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Eccentric rehabilitation for runners with Achilles tendinopathy improves endurance capacity of the plantarflexors
WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS833–eS1237
Plantarflexor muscle endurance was measured during concentric–eccentric muscle contractions at 90◦ /sec over 20 repetitions using a Humac Norm Isokinetic dynamometer. Testing utilised an 80◦ knee flexed position as this significantly inhibits Gastrocnemius thereby testing the function of Soleus, which is the endurance muscle. Previous work has already shown that Soleus is most affected by tendinopathy. Total work done was used to measure endurance capacity as it has been shown to be the most reliable measure. Results: Participants with tendinopathy had a mean total work done of 1313 NM on the symptomatic side and 1490 NM on the non-symptomatic side, whilst controls had a mean of 1900 NM. This data clearly shows that those with tendinopathy have a lower endurance than healthy age, sex and activity matched controls. Independent t tests show a clear statistical difference between the symptomatic leg and healthy controls (p = 0.001) and between the non-symptomatic leg and healthy controls (p = 0.006). There was a significant difference between symptomatic and non-symptomatic legs in participants with disease (p = 0.009). Conclusion(s): Runners with Achilles tendinopathy have less Plantarflexor endurance capacity compared to those without tendinopathy. These differences are bilateral and may be associated with central nervous system changes or may be pre-existing weakness. Further research needs to ascertain whether these differences are pre-existing and lead to tendinopathy or are a direct result of tendinopathy. Future prospective risk factor studies need to incorporate Plantarflexor endurance in addition to strength parameters so that a more comprehensive understanding of neuromuscular factors can be developed. Implications: Endurance is affected by tendinopathy and as such conservative management (Physiotherapy) needs to fully resolve these deficits. This research highlights that the contralateral limb should not be used as a “normal” measure of endurance and that further studies need to use healthy control data. Keywords: Achilles;. Tendinopathy; Tendinitis Funding acknowledgements: No funding was provided for this study. Ethics approval: Ethics approval was provided by the University of Leicester ethics committee. http://dx.doi.org/10.1016/j.physio.2015.03.2051
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Research Report Poster Presentation Number: RR-PO-21-22-Sun Sunday 3 May 2015 13:00 Exhibit halls 401–403 ECCENTRIC REHABILITATION FOR RUNNERS WITH ACHILLES TENDINOPATHY IMPROVES ENDURANCE CAPACITY OF THE PLANTARFLEXORS S. O’Neill 1 , P. Watson 2 , S. Barry 3 1 University
of Leicester, Medical and Social Care Education, Leicester, United Kingdom; 2 University of Leicester, Health Sciences, Leicester, United Kingdom; 3 Coventry University, Department of Applied Sciences and Health, Coventry, United Kingdom Background: Our previous work has highlighted that runners with Achilles tendinopathy have lowered Plantarflexor endurance capacity compared to healthy controls. It is currently unknown how common tendinopathy rehabilitation protocols alter this deficit in endurance capacity. Purpose: To determine how an eccentric rehabilitation protocol alters Plantarflexor endurance capacity in participants with Achilles tendinopathy. Methods: 20 endurance runners with Achilles tendinopathy were recruited and underwent an eccentric rehabilitation program based on Alfredson’s regime. Achilles tendinopathy was diagnosed on clinical and ultrasonographic examination. Inclusion criteria were – symptoms for 3 months or more. Participants were excluded if they had insertional tendinopathy, bilateral tendinopathy or a clinical history and/or ultrasound diagnosis suggestive of partial rupture. A control group of 24 healthy endurance runners was used from a previous study. These participants were age, sex, leg and activity matched to the Achilles tendinopathy group. Plantarflexor muscle endurance was measured during concentric and eccentric muscle contractions at 90◦ /sec over 20 repetitions using a Humac Norm Isokinetic dynamometer. This testing protocol has been shown to be reliable. Endurance can be measured using “total work done”, “fatigue index” or “endurance ratio”, but previous work has identified that “total work done” measured in Newton Metres (NM) is the most reliable measure. Participants with Achilles tendinopathy were tested at baseline and after 12 weeks of an eccentric exercise regime whilst the control group were only tested at one time point. Results: At baseline participants with tendinopathy had a mean total work done of 1168 NM on the symptomatic side and 1350 NM on the non-symptomatic side, whilst healthy controls had a mean of 1900 NM. After completion of the intervention protocol the symptomatic leg increased to 1618 NM whilst the non-symptomatic leg increased to 1763 NM. The intervention significantly increased endurance capacity of the symptomatic and non-symptomatic legs (p ≥ 0.001).
