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Conservative management of Achilles tendinopathy: A mixed methods study, integrating a systematic review and clinical reasoning
Thursday 1 November Papers / Journal of Science and Medicine in Sport 15 (2013) S34–S126
231 Specific hip muscle atrophy with acetabular labral tears D. Mendis 1,2,∗ , S. Wilson 2 , D. Hayes 3 , J. Hides 1 1
Australian Catholic University The University of Queensland 3 Brisbane Orthopaedic and Sports Medicine Centre 2
Introduction: Acetabular labral tears are a source of hip and groin pain in active individuals and are thought to be a precursor to hip osteoarthritis. Currently, limited evidence exists to guide appropriate physiotherapy management for this population of patients. Identification of which hip muscles are affected by labral tear pathology may help to develop effective exercise programs to treat these patients. However, there is little information in the literature about individual hip muscle size in patients with labral tear pathology. This study aimed to investigate hip muscle size and symmetry in patients with acetabular labral tears compared to healthy subjects. Methods: 12 participants (8 females, 4 males), aged 20 to 53 years, with a unilateral acetabular labral tear were recruited from an orthopaedic practice prior to undergoing hip arthroscopy. 12 healthy participants matched for age and gender were recruited from a general university population. Magnetic resonance imaging was used to examine the lumbo-pelvic region of all participants. Muscle cross-sectional areas of the piriformis, iliacus, psoas, gluteus minimus, gluteus medius, upper gluteus maximus and lower gluteus maximus muscles on both sides were measured. Repeated measures ANOVA was used to examine differences in hip muscle size between groups (labral tear vs healthy) and between sides (dominant vs non-dominant leg). Results: Gluteus medius muscle cross-sectional area was found to be significantly different between groups (p < 0.01) with muscle size found to be smaller in the labral tear group. For the lower gluteus maximus muscle, a significant interaction effect of group and side was found (p < 0.03) with muscle cross-sectional area on the dominant leg found to be smaller in the labral tear group. No differences were found for the other hip muscles (p > 0.05). Discussion and Conclusions: The results suggest that not all hip muscles are affected equally by the presence of acetabular labral pathology. Specific atrophy of the gluteus medius muscle, which is important in hip joint and pelvic stability, and the lower gluteus maximus muscle, which contributes to hip extension and absorbing ground reaction forces in gait, may alter hip joint function. Further research needs to investigate if motor control and strength in these muscles is also affected. Clinicians treating patients with acetabular labral tears may need to prescribe exercises targeted to the specific muscle dysfunction observed. http://dx.doi.org/10.1016/j.jsams.2012.11.234 232 Patellar tendon stiffness is responsive to load intensity but not contraction type among healthy young men P. Malliaras 1,2,∗ , A. Nowell 1 , B. Kamal 1 , T. Farley 1 , H. Dhamu 1 1 2
Queen Mary, University of London PhysioEast
Introduction: There is some evidence that isolated eccentric muscle contractions (eccentric training) are effective in managing patellar and Achilles tendinopathy. The underlying mechanisms of eccentric training are not known and may include a differential or greater response of the muscle, tendon or nervous system with
S97
eccentric contraction, or even a specific effect on pain mechanisms. The aim of this study was to investigate the effect of contraction type and load intensity on patellar tendon stiffness response among healthy participants. Method: 38 healthy men between 18–35 years old were recruited and randomized into four groups: control (n = 9), concentric training (n = 9), eccentric low load training (n = 10) and eccentric high load training (n = 10). Each group performed progressive loaded leg extension training three times per week for 12 weeks, with 5 seconds of time under tension for each contraction. Exercises were monitored and 5 repetition maximum (RM) measured once per week. Load was equalized in the eccentric low load and concentric training groups (80% of concentric 1 RM). Load was higher in the eccentric high load group (80% of eccentric 1 RM). Patellar tendon elongation was measured in vivo with ultrasound during a maximal isometric voluntary contraction and used to calculate tendon stiffness. Results: All participants completed the exercise program and compliance was between 81–100%. Mean 5 RM performance increased significantly in all exercise