Inhibitory kinesiotaping has no effect on post-stroke spasticity: Prospective, randomised, controlled study.

OBJECTIVE: Motor neuron pool activity is high in spasticity. The effect of inhibitory kinesiotaping (KT) on spasticity is unclear. The aim of this study is to investigate the effect of inhibitory KT on spasticity after stroke. METHODS: Fifty stroke patients with ankle plantarflexor spasticity were randomised to intervention (27) and control (23) groups. Inhibitory KT was applied to the triceps surae muscle in the intervention group and sham KT to the Achilles tendon in the control group. Inhibitory and sham KT were applied for 72 h with a combined conventional rehabilitation programme. Spasticity was assessed at baseline and 72 h after KT using three instruments: Modified Ashworth Scale (MAS), Homosynaptic Post-Activation Depression (HPAD) reflecting the level of motor neuron pool activity, and joint torque as a measure of resistance to passive ankle dorsiflexion. RESULTS: The baseline MAS score, HPAD levels and dorsiflexion torque of the two groups were not significantly different. The change in MAS score was -3.7 ± 17.5 (p = 0.180) in the intervention group and 3.6 ± 33.3 (p = 0.655) in the control group. The change in dorsiflexion torque was -0.3 ± 16.1 kg m (p = 0.539) in the intervention group and 8.0 ± 24.1 kg m (p = 0.167) in the control group. The change in mean HPAD was 8.7 ± 34.7 (p = 0.911) in the intervention group and 10.1 ± 41.6 (p = 0.609) in the control group. CONCLUSIONS: The present study showed that inhibitory KT has no antispastic effect in stroke patients.

Efficacy of heel lifts for mid-portion Achilles tendinopathy (the LIFT trial): study protocol for a randomised controlled trial.

BACKGROUND: Mid-portion Achilles tendinopathy is a common condition, characterised by localised Achilles tendon load-related pain and dysfunction. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. Heel lifts have also been advocated as a treatment for Achilles tendinopathy, but the efficacy and mechanism of action of this intervention is unclear. This proposal describes a randomised controlled trial comparing the effectiveness of heel lifts versus sham heel lifts for reducing pain associated with mid-portion Achilles tendinopathy, with an embedded biomechanical analysis. METHODS: One hundred and eight men and women aged 18 to 65 years with mid-portion Achilles tendinopathy (who satisfy the inclusion and exclusion criteria) will be recruited. Participants will be randomised, using the website Sealed Envelope, to either a control group (sham heel lifts) or an experimental group (heel lifts). Both groups will be provided with education regarding acceptable pain levels to ensure all participants receive some form of treatment. The participants will be instructed to use their allocated intervention for at least 8 h every day for 12 weeks. The primary outcome measure will be pain intensity (numerical rating scale) at its worst over the previous week. The secondary outcome measures will be additional measures of Achilles tendon pain and disability, participant-perceived global ratings of change, function, level of physical activity and health-related quality of life. Data will be collected at baseline and the primary endpoint (week 12). Data will be analysed using the intention-to-treat principle. In addition, the acute kinetic and kinematic effects of the interventions will be examined at baseline in a subpopulation of the participants (n = 40) while walking and running using three-dimensional motion analysis. DISCUSSION: The LIFT trial (efficacy of heeL lIfts For mid-portion Achilles Tendinopathy) will be the first randomised trial to compare the efficacy of heel lifts to a sham intervention in reducing pain and disability in people with Achilles tendinopathy. The biomechanical analysis will provide useful insights into the mechanism of action of heel lifts. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12623000627651 . Registered 7 June 2023.

Four hours of normobaric hypoxia reduces Achilles tendon reflex inhibition.

