Preventive interventions for tendinopathy: A systematic review

doi:10.1016/j.jsams.2015.03.008

Journal of Science and Medicine in Sport

Volume 19, Issue 3, March 2016, Pages 205-211

https://doi.org/10.1016/j.jsams.2015.03.008 Get rights and content

Abstract

Objectives

Tendinopathy, the most prevalent tendon disorder which is considered as the clinical diagnosis of pain and dysfunction, is common in sports and its prevalence is ever-increasing. Despite the lack of clarity about risk factors, various preventive interventions for tendinopathy have been investigated. The main objective of this study is to review current preventive interventions for tendinopathy in the major regions: ankle, knee, hip, groin, shoulder and elbow.

Design

A systematic literature search was conducted.

Methods

The PubMed and Embase databases were explored to identify articles that met the inclusion criteria. The included studies were assessed on methodological quality and data was summarized.

Results

Ten articles were included that describe a wide variety of preventive interventions. These were divided into three categories: stretch and exercise interventions, shoe adaptations and other interventions. The methodological quality of the studies was moderate to high. Three out of ten studies showed a significant beneficial result.

Conclusions

There is limited evidence that a long-term intervention including balance training is effective in the prevention of patellar and Achilles tendinopathy. Shoe adaptations in the form of shock absorbing insoles could have a preventive effect on Achilles tendinopathy. Hormone replacement therapy seems to reduce the risk for structural Achilles tendon changes in active post-menopausal women. No evidence was found for a positive effect of stretching exercises. Prophylactic eccentric training and stretching can increase the risk of injury in asymptomatic players with patellar tendon abnormalities. A limited amount of studies was available and more research is needed on (multifactorial) etiology, risk factors and preventive interventions.

Introduction

Tendinopathy, the most prevalent tendon disorder which is considered as the clinical diagnosis of pain and dysfunction of a tendon, is common in sports and its prevalence is ever-increasing.1, 2, 3, 4 It is frequent among athletes but can also affect non-athletes.⁵ It affects more men than women and the general incidence of tendon injuries changes with age.3, 6, 7, 8, 9 Tendinopathy is characterized clinically by pain and dysfunction and histopathologically by tendon disrepair and degeneration.10, 11, 12 The prognosis is often poor, with a high incidence of chronicity and recurrence.13, 14, 15 Risk factors include the presence of a tendon abnormality as shown on ultrasound and a change in tendon load.10, 16 No established treatment method exists, thereby treatment usually consists of relative rest and load management. This makes the rehabilitation of tendinopathy a time-consuming process. The presumable consequences of this type of overuse injury constitute a major influence on an athlete's sports career, physical and psychosocial well-being, and quality of life.17, 18 These characteristics of tendinopathy stress the importance of prevention.19, 20

van Mechelen et al. designed a model for the development of preventive interventions for sports injuries.²¹ The first step in this model is to identify the extent of the injury problem, by describing injury incidence and indicators of severity. Second, etiologic factors and mechanisms that play a role in the emergence of the injury have to be described. The following step includes the development of measures that reduce the risk and/or severity of the sports injury, based on the etiological factors described in step 2. The fourth and final step comprises the evaluation of the effect of these measures by repeating step 1. According to this model, it is clear that knowledge of risk factors, including both extrinsic modifiable and intrinsic modifiable risk factors, is essential for the development of preventive measures.11, 21, 22 It is known that tendinopathy has a multifactorial etiology, but studies examining risk factors of tendinopathy show a lack of uniformity and statistical power and are mostly not prospective.11, 22

Despite the lack of clarity about risk factors, various preventive interventions for tendinopathy have already been described. The main objective of this study is to review current preventive interventions for tendinopathy in the major regions: ankle, knee, hip, groin, shoulder and elbow.

Section snippets

Methods

The focus of the review lay on tendinopathy in the major regions: ankle, knee, hip, groin, shoulder and elbow. The PubMed and Embase databases were explored in February 2015 to identify articles that met the inclusion criteria, using the search terms as shown in Table 1.

Articles were included if they met the following criteria: they studied a preventive intervention for tendinopathy in a specific tendon of the ankle, knee, hip, groin, shoulder or elbow, were written in English, the outcome

Results

The search in PubMed resulted in 945 articles and the search in Embase in 1036 articles. After removing duplicates and screening on title, abstract and full text, six articles remained in the analysis. The screening of reference lists led to four extra articles, which ultimately resulted in a total number of 10 included articles. Fig. 1 demonstrates a flowchart of the inclusion.

