Motor responses to Achilles tendon pain

NewsBot · Jun 11, 2010

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Motor responses to experimental Achilles tendon pain
Marius Henriksen, Jens Aaboe, Thomas Graven-Nielsen, Henning Bliddal, Henning Langberg
Br J Sports Med doi:10.1136/bjsm.2010.072561

Background Achilles tendinopathies are characterised by pain and reduced function, and heavy-load exercises have been shown to be effective in the treatment of painful chronic Achilles tendinopathies. However, basic information is needed on how the biomechanics and neuromuscular control of the exercise are affected by Achilles tendon pain.

Objective The authors aimed to determine the effects of experimental Achilles tendon pain on motor function during one-legged weight bearing ankle plantar and dorsal flexion exercises.

Methods In a crossover study, with 16 healthy subjects tested on two different days separated by 1 week, three-dimensional ground reaction forces, ankle joint kinematics and surface electromyography (EMG) of the lower leg muscles were recorded during one-legged full weight-bearing ankle plantar (concentric) and dorsal (eccentric) flexion exercises. Measurements were done before, during and after either experimental Achilles tendon pain or a non-painful control condition. Pain was induced by intratendinous injections of hypertonic saline with isotonic saline injections as control. Joint kinematics, ground reaction force frequency contents and average EMG amplitudes were calculated.

Results Compared with the control condition experimental Achilles tendon pain reduced the EMG activity in agonistic, synergistic and antagonistic muscles, and increased the ground reaction force frequency content around 10 Hz, during both eccentric and concentric movement phases.

Conclusions These data show that experimental Achilles tendon pain causes widespread and reduced motor responses with functional effects on the ground reaction force.
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NewsBot · Aug 5, 2011

Professor Richard Carey Smith interviews physiotherapist James Debenham

In this interview (5 minutes, 4 seconds) Orthopaedic Surgeon, Professor Richard Carey Smith interviews physiotherapist James Debenham.

Professor Carey Smith saw Mr Debenham's presentation this afternoon and wanted to speak to him about motor control strategies in the Aetiology of Achilles Tendinopathy.
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NewsBot · Oct 1, 2011

Evoked Spinal Reflexes and Force Development in Elite Athletes With Middle-Portion Achilles Tendinopathy
Hsing-Kuo Wang, Kwan-Hwa Lin, Yu-Kuang Wu, Shyh-Ching Chi, Tifany Ting-Fang Shih, Yung-Cheng Huang
J Orthop Sports Phys Ther 2011;41(10):785-794

STUDY DESIGN: Controlled laboratory study.

OBJECTIVES: To compare the neuromuscular function of the triceps surae muscle bilaterally in elite athletes with unilateral chronic Achilles tendinopathy.

BACKGROUND: Previous studies suggest that tendinopathies or chronic pain may lead to a spinal/supraspinal level modulation of the excitability or voluntary activation of ipsilateral motor units. However, this has not been studied in Achilles tendinopathy.

METHODS: Fourteen college athletes (mean ± SD age, 24.2 ± 1.7 years) who had unilateral chronic middle-portion tendinopathy in their Achilles tendons were recruited. Bilateral measurements of soleus reflex tests, including H-reflex and V wave, and rate of force development (RFD), as well as corresponding electromyography of the tibialis anterior and triceps surae muscles, were performed. Statistical within-subject and between-leg comparisons were made.

RESULTS: In the leg with tendinopathy, the V wave of the soleus muscle was significantly increased (P<.001). The side with tendinopathy also had a reduced normalized RFD (0-30, 0-50, and 0-100 ms) in plantar flexion, and concomitant higher electromyography ratios between the tibialis anterior and soleus (0-30 and 0-50 milliseconds) during the early stage of explosive contractions (P<.05). No significant differences were found for H-reflex, maximal plantar flexion and dorsiflexion torque, and absolute RFD.

CONCLUSIONS: Higher volitional supraspinal reflexes and lower maximal-strength independent force development occur in the triceps surae of elite athletes with unilateral middle-portion Achilles tendinopathy. These changes potentially indicate an acquired compensatory mechanism for maximal force production and deficits in explosive strength. The RFD is also suggested as a sensitive parameter to depict neuromuscular changes during treatment of chronic tendinopathies.
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NewsBot · Nov 12, 2012

Triceps surae activation is altered in male runners with Achilles tendinopathy
N. Wyndow, S.M. Cowan, T.V. Wrigley, K.M. Crossley
Journal of Electromyography and Kinesiology; 8 November 2012

