Lower Extremity Tendinopathies Research Articles

Results of Randomized Controlled Trials of Platelet-Rich Plasma in Lower-Extremity Tendinopathy Are Not Influenced by Industry Sponsorship

To determine whether industry affiliation influences the results of randomized controlled trials (RCTs) studying the use of platelet-rich plasma (PRP) for the treatment of patellar or Achilles tendinopathy. PubMed, Scopus, Cochrane, and Medline databases were searched in July 2023 for RCTs published between 2009 and July 2023 investigating PRP for treatment of patellar or Achilles tendinopathy. Industry affiliation (IA) was determined by analyzing each study's funding or conflict of interest section. Author disclosures were searched on The American Academy of Orthopaedic Surgeons (AAOS) disclosure database and the Centers for Medicare & Medicaid Services open payments database. An IA designation was given if an author had a relevant disclosure or if the company funding the study manufactured PRP. Otherwise, a non-industry affiliated (NIA) designation was given. Fisher exact analysis was used to determine if PRP had a favorable, no significant, or unfavorable effect on outcome. Analysis was done on 22 studies (10 IA and 12 NIA), with 17 (77.3%) studies reporting a conflict of interest or funding for the research, 4 (18.2%) reporting no conflict of interest, and 1 (4.5%) with no reporting. Of the 22 included studies, 8 (36.4%) reported favorable outcomes regarding PRP utilization and 14 (63.6%) reported no significant effect. Favorable outcomes were found in 4 (40.0%) of the 10 IA studies and no significant effect was reported in 6 (60.0%). The 12 NIA studies included 4 (33.3%) with favorable results and 8 (66.7%) with no significant effect. The comparison between industry affiliation and results reported was not statistically significant (p = 1). Results of RCTs evaluating use of PRP on lower extremity tendinopathy were not influenced by industry sponsorship. The majority of biomedical research is funded through industry sponsorship. While this relationship is necessary as technologies are developed, it is important to scrutinize studies for evidence of industry bias to understand how this bias may be affecting study results published in the literature.

Lower Extremity Tendinopathies are Associated with Metabolic and Chronic Diseases: A Systematic Review

Lower Extremity Tendinopathies are Associated with Metabolic and Chronic Diseases: A Systematic Review

Lower extremity ultrasound-guided interventions: tendon, ligament, and plantar fascia.

Lower extremity tendinopathy and soft tissue injury are common clinical problems that can cause significant disability. Ultrasound-guided minimally invasive treatments using orthobiologics and image-guided percutaneous treatments continue to gain relevance with an ever-growing body of literature. We review the indications, technique, risks, and benefits according to the literature of common ultrasound-guided interventions utilized in the lower extremities.

A Closer Look at Localized and Distant Pressure Pain Hypersensitivity in People With Lower Extremity Overuse Soft-Tissue Painful Conditions: A Systematic Review and Meta-Analysis.