groups but increase was significantly greater in the eccentric high load groups (p < .05). Patellar tendon stiffness increased in all exercises groups over the 12 week intervention period (mean ± SD change: concentric = + 738 ± 859 Nm, eccentric low = + 714 ± 885, eccentric high = + 1121 ± 971) but this change was only significantly different to the control group (-11 ± 327) in the eccentric high load group (p < .05). Discussion: Although all exercise groups could be classified as ‘high’ load, patellar tendon stiffness only increased in the most intense group (80% of eccentric 1 RM). No increase in patellar tendon stiffness was identified at the lower intensity (80% of concentric 1 RM), regardless of contraction type. Contraction type may be less important than load-intensity for increasing tendon stiffness. Increased tendon stiffness may not explain improved patellar tendinopathy symptoms with eccentric training as load-intensity of studies in the literature may not be great enough, although the response of painful/pathological tendon may be different. http://dx.doi.org/10.1016/j.jsams.2012.11.235 233 Conservative management of Achilles tendinopathy: A mixed methods study, integrating a systematic review and clinical reasoning V. Rowe, S. Hemmings, C. Barton ∗ , P. Malliaras, N. Maffulli, D. Morrissey Centre for Sports and Exercise Medicine, Queen Mary University Introduction: The conservative management of Achilles tendinopathy requires clinicians to combine clinical reasoning with the underpinning evidence base. This study aimed to produce a multi-faceted description of clinical practice and guide future research by combining an inclusive review of the current literature with a narrative of expert physiotherapists’ clinical reasoning. Methods: Electronic databases PubMed, ISI Web of Science, PEDro, CINAHL, Embase, and Google Scholar were searched for papers published up to November 2011 evaluating conservative management for mid-portion Achilles tendinopathy. Further searches of reference lists and citation tracking were also completed. Each study was scored using the PEDro scale, with a score of > 8/10 considered of excellent quality, 5–7/10 good, and < 4/10 poor. Evidence for each treatment modality was then graded according to the number and quality of supporting studies: ‘strong,’ ‘moderate,’ ‘limited,’ ‘conflicting, or ‘no evidence’. Clinical reason-
S98
Thursday 1 November Papers / Journal of Science and Medicine in Sport 15 (2013) S34–S126
ing was explored in a purposive sample of consenting experienced physiotherapists using semi-structured interviews until data saturation. Interviews were analysed using the framework method to reveal emerging themes, with this data then being used to illustrate the systematic review data. Results: Initial searching yielded a total of 3497 studies. Forty seven of these met the inclusion criteria. In total, 11 separate treatment modalities were identified, with strong evidence supporting eccentric exercises and extra-corporeal shockwave therapy (ESWT) and moderate evidence for low-level laser therapy, and concentric exercises. Limited evidence was found for foot orthoses and therapeutic ultrasound. Taping and soft-tissue mobilisation studies were only identified by case studies/series rather than randomised controlled trials. There was conflicting evidence for topical glyceryl trinitrate. Framework analysis of semi-structured interviews revealed common themes which highlighted that physiotherapists were frequently utilising eccentric exercises, based on their strong evidence base. Manual therapy was also frequently applied, and foot orthoses prescription was often considered. Barriers to translating the research into practice included heterogeneous outcome measures employed in different studies, over-stringency of traditional evidence synthesis approaches and lack of access to primary research reports. Discussion: The graded evidence combined with qualitatively analysed clinical reasoning produced a novel guide for clinicians conservatively managing mid-portion Achilles tendinopathy. Additionally, these findings allow experienced clinicians to review the evidence base and reflect on their clinical reasoning. Key areas for future research include evaluating the efficacy of foot orthoses, manual therapy, aetiological factors, how to manage different stages of presentation such as reactive or degenerative tendinopathy and eccentric exercise protocol adaptation. http://dx.doi.org/10.1016/j.jsams.2012.11.236 234
