Lupine Publishers | Is There a Role for Platelet-Rich Plasma Injection in Pediatrics? a Narrative Review

 Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

This review identifies some of the relevant literature regarding the application of platelet-rich plasma (PRP) and the corresponding evidence of its use in the pediatric population. Because of its potential in various regenerative processes, there is a building interest in its utilization. However, very few high-quality studies investigating the therapeutic use of PRP exist for many reasons. The concentration of plasma constituents, response to PRP in different tissues, and its preparation are some of the issues that have been overlooked or not standardized when investigating its efficacy. With this lack of evidence, PRP’s utilization in the general population, and consequently in pediatrics, has been under-investigated and relegated mostly to animal models. We postulate that PRP may have some of its best utility in the young athlete with musculoskeletal derangements. In addition, further investigations need to be conducted in pediatric patients to determine whether PRP will be beneficial.

Keywords:Orthobiologics; Platelet rich plasma (PRP); Pediatrics, Sports injuries; Sports medicine; Orthopedic surgery

Abbreviations:(PRP): Platelet rich plasma; (ACL): Anterior cruciate ligament; (UCL): Ulnar collateral ligament; (MCL): Medial collateral ligament; (MPFL): Medial patellofemoral ligament; (RICE): Rest ice compression and elevation; (DASH): Disabilities of the Arm Shoulder and Hand; (KJOC): Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow

Introduction

Over the last three decades, there has been increasing interest in biological treatments for musculoskeletal pathology. Advances in plasma and stem cell research have led to the study and utilization of our own biologic machinery’s regenerative or reparative potential. Uses of these therapies have their roots in plastic surgery starting in the 1990s, and since that time, there has been an increased focus on their use in sports medicine [1] The theory behind platelet-rich plasma (PRP) is the sequestration of blood plasma, which contains many of the healing factors responsible for tissue repair, to the area in question. This article aims to review PRP as a treatment modality and identify the most common uses of PRP in the pediatric population. We will also bring attention to its current limitations and future potential. There is a wealth of studies on its use in several sports-related pathologies, but studies on pediatric use and indications are still lacking [2]

What is PRP

Traditionally, PRP has been defined depending on its most abundant constituent, and fibrin density once activated.3 The four major types are Pure Platelet-Rich Plasma (P-PRP) (or Leukocyte- Poor Platelet-Rich Plasma (LP-PRP)), Leukocyte-and Platelet-Rich Plasma (LR-PRP), Pure Platelet-Rich Fibrin (P-PRF) (or Leukocyte- Poor Platelet-Rich Fibrin, and Leukocyte-and Platelet-Rich Fibrin (L-PRF)) [3] Each of these preparations has its specific composition, which has indications depending on the pathology in question. Each formulation induces specific effects on cartilage depending on the concentration of different factors. However, one of the significant difficulties with the administration of PRP products is utilizing the correct concentration or ratio of plasma factors that will induce the appropriate response [4]. For instance, in a 2015 study by Zhou, both L-PRP and P-PRP demonstrated different responses to the differentiation of trophoblast stem cells to tenocytes. L-PRP was detrimental to these tenocytes by activating catabolic effects on tendons. On the other hand, P-PRP was anabolic to tenocytes, leading to healing via scar tissue formation [5].

Current literature has recognized some evidence for the use of PRP depending on the pathology in question. In a review by Le, there is support for the use of LR-PRP for lateral epicondylitis, osteoarthritis in the knee, patella tendonitis, plantar fasciitis, and as an adjunct for pain following bone-patellar tendon-bone ACL reconstruction. Alternatively, PRP is also shown to be ineffective in Achilles tendinitis, injured muscle, fracture non-unions, and ACL or Achilles tendon repair. Furthermore, there is incomplete evidence for PRP in rotator cuff tears, osteoarthritis of the hip, and ankle sprains [6]. Some of the criticism from lack of evidence or utility for PRP is due to the varying methodology of PRP preparation and formulation across studies. There is little to no clear literature on the active components responsible for the bulk of the biologic response that PRP theoretically induces. We are aware of these molecules and the responses they impart. However, the concentration and heterogeneity between samples obtained from different patients vary. This diversity between formulations of PRP can potentially produce varying results from case to case [7].

Uses for PRP

Regardless of the heterogeneity with PRP’s formulations, it can be appreciated that cytokines and PRP factors may be responsible for its regenerative properties. There is evidence that these factors may very well expedite healing, especially in chronic tendinopathies, where the tendon in question lacks the nutrient environment to repair itself [6] A systematic review and metaanalysis by Miller concluded that PRP was effective in treating and expediting the healing in these aforementioned chronic conditions [8] Other indications for PRP’s use in the literature review include but are not limited to rotator cuff repair, Achilles tendon repair, and ACL surgery. Sprains and muscle injuries have also been a subject of interest. Moreover, PRP has been studied for use in other non-soft tissue-related pathologies, including osteoarthritis of hip and knee and fracture management and nonunions. [6] It must be mentioned that the majority of randomized controlled trials testing the efficacy of PRP are not high quality. Furthermore, to achieve better studies and obtain reproducible results, Chahla, et al. published the importance of standardizing PRP harvesting preparations and PRP compositions to make comparisons between studies.

Further emphasizing the issue of timing and formulation of a PRP injection, Laprade, et al. investigated whether or not the use of a single dose of varying concentrations of PRP accelerates ligament healing and improves the histological characteristics and biomechanical properties with a comparison to standard saline injections on the contralateral limb [9] The study was conducted by inducing a grade 3 MCL sprain on New Zealand White rabbits, and then an injection of either saline or varying concentrations of PRP was delivered immediately post-operatively. The study concluded that low dose concentrations of PRP injections into injured ligaments did not improve the healing of injured MCLs, and higher doses seemed to decrease the quality of the ligament healing. The study further emphasized that additional in vivo studies are needed to standardize the timing of injection and the concentration of PRP injection in the treatment of ligament injuries [9].

Use in pediatrics

With the advent of PRP use in adults, there is gaining interest in its use for pediatric sports injuries. The following points call attention for further investigation when considering PRP in the young athlete: increasingly promising data with more randomized controlled trials, a better understanding of the healing factors found in plasma, improved protocols for obtaining specific formulations, and reducing heterogeneity among said formulations. Furthermore, we should note the potentially increased efficacy among the younger population due to genetic factors, the negative immunogenicity with autologous PRP, and the non-invasive nature of these treatments. With the increasing number of sports injuries in the younger population, research in biological treatment is imperative. Schroeder et al. investigated overuse injuries from 2006 to 2012 and found these injuries occurred in 1.50 per 10,000 athletic exposures within the interest population. Females had a greater risk of overuse versus males, with the most significant risk being in track and field. 7.7% of all injuries in this population were overuse injuries. The most frequent site was in the lower leg. Injuries most frequently resulted in less than a week of time off, with 7.6% of the patients reporting time loss greater than three weeks [10].