The nociceptive pain processing of soft-tissue overuse conditions is under debate because no consensus currently exists. The purpose of this meta-analysis was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas in 2 groups: participants with symptomatic lower extremity overuse soft-tissue conditions and controls who were pain free. Five databases were searched from inception to December 1, 2021, for case-control studies comparing PPTs between individuals presenting with symptomatic lower extremity tendinopathy/overuse injury and controls who were pain free. Data extraction included population, diagnosis, sample size, outcome, type of algometer, and results. The methodological quality (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development, and Evaluation) were assessed. Meta-analyses of symptomatic, segmental related, and distant pain-free areas were compared. After screening 730 titles and abstracts, a total of 19 studies evaluating lower extremity overuse conditions (Achilles or patellar tendinopathy, greater trochanteric pain syndrome, plantar fasciitis, and iliotibial band syndrome) were included. The methodological quality ranged from fair (32%) to good (68%). Participants with lower extremity overuse injury had lower PPTs in both the painful and nonpainful areas, mirrored test-site, compared with controls (affected side: mean difference [MD] = -262.92kPa, 95% CI = 323.78 to -202.05kPa; nonaffected side: MD = -216.47kPa, 95% CI = -304.99 to -127.95kPa). Furthermore, people with plantar fasciitis showed reduced PPTs in the affected and nonaffected sides at segmental-related (MD = -176.39kPa, 95% CI = -306.11 to -46.68kPa) and distant pain-free (MD = -97.27kPa, 95% CI = 133.21 to -61.33kPa) areas compared with controls. Low- to moderate-quality evidence suggests a reduction of PPTs at the symptomatic area and a contralateral/mirror side in lower extremity tendinopathies and overuse conditions compared with pain-free controls, particularly in plantar fasciitis and greater trochanteric pain syndrome. Participants with plantar fasciitis showed a reduction of PPTs on the affected and non-affected sides at a segmental-related area (very low-quality evidence) and at a remote asymptomatic area (moderate-quality evidence). Some overuse peripheral pain conditions may be more associated with pressure pain sensitivity than others. Accordingly, examination and identification of conditions more peripherally, centrally, or mixed mediated could potentially lead to more specific and different treatment strategies.

Efficacy of low-level laser therapy in patients with lower extremity tendinopathy or plantar fasciitis: systematic review and meta-analysis of randomised controlled trials

ObjectivesWe investigated the effectiveness of low-level laser therapy (LLLT) in lower extremity tendinopathy and plantar fasciitis on patient-reported pain and disability.DesignSystematic review and meta-analysis.Data sourcesEligible articles in any language were...

Efficacy of Extracorporeal Pulse-Activated Therapy in the Management of Lower-Extremity Running-Related Injuries: Findings From a Large Case Cohort

Running is one of the most popular sports worldwide, with many health benefits. Injuries are also common, with running-related injuries reported in up to 79% of runners annually. Extracorporeal shockwave treatment can be used to treat soft tissue conditions, with the strongest level of evidence for management of plantar fasciitis. However, most studies have focused on nonathletes or studied a single condition, and few investigations have reported outcomes for extracorporeal pulse-activated therapy. In this case series, we evaluated the outcomes of 94 runners receiving extracorporeal pulse-activated therapy for lower-extremity running-related injuries, including plantar fasciitis and lower-extremity tendinopathy (Achilles, posterior tibialis, patellar, hamstring). We hypothesized that most runners with foot and ankle injuries would respond favorably to treatment and that success rates would be similar across conditions. Overall, 74 runners (79%) met their respective minimal clinically important difference for functional outcome measures, with no differences in response by age, sex, body mass index, or chronicity of condition. Further, no differences were noted in proportion achieving the minimal clinically important difference between foot and ankle (Achilles, posterior tibialis, and plantar fascia) compared with proximal injuries (53 [84.3%] versus 31 [72%], p = .15). A mean of 4 treatments resulted in achieving the minimal clinically important difference, with 95% achieving it by 5 treatments. No differences in bars of pressure, frequency, or other aspects of treatments were observed to predict response. Our findings suggest that a majority of runners with lower-extremity injuries respond favorably to extracorporeal pulse-activated therapy, including those with foot and ankle injuries.

Obesity Increases the Risk of Tendinopathy, Tendon Tear and Rupture, and Postoperative Complications: A Systematic Review of Clinical Studies.

