Approximately 6% of the general population reports Achilles tendon pain during their lifetime.63 Of these patients, roughly one-third will have insertional Achilles tendinopathy (IAT).55,58,63,83 Patients with IAT often report stiffness that is aggravated by prolonged rest as well as pain that is aggravated by physical activity. Patients often report that their symptoms limit their activity at work and participation in sports. In addition, because of sensitivity over the posterior heel, many struggle with shoewear.
This Current Concepts Review provides an update to Dr Irwin’s review and highlights evidence on treatment published since the previous 2010 publication.50 In addition, this update provides Levels of Evidence and Grades of Recommendation for treatment recommendations (Table 1) that are consistent with the previous and recently published reviews.20,50
Table 1
Levels of Evidence and Grades of Recommendation.
Objective measurement of physical activity (PA) using accelerometers has become increasingly popular across recreational and clinical applications. However, the effects of multiple processing algorithms, filters, and corrections on PA measurement variability may be underappreciated.To examine how lifestyle PA estimates are impacted by multiple available scoring methods.Wrist-worn accelerometers (ActiGraph GT3X+) were worn by 132 adults (87 F) having various activity levels for one week. Lifestyle PA was assessed across four PA domains: daily energy expenditure (EE); active EE; moderate-to-vigorous PA (MVPA); and steps using 1-5 algorithms per domain, with/without wrist correction and low-frequency-extension (LFE). Estimates were compared to self-report (International Physical Activity Questionnaire).PA estimates differed between algorithms with variable but frequently large effect sizes (d = 0.08-1.88). The wrist correction reduced PA estimates across all domains (p < 0.05, d = 0.26-3.04) except step counts and one daily EE algorithm (d = 0.0). Conversely, the LFE increased step counts (d = 1.44, p < 0.05) but minimally affected all other outcomes (d = 0.08-0.20, p < 0.05). Correlations between objective and self-reported PA were small to moderate (ρ = 0.22-0.45) and decreased with the wrist correction.Measurement of PA using accelerometry is highly dependent on algorithm and filter selection; previously validated methods are therefore not interchangeable. Users should take caution when interpreting absolute PA estimates, and reporting standards should require detailed methodology disclosure to optimize comparisons across studies.
Abstract Objective The purpose of this study was to compare the efficacy of physical therapy delivered via an all telehealth or hybrid format with an all in-person format on movement-evoked pain for individuals with chronic Achilles tendinopathy (AT). Methods Sixty-six individuals with chronic AT participated (age, 43.4 [SD = 15.4] years; 56% female; body mass index, 29.9 [SD = 7.7] kg/m2). Participants completed all in-person visits from the initiation of recruitment in September 2019 to March 16, 2020 (in-person group). From March 17 to July 15, 2020, participants completed all telehealth visits (telehealth group). From July 16, 2020, to enrollment completion in December 2020, participants could complete visits all in-person, all telehealth, or a combination of in-person and telehealth (hybrid group) based on their preference. A physical therapist provided 6 to 7 visits, including an exercise program and patient education. Noninferiority analyses of the telehealth and hybrid groups compared with the in-person group were completed for the primary outcome of movement-evoked pain during single-limb heel raises. Results All groups demonstrated decreases in movement-evoked pain beyond the minimal clinically important difference from baseline to 8 weeks (2 out of 10 on a numeric pain rating scale). Lower bounds of the 95% CIs for mean differences between groups did not surpass the preestablished noninferiority margin (2 out of 10) for movement-evoked pain in both the telehealth and hybrid groups (telehealth vs in-person: 0.45 [−1.1 to 2.0]; hybrid vs in-person: 0.48 [−1.0 to 1.9]). Conclusion Individuals with chronic AT who completed a tendon-loading program with patient education through a telehealth or hybrid format had no worse outcomes for pain than those who received the same intervention through in-person visits. Impact Physical therapist–directed patient care delivered via telehealth may enhance accessibility to best practice AT rehabilitation, including exercise and education. Use of telehealth technology may also provide an opportunity to prioritize patient preference for physical therapy visit format. Lay Summary If you are a patient with chronic AT, physical therapist–directed patient care delivered via telehealth may improve your accessibility to best practice AT rehabilitation, including exercise and education. Use of telehealth technology may also prioritize your preferences regarding the format of the physical therapy visit.
Objectives Peripherally directed treatments (targeted exercise, surgery) can reduce, but not fully eliminate, pain for up to 40% of patients with Achilles tendinopathy. The objectives of the present study were (1) to identify indicators of altered central processing in participants with Achilles tendinopathy compared to controls, and (2) to determine which indicators of altered central processing would persist after a local anesthetic injection in patients with Achilles tendinopathy. Design Mechanistic clinical trial. Methods Forty-six adults (23 with chronic Achilles tendinopathy, 23 matched controls) repeated (1) a movement-evoked pain rating, (2) motor performance assessment, (3) pain psychology questionnaires, and (4) quantitative sensory testing. Participants with Achilles tendinopathy received a local anesthetic injection before repeat testing and controls did not. Mixed-effects analyses of variance examined the effects of group, time, and group by time. Results The Achilles tendinopathy group had movement-evoked pain, motor dysfunction, and higher pain psychological factors (pain catastrophizing, kinesiophobia) compared to controls (P<.05). The Achilles tendinopathy group did not have indicators of nociplastic pain with quantitative sensory testing (P>.05). In those with Achilles tendinopathy, local anesthetic injection eliminated pain and normalized the observed deficits in heel-raise performance and pain catastrophizing (group-by-time effect, P<.01), but not in kinesiophobia (P = .45). Injection did not affect measures of nociplastic pain (P>.05). Conclusion People with Achilles tendinopathy had elevated pain psychological factors and motor dysfunction but no signs of nociplastic pain with quantitative sensory testing. Removal of nociceptive input normalized movement-evoked pain and some indicators of altered central processing (motor dysfunction, pain catastrophizing), but not kinesiophobia. J Orthop Sports Phys Ther 2020;50(6):334–343. Epub 29 Apr 2020. doi:10.2519/jospt.2020.9242
We evaluated construct validity (structural validity and hypothesis-testing) and reliability (test-retest reliability, measurement error and internal consistency) of the new TENDINopathy Severity assessment-Achilles (TENDINS-A), which is the only outcome measure with adequate content validity for assessment of disability in Achilles tendinopathy.
Materials and Methods
Participants with Achilles tendinopathy completed an online survey: demographics, TENDINS-A, Foot and Ankle Outcome Score (FAOS) and Victorian Institute of Sport Assessment-Achilles (VISA-A). Exploratory factor analysis (EFA) evaluated dimensionality. Confirmatory Factor Analysis (CFA) evaluated structural validity [Comparative Fit Index (CFI); Standardised Root Measure Square (SRMS)]. Correlations between TENDINS-A and the FAOS/VISA-A evaluated hypothesis-testing. Intraclass correlation co-efficient (ICC) represents test-retest reliability. Cronbach's α represents internal consistency. Standard error of the measurement (SEM) represents measurement error.
Results
Seventy-nine participants (51% female) with a mean (SD) age= 42.6 (13.0) years, height= 175.0 (11.7) cm and body mass= 82.0 (19.1) kg were included. EFA identified three meaningful factors, proposed to be pain, symptoms and function. The best model identified using CFA had adequate structural validity (CFI= 0.959, SRMS=0.068), excluded three items from the original TENDINS-A and included three factors (Pain, Symptoms, and Function). The TENDINS-A exhibited moderate positive correlation with FAOS (rho=0.598,p<0.001), and moderate, negative correlation with VISA-A (r=-0.639,p<0.001). Reliability of the TENDINS-A is excellent (ICC=0.930; Cronbach's α=0.808; SEM=6.54 units).
Conclusions
Our evaluation of the revised 10-item TENDINS-A has determined it has adequate validity and reliability. Thus, the TENDINS-A can be recommended for immediate use, being the preferred tool over all others to assess disability in Achilles tendinopathy.
Insertional Achilles tendinopathy (IAT) is characterized by tendon degeneration and thickening near the tendon-bone insertion.11 Calcaneal impingement is believed to contribute to the pathogenesis of IAT.5 However, it is unclear how increased tendon thickness in individuals with IAT influences impingement. This study aimed to compare Achilles tendon impingement in individuals with and without IAT.Eight healthy adults and 12 adults with clinically diagnosed symptomatic IAT performed a passive flexion exercise during which ankle flexion angle, anterior-posterior (A-P) thickness, and an ultrasonographic image sequence of the Achilles tendon insertion were acquired. The angle of ankle plantarflexion at which the calcaneus first impinges the Achilles tendon, defined as the impingement onset angle, was identified by (1) a anonymized observer (visual inspection method) and (2) a computational image deformation-based approach (curvature method).Although the 2 methods provided different impingement onset angles, the measurements were strongly correlated (R2 = 0.751, P < .05). The impingement onset angle and the thickness of the Achilles tendon insertion were greater in subjects with clinically diagnosed IAT (P = .0048, P = .0047). Furthermore, impingement onset angle proved to have a moderate correlation with anterior-posterior thickness (R2 = 0.454, P < .05).Our findings demonstrated that increased tendon thickness in IAT patients is associated with larger impingement onset angles, raising the range of ankle angles over which the tendon is exposed to impingement.Increased susceptibility to impingement may exacerbate or perpetuate the pathology, highlighting the need for clinical strategies to reduce impingement in IAT patients.