Similarly, there is an increased amount of ligamentous injuries necessitating reconstruction in the young population. According to some studies, ACL injuries requiring reconstruction alone have increased 924% from 1994 to 2006 [11] This study identified prolonged sports participation, increased amount of athletes participating, and a focus on a single sport as risk factors for the increased incidence. Other common sports injuries in the pediatric population include the medial patellofemoral ligament (MPFL) and the ulnar collateral ligament (UCL) [2] There are currently no studies examining PRP’s use as an augment for MPFL injury or repair. Other indications presented by Bray, et al. that warrant further study include PRP for tendon injuries, cartilage defects, and fractures, although even less data is available for these situations. The majority of studies investigating PRP’s potential in these instances continue to be limited in number, contradictory in results, and limited to adult subjects.

Potential Benefits of PRP in pediatrics

With increasing sports participation and focus on specialization in a single sport with minimal rest in training, overuse injuries in adolescent athletes are increasing. These injuries vary in morbidity from requiring rest for a few days and subsequently missing a few games or practices to season-ending injuries. While rest, ice, compression, elevation (RICE therapy) with or without accompanying physical therapy are often chosen as treatment regimens, there is a lack of level I evidence to support their efficacy.12 While not performed in pediatric patients but rather patients >/= 18 years of age with a median age of 21 years old, a randomized controlled trial by Hamid, et al. in 2014 investigated the effect of a single PRP injection and a standardized rehab protocol versus a rehabilitation program alone on grade 2 hamstring injuries. The primary outcome of return to play was found to be statistically significant (p=.02), and substantially sooner with the PRP injection with an average return to play of 26.7 days +/- 7.0 days versus 42.5 +/- 20.6 days in the control group [13]

A systematic review by Figueroa et al. compared ACL reconstruction with PRP as an adjunct versus ACL reconstruction alone. In total, eleven studies were reviewed. Six of those demonstrated statistical significance in regards to “graft maturation” with PRP. One study showed improved tunnel healing and another showed better clinical outcomes. Five studies showed no added benefit when PRP was added to ACL reconstruction [14] Podesta, et al. conducted a case series in 2013 on 34 athletes with partialthickness UCL tears as evidenced by clinical examination and confirmed on MRI, who failed at least two months of nonoperative care. The patients were treated with a single leukocyte rich PRP injection. The average age of these players was 18 years, with a range from 14 to 34 years. The study resulted in 30 out of 34 patients returning to the same level of play without issues at an average of 12 weeks post-treatment. The average Disabilities of the Arm, Shoulder and Hand (DASH) score improved from 21 to 1, and the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score improved from 46 to 93-both of which were statistically significant. The study concluded that PRP was effective in treating partial UCL tears of the elbow in young athletes [15]

On the contrary, Chauhan, et al. conducted a retrospective study on PRP injections in 133 MLB pitchers versus no PRP in 411 MLB pitchers in the nonoperative treatment of UCL injuries. The PRP group resulted in a significantly longer return to throwing and a significantly longer return to play. However, PRP’s formulation was non-standardized, with some patients receiving leukocyte rich PRP and others receiving leukocyte poor injections. Additionally, the time from injury to injection was not standardized. Notably, the average age of the non-PRP group was 22.6 years old versus 24.3 years old for the PRP group. [16] However, as evidenced by Podesta, et al. PRP’s efficacy was seen in young athletes with PRP. While the two studies’ results differ in their outcomes, both suggest younger patients can do well with the nonoperative case of UCL injuries. The two studies differed on major criteria such as time from injury to injection and type of PRP injections. Therefore, further investigation needs to be conducted on the type of injection and the time from injury to injection, both of which need to be standardized for further conclusions, which seems to be one of the underlying problems with PRP studies. Additionally, since younger patients have a greater healing capacity, an appropriately timed PRP injection of the correct formulation may further enhance their recovery and return to sport.

Tendinopathies are another indication for the potential benefit of PRP administration. Sanchez, et al. injected PRP during Achilles tendon repair in a case-control study from 2007. In the participants treated with PRP, return to base function was faster than in the non-PRP group [17] Kon, et al. found significant improvement in all functional scores used in their study when PRP was used to treat jumper’s knee (patellar tendinitis) [18]. One of the most common injuries to young athletes is chondral damage. Chondral injury is another area of interest as it is a common injury with the potential for arthritis development. Many treatments have been developed to treat cartilage lesions, including microfracture, which is a similar concept to PRP. By surrounding the defective cartilage with a nutrient-rich environment, microfracture and PRP theoretically lead to chondral repair via similar mechanisms. Again, Bray et al. suggest future investigation into PRP as a therapeutic for these injuries; however, at this time, these injuries are mostly treated with microfracture, osteochondral autograft, osteochondral allografts, and autologous chondrocyte implantation. Good results have been documented in the pediatric population. One of the reasons why PRP use in this group is possibly incomplete is the more urgent nature of treating these injuries, which can accelerate towards arthritis.

Finally, fracture management is another area where PRP administration has piqued some interest. One study demonstrated reduced clinical and radiographic healing time of femoral neck fractures with PRP in addition to cannulated screw fixation compared to just cannulated screw fixation [19, 20] However, a subsequent paper demonstrated the opposite effect. Singh reports that although PRP may provide an artificial hematoma effect in the initial healing phase, it does not affect femoral shaft fracture healing when used with intramedullary nailing.

Conclusion

Young athletes often participate in year-round sports. These athletes are also focusing on single sports at a younger age, and therefore participation in multiple sports and appropriate crosstraining is often lacking. Without consistent rest periods or cross training, an increasing number of athletes will continue to sustain overuse and sports-related injuries. Since younger patients have a greater healing capacity, adding PRP to the treatment regimen, in theory, may enhance their ability to return to their sport sooner. While PRP’s potential applications in sports medicine are still being studied extensively, no trials are specifically studying pediatric patients. Since cytokines found in PRP are involved in the signaling pathways that occur during healing stages of inflammation, cellular proliferation, and subsequent tissue remodeling, investigations into the appropriate timing, makeup (Pure PRP, Leukocyte and PRP, Pure PRF, Leukocyte and PRF), and concentration of PRP need to be further investigated. In place of the increasingly promising data in adult patients, further investigations need to be conducted in pediatric patients to determine whether PRP will have any considerable benefit.

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Lupine Publishers | Case Report of Multiple Myeloma Presenting with Unique Skin Manifestation with Literature Review

 

Lupine Publishers | Open Access Journal of Oncology and Medicine (OAJOM)

Introduction

Multiple myeloma (MM) accounts for approximately 2% of all malignancies and 13% of hematological malignancies worldwide [1]. MM is the second most common hematologic malignancy [1] and it is a neoplasm of clonal plasma cells which originate from the B-cell lineage and develop after lineage commitment in the bone marrow of progenitor cells [9]. Cutaneous involvement in patients with multiple myeloma is rare and it usually represents of a poor prognosis. Cutaneous involvement indicates an increased tumor burden. The most common cause of cutaneous involvement is due to direct extension from underlying bone lesions of MM or solitary plasmacytoma of bone [2]. It is very rare to have primary cutaneous plasmacytoma [3].