Inflammation and mechanical demands play a role in the development of tendon conditions and the dysregulation of tendon healing. In patients with obesity, high levels of pro-inflammatory cytokines and a high mechanical demand promote chronic low-grade inflammation. Although controversial results have been reported, we aimed to summarize current evidence while highlighting the role of obesity in tendinopathy. (1) Do patients with obesity have a greater risk of tendinopathy, stratified by upper and lower extremity sites, than patients who do not have obesity? (2) Is obesity associated with a higher risk of upper and lower extremity tendon tear and ruptures? (3) Is obesity associated with an increased risk of complications after upper and lower extremity tendon surgery? We performed a systematic review by searching the PubMed, Embase, and Cochrane Library databases, combining the term "tendon" with common terms for tendinopathy and rupture such as "tendon injury OR tendinopathy OR tendon rupture" and "obese" OR "obesity." We included studies with any level of evidence published from January 2000 to July 10, 2019 in peer-reviewed journals reporting clinical results. After we removed the duplicates, there were 365 records. Two independent authors screened these records and excluded 320 based on abstract and title screening. Of the remaining 45 studies, 23 were excluded because the topic did not address the research questions (n = 19), the article was outdated (n = 3), or because there was a serious risk of bias (n = 1). Finally, we included 22 studies with 49,914 participants (5984 with obesity), 31,100 (1884 with obesity) of whom had upper-extremity tendinopathy, while 18,814 (4010 with obesity) had lower-extremity tendinopathy. Obesity was defined as a BMI ≥ 30 kg/m according to the WHO's criteria. Data were extracted and analyzed critically. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were applied, and the risk of bias (ROBINS tool) of the studies was assessed, as was the methodological quality (Coleman score). The assessment was performed independently by two authors. Inter-rater agreement for the assessments of the risk of bias and methodological quality were 89% and 94%, respectively. All studies were observational, and most were retrospective case-control studies. Any discrepancy was discussed and solved by consensus. The articles had a moderate risk of bias (eight articles) or a low risk of bias (fourteen articles). We excluded one article because of a serious risk of bias. The mean (range) Coleman score was 53.5 (42-74). Obesity was associated with a greater risk of upper extremity tendinopathy (rotator cuff: odds ratio 1.25 [95% confidence interval 1.12 to 1.40]; p < 0.001; medial epicondylitis: OR 1.9 [95% CI 1.0 to 3.7]; p < 0.05) and lower-extremity tendinopathy (Achilles tendon: OR 3.81 [95% CI 2.57 to 5.63]; OR 3.77 [95% CI 2.24 to 6.34]; OR 6.56 [95% CI 3.18 to 13.55], for obesity Classes I, II and III, respectively; patellar tendon: OR 1.10 [95% CI 1.05 to 1.90]; p = 0.001; plantar fascia: OR 2.97 [95% CI 1.64 to 5.37]; p = 0.004). Obesity was associated with a greater risk of upper extremity tendon tear (rotator cuff: OR 2.35 [95% CI 1.62 to 3.40]; p < 0.001) and rupture leading to tendon surgery (rotator cuff in men: OR 3.13 [95% CI 1.29 to 7.61]; p < 0.001 and women: OR 3.51 [95% CI 1.80 to 6.85]; p < 0.001). However, no association was found between BMI and lower extremity rupture (Achilles mean BMI: 27.77 kg/m [95% CI 26.94 to 28.49] versus control: 26.66 kg/m [95% CI 26.06 to 27.27]; p = 0.047). Upper extremity complications (n = 359) after tendon repair surgery had a weighted incidence of 13.27% and 8.13% for rotator cuff surgery in patients with and without obesity, respectively. In the lower extremity (n = 21,152), the weighted incidence for Achilles tendon surgery was 11.28% and 8.6% in patients with and without obesity, respectively. Obesity is associated with a higher risk of tendinopathy, tendon tear and rupture, and complications after tendon surgery than non-obesity. However, the high heterogeneity and observational nature of the studies highlight the need to be cautious about the results of our study. We encourage researchers to perform clinical and preclinical studies to explore pathways related to the metabolic state of this population. Level IV, prognostic study.