Achilles tendinopathy is a common injury in running sports however the exact etiology of Achilles injury is still unclear. In recent years, altered neuromotor recruitment patterns of the triceps surae have been hypothesized to create differential intra-tendinous loads leading to pathology; however, this hypothesis has not been investigated. Further, the effect foot orthoses may have on neuromotor recruitment of the triceps surae in Achilles tendinopathy has not been investigated. Methods: The electromyographic activity of the triceps surae was recorded during an over-ground running task. Fifteen Achilles injured participants and 19 asymptomatic controls were assessed in a footwear only condition. The Achilles injured participants were also assessed running in a pre-fabricated foot orthoses. Results: In Achilles injured participants, there was a significant difference between soleus and lateral gastrocnemius offset times during running compared to the asymptomatic controls (p < 0.05). There were no significant differences in triceps surae muscle activity between the footwear only and footwear and orthoses condition in the Achilles injured participants. Conclusions: The finding that triceps surae activity is altered in participants with Achilles tendinopathy may have clinical importance as it suggests that intra-tendinous loads are altered which may contribute to pathological changes. Further, foot orthoses have no immediate effect on the neuromotor control of the triceps surae.
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NewsBot · May 7, 2013

The effect of exercise repetition on the frequency characteristics of motor output force: Implications for Achilles tendinopathy rehabilitation
Nicole L. Grigga, Scott C. Wearing, John M. O’Toole, James E. Smeathers
Journal of Science and Medicine in Sport; Available online 1 May 2013

Objectives
To investigate the frequency characteristics of the ground reaction force (GRF) recorded throughout the eccentric Achilles tendon rehabilitation programme described by Alfredson.

Design
Controlled laboratory study, longitudinal.

Methods
Nine healthy adult males performed six sets (15 repetitions per set) of eccentric ankle exercise. Ground reaction force was recorded throughout the exercise protocol. For each exercise repetition the frequency power spectrum of the resultant ground reaction force was calculated and normalised to total power. The magnitude of peak relative power within the 8–12 Hz bandwidth and the frequency at which this peak occurred was determined.

Results
The magnitude of peak relative power within the 8–12 Hz bandwidth increased with each successive exercise set and following the 4th set (60 repetitions) of exercise the frequency at which peak relative power occurred shifted from 9 to 10 Hz.

Conclusions
The increase in magnitude and frequency of ground reaction force vibrations with an increasing number of exercise repetitions is likely connected to changes in muscle activation with fatigue and tendon conditioning. This research illustrates the potential for the number of exercise repetitions performed to influence the tendons’ mechanical environment, with implications for tendon remodelling and the clinical efficacy of eccentric rehabilitation programmes for Achilles tendinopathy.
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NewsBot · Oct 11, 2013

Neuromotor Control of Gluteal Muscles in Runners with Achilles Tendinopathy
Smith, Melinda M.; Honeywill, Conor; Wyndow, Narelle; Crossley, Kay M.; Creaby, Mark W.
Medicine & Science in Sports & Exercise: 10 October 2013

Purpose: The purpose of this study was to compare the neuromotor control of the Gluteus Medius (GMED) and Gluteus Maximus (GMAX) muscles in runners with Achilles tendinopathy to that of healthy controls.

Methods: Fourteen male runners with Achilles tendinopathy and nineteen healthy male runners (Control) ran over-ground whilst electromyography of GMED and GMAX was recorded. Three temporal variables were identified via visual inspection of EMG data: (i) onset of muscle activity (onset), (ii) offset of muscle activity (offset), and (iii) duration of muscle activity (duration). A multivariate analysis of covariance with between subject factor of group (Achilles tendinopathy, Control) and variables of onset, offset, and duration was performed for each muscle. Age, weight and height were included as covariates and alpha level set at 0.05.

Results: The Achilles tendinopathy group demonstrated a delay in the activation of the GMED relative to heel strike (p < 0.001) and a shorter duration of activation (p < 0.001) compared to that of the Control group. GMED offset time relative to heel strike was not different between the groups (p = 0.063). For GMAX the Achilles tendinopathy group demonstrated a delay in its onset (p = 0.008), a shorter duration of activation (p = 0.002), and earlier offset (p < 0.001) compared to the Control group.

Conclusion: This study provides preliminary evidence of altered neuromotor control of the GMED and GMAX muscles in male runners with Achilles tendinopathy. Whilst further prospective studies are required to discern the causal nature of this relationship, this study highlights the importance of considering neuromotor control of the gluteal muscles in the assessment and management of patients with Achilles tendinopathy.
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AJM · Oct 15, 2013

In case anyone ever tries to follow this up the reference given above:

The effect of exercise repetition on the frequency characteristics of motor output force: Implications for Achilles tendinopathy rehabilitation

Nicole L. Grigga, Scott C. Wearing, John M. O’Toole, James E. Smeathers
Journal of Science and Medicine in Sport; Available online 1 May 2013

The first author's name is printed as "Grigg". The journal gave it footnote reference "a" (for contact details). That seems to have led to copying it over as "Grigga".