Case Presentation

We present the case of a friendly Caucasian American 70-yearold female with no significant PMH who initially presented to Ruby Memorial Emergency Department in November 2015 with persistent back and left side pain. At that time, she began to notice weakness and some numbness in lower extremities and along with the increasing low back pain decided to seek medical attention and presented to the hospital. On admission, CT thoracic spine (11/16/15) revealed a T5 wedge compression deformity. CT lumbar spine revealed degenerative changes with diffuse osteoporosis. MRI thoracic spine (11/17/15) revealed a T5 burst fracture with retropulsion, focal kyphotic deformity, severe central canal stenosis, possible pathologic fracture deformity, And possible cord contusion at T5. CBC on admission revealed WBC 5.1 with normal differential, Hgb 11.5 with MCV 105.3 and platelet count 170,000. BMP normal, creatinine 0.75, corrected calcium 10.2. Subsequently, she underwent a posterior spinal fusion T3-T8, left costotransversectomy with left pedulectomy and subtotal corpectomy (excision of tumor) via transpedicular approach with placement of anterior cage, T5 laminectomy, and T6-7 partial laminectomy. Pathology revealed a tumor composed of sheets of atypical plasmacytoid cells positive with immunostain for CD138 and negative for pancytokeratin, CD20, and CD3. Insufficient tissue remained for kappa and lambda ISH. The finding was consistent with plasma cell neoplasm. SPEP revealed an M spike seen in the gamma, consistent with monoclonal gammopathy. Random UPEP/ IFE revealed a monoclonal lambda protein without detectable associated IgG, IgA or IgM heavy chain. In December, SPEP/IFE revealed an IgG Lambda monoclonal protein (5.95 g/dL). Free light chain ratio 0.013 (Kappa 0.80 mg/dL, Lambda 60.50 mg/dL). Quantitative IgG 5950 g/dL. Hgb 9.4 with MCV 98.5. Creatinine 0.62. Corrected serum calcium 11.2. Albumin 2.0. Beta 2 microglobulin 4.25. Skeletal survey reveals diffuse osteolytic process with multiple calvarial, vertebral body and rib lesions identified. T3-T8 posterior spinal fusion for pathological T5 compression fracture noted.

She had a bone marrow biopsy/aspirate which revealed 47% lambda restricted plasma cells, with marked atypia including a plasmablastic morphology. Preliminary FISH results indicate multiple trisomies, 1q21 gain, del (13q14) and a non-standard IGH rearrangement-t(8;14). Hyperdiploidy detected. She was diagnosed with IgG Lambda Multiple Myeloma. ISS Stage II, DS IIIA. Soon thereafter, she was started on a bortezomib-based triplet regimen - bortezomib, cyclophosphamide, dexamethasone (CyBorD). She completed 4 cycles. In April 2016, SPEP/IFE revealed an IgG Lambda monoclonal protein - not quantified. Quantitative immunoglobulins: IgG 1013 mg/dL. Free light chain assay revealed a ratio of 1.169 (kappa 2.98 mg/dL, Lambda 2.55 mg/ dL). CBC normal. Hgb 13.2. Serum creatinine 0.59. Serum calcium 9.7 (corrected). Serum albumin 3.0 g/dL. Beta 2 microglobulin 2.65 mcg/mL. Skeletal survey demonstrated new evidence of L5 pathological compression fracture. A repeat bone marrow biopsy revealed a variably cellular marrow (10-50%). Maturing trilineage hematopoiesis noted. No atypical plasma cell infiltrate (<5% by CD138 ICH). Cytogenetics normal. Unable to run FISH. At the end of the month, her regimen switched to Lenalidimide/Dexamethasone and she completed 4 cycles. In August, she began maintenance therapy with Lenalidomide at 10 mg daily. She then presented with multiple skin papule skin lesions (Figure 1) mostly on her gluteal region. In January 2017, she had a left gluteal skin biopsy consistent with plasma cell neoplasm with high grade features (plasmablastic differentation) In February 2017, SPEP/IFE revealed a IgG Kappa monoclonal protein (not quantified). IgG level 2303 mg/dL. Free light chain assay reveals a ratio of 1.31 (Kappa 12.63 mg/dL, Lambda 9.62 mg/dL). She completed radiation therapy to left gluteal skin - received 30 Gy/15 fractions. SPEP/IFE revealed a IgG Kappa monoclonal protein (not quantified). IgG level 2357 mg/dL. Free light chain assay reveals a ratio of 1.47 (Kappa 12.20 mg/dL, Lambda 8.32 mg/dL). In March 2017, she was started on Pomalidomide/ Dex. Unfortuatnely she was found to have progression of her disease noted. She was then started on Daratumumab which she could not tolerate and was then started on Carfilzomib/Dex. She has received multiple radiation therapy to her left gluteal region, mid back and left upper lip with significant resolution in all areas. In February 2017, she was admitted to Ruby with worsening pain and lesions located in her lower extremities and edema (Figure 1). Peripheral duplex was obtained and blood cultures to rules out a venous clot and infection respectively. A biopsy was obtained (Figure 2) which showed cutaneous involvement of her multiple myeloma. Radiation Oncology was consulted, and she was started on palliative radiation for 5days which initially improved her pain and swelling. Unfortunately, her lesions continue to arise with intermittent, short lived responses to systemic therapy. Her lesions now too widespread for continued radiation therapy. She noticed lesion in her scalp. She continues to follow up in clinic where she was started on single agent Doxil 40 mg/m2 every 4 weeks. Sadly, she continues have progressive cutaneous disease around the flank, abdomen, and bilateral thighs.

Discussion

We present an interesting case of cutaneous involvement of multiple myeloma where although the patient has been on multiple therapies continues to progress in her disease. Her case is interesting from other presentations in that they don’t usually do not describe the course of regimen used in treatment. The standard of care of cutaneous involvement revolves controlling the origin of the disease. One specific treatment that we tried was localized radiation. There is not much data or past literature discussing the use of radiation or its efficacy. Unfortunately for our case, the treatment only helped briefly. Most common involvement for MM is soft tissue involvement of the upper airway and oral cavity. They usually consist of firm, erythematous, nontender nodules involving the neck, ears, shoulders, axillae, chest, abdomen, and dorsum of the hands [11]. The first reported case of skin involvement in a person with MM was presented by Bruno Block in 1910. He described a patient who had small reddish macules that evolved into brown reddish papules and nodules with scale crusts. Histologically these lesions showed epidermal necrosis. He eventually had disease in pleura, stomach, and heart and passed away two years later [3]. A review of literature reveals that there are over 100 described cases. The age ranges from 36 to 81 with a median of 60 years old. Numeric date was available for 87 cases and 63 of them were male and 24 were female [4]. Cutaneous involvement of MM may appear in area of the skin, but it has been reported most commonly on the trunk and abdomen. Skin lesions is commonly described as papules or nodules that measure 1-5 cm in diameter with firm consistency, smooth surface, and a red or violaceous color [5]. Some authors reported that cutaneous involvement of MM only occurs when the tumor mas burden is over 2-3 kg [6]. Cutaneous involvement in patient with MM and extramedullary plasmacytoma generally appears late during the disease. On average, death occurred within 12 months after the diagnosis. Autopsy of these patients reveal extensive plasmacytic infiltration of multiple organs [7].

A review of the cases of MM involving the skin revealed that 40 cases were IgG, 21 cases were IgA, and 9 cases were IgD. The risk of cutaneous involvement by MM is not associated with a particular class of myeloma immunoglobins. Histopathologically, the lesions of MM involving the skin show 2 patterns: nodular and diffuse interstitial [6]. (Figure 2, 3). The worldwide incidence of myeloma is 86,000 cases annually. Mortality rate in MM is high with a median survival of 50-55 months and 63,000 deaths being reported worldwide each year [8]. Significant advances have been made in understanding multiple myeloma (MM) and its precursor diseases. These advances include the gain in knowledge in the underlying pathophysiology, Food and Drug Administration (FDA) approvals of novel therapies with meaningful efficacy and the science in underlying disparities in patients with MM [9].

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Lupine Publishers | A literature review of the treatment options for Idiopathic Adhesive Capsulitis of the Shoulder

  Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

Goal: Systematic review of current therapeutic options for Idiopathic Adhesive Capsulitis of the shoulder (IAC).

Materials and Methods: Research carried out in the MEDLINE / Pubmed database using MeshTerms: “adhesive capsulitis”, “frozen shoulder”, “treatment”. The articles in Portuguese or English published were selected, after which non-relevant articles were excluded based on the title, reading of the abstract and full article.

Results: Physical therapy has proven to be beneficial, either isolated or concomitantly with other therapeutic approaches. Options like capsular distention, manipulation under anesthesia and arthroscopic surgery have reported good results, especially in refractory cases. No significant benefits were found with the use of oral corticosteroids, NSAIDs or acupuncture. New treatment options are currently being tested with promising results.

Conclusions: There are several effective options for the treatment of Adhesive Capsulitis. In the early stages, conservative measures should be chosen, with special emphasis on physical therapy within the limits of pain associated with low-dose intraarticular injection of corticosteroids. In refractory cases, more invasive treatment options should be suggested namely capsular distension and manipulation under anesthesia.

Keywords: Adhesive Capsulitis; Frozen Shoulder; Diagnosis; Treatment

Introduction

Adhesive capsulitis is a pathology characterized by a spontaneous onset of insidious and diffuse pain in the shoulder associated with progressive restriction of active and passive motion of the glenohumeral joint [1]. Almost 150 years after its first description, it remains an uncertain entity. The proper terminology, used for the first time in 1945, is also controversial, since this condition is related to the contraction and thickening of the glenohumeral capsule, in particular the coracohumeral ligament in the rotator’s interval [1, 2]. The disease is classified as primary and secondary. The primary entity has an unknown etiology and will be addressed in this review [3]. Secondary adhesive capsulitis is caused by an event or triggering condition such as trauma, surgery or a systemic condition such as diabetes mellitus, thyroid abnormalities, etc. [2]. Diabetes mellitus has the most established connection, with an estimated incidence of adhesive capsulitis in 20% of this population [4]. The prevalence of this pathology in the general population is believed to be 2-5%. However, it is believed that the true prevalence is actually inferior and difficult to determine, not only because vague and insidious symptoms lead to numerous diagnostic errors, but also because most studies include specific comorbidities with a greater incidence of IAC than within the general population [2, 3, 5, 6].
This pathology occurs mainly between the 4th and 6th decade of life and is thought to be more frequent in women [7]. Some argue that it affects the non-dominant side more often and that in about 20-30% of cases it recurs on the contralateral shoulder, usually in the first 5 years after the resolution of the primary condition [1, 3, 7-10]. Although considered a benign condition, with a self-limiting pattern and resolution within 2 to 3 years, it is estimated that 20-50% of the cases continue with mild to moderate pain and restricted movement over a period of up to 10 years [4, 11]. The etiology of adhesive capsulitis also remains uncertain and theories vary. However, the evidence points to a chronic inflammatory response with subsequent capsular fibrosis that possibly involves increased deposition of cytokines such as TGF-β, PDGF, TNF-α and IL-1 [1-3, 7]. There are also studies that advocate an association with Dupuytren’s contracture that may involve the same abnormalities. The changes found include: contraction and fibrosis of the coracohumeral ligament, thickening and fibrosis of the rotator’s interval, contraction of the anterior and inferior capsule, decrease in joint volume, obliteration of the axillary recess and neovascularization [2, 3]. The evolution of this pathology can be divided into three phases. The acute initial phase (freezing phase) is characterized by the insidious appearance of diffuse pain and restriction of the range of motion of the glenohumeral joint, which lasts for about 10 to 36 weeks (Figure1). In the second phase (frozen phase), for about 4 to 12 months, the pain slightly decreases but the movement restriction continues, with almost total loss of external rotation. In the resolution phase (thawing phase) there is spontaneous progressive improvement in the range of motion and resolution of pain. This last phase has an average duration of 30 months (12 to 42 months) [3, 6-8]. Numerous studies have attempted to determine which treatment is the most effective for adhesive capsulitis. However, currently, despite the various options, there is still no consensus among the authors regarding the most advantageous treatment and at what stages of the disease it should be performed [4, 12, 13]. Most of the evidence is inconclusive due to the precarious methodology of the studies [14].

Diagnosis

There is no standard diagnostic method for this condition, which is based on clinical examination, exclusion of differential diagnosis, normal radiographic appearance and findings on ultrasound, magnetic resonance imaging (MRI) and arthrographic magnetic resonance imaging (arthroMRI) [2, 15]. The early diagnosis of adhesive capsulitis is extremely important since it allows the institution of therapy before the progression of thickening and contracture of the capsule observed in advanced stages [15]. Clinically, an insidious diffuse pain with at least four weeks that interferes with the activities of daily life should be investigated. Night pain is also common, with the patient complaining of more severe pain while sleeping on the affected side. Painful restriction of active and passive motion of the glenohumeral joint is also frequent, with special emphasis on external rotation (more than 50% of restriction) and elevation (less than 100ᴼ) [1, 3]. Radiographs do not normally show any changes, except for a slight periarticular osteopenia of the humeral head and neck, which can occasionally be found [1, 3, 7,15]. The most important role of radiography is the possibility of ruling out other pathologies such as calcifying tendinitis of the rotator cuff, osteoarthritis, avascular necrosis or fractures that can also cause painful movement restriction and be misdiagnosed as adhesive capsulitis [15, 16]. For a more accurate diagnosis, ultrasound, MRI or ArtroRM are usually necessary [15]. With the use of ultrasound, the diagnosis can be suspected by a thickening of the structures in the rotator’s interval, namely of the coracoumeral ligament, and restriction of the motion of the supraspinatus tendon during abduction. With echodoppler, synovial inflammation can be readily detected (Figure 2), which has advantages when compared with MRI and ArtroMRI since it is less expensive, faster, more dynamic and easily accessible [2, 3, 15].