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WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS833–eS1237
Baseline testing comparing those with Achilles tendinopathy to healthy controls showed a clear difference between the groups (p ≥ 0.001 for symptomatic and non-symptomatic sides) whilst after rehabilitation there is no statistical difference on the symptomatic or non-symptomatic leg (p = 0.103 and p = 0.332). Conclusion(s): This was the first study to determine how an eccentric exercise regime for the Plantarflexors affects endurance capacity in those with Achilles tendinopathy. This study highlighted significant differences in endurance capacity prior to the intervention, these deficits were resolved after the completion of an eccentric regime. This study also highlights that eccentric rehabilitation regimes alter endurance capacity in both legs despite only being performed on one leg. Implications: Eccentric exercise protocols appear to correct endurance capacity of those with tendinopathy, further studies need to determine if this is critical to good clinical outcomes. Keywords: Achilles; Tendinopathy; Tendinitis Funding acknowledgements: No funding was provided for this study. Ethics approval: Ethics approval was provided by the University of Leicester ethics committee. http://dx.doi.org/10.1016/j.physio.2015.03.2052 Research Report Poster Presentation Number: RR-PO-06-08-Sat Saturday 2 May 2015 13:00 Exhibit halls 401–403 NOVEL METHOD FOR EVALUATION OF SUBTALAR JOINT ALIGNMENT UNDER WEIGHT-BEARING CONDITIONS USING LASER BEAM T. Onishi 1,2 , M. Hida 3 , Y. Nakamura 4 , T. Honda 5 , C. Wada 6 1 Engineering
Kyushu Institute of Technology, Department of Human Intelligence Systems, Kitakyushu, Japan; 2 Showa Inan General Hospital, Department of Rehabilitation, Komagane, Japan; 3 Division of Physical Therapy, Faculty of Allied Health Sciences, Yamato University, Department of Rehabilitation, Suita City, Japan; 4 Shinshu University School of Medicine, Department of Orthopaedic Surgery, Matsumoto, Japan; 5 Showa Inan General Hospital, Department of Rehabilitation medicine, Komagane, Japan; 6 Graduate School of Life Science and Systems Engineering Kyushu Institute of Technology, Department of Human Intelligence Systems, Kitakyushu, Japan Background: It is difficult to accurately measure the alignment of the subtalar joint (STJ) through the skin surface under weight-bearing conditions because there are extensive
individual differences in the shape and motion axis. However, the movement of STJ is important in the human kinematic chain. Therefore, we propose a new method for measuring the degree of STJ varus/valgus alignment through the skin surface using a laser beam. We believe our method will allow the assessment of STJ alignment not only at a healthcare institution with well-trained medical staff but also at a nursery where such staff is unavailable. This report shows correlation of the alignment data obtained using our new method with X-ray. Purpose: To develop a method for assessing STJ alignment under weight-bearing conditions using a laser beam through the skin surface. Methods: Sixteen subjects (73.8 ± 9.9 years old, 3 males and 13 females), diagnosed with an orthopedic disease, were enrolled. The assessment of STJ alignment through the skin surface was conducted according to the method by Elveru (1988). First, subjects maintained a prone position and the outline of the calcaneus was palpated in order to mark three points to bisect the calcaneus into the inside and outside parts. Second, subjects were asked to stand and a laser was then applied. The laser beam was vertically applied from the floor to pass the median of the trochlea of talus, which was 1 cm above the center of the malleolus lateralis. Whether the STJ alignment was “valgus” or “varus” was determined as follows. If all three points were located on the laser beam, then the STJ alignment was determined to be neutral. If the points were located inside the laser beam, then the STJ alignment was determined to be “varus.” Further, if the points were located outside the laser beam, the STJ alignment was labeled “valgus.” The degree of STJ varus/valgus alignment was subdivided into seven groups by a researcher. We tested whether our varus/valgus classification of the STJ alignment correlated with that obtained using X-ray. We assessed the STJ varus/valgus status by radiography under weight-bearing conditions using Cobey’s method (1976). Spearman’s rank correlation coefficient was used to analyze the correlation between the two methods. Results: There was a strong negative correlation between our method and X-ray imaging (r = −0.83, P = 0.0002). Conclusion(s): Our method strongly correlates with Xray analysis and allows an accurate measurement of the varus/valgus degree of STJ alignment. We believe this method will provide physical therapists and other medical staff at healthcare institutions with important information on the STJ alignment under weight-bearing conditions because our method seems to work well under such conditions. In future, we plan to enroll more subjects to assess reliability and validity of the method. Implications: We developed a new method for measuring the degree of STJ varus/valgus alignment using a laser beam. Keywords: Subtalar joint; Laser beam; Weight-bearing Funding acknowledgements: This study was not funded.