Nine studies investigated the effects of a preventive intervention on the incidence of tendinopathy and one study

Discussion

The objective of this review was to study the literature on preventive interventions associated with tendinopathy. Ten articles were included, of which three articles found a significant positive result of their intervention, all preventing Achilles tendinopathy. The first study found a positive effect of a program that included soccer specific balance training, the second of shock absorbing insoles and the third concluded that Hormone Replacement therapy (HRT) seems to reduce the risk for

Conclusion

The results of this systematic review show that there is limited evidence that a long-term intervention including balance training is effective in the prevention of patellar and Achilles tendinopathy. In addition, shoe adaptations in the form of shock absorbing insoles could have a preventive effect on Achilles tendinopathy. Hormone replacement therapy seems to reduce the risk for structural Achilles tendon changes in active post-menopausal women. No evidence was found for a positive effect of

Practical implications

•
The current review has shown that a prolonged (up to three years), combined intervention that includes balance training can have a preventive effect on patellar and Achilles tendinopathy.
•
Prevention of Achilles tendinopathy could possibly be achieved by shoe adaptations in the form of shock absorbing insoles and hormone replacement therapy in active post-menopausal women.
•
There is lack of evidence that frequently-performed stretch exercises are effective preventive interventions.
•
As the etiology

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Die Einlagenversorgung im Leistungssport stellt den Orthopädieschuhmacher vor besondere Herausforderungen. Auch wenn sich der Versorgungsablauf im Grundsatz kaum von dem bei Alltagspatienten unterscheidet, gilt es hinsichtlich der Befundung und Analyse sportspezifische Aspekte zu berücksichtigen. Die hierzu notwendigen Kenntnisse über funktionelle Anatomie, Pathologie und Biomechanik sind Voraussetzung, um den individuellen Bedürfnissen der Athleten zu begegnen und Beeinträchtigungen in dem eng getakteten Wettkampfkalender durch Fehlversorgungen zu vermeiden. Ziel dieses Beitrags ist es daher, ausgehend von einem Überblick über den allgemeinen Versorgungsstandard, ausgewählte Besonderheiten in der sportspezifischen Analyse darzustellen und deren Implikationen für die Einlagenversorgung auch anhand von Fallbeispielen zu verdeutlichen.
The provision of insoles in elite sports presents special challenges for orthopedic shoemakers. Although the supply process is essentially no different from that for everyday patients, it is important to consider important, sport-specific aspects with regard to the diagnosis and analysis. Knowledge of functional anatomy, pathology, and biomechanics is essential to meet the individual needs of athletes and avoid downtime in the tightly scheduled competition calendar due to incorrect treatments. The aim of this article is therefore to outline selected features of sports analysis based on an overview of the general standard of care and to highlight their implications for insole provision, using case examples.
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Citation Excerpt :
It is characterized by persistent tendon pain and loss of function related to mechanical loading (Scott et al., 2020). It is an overuse injury with a poor prognosis and high incidence of recurrence (Peters et al., 2016). Any tendon and its surrounding tissues may undergo a tendinopathic process.
The objective of the study is to evaluate the best available evidence on the effectiveness of DN in the management of tendinopathy.
Seven randomized control trials were selected following an electronic search in PubMed, Web of Science, Scopus, and SPORTDiscus databases. To be included in the current systematic review, the study had to be an RCT conducted on human participants, which investigated the effect of the DN technique on the management of tendinopathies. Only studies in the English language published in peer-reviewed journals between 1999 and 2020 were included. The methodological quality of the studies was assessed using the PEDro scale.
The PEDro score of the studies ranged from 5 to 9 with a mean score of 6.7 ± 1.2 (mean ± SD). A total of 357 participants were enrolled in the seven included studies, which were on greater trochanteric pain syndrome, lateral epicondylitis, supraspinatus tendinopathy and Achilles tendinopathy. DN was compared with various interventions, including platelet-rich plasma injection, autologous blood injection and non-steroidal anti-inflammatory medication. All the selected studies reported a significant positive effect of DN on pain intensity and other outcome measures, such as patient-specific functional score, disability index, range of motion and health-related quality of life.
The results indicate that DN appears to be as effective as other treatment methods at relieving pain and other symptoms of tendinopathy immediately after treatment and up to 6 months. DN can be considered among the many options available for the management of tendinopathy.
Interventions for prevention and in-season management of patellar tendinopathy in athletes: A scoping review
2022, Physical Therapy in Sport
Citation Excerpt :
The results of the search are reported in accordance with the PRISMA-ScR (Fig. 1). In accordance with guidance on conducting scoping reviews, critical appraisal was not conducted (Peters et al., 2016). Data were extracted from sources included in the scoping review by one reviewer (IB), with independent data extraction by a second reviewer (AM) for 10% of studies.
Patellar tendinopathy (PT) has a high prevalence in jumping athletes and presents a significant burden on athletes and clinicians due to its long-lasting duration and persistent symptoms. This scoping review aimed to map existing evidence on prevention and in-season management interventions for PT in athletes, evaluating intervention parameters and outcomes.
This scoping review was reported in accordance with the PRISMA-ScR. Databases searched included MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library (Controlled trials, Systematic reviews). All primary study designs investigating prevention or in-season management interventions for PT, while maintaining athletes in sport were considered for inclusion.
