Isometric Contractions for In-Season Treatment of Patellar Tendinopathy

image2

Guest blogger Dr. Napolitano grinding it out on the water.

One of the great features of modern medical journals like CJSM is the ability to publish studies ahead of print – we call it “Published Online First.”

With the flexibility  allowed by the internet and emerging media, we are able to get studies that have gone through peer review and are in the queue for printing out to the reading public months before they otherwise would see the light of day.

We have one of our “Published Online First” studies burning things up on emerging media.  At CJSM we follow the Altmetrics on the studies in our pages, and this new one — Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial — currently has a very hot rating of 107 (and climbing).

The treatment of such a common condition will be of inherent interest to those who practice sports medicine. Moreover, managing this nagging condition in mid-season can prove to be a Sisyphean task for the athlete and clinician.  This study has great promise to make a significant impact on your care of the athletes you see.

I asked the physician fellow working with me at NCH sports medicine, Jonathan Napolitano, MD, to do a guest post on this study authored by Rio et al.  Dr. Napolitano’s commentary, forthwith:

________________________________________________________

Basketball season is upon us and our clinics have begun to fill with athletes ailing from patellar tendinopathy, seeking pain relief and a quick return to the hardwood.  As a sports medicine fellow with a residency background in physical medicine and rehabilitation I have used this time to step back and review the therapeutic exercises we prescribe for tendinopathies.  I have always paired the concept of eccentric strengthening with tendon repair.  However, various other types of muscle contraction and strengthening exercises can (and perhaps should be) prescribed as well.

image3

In between isotonic beer curls at World Series 2017 game (L – R): Drs. Stephen Cuff, Reno Ravindran, Jonathan Napolitano

As an educational exercise I would like to take a moment to review the types of muscle contractions.  Isometric contraction occurs without any movement of the joint on which the muscle acts.  Isokinetic contraction occurs at a constant speed across a joint range of motion with variable resistance.  Finally, isotonic exercises are performed through normal joint range of motion with a consistent resistance at variable speed.  Isotonic contractions are further divided into concentric (muscle shortening) and eccentric (muscle lengthening).

Tendon pain is a factor that limits participation and performance in athletes.  Eccentric strengthening has shown good clinical outcomes in the long-term; however, this intervention can lead to increased pain in the short-term, and in 2005 Visnes et al showed eccentric strengthening to be of no benefit for in-season athletes.

Recent research by Dr. Rio et al [including senior author Dr. Jill Cook] compared rehabilitation programs for in-season athletes with patellar tendon pain.  Read more of this post

Advertisements

Altmetrics

ga9jrnsf

Are you familiar with this logo?

As 2016 winds down, you’re all certainly aware of the power of social media. You would probably have to have been on a space ship heading to Mars to be unaware of the phenomenon of Donald Trump: TIME’s “Person of the Year”, and the president-elect of the USA, has achieved so much of his success arguably through his use of Twitter!

Imagine that.  Only a few years ago, I recall seeing people still smile at the absurdity of ‘tweeting’, of compressing ideas into a mere 140 characters.  And now we have the proverbial ‘leader of the free world’ ascendant at least in part because of his use of social media.

There is no doubt that Twitter, and other social media platforms (such as this blog, or our podcasts), have become major suppliers of information to the media consumer.  If not supplanting traditional media, social media is certainly nudging it to the side.  This is as true in the worlds of sports, sports medicine, and sports medicine research as it is elsewhere.

In the world of sports medicine research, the ‘impact factor’ has played the defining role as the measuring stick of a journal’s heft for a long time.  The metric has had its critics, but its importance has not waned.  I for one can vouch for that:  when I went ‘up’ from Assistant to Associate Professor last year, part of my application involved demonstration of publication in journals with a worthy impact factor.

At CJSM we just concluded our semi-annual associate editors meeting, bringing together a host of clinicians and researchers from around the world.  We are proud of our journal’s impact factor (2.308), but we are also self-critical and are looking for other measures of the journal’s role in the modern world.

Altmetric is one such measure.