Plantarflexor muscle endurance was measured during concentric–eccentric muscle contractions at 90◦ /sec over 20 repetitions using a Humac Norm Isokinetic dynamometer. Testing utilised an 80◦ knee flexed position as this significantly inhibits Gastrocnemius thereby testing the function of Soleus, which is the endurance muscle. Previous work has already shown that Soleus is most affected by tendinopathy. Total work done was used to measure endurance capacity as it has been shown to be the most reliable measure. Results: Participants with tendinopathy had a mean total work done of 1313 NM on the symptomatic side and 1490 NM on the non-symptomatic side, whilst controls had a mean of 1900 NM. This data clearly shows that those with tendinopathy have a lower endurance than healthy age, sex and activity matched controls. Independent t tests show a clear statistical difference between the symptomatic leg and healthy controls (p = 0.001) and between the non-symptomatic leg and healthy controls (p = 0.006). There was a significant difference between symptomatic and non-symptomatic legs in participants with disease (p = 0.009). Conclusion(s): Runners with Achilles tendinopathy have less Plantarflexor endurance capacity compared to those without tendinopathy. These differences are bilateral and may be associated with central nervous system changes or may be pre-existing weakness. Further research needs to ascertain whether these differences are pre-existing and lead to tendinopathy or are a direct result of tendinopathy. Future prospective risk factor studies need to incorporate Plantarflexor endurance in addition to strength parameters so that a more comprehensive understanding of neuromuscular factors can be developed. Implications: Endurance is affected by tendinopathy and as such conservative management (Physiotherapy) needs to fully resolve these deficits. This research highlights that the contralateral limb should not be used as a “normal” measure of endurance and that further studies need to use healthy control data. Keywords: Achilles;. Tendinopathy; Tendinitis Funding acknowledgements: No funding was provided for this study. Ethics approval: Ethics approval was provided by the University of Leicester ethics committee. http://dx.doi.org/10.1016/j.physio.2015.03.2051
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Research Report Poster Presentation Number: RR-PO-21-22-Sun Sunday 3 May 2015 13:00 Exhibit halls 401–403 ECCENTRIC REHABILITATION FOR RUNNERS WITH ACHILLES TENDINOPATHY IMPROVES ENDURANCE CAPACITY OF THE PLANTARFLEXORS S. O’Neill 1 , P. Watson 2 , S. Barry 3 1 University
of Leicester, Medical and Social Care Education, Leicester, United Kingdom; 2 University of Leicester, Health Sciences, Leicester, United Kingdom; 3 Coventry University, Department of Applied Sciences and Health, Coventry, United Kingdom Background: Our previous work has highlighted that runners with Achilles tendinopathy have lowered Plantarflexor endurance capacity compared to healthy controls. It is currently unknown how common tendinopathy rehabilitation protocols alter this deficit in endurance capacity. Purpose: To determine how an eccentric rehabilitation protocol alters Plantarflexor endurance capacity in participants with Achilles tendinopathy. Methods: 20 endurance runners with Achilles tendinopathy were recruited and underwent an eccentric rehabilitation program based on Alfredson’s regime. Achilles tendinopathy was diagnosed on clinical and ultrasonographic examination. Inclusion criteria were – symptoms for 3 months or more. Participants were excluded if they had insertional tendinopathy, bilateral tendinopathy or a clinical history and/or ultrasound diagnosis suggestive of partial rupture. A control group of 24 healthy endurance runners was used from a previous study. These participants were age, sex, leg and activity matched to the Achilles tendinopathy group. Plantarflexor muscle endurance was measured during concentric and eccentric muscle contractions at 90◦ /sec over 20 repetitions using a Humac Norm Isokinetic dynamometer. This testing protocol has been shown to be reliable. Endurance can be measured using “total work done”, “fatigue index” or “endurance ratio”, but previous work has identified that “total work done” measured in Newton Metres (NM) is the most reliable measure. Participants with Achilles tendinopathy were tested at baseline and after 12 weeks of an eccentric exercise regime whilst the control group were only tested at one time point. Results: At baseline participants with tendinopathy had a mean total work done of 1168 NM on the symptomatic side and 1350 NM on the non-symptomatic side, whilst healthy controls had a mean of 1900 NM. After completion of the intervention protocol the symptomatic leg increased to 1618 NM whilst the non-symptomatic leg increased to 1763 NM. The intervention significantly increased endurance capacity of the symptomatic and non-symptomatic legs (p ≥ 0.001).
