ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy.

BACKGROUND: Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated. OBJECTIVE: To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains. DESIGN: Systematic review. DATA SOURCES: Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series. RESULTS: 9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain. CONCLUSION: 233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures. PROSPERO REGISTRATION: CRD42020156763.

Running a Marathon-Its Influence on Achilles Tendon Structure.

CONTEXT: Several studies have been conducted to better understand the effect of load on the Achilles tendon structure. However, the effect of a high cumulative load consisting of repetitive cyclic movements, such as those that occur during the running of a marathon, on Achilles tendon structure is not yet clear. Clinicians, coaches, and athletes will benefit from knowledge about the effects of a marathon on the structure of the Achilles tendon. OBJECTIVE: To investigate the short-term response of the Achilles tendon structure to running a marathon. DESIGN: Case series (prospective). SETTING: Sports medicine centers. PATIENTS OR OTHER PARTICIPANTS: Ten male nonelite runners who ran in a marathon. MAIN OUTCOMES MEASURE(S): Tendon structure was assessed before and 2 and 7 days after a marathon using ultrasound tissue characterization (UTC), an imaging tool that quantifies tendon organization in 4 echo types (I-IV). Echo type I represents the most stable echo pattern, and echo type IV, the least stable. RESULTS: At 7 days postmarathon, both the insertional and midportion structure changed significantly. At both sites, the percentage of echo type II increased (insertion P < .01; midportion P = .02) and the percentages of echo types III and IV decreased (type III: insertion P = .01; midportion P = .02; type IV: insertion P = .01; midportion P < .01). Additionally, at the insertion, the percentage of echo type I decreased (P < .01). CONCLUSIONS: We observed the effects of running a marathon on the Achilles tendon structure 7 days after the event. Running the marathon combined with the activity performed shortly thereafter might have caused the changes in tendon structure. This result emphasizes the importance of sufficient recovery time after running a marathon to prevent overuse injuries.

Inter- and intra-rater reliability of ultrasound tissue characterization (UTC) in patellar tendons.

PURPOSE: Ultrasound tissue characterization (UTC) is used in research and clinical practice to quantify tendon structure of the patellar tendon. This is the first study to investigate the inter- and intra-rater reliability for UTC of the patellar tendon on a large scale. METHOD: Fifty participants (25 patellar tendinopathy, 25 asymptomatic) were recruited. The affected patellar tendons in symptomatic and right tendons in asymptomatic participants were scanned with UTC twice by one researcher and once by another. The same was done for contour marking (needed to analyze a UTC scan) of the tendon. Intraclass correlation coefficient (ICC (2,1)) for echo-types I, II, III, IV, aligned fibrillar structure (echo-types I + II), and disorganized structure (echo-types III + IV) were calculated. This was done for UTC scans as well as solely marking contours. RESULTS: Inter-rater reliability showed fair to good ICC values for echo-types I (0.65) and II (0.46) and excellent ICC values for echo-type III (0.81), echo-type IV (0.83), aligned fibrillar structure (0.82), and disorganized structure (0.82). Intra-rater reliability showed excellent ICC values for echo-types I (0.76), III (0.88), IV (0.85), aligned fibrillar structure (0.88), and disorganized fibrillar structure (0.88) and a fair to good value for echo-type II (0.61). Contour marking showed excellent ICC values for all echo-types. CONCLUSION: This study showed that UTC scans for patellar tendons have overall good intra-rater and inter-rater reliability. To optimize reliability of UTC scans of the patellar tendon, using the same rater and using aligned fibrillar structure (echo-types I + II combined) and disorganized structure (echo-types III + IV combined) as outcome measures can be considered.

Clinical Improvements Are Not Explained by Changes in Tendon Structure on Ultrasound Tissue Characterization After an Exercise Program for Patellar Tendinopathy.