Acute exposure to hypoxia increases postural sway, but the underlying neurophysiological factors are unclear. Golgi tendon organs (GTOs), located within the musculotendinous junction (MTJ), provide inhibitory signals to plantar flexor muscles that are important for balance control; however, it is uncertain if GTO function is influenced by hypoxia. The aim of this study was to determine how normobaric hypoxia influences lower limb tendon-evoked inhibitory reflexes during upright stance. We hypothesized that tendon-evoked reflex area and duration would decrease during hypoxia, indicating less inhibition of postural muscles compared with normoxia. At baseline (BL; 0.21 fraction of inspired oxygen, FIO2) and at ∼2 (H2) and 4 (H4) h of normobaric hypoxia (0.11 FIO2) in a normobaric hypoxic chamber, 16 healthy participants received electrical musculotendinous stimulation (MTstim) to the MTJ of the left Achilles tendon. The MTstim was delivered as two sets of 50 stimuli while the participant stood on a force plate with their feet together. Tendon-evoked inhibitory reflexes were recorded from the surface electromyogram of the ipsilateral medial gastrocnemius, and center of pressure (CoP) variables were recorded from the force plate. Normobaric hypoxia increased CoP velocity (P ≤ 0.002) but not CoP standard deviation (P ≥ 0.12). Compared with BL, normobaric hypoxia reduced tendon-evoked inhibitory reflex area by 45% at H2 and 53% at H4 (P ≤ 0.002). In contrast, reflex duration was unchanged during hypoxia. The reduced inhibitory feedback from the GTO pathway could likely play a role in the increased postural sway observed during acute exposure to hypoxia.NEW & NOTEWORTHY The Ib pathway arising from the Golgi tendon organ provides inhibitory signals onto motor neuron pools that modifies force and, hence, postural control. Although hypoxia influences standing balance (increases sway), the underlying mechanisms have yet to be unraveled. Our study identified that tendon-evoked inhibition onto a plantar flexor motoneuron pool is reduced by acute exposure to normobaric hypoxia. This reduction of inhibition may contribute to the hypoxia-related increase in postural sway.

Are we asking the right questions to people with Achilles tendinopathy? The best questions to distinguish mild versus severe disability to improve your clinical management.

OBJECTIVE: Determine the capacity of individual items on the Tendinopathy Severity Assessment - Achilles (TENDINS-A), Foot and Ankle Outcome Score (FAOS), and Victorian Institute of Sports Assessment - Achilles (VISA-A) to differentiate patients with mild and severe tendon-related disability in order to provide clinicians the best questions when they are consulting patients with Achilles tendinopathy. DESIGN: Cross-sectional. PARTICIPANTS: Seventy participants with Achilles tendinopathy (61.4% mid-portion only, 31.4% insertional only, 7.2% both). OUTCOME MEASURES: The discrimination index was determined for each TENDINS-A, FAOS, and VISA-A item to determine if items could discriminate between mild and severe disability. A Guttman analysis for polytomous items was conducted. RESULTS: All 62 tems from the TENDINS-A, FAOS, and VISA-A were ranked with the best items relating to pain with physical tendon loading, time for pain to settle following aggravating activities and time for the tendon to 'warm-up' following inactivity. CONCLUSIONS: Pain with loading the Achilles tendon, time for pain to settle following aggravating activity, as well as time taken for the tendon symptoms to subside after prolonged sitting or sleeping are the best questions indicative of the severity of disability in patients with Achilles tendinopathy. These questions can assist clinicians with assessing baseline severity and monitoring treatment response.

Asymmetric running is associated with pain during outdoor running in individuals with Achilles tendinopathy in the return-to-sport phase.

OBJECTIVES: To determine the relationships between (1) Achilles tendon pain and loading symmetry, and (2) number of running bouts and symptom severity, during two weeks of outdoor running in individuals with Achilles tendinopathy. DESIGN: Prospective, observational study. SETTING: Biomechanics laboratory and outdoors. PARTICIPANTS: Seventeen runners with Achilles tendinopathy in the return-to-sport phase of rehabilitation. MAIN OUTCOME MEASURES: Symptom severity was recorded with the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Running bouts and Achilles tendon pain during runs were recorded with daily training logs. Ground contact time was collected during runs with wearable sensors. Linear mixed modeling determined if the relationship between Achilles tendon pain and ground contact time symmetry during running was moderated by consecutive run days. Multiple regression determined the relationship between number of running bouts and change in VISA-A scores over two weeks, adjusted for run distance. RESULTS: Greater ground contact time on the contralateral leg corresponded to increased ipsilateral tendon pain for each consecutive run day (b = -0.028, p < 0.001). Number of running bouts was not associated with 2-week changes in VISA-A scores (p = 0.672). CONCLUSIONS: Pain during running is associated with injured leg off-loading patterns, and this relationship strengthened with greater number of consecutive run days. Number of running bouts was not related to short-term symptom severity.

