The effects of exercise and intra-articular injections versus exercise alone for the treatment of knee osteoarthritis: A scoping review of the evidence.

Objective: Current treatment for knee Osteoarthritis (OA) includes exercise and intra-articular injections with corticosteroid (CS), hyaluronic acid (HA), etc., which address OA-related pain and functional limitation. While these interventions can be given together, little is known about the efficacy of a multi-modal approach. The purpose of this scoping review is to examine studies that compare combining exercise and intra-articular knee injections to exercise alone for the management of knee OA. Methods: A search was performed using PubMed, CINAHL, and Clinicaltrials.gov with MeSH terms "knee osteoarthritis" AND "exercise" AND "injections". Abstracts were screened to meet inclusion criteria of both intervention groups including exercise and one group receiving an injection for treatment of knee OA. Full text articles were screened to meet inclusion criteria and rated using the Pedro Scale. Results: 11 studies that met inclusion criteria. The included studies utilized CS, hyaluronic acid (HA), and Bone Marrow Concentrate (BMC), botulinum toxin A, or a combination of dextrose and lidocaine injections. Most studies included supervised exercise interventions with all studies including strengthening of the quadriceps. CS and exercise compared to exercise alone showed similar improvements in pain. The HA injection studies yielded mixed results with two studies finding HA and exercise was not superior than exercise alone while two other studies found that HA and exercise were superior. Conclusion: There was a paucity of literature investigating multimodal approaches. Most of the included studies did not find superior effects of adding a knee injection to exercise compared to exercise alone for knee OA.

Determining the feasibility of exercise therapy and activity modification for treating adolescents with heel pain: a study protocol.

Calcaneal apophysitis and Achilles tendinopathy are common overuse injuries characterised by insidious posterior heel pain with activity. Calcaneal apophysitis is commonly diagnosed in adolescents, although Achilles tendinopathy is understudied in the adolescent population and is therefore rarely considered until adulthood. Exercise therapy and activity modification have the highest level of evidence for treating Achilles tendinopathy, while calcaneal apophysitis is treated with anecdotal and passive treatment or complete rest. It remains unknown whether exercise therapy is effective for adolescents with heel pain related to either diagnosis. This is a pilot and feasibility study. Thirty participants between the ages of 7 years and 17 years with posterior heel pain will be recruited from the local community and club sports team and local physicians, school nurses, and athletic trainers through flyers and social media. Participants will be asked to complete evaluations and treatment sessions every 4 weeks with three virtual visits every 2 weeks in between for 12 weeks. All participants will receive standardised treatment consisting of daily Achilles tendon loading exercises and education on pain-guided activity modification. Feasibility outcomes will include recruitment, enrolment, retention and compliance. Clinical outcomes will include the measures of symptom severity, quality of life, tendon morphology and lower extremity function. This protocol will provide preliminary data to inform a larger clinical trial based on the feasibility of the proposed intervention and methodology. Additionally, the results will provide preliminary evidence on whether Achilles tendon injury occurs in the adolescent population. The trial is registered with clinicaltrials.gov (ID:1652996).

Clinical Assessment and Thickness Changes of the Oblique and Multifidus Muscles Using a Novel Screening Tool and Exercise Program: A Randomized Controlled Trial.

CONTEXT: Training and assessment of the abdominal and trunk muscles are widely used in the clinical setting. However, it is unknown what types of exercises are most effective in activation of both the global and local stabilizers in these regions. OBJECTIVE: The purpose of this study was to establish the reliability of a novel clinical screening tool (sling screen) to assess the muscles of the abdomen and trunk. The second aim was to use the clinical screening tool and musculoskeletal ultrasound to compare the effects of a rotary-based exercise program that targets both the global and local muscles to the effects of a traditional exercise program on the activation of the abdominal and trunk muscles. DESIGN: Double-blind, randomized controlled trial. SETTING: Sports medicine facility. PARTICIPANTS AND INTERVENTIONS: Thirty-one healthy participants were randomly allocated to receive a single-session rotary-based or traditional "core" exercise program. MAIN OUTCOME MEASURES: The participants were assessed at the baseline and immediately postintervention. The primary outcome measures were muscle thickness examined by musculoskeletal ultrasound and clinical examination of muscle activation using a screening tool. The data were collected by blind assessors. Reliability and validity of a clinical screening tool (sling screen) were also assessed. RESULTS: The analysis of the covariance tests showed a significant increase in oblique thickness for the rotary exercise group. All participants displayed a significant increase in multifidus thickness. The Wilcoxon signed-rank tests revealed a significant increase in clinical assessment scores in the rotary exercise group but not the traditional exercise group. Reliability of the sling screen ranged from moderate to good. CONCLUSION: This clinical trial provides evidence that a rotary-based exercise program may be more effective in producing increases in oblique muscle thickness than traditional "core" exercises in young, healthy adults. The sling screen tool was able to identify these muscle thickness changes. Future studies should investigate how these results correlate to injury risk, other populations, and also how to implement the sling screen into clinical practice.

FREQUENCY OF PATHOLOGY ON DIAGNOSTIC ULTRASOUND AND RELATIONSHIP TO PATIENT DEMOGRAPHICS IN INDIVIDUALS WITH INSERTIONAL ACHILLES TENDINOPATHY.

BACKGROUND: Insertional tendinopathy is likely caused by different pathologies. This variation could account for the recalcitrant nature of this condition to treatment. Ultrasound imaging may assist in identifying underlying pathology to inform patient management. HYPOTHESIS/PURPOSE: The primary purpose of this study was to quantify the presence of underlying pathology using ultrasound in individuals with a clinical diagnosis of insertional Achilles tendinopathy. Secondarily, we sought to examine the relationship of abnormal ultrasound findings to age and body mass index (BMI). STUDY DESIGN: Cross-sectional study. METHODS: Fifty-six individuals with insertional tendinopathy were included in this study. B-mode ultrasound imaging was used to descriptively and quantitatively describe tendon pathology. RESULTS: A greater proportion of bone defect (p<0.001), intratendinous calcifications (p = 0.01) and midportion tendinosis (p<0.001) were observed on the injured side compared to the uninjured side. Higher BMI was associated with presence of bone deformity, intratendinous calcifications and distal tendinosis (p = 0.001-0.04); adding age did not significantly improve the regression model. CONCLUSION: Patients with insertional tendinopathy present with multiple underlying pathologies. This may account for variable response to treatment. It may be helpful to include imaging to better identify underlying pathology when trying to determine an appropriate treatment strategy. LEVEL OF EVIDENCE: Level 3.

Imaging of Tendinopathy: A Physician's Perspective.

Imaging plays an important role in the clinical evaluation of patients with musculoskeletal-related pain, but its utility for the management of tendinopathy is debatable. Findings on ultrasound and magnetic resonance imaging may not correlate with clinical symptoms, and it is not uncommon to find anatomical changes associated with tendinopathy in tendons of asymptomatic individuals. Likewise, patients with clinical symptoms of tendinopathy can present with normal imaging evaluation. The use of diagnostic and interventional ultrasound has significantly increased over the past decade in a bid for better treatments of tendinopathy. Despite the limitations of traditional imaging in the diagnosis and management of tendinopathy, interventional procedures that utilize ultrasound hold promise. J Orthop Sports Phys Ther 2015;45(11):826-828. doi:10.2519/jospt.2015.0113.