eS1144
WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS833–eS1237
Baseline testing comparing those with Achilles tendinopathy to healthy controls showed a clear difference between the groups (p ≥ 0.001 for symptomatic and non-symptomatic sides) whilst after rehabilitation there is no statistical difference on the symptomatic or non-symptomatic leg (p = 0.103 and p = 0.332). Conclusion(s): This was the first study to determine how an eccentric exercise regime for the Plantarflexors affects endurance capacity in those with Achilles tendinopathy. This study highlighted significant differences in endurance capacity prior to the intervention, these deficits were resolved after the completion of an eccentric regime. This study also highlights that eccentric rehabilitation regimes alter endurance capacity in both legs despite only being performed on one leg. Implications: Eccentric exercise protocols appear to correct endurance capacity of those with tendinopathy, further studies need to determine if this is critical to good clinical outcomes. Keywords: Achilles; Tendinopathy; Tendinitis Funding acknowledgements: No funding was provided for this study. Ethics approval: Ethics approval was provided by the University of Leicester ethics committee. http://dx.doi.org/10.1016/j.physio.2015.03.2052 Research Report Poster Presentation Number: RR-PO-06-08-Sat Saturday 2 May 2015 13:00 Exhibit halls 401–403 NOVEL METHOD FOR EVALUATION OF SUBTALAR JOINT ALIGNMENT UNDER WEIGHT-BEARING CONDITIONS USING LASER BEAM T. Onishi 1,2 , M. Hida 3 , Y. Nakamura 4 , T. Honda 5 , C. Wada 6 1 Engineering
Kyushu Institute of Technology, Department of Human Intelligence Systems, Kitakyushu, Japan; 2 Showa Inan General Hospital, Department of Rehabilitation, Komagane, Japan; 3 Division of Physical Therapy, Faculty of Allied Health Sciences, Yamato University, Department of Rehabilitation, Suita City, Japan; 4 Shinshu University School of Medicine, Department of Orthopaedic Surgery, Matsumoto, Japan; 5 Showa Inan General Hospital, Department of Rehabilitation medicine, Komagane, Japan; 6 Graduate School of Life Science and Systems Engineering Kyushu Institute of Technology, Department of Human Intelligence Systems, Kitakyushu, Japan Background: It is difficult to accurately measure the alignment of the subtalar joint (STJ) through the skin surface under weight-bearing conditions because there are extensive
individual differences in the shape and motion axis. However, the movement of STJ is important in the human kinematic chain. Therefore, we propose a new method for measuring the degree of STJ varus/valgus alignment through the skin surface using a laser beam. We believe our method will allow the assessment of STJ alignment not only at a healthcare institution with well-trained medical staff but also at a nursery where such staff is unavailable. This report shows correlation of the alignment data obtained using our new method with X-ray. Purpose: To develop a method for assessing STJ alignment under weight-bearing conditions using a laser beam through the skin surface. Methods: Sixteen subjects (73.8 ± 9.9 years old, 3 males and 13 females), diagnosed with an orthopedic disease, were enrolled. The assessment of STJ alignment through the skin surface was conducted according to the method by Elveru (1988). First, subjects maintained a prone position and the outline of the calcaneus was palpated in order to mark three points to bisect the calcaneus into the inside and outside parts. Second, subjects were asked to stand and a laser was then applied. The laser beam was vertically applied from the floor to pass the median of the trochlea of talus, which was 1 cm above the center of the malleolus lateralis. Whether the STJ alignment was “valgus” or “varus” was determined as follows. If all three points were located on the laser beam, then the STJ alignment was determined to be neutral. If the points were located inside the laser beam, then the STJ alignment was determined to be “varus.” Further, if the points were located outside the laser beam, the STJ alignment was labeled “valgus.” The degree of STJ varus/valgus alignment was subdivided into seven groups by a researcher. We tested whether our varus/valgus classification of the STJ alignment correlated with that obtained using X-ray. We assessed the STJ varus/valgus status by radiography under weight-bearing conditions using Cobey’s method (1976). Spearman’s rank correlation coefficient was used to analyze the correlation between the two methods. Results: There was a strong negative correlation between our method and X-ray imaging (r = −0.83, P = 0.0002). Conclusion(s): Our method strongly correlates with Xray analysis and allows an accurate measurement of the varus/valgus degree of STJ alignment. We believe this method will provide physical therapists and other medical staff at healthcare institutions with important information on the STJ alignment under weight-bearing conditions because our method seems to work well under such conditions. In future, we plan to enroll more subjects to assess reliability and validity of the method. Implications: We developed a new method for measuring the degree of STJ varus/valgus alignment using a laser beam. Keywords: Subtalar joint; Laser beam; Weight-bearing Funding acknowledgements: This study was not funded.