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Sports Health 2021Distance running is one of the most popular physical activities, and running-related injuries (RRIs) are also common. Foot strike patterns have been suggested to affect... (Meta-Analysis)
Meta-Analysis
CONTENT
Distance running is one of the most popular physical activities, and running-related injuries (RRIs) are also common. Foot strike patterns have been suggested to affect biomechanical variables related to RRI risks.
OBJECTIVE
To determine the effects of foot strike techniques on running biomechanics.
DATA SOURCES
The databases of Web of Science, PubMed, EMBASE, and EBSCO were searched from database inception through November 2018.
STUDY SELECTION
The initial electronic search found 723 studies. Of these, 26 studies with a total of 472 participants were eligible for inclusion in this meta-analysis.
STUDY DESIGN
Systematic review and meta-analysis.
LEVEL OF EVIDENCE
Level 4.
DATA EXTRACTION
Means, standard deviations, and sample sizes were extracted from the eligible studies, and the standard mean differences (SMDs) were obtained for biomechanical variables between forefoot strike (FFS) and rearfoot strike (RFS) groups using a random-effects model.
RESULTS
FFS showed significantly smaller magnitude (SMD, -1.84; 95% CI, -2.29 to -1.38; < 0.001) and loading rate (mean: SMD, -2.1; 95% CI, -3.18 to -1.01; < 0.001; peak: SMD, -1.77; 95% CI, -2.21 to -1.33; < 0.001) of impact force, ankle stiffness (SMD, -1.69; 95% CI, -2.46 to -0.92; < 0.001), knee extension moment (SMD, -0.64; 95% CI, -0.98 to -0.3; < 0.001), knee eccentric power (SMD, -2.03; 95% CI, -2.51 to -1.54; < 0.001), knee negative work (SMD, -1.56; 95% CI, -2.11 to -1.00; < 0.001), and patellofemoral joint stress (peak: SMD, -0.71; 95% CI, -1.28 to -0.14; = 0.01; integral: SMD, -0.63; 95% CI, -1.11 to -0.15; = 0.01) compared with RFS. However, FFS significantly increased ankle plantarflexion moment (SMD, 1.31; 95% CI, 0.66 to 1.96; < 0.001), eccentric power (SMD, 1.63; 95% CI, 1.18 to 2.08; < 0.001), negative work (SMD, 2.60; 95% CI, 1.02 to 4.18; = 0.001), and axial contact force (SMD, 1.26; 95% CI, 0.93 to 1.6; < 0.001) compared with RFS.
CONCLUSION
Running with RFS imposed higher biomechanical loads on overall ground impact and knee and patellofemoral joints, whereas FFS imposed higher biomechanical loads on the ankle joint and Achilles tendon. The modification of strike techniques may affect the specific biomechanical loads experienced on relevant structures or tissues during running.
Topics: Achilles Tendon; Ankle; Biomechanical Phenomena; Foot; Gait Analysis; Humans; Knee; Risk Factors; Running; Stress, Mechanical
PubMed: 32813597
DOI: 10.1177/1941738120934715 -
BMJ Open Sport & Exercise Medicine 2020To systematically review and critically appraise the literature on the effectiveness of isometric exercise in comparison with other treatment strategies or no treatment...
OBJECTIVE
To systematically review and critically appraise the literature on the effectiveness of isometric exercise in comparison with other treatment strategies or no treatment in tendinopathy.
DESIGN
A systematic review and meta-analysis of randomised controlled trials.
DATA SOURCES
Electronic searches of Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE and Cochrane were undertaken from inception to May 2020.
METHODS
Overall quality of each study was determined based on a combined assessment of internal validity, external validity and precision. For each outcome measure, level of evidence was rated based on the system by van Tulder .