Extracorporeal Shockwave Therapy in Lower Limb Sports Injuries

To outline current evidence on the use of ESWT for the treatment of lower limb sports injuries. There is growing evidence to support the use of extracorporeal shockwave therapy (ESWT) for a variety of musculoskeletal conditions in the general population. However, research focused on the use of ESWT specifically for lower extremity injuries in the athletic population is more limited. Athletes represent a subgroup of patients that may benefit from ESWT. Compared with injections or surgical interventions, athletes undergoing ESWT often are able to continue sports participation with fewer limitations in activity during treatment. The review identifies considerable variability in study design and treatment protocols that affect the overall quality of evidence. Sports participation was allowed in most studies. One case of plantar fascia tear was identified during ESWT treatment; this injury was self-limited. Most studies report pain-relieving and/or functional benefit with the use of ESWT for common lower extremity tendinopathies, plantar fasciitis, and medial tibial stress syndrome. This review highlights the need for further investigations on optimal methods of ESWT use in athletes given the high prevalence of lower extremity injuries and favorable safety profile for treatment.

Prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice: a registry-based study

BackgroundTendinopathies of the lower extremity (e.g. Achilles, patellar, and plantar heel pain) are common in both general and sporting populations. However, the prevalence and incidence in Danish general practice is unknown. The aim was to determine the prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice.MethodsIn this registry-based study, we extracted data from the electronic patient files of all patients in a single Danish general practice. The practice included 8836 patients. We searched ICPC-2 codes to identify patients with either of the following lower-extremity tendinopathies: plantar heel pain; Achilles tendinopathy; patellar tendinopathy; greater trochanteric pain syndrome or adductor tendinopathy. We defined an incident and prevalent case as a patient with a consultation because of tendinopathy in 2016 only. A prevalent, but not incident case was a patient with consultations in both 2015 and 2016. Incidence and prevalence were expressed as the number of patients with a tendinopathy per 1000 registered patients.ResultsThe prevalence and incidence rate were 16.6 and 7.9 per 1000 registered patients, respectively. Plantar heel pain was the most prevalent tendinopathy and accounted for 39% of lower-extremity tendinopathies. Patients with tendinopathies were significantly older than all registered patients (46.0 years (95%CI: 43.3;48.7) versus 38.8 years (95%CI: 38.4;39.3), respectively).ConclusionsLower-extremity tendinopathies, especially plantar heel pain, had a high prevalence and incidence rate in a Danish general practice. In a typical general practice with 5000 patients, general practitioners should expect to see more than 80 patients with a lower-extremity tendinopathy every year.

The Long-Term Effects of Eccentric Exercise Vs. Extracorporeal Shockwave Therapy in Athletes Aged 18-50 with Lower Extremity Tendinopathy: A Meta-Analysis and Systematic Review

The Long-Term Effects of Eccentric Exercise Vs. Extracorporeal Shockwave Therapy in Athletes Aged 18-50 with Lower Extremity Tendinopathy: A Meta-Analysis and Systematic Review

The Role of Strength Training for Lower Extremity Tendinopathy

ABSTRACT TENDON INJURIES REPRESENT A COMMON PROBLEM FOR ATHLETES AND THE GENERAL POPULATION. SYMPTOMS CAN RESULT IN PROLONGED IMPAIRMENT OF PERFORMANCE. THIS REVIEW AIMED TO EXAMINE THE CURRENT RESEARCH UNDERPINNING COMMONLY USED STRENGTH TRAINING METHODS TO MANAGE LOWER LIMB TENDINOPATHY AND SUGGEST APPROPRIATE WAYS IN WHICH THESE METHODS CAN BE APPLIED BY STRENGTH AND CONDITIONING PROFESSIONALS. ECCENTRIC TRAINING AND TRADITIONAL RESISTANCE TRAINING ARE OFTEN USED TO INCREASE A TENDON'S TOLERANCE TO LOAD, AND ISOMETRIC TRAINING IS EMERGING AS AN EFFECTIVE METHOD TO ACHIEVE SIMILAR OUTCOMES. THESE TRAINING MODALITIES SHOULD BE CONSIDERED WHEN MANAGING TENDINOPATHY.

