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Achilles tendon is not a single elastic structure: Preconditioning of different regions of Achilles tendon
Abstracts / Journal of Science and Medicine in Sport 19S (2015) e88–e104
218 Testing the effectiveness of prolotherapy compared to physiotherapy for tennis elbow: A randomised control trial L. Bisset ∗ , M. Yelland, M. Ryan, S. Ng, D. Rabago Menzies Health Institute Queensland, Griffith University, Australia Introduction: Chronic lateral epicondylosis (LE), also known as ‘tennis elbow’, is a common and costly type of tendinopathy primarily of the common extensor tendon of the elbow. Approximately 20% of all tendinopathy cases are recalcitrant to conservative treatment, leaving these patients with little recourse other than living with the condition or progressing to surgery. Prolotherapy is an emerging injection therapy thought to stimulate tendon repair and has demonstrated some efficacy in the Achilles tendon. A specific physiotherapy program is known to be effective in both the short and long-term in people with LE. The aim of this randomised controlled trial is to examine the short-term clinical effectiveness of prolotherapy (Prolo) alone, and in combination with physiotherapy, compared to physiotherapy alone (PT). Methods: 120 participants with a clinical diagnosis of LE were randomised by concealed allocation to one of three treatment groups: Prolo, Prolo + PT, or PT. Prolo comprised a series of four injections of dextrose delivered at monthly intervals. PT comprised four sessions of manual therapy and exercise over a 4-week period. Blinded follow-up assessments occurred at baseline and 12 weeks follow-up. The primary outcome measure was the change in Patient Rated Tennis Elbow Evaluation (PRTEE) and self-perceived global improvement, from which success was calculated. Analyses were conducted on an intention-to-treat basis using linear mixed and logistic regression models. Results: 120 (62 men; mean age 49.8 ± 7.8 years) participants were enrolled in the study and 109 (91%) completed the 12-week follow up. There was a significant effect of Time (p < 0.001) but no Time × Group interaction (p = 0.2) for PRTEE. PRTEE scores significantly improved from baseline to 12 weeks follow up by 16 (95% CI 9.9–22.5) points for Prolo, 21.9 (95%CI 15.6–28.3) points for Prolo + PT, and 23.7 (95% CI 16.8–30.7) points for PT. There was no difference between groups for success at 12 weeks (p = 0.7), with 46% in the Prolo, 54% in Prolo + PT and 56% in the PT group reporting their condition as either much improved or completely recovered. Discussion: Overall, there was no difference in outcomes between prolotherapy injections and physiotherapy, and no added benefit in combing the two treatments. There is a need for cost evaluation and long-term follow up assessment to determine whether the short-term improvements are maintained. http://dx.doi.org/10.1016/j.jsams.2015.12.369
e99
Award Finalist 219 Achilles tendon is not a single elastic structure: Preconditioning of different regions of Achilles tendon L. Nuri ∗ , R. Newsham-West, M. Ryan Griffith University, Centre for Musculoskeletal Research, Australia Background: Preconditioning is a process where successive standardized cyclic loading is applied to the tissue in an attempt to produce a consistent and repeatable mechanical response. Recent biomechanical studies demonstrated that two different regions of Achilles tendon (AT) (e.g., proximal AT and free AT) exhibit different elastic behavior during submaximal contraction of plantarflexors. However, these studies have not addressed whether or not these regions exhibit different viscoelastic behavior during cyclic preconditioning. Freehand three-dimensional (3D) ultrasonography (US) has recently been described that provides a reliable and high fidelity assessment of in-vivo human AT tissue elasticity. The present study aimed to use 3DUS to investigate the preconditioning process of the free AT, proximal AT and whole AT (e.g., free AT + proximal AT) experiencing 70% maximal voluntary isometric contraction (MVIC) in vivo. Methods: Eleven healthy male adults (means ± SD for age, height, and weight were 28y, 177.63 cm, and 76.72 kg respectively) were positioned prone on a test bench, with their left knee and hip at full extension and left ankle at 90◦ . The 3DUS scan involved synchronous B-mode ultrasound imaging and 3D motion capture of the position and orientation of the transducer while successive crosssectional images were collected by sweeping a transducer from the base of the heel to medial gastrocnemius muscle tendon junction in a transverse orientation at a steady speed. Scanning was performed at rest and during 10 successive ankle plantarflexion movements at 70% of their MVIC. The resultant ultrasound images were imported into Stradwin software (Cambridge, UK) to render a 3D reconstruction of AT for the measurement purposes. For each trial, AT strain was calculated as the ratio (%) of tendon elongation relative to the resting length. Results: There was a significant main effect of contraction numbers on free AT and whole AT strain response, with no changes obtained after the second and the third contraction for the respective regions. Furthermore, significant reduction in free AT and whole AT compliance was observed following successive trials. Regarding the proximal AT strain, no significant difference was found between contractions. Discussion: The different preconditioning response across the free AT, proximal AT and whole AT documented in this study supports previous studies reporting non-uniform strain distribution between two regions of the human AT. This finding may have important implications for standard warm up and preconditioning protocol of AT in athletic, research, and clinical communities. http://dx.doi.org/10.1016/j.jsams.2015.12.370
