Bakgrund: Patellar tendinopati (PT) är framförallt en vanlig diagnos bland aktiva inom idrotter där hopprörelser ofta förekommer. Diagnosen innebär ofta överbelastning av knäskålsenan, vilket leder till smärta och nedsatt funktionsförmåga. Fysioterapeutisk behandling syftar till att minska smärtan och återställa funktionsförmågan. Infrapatellara remmar (IPR) har använts sedan många år för symptomlindring vid idrottsaktiviteter men det saknas forskning som har sammanställt effekter av användning, vilket föranleder behovet av en systematisk litteraturöversikt. Syftet var att genom en systematisk litteraturstudie beskriva hur IPR används och utvärderas i studier vid PT, rapporterade effekter samt studiekvalitet och preliminär evidensstyrka. Metod: Artikelsökning genomfördes i databaserna PubMed och PEDro. Fem studier analyserades utifrån litteraturstudiens syfte och frågeställningar samt kvalitetsgranskades enligt SBU:s granskningsmallar. Resultat: Av studierna undersökte tre IPR:s effekt på smärtintensitet, två proprioception och två indirekt uppmätt senbelastning. Endast kortsiktiga utfall mättes och när dessa var statistiskt signifikanta var kliniska relevansen ofta oklar. Sammantagen preliminär evidensstyrka bedömdes som måttligt stark. Slutsatser: Studierna visade på varierande effekt av att använda IPR avseende förbättring av proprioception, smärtintensitet och indirekt uppmätt senbelastning. Fler högkvalitativa randomiserade studier behövs och framtida forskning bör undersöka långsiktiga effekter vid användning av IPR. / Background: Patellar tendinopathy (PT) is common in jumping athletes. It’s mostly related to excessive loading of the patellar tendon, which leads to pain and decreased functional capacity. Physiotherapy treatment aims to reduce pain and restore functional capacity. Infrapatellar straps (IPS) have been utilized for many years to alleviate symptoms during sports activities but there is a lack of research that has compiled reports on effects of usage, which leads to the need of a systematic review. Objective: To describe use and evaluation of IPS in studies on patients with PT and describe reported effects, study quality and preliminary strength of evidence. Method: The PubMed and PEDro databases were searched for articles. Five studies were analyzed considering the review’s objective. Study quality was assessed according to SBU’s checklists. Results: Among the studies three investigated the effect of IPS on pain intensity, two on proprioception and two on indirectly measured tendon load. Short-term outcomes were investigated and the clinical relevance was often unclear when outcomes were statistically significant. Total preliminary strength of evidence was assessed as moderate. Conclusion: Variable effects are shown from IPS usage regarding pain intensity, proprioception and indirectly measured tendon load. More high-quality randomized trials and investigations of long-term effects are needed.

Olika träningsprogram används vid rehabilitering av Akillestendinopati och skiljer sig åt avseende frekvens, intensitet, typ av träning och hur patienter skall förhålla sig till smärta när de tränar. Vilken nivå av smärta som är mest effektiv vid träning är ej tidigare utforskat. Syftet med denna litteraturöversikt är därför att jämföra träningsprogram som skall utföras med smärta med program som tillåter viss smärta samt med program som skall utföras smärtfritt vid rehabilitering av Akillestendinopati i senans mellanportion. Litteraturöversikten utfördes systematiskt och följde riktlinjerna enligt PRISMA. Studier från PubMed och Web of Science inkluderades. Endast studiedeltagare med Akillestendinopati i senans mellanportion som utförde träningsterapi som behandling och utvärderades med VISA-A inkluderades. Risk för bias bedömdes enligt Rob 2 tool för RCT-studier och ROBINS-1 tool för CCT-studier. En narrativ syntes användes som analysmetod och evidensgraderingen utfördes med GRADE. Åtta studier inkluderades i litteraturöversikten och samtliga av dessa innehöll träningsprogram som skulle utföras med smärta. Två studier involverade träningsprogram som tillät viss typ av smärta och ingen studie involverade träning som skulle utföras smärtfritt. Träningsterapi oavsett typ av träningsprogram visade sig vara associerat med förbättrade VISA-A värden och det går ej att avgöra vilken av dessa träningsprogram som är mest effektiv. Den här litteraturöversikten pekar mot att träning med smärta, som gäller vid Alfredsons standardprogram från 1998, är effektivt och har bäst evidens av de träningsprogram som presenteras i litteraturöversikten. Fler högkvalitativa interventionsstudier behövs för att öka evidensen för att träna utan krav på smärta vid Akillestendinopati i mellanportionen. / Different loading programs are used when rehabilitating Achilles tendinopathy varying regarding frequency, intensity, type of training and how to approach pain. The level of pain which is most effective in training, when rehabilitating Achilles tendinopathy, has not yet been explored. Therefore, the purpose of this review is to compare loading programs when inducing pain is a criterion with loading programs allowing some pain and with loading programs inducing no pain when rehabilitating midportion Achilles tendinopathy. The review was conducted systematically and followed the guidelines presented by PRISMA. Studies from PubMed and Web of Science were included. Only participants with midportion Achilles tendinopathy that rehabilitated with a loading program and were evaluated with VISA-A were included. Risk of bias was evaluated with the Rob 2 tool for RCT-studies and with ROBINS-1 tool for CCT-studies. A narrative synthesis was conducted, and the level of evidence was set with GRADE. Eight studies were included and all of them involved training with pain. Two studies included loading programs that allowed some pain and no study included training without pain. All loading programs included are associated with improved VISA-A scores and none are more superior than the others. This review shows that training with pain, as in Alfredsons eccentric loading program from 1998, is effective and has the best level of evidence of the different loading programs presented in this review. More high-quality studies are needed to increase the evidence for training when pain is not a criterion in midportion Achilles tendinopathy.