5987 articles were identified with 29 included in the review. Five studies investigated exercise-based prevention interventions on athletes at risk for PT, including two randomized controlled trials (RCTs), two cohort studies and one case-control study. 24 studies investigated in-season management or rehabilitation in athletes with PT, including 18 RCTs, three case reports, one cohort study, one case series, and one retrospective review. Of these 24 studies, 22 used various resistance training interventions, one used ESWT and one used patellar strapping and taping. The types of resistance training included eccentric, heavy-slow, isometric, inertial flywheel, blood-flow restriction, and isotonic training. Eccentric training was used in 9 studies, with single leg decline squats the most common exercise used in 7 studies. Outcome measures and intervention parameters were heterogenous throughout studies.
Despite a dearth of studies on preventative interventions for athletes with PT, resistance training may be a useful prophylactic method. Eccentric, heavy slow and isometric resistance training have been found to be feasible and clinically beneficial in-season. There are a lack of studies showing that ESWT offers any additional benefit over resistance training in competing athletes. Patellar strapping and taping may offer short-term pain relief during training and competition. Systematic reviews are required to make definitive recommendations for PT.
Preventive effect of tailored exercises on patellar tendinopathy in elite youth athletes: A cohort study
2022, Physical Therapy in Sport
To investigate the effects of an intervention with tailored exercises on the incidence of patellar tendinopathy (PT) in elite youth jumping athletes.
Prospective crossover cohort.
One sport club facility.
271 elite youth basketball and volleyball player were followed in the first year of the study (Observation year) and 270 athletes were followed in the second year (intervention year).
Incidence rates of PT per 1,000h of exposure. Cox survival analysis was used to verify the effects of the intervention (exercises implemented according to the findings of a preseason assessment) on PT incidence.
The exercise prevention program significantly reduced the number of cases of PT, with athletes submitted to the intervention showing 51% less risk of developing PT. The overall PT incidence in the Observation year (5.9 per 1,000h of exposure) was significantly higher than that in the intervention year (2.8 per 1,000h of exposure) (P = .037). Twenty-six athletes developed PT in the observation year, whereas 13 athletes developed PT in the intervention year.
A tailored preventive program may be able to reduce the incidence of patellar tendinopathy, especially in male youth volleyball athletes. Randomized controlled trials are encouraged to confirm these findings.
Relationship between the architecture and function of ankle plantar flexors with Achilles tendon morphology in ballet dancers
2019, Human Movement Science
Citation Excerpt :
These aspects highlight the importance of studies involving tendon morphology in ballet dancers. This is especially relevant considering the lack of evidence regarding preventive programs for AT (Peters, Zwerver, Diercks, Elferink-Gemser, & van den Akker-Scheek, 2016). Therefore, the present study aimed to assess whether there is a relationship between Achilles tendon morphology, gastrocnemius muscle architecture and ankle plantar flexors function (strength, flexibility and endurance) in ballet dancers.
Achilles tendinopathy is the most frequent foot overuse injury in ballet dancers and knowledge of clinically modifiable factors related to tendon structure in a population at risk, such as ballet dancers, would be important for the development of preventive programs. Therefore, the present study aimed to assess relationships of gastrocnemius muscle architecture and ankle plantar flexors function with Achilles tendon morphology in ballet dancers. Fifty-four measures from 27 ballet dancers were collected. Tendon morphology (thickness, echogenicity, hypoechoic areas and neovascularisation) and muscle architecture (thickness, pennation angle and fascicle length) were evaluated using ultrasonography; ankle plantar flexors torque was evaluated using hand-held dynamometry, flexibility was evaluated in maximal weight-bearing ankle dorsiflexion position using inclinometer, and endurance was evaluated using the heel rise test. Ankle plantar flexors torque and medial gastrocnemius muscle architecture (thickness, pennation angle and fascicle length) are associated with Achilles tendon thickness in ballet dancers (r² = 0.24, p = 0.008). Ankle plantar flexors torque and medial gastrocnemius muscle fascicle length are also associated with the echogenicity of the Achilles tendon (r² = 0.13, p = 0.03). These findings call attention to the potential importance of ankle plantar flexors muscle force in healthy ballet dancers for the prevention of alterations in Achilles tendon structure.
Magnolol prevents ossified tendinopathy by inhibiting PGE2-induced osteogenic differentiation of TDSCs
2019, International Immunopharmacology
Citation Excerpt :
Thus, based on in vitro experiments in TDSCs, we depicted the molecular mechanism by which magnolol prevents (Heterotopic) ossification (Fig. 8). Tendon injuries often result from excessive or repetitive mechanical loading, impairing the ability of the local tendon cell population to maintain normal tendon function [26]. Excessive mechanical loading is the major factor that initiates tendon injury and degeneration, and thus the healing process begins [1,6].
Magnolol is a compound that is extracted from magnolia, is used in Chinese medicine and is a type of lignan. Magnolol has various anti-inflammation, anti-proliferation and pro-autophagy effects. Ossified tendinopathy affects many athletes and people with repetitive tendon injuries. Ossified tendinopathy is a tremendous economic burden, and no effective and safe drugs are available to prevent the pathogenesis of ectopic ossification. In this study, we aimed to study how magnolol affects ossified tendinopathy by evaluating its effects on osteogenic differentiation of tendon-derived stem cells (TDSCs). Our data suggested that magnolol attenuated ectopic ossification in the Achilles tendon caused by Achilles tenotomy. Magnolol inhibited PGE2-induced ALP activity and prevented calcium deposits in TDSCs in vitro. Magnolol also exerted inhibitory effects on expression of osteogenic factors, such as Runx2, OCN, and BMP2 in vivo. Further investigation revealed the underlying mechanism by which magnolol prevents PGE2-induced ectopic ossification. Specifically, magnolol inhibits PGE2-induced PI3K/AKT/β-catenin pathway activation in TDSCs. Our findings demonstrated that magnolol inhibited ossified tendinopathy through preventing osteogenic differentiation of TDSCs via downregulation PGE2-induced PI3K/AKT/β-catenin pathways.