for hamstring muscle pairs e.g. biceps femoris short head (BFSH): biceps femoris long head (BFLH) ratio as well as for a medial vs lateral muscle group comparison e.g. BFSH + BFLH: semitendinosus (ST) + semimembranosus (SM) ratio. Results: Manual segmentation of axial MR images was shown to have high reliability for determining hamstring muscle volumes with CV’s ranging from 1.1% for SM to 2.7% for BFSH. Baseline normative muscle ratio data for the various muscle pair comparisons are presented as median (interquartile range 25%–75%) values with preferred kicking leg defining dominance. The following ratios were found; BFSH:BFLHdominant 0.53(0.46–0.62), BFSH:BFLHnon-dominant 0.50(0.47–0.58); ST:SMdominant 0.98(0.91–1.03), ST:SMnon-dominant 0.95(0.86–1.02). The normative muscle ratios for the medial vs lateral muscle group comparison were BFLH + BFSH:ST + SMdominant 0.68(0.64–0.70), BFLH + BFSH:ST + SMnon-dominant 0.65(0.62–0.71). In a first series of analyses, SSM was able to accurately classify players with injured vs non-injured BFLH. Conclusion: The current hamstring muscle morphometric data in uninjured players provides valuable “normative” data for future prospective studies into hamstring strains. The large differences in the volume ratios between the BFLH and BFSH maybe of potential importance in (re)injury of the hamstrings as may the smaller overall lateral vs medial muscle group volume (∼30%) given the predominance of lateral hamstring strains. Information provided by SSM on shape parameters in relation to muscle injury may provide information of further clinical interest. http://dx.doi.org/10.1016/j.jsams.2012.11.237 235 Hip and groin MRI and US findings in elite asymptomatic Australian football players G. Lammers 1,∗ , D. Connell 1 , P. Baquie 2 , T. Page 3 , M. Opar 4 1
Imaging @ Olympic Park, Victoria Hawthorn Football Club 3 Collingwood Football Club 4 La Trobe University 2
Muscle morphometry of the individual hamstring muscles in semi-elite AFL Players: Preliminary findings from a longitudinal study T. Brancato 1,∗ , C. Engstrom 1 , J. Fripp 2,1 1 2
The University of Queensland Commonwealth Scientific and Industrial Research Organisation
Introduction: Hamstring strains in the Australian Football League (AFL) have a high incidence (15%) and recurrence rate (34%) with lateral hamstring injuries most common (83%). Retrospective studies have found significant muscle volume asymmetries ≤23 months post hamstring injury; however examination of the association between hamstring strains and muscle asymmetry has not been investigated prospectively. This study presents baseline data from a longitudinal study focusing on individual hamstring morphometry in uninjured and injured semi-elite AFL players. Methods: Bilateral, contiguous 5 mm axial magnetic resonance (MR) images of the hamstring muscles were acquired from 26 male semi-elite AFL players (23 ± 4 years, 6 ± 4 years playing history at semi-elite level; uninjured [N = 16], self-reported previous hamstring injury [N = 10]). Manual segmentation procedures for the MR images were extensive with reliability analyses conducted using Coefficients of Variation (CV) and Dice Coefficients. Slice sampling and statistical shape modelling (SSM) approaches were also explored as a means of increasing the clinical applicability and efficiency of morphometric analyses. In the uninjured players, “normative” unilateral and bilateral volume ratios were calculated
Introduction: Hip and groin pain is a common injury at the elite level of Australian football with musculoskeletal imaging playing an important role in diagnosis. Radiology findings in athletes without pain are important as they increase diagnostic accuracy and improve the ability to interpret findings with clinical relevance. Several MRI studies exist that report on findings in asymptomatic athletes. However, recent advances in the understanding of enthesopathy and the potential contribution of the hip joint in the development of groin pain warrants further MRI investigation in asymptomatic athletes. When considering pathologies associated with groin pain ultrasound (US) may be a more relevant diagnostic tool for some structures including the adductor tendons, inguinal ligament and conjoint tendon. Ultrasound studies are less frequent in groin pain research with the exception of hernia studies. The purpose of this study was to examine US and MRI findings in asymptomatic Australian football players and to compare findings with the development of hip and groin symptoms in the following season. Methods: Sixty-three Australian football players from two AFL clubs completed US and MRI imaging during the 2011 preseason. At the time of imaging all players were free of groin pain symptoms. All images were independently reviewed by two radiologists with 19 and 15 years of clinical experience. Throughout the season, players were tracked for onset of symptoms by club medical staff and compared against pre-season imaging findings.