Efficacy of extracorporeal shock wave therapy for lower limb tendinopathy: A systematic review and meta-analysis

Extracorporeal shock-wave therapy (ESWT), including radial (RaSW) and focused (FoSW) shock-wave types, has been widely used in clinical practice for managing musculoskeletal disorders such as tendinopathy. The difference in therapeutic effects between two shock-wave characteristics with different dosage levels for lower extremity (LE) tendinopathy remains controversial. The purpose of this systematic review and meta-analysis was to determine the difference in effectiveness between RaSW and FoSW as well as between high-dosage (HD) and low-dosage (LD) applications for patients with LE tendinopathy. A comprehensive search of online databases and search engines, namely Medline, PubMed, Excerpta Medica dataBASE, the Cochrane Library Database, the Physiotherapy Evidence Database (PEDro), and Google Scholar, was performed. We included randomized controlled trials (RCTs) and observational studies reporting the efficacy of ESWT in treating LE tendinopathy. The included articles were subjected to a meta-analysis and risk of bias assessment. We finally included 19 RCTs, all of which were of high or good methodological quality, with a PEDro score ≥ 7/10. Meta-analyses revealed significant effects favoring general ESWT at immediate follow-up [pain score: standardized mean difference (SMD) −1.41, 95% confidence interval (CI) −2.01 to −0.82 P < 0.00001; heterogeneity ( I 2 ) = 95%; function: SMD 2.59, 95% CI 1.54 to 3.64 P < 0.00001; I 2 = 97%] as well as at 3, 6, and ≥12 months. In sequence, HD-FoSW, HD-RaSW, and LD-RaSW have superior pooled effects on overall clinical outcomes. ESWT exerts an overall effect on pain and function, particularly in patients with LE tendinopathy. Shock-wave types and dosage levels may have different contributions to treatment efficacy, which must be investigated further for optimizing clinical practice.

Incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population: a cross sectional study.

BackgroundLower extremity tendinopathy is a common sports injury, but it can also affect non-athletes. Because tendinopathy is difficult to treat and has negative effects on the ability to work and quality of life, development of preventive interventions is important. The first step in the Van Mechelen prevention model is to determine the extent of the problem. The primary aim of this study was to determine the incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population. The secondary aim was to investigate possible associated factors.MethodsA cross-sectional study was performed in a Dutch general practice. Using International Classification of Primary Care codes, the electronic patient files were searched to identify cases of adductor tendinopathy, greater trochanteric pain syndrome, jumper’s knee, Achilles tendinopathy, and plantar fasciopathy in 2012. The tendinopathy patients were compared to the general practice population regarding age, gender, use of medication, and comorbidity using 95 % confidence intervals.ResultsThe prevalence and incidence rates of lower extremity tendinopathy found in this study were 11.83 and 10.52 per 1000 person-years. Lower extremity tendinopathy was more prevalent among older patients. No differences between tendinopathy patients and the general practice population were found regarding gender, use of medication, or comorbidity.ConclusionsIn this cross-sectional study in a Dutch general practice, the prevalence and incidence rates of lower extremity tendinopathy were 11.83 and 10.52 per 1000 person-years. Lower extremity tendinopathy deserves a higher place in locomotor system research to develop preventive interventions.

Neovascularization Prevalence in the Supraspinatus of Patients With Rotator Cuff Tendinopathy

