Background:
Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse.
Purpose:
To determine whether ...eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT.
Study Design:
Randomized controlled trial; Level of evidence, 1.
Methods:
A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment–Achilles VISA-A). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale VAS), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up.
Results:
VISA-A scores improved in all groups at all time points (P < .05), with greater improvement in the HVI group (mean ± SEM, 6 weeks = 27 ± 3 points; 12 weeks = 29 ± 4 points) versus PRP (6 weeks = 14 ± 4; 12 weeks = 15 ± 3) and placebo (6 weeks = 10 ± 3; 12 weeks = 11 ± 3) at 6 and 12 weeks (P < .01) and in the HVI (22 ± 5) and PRP (20 ± 5) groups versus placebo (9 ± 3) at 24 weeks (P < .01). VAS scores improved in all groups at all time points (P < .05), with greater decrease in HVI (6 weeks = 49 ± 4 mm; 12 weeks = 45 ± 6 mm; 24 weeks = 34 ± 6 mm) and PRP (6 weeks = 37 ± 7 mm; 12 weeks = 41 ± 7 mm; 24 weeks = 37 ± 6 mm) versus placebo (6 weeks = 23 ± 6 mm; 12 weeks = 30 ± 5 mm; 24 weeks = 18 ± 6 mm) at all time points (P < .05) and in HVI versus PRP at 6 weeks (P < .05). Tendon thickness showed a significant decrease only in HVI and PRP groups during the intervention, and this was greater in the HVI versus PRP and placebo groups at 6 and 12 weeks (P < .05) and in the HVI and PRP groups versus the placebo group at 24 weeks (P < .05). Muscle function improved in the entire cohort with no difference between the groups.
Conclusion:
Treatment with HVI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVI may be more effective in improving outcomes of chronic AT than PRP in the short term.
Registration:
NCT02417987 (ClinicalTrials.gov identifier).
Background
High volume injection (HVI) shows promising results in the treatment of chronic midportion Achilles tendinopathy (AT). HVI consists of a large volume of saline with a small amount of ...corticosteroid and local anesthetic.
Objective
To determine the effect of corticosteroid in HVI in AT.
Methods
A total of 28 men (18‐59 years) with chronic (>3 months) AT were included in a double‐blinded RCT and followed for 24 weeks. All performed eccentric training and randomized to either (a) HVI injection with corticosteroid or (b) HVI injection without corticosteroid. Outcomes included self‐reported function (VISA‐A score) and pain (VAS score) and ultrasound imaging (tendon thickness, Doppler flow).
Results
VISA‐A and VAS score improved in both groups at all time‐points (P < 0.05). VISA‐A improvement was significantly greater in HVI with corticosteroid (mean ± SEM; 6‐weeks = 31 ± 3 points; 12‐weeks = 32 ± 5 points) vs HVI without corticosteroid (6 weeks = 14 ± 3; 12‐weeks = 17 ± 3) at 6 and 12 weeks (P < 0.05), but not at 24 weeks. Decrease in VAS scores was significantly greater in HVI with corticosteroid (6 weeks = 55 ± 3 mm; 12 weeks = 53 ± 5 mm) vs HVI without corticosteroid (6 weeks = 16 ± 3 mm; 12 weeks = 25 ± 5 mm) at 6 and 12 weeks (P < 0.05) but not at 24 weeks. Tendon thickness decreased significantly in both groups at all time‐points (P < 0.05), but more in the HVI with corticosteroid vs HVI without corticosteroid at 6 and 12 weeks (P < 0.05) but not at 24 weeks.
Conclusion
High volume injection with or without corticosteroid in combination with eccentric training seems effective in AT. HVI with corticosteroid showed a better short‐term improvement than HVI without corticosteroid indicating a short‐term effect of corticosteroid in HVI treatment of AT.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used as pain killers during periods of unloading caused by traumatic occurrences or diseases. However, it is unknown how tendon protein turnover and ...mechanical properties respond to unloading and subsequent reloading in elderly humans, and whether NSAID treatment would affect the tendon adaptations during such periods. Thus we studied human patellar tendon protein synthesis and mechanical properties during immobilization and subsequent rehabilitating resistance training and the influence of NSAIDs upon these parameters. Nineteen men (range 60-80 yr) were randomly assigned to NSAIDs (ibuprofen 1,200 mg/day; Ibu) or placebo (Plc). One lower limb was immobilized in a cast for 2 wk and retrained for 6 wk. Tendon collagen protein synthesis, mechanical properties, size, expression of genes related to collagen turnover and remodeling, and signal intensity (from magnetic resonance imaging) were investigated. Tendon collagen synthesis decreased (P < 0.001), whereas tendon mechanical properties and size were generally unchanged with immobilization, and NSAIDs did not influence this. Matrix metalloproteinase-2 mRNA tended to increase (P < 0.1) after immobilization in both groups, whereas scleraxis mRNA decreased with inactivity in the Plc group only (P < 0.05). In elderly human tendons, collagen protein synthesis decreased after 2 wk of immobilization, whereas tendon stiffness and modulus were only marginally reduced, and NSAIDs had no influence upon this. This indicates an importance of mechanical loading for maintenance of tendon collagen turnover. However, reduced collagen production induced by short-term unloading may only marginally affect tendon mechanical properties in elderly individuals.