Can the Achilles tendon regenerate completely following percutaneous tenotomy in older children with clubfoot?

PURPOSE: The aims of the study were to document the outcomes of percutaneous Achilles tenotomy (pAT) performed in older children with clubfoot, by assessing the clinical, functional and ultrasonographic evidence of Achilles tendon regeneration. METHODS: A retrospective case series of older children with clubfoot treated between August 2011 and July 2020 was studied. Clinical assessment of ankle range of motion and calf strength, functional assessment of triceps surae muscle endurance by single leg heel-rise test, and ultrasonographic assessment of Achilles tendon echotexture and dimensions to assess tendon regeneration were performed. RESULTS: Percutaneous Achilles tenotomy was performed on 31 children (48 clubfeet) at a mean age of 5.24 ± 2.14 years (1-10.2 years). At a mean follow-up of 4.86 ± 1.97 years, all children demonstrated normal calf strength with mean dorsiflexion range of 13.64° (0-25°) and mean plantarflexion range of 37.95° (10-40°). The heel-rise endurance test was completed by 27 children with mean 25.85 heel rises/minute (range 17-30) and mean height of heel rise of 6.29 cm (range 4-10 cm). Normal fibrillar tendinous echotexture with homogenous echogenicity was seen on ultrasonography in 41 feet (85.4%) with mean tendon width of 9.7 mm (3.3-16 mm) and thickness of 5.1 mm (1.8-15 mm), comparable with unaffected feet. CONCLUSIONS: Clinical, functional and ultrasonographic parameters unequivocally demonstrate complete regeneration of the Achilles tendon, when pAT is performed in older children with delayed-presenting idiopathic clubfoot treated using Ponseti principles.

Double-Row Achilles Insertional Repair With Rip-Stop Increases Construct Strength Compared to Traditional Techniques: A Biomechanical Study.

BACKGROUND: Although double-row suture-anchored (DRSA) techniques for Achilles insertional tendinosis has proven successful, a reoccurring failure mode not yet addressed is suture tearing through the tendon. This study aims to address suture tearing by incorporating a rip-stop element. Authors hypothesized that the Rip-Stop group would demonstrate increased strength compared with more traditional techniques. METHODS: 12 paired cadaveric feet were used in this study (n = 24). One sample from each pair was assigned to receive the standard double-row (SDR) Achilles repair with 4.75-mm knotless anchors (n = 12). The control's matched sides were divided between 2 DRSA bridge groups: modified double-row (MDR) bridge with 3.9-mm anchors or rip-stop double-row (RS-DR) bridge repair with soft proximal anchors and 3.9-mm anchored distal row. In neutral position, specimens underwent 1000 cycles (20-100 N) followed by load to failure. Displacements, stiffness, ultimate load, and failure mode were recorded. RESULTS: RS-DR had the lowest initial displacement values followed by SDR and MDR (1.3 ± 0.4, 2.7 ± 1.4, and 3.2 ± 1.3 mm, respectively). Significance was detected when comparing initial displacement of RS-DR to MDR (P = .038). Cyclic displacement was lowest for RS-DR, followed by MDR and SDR (1.6 ± 0.9, 2.2 ± 1.1, and 4.5 ± 3.2 mm, respectively). Cyclic stiffness was similar for RS-DR and MDR (89.1 ± 24.6 and 81.9 ± 5.6 N/mm, respectively). RS-DR ultimate load (1116.8 ± 405.7 N) was statistically greater than SDR (465.6 ± 352.7, P = .003). CONCLUSION: RS-DR-repaired specimens demonstrated a decrease in displacement values and increased ultimate load and stiffness when compared to other groups. Results of this cadaveric model suggest that the addition of a rip-stop to DRSA Achilles repair is more impactful than anchor size. Limitations include that this was a time-zero biomechanical study, which cannot simulate the performance of the repairs during postoperative healing and recovery. CLINICAL RELEVANCE: A rip-stop technique for Achilles repair effectively improves dynamic mechanical characteristics and may mitigate suture tearing through tendon in a patient cohort.

Evaluation of tendon and ligament microstructure and mechanical properties in a canine model of mucopolysaccharidosis I.

Mucopolysaccharidosis (MPS) I is a lysosomal storage disorder characterized by deficient alpha-l-iduronidase activity, leading to abnormal accumulation of glycosaminoglycans (GAGs) in cells and tissues. Synovial joint disease is prevalent and significantly reduces patient quality of life. There is a strong clinical need for improved treatment approaches that specifically target joint tissues; however, their development is hampered by poor understanding of underlying disease pathophysiology, including how pathological changes to component tissues contribute to overall joint dysfunction. Ligaments and tendons, in particular, have received very little attention, despite the critical roles of these tissues in joint stability and biomechanical function. The goal of this study was to leverage the naturally canine model to undertake functional and structural assessments of the anterior (cranial) cruciate ligament (CCL) and Achilles tendon in MPS I. Tissues were obtained postmortem from 12-month-old MPS I and control dogs and tested to failure in uniaxial tension. Both CCLs and Achilles tendons from MPS I animals exhibited significantly lower stiffness and failure properties compared to those from healthy controls. Histological examination revealed multiple pathological abnormalities, including collagen fiber disorganization, increased cellularity and vascularity, and elevated GAG content in both tissues. Clinically, animals exhibited mobility deficits, including abnormal gait, which was associated with hyperextensibility of the stifle and hock joints. These findings demonstrate that pathological changes to both ligaments and tendons contribute to abnormal joint function in MPS I, and suggest that effective clinical management of joint disease in patients should incorporate treatments targeting these tissues.

Human Achilles tendon mechanical behavior is more strongly related to collagen disorganization than advanced glycation end-products content.

Diabetes is associated with impaired tendon homeostasis and subsequent tendon dysfunction, but the mechanisms underlying these associations is unclear. Advanced glycation end-products (AGEs) accumulate with diabetes and have been suggested to alter tendon function. In vivo imaging in humans has suggested collagen disorganization is more frequent in individuals with diabetes, which could also impair tendon mechanical function. The purpose of this study was to examine relationships between tendon tensile mechanics in human Achilles tendon with accumulation of advanced glycation end-products and collagen disorganization. Achilles tendon specimens (n = 16) were collected from individuals undergoing lower extremity amputation or from autopsy. Tendons were tensile tested with simultaneous quantitative polarized light imaging to assess collagen organization, after which AGEs content was assessed using a fluorescence assay. Moderate to strong relationships were observed between measures of collagen organization and tendon tensile mechanics (range of correlation coefficients: 0.570-0.727), whereas no statistically significant relationships were observed between AGEs content and mechanical parameters (range of correlation coefficients: 0.020-0.210). Results suggest that the relationship between AGEs content and tendon tensile mechanics may be masked by multifactorial collagen disorganization at larger length scales (i.e., the fascicle level).

Achilles Tendinopathy, A Brief Review and Update of Current Literature.

ABSTRACT: Chronic pain in the Achilles tendon is a common problem in both athletes and nonathletes alike. The etiology for the development of Achilles tendinopathy has not been fully elucidated, and there remains multiple theories to explain the pain and dysfunction accompanying this condition. The diagnosis of Achilles tendon problems continues to rely on the clinical history and physical examination. The optimal management of pain, restoration of function, and return-to-sports participation with Achilles tendinopathy are evolving because of the advancement in technologies and research regarding its pathophysiology. This article aims to provide a brief review of the relevant anatomy, differential diagnosis, imaging findings, and an update of the literature on conservative and minimally invasive managements of chronic Achilles tendinopathy.

Grafting of iPS cell-derived tenocytes promotes motor function recovery after Achilles tendon rupture.

Tendon self-renewal is a rare occurrence because of the poor vascularization of this tissue; therefore, reconstructive surgery using autologous tendon is often performed in severe injury cases. However, the post-surgery re-injury rate is relatively high, and the collection of autologous tendons leads to muscle weakness, resulting in prolonged rehabilitation. Here, we introduce an induced pluripotent stem cell (iPSC)-based technology to develop a therapeutic option for tendon injury. First, we derived tenocytes from human iPSCs by recapitulating the normal progression of step-wise narrowing fate decisions in vertebrate embryos. We used single-cell RNA sequencing to analyze the developmental trajectory of iPSC-derived tenocytes. We demonstrated that iPSC-tenocyte grafting contributed to motor function recovery after Achilles tendon injury in rats via engraftment and paracrine effects. The biomechanical strength of regenerated tendons was comparable to that of healthy tendons. We suggest that iPSC-tenocytes will provide a therapeutic option for tendon injury.