218 Testing the effectiveness of prolotherapy compared to physiotherapy for tennis elbow: A randomised control trial L. Bisset ∗ , M. Yelland, M. Ryan, S. Ng, D. Rabago Menzies Health Institute Queensland, Griffith University, Australia Introduction: Chronic lateral epicondylosis (LE), also known as ‘tennis elbow’, is a common and costly type of tendinopathy primarily of the common extensor tendon of the elbow. Approximately 20% of all tendinopathy cases are recalcitrant to conservative treatment, leaving these patients with little recourse other than living with the condition or progressing to surgery. Prolotherapy is an emerging injection therapy thought to stimulate tendon repair and has demonstrated some efficacy in the Achilles tendon. A specific physiotherapy program is known to be effective in both the short and long-term in people with LE. The aim of this randomised controlled trial is to examine the short-term clinical effectiveness of prolotherapy (Prolo) alone, and in combination with physiotherapy, compared to physiotherapy alone (PT). Methods: 120 participants with a clinical diagnosis of LE were randomised by concealed allocation to one of three treatment groups: Prolo, Prolo + PT, or PT. Prolo comprised a series of four injections of dextrose delivered at monthly intervals. PT comprised four sessions of manual therapy and exercise over a 4-week period. Blinded follow-up assessments occurred at baseline and 12 weeks follow-up. The primary outcome measure was the change in Patient Rated Tennis Elbow Evaluation (PRTEE) and self-perceived global improvement, from which success was calculated. Analyses were conducted on an intention-to-treat basis using linear mixed and logistic regression models. Results: 120 (62 men; mean age 49.8 ± 7.8 years) participants were enrolled in the study and 109 (91%) completed the 12-week follow up. There was a significant effect of Time (p < 0.001) but no Time × Group interaction (p = 0.2) for PRTEE. PRTEE scores significantly improved from baseline to 12 weeks follow up by 16 (95% CI 9.9–22.5) points for Prolo, 21.9 (95%CI 15.6–28.3) points for Prolo + PT, and 23.7 (95% CI 16.8–30.7) points for PT. There was no difference between groups for success at 12 weeks (p = 0.7), with 46% in the Prolo, 54% in Prolo + PT and 56% in the PT group reporting their condition as either much improved or completely recovered. Discussion: Overall, there was no difference in outcomes between prolotherapy injections and physiotherapy, and no added benefit in combing the two treatments. There is a need for cost evaluation and long-term follow up assessment to determine whether the short-term improvements are maintained. http://dx.doi.org/10.1016/j.jsams.2015.12.369
e99
Award Finalist 219 Achilles tendon is not a single elastic structure: Preconditioning of different regions of Achilles tendon L. Nuri ∗ , R. Newsham-West, M. Ryan Griffith University, Centre for Musculoskeletal Research, Australia Background: Preconditioning is a process where successive standardized cyclic loading is applied to the tissue in an attempt to produce a consistent and repeatable mechanical response. Recent biomechanical studies demonstrated that two different regions of Achilles tendon (AT) (e.g., proximal AT and free AT) exhibit different elastic behavior during submaximal contraction of plantarflexors. However, these studies have not addressed whether or not these regions exhibit different viscoelastic behavior during cyclic preconditioning. Freehand three-dimensional (3D) ultrasonography (US) has recently been described that provides a reliable and high fidelity assessment of in-vivo human AT tissue elasticity. The present study aimed to use 3DUS to investigate the preconditioning process of the free AT, proximal AT and whole AT (e.g., free AT + proximal AT) experiencing 70% maximal voluntary isometric contraction (MVIC) in vivo. Methods: Eleven healthy male adults (means ± SD for age, height, and weight were 28y, 177.63 cm, and 76.72 kg respectively) were positioned prone on a test bench, with their left knee and hip at full extension and left ankle at 90◦ . The 3DUS scan involved synchronous B-mode ultrasound imaging and 3D motion capture of the position and orientation of the transducer while successive crosssectional images were collected by sweeping a transducer from the base of the heel to medial gastrocnemius muscle tendon junction in a transverse orientation at a steady speed. Scanning was performed at rest and during 10 successive ankle plantarflexion movements at 70% of their MVIC. The resultant ultrasound images were imported into Stradwin software (Cambridge, UK) to render a 3D reconstruction of AT for the measurement purposes. For each trial, AT strain was calculated as the ratio (%) of tendon elongation relative to the resting length. Results: There was a significant main effect of contraction numbers on free AT and whole AT strain response, with no changes obtained after the second and the third contraction for the respective regions. Furthermore, significant reduction in free AT and whole AT compliance was observed following successive trials. Regarding the proximal AT strain, no significant difference was found between contractions. Discussion: The different preconditioning response across the free AT, proximal AT and whole AT documented in this study supports previous studies reporting non-uniform strain distribution between two regions of the human AT. This finding may have important implications for standard warm up and preconditioning protocol of AT in athletic, research, and clinical communities. http://dx.doi.org/10.1016/j.jsams.2015.12.370