Evaluation of the Relationship between Acromiohumeral Distance and Supraspinatus Tendon Thickness Measured by Ultrasonography and Rotator Cuff Pathologies, Pain, and Function.

PURPOSE OF THE STUDY: In this study, we aimed to evaluate acromiohumeral distance (AHD) and supraspinatus tendon (ST) thickness measurements and their relationship with pain and function in ST pathologies. MATERIAL AND METHODS: The study included 111 patients and 25 healthy controls (HC). Patients were divided into 3 groups according to their diagnosis: non-tear tendinopathy (NTT), partial thickness tear (PTT), and full thickness tear (FTT). The AHD and ST thickness of the participants were measured with ultrasound. The pain and functional status of the patients were evaluated with the Numeric Rating Scale (NRS), The QuickDASH shortened version of the DASH Outcome Measure - Disabilities of the Arm Shoulder and Hand (QDASH), and Simple Shoulder Test (SST). RESULTS: The AHD value was significantly higher in the NTT group (p=0.000). The AHD value was significantly lower in the FTT group (p=0.000). ST thickness value was significantly lower in the PTT group compared to the NTT group (p=0.000). There was a positive correlation between ST thickness and BMI (r=0.553,p<0.01). There was a negative correlation between ST thickness and SST and a positive correlation between ST thickness (r=-0.223,p<0.05) and QDASH (r=0.276,p<0.05). CONCLUSIONS: We found that AHD and SST thicknesses significantly differed in the NTT, PTT, FTT, and HC groups. This difference may be important for diagnosis. In addition, the effect of obesity on ST thickness and the relationship between ST thickness and functional scores may be considered. Weight control may be effective at this point. KEY WORDS: acromiohumeral distance, supraspinatus tendon thickness, ultrasound.

Reduced Intratendinous Sliding in Achilles Tendinopathy During Active Plantarflexion Regardless of Horizontal Foot Position.

PURPOSE: The Achilles tendon consists of three subtendons with the ability to slide relative to each other. As optimal intratendinous sliding is thought to reduce the overall stress in the tendon, alterations in sliding behavior could potentially play a role in the development of Achilles tendinopathy. The aims of this study were to investigate the difference in intratendinous sliding within the Achilles tendon during isometric contractions between asymptomatic controls and patients with Achilles tendinopathy and the effect of changing the horizontal foot position on intratendinous sliding in both groups. METHODS: Twenty-nine participants (13 Achilles tendinopathy and 16 controls) performed isometric plantarflexion contractions at 60% of their maximal voluntary contraction (MVC), in toes-neutral, and at 30% MVC in toes-neutral, toes-in, and toes-out positions during which ultrasound images were recorded. Intratendinous sliding was estimated as the superficial-to-middle and middle-to-deep relative displacement. RESULTS: Patients with Achilles tendinopathy present lower intratendinous sliding than asymptomatic controls. Regarding the horizontal foot position in both groups, the toes-out foot position resulted in increased sliding compared with both toes-neutral and toes-out foot position. CONCLUSION: We provided evidence that patients with Achilles tendinopathy show lower intratendinous sliding than asymptomatic controls. Since intratendinous sliding is a physiological feature of the Achilles tendon, the external foot position holds promise to increase sliding in patients with Achilles tendinopathy and promote healthy tendon behavior. Future research should investigate if implementing this external foot position in rehabilitation programs stimulates sliding within the Achilles tendon and improves clinical outcome.

Current research trends on the effect of diabetes mellitus on rotator cuff tendon healing/tendinopathy.

Rotator cuff tendon tears are a leading cause of shoulder pain. They are challenging to treat, and tendon-bone healing has a high failure rate despite successful surgery. Tendons connect the muscles and bones, which make them important for the body's overall mobility and stability. Metabolic diseases, including diabetes or high blood pressure, can affect the healing process after repair of a damaged tendon. With a global incidence of 9.3%, diabetes is considered as a significant risk factor for rotator cuff tendon healing because it causes structural, inflammatory, and vascular changes in the tendon. However, the mechanisms of how diabetes affects tendon healing remain unknown. Several factors have been suggested, including glycation product accumulation, adipokine dysregulation, increased levels of reactive oxygen species, apoptosis, inflammatory cytokines, imbalanced matrix-metalloproteinase-to-tissue-inhibitor ratio, and impaired angiogenesis and differentiation of the tendon sheath. Despite the effects of diabetes on tendon function and healing, few treatments are available to improve recovery in these patients. This review summarizes the current literature on the pathophysiological changes of the tendon in diabetes and hyperlipidemia. Preclinical and clinical evidence regarding the association between diabetes and tendon healing is presented. Moreover, current approaches to improve tendon healing in patients with diabetes are reviewed.