Assessment of Functional Conservative Treatment of Acute Complete Achilles Tendon Rupture.

BACKGROUND: In recent years, treatment for Achilles tendon rupture (ATR) went through radical changes: from the conservative non-weight bearing approach to a functional protocol. This functional protocol allows complete weight bearing after only 2 weeks by placing the foot in a plastic boot in tapered down equines and using interchangeable wedges under the heel. This change of approach has dramatically lowered the rate of re-rupture. OBJECTIVES: To describe our preliminary results with this functional protocol and to assess outcome measures in the functional conservative treatment. METHODS: The study comprised 15 people who were evaluated clinically and by sonograph. We measured calf circumference, ankle joint range of motion (ROM), and single-leg heel-rise test (SLHRT). In addition, standard scoring methods (Achilles Tendon Rupture Score and Physical Activity Scale) were examined. RESULTS: In our cohort 14 people successfully gained SLHRT. The mean Achilles Tendon Rupture Score functional questionnaire and Physical Activity Scale physical activity questionnaire score was 85.6 of 100, and 4.7 of 6, respectively. There were no significant differences in ankle ROM compared to the uninjured limb. There was statistically significant reduction in the calf circumference and soleus muscle thickness sonographically. CONCLUSIONS: It seems that the conservative functional treatment of ATR demonstrates good functional outcomes, with the patients returning to close to normal activity, although noted muscle wasting and weakness. This protocol presents a true alternative to surgery and should be considered for most non-insertional Achilles tendon tears.

Static foot posture and its relation to clinical variables in ankylosing spondylitis.

AIM: Postural abnormalities of the foot are common in rheumatic diseases. Static foot posture is a poorly studied clinical parameter in ankylosing spondylitis (AS). The aim of the study was to evaluate static foot posture in patients with AS and to determine the potential impact of clinical variables on foot posture. METHOD: Fifty patients with AS and 40 age- and sex-matched healthy controls were enrolled in the study. Disease activity was measured using the Ankylosing Spondylitis Disease Activity Score. Axial mobility was evaluated with the Bath Ankylosing Spondylitis Metrology Index three-point answer scale. Functional status was assessed by the Bath Ankylosing Spondylitis Functional Index and Health Assessment Questionnaire-Disability Index. Enthesitis and foot posture were evaluated by the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and Foot Posture Index-6, respectively. RESULTS: Patients with AS revealed significantly higher scores of foot posture index when compared with controls (P = 0.005). Abnormal foot posture (pronated and supinated) was more common in the patient group (P < 0.01). According to the multinomial logistic regression analysis, a higher MASES score was associated with supinated foot posture in AS patients (odds ratio 1.47, 95% confidence interval 1.03-2.09, P = 0.035). In addition, supinated foot posture was associated with enthesitis of the Achilles tendon (P = 0.002). CONCLUSION: Enthesitis is related to deteriorated static foot posture in patients with AS. Enthesitis of the Achilles tendon is closely associated with the supinated foot posture.

Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy.

OBJECTIVE: To identify latent subgroups among patients with Achilles tendinopathy, describe patient characteristics and clinical attributes that defined each subgroup, and develop a clinical classification model for subgroup membership. DESIGN: Cross-sectional study. METHODS: One hundred forty-five participants (men, n = 73; mean ± SD age, 51 ± 14 years) with clinically diagnosed Achilles tendinopathy completed a baseline evaluation, including demographics and medical history, patient-reported outcome measures, a clinical exam, tendon structure measures via ultrasound imaging and continuous shear-wave elastography, and a functional test battery. Subgroups were identified using mixture modeling. We compared the subgroups using a 1-way analysis-of-variance or chi-square test and the Tukey post hoc test to identify defining attributes. We developed a clinical classification model using logistic regression and receiver operating characteristic curves. RESULTS: Three latent subgroups were identified and named by their distinctive patient characteristics and clinical attributes. The activity-dominant subgroup (n = 67), on average, had the highest physical activity level, function, and quality of life; reported mild symptoms; and was the youngest. The psychosocial-dominant subgroup (n = 56), on average, had the worst symptoms, impaired function, heightened psychological factors, the poorest quality of life, minimal tendon structural alterations, and was obese and predominantly female. The structure-dominant subgroup (n = 22), on average, had the most tendon structural alterations, severe functional deficits, moderate symptoms and psychological factors, reduced quality of life, and was the oldest, obese, and predominantly male. The clinical classification model correctly classified 85% (123/145) of participants. CONCLUSION: Three Achilles tendinopathy subgroups (activity dominant, psychosocial dominant, and structure dominant) differed in patient characteristics and clinical attributes. J Orthop Sports Phys Ther 2021;51(9):440-448. Epub 1 Jun 2021. doi:10.2519/jospt.2021.10271.