RESULTS
Ten studies were identified and included in the review, including participants with patellar (n=4), rotator cuff (n=2), lateral elbow (n=2), Achilles (n=1) and gluteal (n=1) tendinopathies. Three were of good and seven were of poor overall quality. Based on limited evidence (level 3), isometric exercise was not superior to isotonic exercise for chronic tendinopathy either immediately following treatment or in the short term (≤12 weeks) for any of the investigated outcome measures. Additionally, for acute rotator cuff tendinopathy, isometric exercise appears to be no more effective than ice therapy in the short term (limited evidence; level 3).
SUMMARY
Isometric exercise does not appear to be superior to isotonic exercise in the management of chronic tendinopathy. The response to isometric exercise is variable both within and across tendinopathy populations. Isometric exercise can be used as part of a progressive loading programme as it may be beneficial for selected individuals.
PROSPERO REGISTRATION NUMBER
CRD42019147179.
PubMed: 32818059
DOI: 10.1136/bmjsem-2020-000760 -
Sports Medicine - Open Dec 2015The present article systematically reviews recent literature on the in vivo adaptation of asymptomatic human tendons following increased chronic mechanical loading, and... (Review)
Review
BACKGROUND
The present article systematically reviews recent literature on the in vivo adaptation of asymptomatic human tendons following increased chronic mechanical loading, and meta-analyzes the loading conditions, intervention outcomes, as well as methodological aspects.
METHODS
The search was performed in the databases PubMed, Web of Knowledge, and Scopus as well as in the reference lists of the eligible articles. A study was included if it conducted (a) a longitudinal exercise intervention (≥8 weeks) on (b) healthy humans (18 to 50 years), (c) investigating the effects on mechanical (i.e., stiffness), material (i.e., Young's modulus) and/or morphological properties (i.e., cross-sectional area (CSA)) of tendons in vivo, and was reported (d) in English language. Weighted average effect sizes (SMD, random-effects) and heterogeneity (Q and I statistics) of the intervention-induced changes of tendon stiffness, Young's modulus, and CSA were calculated. A subgroup analysis was conducted regarding the applied loading intensity, muscle contraction type, and intervention duration. Further, the methodological study quality and the risk of bias were assessed.
RESULTS
The review process yielded 27 studies with 37 separate interventions on either the Achilles or patellar tendon (264 participants). SMD was 0.70 (confidence interval: 0.51, 0.88) for tendon stiffness (N=37), 0.69 (0.36, 1.03) for Young's modulus (N=17), and 0.24 (0.07, 0.42) for CSA (N=33), with significant overall intervention effects (p<0.05). The heterogeneity analysis (stiffness: I =30%; Young's modulus: I =57%; CSA: I =21%) indicated that differences in the loading conditions may affect the adaptive responses. The subgroup analysis confirmed that stiffness adaptation significantly (p<0.05) depends on loading intensity (I =0%), but not on muscle contraction type. Although not significantly different, SMD was higher for interventions with longer duration (≥12 weeks). The average score of 71±9% in methodological quality assessment indicated an appropriate quality of most studies.
CONCLUSIONS
The present meta-analysis provides elaborate statistical evidence that tendons are highly responsive to diverse loading regimens. However, the data strongly suggests that loading magnitude in particular plays a key role for tendon adaptation in contrast to muscle contraction type. Furthermore, intervention-induced changes in tendon stiffness seem to be more attributed to adaptations of the material rather than morphological properties.