231 Specific hip muscle atrophy with acetabular labral tears D. Mendis 1,2,∗ , S. Wilson 2 , D. Hayes 3 , J. Hides 1 1
Australian Catholic University The University of Queensland 3 Brisbane Orthopaedic and Sports Medicine Centre 2
Introduction: Acetabular labral tears are a source of hip and groin pain in active individuals and are thought to be a precursor to hip osteoarthritis. Currently, limited evidence exists to guide appropriate physiotherapy management for this population of patients. Identification of which hip muscles are affected by labral tear pathology may help to develop effective exercise programs to treat these patients. However, there is little information in the literature about individual hip muscle size in patients with labral tear pathology. This study aimed to investigate hip muscle size and symmetry in patients with acetabular labral tears compared to healthy subjects. Methods: 12 participants (8 females, 4 males), aged 20 to 53 years, with a unilateral acetabular labral tear were recruited from an orthopaedic practice prior to undergoing hip arthroscopy. 12 healthy participants matched for age and gender were recruited from a general university population. Magnetic resonance imaging was used to examine the lumbo-pelvic region of all participants. Muscle cross-sectional areas of the piriformis, iliacus, psoas, gluteus minimus, gluteus medius, upper gluteus maximus and lower gluteus maximus muscles on both sides were measured. Repeated measures ANOVA was used to examine differences in hip muscle size between groups (labral tear vs healthy) and between sides (dominant vs non-dominant leg). Results: Gluteus medius muscle cross-sectional area was found to be significantly different between groups (p < 0.01) with muscle size found to be smaller in the labral tear group. For the lower gluteus maximus muscle, a significant interaction effect of group and side was found (p < 0.03) with muscle cross-sectional area on the dominant leg found to be smaller in the labral tear group. No differences were found for the other hip muscles (p > 0.05). Discussion and Conclusions: The results suggest that not all hip muscles are affected equally by the presence of acetabular labral pathology. Specific atrophy of the gluteus medius muscle, which is important in hip joint and pelvic stability, and the lower gluteus maximus muscle, which contributes to hip extension and absorbing ground reaction forces in gait, may alter hip joint function. Further research needs to investigate if motor control and strength in these muscles is also affected. Clinicians treating patients with acetabular labral tears may need to prescribe exercises targeted to the specific muscle dysfunction observed. http://dx.doi.org/10.1016/j.jsams.2012.11.234 232 Patellar tendon stiffness is responsive to load intensity but not contraction type among healthy young men P. Malliaras 1,2,∗ , A. Nowell 1 , B. Kamal 1 , T. Farley 1 , H. Dhamu 1 1 2
Queen Mary, University of London PhysioEast
Introduction: There is some evidence that isolated eccentric muscle contractions (eccentric training) are effective in managing patellar and Achilles tendinopathy. The underlying mechanisms of eccentric training are not known and may include a differential or greater response of the muscle, tendon or nervous system with
S97
eccentric contraction, or even a specific effect on pain mechanisms. The aim of this study was to investigate the effect of contraction type and load intensity on patellar tendon stiffness response among healthy participants. Method: 38 healthy men between 18–35 years old were recruited and randomized into four groups: control (n = 9), concentric training (n = 9), eccentric low load training (n = 10) and eccentric high load training (n = 10). Each group performed progressive loaded leg extension training three times per week for 12 weeks, with 5 seconds of time under tension for each contraction. Exercises were monitored and 5 repetition maximum (RM) measured once per week. Load was equalized in the eccentric low load and concentric training groups (80% of concentric 1 RM). Load was higher in the eccentric high load group (80% of eccentric 1 RM). Patellar tendon elongation was measured in vivo with ultrasound during a maximal isometric voluntary contraction and used to calculate tendon stiffness. Results: All participants completed the exercise program and compliance was between 81–100%. Mean 5 RM performance increased significantly in all exercise groups but increase was significantly greater in the eccentric high load groups (p < .05). Patellar tendon stiffness increased in all exercises groups over the 12 week intervention