MRI is an effective non-invasive diagnostic tool, not only for cases where this condition is suspected, but also provides information that can help the surgeon differentiate between the different stages of the disease [3,15,17]. Although it is not diagnostic, some argue that the degree of capsular thickening, measured in the axillary recess, can be correlated with the clinical stage of adhesive capsulitis [16]. Among other findings, several characteristics of this condition can be seen: thickening of the coracohumeral and capsular ligament in the rotator’s interval and axillary recess (greater than 4 mm) and obliteration of the subcoracoid space by the thickened capsule (Figure 3). Thus, MRI allows for early diagnosis, determining the pathophysiological stage and ruling out differential diagnosis [15]. ArtroMRI allows for visualization of basic disease characteristics, namely the thickening of the coracohumeral ligament and the capsule, possibly with greater precision than the MRI, but also to detect decreased joint volume [1,3,15]. However, some claim that both MRI and ArtroMRI, despite the useful findings, are not indicated as a means of diagnosis for adhesive capsulitis and should only be used as a method of excluding other intra-articular pathologies [3].

Treatment

A great variety of therapeutic options are available for the treatment of adhesive capsulitis. During the early stages, where pain predominates, treatment should be directed towards pain relief and patients should be advised to limit activities according to their tolerance [7]. The secondary objective is to improve the range of motion [4] and restore the ability to perform the daily activities.

Conservative Treatment

Conservative treatment, such as physical therapy, is recommended in the freezing phase [4, 6]. Most patients will recover with this initial management [16, 18, 63]. The conservative approach has a wide range of modalities, with well documented results.

Physiotherapy

Isolated physiotherapy is a widely accepted treatment option, which can also be used as a complement to other therapeutic modalities [1, 3], with some reports considering it to be crucial for success [4]. Currently, various techniques are used, such as the application of moist heat, strengthening exercises, stretching and manual exercises [7, 19, 20]. Several studies have compared these modalities with different conclusions, making it difficult to determine which is the most beneficial [4, 9,20]. Most studies in which comparisons were made between two interventions did not detect significant differences between the techniques [21]. In several investigations, the techniques of high and low grade glenohumeral mobilization were compared, with significant improvement after 12 months for both approaches. Some authors concluded that the intensive approach was significantly more effective in restoring mobility and reducing disability [20-22]. In contrast, others argue that the amount of force applied should be adjusted to the patient’s condition, limited to their tolerance, because if excessive force is applied, it can produce extreme pain, periarticular injury or abandonment of treatment, thus, one should opt for prolonged progressive low-load stretches, a method considered safe and effective [7, 9, 23].
In a study with level I evidence, the effectiveness of three different physical therapy modalities was compared: group physiotherapy, individual physiotherapy and home exercise program. Not only was there a greater degree of symptomatic improvement in the shoulder, but also better anxiety control with group physiotherapy. There were also benefits in relation to costeffect and self-management in this group. However, standard physical therapy remains a good alternative and has been shown to be significantly better than unsupervised home exercises [6]. In another study with level II evidence in which regular physical therapy was compared with a new contraction technique, the new approach demonstrated greater recovery of the function of the glenohumeral joint when compared to the group of normal physical therapy. However, further studies are needed to validate this conclusion [24]. Some authors advise a Multimodal Care program that includes mobilization, shoulder orthoses and stretches with strengthening exercises, which appears to be beneficial for symptomatic relief, although the evidence seems limited [25, 26].
Horst, et al. compared structural-oriented (conventional) physical therapy with an activity-oriented physiotherapeutic treatment, concluding that therapy based on performing activities appears to be more effective for pain reduction and the ability to perform daily life activities than conventional treatment methods [64]. When compared to ad initium arthroscopy, physical therapy produces similar results, but without surgical aggression and with a better cost-benefit ratio [27]. Lamplot, et al. in a level III cohort study [57] found a decrease in the need of a second intra-articular injection in the patients who underwent physical therapy following the first injection, underlining the major role of physiotherapy in the treatment of IAC.

Intra-Articular Injection of Corticosteroids

Corticosteroids have been administered to the glenohumeral joint in several ways, namely anterior, lateral and / or posterior approach [4, 28]. Although clinically it is common practice to use an injection via an anterior or posterior approach, studies comparing different techniques have not found significant differences in the improvement of pain or range of motion [11, 29]. Cho, et al. [60] in a randomized trial study found that the efficacy of corticosteroid injection into the subacromial space in IAC was inferior to intraarticular injection up to 12 weeks. However, a combination of injection sites had an additive effect on the benefits in the internal rotation angle There is no agreement regarding the optimal dose of intra-articular corticosteroids. Yoon et al. did not detect a significant difference between the low (20 mg) or high (40 mg) dose groups, indicating, due to its side effects, the preferential use of low dose corticosteroids for the treatment of adhesive capsulitis [30].
A limitation of the use of intra-articular corticosteroids is the fact that blind injections can be inaccurate in about 60% of cases. The current use of ultrasound or fluoroscopy-guided injection can overcome this problem [8, 16]. It has been shown in several studies that this practice improves accuracy and results compared to the “blind-technique” [3, 31]. There is evidence that the initial corticosteroid injection can reduce pain and improve range of motion in the short term and that its benefit can be increased in the short and medium term when these injections are followed by physical therapy [11, 21, 57]. Kraal et al. in a two center, randomized controlled trial, found that additional physiotherapy after corticosteroid injection improves ROM and functional limitations in early-stage IAC up to the first three months, underlining the good results of these techniques combined [61].
When compared as isolated treatments, there is strong evidence in benefit of corticosteroid injection in the short term (4-6 weeks), compared to isolated physical therapy, but not in the long term [11, 22, 30, 32, 33]. In a study that compared the injection of corticosteroids and the benefit of isolated intra-articular analgesics, significant improvements were found with the administration of corticosteroids [22]. Hettrich et al. showed that corticosteroid injections decreased fibromatosis and myofibroblasts in the shoulders with IAC [58]. On the other hand, some studies conclude that this form of treatment has results similar to isolated physical therapy or more invasive treatments such as MUA and arthroscopy [29, 32, 34], confirming the high degree of controversy surrounding this disease.

Echography-Guided Capsular Distension

Ultrasound-guided interventions have several strong points like the lack of radiation and the possibility of real time visualization of the needle’s trajectory. This technique has advantages when compared to fluoroscopy, CT and MRI since these are less practical, more time consuming and involve radiation or a specific needle [35]. One of the modalities of capsular distention is based on the use of hyaluronic acid. The ideal time between injections is one week and the effects are usually seen after the second injection [36]. In a study comparing this approach with the injection of corticosteroids, it was found to be more effective in favor of distension with hyaluronic acid in passive external rotation (10ᴼ) at 2 and 6 weeks, with no significant differences in pain relief or in function recovery. This study also concluded that this approach is a good alternative to intra-articular injection of corticosteroids and can be especially useful in patients with diabetes mellitus or contraindicated to the use of corticosteroids [37]. Calis et. al. also concluded that this approach is effective in the treatment of adhesive capsulitis when compared to isolated corticosteroid injection, physical therapy and exercise [36]. Ultrasound-guided capsular hydrodistension is a procedure that aims to distend the capsule contracted by increasing pressure by injecting large amounts of sodium chloride into the glenohumeral joint [9]. There is evidence that it provides relief from pain and improves range of motion, especially when it is followed by physical therapy [29, 38]. Other studies have found that saline distension with or without concomitant corticosteroids are more effective than MUA, describing better results after 6 months with this procedure, with less risk, and resulting in a higher level of satisfaction on the part of patients. However, the effects do not seem to persist beyond 6-12 weeks [9, 29, 39, 40].