PubMed: 27747846
DOI: 10.1186/s40798-015-0009-9 -
Cureus Jul 2022Achilles tendinopathy is one of the most common lower limb injuries in both athletes and the general population. Despite the plethora of conservative treatment options... (Review)
Review
Achilles tendinopathy is one of the most common lower limb injuries in both athletes and the general population. Despite the plethora of conservative treatment options available for the management of Achilles tendinopathy, as many as one in four patients will go on to require surgery. Extracorporeal shockwave therapy (ESWT) has emerged as a promising treatment option and has been successful in the management of other common musculoskeletal injuries such as plantar fasciitis. However, the evidence for ESWT in the management of Achilles tendinopathy remains inconclusive. Therefore, the aim of this systematic review was to evaluate the current evidence for the use of ESWT in the management of midportion Achilles tendinopathy. A comprehensive literature search was conducted using the databases MEDLINE (Pubmed), AMED, EMBASE, CINAHL, and CENTRAL. The databases were searched from their inception to December 2021. This was conducted to identify randomised control trials (RCTs) evaluating the effectiveness of ESWT versus control treatment in the management of midportion Achilles tendinopathy. Following a comprehensive search of the literature, a total of 283 articles were identified. Following the screening of titles and abstracts, 236 articles were excluded. The main reasons for exclusion were the identification of duplicates, non-randomised studies, and the use of ESWT on other pathology. Following the exclusion of 236 articles, 47 articles were retrieved for full-text review. Of these 47 articles, 40 were excluded leaving a total of 7 RCTs eligible for inclusion in this review. There was consistent evidence from 4 RCTs that ESWT is effective in the management of midportion Achilles tendinopathy. This review suggests that ESWT is a safe and effective modality for treating midportion Achilles tendinopathy as it reduces pain and improves function. The best available evidence suggests that a combination of ESWT with eccentric exercises and stretching may be even more effective than ESWT alone. Further research is required to confirm this and to determine the optimum ESWT treatment protocol.
PubMed: 35989757
DOI: 10.7759/cureus.26960 -
Cureus Jul 2022Posterosuperior calcaneal prominence, also known as Haglund's deformity, can often lead to retrocalcaneal bursitis, a significant cause of posterior heel pain. Surgery... (Review)
Review
Posterosuperior calcaneal prominence, also known as Haglund's deformity, can often lead to retrocalcaneal bursitis, a significant cause of posterior heel pain. Surgery is indicated for symptomatic patients, after a period of conservative treatment including analgesia, physiotherapy, activity, and shoe wear modification has failed. Surgical options include both open and endoscopic techniques, and typically involve excision of the retrocalcaneal bursa, resection of the calcaneal prominence, and debridement of the diseased Achilles tendon. This article aims to provide an evidence-based literature review for the surgical management of Haglund's deformity. A comprehensive evidence-based literature review of the PubMed database conducted in July 2021 identified 20 relevant articles assessing the efficacy of surgical modalities for Haglund's deformity. The 20 studies were assigned to a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against the surgical modality. Qualitative and quantitative analysis was performed for the 20 studies. The results show that both open and endoscopic surgical modalities are efficacious in the treatment of Haglund's deformity, significantly improving functional outcome scores such as American Orthopaedic Foot & Ankle Society (AOFAS) scores and patient satisfaction post-operatively. Endoscopic surgery appears to have the advantage of shorter operative times, lower complication rates, and better cosmesis. More studies are required to further validate and optimize these surgical techniques.
PubMed: 36060327
DOI: 10.7759/cureus.27500 -
British Journal of Sports Medicine Nov 2019Achilles tendinopathy is a common problem, but its exact aetiology remains unclear.
BACKGROUND
Achilles tendinopathy is a common problem, but its exact aetiology remains unclear.
OBJECTIVE
To evaluate the association between potential clinical risk factors and Achilles tendinopathy.
DESIGN
Systematic review.
DATA SOURCES
The databases Embase, MEDLINE Ovid, Web of Science, Cochrane Library and Google Scholar were searched up to February 2018.
ELIGIBILITY CRITERIA
To answer our research question, cohort studies investigating risk factors for Achilles tendinopathy in humans were included. We restricted our search to potential clinical risk factors (imaging studies were excluded).