Introduktion: Det Muskuloskeletala systemet består av skelettmuskulatur, nervsystem och skelett. Systemet bidrar till att kroppen kan röra sig. Muskelskador kan uppkomma genom direktvåld mot muskeln eller kraftig uttöjning och skadan bidrar till smärta och svullnad. Vanliga behandlingsmetoder på muskelskada är NSAID och andra fysioterapeutiska interventioner. Low- level laser therapy (LLLT) har senaste tiden fått ökad acceptans och blivit mer intressant. LLLT används med varierad dosering för att stimulera cellfunktion, minska smärta och påskynda läkningsprocessen. Tidigare studier visar varierat resultat av LLLT på muskelskador, därför vill vi undersöka den beprövade erfarenheten, eftersom det inte undersöks vetenskapligt utan finns bland klinikerna. När LLLT utförs med den mest gynnsamma dosen har behandlingen en pålitlig och biologisk verkan på muskelvävnad. Vi vill se om fysioterapeuters upplevelse av LLLT speglar tidigare forskning. Syftet: med studien är att undersöka fysioterapeuters subjektiva upplevelse och erfarenhet av low-level laser therapy (LLLT) som behandlingsmetod vid muskelskada. Metod: Studien är en kvantitativ tvärsnittsstudie med en online enkät. 30 Leg. Fysioterapeuter med mer än 1 års erfarenhet av LLLT deltog. Fysioterapeuterna rekryterades via 2 portaler och mejlutskick. Resultat: Majoriteten av fysioterapeuterna anser att LLLT är en adekvat behandlingsmetod på muskelskada och patienter upplevs nöjda. Fysioterapeuterna hade varierade upplevelser med en antydan till samband mellan upplevd effekt och dosering (J) på muskelskada som kunde noteras. Konklusion: Enligt de deltagande fysioterapeuterna har LLLT effekt på muskelskada och anses vara en adekvat behandlingsmetod. Det finns en antydan till ett visst samband mellan hänsynstagandet till dos och effekten.

As a common source of long-term pain and physical disability, overuse injuries, such as chronic tendinopathies, severely impact a patient’s quality of life. Caused by repetitive trauma, chronic tendinopathies affect hundreds of millions of people each year. The exact pathogenic mechanism in developing this musculoskeletal injury is still largely unknown, making clinical recommendations on the best course of treatment highly debatable. Nonetheless, advancements in biotechnology have made autologous blood products, specifically the use of platelet rich plasma injections, an increasingly popular method in the orthopedic field. Studies have shown that the concentrated platelet sample harbors a number of bioactive mediators. Once activated and injected at the site of injury, these growth factors and cytokines augment the natural healing process in tendinopathic cases. With limited reported complications, many clinicians believe that platelet rich plasma therapy is a safe and accessible treatment option for patients diagnosed with chronic tendinopathy. As such, the primary purpose of this paper is to determine the efficacy of platelet rich plasma injections in treating chronic tendinopathies. This literature review determined that current published studies and research on the effectiveness of PRP injections have produced contradictory results. Due to its autologous characteristic, platelet concentration differs significantly from patient to patient, contributing to high variability in terms of its effectiveness between patients. However, with low long-term costs and fast recovery, PRP injections are a promising, non-surgical intervention for treating chronic tendinopathies. Several patient-centered clinical studies have reported significant improvements in range of motion and pain management when compared to traditional injection treatments. These effects are maximized when administered under ultrasound guidance or when used in conjunction with a strict eccentric exercise program. Nonetheless, continued research is needed to determine optimal injection standards so that clinical recommendations can be further developed and supported.

