Martin Fahlström

New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study

Background: Chronic painful insertional Achilles tendinopathy is seen in both physically active and non-active individuals. Painful eccentric training, where the patients load the Achilles tendon into full dorsiflexion, has shown good results in patients with mid-portion Achilles tendinosis. However, only 32% of patients with insertional Achilles tendinopathy had good clinical results with that type of eccentric training regimen. Aim: To investigate whether a new model of painful eccentric training had an effect on chronic painful insertional Achilles tendinopathy. Patients and methods: 27 patients (12 men, 15 women, mean age 53 years) with a total of 34 painful Achilles tendons with a long duration of pain (mean 26 months), diagnosed as insertional Achilles tendinopathy, were included. The patients performed a new model of painful eccentric training regimen without loading into dorsiflexion. This was done as 3×15 reps, twice a day, 7 days/week, for 12 weeks. Pain during Achilles-tendon-loading activity (VAS) and patient’s satisfaction (back to previous activity) were evaluated. Results: At follow-up (mean 4 months) 18 patients (67%, 23/34 tendons) were satisfied and back to their previous tendon-loading activity. Their mean VAS had decreased from 69.9 (SD 18.9) to 21 (SD 20.6) (p<0.001). Nine patients (11 tendons) were not satisfied with the treatment, although their VAS was significantly reduced from 77.5 (8.6) to 58.1 (14.8) (p<0.01). Conclusion: In this short-term pilot study this new model of painful eccentric calf-muscle training showed promising clinical results in 67% of the patients.

Glutamate NMDAR1 receptors localised to nerves in human Achilles tendons. Implications for treatment

In this investigation, we show the presence of both free glutamate (microdialysis) and glutamate NMDAR1 receptors (immunohistochemical analyses of tendon biopsies), in tendons from patients with chronic Achilles tendon pain (Achilles tendinosis) and in controls (pain-free tendons). The NMDAR1 immunoreaction was usually confined to acetylcholinesterase-positive structures, implying that the reaction is present in nerves. Glutamate is a potent pain mediator in the human central nervous system, and in animals it has been shown that peripherally administered glutamate NMDA receptor antagonists diminish the response to formalin-induced nociception. Our present finding of glutamate NMDA receptors in human Achilles tendons might have implications for pain treatment.

Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study

Background: “Tennis elbow” is a difficult condition to treat. Ultrasonography (US) and colour Doppler (CD) guided injections with polidocanol targeting the area with increased blood flow in the extensor origin have shown promising clinical results. Objective: To evaluate and compare effects of US and CD guided intratendinous injections with sclerosing polidocanol and a local anaesthetic (lidocaine + epinephrine), in patients with tennis elbow. Design: Prospective, randomised, controlled, double-blind, crossover study. Setting: Sports Medicine Unit, Umeå University. Patients: 32 patients (36 elbows), age range 27 to 66 years, with a long duration of elbow pain diagnosed as tennis elbow, were included in the study. All patients were followed up 3 and 12 months after treatment. Two patients were excluded due to other interventions during the study. Interventions: One US and CD guided injection with the sclerosing agent polidocanol (group 1) or the local anaesthetic lidocaine plus epinephrine (group 2). At the 3 month follow-up, additional injections with polidocanol were offered to both groups (crossover for group 2). Main outcome measures: Satisfaction with treatment (Yes/No), elbow pain during activity (visual analogue scale), and maximum voluntary grip strength. Results: There were no significant (p<0.05) differences in the outcome between group 1 and group 2. In both groups, there was a significantly lower VAS at the 3-month and 12-month follow-ups, and grip strength was significantly higher at the 12-month follow-up. Conclusions: US and CD guided intratendinous injections gave pain relief in patients with tennis elbow. Polidocanol and lidocaine plus epinephrine injections gave similar results.

Sclerosing polidocanol injections or arthroscopic shaving to treat patellar tendinopathy/jumper's knee? A randomised controlled study

Background Proximal patellar tendinopathy/jumpers knee (PT/JK) is well known to be difficult to treat. Recent studies using an ultrasound and colour Doppler-based treatment approach on the dorsal side of the tendon, sclerosing polidocanol injections and ultrasound-guided arthroscopic shaving, have shown promising clinical results. Objectives To compare the clinical effects after treatment with sclerosing polidocanol injections and arthroscopic shaving. Material and methods 52 patellar tendons (43 men and two women) with ultrasound and colour Doppler-verified diagnosis of PT/JK were randomly assigned to treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections (group A) or ultrasound and colour Doppler-guided arthroscopic shaving (group B). All patients were involved in patellar tendon loading sports or recreational activities, and had had a long duration of pain symptoms from the proximal patellar tendon. Pain during patellar tendon loading activity, and at rest, before and after treatment (visual analogue scale; VAS), and patient satisfaction with the result of the treatment, was registered. Results After treatment, the patients treated with arthroscopic shaving had a significantly lower VAS score at rest and during activity, and were significantly more satisfied compared with the patients in the sclerosing injection group. Conclusions Both treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections and arthroscopic shaving showed good clinical results, but patients treated with arthroscopic shaving had less pain and were more satisfied with the treatment result. Because surgical treatment is a one-stage treatment return to sports was faster in this group.

Kinesiophobia in patients with chronic musculoskeletal pain: differences between men and women.