NewsBot · Mar 25, 2014

Plantarflexor muscle function in healthy and chronic Achilles tendon pain subjects evaluated by the use of EMG and PET imaging
Tahir Masood, Kari Kalliokoski, Jens Bojsen-Møller, S. Peter Magnusson, Taija Finni
Clinical Biomechanics; Available online 19 March 2014

Background
Achilles tendon pathologies may alter the coordinative strategies of synergistic calf muscles. We hypothesized that both surface electromyography and positron emission tomography would reveal differences between symptomatic and asymptomatic legs in Achilles tendinopathy patients and between healthy controls.
Methods
Eleven subjects with unilateral chronic Achilles tendon pain (28 yr) and eleven matched controls (28 yr) were studied for triceps surae and flexor hallucis longus muscle activity in response to repetitive isometric plantarflexion tasks performed at 30% of maximal voluntary contraction using surface electromyography and glucose uptake using positron emission tomography. Additionally, Achilles tendon glucose uptake was quantified.
Findings
Normalized myoelectric activity of soleus was higher (P < 0.05) in the symptomatic leg versus the contralateral and control legs despite lower absolute force level maintained (P < 0.005). Electromyography amplitude of flexor hallucis longus was also greater on the symptomatic side compared to the healthy leg (P < 0.05). Both the symptomatic and asymptomatic legs tended to have higher glucose uptake compared to the control legs (overall effect size: 0.9 and 1.3, respectively). Achilles tendon glucose uptake was greater in both legs of the patient group (P < 0.05) compared to controls. Maximal plantarflexion force was ~ 14% greater in the healthier leg compared to the injured leg in the patient group.
Interpretations
While the electromyography showed greater relative amplitude in the symptomatic leg, the results based on muscle glucose uptake suggested relatively similar behavior of both legs in the patient group. Higher glucose uptake in the symptomatic Achilles tendon suggests a higher metabolic demand.
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NewsBot · Jul 8, 2014

Chronic Mid Portion Achilles Tendinopathy is Not Associated with Central Sensitisation
Skinner, Ian W; Debenham, James R; Krumenachera, Sarah; Bulsarab, Max K; Wand, Benedict M
Pain and Rehabilitation - the Journal of Physiotherapy Pain Association, Volume 2014, Number 37, Summer 2014, pp. 34-40(7)

Achilles tendinopathy (AT) is a common painful and disabling condition and current understanding of its pathophysiology is incomplete. Widespread hyperalgesia as a clinical manifestation of central sensitisation has emerged as a possible contributor to the pain state in chronic musculoskeletal injuries. Eight AT participants and eight healthy, gender, age and activity matched participants were recruited to participate in a case-controlled repeated measures study. Pressure pain threshold (PPT) was measured with a manual electronic algometer at four sites bilaterally; tibialis anterior (TA), patella tendon (PT), common wrist extensor tendon (CWET), and first dorsal interosseous (1DI). We hypothesised a reduction in PPT scores in the AT group at locations remote to the Achilles tendon compared to the healthy group. A linear mixed model analysis was used to compare the groups with age and gender adjustment. No significant difference was found between groups at any of the locations investigated: TA p= 0.638, PT p= 0.334, CWET p= 0.474, 1DI p= 0.056. Central sensitisation as represented through widespread hyperalgesia was not demonstrated in participants with AT. Our results must be treated with caution given the small number of participants tested. We also expect that the younger average age of our participants combined with a possible predisposition for decreased PPT scores secondary to high training loads may have influenced our results. Further research into pain processing changes with AT patients should be pursued with larger sample sizes and careful attention to participant matching. This will assist in developing the current understanding of pain mechanisms and guide treatment approaches in patients with AT.
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NewsBot · Oct 20, 2016

Hip Biomechanics Are Altered in Male Runners with Achilles Tendinopathy.
Creaby, Mark W.; Honeywill, Conor; Franettovich Smith, Melinda M.; Schache, Anthony G.; Crossley, Kay M.
Medicine & Science in Sports & Exercise: October 17, 2016

Purpose: Achilles tendinopathy (AT) is a prevalent injury in running sports. Understanding the biomechanical factors associated with AT will assist in its management and prevention. The purpose of this study was to compare hip and ankle kinematics and kinetics in runners with and without AT.