Dutch multidisciplinary guideline on Achilles tendinopathy.

OBJECTIVE: To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients. DESIGN: Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase. DATA SOURCES: Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference. STUDY ELIGIBILITY CRITERIA: Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module. DATA EXTRACTION AND SYNTHESIS: To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations. PRIMARY OUTCOME MEASURE: The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions. RESULTS: Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy. SUMMARY/CONCLUSION: Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice.

Shockwave Therapy Plus Eccentric Exercises Versus Isolated Eccentric Exercises for Achilles Insertional Tendinopathy: A Double-Blinded Randomized Clinical Trial.

BACKGROUND: There remains a lack of consensus regarding the treatment of Achilles insertional tendinopathy. The condition is typically treated with eccentric exercises despite the absence of satisfactory and sustained results. Shockwave therapy was presented as an alternative, but there is a paucity of literature, with good outcomes, supporting its use. The purpose of the present single-center, double-blinded, placebo-controlled, randomized trial was to determine if the use of shockwave therapy in combination with eccentric exercises improves pain and function in patients with Achilles insertional tendinopathy. METHODS: A total of 119 patients with Achilles insertional tendinopathy were evaluated and enrolled in the study from February 2017 to February 2019. Patients were allocated to 1 of 2 treatment groups, eccentric exercises with extracorporeal shockwave therapy (SWT group) and eccentric exercises with sham shockwave therapy (control group). Three sessions of radial shockwaves (or sham treatment) were performed every 2 weeks and eccentric exercises were undertaken for 3 months. The primary outcome was the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) at 24 weeks. Secondary outcomes included the visual analogue scale, algometry, the Foot and Ankle Outcome Score, and the 12-Item Short Form Health Survey. RESULTS: Both groups showed significant improvement during the study period; however, there were no between-group differences in any of the outcomes (all p >0.05). At the 24-week evaluation, the SWT group exhibited a mean VISA-A of 63.2 (95% confidence interval, 8.0) compared with 62.3 (95% confidence interval, 6.9) in the control group (p = 0.876). There was a higher rate of failure (38.3%) but a lower rate of recurrence (17.0%) in the SWT group compared with the control group (11.5% and 34.6%, respectively; p = 0.002 and p = 0.047). There were no complications reported for either group. CONCLUSIONS: Extracorporeal shockwave therapy does not potentiate the effects of eccentric strengthening in the management of Achilles insertional tendinopathy. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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

OBJECTIVE: to 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. DESIGN: cross-sectional study. SETTING: online survey platform. PARTICIPANTS: 119 patients (mean age: 44 years (SD 14)) diagnosed with Achilles or patellar tendinopathy. MAIN OUTCOME MEASURES: A 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. RESULTS: Psychological 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. CONCLUSION: The 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.

Effects of kinesiophobia and pain on performance and willingness to perform jumping tests in Achilles tendinopathy: A cross-sectional study.

OBJECTIVES: Fear of movement may be a source of systemic bias in studies reporting functional deficits in patients with Achilles tendinopathy. The purpose of this study was to assess the effects of kinesiophobia on completion rate and performance on tests evaluating lower extremity function, while controlling for self-reported pain. DESIGN: Cross-sectional study; SETTING: Tendon research laboratory. PARTICIPANTS: Ninety-four participants with Achilles tendinopathy. MAIN OUTCOME MEASURES: Completion (yes/no) and performance (cm) on the counter-movement jump, hopping, and drop counter-movement jump. RESULTS: The models fit the data (R^2 = 0.81, both models). TSK score did not predict completion (beta = -0.01, 95% CI = -0.13 - 0.09, P = 0.74) but pain did (beta = -0.36, 95% CI = -0.53 to -0.19, P < 0.0001). TSK score did not predict performance (beta = -0.06, 95% CI = -0.14 - 0.003, P = 0.07), but pain did (beta = -0.15, 95% CI = -0.22 to -0.07, P < 0.0001). CONCLUSIONS: Kinesiophobia did not affect the physical performance tests in patients with Achilles tendinopathy. Measures of physical performance should be interpreted alongside self-reported pain.

