Unsupervised isometric exercise versus wait-and-see for lateral elbow tendinopathy

Purpose This study aimed to investigate the effect of unsupervised isometric exercise compared with a wait-and-see approach on pain, disability, global improvement, and pain-free grip strength in individuals with lateral elbow tendinopathy. Methods Forty participants with unilateral lateral elbow tendinopathy of at least 6 wk duration were randomized to either wait-and-see (n = 19) or a single supervised instruction session by a physiotherapist, followed by an 8-wk unsupervised daily program of progressive isometric exercise (n = 21). Primary outcomes were Patient-Rated Tennis Elbow Evaluation, global rating of change on a six-point scale (dichotomized to success and no success) and pain-free grip strength at 8 wk. Secondary outcomes were resting and worst pain on an 11-point numerical rating scale, and thermal and pressure pain thresholds as a measure of pain sensitivity. Results Thirty-nine (98%) participants completed 8-wk measurements. The exercise group had lower Patient-Rated Tennis Elbow Evaluation scores compared with wait-and-see at 8 wk (standardized mean difference [SMD],-0.92; 95% confidence interval [CI],-1.58 to-0.26). No group differences were found for success on global rating of change (29% exercise vs 26% wait-and-see (risk difference, 2.3%; 95% CI,-24.5 to 29.1)), or pain-free grip strength (SMD,-0.33; 95% CI,-0.97 to 0.30). No differences were observed for all secondary outcomes except for worst pain, which was moderately lower in the exercise group (SMD,-0.80; 95% CI,-1.45 to-0.14). Conclusions Unsupervised isometric exercise was effective in improving pain and disability, but not perceived rating of change and pain-free grip strength when compared with wait-and-see at 8 wk. With only one of the three primary outcomes being significantly different after isometric exercises, it is doubtful if this form of exercise is efficacious as a sole treatment. © Lippincott Williams & Wilkins

Response to considerations on “Achilles tendinopathy and patellar tendinopathy display opposite changes in elastic properties”

Letter to the edito

Achilles and patellar tendinopathy display opposite changes in elastic properties: A shear wave elastography study

To compare tendon elastic and structural properties of healthy individuals with those with Achilles or patellar tendinopathy. Sixty-seven participants (22 Achilles tendinopathy, 17 patellar tendinopathy, and 28 healthy controls) were recruited between March 2015 and March 2016. Shear wave velocity (SWV), an index of tissue elastic modulus, and tendon thickness were measured bilaterally at mid-tendon and insertional regions of Achilles and patellar tendons by an examiner blinded to group. Analysis of covariance, adjusted for age, body mass index, and sex was used to compare differences in tendon thickness and SWV between the two tendinopathy groups (relative to controls) and regions. Tendon thickness was included as a covariate for analysis of SWV. Compared to controls, participants with Achilles tendinopathy had lower SWV at the distal insertion (Mean difference MD; 95% CI: −1.56; −2.49 to −0.62 m/s; P <.001) and greater thickness at the mid-tendon (MD 0.19; 0.05-0.33 cm; P =.007). Compared to controls, participants with patellar tendinopathy had higher SWV at both regions (MD 1.25; 0.40-2.10 m/s; P =.005) and greater thickness proximally (MD 0.17; 0.06-0.29 cm; P =.003). Compared to controls, participants with Achilles and patellar tendinopathy displayed lower Achilles tendon elastic modulus and higher patellar tendon elastic modulus, respectively. More research is needed to explore whether maturation, aging, or chronic load underlie these findings and whether current management programs for Achilles and patellar tendinopathy need to be tailored to the tendon. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Lt

Do insertional and mid-portion Achilles tendinopathy display different material properties?

We thank Zhang et al for their letter to the editor which raises the question as to whether insertional and non-insertional (or midportion) Achilles tendinopathy have different “stiffness patterns.” This proposal is based on findings of greater “hardness” in insertional Achilles tendinopathy in the study by Zhang et al,1 and lower “elastic modulus” in the study by Coombes et al,2 which recruited participants with a clinical diagnosis of Achilles tendinopathy at either region. While plausible, there are several critical differences between the two studies that ought to be considered

Development of a core outcome set for lateral elbow tendinopathy (COS-LET) using best available evidence and an international consensus process

OBJECTIVES: To develop a core outcome set for lateral elbow tendinopathy (COS-LET) and to provide guidance for outcome evaluation in future studies. METHODS: We implemented a multi-stage mixed-methods design combining two systematic reviews, domain mapping of outcome measurement instruments to the core domains of tendinopathy, psychometric analysis of instruments, two patient focus groups and a Delphi study incorporating two surveys and an international consensus meeting. Following the OMERACT guidelines, we used a 70% threshold for consensus. RESULTS: 38 clinicians/researchers and 9 patients participated. 60 instruments were assessed for inclusion. The only instrument that was recommended for the COS-LET was Patient Rated Tennis Elbow Evaluation (PRTEE) for the disability domain. Interim recommendations were made to use: the PRTEE function subscale for the function domain; PRTEE pain subscale items 1, 4 and 5 for the pain over a specified time domain; pain-free grip strength for the physical function capacity domain; a Numerical Rating Scale measuring pain on gripping for the pain on activity/loading domain; and time off work for the participation in life activities domain. No recommendations could be made for the quality-of-life, patient rating of condition and psychological factors domains. CONCLUSIONS: The COS-LET comprises the PRTEE for the disability domain. Interim-use recommendations included PRTEE subscales, time off work, pain-free grip strength and a Numerical Rating Scale measuring pain on gripping. Further work is required to validate these interim measures and develop suitable measures to capture the other domains.The article is available via Open Access. Click on the 'Additional link' above to access the full-text.Published version, accepted versio

Patellar and Achilles tendinopathies are predominantly peripheral pain states: A blinded case control study of somatosensory and psychological profiles

study design Case–control design. background Tendinopathy is characterised by pain on tendon loading. In persistent cases of upper limb tendinopathy, it is frequently associated with central nervous system sensitisation, whereas less commonly linked in the case of persistent lower limb tendinopathies. Objectives Compare somatosensory and psychological profiles of participants with persistent patellar (PT) and Achilles tendinopathies (AT) with pain free controls. Methods A comprehensive battery of Quantitative Sensory Testing (QST) was assessed at standardised sites of the affected tendon and remotely (lateral elbow) by a blinded assessor. Participants completed the Victorian Institute of Sports Assessment, a health-related quality of life questionnaire, the Hospital Anxiety and Depression Scale and the Active Australia Questionnaire. Independent t-test and analysis of covariance (sex-adjusted and age-adjusted) were performed to compare groups. results Participants with PT and AT did not exhibit differences from controls for the QST at the remote site, but there were differences at the affected tendon site. Compared with controls, participants with PT displayed significantly lower pressure pain threshold locally at the tendon (p=0.012) and fewer single limb decline squats before pain onset, whereas participants with AT only displayed fewer single heel raises before pain onset, but this pain was of a higher intensity. Conclusion PT and AT appear to be predominantly local not widespread pain states related to loading of tendons without significant features of central sensitisation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved