Sensory and central pain processing issues in Achilles tendinopathy

NewsBot · Dec 24, 2015

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Central pain processing is altered in people with Achilles tendinopathy
Nefeli Tompr et al
Br J Sports Med doi:10.1136/bjsports-2015-095476

Background Tendinopathy is often a chronic condition. The mechanisms behind persistent tendon pain are not yet fully understood. It is unknown whether, similar to other persistent pain states, central pain mechanisms contribute to ongoing tendon pain.

Aim We investigated the presence of altered central pain processing in Achilles tendinopathy by assessing the conditioned pain modulation (CPM) effect in people with and without Achilles tendinopathy.

Methods 20 people with Achilles tendinopathy and 23 healthy volunteers participated in this cross-sectional study. CPM was assessed by the cold pressor test. The pressure pain threshold (PPT) was recorded over the Achilles tendon before and during immersion of the participant's hand into cold water. The CPM effect was quantified as the absolute difference in PPT before and during the cold pressor test.

Results An increase in PPT was observed in the Achilles tendinopathy and control group during the cold pressor test (p<0.001). However, the CPM effect was stronger in the control group (mean difference=160.5 kPa, SD=84.9 kPa) compared to the Achilles tendinopathy group (mean difference=36.4 kPa, SD=68.1 kPa; p<0.001).

Summary We report a reduced conditioned pain modulation effect in people with Achilles tendinopathy compared to people without Achilles tendinopathy. A reduced conditioned pain modulation effect reflects altered central pain processing which is believed to contribute to the persistence of pain in other conditions. Altered central pain processing may also be an important factor in persistent tendon pain that has traditionally been regarded to be dominated by peripheral mechanisms.
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NewsBot · Oct 31, 2016

Disrupted Tactile Acuity in People With Achilles Tendinopathy: A Preliminary Case-Control Investigation
James Debenham et al
Journal of Orthopaedic & Sports Physical Therapy, 2016 Volume:0 Issue:0 Pages:1–10 DOI: 10.2519/jospt.2016.6514

Study Design
Controlled laboratory study, preliminary case-control design.

Background
The mechanisms contributing to the problem of Achilles tendinopathy remain poorly understood. The disparity between pain experience and peripheral pathology demonstrated in patients with Achilles tendinopathy opens the door to the possibility that changes in central nervous system function may be involved.

Objectives
To investigate if lower limb tactile acuity is impaired in people with non-acute Achilles tendinopathy.

Methods
Thirteen consecutive participants with non-acute mid-portion Achilles tendinopathy and thirteen healthy controls were enrolled. Two point discrimination thresholds over the affected Achilles tendon, unaffected tendon and over the tendon of healthy controls were evaluated. Independent and dependent t-tests were used to compare group means.

Results
Two-point discrimination distance over the affected limb in participants with Achilles tendinopathy was significantly increased when compared to the unaffected limb (mean difference, 11.7mm, 95% CI: 1.9 - 21.5, P = 0.02) and to healthy controls (mean difference, 13.1mm, 95% CI: 1.6 - 24.6, P = 0.03). There was no significant difference between the healthy controls and the unaffected side in people with Achilles tendinopathy (mean difference, 1.4mm 95%CI:-7.9-5.1, P = 0.66).

Conclusions
These data provide the first evidence of reduced two-point discrimination over the affected tendon in patients with Achilles tendinopathy. Further research is needed to determine the cause for the change in tactile acuity
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NewsBot · Jul 12, 2017

Patellar and Achilles tendinopathies are predominantly peripheral pain states: a blinded case control study of somatosensory and psychological profiles
Melanie L Plinsinga et al
Br J Sports Med Published Online First: 11 July 2017

Study design Case–control design.

Background Tendinopathy is characterised by pain on tendon loading. In persistent cases of upper limb tendinopathy, it is frequently associated with central nervous system sensitisation, whereas less commonly linked in the case of persistent lower limb tendinopathies.

Objectives Compare somatosensory and psychological profiles of participants with persistent patellar (PT) and Achilles tendinopathies (AT) with pain-free controls.

Methods A comprehensive battery of Quantitative Sensory Testing (QST) was assessed at standardised sites of the affected tendon and remotely (lateral elbow) by a blinded assessor. Participants completed the Victorian Institute of Sports Assessment, a health-related quality of life questionnaire, the Hospital Anxiety and Depression Scale and the Active Australia Questionnaire. Independent t-test and analysis of covariance (sex-adjusted and age-adjusted) were performed to compare groups.

Results Participants with PT and AT did not exhibit differences from controls for the QST at the remote site, but there were differences at the affected tendon site. Compared with controls, participants with PT displayed significantly lower pressure pain threshold locally at the tendon (p=0.012) and fewer single limb decline squats before pain onset, whereas participants with AT only displayed fewer single heel raises before pain onset, but this pain was of a higher intensity.

Conclusion PT and AT appear to be predominantly local not widespread pain states related to loading of tendons without significant features of central sensitisation.
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NewsBot · Feb 16, 2018

Patellar and Achilles tendinopathies are predominantly peripheral pain states: a blinded case control study of somatosensory and psychological profiles
Melanie L Plinsinga et al
Br J Sports Med 2018;52:284-291.

Study design Case–control design.

Background Tendinopathy is characterised by pain on tendon loading. In persistent cases of upper limb tendinopathy, it is frequently associated with central nervous system sensitisation, whereas less commonly linked in the case of persistent lower limb tendinopathies.

Objectives Compare somatosensory and psychological profiles of participants with persistent patellar (PT) and Achilles tendinopathies (AT) with pain-free controls.

Methods A comprehensive battery of Quantitative Sensory Testing (QST) was assessed at standardised sites of the affected tendon and remotely (lateral elbow) by a blinded assessor. Participants completed the Victorian Institute of Sports Assessment, a health-related quality of life questionnaire, the Hospital Anxiety and Depression Scale and the Active Australia Questionnaire. Independent t-test and analysis of covariance (sex-adjusted and age-adjusted) were performed to compare groups.

Results Participants with PT and AT did not exhibit differences from controls for the QST at the remote site, but there were differences at the affected tendon site. Compared with controls, participants with PT displayed significantly lower pressure pain threshold locally at the tendon (p=0.012) and fewer single limb decline squats before pain onset, whereas participants with AT only displayed fewer single heel raises before pain onset, but this pain was of a higher intensity.

Conclusion PT and AT appear to be predominantly local not widespread pain states related to loading of tendons without significant features of central sensitisation
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NewsBot · May 31, 2018

BMJ Editorial:
Central sensitisation in different tendinopathies: are we comparing apples and oranges?

NewsBot · Sep 26, 2018

Up to a quarter of patients with certain chronic recalcitrant tendinopathies may have central sensitisation: a prospective cohort of more than 300 patients
Patrick C Wheeler
British Journal of Pain; September 21, 2018

Introduction:
To identify the possible prevalence of ‘central sensitisation’, in patients with chronic recalcitrant lower limb tendinopathy conditions, with the Central Sensitisation Inventory (CSI) questionnaire.

Methods:
Patients with chronic lower limb tendinopathy conditions treated within a single hospital outpatient clinic specialising in tendinopathy were identified from clinical records. As part of routine care, self-reported numerical markers of pain, global function (using the EuroQol-5D (EQ-5D) questionnaire) and the CSI score to investigate the possibility of central sensitisation were completed.

Results:
A total of 312 suitable patients with chronic lower limb tendinopathy and similar conditions were identified, who had completed a CSI questionnaire. Of these, 108 presented with greater trochanteric pain syndrome, 12 with patella tendinopathy, 33 with non-insertional Achilles tendinopathy, 48 with insertional Achilles tendinopathy and 110 with plantar fasciitis. A total of 66% of the patients were female, the median age was 54.9 years and the median duration of symptoms was 24 months. There was a median CSI score of 25%, with statistically significant differences noted between the different conditions studied. Overall, 20% of patients scored above a threshold of 40% on CSI questionnaire, indicating that central sensitisation was possible. Greater trochanteric pain syndrome and plantar fasciitis had the highest proportions in the conditions studied. Weak correlations were found between CSI and other pain scores studied.

Conclusion:
The CSI questionnaire may identify up to a quarter of patients with some chronic lower limb tendinopathy and associated conditions as being more likely to have central sensitisation, and these proportions differed between conditions. The clinical significance of this is unclear, but worth further study to see if/how this may relate to treatment outcomes. These are results from a single hospital clinic dealing with patients with chronic tendinopathy, and comparison with a control group is currently lacking. However, on the information presented here, the concept of central sensitisation should be considered in patients being treated for chronic tendinopathy.
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NewsBot · Nov 14, 2018

Prediction of running-induced Achilles tendinopathy with pain sensitivity – a 1-year prospective study
René B.K. Brund et al
Scandinavian Journal of Pain: 2018-11-08

Background and aims
Achilles tendinopathy is common among runners, but the etiology remains unclear. High mechanical pain sensitivity may be a predictor of increased risk of developing Achilles tendinopathy in this group. The purpose of this study was to investigate whether local pain sensitivity could predict the development of Achilles tendinopathy in recreational male runners. The overall hypothesis was that high pain sensitivity would be related to a higher risk of developing Achilles tendinopathy among recreational male runners.

Methods
Ninety-nine recreational male runners were recruited and followed prospectively for 1 year. At baseline and after 500 km of running the pressure pain threshold (PPT) was assessed at the infraspinatus and at the Achilles tendon (AT-PPT). Based on the AT-PPT at baseline, a median split was used to divide the runners into two groups. The high pain sensitivity groups was defined as runners displaying a pain pressure threshold below 441 kPa on the Achilles tendon, while the low pain sensitivity group was defined as runners displaying a pain pressure threshold above 441 kPa on the Achilles tendon, respectively. Subsequently, the cumulative risk difference between the two groups was assessed by using the pseudo-observation method.

Results
High pain sensitivity runners sustained 5%-point (95% CI: −0.18 to 0.08) more Achilles tendinopathy episodes during the first 1,500 km. No significant group differences in risk were found at 100, 250, 500, 1,000 and 1,500 km of running.

Conclusions
No significant association was found between mechanical pain sensitivity in the Achilles tendon and the risk of developing Achilles tendinopathy. However, the risk difference indicated a association between a high mechanical pain sensitivity and an increased risk of developing Achilles tendinopathy. It is plausible that changes in pain sensitivity were masked by unmeasured covariates, such as the differences in progression/regression of training volume and running speed between the two groups. This study was limited in size, which limited the possibility to account for covariates, such as differences in progression/regression of running speed between runners. With the limitations in mind, future studies should control the training volume, speed and running shoes in the design or account for it in the analysis.

Implications
Pain sensitivity of the Achilles tendon seems not to be related to an increased risk of developing Achilles pain in relation to running.
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NewsBot · Jan 1, 2021

Sensory Processing in People With and Without Tendinopathy: A Systematic Review With Meta-analysis of Local, Regional, and Remote Sites in Upper- and Lower-Limb Conditions
Journal of Orthopaedic & Sports Physical Therapy

Objective
To synthesize results of somatosensory processing tests in people with upper- and lower-limb tendinopathy, compared to controls.

Design
Systematic review with meta-analysis.

Literature Search
Four electronic databases (MEDLINE, CINAHL Plus, SPORTDiscus, and Embase) were searched.

Study Selection Criteria
Included studies measured a domain of sensory processing and compared a tendinopathy group to a healthy control group.

Data Synthesis
Meta-analysis was conducted for outcomes with homogeneous data from at least 2 studies. Upper- and lower-limb conditions were compared and outcomes were examined by measurement site (local, regional, or remote to location of pain).

Results
Of the 30 studies included, 18 investigated lateral elbow tendinopathy. The most commonly assessed outcome measures were pressure pain threshold (PPT) and thermal pain threshold. There was moderate evidence for local and regional reduction of PPT in upper-limb tendinopathies, but not at remote sites. In lower-limb tendinopathies, there was conflicting evidence regarding reduced PPT at local sites and limited evidence of normal PPT at remote sites. There was moderate evidence of sensitization of thermal pain threshold at local sites in upper-limb tendinopathies and limited evidence of no difference in thermal pain threshold in lower-limb tendinopathies. Findings across other domains were variable.

Conclusion
Sensory processing was different between upper-limb tendinopathy and lower-limb tendinopathy. Upper-limb tendinopathies showed signs consistent with primary and secondary hyperalgesia, but lower-limb tendinopathies did not. There was mixed evidence for primary hyperalgesia and limited evidence against secondary hyperalgesia
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NewsBot · Apr 25, 2021

Are pain coping strategies and neuropathic pain associated with a worse outcome after conservative treatment for Achilles tendinopathy? A prospective cohort study
Iris F. Lagas, MD
April 19, 2021

Objectives
To analyse whether 1) passive or active pain coping strategies and 2) presence of neuropathic pain component influences the change of Achilles tendinopathy (AT) symptoms over a course of 24 weeks in conservatively-treated patients.
Design
Prospective cohort study.
Methods
Patients with clinically-diagnosed chronic midportion AT were conservatively treated. At baseline, the Pain Coping Inventory (PCI) was used to determine scores of coping, which consisted of two domains, active and passive (score ranging from 0-1; the higher, the more active or passive). Presence of neuropathic pain (PainDETECT questionnaire, -1 to 38 points) was categorized as (a)unlikely (≤12 points), (b)unclear (13-18 points) and (c)likely (≥19 points). The symptom severity was determined with the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire (0-100) at baseline, 6, 12 and 24 weeks. We analysed the correlation between 1)PCI and 2)PainDETECT baseline scores with change in VISA-A score using an adjusted Generalized Estimating Equations model.
Results
Of 80 included patients, 76 (95%) completed the 24-weeks follow-up. The mean VISA-A score (standard deviation) increased from 43 (16) points at baseline to 63 (23) points at 24 weeks. Patients had a mean (standard deviation) active coping score of 0.53 (0.13) and a passive score of 0.43 (0.10). Twelve patients (15%) had a likely neuropathic pain component. Active and passive coping mechanisms and presence of neuropathic pain did not influence the change in AT symptoms (p = 0.459, p = 0.478 and p = 0.420, respectively).
Conclusions
Contrary to widespread belief, coping strategy and presence of neuropathic pain are not associated with a worse clinical outcome in this homogeneous group of patients with clinically diagnosed AT.
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NewsBot · Oct 19, 2021

Implicit Motor Imagery of the Foot and Hand in People with Achilles Tendinopathy: A Left Right Judgement Study
Ebonie K Rio, PhD, Tasha R Stanton, PhD, Benedict M Wand, PhD, James R Debenham, PhD, Jill Cook, PhD, Mark J Catley, PhD, G Lorimer Moseley, PhD, Prudence Butler, Kylie Cheng, Adrian J Mallows, PhD
Pain Medicine, 14 September 2021

Objective
To determine if impairment in motor imagery processes is present in Achilles tendinopathy (AT), as demonstrated by a reduced ability to quickly and accurately identify the laterality (left-right judgement) of a pictured limb. Additionally, this study aimed to use a novel data pooling approach to combine data collected at 3 different sites via meta-analytical techniques that allow exploration of heterogeneity.

Design
Multi-site case-control study.

Methods
Three independent studies with similar protocols were conducted by separate research groups. Each study-site evaluated left/right judgement performance for images of feet and hands using Recognise© software and compared performance between people with AT and healthy controls. Results from each study-site were independently collated, then combined in a meta-analysis.

Results
In total, 126 participants (40 unilateral, 22 bilateral AT cases, 61 controls) were included. There were no differences between AT cases and controls for hand image accuracy and reaction time. Contrary to the hypothesis, there were no differences in performance between those with AT and controls for foot image reaction time, however there were conflicting findings for foot accuracy, based on four separate analyses. There were no differences between the affected and unaffected sides in people with unilateral AT.

Conclusions
Impairments in motor imagery performance for hands were not found in this study, and we found inconsistent results for foot accuracy. This contrasts to studies in persistent pain of limbs, face and knee osteoarthritis, and suggests that differences in pathoetiology or patient demographics may uniquely influence proprioceptive representation.
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NewsBot · Jul 27, 2022

Tendinopathies and Pain Sensitisation: A Meta-Analysis with Meta-Regression
Davide Previtali et al
Biomedicines 2022, 10(7), 1749; https://doi.org/10.3390/biomedicines10071749

The presence of pain sensitisation has been documented and reported as being a possible cause of treatment failure and pain chronicity in several musculoskeletal conditions, such as tendinopathies. The aim of the present study is to analyse existing evidence on pain sensitisation in tendinopathies comparing the local and distant pain thresholds of healthy and affected subjects with distinct analysis for different tendinopathies. PubMed, Cochrane Central Register, Scopus, and Web Of Science were systematically searched after registration on PROSPERO (CRD42020164124). Level I to level IV studies evaluating the presence of pain sensitisation in patients with symptomatic tendinopathies, documented through a validated method, were included. A meta-analysis was performed to compare local, contralateral, and distant pain thresholds between patients and healthy controls with sub-analyses for different tendinopathies. Meta-regressions were conducted to evaluate the influence of age, activity level, and duration of symptoms on results. Thirty-four studies out of 2868 were included. The overall meta-analysis of local pressure pain thresholds (PPT) documented an increased sensitivity in affected subjects (p < 0.001). The analyses on contralateral PPTs (p < 0.001) and distant PPTs (p = 0.009) documented increased sensitivity in the affected group. The results of the sub-analyses on different tendinopathies were conflicting, except for those on lateral epicondylalgia. Patients’ activity level (p = 0.02) and age (p = 0.05) significantly influenced local PPT results. Tendinopathies are characterized by pain sensitisation, but, while features of both central and peripheral sensitisation can be constantly detected in lateral epicondylalgia, results on other tendinopathies were more conflicting. Patients’ characteristics are possible confounders that should be taken into account when addressing pain sensitisation
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NewsBot · Apr 18, 2024

PSYCHOLOGICAL FACTORS SHOW LIMITED ASSOCIATION WITH THE SEVERITY OF ACHILLES TENDINOPATHY
Yanka Aparecida Bandeira Murakawa et al
Physical Therapy in Sport; 18 April 2024

HIGHLIGHTS
•Psychological Factors Minimally Impact Achilles Pain Severity (β=0.42, p=0.00).
•Self-Efficacy for Chronic Pain Shows Weak Association with Pain Intensity (19%).
•Anxiety, Depression, Catastrophic Thoughts, and Kinesiophobia Not Associated with Pain.
•Clinical Relevance of Psychological Factors in Achilles Pain Is Inconsequential
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Background
This study aimed to investigate the association between psychosocial factors and the severity of Achilles tendinopathy, along with exploring their potential link to the pain's duration.

Methods
A cross-sectional study involving 111 individuals with Achilles tendon pain was conducted. Methods: A cross-sectional study involving 111 individuals with Achilles tendon pain was conducted. Various psychological factors were assessed using the Pain Catastrophizing Scale, Chronic Pain Self-Efficacy Scale (CPSS), Tampa Scale for Kinesiophobia, and Hospital Anxiety and Depression Scale (HAD). Additionally, the severity of Achilles tendon pain was evaluated using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-Br). Regression analyses were employed to determine the association of these psychosocial factors with pain severity and duration.

Results
Self-efficacy for chronic pain showed a slight association with Achilles tendon pain severity (β = 0.42 [95% CI: 0.06 to 0.16], p = 0.001), explaining only 19% of the dependent variable. The other variables, including anxiety, depression, pain catastrophizing, and fear of movement, did not exhibit significant associations.

Conclusion
The study suggests that psychological factors demonstrate limited association with the severity of Achilles tendinopathy. While self-efficacy for chronic pain was weakly associated, its clinical relevance remains uncertain. Future research, particularly longitudinal studies, should explore the influence of psychosocial factors on treatment adherence and response to enhance management strategies for Achilles tendon pain.
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