In elderly humans, 2 wk of inactivity reduces tendon collagen protein synthesis, while tendon stiffness and modulus are only marginally reduced, and NSAID treatment does not affect this. This indicates that mechanical loading is important for maintenance of tendon collagen turnover and that changes in collagen turnover induced by short-term immobilization may only have minor impact on the internal structures that are essential for mechanical properties in elderly tendons.
Diabetic patients have an increased risk of foot ulcers, and glycation of collagen may increase tissue stiffness. We hypothesized that the level of glycemic control (glycation) may affect Achilles ...tendon stiffness, which can influence gait pattern. We therefore investigated the relationship between collagen glycation, Achilles tendon stiffness parameters, and plantar pressure in poorly (n = 22) and well (n = 22) controlled diabetic patients, including healthy age-matched (45-70 yr) controls (n = 11). There were no differences in any of the outcome parameters (collagen cross-linking or tendon stiffness) between patients with well-controlled and poorly controlled diabetes. The overall effect of diabetes was explored by collapsing the diabetes groups (DB) compared with the controls. Skin collagen cross-linking lysylpyridinoline, hydroxylysylpyridinoline (136%, 80%, P < 0.01) and pentosidine concentrations (55%, P < 0.05) were markedly greater in DB. Furthermore, Achilles tendon material stiffness was higher in DB (54%, P < 0.01). Notably, DB also demonstrated higher forefoot/rearfoot peak-plantar-pressure ratio (33%, P < 0.01). Overall, Achilles tendon material stiffness and skin connective tissue cross-linking were greater in diabetic patients compared with controls. The higher foot pressure indicates that material stiffness of tendon and other tissue (e.g., skin and joint capsule) may influence foot gait. The difference in foot pressure distribution may contribute to the development of foot ulcers in diabetic patients.
Purpose
The discovery of musculoskeletal tissues, including muscle, tendons, and cartilage, as peripheral circadian clocks strongly implicates their role in tissue-specific homeostasis. Age-related ...dampening and misalignment of the tendon circadian rhythm and its outputs may be responsible for the decline in tendon homeostasis. It is unknown which entrainment signals are responsible for the synchronization of the tendon clock to the light–dark cycle.
Methods
We sought to examine any changes in the expression levels of core clock genes (
BMAL1, CLOCK, PER2, CRY1,
and
NR1D1
) in healthy human patellar tendon biopsies obtained from three different intervention studies: increased physical activity (leg kicks for 1 h) in young, reduced activity (2 weeks immobilization of one leg) in young, and in old tendons.
Results
The expression level of clock genes in human tendon in vivo was very low and a high variation between individuals was found. We were thus unable to detect any differences in core clock gene expression neither after acute exercise nor immobilization.
Conclusions
We are unable to find evidence for an effect of exercise or immobilization on circadian clock gene expression in human tendon samples.
Recent studies have shown that vitamin-D intake can improve skeletal muscle function and strength in frail vitamin-D insufficient individuals. We investigated whether vitamin-D intake can improve the ...muscular response to resistance training in healthy young and elderly individuals, respectively.
Healthy untrained young (n = 20, age 20-30) and elderly (n = 20, age 60-75) men were randomized to 16 weeks of daily supplementary intake of either 48 μg of vitamin-D + 800 mg calcium (Vitamin-D-group) or 800 mg calcium (Placebo-group) during a period and at a latitude of low sunlight (December-April, 56°N). During the last 12 weeks of the supplementation the subjects underwent progressive resistance training of the quadriceps muscle. Muscle hypertrophy, measured as changes in cross sectional area (CSA), and isometric strength of the quadriceps were determined. Muscle biopsies were analyzed for fiber type morphology changes and mRNA expression of vitamin-D receptor (VDR), cytochrome p450 27B1 (CYP27B1) and Myostatin.
