability and feasibility of questionnaire, clinical and biomechanical measures selected to generate a prognostic model in a subsequent cohort study. METHODS: Thirty-six people (19 females & 17 males; 20-63 years) were recruited with equal numbers in each of three groups: people with PHP (PwPHP), other foot pain (PwOP) and healthy (H) controls. Eighteen people performed a questionnaire battery twice in a randomised order to determine online and face-to-face agreement. The remaining 18 completed the online questionnaire once, plus clinical measurements including strength and range of motion, mid-foot mobility, palpation and ultrasound assessment of plantar fascia. Nine of the same people underwent biomechanical assessment in the form of a graded loaded challenge augmenting walking with added external weight and amended step length on two occasions. Outcome measures were (1) feasibility of the data collection procedure, measurement time and other feedback; (2) establishing equivalence to usual procedures for the questionnaire battery; known-group validity for clinical and imaging measures; and initial validation and reliability of biomechanical measures. RESULTS: There were no systematic differences between online and face-to-face administration of questionnaires (p-values all > .05) nor an administration order effect (d = - 0.31-0.25). Questionnaire reliability was good or excellent (ICC2,1_absolute)(ICC 0.86-0.99), except for two subscales. Full completion of the survey took 29 ± 14 min. Clinically, PwPHP had significantly less ankle-dorsiflexion and hip internal-rotation compared to healthy controls [mean (±SD) for PwPHP-PwOP-H = 14°(±6)-18°(±8)-28°(±10); 43°(±4)- 45°(±9)-57°(±12) respectively; p < .02 for both]. Plantar fascia thickness was significantly higher in PwPHP (3.6(0.4) mm vs 2.9(0.4) mm, p = .01) than the other groups. The graded loading challenge demonstrated progressively increasing ground reaction forces. CONCLUSION: Online questionnaire administration was valid therefore facilitating large cohort recruitment and being relevant to remote service evaluation and research. The physical and ultrasound examination revealed the expected differences between groups, while the graded loaded challenge progressively increases load and warrants future research. Clinician and researchers can be confident about these methodological approaches and the cohort study, from which useful clinical tools should result, is feasible. LEVEL OF EVIDENCE: IV

Bilateral scapular kinematics, asymmetries and shoulder pain in wheelchair athletes

Background Shoulder pain is the most common complaint for wheelchair athletes. Scapular orientation and dyskinesia are thought to be associated with shoulder pathology, yet no previous studies have examined the bilateral scapula kinematics of wheelchair athletes during propulsion. Research question To examine bilateral scapular kinematics of highly trained wheelchair rugby (WR) players and any associations with self-reported shoulder pain during everyday wheelchair propulsion. Methods Ten WR players (5 with shoulder pain, 5 without) performed 2 × 3-minute bouts of exercise in their everyday wheelchair on a wheelchair ergometer at two sub-maximal speeds (3 and 6 km∙h-1). During the final minute, 3D kinematic data were collected at 100 Hz to describe scapulothoracic motion relative to each propulsion cycle. Instantaneous asymmetries in scapular orientation between dominant and non-dominant sides were also reported. Differences in scapular kinematics and propulsion asymmetries were compared across shoulders symptomatic and asymptomatic of pain. Results An internally rotated, upwardly rotated and anteriorly tilted scapula was common during wheelchair propulsion and asymmetries ≤ 14° did exist, yet minimal changes were observed across speeds. Participants with bilateral shoulder pain displayed a less upwardly rotated scapula during propulsion, however large inter-individual variability in scapular kinematics was noted. Significance Scapular asymmetries are exhibited by wheelchair athletes during wheelchair propulsion, yet these were not exacerbated by increased speed and had limited associations to shoulder pain. This suggests that propulsion kinematics of highly trained athletes may not be the primary cause of pain experienced by this population

Which treatments are most effective for common tendinopathies? A systematic review and network meta-analysis protocol.

This is a preprint for a protocol. The purpose of the study described by the protocol was to compare the effectiveness of different treatment classes across a range of tendinopathies and outcomes, to better establish a treatment hierarchy. Where sufficient data were obtained, the potential for covariates - including patient demographics and condition specifics (e.g. symptom severity) - to explain statistical heterogeneity was explored