Artrographic Capsular Distension

This technique can be performed with sodium chloride, local anesthetic, steroids, contrast or air. It should be reserved for patients who do not improve despite physical therapy [22]. It is also considered a good therapeutic option for rapid symptom relief. Better results were observed when followed by physical therapy [38]. There was no significant difference in the efficacy of capsular distention with or without corticosteroids in most investigations [39, 41]. However, Rysns et al. when comparing distension with corticosteroid injection with placebo saline injection to determine whether the results were due only to the increase in volume, found a significant improvement with the concomitant use of corticosteroids [32].

Extracorporeal Shockwave Therapy

The use of Extracorporeal Shock Wave Therapy (ESWT) in the treatment of several shoulder diseases, namely in calcific tendinopathy of the rotators cuff, is well documented. Several studies evaluate its usefulness in IAC, with positive effects such as a quicker return to daily activities and quality-of-life improvement [66, 67], at least in the short-term. El Naggar, et al. compared the effectiveness of radial extracorporeal shock-wave therapy versus ultrasound-guided low-dose intra-articular steroid injection in in diabetic patients, concluding that in the short-term follow-up ESWT was superior to a low-dose intra-articular steroid injection in improving function and pain in diabetic patients with shoulder IAC [68], therefore validating it as an alternative to steroid injections in diabetic patients with this pathology. This particular usefulness of ESWT in diabetic patients has also been documented in other studies [69, 70]. Many prospective randomized trials are underway to further validate ESWT as a treatment option in IAC, especially in the diabetic population.

Other

Oral non-steroidal anti-inflammatory drugs, although widely used in the initial / inflammatory phases for pain relief in the short term, did not prove their benefit when compared with placebo [3, 7, 9]. Prednisone at a dose of 40 to 60 mg / day for two to three weeks provides faster relief of symptoms in the short term, but their effects are not significant after 6 weeks and there is no evidence that they shorten the duration of disease [28]. Some studies have concluded that there may be a moderate short-term benefit with acupuncture associated with exercise [22], however the usefulness of this therapeutic approach remains undetermined [21]. Calcitonin is a polypeptide hormone secreted from parafollicular cells of the thyroid that has been used for pain control in several pathologies. Although its pathophysiology is not totally clear, it is thought to diminish the inflammatory response and increase endorphins’ release [71, 72]. Rouhani, et al. in a double-blinded randomized controlled trial compared intranasal calcitonin versus placebo for 6 weeks and found great improvement of shoulder pain, ROM, and functional scores in the calcitonin group [71]. Currently the dose recommendation is 200 U (1 puff) daily [73]. Regarding future approaches, Badalamente, et al. [53, 54] published two papers evaluating the applicability of extra-articular collagenase injections in the anterior shoulder capsule. In a placebo controlled doubleblind RCT, they found improvements in shoulder motion, functional score and pain control in the collagenase group in their 1.8 years follow up. In a randomized pilot study comparing subcutaneous adalimumab with local corticosteroids, Schydlowsky et al. found no benefits with the anti-TNF agent in the treatment of frozen shoulder [55] These new treatment approaches for IAC must undergo further investigation, but, if developed, could also play a role in the management of other arthrofibrosis [56].

Surgical Treatment

Surgical treatment of adhesive capsulitis is considered after failure of conservative treatment. It is estimated that 10% of patients do not respond to non-invasive treatment [25, 26]. There are no defined guidelines for this transition. However, regardless of the chosen conservative treatment, a surgical approach is only considered after about 6 months of non-surgical treatment without clinical improvement [3, 4, 8, 12, 16, 42]. Its benefit in refractory / severe adhesive capsulitis is proven and well documented [43], and some studies have found that in patients with high risk factors such as diabetes mellitus, and those who suffer chronic symptoms or bilaterally affected, early surgery is beneficial [65]. In a recent questionnaire to health professionals, only 3% recommended surgical treatment in the acute phase, while 47% recommended it in the second and third stages of the disease [4]. Surgical treatments should be complemented with an appropriate physical therapy scheme [63]. Some advocate the initiation of immediate postoperative physiotherapy, with light isometric exercises after 1-2 weeks and isotonic exercises in the following 2-3 weeks. Ideally the range of motion without complete restriction should be achieved in 12 to 16 weeks [4].

Manipulation Under Anesthesia

This procedure involves stabilizing the shoulder blade with flexion, abduction and adduction, followed by maximum internal and external rotation. Some studies advocate good results with this technique, mainly in terms of range of motion [44], others have not found significant differences in comparison with other treatments [45]. There is modest evidence of the benefit of MSA in relieving pain and recovering mobility when followed by physical therapy [46]. However, some authors have not found significant differences in the improvement of pain, function, disability or range of motion in the short, medium or long term between isolated MUA and exercise-associated MUA when compared to physical therapy alone [21, 45]. When compared with arthroscopy, better results were observed with arthroscopic distention at 6 months [21]. However, more recently, Schoch et al. in a study with the largest series of patients undergoing surgical treatment of adhesive capsulitis with a direct comparison between MUA, MUA/Capsular release (CR), and CR alone, found significant improvement of the ROM in all surgical modalities, however, the MUA group had the greatest external rotation, postoperatively [59]. MUA has been associated with several intra-articular iatrogenic complications such as humeral fracture, glenohumeral dislocation, brachial plexus injury rotator cuff injury and hemarthrosis [4, 46, 47]. Nonetheless, some argue that these lesions have no clinical relevance or that they can be minimized by performing the technique properly [44, 47]. Others advise that this procedure should be avoided in patients with osteoporosis, osteopenia or previous MUA recurrence [46]. Another limitation of manipulation is the fact that stretching the tissues can cause severe pain after the end of the anesthesia effect, leading to delays in recovery [8].

Arthroscopy

Arthroscopy allows the distension of the glenohumeral joint to be combined with a series of other procedures, such as adhesions release, opening of the rotator’s interval, circular capsulotomy and section of the coracohumeral ligament. This procedure must be followed by physiotherapy [2]. Several studies have supported the role of this approach as safe and effective in the treatment of adhesive capsulitis [27, 48, 49]. Several authors support the use of arthroscopy, claiming that, in addition to the good results obtained, it makes it possible to deepen and confirm the diagnosis by a complete assessment of the shoulder joint during the procedure [4, 8]. Some, on the contrary, argue that currently the evidence does not support the use of this technique [50], underlining the prevalent controversy in the treatment of this pathology. Recent investigations have not shown greater benefits in range of motion with more extensive release of the capsule (anterior release vs. Anterior plus posterior release) [9, 62]. Sivasubramanian et al. made a systematic review and meta-analysis which suggests that less extensive releases may result in better functional and pain scores. The addition of a posterior release appears to increase early internal rotation, but doesn’t maintain that benefit over time. No benefit was found with the complete 360 release [62]. Some authors suggest that arthroscopic distension can be associated with concomitant manipulation, with improved outcomes [8]. In a study comparing arthroscopy plus manipulation against isolated intraarticular corticosteroid injection, both approaches were effective in improving pain and range of motion. However, the objectives were achieved sooner by the group that underwent arthroscopy (6 weeks vs 12 weeks) [51]. Grant, et al. compared arthroscopic distention with MUA finding a small benefit in favor of arthroscopy alone or in association with manipulation, advising this technique due to the lower number of complications [52]. On the other hand, Jerosch et al. concluded that this therapy has a greater benefit in reducing pain and improving movement, even in the long term, being a valuable, more precise, controlled option with fewer complications than manipulation [12].