RESULTS
We included 10 cohort studies, all with a high risk of bias, from 5111 publications identified. There is limited evidence for nine risk factors: (1) prior lower limb tendinopathy or fracture, (2) use of ofloxacin (quinolone) antibiotics, (3) an increased time between heart transplantation and initiation of quinolone treatment for infectious disease, (4) moderate alcohol use, (5) training during cold weather, (6) decreased isokinetic plantar flexor strength, (7) abnormal gait pattern with decreased forward progression of propulsion, (8) more lateral foot roll-over at the forefoot flat phase and (9) creatinine clearance of <60 mL/min in heart transplant patients. Twenty-six other putative risk factors were not associated with Achilles tendinopathy, including being overweight, static foot posture and physical activity level.
CONCLUSION
From an ocean of studies with high levels of bias, we extracted nine clinical risk factors that may increase a person's risk of Achilles tendinopathy. Clinicians may consider ofloxacin use, alcohol consumption and a reduced plantar flexor strength as modifiable risk factors when treating patients with Achilles tendinopathy.
TRIAL REGISTRATION NUMBER
CRD42017053258.
Topics: Achilles Tendon; Alcohol Drinking; Cold Temperature; Foot; Gait; Heart Transplantation; Humans; Ofloxacin; Posture; Risk Factors; Tendinopathy
PubMed: 30718234
DOI: 10.1136/bjsports-2018-099991 -
Sports Medicine - Open May 2022Extracorporeal shockwave therapy (ESWT) is used commonly to treat pain and function in Achilles tendinopathy (AT). The aim of this study was to synthesize the evidence...
BACKGROUND
Extracorporeal shockwave therapy (ESWT) is used commonly to treat pain and function in Achilles tendinopathy (AT). The aim of this study was to synthesize the evidence from (non-) randomized controlled trials, to determine the clinical effectiveness of ESWT for mid-portion Achilles tendinopathy (mid-AT) and insertional Achilles tendinopathy (ins-AT) separately.
METHODS
We searched PubMed/Medline, Embase (Ovid), and Cochrane Central, up to January 2021. Unpublished studies and gray literature were searched in trial registers (ACTRN, ChiCTR, ChiCtr, CTRI, DRKS, EUCTR, IRCT, ISRCTN, JPRN UMIN, ClinicalTrials.gov, NTR, TCTR) and databases (OpenGrey.eu, NARCIS.nl, DART-Europe.org, OATD.org). Randomized controlled trials (RCTs) and non-randomized controlled clinical trials (CCTs) were eligible when investigating the clinical effectiveness of ESWT for chronic mid-AT or chronic ins-AT. We excluded studies that focused on treating individuals with systemic conditions, and studies investigating mixed cohorts of mid-AT and ins-AT, when it was not possible to perform a subgroup analysis for both clinical entities separately. Two reviewers independently performed the study selection, quality assessment, data extraction, and grading of the evidence levels. Discrepancies were resolved through discussion or by consulting a third reviewer when necessary.
RESULTS
We included three RCTs on mid-AT and four RCTs on ins-AT. For mid-AT, moderate quality of evidence was found for the overall effectiveness of ESWT compared to standard care, with a pooled mean difference (MD) on the VISA-A of 9.08 points (95% CI 6.35-11.81). Subgroup analysis on the effects of ESWT additional to standard care for mid-AT resulted in a pooled MD on the VISA-A of 10.28 points (95% CI 7.43-13.12). For ins-AT, we found very low quality of evidence, indicating that, overall, ESWT has no additional value over standard care, with a standardized mean difference (SMD) of - 0.02 (95% CI - 0.27 to 0.23). Subgroup analysis to determine the effect of ESWT additional to standard care for ins-AT showed a negative effect (SMD - 0.29; 95% CI - 0.56 to - 0.01) compared to standard care alone.
CONCLUSIONS
There is moderate evidence supporting the effectiveness of ESWT additional to a tendon loading program in mid-AT. Evidence supporting the effectiveness of ESWT for ins-AT is lacking.
TRIAL REGISTRATION
PROSPERO Database; No. CRD42021236107.