period (mean ± SD change: concentric = + 738 ± 859 Nm, eccentric low = + 714 ± 885, eccentric high = + 1121 ± 971) but this change was only significantly different to the control group (-11 ± 327) in the eccentric high load group (p < .05). Discussion: Although all exercise groups could be classified as ‘high’ load, patellar tendon stiffness only increased in the most intense group (80% of eccentric 1 RM). No increase in patellar tendon stiffness was identified at the lower intensity (80% of concentric 1 RM), regardless of contraction type. Contraction type may be less important than load-intensity for increasing tendon stiffness. Increased tendon stiffness may not explain improved patellar tendinopathy symptoms with eccentric training as load-intensity of studies in the literature may not be great enough, although the response of painful/pathological tendon may be different. http://dx.doi.org/10.1016/j.jsams.2012.11.235 233 Conservative management of Achilles tendinopathy: A mixed methods study, integrating a systematic review and clinical reasoning V. Rowe, S. Hemmings, C. Barton ∗ , P. Malliaras, N. Maffulli, D. Morrissey Centre for Sports and Exercise Medicine, Queen Mary University Introduction: The conservative management of Achilles tendinopathy requires clinicians to combine clinical reasoning with the underpinning evidence base. This study aimed to produce a multi-faceted description of clinical practice and guide future research by combining an inclusive review of the current literature with a narrative of expert physiotherapists’ clinical reasoning. Methods: Electronic databases PubMed, ISI Web of Science, PEDro, CINAHL, Embase, and Google Scholar were searched for papers published up to November 2011 evaluating conservative management for mid-portion Achilles tendinopathy. Further searches of reference lists and citation tracking were also completed. Each study was scored using the PEDro scale, with a score of > 8/10 considered of excellent quality, 5–7/10 good, and < 4/10 poor. Evidence for each treatment modality was then graded according to the number and quality of supporting studies: ‘strong,’ ‘moderate,’ ‘limited,’ ‘conflicting, or ‘no evidence’. Clinical reason-
S98
Thursday 1 November Papers / Journal of Science and Medicine in Sport 15 (2013) S34–S126
ing was explored in a purposive sample of consenting experienced physiotherapists using semi-structured interviews until data saturation. Interviews were analysed using the framework method to reveal emerging themes, with this data then being used to illustrate the systematic review data. Results: Initial searching yielded a total of 3497 studies. Forty seven of these met the inclusion criteria. In total, 11 separate treatment modalities were identified, with strong evidence supporting eccentric exercises and extra-corporeal shockwave therapy (ESWT) and moderate evidence for low-level laser therapy, and concentric exercises. Limited evidence was found for foot orthoses and therapeutic ultrasound. Taping and soft-tissue mobilisation studies were only identified by case studies/series rather than randomised controlled trials. There was conflicting evidence for topical glyceryl trinitrate. Framework analysis of semi-structured interviews revealed common themes which highlighted that physiotherapists were frequently utilising eccentric exercises, based on their strong evidence base. Manual therapy was also frequently applied, and foot orthoses prescription was often considered. Barriers to translating the research into practice included heterogeneous outcome measures employed in different studies, over-stringency of traditional evidence synthesis approaches and lack of access to primary research reports. Discussion: The graded evidence combined with qualitatively analysed clinical reasoning produced a novel guide for clinicians conservatively managing mid-portion Achilles tendinopathy. Additionally, these findings allow experienced clinicians to review the evidence base and reflect on their clinical reasoning. Key areas for future research include evaluating the efficacy of foot orthoses, manual therapy, aetiological factors, how to manage different stages of presentation such as reactive or degenerative tendinopathy and eccentric exercise protocol adaptation. http://dx.doi.org/10.1016/j.jsams.2012.11.236 234