Sensitivity to change and responsiveness of provocative load tests among athletes with patellar tendinopathy.

BACKGROUND: Pain provocation tests are recommended for assessing pain severity and as an outcome measure for individuals with patellar tendinopathy. OBJECTIVE: To evaluate floor and ceiling effects, sensitivity to change, and responsiveness cut-offs of two provocative load tests among athletes with patellar tendinopathy. METHODS: Athletes (N = 41) performed six repetitions for the single leg decline squat (SLDS) and resisted knee extension (KE) at baseline and 12 weeks. Participants rated their pain during each test on a visual analog scale (VAS). Sensitivity to change was assessed by calculating effect size (ES) and the standardized response mean (SRM). The responsiveness cut-offs were assessed using a combination of anchor and distribution- based methods to determine the minimal clinically important difference (MCID) for each test. RESULTS: A floor or ceiling effect was observed in only a small number of participants for both tests except for KE, for which approximately one third of participants had a floor effect at week 12. There was higher sensitivity to change for SLDS (ES: 1.93/SRM: 1.43) compared with KE (ES:0.96/SRM: 1.09). The MCID corresponded to a decrease of 1.6 points for SLDS and 1.0 for KE, while the distribution-based method estimated 1.2 points for SLDS and 1.1 for KE. CONCLUSION: This study found moderate to high sensitivity to change and established MCID values for the SLDS and KE test in athletes with patellar tendinopathy before and after rehabilitation. Both tests may be useful as pain on loading outcomes as athletes progress with their rehabilitation, but the KE test results in higher floor effects and has lower sensitivity to change.

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.

Whipping or tearing? The biomechanics of Achilles tendinopathy in rearfoot strike runners.

BACKGROUND: Two biomechanical mechanisms for the development of Achilles tendinopathy in runners have been proposed: A whipping mechanism characterized by prolonged and excessive rearfoot eversion, and a tearing mechanism characterized by high eccentric plantar flexor forces. The purpose of this pilot study was to determine if runners with and without a history of Achilles tendinopathy exhibited gait biomechanics consistent with either of these mechanisms. METHODS: Seven male runners with previous or current Achilles tendinopathy and seven healthy male control runners were evaluated by three-dimensional gait analysis. Peak rearfoot eversion angle, rearfoot eversion excursion, duration of rearfoot eversion, and peak rearfoot inversion angle were compared between groups to evaluate the whipping mechanism of injury. Peak dorsiflexion angle, peak dorsiflexion velocity, and peak ankle power absorption were compared between groups to evaluate the tearing mechanism. Additionally, rearfoot eversion angle and sagittal plane ankle power waveforms were compared between groups using statistical parametric mapping. FINDINGS: There were no differences in any rearfoot eversion, inversion, or dorsiflexion variables or waveforms during running in the Achilles tendinopathy group compared to controls. INTERPRETATION: Rearfoot strike runners with Achilles tendinopathy do not exhibit running biomechanics consistent with either the whipping or tearing mechanisms of injury.

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.

Medial arch instability/internal foot overload association with non-insertional Achilles tendinopathy and the 'Zone of Conflict Theory'.

BACKGROUND: Non insertional Achilles tendinopathy [AT] is a degenerative condition that is prevalent in runners. 30% have no preceding history and many runners do not develop AT. Overuse, pronation, and compromised blood supply are hypothesised as causal. The exact precipitant is still unknown. The link between medial arch instability and AT has not been made. The purpose of this study was to investigate the association between spring ligament (SL) laxity and first ray (FRI) instability, and the presence of (AT). METHODS: Ethical approval was obtained. Patients were identified from hospital databases for unilateral AT, allowing the opposite unaffected foot to be used as an internal control. SL laxity was measured using the lateral translation score and FRI was measured using a modified digital Klauemeter. Ultrasound was used to assess the tendoachilles [TA] in affected vs unaffected legs. RESULTS: 17 patients were recruited with a mean age of 55.6 and mean body mass index (BMI) of 33.3. The average symptom duration was 3.62 years. There were 12 left feet and 5 right feet. There was no statistical difference in dorsiflexion angles for the TA or the gastrocnemius. All Beighton scores < 5. Lateral translation scores, FRI scores and TA thickness was significantly greater in AT feet [p < 0.05]. More affected feet had Tibialis posterior tendon pain (TP) [p < 0.05]. CONCLUSIONS: Feet with AT exhibit higher lateral translation scores and greater FRI compared to healthy feet, and combined with previous literature evidence, suggests alteration of the subtalar axis alters force moments that may lead to an intrinsic overload of the TA, when the foot enters a "zone of conflict". Medial arch instability, in particular SL laxity and FRI, may contribute to the development of non-insertional AT and treatment of this with early arch support may prevent progressive degeneration.