PubMed: 35552903
DOI: 10.1186/s40798-022-00456-5 -
The American Journal of Sports Medicine Jul 2018There has been a surge in high-level studies investigating platelet-rich plasma (PRP) for tendon and ligament injuries. A number of meta-analyses have been published,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
There has been a surge in high-level studies investigating platelet-rich plasma (PRP) for tendon and ligament injuries. A number of meta-analyses have been published, but few studies have focused exclusively on tendon and ligament injuries.
PURPOSE
To perform a meta-analysis assessing the ability of PRP to reduce pain in patients with tendon and ligament injuries.
STUDY DESIGN
Systematic review and meta-analysis.
METHODS
This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive search of the literature was carried out in April 2017 using electronic databases PubMed, MEDLINE, and the Cochrane Library. Only level 1 studies were included. Platelet and leukocyte count, injection volume, kit used, participant age/sex, comparator, and activating agent used were recorded. The short-term and long-term efficacy of PRP was assessed using the visual analog scale (VAS) to measure pain intensity. Injury subgroups (rotator cuff, tendinopathy, anterior cruciate ligament, and lateral epicondylitis) were evaluated. Funnel plots and the Egger test were used to screen for publication bias, and sensitivity analysis was performed to evaluate the effect of potential outliers by removing studies one at a time.
RESULTS
Thirty-seven articles were included in this review, 21 (1031 participants) of which could be included in the quantitative analysis. The majority of studies published investigated rotator cuff injuries (38.1%) or lateral epicondylitis (38.1%). Seventeen studies (844 participants) reported short-term VAS data, and 14 studies (771 participants) reported long-term VAS data. Overall, long-term follow-up results showed significantly less pain in the PRP group compared with the control group (weighted mean difference [WMD], -0.84; 95% CI, -1.23 to -0.44; P < .01). Patients treated with PRP for rotator cuff injuries (WMD, -0.53; 95% CI, -0.98 to -0.09; P = .02) and lateral epicondylitis (WMD, -1.39; 95% CI, -2.49 to -0.29; P = .01) reported significantly less pain in the long term. Substantial heterogeneity was reported at baseline ( I = 72.0%; P < .01), short-term follow-up ( I = 72.5%; P < .01), long-term follow-up ( I = 76.1%; P < .01), and overall ( I = 75.8%; P < .01). The funnel plot appeared to be asymmetric, with some missingness at the lower right portion of the plot suggesting possible publication bias.
CONCLUSION
This review shows that PRP may reduce pain associated with lateral epicondylitis and rotator cuff injuries.
Topics: Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Humans; Pain; Platelet-Rich Plasma; Rotator Cuff; Rotator Cuff Injuries; Tendinopathy; Tennis Elbow; Treatment Outcome; Visual Analog Scale
PubMed: 29268037
DOI: 10.1177/0363546517743746 -
British Journal of Sports Medicine Nov 2016This systematic review and meta-analysis sought to identify return to play (RTP) rates following Achilles tendon rupture and evaluate what measures are used to determine...
AIM
This systematic review and meta-analysis sought to identify return to play (RTP) rates following Achilles tendon rupture and evaluate what measures are used to determine RTP.
DESIGN
A systematic review and meta-analysis were performed. Studies were assessed for risk of bias and grouped based on repeatability of their measure of RTP determination.
DATA SOURCES
PubMed, CINAHL, Web of Science and Scopus databases were searched to identify potentially relevant articles.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Studies reporting RTP/sport/sport activity in acute, closed Achilles tendon rupture were included.
RESULTS
108 studies encompassing 6506 patients were included for review. 85 studies included a measure for determining RTP. The rate of RTP in all studies was 80% (95% CI 75% to 85%). Studies with measures describing determination of RTP reported lower rates than studies without metrics described, with rates being significantly different between groups (p<0.001).
CONCLUSIONS
80 per cent of patients returned to play following Achilles tendon rupture; however, the RTP rates are dependent on the quality of the method used to measure RTP. To further understand RTP after Achilles tendon rupture, a standardised, reliable and valid method is required.