Methods: Fourteen male runners with AT and eleven healthy male runners (CTRL) ran over-ground whilst lower-limb joint motion and ground reaction force data were synchronously captured. Hip and ankle joint angles, moments, and impulses in all three planes (sagittal, transverse and frontal) were extracted for analysis. Independent t-tests were used to compare the differences between the AT and CTRL groups for the biomechanical variables of interest. Following Bonferroni adjustment, an alpha level of 0.0026 was set for all analyses.

Results: The AT group exhibited an increased peak hip external rotation moment (p= 0.001), hip external rotation impulse (p <0.001) and hip adduction impulse (p <0.001) compared to the CTRL group. No significant differences in ankle biomechanics were observed.

Conclusion: This study presents preliminary evidence indicating that male runners with AT display altered hip biomechanics with respect to their healthy counterparts. Due to the retrospective design of the study, it is unknown whether these alterations are a predisposing factor for the disorder, a result of the condition, or a combination of both. The results of this study suggest that optimizing hip joint function should be considered in the rehabilitation of runners with AT.
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NewsBot · Dec 28, 2016

Pain duration is associated with increased muscle sympathetic nerve activity in patients with Achilles tendinopathy
Authors
J. L. Jewson, E. A. Lambert, S. Docking, M. Storr, G. W. Lambert, J. E. Gaida
Scandinavian Journal of Medicine & Science in Sports 28 DEC 2016

Tendinopathy is a common condition, which has been linked to surrogate measures of sympathetic nervous system (SNS) activity and insulin resistance. This study aimed to compare in vivo measures of the SNS and insulin resistance between individuals with and without Achilles tendinopathy. This case–control study compared Achilles tendinopathy sufferers to healthy controls. SNS activity was quantified using muscle sympathetic nerve activity (MSNA), while metabolic status was assessed via a modified glucose tolerance test and fasting lipid panel. Ultrasound tissue characterization assessed tendon structure. Resting MSNA did not differ between the 15 cases and 20 controls. Tendon pain duration in tendinopathy patients was correlated with burst frequency (R2=.32, P=.02) and burst incidence (R2=.41, P=.01) of MSNA. After adjusting for multiple comparisons, there was a trend suggesting fasting glucose was greater in cases (median 4.80, IQR .70 in cases vs 4.51, .38 in controls) and correlated with pain severity (R2=.14, P=.03), but no other metabolic measures were associated with tendon pain/structure. This study indicates that SNS activity is associated with tendon pain duration, building on previous data indicating the SNS is involved in recalcitrant tendinopathy. Metabolic parameters had little relationship with Achilles tendinopathy in this metabolically homogenous sample. Prospective studies are required to uncover the precise relationship between SNS activity, insulin resistance, and tendinopathy.
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NewsBot · Oct 7, 2017

Men with unilateral Achilles tendinopathy have impaired balance on the symptomatic side
M. Scholes et al
JSMS Article in Press

Objectives
To investigate single leg standing balance in males with mid-portion Achilles tendinopathy (AT).

Design
Cross sectional case study.

Methods
Centre of pressure (COP) path length was measured using a Wii Balance Board (WBB) in 21 male participants (20-60 years) with unilateral mid-portion AT during single-limb standing on each limb with eyes open and closed. Ultrasound imaging of both Achilles tendons was also performed by one blinded assessor, and the anteroposterior (AP) thickness and presence of pathology was determined. Comparisons were made between symptomatic and asymptomatic sides for key outcomes, and correlation between COP path length and variables of interest were investigated.

Results
Symptomatic Achilles tendons demonstrated significantly increased AP tendon thickness (p < 0.001). Participants with AT demonstrated increased COP path length (sway amplitude) on their affected side during the eyes closed task (p = 0.001). Increased tendon thickness was associated with increased sway amplitude during the eyes open task on both the affected (rho = 0.44, p = 0.045) and unaffected sides (rho = 0.62, p = 0.003).