In the vitamin-D groups, serum 25(OH)D concentration increased significantly and at week 12 was significantly different from placebo in both young men (71.6 vs. 50.4 nmol/L, respectively) and elderly men (111.2 vs. 66.7 nmol/L, respectively). After 12 weeks of resistance training, quadriceps CSA and isometric strength increased compared to baseline in young (CSA p < 0.0001, strength p = 0.005) and elderly (CSA p = 0.001, strength p < 0.0001) with no difference between vitamin-D and placebo groups. Vitamin-D intake and resistance training increased strength/CSA in elderly compared to young (p = 0.008). In the young vitamin-D group, the change in fiber type IIa percentage was greater after 12 weeks training (p = 0.030) and Myostatin mRNA expression lower compared to the placebo group (p = 0.006). Neither resistance training nor vitamin-D intake changed VDR mRNA expression.
No additive effect of vitamin-D intake during 12 weeks of resistance training could be detected on either whole muscle hypertrophy or muscle strength, but improved muscle quality in elderly and fiber type morphology in young were observed, indicating an effect of vitamin-D on skeletal muscle remodeling.
ClinicalTrials with nr. NCT01252381.
Background: Color Doppler ultrasound is widely used to examine intratendinous flow in individuals with overuse tendon problems, but the association between color Doppler and pain is still unclear.
...Hypothesis: Intratendinous flow is present and associated with pain in badminton players, and intratendinous flow and pain increase during a badminton season.
Study Design: Cohort study (prognosis); Level of evidence, 2.
Methods: Ninety-five semiprofessional badminton players were included in the study at a tournament at the start of the badminton season. All players were interviewed regarding pain. The anterior knee tendons and Achilles tendons were studied. Each tendon was scored using a quantitative grading system (grades 0-5) and a qualitative scoring system (color fraction) using color Doppler ultrasound. Eight months later, 86 of the players (91%) were retested by the same investigators during an equivalent badminton tournament (including 1032 tendon regions; 86 players with 4 tendons each with 3 regions), thus forming the study group.
Results: At the start of the season, 24 players (28%) experienced pain in 37 tendons (11%), and at the end of the season, 31 players (36%) experienced pain in 51 tendons (15%), which was a statistically significant increase (P = .0002). Abnormal flow was found in 230 tendon regions in 71 players (83%) at the start of the season compared with 78 tendon regions in 41 players (48%) at the follow-up. The decrease in abnormal flow was statistically significant (P < .0001). Of the 37 painful tendons at the start of the season, 25 had abnormal flow (68%). In contrast, 131 tendons (85%) with abnormal flow at the start of the season were pain free. At the end of the season, 18 of the 51 painful tendons (35%) had abnormal flow. Ninety-six of the 131 pain-free tendons (73%) with abnormal flow at the start of the season were normalized (no pain and normal flow) at the end of the season.
Conclusion: It was not possible to verify any association between intratendinous flow and pain at the start of the season or at the follow-up (end of the season). Intratendinous flow at the start of the season could not predict symptomatic outcome at the end of the season. The decrease in Doppler flow during the season might suggest that intratendinous flow could be part of a physiological adaptive response to loading and that intratendinous flow as previously believed is not always a sign of pathological changes.
Rheumatoid arthritis (RA) is often associated with diminished muscle mass, reflecting an imbalance between protein synthesis and protein breakdown. To investigate the anabolic potential of both ...exercise and nutritional protein intake we investigated the muscle protein synthesis rate and anabolic signaling response in patients with RA compared to healthy controls.
Thirteen RA patients (age range 34-84 years; diagnosed for 1-32 years, median 8 years) were individually matched with 13 healthy controls for gender, age, BMI and activity level (CON). Plasma levels of C-reactive protein (CRP), interleukin (IL)-6 and tumor necrosis factor (TNF)-α were measured using enzyme-linked immunosorbent assay (ELISA) in resting blood samples obtained on two separate days. Skeletal muscle myofibrillar and connective tissue protein fractional synthesis rate (FSR) was measured by incorporation of the amino acid (13)C6-phenylalanine tracer in the overnight fasted state for 3 hours (BASAL) and 3 hours after intake of whey protein (0.5 g/kg lean body mass) alone (PROT, 3 hrs) and in combination with knee-extensor exercise (EX) with one leg (8 × 10 reps at 70 % of 1RM; PROT + EX, 3 hrs). Expression of genes related to inflammatory signaling, myogenesis and muscle growth/atrophy were analyzed by real-time reverse transcriptase-polymerase chain reaction (RT-PCR).