The Iliopsoas: Anatomy, Clinical Evaluation, and Its Role in Hip Pain in the Athlete: A Scoping Review.

Disability due to iliopsoas (IP) pain and dysfunction is underdiagnosed in the athletic population. The IP unit consists of the psoas major and iliacus muscles converging to form the IP tendon and is responsible primarily for hip flexion strength but has a number of secondary contributions such as femoral movement, trunk rotation, core stabilization, and dynamic anterior stability to the hip joint. As the IP passes in front of the anterior acetabulum and labrum, the diagnosis of IP pain may be confused with labral tearing seen on magnetic resonance imaging. This is in addition to the low sensitivity of magnetic resonance imaging to detect IP tendinitis and bursitis. Resisted seated hip flexion as well as direct palpation of the IP tendon and muscle belly are useful to assess function and help determine whether the IP may be the source of pain, which is common in athletes. Both biomechanical and clinical investigations have demonstrated the role of IP as an anterior hip stabilizer. Patients with signs of hip microinstability, developmental dysplasia of the hip, and increased femoral anteversion are at risk of IP pain and poor outcomes after IP lengthening, highlighting the importance of the IP in providing dynamic anterior hip stability.

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.

Effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy: A systematic review and meta-analysis.

BACKGROUND: Lateral elbow tendinopathy is a common musculoskeletal disorder. Effectiveness of non-invasive therapies for this health condition are unclear. OBJECTIVE: To investigate the effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy. METHODS: Searches were conducted on MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Library, SPORTDiscus and PsycINFO without language or date restrictions up to May 3rd, 2023. Randomized trials investigating the effectiveness of any non-invasive therapy compared with control or other invasive interventions were included. Two independent reviewers screened eligible trials, extracted data, and assessed the risk of bias of included trials and certainty of the evidence. RESULTS: Twenty-two different therapies investigated in 47 randomized trials were included in the quantitative analysis. Moderate certainty evidence showed that betamethasone valerate medicated plaster may reduce disability (mean difference -6.7; 95% CI -11.4, -2.0) in the short-term when compared with placebo. Low certainty evidence showed that acupuncture may reduce disability (MD -9.1; 95% CI -11.7, -6.4) in the short-term when compared with sham. Moderate to very low certainty of evidence also showed small to no effect of non-invasive therapies on pain intensity, maximum grip strength, and disability outcomes in the short-term compared to control or invasive interventions. Most therapies had only very low certainty of evidence to support their use. CONCLUSIONS: Decision-making processes for lateral elbow tendinopathy should be carefully evaluated, taking into consideration that most investigated interventions have very low certainty of evidence. There is an urgent call for larger high-quality trials.

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.

Biomechanical analysis of two runners who developed leg injuries during a six-week transition to maximal running shoes: A case series.

Achilles tendinopathy (AT) and medial tibial stress syndrome (MTSS) are two of the most common running-related injuries. In a previous study investigating running biomechanics before and after a six-week transition to maximal running shoes, two runners dropped out of this study due to Achilles pain and shin pain, respectively. The purpose of this case series was to investigate running biomechanics in those two runners, identifying potential causes for injury in relation to maximal shoe use. Running biomechanics were collected in a laboratory setting for these two runners wearing both a maximal running shoe and traditional running shoe before the six-week transition using an 8-camera motion capture system and two embedded force plates. Both runners displayed prolonged eversion in the maximal shoe, which has been previously cited as a potential risk factor for developing Achilles tendinopathy and medial tibial stress syndrome. Relatively high loading rates and impact forces were also observed in the runner with shin pain in the maximal shoe, which may have contributed to their pain. More prospective research on injury rates in individuals running in maximal shoes is needed.

Patellar mobility and lower limb kinematics during functional activities in individuals with and without patellar tendinopathy.