Conclusions
In males with AT, single-leg standing balance with eyes closed is impaired on the symptomatic side. This indicates that neuromuscular deficits affecting functional ability may be present in people with AT during more challenging balance activities. It is unclear if this deficit precedes the onset of symptoms, or is a consequence of tendon pain. Work is now needed to understand the mechanisms that may explain standing balance deficits among people with AT.
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NewsBot · Jul 13, 2022

Contralateral mechanical hyperalgesia and altered pain modulation in men who have unilateral insertional Achilles tendinopathy: A cross-sectional study
PatrickVallance et al
Musculoskeletal Science and Practice; Volume 52, April 2021, 102353

Highlights
•This is the first investigation for pain mechanisms in an exclusively IAT cohort.
•Compared to asymptomatic controls, individuals with IAT had lower PPT.
•Increase in PPT following painful cold water immersion was greater in controls.
•These findings infer there are pain processing alterations in individuals with IAT.
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Objective
The primary aim was to assess whether men who have insertional Achilles tendinopathy (IAT) have altered endogenous modulation of painful stimuli, and secondarily if they exhibit unaffected-side pressure hyperalgesia.

Methods
Using a cross-sectional design, we recruited men with unilateral IAT and asymptomatic men as controls matched for age, body mass index (BMI) and activity history (participation in running, lower limb loading sport or sedentary). We collected pressure pain threshold (PPT) at the asymptomatic side Achilles tendon insertion for cases, and dominant side Achilles tendon insertion for controls. We compared PPT between groups before and after immersion of the hand in painful cold water.

Results
Twenty men with unilateral IAT (45.4 years [SD 10.02], BMI 29.09 [SD 4.61], 60% sedentary) and 34 men without symptoms (43.2 years [SD 8.78], BMI 27.59 [SD 3.18], 50% sedentary) participated. An interaction effect was found for group x time (F (1,50) = 7.67, p = 0.008), with PPT increase after cold water immersion being 1.20 (95%CI 0.25 to 2.15) Kg greater in the control group (1.44 Kg [SD 1.79]) compared to IAT unaffected side (0.24 Kg [SD 1.47]). Before cold water immersion, PPT was 4.77 (CI 3.22 to 6.31; p < 0.001) Kg greater in the control group.

Discussion
This study provides evidence men with IAT have altered endogenous modulation of a painful stimulus, and display pressure hyperalgesia at their unaffected side compared to men without symptoms. These findings infer alterations to pain processing in men with IAT, suggesting nociplastic mechanism(s) may contribute to pain.
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NewsBot · Jul 13, 2022

Are Plantarflexor Muscle Impairments Present Among Individuals with Achilles Tendinopathy and Do They Change with Exercise? A Systematic Review with Meta-analysis
Fatmah Hasani, Patrick Vallance, Terry Haines, Shannon E. Munteanu & Peter Malliaras
Sports Medicine - Open volume 7, Article number: 18 (2021)

Background
Understanding plantarflexor muscle impairments among individuals with Achilles tendinopathy (AT) may help to guide future research and inform clinical management of AT. Therefore, the aim of this review is to evaluate plantarflexor muscle impairments among individuals with AT and whether plantarflexor muscle function changes following resistance training interventions.

Methods
We searched relevant databases including Cochrane Central Register of Controlled Trials, Ovid (MEDLINE, EMBASE, AMED) and EBSCO (CINAHL Plus and SPORTDiscus) up to September 2020. Studies investigating plantarflexor muscle function were included if they met the following criteria: (1) any study design enabled comparison of plantarflexor muscle function between individuals with and without AT, or the affected and unaffected side of individuals with unilateral AT, and (2) any studies enabled investigation of change in plantarflexion muscle function over time with use of resistance training intervention. We included studies that recruited adults with either insertional or mid-portion AT of any duration. Study selection, quality assessment and data extraction were undertaken independently by two reviewers. Discrepancies were resolved via discussion, or by consulting a third reviewer where necessary. The Joanna Briggs Institute (JBI) critical appraisal tools specific to each study design were used to assess the methodological quality of included studies. Grading the strength of evidence for each outcome was determined according to the quality and number of studies.

Results
A total of 25 studies (545 participants) met inclusion. Participants’ mean age was 40 ± 7 years old. Six studies were high quality for all domains, while the remaining were susceptible to the risk of bias (e.g. selection criteria, reporting findings). This review identified moderate evidence that individuals with AT have impairment in maximal plantarflexor torque (seven studies including one with a mixed population) on their affected side, compared with the unaffected side. Impairments were modest (9% and 13% [pooled effect divided by mean of the unaffected side scores]) and of uncertain clinical importance. The remaining evidence, primarily among individuals with mid-portion AT, showed conflicting impairments for plantarflexor function (i.e. explosive strength and endurance) between sides. There was limited to very limited evidence for improvement in plantarflexor endurance (7% and 23%) but not power or strength (five studies including one with a mixed population for strength) over time, despite individuals undertaking several weeks of resistance training.

Conclusions
Plantarflexor impairments appear more common between sides than compared with control groups but given limitations in the literature further exploration of these relationships is needed.
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