The association of psychological variables and outcome in tendinopathy: a systematic review ABSTRACT Objective: Fear, anxiety, depression, distress and catastrophisation are all factors known to affect pain and disability levels. To date, the association of such psychological factors has yet to be established in tendinopathy. Therefore, the purpose of this paper was to determine if psychological variables are associated with tendinopathy and whether any such variables may be associated with pain and disability outcomes in conservative management of tendinopathy.Design: A systematic review was undertaken and included studies were appraised for risk of bias using the Newcastle Ottawa Scale. Due to heterogeneity of studies, a qualitative synthesis was undertaken.Data sources: An electronic search of MEDLINE, CiNAHL, SPORTDiscus, PsycINFO, EMBASE and PsycARTICLES was undertaken from their inception to April 2016.Eligibility criteria for selecting studies: Any study design that incorporated psychological measures and clinical outcomes using participants with tendinopathy.Results: Ten articles describing nine studies and 1108 participants were included. Conflicting evidence exists regarding the association of anxiety, depression and lateral epicondylalgia (LE). Strong evidence suggests LE is not associated with kinesiophobia. Moderate evidence links catastrophisation and distress with LE. Moderate evidence suggests distress is not associated with rotator cuff tendinopathy, but kinesiophobia and catastrophisation are. Limited evidence suggests patella tendinopathy is not associated with anxiety or depression and kinesiophobia may be linked with suboptimal outcomes in Achilles tendinopathy. Summary/conclusions:Tendinopathy requires an individualised approach to management. Clinicians should consider using validated screening tools for the presence of psychological variables as a part their holistic management. What are the new findings Psychological variables may be associated with tendinopathy and a suboptimal outcome  Multi-dimensional factors influence the development and maintenance of pain and disability in tendinopathy  The underlying factors for the presence of these variables and their amenability to change warrant further investigation How might it impact on clinical practice in the near future  Tendinopathy management should include an individualised, holistic assessment  Management strategies may need to be adapted to address individual psychological variables and any underlying cognitive barriers.

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In light of this review, the association of psychosocial variables and plantar heel pain cannot be ruled out. Given recommendations to adopt an individualized and stratified approach to other musculoskeletal conditions, clinicians should remain vigilant to their presence.

Background Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated. Objective To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains. Design Systematic review. Data Sources Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar. Eligibility Criteria for Selecting Studies Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series. Results 9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain. Conclusion 233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures. Prospero Registration CRD42020156763.

ObjectiveAchilles tendinopathy is a common type of overuse condition, with isolated eccentric loading (ECL) programmes being the principal conservative treatment of choice. However, alternative protocols, involving different contraction types, have more recently been investigated. The purpose of the present review was to examine the evidence from studies comparing two or more different types of loading programmes in relation to patient‐reported outcomes for people with Achilles tendinopathy.MethodsA systematic review was undertaken, and the risk of bias of included papers were assessed using the Cochrane Risk of Bias tool. An electronic search of CINAHL, MEDLINE, Embase and SPORTDiscus was undertaken from their inception to May 2018. The eligibility criteria for selecting studies were randomized controlled or clinical controlled trials investigating two or more different loading programmes for chronic (>3 months) Achilles tendinopathy.ResultsSeven articles were included in the review. Low‐quality evidence exists that a do‐as‐tolerated modification of the Alfredson programme is more effective than the standardized programme at improving function in the short term. Very‐low‐quality evidence suggests that ECL is superior at reducing pain levels than concentric in isolation, but no more effective at improving pain or disability than concentric–eccentric programmes.ConclusionsThere is conflicting evidence regarding the superiority of ECL over other contraction types, challenging the current approach to managing Achilles tendinopathy. There is also evidence that do‐as‐tolerated repetition volumes are more effective at improving function in the short term compared with those recommended by the standardized Alfredson protocol.

Study Design Controlled laboratory study, preliminary case-control design. Background The mechanisms that contribute to Achilles tendinopathy remain poorly understood. The disparity between pain experience and peripheral pathology demonstrated in patients with Achilles tendinopathy suggests that changes in central nervous system function may be involved. Objectives To investigate whether lower-limb tactile acuity is impaired in people with nonacute Achilles tendinopathy. Methods Thirteen consecutive participants with nonacute midportion Achilles tendinopathy and 13 healthy controls were enrolled. Two-point discrimination thresholds over the affected Achilles tendon, unaffected tendon, and 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, 11.7 mm; 95% confidence interval [CI]: 1.9, 21.5; P = .02) and to healthy controls (mean difference, 13.1 mm; 95% CI: 1.6, 24.6; P = .03). There was no significant difference between the healthy controls and the unaffected side in people with Achilles tendinopathy (mean difference, 1.4 mm; 95% CI: -7.9, 5.1; P = .66). Conclusion These data provide the first evidence of reduced 2-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. J Orthop Sports Phys Ther 2016;46(12):1061-1064. Epub 30 Oct 2016. doi:10.2519/jospt.2016.6514.

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