To 1) determine the types and frequency of complications within 3 months following ultrasound-guided surgical procedures, and 2) identify any patient demographics, co-morbidities, or procedural characteristics that were associated with an increased risk of complications.A retrospective chart review was performed at six Sports Medicine clinics across the United States. The Clavien-Dindo classification was used to categorize procedural complications on a 5-point scale from 1, representing any deviation in post-procedure care without requiring pharmacological or invasive treatment to 5, representing death. Generalized Estimating Equations for binomial outcomes with a logit link were used to estimate the overall and procedure-specific 3-month complication rates.Among 1902 patients, 8.1% (n = 154) had diabetes and 6.3% (n = 119) were current smokers. The analysis included 2,369 procedures, which were performed in either the upper extremity (44.1%, n = 1045) or lower extremity (55.2%, n = 1308) regions. The most common procedure was ultrasound-guided tenotomy (69.9%, n = 1655). Additional procedures included, trigger finger release (13.1%, n = 310), tendon scraping (8.0%, n = 189), carpal tunnel release (5.4%, n = 128), soft tissue release (2.1%, n = 50), and compartment fasciotomy (1.6%, n = 37). Overall, there was a complication rate of 1.2% (n = 29 complications; 95% CI: 0.8-1.7%). Individual procedures had complication rates that ranged from 0 to 2.7%. There were 13 Grade I complications in 13 patients, 12 Grade II complications in 10 patients, 4 Grade III complications in 4 patients, and 0 Grade IV or V complications. No associations between complication risk and any patient demographics (age, sex, BMI), co-morbidities (diabetes, smoker), or procedure characteristics (type, region) were identified.This retrospective review provides an evidence-based estimate supporting the low level of risk associated with ultrasound-guided surgical procedures for patients from a variety of geographical settings who are seeking care at private and academic-affiliated clinics.
Exercise is the standard of care for Achilles tendinopathy (AT), but 20% to 50% of patients continue to have pain following rehabilitation. The addition of pain science education (PSE) to an exercise program may enhance clinical outcomes, yet this has not been examined in patients with AT. Furthermore, little is known about how rehabilitation for AT alters the fear of movement and central nervous system nociceptive processing. Participants with chronic AT (N = 66) were randomized to receive education about AT either from a biopsychosocial (PSE) or from a biomedical (pathoanatomical education [PAE]) perspective. Simultaneously, all participants completed an exercise program over 8 weeks. Linear mixed models indicated that there were no differences between groups in (1) movement-evoked pain with both groups achieving a clinically meaningful reduction (mean change [95% CI], PSE: -3.0 [-3.8 to -2.2], PAE = -3.6 [-4.4 to -2.8]) and (2) self-reported function, with neither group achieving a clinically meaningful improvement (Patient-Reported Outcomes Measurement Information System Physical Function-PSE: 1.8 [0.3-3.4], PAE: 2.5 [0.8-4.2]). After rehabilitation, performance-based function improved (number of heel raises: 5.2 [1.6-8.8]), central nervous system nociceptive processing remained the same (conditioned pain modulation: -11.4% [0.2 to -17.3]), and fear of movement decreased (Tampa Scale of Kinesiophobia, TSK-17: -6.5 [-4.4 to -8.6]). Linear regression models indicated that baseline levels of pain and function along with improvements in self-efficacy and knowledge gain were associated with a greater improvement in pain and function, respectively. Thus, acquiring skills for symptom self-management and the process of learning may be more important than the specific educational approach for short-term clinical outcomes in patients with AT.
Low back pain (LBP) can be detrimental to the career of a circus arts performer, yet there is minimal population-specific literature to guide care. Moreover, reluctance to discontinue training and the need to resume end-range lumbar motion can impede the success of conservative care. The purpose of this case report is to describe the use of a patient-specific outcome measure and a movement classification system to structure a home exercise program (HEP) for an adolescent training to be a circus performer. The patient was a 16-year-old female with a 10-month history of LBP. A Movement System Impairment examination indicated that she had lower abdominal weakness, gluteal weakness, and hip flexors that were short and stiff; hence, extension and rotation were repeated patterns of lumbopelvic movement associated with her LBP symptoms. The patient was seen for 16 visits over 16 weeks. The HEP focused on minimizing lumbopelvic extension and rotation movements while improving abdominal and gluteal strength and hip flexor flexibility. Resumption of acrobatic activities was guided by the Patient-Specific Functional Scale. As measured by this scale, her difficulty with five functional and acrobatic activities decreased from 4/10 at initial evaluation to less than or equal to 1/10 by discharge. It is concluded that using an outcome measure to assess difficulty of activities chosen by the patient and education on how to avoid movement patterns associated with LBP symptoms can help facilitate return to performance.
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