OBJECTIVE To investigate the degree of kinesiophobia in patients with chronic pain, to examine differences in kinesiophobia and other pain-related characteristics between men and women, and to examine differences in pain-related characteristics between patients with high and low levels of kinesiophobia. DESIGN Postal survey. SUBJECTS/PATIENTS Eighty-eight men and 173 women with chronic musculoskeletal pain. METHODS Patients completed questionnaires covering background data, pain variables, disability and psychological characteristics. The Swedish version of Tampa Scale for Kinesiophobia (TSK-SV) was used to measure kinesiophobia. RESULTS Kinesiophobia (TSK-SV score >37) was found in 56% of patients, with men having a higher frequency (72%) than women (48%). Pain intensity was correlated with TSK-SV score in both men and women. No correlations were found between kinesiophobia and age, pain duration or probable depression/anxiety. Women with high kinesiophobia tended to be younger, had more pain and showed more tiredness, disability, stress, interference and life dissatisfaction compared with women with low kinesiophobia. These differences were not seen in men. CONCLUSION The results indicate differences between men and women with chronic pain. The use of the TSK-SV questionnaire might assist therapists to identify patients whose fear of movement may negatively impact their rehabilitation. There is some evidence to suggest that optimal cut-off scores may differ between male and female patients.

Painful conditions in the Achilles tendon region in elite badminton players.

The purpose of this study was to investigate the prevalence and characteristics of painful conditions in the Achilles tendon region in elite badminton players. The study group consisted of 66 players in the Swedish elite division (highest level) in badminton, 41 men (mean age, 24.4 years) and 25 women (mean age, 21.9 years). Twenty-one players (32%) reported the occurrence of a disabling painful condition in the Achilles tendon region during the previous 5 years, and 11 players (17%) had an ongoing painful condition. A majority of the painful conditions (12 of 21, or 57%) were described as involving the midportion of the Achilles tendon. The players who had a painful condition reported a significantly higher weekly training load as measured by the number of hours spent in total training, badminton training, and endurance and strength training. There were no differences in age, sex, and body mass index between the players with and without painful conditions in the Achilles tendon region.

Acute Achilles Tendon Rupture in Badminton Players

All patients with badminton-related acute Achilles tendon ruptures registered during 1990 to 1994 at the University Hospital of Umeå were retrospectively followed up using a questionnaire. Thirty-one patients (mean age, 36.0 years), 27 men and 4 women, were included. Thirty patients (97%) described themselves as recreational players or beginners. The majority of the injuries (29 of 31, 94%) happened at the middle or end of the planned game. Previous local symptoms had been noticed by five patients (16%). Long-term results showed that patients treated with surgery had a significantly shorter sick leave absence than patients treated without surgery (50 versus 75 days). There was no obvious selection favoring any treatment modality. None of the surgically treated patients had reruptures, but two reruptures occurred in the nonsurgically treated group. There seemed to be fewer remaining symptoms and a higher sports activity level after the injury in the surgically treated group. Our results indicate that local muscle fatigue may interfere with strength and coordination. Preventive measures such as specific treatment of minor injuries and adequate training of strength, endurance, and coordination are important. Our findings also indicate that surgical treatment and careful postoperative rehabilitation is of great importance among badminton players of any age or sports level with Achilles tendon ruptures.

A two-year sonographic follow-up after intratendinous injection therapy in patients with tennis elbow

Background Tennis elbow is a tendinopathy affecting the upper extremity. Recent studies have shown high sensitivity for ultrasound (US) examination and high specificity for colour Doppler (CD) examination. There are no mid- or long-term follow-up investigations of the tendon structure and blood flow using these techniques. Objective To use US and CD to study structure and blood flow in the extensor origin in patients with tennis elbow treated with intratendinous injections. Design Follow-up study Setting Sports Medicine Unit, Umeå University. Patients 25 patients (28 elbows), mean age 46 years (range 27–66), treated with intratendinous injections due to chronic pain from tennis elbow. Method US and CD examination of the extensor origin was carried out at inclusion and at follow-up two years after intratendinous injection treatment with polidocanol and/or a local anaesthetic. Main outcome measurements US (structure) and CD (blood flow) findings. Results All patients had structural tendon changes and high blood flow at inclusion when given the injection treatment. At the two-year follow-up, structural tendon changes were seen in 20/28 elbows and high blood flow was seen in 4/28 elbows. The majority of patients with a good clinical result after treatment had no visible blood flow (17/20), but the structural changes showed no relation to a good result (13/20 remaining changes). Conclusions Doppler findings, but not structure, might be related to the clinical result after intratendinous injection treatment of tennis elbow.

Shoulder pain – a common problem in world-class badminton players

Badminton is a sport that requires a lot of over‐shoulder motion, with the shoulder in abduction/external rotation. This questionnaire study on 188 international top‐level badminton players during the World Mixed Team Championships showed that previous or present shoulder pain on the dominant side was reported by 52% of the players. Previous shoulder pain was reported by 37% of the players and on‐going shoulder pain by 20% of the players. There were no significant differences in the prevalence of shoulder pain between men and women. The majority of the shoulder pain had started gradually. The pain was usually associated with shoulder activity, and stiffness was a common, associated symptom. Furthermore, the shoulder pain was associated with consequences such as sleeping disturbances, changes in training and competition habits, and it also affected activities of daily living. The majority of the players had sought medical advice and had been given different kinds of treatment. The study showed that shoulder pain is a common and significant problem in world‐class badminton players, and the consequences are most likely of importance for their training and playing capacity.

Acute badminton injuries

During 1990‐1994, 1.2% of all sports injuries that required emergency care at the Universytiy Hospital of Umeå were caused by badminton. In 90.7% of the cases the patients described themselves as recreational players of beginners. There were 51.3% minor injuries (AIS 1) and 48.7% moderate injureis (AIS 2). The lower extremities were affected in 92.3% of the cases. Achilles tendon ruptures (34.6%) and ankle sprains and fractures (29.5%) were the most frequent. By the time of the follow‐up (10‐69 months), 52.6% of the players still had symptoms from the injuries and 39.5% had not been able to return to playing badminton. Our data indicate the importance of adequate treatment and rehabilitation after actue badminton injuries.