Background: The effect of trigger point dry needling (TDN) on myofascial trigger points (MTP) in Achilles tendinopathy are unknown. Objectives: To determine the feasibility of a large randomized controlled trial (RCT) to compare the effects of TDN to exercise in a patient population with Achilles tendinopathy. Methods: This single-factor, pretest-posttest control group design included 22 subjects between the ages of 24 and 65 years with Achilles tendinopathy. Subjects were randomly assigned to either a control group (MT+Ex) or experimental group (TDN+MT+Ex). Subjects in both groups completed 8 physical therapy treatment sessions over 4 weeks. The intervention for the TDN+MT+Ex group included TDN to MTPs in the gastrocnemius, soleus or tibialis posterior each session while the same soft tissue mobilization and exercise program was conducted in both groups. Results: Within group analysis was performed for each group at 4 week and 90 day follow up. Significant improvement (p < .05) was achieved for FAAM, NPRS, pain pressure threshold and strength in both groups at 4 weeks and 90 days. The GROC was significant for MT + Ex at 90 days. The MCID for the FAAM, GROC were surpassed in both groups at 4 weeks and 90 days. NPRS surpassed the MCID for the MT + Ex group at 4 weeks. Conclusion: A large RCT to investigate the effects of TDN on MTP in Achilles tendinopathy is feasible with modifications. Recommendations: Special considerations for data collection sites should be given to the health care system, insurance payor, and financial burden to subjects.

Tendon injuries are prevalent, debilitating and difficult to treat. Common interventions such as anti-inflammatory medication, growth factor injections and surgery are associated with short-term efficacy and long rehabilitation periods. Tendons possess an incomplete healing response which is reparative (scar-mediated) rather than regenerative, resulting in a 'healed' tissue that is mechanically inferior to the native tendon. While it is widely accepted that mechanical-loading based treatments offer long-term symptomatic resolution and improved functionality, the exact mechanisms of action of such mechanotransduction-based healing cascades remain unclear. Nevertheless, there is significant motivation for the development of non-invasive and efficient rehabilitative treatments that mechanically stimulate the injured tendons to achieve functional healing responses. Focused Ultrasound (FUS) methods are an attractive treatment option as they are non-invasive, utilize higher intensities for shorter durations and are targeted to a very specific treatment volume, hence inducing significant bio-effects in the tissue without affecting surrounding structures. Herein, we present a body of work that includes the development of FUS pulsing to precisely target murine Achilles tendons and emphasize distinct bioeffects (thermal-dominant and mechanical-dominant). We investigated the feasibility of applying FUS pulsing to murine Achilles tendons ex vivo and in vivo and demonstrated that FUS can be safely applied without any deleterious effects in the tendons and surrounding tissues. The animals showed no symptoms of distress after multi-session treatments. Overall, results suggest that tendon material properties are not adversely altered by FUS pulsing. Histological analyses showed mild matrix disorganization, suggesting the need for slight modifications in the ultrasound pulsing parameters and treatment durations. When applied to injured tendons, mechanical dominant schemes seemed to drive larger improvements in material properties compared to thermal-dominant pulsing, confirming our original hypothesis that mechanical stimulation may play a bigger role in tendon healing compared to purely thermal-dominant stimulation. Additionally, feasibility of histotripsy ablation in murine Achilles tendons was successfully investigated ex vivo and in vivo and experimentation to further optimize these methods are ongoing. Such (non-thermal) ablative paradigms will be extremely useful when conservative treatment options are unavailable and debridement of scar tissue is warranted to interrupt the degenerative process and stimulate healing. Finally, a