A high prevalence of neovascularity in lower extremity tendinopathies has been reported. Neovascularity in those with rotator cuff tendinopathy exclusively has not been examined. The objective was to determine the prevalence of neovascularization in patients with rotator cuff tendinopathy compared with asymptomatic controls. Single-blind cross-sectional study. Research laboratory. Participants (n = 40; age = 44.9 years, 23-62 years; 20 females) with rotator cuff tendinopathy (n = 20) but without full-thickness rotator cuff tears, and asymptomatic controls that were age, gender, and hand dominance matched (n = 20) to the patients. The participants laying in supine had their shoulder positioned in internal rotation and extension. Ultrasound images were collected of the supraspinatus tendon and subacromial bursae in the transverse and longitudinal planes using a linear transducer in color Doppler mode. Images were assessed for neovascularization by 2 trained raters who were blinded to group (rotator cuff tendinopathy or asymptomatic group). No statistically significant difference in neovascularization was identified between participants with and without rotator cuff tendinopathy (χ = 0.13, df = 1, P = 0.72). Neovascularization was identified in 6 of 20 patients with rotator cuff tendinopathy (30%) and 5 of 20 asymptomatic control participants (25%). The authors found no differences in neovascularization rate in patients with rotator cuff tendinopathy (30%) and asymptomatic controls (25%). The study indicates that neovascularization is not related to presence of symptomatic tendinopathy in those with rotator cuff tendinopathy. Neovascularization may not be a relevant sonographic finding to aid the clinical assessment of those with rotator cuff tendinopathy.

Risk Factors for Lower Extremity Tendinopathies in Military Personnel.

Background:Overuse injuries have a significant impact on United States military service members, but research to date has been limited in its ability to assess occupational and behavioral risk factors.Hypothesis/Purpose:To prospectively identify risk factors for the development of lower extremity tendinopathy and plantar fasciitis in United States military personnel.Study Design:Descriptive epidemiology study.Methods:Baseline data from the Millennium Cohort Study, a long-term observational cohort of military personnel, were utilized. Service members were enrolled in the cohort in 2001, 2004, and 2007. A total of 80,106 active-duty personnel were followed over 1 year for the development of patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis. Regression analyses were used to estimate significant associations between each tendinopathy, plantar fasciitis, and demographic, behavioral, and occupational characteristics.Results:Using medical records, 450 cases of Achilles tendinitis, 584 cases of patellar tendinopathy, and 1228 cases of plantar fasciitis were identified. Recent deployment was associated with an increased risk for developing plantar fasciitis (adjusted odds ratio [AOR], 1.27; 95% confidence interval [CI], 1.04-1.56). Moderate weekly alcohol consumption was marginally associated with an increased risk for Achilles tendinopathy (AOR, 1.33; 95% CI, 1.00-1.76). Overweight or obese individuals were more likely to develop Achilles tendinopathy and plantar fasciitis.Conclusion:Lower extremity tendinopathies and plantar fasciitis are common among military service members, and this study identified several modifiable risk factors for their occurrence. These potential risk factors could serve as the focus for future preventive and intervention studies.

Kann exzentrisches Training in der konservativen Therapie von chronischen Supraspinatus-Tendinopathien effektiv sein? Eine Übersicht zur aktuellen Literatur

Eccentric training (ET) has been shown to be an effective conservative treatment option for chronic patellar and Achilles tendinopathies. As part of the four-muscle-tendon-complex of the rotator cuff, the supraspinatus is involved most commonly in shoulder disorders. Histopathologic alterations of the supraspinatus tendon are comparable to findings in lower extremity tendinopathies. Hence, the question arises whether the concept of eccentric training can be successfully transferred to the upper extremity. Yet, no randomised controlled trials have been published to support this theory. This problem emerges from the fact that the supraspinatus is part of a complex functional unit. Consequently, surrounding soft tissues are frequently concomitantly affected. The inherent etiology and genesis of pathologic alterations in the supraspinatus tendon and its influence on shoulder disorders is not clear to date. However, the apparent success of ET in managing tendinopathies of the lower extremity urges further scientific work for developing evidence-based guidelines for the conservative treatment of tendinopathies in the shoulder region. Taking into account this lack of data as well as the anatomical and functional constraints, the aim of this work is to review the current state of the literature.

Using Eccentric Exercise in the Treatment of Lower Extremity Tendinopathies

Using Eccentric Exercise in the Treatment of Lower Extremity Tendinopathies