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ReviewPreventive interventions for tendinopathy: A systematic review

Abstract

Objectives

Design

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Practical implications

Foot Ankle Clin

Clin Sports Med

Clin Sports Med

Phys Ther Sport

Clin Sports Med

Aust J Physiother

J Manipulative Physiol Ther

Tendinopathy in sport

Sports Health

Tendinopathy: a major medical problem in sport, chapter 1

Tendinopathy in Athletes

Incidence of midportion Achilles tendinopathy in the general population

Br J Sports Med

Lesions of the flexor carpi radialis tendon and sheath causing pain at the wrist

J Bone Joint Surg Br

Computerized recording of visits to an outpatient sports clinic

Am J Sports Med

Achilles tendon injuries in athletes

Sports Med

Is tendon pathology a continuum?. A pathology model to explain the clinical presentation of load-induced tendinopathy

Br J Sports Med

The basic science of tendinopathy

Clin Orthop Relat Res

A cross sectional study of 100 athletes with jumper's knee managed conservatively and surgically. The Victorian Institute of Sport Tendon Study Group

Br J Sports Med

Prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in Achilles and patellar tendons: the Danish Super League Study

Am J Sports Med

Long-term prognosis for jumper's knee in male athletes. A prospective follow-up study

Am J Sports Med

Is compressive load a factor in the development of tendinopathy?

Br J Sports Med

No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports

Br J Sports Med

Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study

Am J Sports Med

Risk factors for patellar tendinopathy: a systematic review of the literature

Br J Sports Med

Running injuries. A review of the epidemiological literature

Sports Med

Risk factors for patellar tendinopathy in basketball and volleyball players: a cross-sectional study

Scand J Med Sci Sports

Review
Preventive interventions for tendinopathy: A systematic review