pilot investigation into FUS-induced strains was performed to guide our parameter selection process and deliver controlled strains to achieve healing responses (similar to current clinical rehabilitation protocols). We were able confirm that strains between 1% and 6% (or higher) can be induced by manipulating ultrasound treatment parameters. Overall, or results reiterate the potential of FUS in eliciting the desired bioeffects and thus achieve healing in tendons and provide a snapshot of the expected effects of using such pulsing methods to treat tendon injuries. / Doctor of Philosophy / Tendons are tissues that connect muscles to bones, and are unfortunately prone to injuries. Such injuries are prevalent and difficult to treat. Effective treatment options remain limited, as common methods such as surgery, anti-inflammatory medications and corticosteroid injections do not provide long-term relief. One of the few treatments that has been proven to provide symptomatic relief and improved the functionality of chronically (over a long period of time) injured tendons is physical therapy. However, researchers are still investigating the reasons for this successful healing response. Some limitations of physical therapy are long rehabilitation and recovery periods, and the need for patient compliance (i.e., performing painful exercises while already being under significant pain). In this research, we explore the use of a non-invasive modality known as ultrasound to treat tendon injuries. Ultrasound is commonly thought of as a diagnostic tool, i.e., to detect injuries in musculoskeletal medicine. It, however, is also an attractive therapeutic (treatment) modality, as sound waves can be concentrated in the required area of interest which results in different types of effects in the chosen tissue, such as heating. A huge advantage is that ultrasound is non-invasive, painless, and safe, as the energy is only applied to the chosen volume of interest and surrounding structures are unaffected. To examine the utility of therapeutic ultrasound in treating tendon injuries, we used a mouse model that has been previously used in our lab, and designed different types of ultrasound treatments that elicit two main types of effects in the tissue, namely, thermal, or heating effects and mechanical, or physical therapy-like effects. Prior to applying these treatments, we measured how much heating is produced in mouse Achilles tendons via these treatments, to establish safety. Once we identified safe thermal and mechanical treatment sets, we treated mouse Achilles tendons ex vivo, i.e., after euthanasia. We tested the mechanical properties of the treated tendons and determined that treatments do not alter the mechanical properties of tendons, which is encouraging, given that we do not want treatments to interfere with the properties of native tendons. We also examined the influence of treatments on structure of Achilles tendons after treatments and deducted that the structure was not damaged due to treatments. We followed up these studies with treatments conducted in live mice, which received four treatment sessions in one week. These studies were conducted to further determine the safety and tolerance to these procedures and also examine the healing effects of treatments in injured Achilles tendons. Results suggest that focused ultrasound treatments are safe and tolerable to mice and seem to elicit improvements in tendon properties. In other studies, we also examined a different ultrasound method named histotripsy, as a non-invasive alternative to dry needling (which is another methodology used to treat tendon injuries) and scar debridement (removal of scar tissue to stimulate a new healing response). This research establishes that therapeutic ultrasound is a novel, non-invasive alternative with good potential to treat tendon injuries. Future studies will investigate the effects of ultrasound treatments over longer durations and also aim to clarify the exact type and magnitude of physical therapy-like forces that are produced by ultrasound treatments. This understanding will enhance our treatment design process to be able to mimic clinical treatments that are known to be effective.