PubMed: 27259751
DOI: 10.1136/bjsports-2016-096106 -
Clinical Orthopaedics and Related... Oct 2021Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study designs is problematic; multiarm clinical trials often are logistically constrained to small sample sizes, and traditional meta-analyses are limited to comparisons of only two treatments that have been compared in head-to-head trials. Network meta-analyses allow for simultaneous comparison of all existing treatments utilizing both direct (head-to-head comparison) and indirect (not previously compared head-to-head) evidence.
QUESTIONS/PURPOSES
We performed a network meta-analysis of randomized controlled trials (RCTs) to answer the following questions: Considering open repair, minimally invasive surgery (MIS) repair, functional rehabilitation, or primary immobilization for acute Achilles tendon ruptures, (1) which intervention is associated with the lowest risk of rerupture? (2) Which intervention is associated with the lowest risk of complications resulting in surgery?
METHODS
This study was conducted with methods guided by the Cochrane Handbook for Systematic Reviews of Interventions and is reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for incorporating network meta-analysis. Five databases and grey literature sources (such as major orthopaedic meeting presentation lists) were searched from inception to September 30, 2019. Included studies were RCTs comparing treatment of acute Achilles tendon ruptures using two or more of the following interventions: primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. We excluded studies enrolling patients with chronic ruptures, reruptures, and preexisting Achilles tendinopathy as well as studies with more than 20% loss to follow-up or less than 6 months of follow-up. Nineteen RCTs (1316 patients) were included in the final analysis. The mean number of patients per study treatment arm was 35 ± 16, mean age was 41 ± 5 years, mean sex composition was 80% ± 10% males, and mean follow-up was 22 ± 12 months. The four treatment groups were compared for the main outcomes of rerupture and complications resulting in operation. The analysis was conducted using random-effects Bayesian network meta-analysis with vague priors. Evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation methodology. We found risk of selection, attrition, and reporting bias to be low across treatments, and we found the risk of performance and detection bias to be high. Overall risk of bias between treatments appeared similar.
RESULTS
We found that treatment with primary immobilization had a greater risk of rerupture than open surgery (odds ratio 4.06 [95% credible interval {CrI} 1.47 to 11.88]; p < 0.05). There were no other differences between treatments for risk of rerupture. Minimally invasive surgery was ranked first for fewest complications resulting in surgery and was associated with a lower risk of complications resulting in surgery than functional rehabilitation (OR 0.16 [95% CrI 0.02 to 0.90]; p < 0.05), open surgery (OR 0.22 [95% CrI 0.04 to 0.93]; p < 0.05), and primary immobilization (OR < 0.01 [95% CrI < 0.01 to 0.01]; p < 0.05). Risk of complications resulting in surgery was no different between primary immobilization and open surgery (OR 1.46 [95% CrI 0.35 to 5.36]). Data for patient-reported outcome scores and return to activity were inappropriate for pooling secondary to considerable clinical heterogeneity and imprecision associated with small sample sizes.
CONCLUSION
Faced with acute Achilles tendon rupture, patients should be counseled that, based on the best-available evidence, the risk of rerupture likely is no different across contemporary treatments. Considering the possibly lower risk of complications resulting in surgery associated with MIS repair, patients and surgeons must balance any benefit with the potential risks of MIS techniques. As treatments continue to evolve, consistent reporting of validated patient-reported outcome measures is critically important to facilitate analysis with existing RCT evidence. Infrequent but serious complications such as rerupture and deep infection should be further explored to determine whether meaningful differences exist in specific patient populations.
LEVEL OF EVIDENCE
Level I, therapeutic study.
Topics: Achilles Tendon; Evidence-Based Medicine; Humans; Randomized Controlled Trials as Topic; Rupture; Tendon Injuries
PubMed: 34180874
DOI: 10.1097/CORR.0000000000001861