Open Surgery

Surgical treatments have changed from open to arthroscopic procedures and, therefore, the open technique, although effective, has fallen into disuse [4]. It is rarely used nowadays, but may be beneficial in cases refractory to MUA and arthroscopy [9].

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Lupine Publishers | The Effectiveness of Lunges and Static Stretching Exercises On Pain And Disability In Chronic Patellar Tendinopathy: A Case Report

 Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

Eccentric exercises are not effective for all patients with chronic patellar tendinopathy (CPT). The aim of the present case report is to present the effect of eccentric - concentric loading combined with stretching exercises on pain and disability in a patient experiencing CPT. A patient with unilateral CPT for 7 months was included in the present report. The patient followed a supervised exercise program five times per week for 6 weeks consisting of slow progressive eccentric - concentric loading of quadriceps using forward step lunge (FSL) with the anterior knee motion going in front of the toes (FT) and static stretching exercises of hamstrings and quadriceps. The program was individualized on the basis of the patient’s description of pain experienced during the procedure. The patient was evaluated using the VISA-P questionnaire at baseline, at the end of treatment (week 6), and 1 month (week 10) after the end of treatment. At the end of the treatment and at the follow-up there was a decline in pain and a rise in function. The results of the present trial suggest that the combination of slow progressive eccentric - concentric loading of quadriceps using forward step lunge (FSL) with the anterior knee motion going in front of the toes (FT) and static stretching exercises of hamstrings and quadriceps can produce significant improvements in terms of pain and disability in CPT.

Keywords: Patellar Tendinopathy; Lunges; Stretching; Jumper’s Knee

Introduction

Chronic Patellar Tendinopathy (CPT) commonly referred to as Jumper’s knee is the most common tendinopathy in the knee area. It is a degenerative condition and not an inflammatory one. Pain and decreased function are the main symptoms of CPT. Diagnosis is simple. The symptoms are reproduced by (1) lower limb activities such as squat or hop; (2) palpation on the site of pain (mainly at the inferior pole of the patella); and (3) clinical tests such as decline test [1]. No ideal treatment has emerged for the management of CPT. Many clinicians advocate a conservative approach [1] and physiotherapy is usually recommended [2]. A wide array of physiotherapy treatments has been recommended for the management of CPT such as electrotherapeutic/physical modalities, exercise program s, soft tissue manipulation, and manual techniques [3]. These treatments have different theoretical mechanisms of action, but all have the same aim, to reduce pain and improve function. Such a variety of treatment options suggests that the optimal treatment strategy is not known, and more research is needed to discover the most effective treatment in patients with CPT. One of the most common physiotherapy treatments for CPT is exercise. Eccentric exercise has shown good clinical results in CPT [4] as well as in conditions similar to CPT in clinical behaviour and histopathological appearance, such as lateral elbow [5], rotator cuff [6] and Achilles tendinopathy [4]. Eccentric training is not enough for all patients with CPT [7]. Malliaras and his colleagues [8] concluded that clinicians should consider eccentricconcentric loading alongside or instead of eccentric loading in lower limb tendinopathy. Tightness of hamstring and quadriceps has been found in patients with CPT as an aetiological factor [9]. Thus, stretching exercises of the above muscles are needed in the rehabilitation program. To our knowledge, there have been no studies to investigate the effectiveness of eccentric-concentric loading and stretching exercises for the management of CPT. It is possible to combine eccentric-concentric loading with stretching exercises to see if the combination of these two therapeutic approaches offers results in the management of CPT. Therefore, the aim of the present case report is to present the effect of eccentricconcentric training combined with stretching exercises on pain and disability in a patient experiencing CPT.

Case Presentation

History

The subject was a 26-year-old female volleyball player with a seventh- month history of anterior knee pain, in her right knee. She was diagnosed by a specialist (orthopaedic) as having CPT. She has played volleyball for about 12 years. The site of pain was over the inferior pole of the patella without spreading down and she complained of pain during her training walking downstairs. The pain subsided within one or two hours after her training. She did not complain of pain after prolonged sitting. She did not have any problems with the other joints. She did not complain of other symptoms such as stiffness, swelling, locking, crepitus or giving away. She took no drugs at the time of assessment; she had no history of trauma in the knee before, only four ankle sprains in the other leg. She had followed a physiotherapy rehabilitation program following the ankle sprains. She had no prior physiotherapy treatment for the problem in her knee. She did not have a history of diabetes, epilepsy or cancer and none in her family did. She did not have any operation or illness in the past.

Examination Findings

Although the condition was diagnosed by a specialist, the physiotherapist D. S. assessed her knee to rule out other conditions and confirm the diagnosis. No pain was mentioned during gait and posture. Body deformity, colour changes, muscle wasting, or swelling were not noted. In palpation, signs of inflammatory activity like heat, swelling and synovial thickening were not found. On physical examination, the movements of the low back, hip and ankle were pain free, with full range of motion and full power. All ligamentous stress tests were normal, meniscal stress tests were normal, muscle strength tests were normal and no capsular pattern was found. Isotonic resisted extension reproduced mild pain on the inferior pole of the patella; what is more, after ten fast squats (decline test) [8], she experienced a mild pain. The squats were carried out, because the researcher wanted to reproduce the pain. Knee extension by gliding the patella medially was negative, without reproducing the pain; furthermore, the position of the patella was normal [10]. These two latter procedures ruled out the patellofemoral joint dysfunction. Tenderness with palpation over the inferior pole of the patella was found, confirming the diagnosis.

Procedure

The patient followed a supervised exercise program consisting of eccentric-concentric loading and static stretching exercises of hamstrings and quadriceps. As eccentric-concentric training, the participant carried out three sets of 15 repetitions of forward step lunge (FSL) with the anterior knee motion going in front of the toes (FT) with 1-min rest interval between each set. The FSLFT was performed at a slow speed at every treatment session. The patient counted to 6 during the FSL-FT. As the subject moved from the standing to the FSL-FT position, the quadriceps muscle and patellar tendon by inference were loaded eccentrically; followed by concentric loading, as the injured leg was used to get back to the start position. At the beginning the load consisted of the body weight and the participant was standing with all her body weight on the injured leg. The subject was told to go ahead with the exercise even if she experienced mild pain. However, she was told to stop the exercise if the pain became disabling. When the FSL-FT was pain-free the load was increased by holding hand weights. Static stretching exercises of quadriceps and hamstrings were performed as described by Dimitrios and his colleagues [9] before and after the eccentric - concentric loading. Each stretch lasted 30 seconds and there was a one minute rest between each stretch.