STUDY DESIGN: Case-control. OBJECTIVE: To examine whether patients with patellar tendinopathy (PT) display greater patellar mobility and different lower body kinematics than patients without PT. BACKGROUND: PT is a common overuse condition of the patellar tendon that can cause pain and impair function. Subjects with overuse knee problems display different hip and knee functional mechanics, specifically valgus collapse. Patellar hypermobility has not been specifically studied as a possible risk factor for PT. METHODS: 11 patients with PT and 11 controls without PT, age 18 to 40, were studied. Using a patellofemoral arthrometer (PFA), maximal lateral and medial patellar displacement was measured. 3-D motion analysis was performed to determine lower extremity joint motions during single-leg step down and drop vertical jump tests. RESULTS: Patients with PT had significantly increased lateral patellar mobility compared to controls (12.21 ± 3.33 mm vs. 9.19 ± 1.92 mm, P = .017). PT patients showed significantly greater peak hip adduction with both drop vertical jump (2.7° ± 6.3° vs. -5.6° ± 4.2°; P = .003) and step down (17.0° ± 3.8° vs. 12.5° ± 4.4°, P = .024). PT patients demonstrated increased peak ankle external rotation with drop vertical jump (-21.1° ± 5.9° vs. -14.8° ± 5.5°, P = .023) and step down (-15.6° ± 5.5° vs. -9.0° ± 6.0°, P = .017). CONCLUSIONS: Patients with PT exhibit increased lateral patellar mobility, hip adduction, and ankle external rotation. The effects of increased patellar mobility deserve further study in the development, management, and prevention of PT.

Left/right discrimination is not impaired in people with unilateral chronic Achilles tendinopathy.

OBJECTIVE: Impaired left/right discrimination of an affected body part has been observed in various chronic pain states. This study aimed to examine whether people with unilateral chronic Achilles tendinopathy also present with impaired left/right discrimination. DESIGN: Cross-sectional study. METHODS: Nineteen runners with persistent unilateral Achilles tendinopathy and 19 matched healthy volunteers performed a left/right discrimination task in a laboratory setting. Participants were shown pictures of feet, hands and Shepard-Metzler figures and were asked to decide as accurately and as fast as possible whether the body part belonged to the left or right side of the body, or whether the Shepard-Metzler figures were rotated or mirrored. Performance was evaluated in terms of accuracy and response time. Data were analysed with mixed-design ANOVAs. RESULTS: The decline in left/right discrimination ability at group level, if present, between affected and unaffected side, or compared to healthy participants, was negligible for both accuracy (<1.5%) and response time (<50 ms). There was no significant effect of side (affected versus unaffected side) or group (people with Achilles tendinopathy versus healthy) for accuracy (p > 0.36) or response time (p > 0.69). CONCLUSIONS: People with Achilles tendinopathy recognised the affected side as accurately and as fast as the non-affected side and their performance was comparable to healthy participants. The absence of impaired left/right discrimination despite the chronicity of the condition may be attributable to the typical intermittent nature of Achilles tendinopathy pain and/or maintained sports activity.

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.

Evidence of Bilateral Localized, but Not Widespread, Pressure Pain Hypersensitivity in Patients With Upper Extremity Tendinopathy/Overuse Injury: A Systematic Review and Meta-Analysis.

OBJECTIVE: The presence of altered nociceptive pain processing in patients with upper extremity tendinopathy/overuse injury is conflicting. Our aim was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas between patients with upper extremity tendinopathy/overuse injury and controls. METHODS: Five databases were searched from inception to October 15, 2020. The authors selected case-control studies comparing PPTs between individuals with upper extremity tendinopathy/overuse injury and pain-free controls. Data were extracted for population, diagnosis, sample size, outcome, and type of algometer. Results were extracted by 3 reviewers. The methodological quality/risk of bias (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development and Evaluation approach) were assessed. Meta-analyses of symptomatic, segment-related, and distant pain-free areas were compared. RESULTS: The search identified 807 publications with 19 studies (6 shoulder, 13 elbow) eligible for inclusion. The methodological quality ranged from fair (48%) to good (37%). Patients exhibited lower bilateral PPTs than controls at the symptomatic area (affected side: MD = -175.89 kPa [95% CI = -220.30 to -131.48 kPa]; nonaffected side: MD = -104.50 kPa [95% CI = -142.72 to -66.28 kPa]) and the segment-related area (affected side: MD = -150.63 kPa [95% CI = -212.05 to -89.21 kPa]; nonaffected side: MD = -170.34 kPa [95% CI = - 248.43 to -92.25]) than controls. No significant differences in PPTs over distant pain-free areas were observed. CONCLUSION: Low to moderate quality evidence suggests bilateral hypersensitivity to pressure pain at the symptomatic and contralateral/mirror areas in patients with upper extremity tendinopathies/overuse injury. Moderate quality of evidence supports bilateral pressure pain sensitivity in the segment-related area (neck) in lateral epicondylalgia, but not in subacromial impingement syndrome. No evidence of widespread pressure pain hyperalgesia was reported. IMPACT: Early identification of people with altered pain modulation could guide clinicians in treatment strategies. This review shows that there is a complex interplay between peripheral and central pain mechanisms in upper extremity tendinopathies/overuse injuries and that there likely are different subgroups of patients with upper extremity conditions.