for hamstring muscle pairs e.g. biceps femoris short head (BFSH): biceps femoris long head (BFLH) ratio as well as for a medial vs lateral muscle group comparison e.g. BFSH + BFLH: semitendinosus (ST) + semimembranosus (SM) ratio. Results: Manual segmentation of axial MR images was shown to have high reliability for determining hamstring muscle volumes with CV’s ranging from 1.1% for SM to 2.7% for BFSH. Baseline normative muscle ratio data for the various muscle pair comparisons are presented as median (interquartile range 25%–75%) values with preferred kicking leg defining dominance. The following ratios were found; BFSH:BFLHdominant 0.53(0.46–0.62), BFSH:BFLHnon-dominant 0.50(0.47–0.58); ST:SMdominant 0.98(0.91–1.03), ST:SMnon-dominant 0.95(0.86–1.02). The normative muscle ratios for the medial vs lateral muscle group comparison were BFLH + BFSH:ST + SMdominant 0.68(0.64–0.70), BFLH + BFSH:ST + SMnon-dominant 0.65(0.62–0.71). In a first series of analyses, SSM was able to accurately classify players with injured vs non-injured BFLH. Conclusion: The current hamstring muscle morphometric data in uninjured players provides valuable “normative” data for future prospective studies into hamstring strains. The large differences in the volume ratios between the BFLH and BFSH maybe of potential importance in (re)injury of the hamstrings as may the smaller overall lateral vs medial muscle group volume (∼30%) given the predominance of lateral hamstring strains. Information provided by SSM on shape parameters in relation to muscle injury may provide information of further clinical interest. http://dx.doi.org/10.1016/j.jsams.2012.11.237 235 Hip and groin MRI and US findings in elite asymptomatic Australian football players G. Lammers 1,∗ , D. Connell 1 , P. Baquie 2 , T. Page 3 , M. Opar 4 1
Imaging @ Olympic Park, Victoria Hawthorn Football Club 3 Collingwood Football Club 4 La Trobe University 2
Muscle morphometry of the individual hamstring muscles in semi-elite AFL Players: Preliminary findings from a longitudinal study T. Brancato 1,∗ , C. Engstrom 1 , J. Fripp 2,1 1 2
The University of Queensland Commonwealth Scientific and Industrial Research Organisation
Introduction: Hamstring strains in the Australian Football League (AFL) have a high incidence (15%) and recurrence rate (34%) with lateral hamstring injuries most common (83%). Retrospective studies have found significant muscle volume asymmetries ≤23 months post hamstring injury; however examination of the association between hamstring strains and muscle asymmetry has not been investigated prospectively. This study presents baseline data from a longitudinal study focusing on individual hamstring morphometry in uninjured and injured semi-elite AFL players. Methods: Bilateral, contiguous 5 mm axial magnetic resonance (MR) images of the hamstring muscles were acquired from 26 male semi-elite AFL players (23 ± 4 years, 6 ± 4 years playing history at semi-elite level; uninjured [N = 16], self-reported previous hamstring injury [N = 10]). Manual segmentation procedures for the MR images were extensive with reliability analyses conducted using Coefficients of Variation (CV) and Dice Coefficients. Slice sampling and statistical shape modelling (SSM) approaches were also explored as a means of increasing the clinical applicability and efficiency of morphometric analyses. In the uninjured players, “normative” unilateral and bilateral volume ratios were calculated
Introduction: Hip and groin pain is a common injury at the elite level of Australian football with musculoskeletal imaging playing an important role in diagnosis. Radiology findings in athletes without pain are important as they increase diagnostic accuracy and improve the ability to interpret findings with clinical relevance. Several MRI studies exist that report on findings in asymptomatic athletes. However, recent advances in the understanding of enthesopathy and the potential contribution of the hip joint in the development of groin pain warrants further MRI investigation in asymptomatic athletes. When considering pathologies associated with groin pain ultrasound (US) may be a more relevant diagnostic tool for some structures including the adductor tendons, inguinal ligament and conjoint tendon. Ultrasound studies are less frequent in groin pain research with the exception of hernia studies. The purpose of this study was to examine US and MRI findings in asymptomatic Australian football players and to compare findings with the development of hip and groin symptoms in the following season. Methods: Sixty-three Australian football players from two AFL clubs completed US and MRI imaging during the 2011 preseason. At the time of imaging all players were free of groin pain symptoms. All images were independently reviewed by two radiologists with 19 and 15 years of clinical experience. Throughout the season, players were tracked for onset of symptoms by club medical staff and compared against pre-season imaging findings.