Title: The analysis of risk factors for tendinopathy in runners Objectives: The aim of this thesis is to find out the most important risk factor for development of Achilles tendinopathy, detect the most relevant diagnostic approach with preventive monitoring for Achilles tendinopathy and evaluate the best treatment for Achilles tendinopathy in runners. Methods: The diploma thesis is in form of literary review. The Scopus, PubMed and Web of science databases were used to search for studie using a combination of keywords. A total of 1084 titles were identified. Due to duplicates 402 titles were excluded. On the basis of the name of the article 51 titles were included. On the basis of the availability 50 titles were included. On the basis of the abstract 46 titles were included. Finally 29 titles were included in this review. Results: The most important risk factor for development of Achilles tendinopathy was training intensity for distances 1500-3000 m, week running volume >65 km or being new to running. The most relevant diagnostic approach for Achilles tendinopaty was clinical examination assessing pain (Achilles tendon pain, positive palpation test) and function (pain during physical aktivity) of Achilles tendon. This approach serves as indication for sonographic assessment of Achilles tendon...

INTRODUÇÃO: A disfunção do tendão tibial posterior (DTTP), principal causa de pé plano adquirido no adulto, é mais frequente em indivíduos do gênero feminino e apresenta pico de incidência na sexta década de vida. Diversos fatores de risco - intrínsecos e extrínsecos - e condições sistêmicas associadas são descritas na literatura. A predisposição genética resultante da maior expressão de genes relacionados ao metabolismo hormonal, principalmente do estrogênio, pode desempenhar influência na fisiopatogenia dessa lesão em associação aos fatores comportamentais e endógenos. OBJETIVO: Analisar a frequência de polimorfismos nos genes dos receptores de estrogênio (RE) dos tipos alfa (RE1) e beta (RE2), em pacientes na pós-menopausa com diagnóstico de tendinopatia do tendão do músculo tibial posterior e em pacientes assintomáticas. CASUÍSTICAS e MÉTODOS: Foram incluídas 202 pacientes do gênero feminino (N=202), com idade superior a 40 anos, divididas em 2 grupos (n=101), de casos e controles. Foram definidos como casos pacientes na pós-menopausa com diagnóstico de DTTP, realizado por meio dos exames clínico e de imagem (RM), e, como controles, pacientes com as mesmas características epidemiológicas, assintomáticas, que apresentavam exames clínico e de imagem normais para a avaliação do tendão tibial posterior. Células epiteliais da mucosa bucal das pacientes incluídas no estudo foram coletadas por meio de bochecho com solução glicosada para extração e análise do RESULTADOS: Pacientes portadoras do genótipo xx do SNP XbaI apresentaram risco estimado 2,38 vezes maior (p = 0,029) de desenvolver a DTTP quando comparadas às portadoras dos genótipos selvagem ou heterozigoto. Já a distribuição dos genótipos dos SNP PvuII e AluI não apresentou associação com o desenvolvimento da doença. ADN genômico. Os SNP dos genes dos RE1 (XbaI e PvuII) e RE2 (AluI) foram avaliados com base em PCR-RFLP. CONCLUSÃO: O presente estudo demonstra que pacientes com polimorfismo XbaI do RE1 apresentam maior risco de desenvolvimento da disfunção do tendão tibial posterior / INTRODUCTION: Posterior tibial tendon dysfunction (PTTD), the most common cause of flatfoot deformity in adults, is more frequent in the female gender with peak incidence in the sixth decade of life. Multiple risk factors - intrinsic and extrinsic - and associated systemic conditions have been described in the literature. Genetic predisposition secondary to hyperexpression of genes related to hormonal metabolism, particularly the estrogens, may play a role in the pathogenesis of this disease acting in association with behavioral and endogenous risk factors. OBJECTIVE: The aim of this study was to analyze the frequency of polymorphisms of the estrogen receptors (ER) alpha (ER1) and beta (ER2) in postmenopausal women with PTTD when compared to asymptomatic control patients. METHODS: 202 female patients over the age of 40 were included in the study (N = 202). They were then divided into 2 different groups (n = 101): cases and controls. We defined as cases postmenopausal women with symptomatic PTTD, diagnosed by clinical and MRI examinations. Females with similar epidemiology, but clinically asymptomatic and with normal MRI evaluation for the posterior tibial tendon were defined as controls. Oral mucosa epithelial cells were collected from the patients and genomic DNA was extracted from the samples. The SNPs for the ER1 (XbaI and PvuII) and ER2 (AluI) genes were assessed by PCR-RFLP. RESULTS: Patients with SNP Xbal genotype xx had 2.38 higher estimated risk (p = 0,029) in developing PTTD, when compared to patients with the other genotypes. No associations were found for the SNP PvuII and AluI. CONCLUSION: The present study demonstrates that patients with the Xbal single nucleotide polymorphism of estrogen receptor 1 gene have higher risk of developing posterior tibial tendon dysfunction

Introduction: Achilles tendinopathy can be a chronic disabling condition. Sclerosing injections under ultrasonographic guidance is one method to treat Achilles tendinopathy. Initially good results have later been questioned. Surgery is another treatment option that has been questioned because of varying reported success rate. Aim: We aimed to assess patient- reported outcome in patients suffering from Achilles tendinopathy, treated with sclerosing injections and/or surgery during a 6 ½ year- period. Method: After review of patient records, the Self-reported foot and ankle score (SEFAS) together with an in-house satisfaction questionnaire were mailed to the patients. A SEFAS score of 48 represents normal foot/ankle function. Results: 97 patients (53 women, 44 men, 104 tendons) were included. 69 patients (41 women, 28 men, 75 tendons) returned the questionnaires. The SEFAS values (median and range) were 37.5 (13-48) in patients treated with sclerosing therapy, 42 (15-48) in patients treated surgically and 47 (19-48) in patients that received both treatments. A greater proportion of surgically treated patients were satisfied (90% vs 50%), experienced symptom improvement and were able to return to the previous level of activity. Complications following surgery were wound infections (n=3) and deep vein thrombosis (n=3), two with pulmonary embolism. Following sclerosing injection, there was one complete Achilles tendon rupture. Conclusion: Sclerosing injections seems to be a safe treatment and a positive outcome in 50% of patients might be sufficient to use this therapy in selected patients with Achilles tendinopathy. However, surgical treatments seem more effective but are associated with more severe complications.

Diss. (sammanfattning) Umeå : Umeå universitet, 2009. / Härtill 5 uppsatser. Även tryckt utgåva.