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Comparison of Rehabilitation Methods in the Treatment of Patellar Tendinitis

Julie K. Wilson, Thomas L. Sevier, Robert Helfst, Eric W. Honing, and Aly Thomann

Objective:

To compare outcomes of 2 rehabilitation protocols on patellar tendinitis subjects.

Design:

Prospective, randomized, blinded, controlled clinical trial.

Setting:

Outpatient rehabilitation clinic.

Subjects:

Randomized into 2 rehabilitation groups—traditional (n = 10) and ASTM AdvantEDGE (n = 10).

Main Outcome Measures:

Clinical data and self-reported questionnaires collected at 0, 6, and 12 weeks.

Results:

On completion of the 6th week, 100% of the ASTM AdvantEDGE group and 60% of the traditional group had resolved. The unresolved subjects were crossed over to the ASTM AdvantEDGE for additional therapy. At the end of the additional therapy, 50% of the crossover subjects had resolved. The ASTM AdvantEDGE group's clinical outcomes and weekly journals indicated a statistically significant (P = .04) improvement in subjective pain and functional-impairment ratings.

Conclusions:

Findings suggest that ASTM AdvantEDGE resulted in improved clinical outcomes in treating patellar tendinitis.

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Effects of Acute and Chronic Pathomechanics on the Normal Histology and Biomechanics of Tendons: A Review

Michelle A. Sandrey

Objective:

To present the basic concepts of normal composition and structure of tendons and indicate how they are affected by acute and chronic tendon-injury pathomechanics.

Data Sources:

MEDLINE (1970-1999) and SPORTDiscus (1970-1999) were searched using the key words pathoanatomic, tendinitis, tendinosis, biomechanics, pathomechanics, histology, chronic, and mechanical behavior.

Data Synthesis:

Acute loading modes to tendons are based on the response of tendons to tensile and compressive stress. Chronic loading modes are based on frictional forces and repetitive movement.

Conclusions and Recommendations:

With an appreciation of the pathologic changes in acute tendon injuries, the clinician can better understand injury mechanics and the healing process. Until we know more about what is happening in and around the tendon, principally in the early and late phases of chronic injury we will not be able to adequately address injury classification of structures and, hence, the pathomechanics of chronic injury

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Treatment of infrapatellar Tendinitis: A Combination of Modalities and Transverse Friction Massage versus Iontophoresis

Geraldine L. Pellecchia, Holly Hamel, and Peter Behnke

The purpose of this study was to compare an established protocol of modalities and transverse friction massage (MOD & TFM) with iontophoresis of dexamethasone and lidocaine (IONTO) in the treatment of patients with infrapatellar tendinitis. Thirty cases with infrapatellar tendinitis were randomly assigned to either the MOD & TFM or the IONTO intervention. Subjects still symptomatic after six sessions of intervention received the alternate treatment protocol. Four measures were used to assess patient status: a functional index questionnaire, a visual analog pain scale, a rating of tenderness with palpation of the involved tendon, and the number of step-ups needed to elicit pain. In response to the MOD & TFM intervention, only the number of step-ups performed to elicit pain showed significant improvement. All status measures improved significantly with the IONTO intervention. The results suggest that iontophoresis may be more effective and efficient in decreasing pain, reducing inflammation, and promoting healing in patients with infrapatellar tendinitis.

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Acute and Chronic Tendon Injuries: Factors Affecting the Healing Response and Treatment

Michelle A. Sandrey

Objective:

Tendons have biomechanical properties based on collaborative remodeling of all their cells through normal lysis and synthesis. This review assesses factors that affect the healing response and presents solutions for rehabilitating acute and chronic tendon injuries.

Data Sources:

MEDLINE (1970–2002) and SPORTDiscus (1970–2002). Key words searched were tendon, tendinitis, tendinosis, tendinopathy, rehabilitation, ultrasound, NSAIDs, exercise, mobilization, aging, immobilization, and healing.

Data Synthesis:

The biomechanical roles tendons play change throughout one’s lifetime and are influenced by maturation and aging, injury and healing, immobilization, exercise, medications, and therapeutic modalities. Suggestions from animal, case, and clinical studies are varied but provide solutions in the treatment of acute and chronic tendon injuries.

Conclusions and Recommendations:

All factors that affect the tendon structure should be considered in a rehabilitation program. Therapeutic exercise, medications, or therapeutic modalities should never be used as a stand-alone therapy.