Supervised exercise program was given five times a week for 6 weeks and was individualized on the basis of the patient’s description of pain experienced during the procedure. The patient was instructed to use her knee during the course of the study but to avoid activities that irritated pain such as jumping, hopping and running [7-11]. She was also told to refrain from taking antiinflammatory drugs throughout the course of the study. Patient compliance was monitored using a treatment diary. Communication and interaction (verbal and non-verbal) between the therapist and patient was kept to a minimum, and behaviors sometimes used by therapists to facilitate positive treatment outcomes were purposefully avoided. For example, patients were given no indication of the potentially beneficial effects of the treatments or any feedback on their performance in the pre-application and postapplication measurements [12]. Pain and function were measured in the present study. The patient was evaluated at the baseline (week 0), at the end of treatment (week 6) and at 1 month (week 10) after the end of treatment. The VISA-P questionnaire was used to monitor the pain and function of patients. The instrument is a simple questionnaire, consisted of eight questions that takes less than five minutes to complete and once patients are familiar with it they will be able to complete most of it themselves. It is a valid and reliable outcome measure for patients with patellar tendinopathy [13].

Results

Discussion

The present study examined the effect of FSL-FT with static stretching exercises of hamstrings and quadriceps in a patient experiencing CPT and its findings have demonstrated significant improvements in terms of pain and disability. The results obtained from this case report are novel; as to date, similar studies have not been conducted. Alfredson, et al. [14] first proposed the eccentric training of the injured tendon. It is the most commonly used conservative approach in the treatment of tendinopathy. Unilateral squat eccentric training of the patellar tendon was the most commonly used conservative approach in the treatment of CPT [15] when the problem is at the inferior pole of the patella; however, no studies have investigated the effectiveness of training on other sites of patellar tendinopathy. Studies determining the effectiveness of exercises at other sites of patellar tendinopathy are needed. Later, it was found that the unilateral squat eccentric training on a 25o decline board applied more load on the tendon [9]. However, squat eccentric training of the patellar tendon alone, on decline board or not, was not effective for many patients with CPT. Malliaras and his colleagues [4] concluded that clinicians should consider eccentricconcentric loading alongside or instead of eccentric loading in Achilles and patellar tendinopathy. A Heavy Slow Resistance (HSR) program is recommended in the management of lower limb tendinopathy [16,17]. The HSR program was produced equivalent pain and function improvement (VISA) than the Alfredson eccentric program, but significantly better patient satisfaction at six months follow-up. In the Achilles tendon, eccentric and HSR have recently been shown to yield similar clinical outcomes (VISA and patient satisfaction) at 1 year follow up. Based on the above findings, the HSR program can be recommended as an alternative to the Alfredson eccentric program lower limb tendinopathy rehabilitation for young active people. Recently, isometric exercises have been recommended to reduce and manage tendon pain increasing the strength at the angle of contraction without producing inflammatory signs [8-18]. Five repetitions of 45-second isometric mid-range quadriceps exercise at 70% of maximal voluntary contraction have been shown to reduce patellar tendon pain for 45 minutes post exercise and this was also associated with a reduction in motor cortex inhibition of the quadriceps that was associated with patellar tendinopathy [18]. The dosage of isometric contractions is based on clinical experience [8-18] and their effect on pain in patients with CPT requires further study. The ‘Spanish squat is- used as isometric contraction and is useful when there is limited or no access to gym equipment [8]. However, conflicting results have been reported in terms of immediate and short-term pain relief [19]. Definitive conclusions about the effectiveness of isometric exercise in tendinopathy are yet to be made [19]. A component lacking from evidence-based programs is adequate potential to alter load distribution on the lower limb kinetic chain and increase the risk of lower limb tendinopathy [1-20]. It is our belief that the improvement of lumbo-pelvic control can be achieved by performing simple exercises such as single leg bridging in supine and four - point prone bridging exercises. Future research is needed to confirm this suggestion. In addition, hip extensors weakness has been associated with patellar tendinopathy [21]. Exercises to strengthen these muscle groups should be considered in exercise protocols and patellar tendinopathy. However, hip extensors were not strengthened in the present case trial because the strength of hip muscles in the assessment was normal. Functional activities such as jumping, cutting and sprinting should also be included in lower limb tendinopathy rehabilitation programs among athletes, but have so far not been included in popular programs in the literature [21]. These activities were included in the present study. The athlete carried out these activities in the court under the supervision of the gymnast. There are different techniques for lunges, including variations in step length, walking or jumping lunges, or different trunk positions [22]. Keeping the knee behind the toes is a common cue during performing a proper form of lunges [22]. Research is needed to find out 1) which technique of lunges is the most effective and 2) if the lunge is more effective treatment approach than squat for CPT patients and 3) the load applied to the patellar tendon during the lunges. The load of exercises was increased according to the patients’ symptoms otherwise the results are poor [23]. Furthermore, eccentric exercises were performed at a low speed in every treatment session because this allows tissue healing [24]. Ice was not recommended at the end of the treatment because research has shown that ice as a supplement to an eccentric exercise program offers no benefit to patients with tendinopathy [25]. Finally, the avoidance of painful activities is crucial for tendon healing, because training during the treatment period increases patients’ symptoms and delays tendon healing [26].

Eccentric exercises appear to reduce the pain and improve function. The mechanism by which eccentric training achieves these outcomes remains uncertain, as there is a lack of good quality evidence relating to physiological effects. The clinical improvement of the HSR group was accompanied by increased collagen turnover. It is unknown if the isometric contractions can reverse the pathology of the tendinopathy and in this case the pathology of CPT. Although a home exercise program can be performed any time during the day without requiring supervision from a therapist, our clinical experience has shown that patients fail to comply with the regimen of home exercise programs [25]. Although many ways can be recommended to improve the compliance of patients with the home exercise program such as phone calls, exercise monitors and better self-management education, it is believed that this problem can be solved by the supervised exercise programs performed in a clinical setting under the supervision of a therapist. It is believed because our experience has shown that many patients stopped the home exercise program without giving an explanation, whereas patients completed the supervised program. One possible reason why they continue the supervised exercise program could be the cost. In the supervised exercise program, the patients visit the therapist more times than the home exercise program, and this is more expensive. A future study will combine the both types of exercise program s in order to maximize the compliance of the patients. Even though the positive effects of such an exercise program in CPT have been reported in the present report, its study design limits the generalization of these findings. Future welldesigned clinical trials are needed to confirm the positive results of this case study establishing the effectiveness of such an exercise program in the management of CPT. In addition, structural changes in the tendons related to the treatment interventions and the longterm effects (6 months or more after the end of treatment) of these treatments are needed to investigate. Further research is needed to establish the possible mechanism of action of this treatment approach, and the cost effectiveness of such treatment, because reduced cost is an important issue for the recommendation of any given treatment.

Conclusions

The exercise program, consisting of FSL-FT and static stretching exercises of hamstrings and quadriceps had reduced the pain and improved the function in a patient with CPT at the end of the treatment and at one month follow-up. Further well-designed trials are needed to confirm the results of the present case report.

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