OBJECTIVES: The aim of this study was to investigate the effects of a 4-wk in-season exercise program of isometric or isotonic exercises on tendon structure and dimensions as quantified by ultrasound tissue characterization (UTC). DESIGN: This was a randomized clinical trial. Volleyball and basketball players (16-31 yrs, n = 29) with clinically diagnosed patellar tendinopathy were randomized to a 4-wk isometric or isotonic exercise program. The programs were designed to decrease patellar tendon pain. A baseline and 4-wk UTC scan was used to evaluate change in tendon structure. RESULTS: No significant change in tendon structure or dimensions on UTC was detected after the exercise program despite patellar tendinopathy symptoms improving. The percentage and mean cross-sectional area of aligned fibrillar structure (echo types I + II) (Z = -0.414, P = 0.679) as well as disorganized structure (echo types III + IV) (Z = -0.370, P = 0.711) did not change over the 4-wk exercise program. Change in tendon structure and dimensions on UTC did not differ significantly between the groups. CONCLUSION: Structural properties and dimensions of the patellar tendon on UTC did not change after a 4-wk isometric or isotonic exercise program for athletes with patellar tendinopathy in-season, despite an improvement in symptoms. It seems that structural improvements are not required for a positive clinical outcome.

Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial.

OBJECTIVE: This study aimed to compare the immediate analgesic effects of 2 resistance programs in in-season athletes with patellar tendinopathy (PT). Resistance training is noninvasive, a principle stimulus for corticospinal and neuromuscular adaptation, and may be analgesic. DESIGN: Within-season randomized clinical trial. Data analysis was conducted blinded to group. SETTING: Subelite volleyball and basketball competitions. PARTICIPANTS: Twenty jumping athletes aged more than 16 years, participating in games/trainings 3 times per week with clinically diagnosed PT. INTERVENTIONS: Two quadriceps resistance protocols were compared; (1) isometric leg extension holds at 60 degrees knee flexion (80% of their maximal voluntary isometric contraction) or (2) isotonic leg extension (at 80% of their 8 repetition maximum) 4 times per week for 4 weeks. Time under load and rest between sets was matched between groups. MAIN OUTCOME MEASURES: (1) Pain (0-10 numerical rating score) during single leg decline squat (SLDS), measured preintervention and postintervention sessions. (2) VISA-P, a questionnaire about tendon pain and function, completed at baseline and after 4 weeks. RESULTS: Twenty athletes with PT (18 men, mean 22.5 ± 4.7 years) participated (isotonic n = 10, isometric n = 10). Baseline median SLDS pain was 5/10 for both groups (isotonic range 1-8, isometric range 2-8). Isometric contractions produced significantly greater immediate analgesia (P < 0.002). Week one analgesic response positively correlated with improvements in VISA-P at 4 weeks (r = 0.64). CONCLUSIONS: Both protocols appear efficacious for in-season athletes to reduce pain, however, isometric contractions demonstrated significantly greater immediate analgesia throughout the 4-week trial. Greater analgesia may increase the ability to load or perform.

Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial.

OBJECTIVES: Many athletes with patellar tendinopathy participate in sports with symptoms during or after activities. Current treatments do not decrease pain in-season; eccentric exercises in-season result in an increase in pain. This study examined if isometric and isotonic exercises relieved pain in competing athletes with patellar tendinopathy. DESIGN: Randomised clinical trial. METHODS: Jumping athletes with patellar tendinopathy playing at least three times per week participated in this study. Athletes were randomised into an isometric or isotonic exercise group. The exercise programs consisted of four isometric or isotonic exercise sessions per week for four weeks. Pain during a single leg decline squat (SLDS) on a Numeric Rating Scale (NRS; 0-10) was used as the main outcome measure; measurements were completed at baseline and at 4-week follow-up. RESULTS: Twenty-nine athletes were included in this study. Median pain scores improved significantly over the 4-week intervention period in both the isometric group (Z=-2.527, p=0.012, r=-0.63) and isotonic group (Z=-2.952, p=0.003, r=-0.63). There was no significant difference in NRS pain score change (U=29.0, p=0.208, r=0.29) between the isometric group (median (IQR), 2.5 (1-4.5)) and isotonic group (median (IQR), 3.0 (2-6)). CONCLUSIONS: This is the first study to show a decrease in patellar tendon pain without a modification of training and competition load and the first study to investigate isometric exercises in a clinical setting. Both isometric and isotonic exercise programs are easy-to-use exercises that can reduce pain from patellar tendinopathy for athletes in-season.

Cross-cultural adaptation and reliability and validity of the Dutch Patient-Rated Tennis Elbow Evaluation (PRTEE-D).

BACKGROUND: Lateral Epicondylalgia (LE) is a common injury for which no reliable and valid measure exists to determine severity in the Dutch language. The Patient-Rated Tennis Elbow Evaluation (PRTEE) is the first questionnaire specifically designed for LE but in English. The aim of this study was to translate into Dutch and cross-culturally adapt the PRTEE and determine reliability and validity of the PRTEE-D (Dutch version). METHODS: The PRTEE was cross-culturally adapted according to international guidelines. Participants (n = 122) were asked to fill out the PRTEE-D twice with a one week interval to assess test-retest reliability. Internal consistency of the PRTEE-D was determined by calculating Crohnbach's alphas for the questionnaire and subscales. Intraclass Correlation Coefficients (ICC) were calculated for the overall PRTEE-D score, pain and function subscale and individual questions to determine test-retest reliability. Additionally, the Disabilities for the Arm, Shoulder and Hand questionnaire (DASH) and Visual Analogue Scale (VAS) pain scores were obtained from 30 patients to assess construct validity; Spearman's correlation coefficients were calculated between the PRTEE-D (subscales) and DASH and VAS-pain scores. RESULTS: The PRTEE was successfully cross-culturally adapted into Dutch (PRTEE-D). Crohnbach's alpha for the first assessment of the PRTEE-D was 0.98; Crohnbach's alpha was 0.93 for the pain subscale and 0.97 for the function subscale. ICC for the PRTEE-D was 0.98; subscales also showed excellent ICC values (pain scale 0.97 and function scale 0.97). A significant moderate correlation exists between PRTEE-D and DASH (0.65) and PRTEE-D and VAS pain (0.68). CONCLUSION: The PRTEE was successfully cross-culturally adapted and this study showed that the PRTEE-D is reliable and valid to obtain an indication of severity of LE. An easy-to-use instrument for practitioners is now available and this facilitates comparing Dutch and international research data.

Injection treatments for patellar tendinopathy.

OBJECTIVE: Injection treatments are increasingly used as treatment for patellar tendinopathy. The aim of this systematic review is to describe the different injection treatments, their rationales and the effectiveness of treating patellar tendinopathy. METHODS: A computerised search of the Medline, Embase, CINAHL and Web of Knowledge databases was conducted on 1 May 2010 to identify studies on injection treatments for patellar tendinopathy. RESULTS: 11 articles on seven different injection treatments (dry needling, autologous blood, high-volume, platelet-rich plasma, sclerosis, steroids and aprotinin injections) were found: 4 randomised controlled trials (RCTs), 1 non-RCT, 4 prospective cohort studies and 2 retrospective cohort studies. All studies reported positive results. The Delphi scores of the four RCTs ranged from 5 to 8 out of 9. Different and sometimes contradictory rationales were used for the injection treatments. CONCLUSION: All seven different injection treatments seem promising for treating patellar tendinopathy. Unlike the other injection treatments, steroid treatment often shows a relapse of symptoms in the long term. Results should be interpreted with caution as the number of studies is low, few high-quality studies have been conducted and the studies are hard to compare due to different methodology. More high-quality studies using the same cross-cultural reliable and valid outcome measure are needed, as well as further research into the pathophysiology. Finally, some implications are provided for clinicians who want to use injection treatments as a part of their treatment for patellar tendinopathy, distinguishing between reactive and degenerative phase of patellar tendinopathy.

Risk factors for patellar tendinopathy: a systematic review of the literature.

Patellar tendinopathy (PT) is an injury with a high prevalence in sports. Knowledge of risk factors is essential for developing preventive measures and rehabilitation programmes. However, risk factors associated with PT have not yet been systematically studied. This review was undertaken to identify risk factors associated with PT. The literature was systematically searched to identify articles that investigated risk factors for PT. There was no strong or moderate evidence that any investigated risk factor was associated with PT. For nine risk factors there was some evidence: weight, body mass index, waist-to-hip ratio, leg-length difference, arch height of the foot, quadriceps flexibility, hamstring flexibility, quadriceps strength and vertical jump performance. Based on the present evidence, reducing body weight, increasing upper-leg flexibility and quadriceps strength and the use of orthotics may be beneficial treatment options. However, it should be stressed that the evidence for the nine identified risk factors was only limited. Therefore, there is a clear need for high-quality studies in order to identify the exact risk factors associated with PT.