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Double-Blind Clinical Efficacy Study of Pulsed Phonophoresis on Perceived Pain Associated with Symptomatic Tendinitis

Caroline E. Penderghest, Iris F. Kimura, and Dawn T. Gulick

The purpose of this study was to determine the clinical efficacy of dexametha-sone-lidocaine (DX-L) phonophoresis on perceived pain associated with symptomatic tendinitis. Twenty-four subjects were randomly assigned to a DX-L or placebo phoresis group. All subjects received strengthening, stretching, and cryotherapy. Five double-blind sessions were administered over a 5- to 10-day period, with 24 to 48 hr between sessions. Perceived pain was quantified using a visual perceived pain scale (VPPS) and a punctate tenderness gauge (PTG). Data were collected before stretching, strengthening, and DX-L/placebo phoresis treatments, 1 min after treatment, and 10 min after cryotherapy. There were no significant differences for VPPS or PTG between groups. There was a significant difference between treatment sessions, regardless of group or test, and there were significant decreases in perceived pain between Tests 1 and 3 and between Treatment Sessions 1 and 5. It was concluded that stretching, strengthening, and cryotherapy significantly decreased the levels of perceived pain associated with symptomatic tendinitis regardless of whether the subjects received phonophoresis.

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Considerations for Evaluation and Treatment of Overuse Tendon Injuries

G. Kelley Fitzgerald

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Adaptation of Tendon Structure and Function in Tendinopathy With Exercise and Its Relationship to Clinical Outcome

Kenneth Färnqvist, Stephen Pearson, and Peter Malliaras

Context: Exercise is seen as the most evidence-based treatment for managing tendinopathy and although the type of exercise used to manage tendinopathy may induce adaptation in healthy tendons, it is not clear whether these adaptations occur in tendinopathy and if so whether they are associated with improved clinical outcomes. Objective: The aim of the study was to synthesize available evidence for adaptation of the Achilles tendon to eccentric exercise and the relationship between adaptation (change in tendon thickness) and clinical outcomes among people with Achilles tendinopathy. Evidence Acquisition: The search was performed in September 2018 in several databases. Studies investigating the response (clinical outcome and imaging on ultrasound/magnetic resonance imaging) of pathological tendons (tendinopathy, tendinosis, and partial rupture) to at least 12 weeks of eccentric exercise were included. Multiple studies that investigated the same interventions and outcome were pooled and presented in effect size estimates, mean difference, and 95% confidence intervals if measurement scales were the same, or standard mean difference and 95% confidence intervals if measurements scales were different. Where data could not be pooled the studies were qualitatively synthesized based on van Tulder et al. Evidence Synthesis: Eight studies met the inclusion and exclusion criteria and were included in the review. There was strong evidence that Achilles tendon thickness does not decrease in parallel with improved clinical outcomes. Conclusions: Whether a longer time to follow-up is more important than the intervention (ie, just the time per se) for a change in tendon thickness remains unknown. Future studies should investigate whether exercise (or other treatments) can be tailored to optimize tendon adaptation and function, and whether this relates to clinical outcomes.

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Orthotic Heel Wedges Do Not Alter Hindfoot Kinematics and Achilles Tendon Force During Level and Inclined Walking in Healthy Individuals

Robert A. Weinert-Aplin, Anthony M.J. Bull, and Alison H. McGregor

Conservative treatments such as in-shoe orthotic heel wedges to treat musculoskeletal injuries are not new. However, weak evidence supporting their use in the management of Achilles tendonitis suggests the mechanism by which these heel wedges works remains poorly understood. It was the aim of this study to test the underlying hypothesis that heel wedges can reduce Achilles tendon load. A musculoskeletal modeling approach was used to quantify changes in lower limb mechanics when walking due to the introduction of 12-mm orthotic heel wedges. Nineteen healthy volunteers walked on an inclinable walkway while optical motion, force plate, and plantar pressure data were recorded. Walking with heel wedges increased ankle dorsiflexion moments and reduced plantar flexion moments; this resulted in increased peak ankle dorsiflexor muscle forces during early stance and reduced tibialis posterior and toe flexor muscle forces during late stance. Heel wedges did not reduce overall Achilles tendon force during any walking condition, but did redistribute load from the medial to lateral triceps surae during inclined walking. These results add to the body of clinical evidence confirming that heel wedges do not reduce Achilles tendon load and our findings provide an explanation as to why this may be the case.

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Preventing VMO Atrophy: The Key to Preventing Patellar Tendinitis in the Postsurgical ACL-Deficient Athlete

Rick Burkholder

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Mechanism and Treatment of Tendinitis of the Flexor Hallucis Longus in Classical Ballet Dancers

Kathleen M.J. Nachazel