Plantar soft tissues and Achilles tendon thickness and stiffness in people with diabetes: a systematic review.

BACKGROUND: Diabetes mellitus is associated with changes in soft tissue structure and function. However, the directionality of this change and the extent to which either tissue thickness or stiffness contributes to the pathogenesis of diabetes-related foot ulcerations is unclear. Hence, this systematic review aims to summarise the existing evidence for soft tissue structural differences in the feet of people with and without diabetes. METHODS: In compliance with MOOSE and PRISMA guidelines, AMED, CINAHL, MEDLINE, ProQuest Health & Medical Collection, ProQuest Nursing & Allied Health Database, and Web of Science electronic databases were systematically searched for studies published from database inception until 1st October 2020 [Prospero CRD42020166614]. Reference lists of included studies were further screened. Methodological quality was appraised using a modified critical appraisal tool for quantitative studies developed by McMaster University. RESULTS: A total of 35 non-randomised observational studies were suitable for inclusion. Within these, 20 studies evaluated plantar tissue thickness, 19 studies evaluated plantar tissue stiffness, 9 studies evaluated Achilles tendon thickness and 5 studies evaluated Achilles tendon stiffness outcomes. No significant differences in plantar tissue thickness were found between people with and without diabetes in 55% of studies (11/20), while significantly increased plantar tissue stiffness was found in people with diabetes in 47% of studies (9/19). Significantly increased Achilles tendon thickness was found in people with diabetes in 44% of studies (4/9), while no significant differences in Achilles tendon stiffness were found between people with and without diabetes in 60% of studies (3/5). CONCLUSIONS: This systematic review found some evidence of soft tissue structural differences between people with and without diabetes. However, uncertainty remains whether these differences independently contribute to diabetes-related foot ulcerations. The heterogeneity of methodological approaches made it difficult to compare across studies and methodological quality was generally inadequate. High-quality studies using standardised and validated assessment techniques in well-defined populations are required to determine more fully the role of structural tissue properties in the pathogenesis of diabetes-related foot ulcerations.

Explaining Variability in the Prevalence of Achilles Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals.

OBJECTIVE: To estimate the prevalence of, and factors associated with, Achilles tendon abnormalities observed on imaging in asymptomatic individuals. DESIGN: Systematic review with stratified meta-analysis and meta-regression. LITERATURE SEARCH: Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science were searched from 1980 to August 2020. STUDY SELECTION CRITERIA: We included studies that reported the prevalence of Achilles tendon abnormalities, observed with any imaging modality, in an asymptomatic population. We excluded studies if participant mean age was younger than 12 years or if participants had current/previous lower-limb tendon injuries/symptoms or other systemic conditions. DATA SYNTHESIS: Random-effects proportion meta-analysis was used to estimate prevalence. We used meta-regression for continuous variables (mean age and body mass index [BMI], sample size, proportion of female participants) and stratified categorical variables (imaging modality and participation in physical activity) to explain between-study heterogeneity. RESULTS: We included 91 studies (10 156 limbs, 5841 participants). The prevalence of Achilles tendon abnormalities on imaging ranged from 0% to 80% per participant. Between-study heterogeneity was high (I2>90%, P<.001), precluding data pooling. Between-study heterogeneity was partly explained by participant mean BMI (slope, 2.8% per 1-unit increase in BMI; 95% confidence interval: 0.57%, 5.03%; P = .015) and participation in physical activity per limb, and mean age of 40 years old or older (P = .022) per participant. CONCLUSION: There was substantial variability in the prevalence of Achilles tendon abnormalities on imaging in asymptomatic individuals. Higher prevalence of abnormalities was associated with older age (40 years old or older), higher BMI, and participation in physical activity. A large proportion of heterogeneity remains unaccounted for, likely due to variations in abnormality definitions and study design. J Orthop Sports Phys Ther 2021;51(5):232-252. Epub 28 Mar 2021. doi:10.2519/jospt.2021.9970.