CRP was significantly higher in the RA patients (2.25 (0.50) mg/l) than in controls (1.07 (0.25) mg/l; p = 0.038) and so was TNF-α (RA 1.18 (0.30) pg/ml vs. CON 0.64 (0.07) pg/ml; p = 0.008). Muscle myofibrillar protein synthesis in both RA patients and CON increased in response to PROT and PROT + EX, and even more with PROT + EX (p < 0.001), with no difference between groups (p > 0.05). The gene expression response was largely similar in RA vs. CON, however, expression of the genes coding for TNF-α, myogenin and HGF1 were more responsive to exercise in RA patients than in CON.
The study demonstrates that muscle protein synthesis rate and muscle gene expression can be stimulated by protein intake alone and in combination with physical exercise in patients with well-treated RA to a similar extent as in healthy individuals. This indicates that moderately inflamed RA patients have maintained their muscle anabolic responsiveness to physical activity and protein intake.
The objective was to investigate, first, whether six weeks of intensive ballet dance exposure is associated with structural and clinical changes in the Achilles tendon; second, the importance of ...demographics, self‐reported Achilles pain, and generalized joint hypermobility (GJH). Data were collected at baseline and at six weeks’ follow‐up, using Achilles tendon ultrasound tissue characteristics (UTC) as primary outcome (percentage distribution of echo‐type I–IV: type I = intact and aligned bundles, type II = discontinuous/wavy bundles, type III = fibrillar, and type IV = amorphous cells/fluid). Secondary outcomes included clinical signs of Achilles tendinopathy, Achilles tendon pain during single‐leg heel raise, self‐reported symptoms (VISA‐A questionnaire), and GJH. Sixty‐three ballet dancers (aged 18–41) participated. From baseline to follow‐up, UTC echo‐type I decreased significantly (β = −3.6, p = 0.001; 95% CI: −5.8;−1.4), whereas echo‐type II increased significantly (β = 3.2, p < 0.0001, 95% CI: 1.6;4.8). Furthermore, a significant effect of limb (left limb showed decreased echo‐type I and increased echo‐type III + IV) and sex (women showed decreased echo‐type I and increased in type II) was found. No significant changes in the remaining secondary outcomes were found. Ballet dancers showed structural changes in UTC, corresponding to a decreased echo‐type I distribution after six weeks of rehearsing for Swan Lake ballet. No changes in self‐reported symptoms, clinical signs of Achilles tendinopathy, and single‐leg heel raise test were seen from pre‐ to post‐rehearsal. Thus, UTC changes in the Achilles tendon seem to appear earlier than clinical signs of tendinopathy.
Background: The most frequent injuries in badminton players are in the lower extremities, especially in the Achilles tendon.
Hypothesis: The game of badminton may be related to abnormal ...intratendinous flow in the Achilles tendon as detected by color Doppler
ultrasound. To a certain extent, this blood flow might be physiological, especially when examined after match.
Study Design: Cohort study (prevalence); Level of evidence, 3.
Methods: Seventy-two elite badminton players were interviewed regarding Achilles tendon pain (achillodynia) in the preceding 3 years.
Color Doppler was used to examine the tendons of 64 players before their matches and 46 players after their matches. Intratendinous
color Doppler flow was graded from 0 to 4. The Achilles tendon was divided into dominant (eg, right side for right-handed
players and vice versa) and nondominant side and classified as midtendon, preinsertional, and calcaneal areas.
Results: Of 72 players, 26 had experienced achillodynia in 34 tendons, 18 on the dominant side and 16 on the nondominant side. In
62% of the players with achillodynia, the problems had begun slowly, and the median duration of symptoms was 4 months (range,
0â36 months). Thirty-five percent had ongoing pain in their tendons for a median duration of 12 months (range, 0â12 months).
Achillodynia was not associated with the self-reported training load or with sex, age, weight, singles or doubles players,
or racket side. Forty-six players were scanned before and after match. At baseline, color Doppler flow was present in the
majority of players, and only 7 (16%) players had no color Doppler flow in either tendon. After match, all players had some
color Doppler flow in 1 or both tendons. Achillodynia and color Doppler flow were related in the nondominant Achilles tendon
(chi-square, P = .008). The grades of Doppler flow also increased significantly after match in the preinsertional area in both the nondominant
( P = .0002) and dominant ( P = .005) side tendons.
Conclusion: A large proportion of the players had experienced achillodynia and habitually played with a degree of pain that demanded
medication. The self-reported pain was associated with increased intratendinous color Doppler flow in the nondominant Achilles
tendon. Doppler flow was found in most players before and in all players after the match and therefore may in part be a physiological
response to activity.
Keywords:
Achilles tendon
color Doppler (CD)
classification
ultrasound (US)
physical activity
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