Sound familiar?  Thinking you have heard about ‘alt-someting’ recently? Read more of this post

Nadal’s Knees

715px-AFONSONADAL

Rafael Nadal, invincible on clay, just might be beaten by this man in table tennis (Portuguese Table Tennis Coach Afonso Vilela)

What a great week it has been at the French Open in Paris.  As I write, I see that Serena Williams has just closed out Maria Sharapova in straight sets to regain the title she last held 11 years ago in 2002.  The men’s final is set for tomorrow, with the incomparable Rafael Nadal facing his Spanish countryman David Ferrer after outlasting Novak Djokovic in an epic five-set semi-final match.

Like many of this blog’s readers, I have been amazed and entertained by men’s tennis over the last decade.  It truly is a golden era for the sport, with Federer and Nadal and Djokovic and Murray each seeming to outdo the other in feats of tennis heroics.  Just yesterday Nadal made an amazing between the legs shot in the fifth set, but is that perhaps outdone by the amazing forehand Djoko ripped off Federer to save match point in the 2011 U.S. Open (going on then to win the semi-final)?

Read more of this post

Patellofemoral pain syndrome – is this a top down or bottom up problem…or both? Guest blog by Simon Lack

Patellofemoral pain syndrome (PFPS) has a high prevalence within the sporting population, with one study of 2159 presentations to sports medicine clinics, reporting 5.4% incidence of PFPS, accounting for 25% of those presenting with knee pain (1).  Despite a more traditional approach to management having been well researched in a high quality RCT (2), the problem has been shown to have a high recurrence.  In a quest to unravel the mystery of long-term successful treatment outcomes, researchers have started looking above and below the knee to potentially identify more effective solutions.

Arguably started by the work of Lee et al (3) that identified that changes in femoral rotation angles have significant consequences for patellofemoral joint loading, in combination with consistently reported weakness of hip musculature in PFPS populations (4), multiple studies have looked to modify top down control through strengthening of the hip rotator muscles.  The outcomes of these studies have shown significant reductions in symptoms and increases in function particularly in weaker individuals.  In addition, better outcomes have been reported if a proximal strengthening programme is started prior to functional strengthening compared with an initial local knee-strengthening programme (5). Thus, a case is emerging in favour of a top-down treatment mechanism.

Distal to the knee a growing body of evidence supporting the use of foot orthoses in PFPS management has started to be established.  A high quality RCT that compared six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy, demonstrated orthoses to be superior to flat inserts, with their use resulting in comparable outcomes to multimodal physiotherapy (6).

Further more, evidence suggests foot orthoses have the ability to change pain immediately within this population of patients (7), with a further reduction of pain experienced following a 12/52 period of orthotic wear (8).  Interventions that have the capacity to reduce pain symptoms immediately, pose a valuable tool in facilitating normal movement patterns, maximising function and minimising detrimental pain inhibition.  Hence, further emerging evidence for a bottom-up treatment mechanism.

What do you think predicts treatment success in PFPS, and why ?

Simon Lack is a Physiotherapist and current PhD student at Queen Mary University, London, currently studying the interaction of hip and foot biomechanics in the presentation and management of patellofemoral pain.

Leave a Comment

Leave a Comment

 

 

 

 

References

1.Devereaux MD, Lachmann SM. Patello-femoral arthralgia in athletes attending a Sports Injury Clinic. Br J Sports Med. 1984 Mar;18(1):18-21.

2. Crossley K, Bennell K, Green S, Cowan S, McConnell J. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. Am J Sports Med. [Clinical Trial Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. 2002 Nov-Dec;30(6):857-65.

3. Lee TQ, Morris G, Csintalan RP. The influence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther. [Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, Non-P.H.S. Review]. 2003 Nov;33(11):686-93.

4. Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Aust J Physiother. 2009;55(1):9-15.

5. Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther. 2011 Aug;41(8):560-70.

6. Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Bmj. [Comparative Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. 2008;337:a1735.

7. Barton CJ, Menz HB, Crossley KM. The immediate effects of foot orthoses on functional performance in individuals with patellofemoral pain syndrome. Br J Sports Med. 2010 Jul 20.

8. Barton CJ, Menz HB, Crossley KM. Effects of prefabricated foot orthoses on pain and function in individuals with patellofemoral pain syndrome: a cohort study. Phys Ther Sport. 2011 May;12(2):70-5.

%d bloggers like this: