New regimen for eccentric calf-muscle training in patients with chronic insertional achilles tendinopathy : results of a pilot study

Background: Chronic painful insertional Achilles tendinopathy is seen in both physically active and non-active individuals. Painful eccentric training, where the patients load the Achilles tendon into full dorsiflexion, has shown good results in patients with mid-portion Achilles tendinosis. However, only 32% of patients with insertional Achilles tendinopathy had good clinical results with that type of eccentric training regimen.

Aim: To investigate whether a new model of painful eccentric training had an effect on chronic painful insertional Achilles tendinopathy.

Patients and methods: 27 patients (12 men, 15 women, mean age 53 years) with a total of 34 painful Achilles tendons with a long duration of pain (mean 26 months), diagnosed as insertional Achilles tendinopathy, were included. The patients performed a new model of painful eccentric training regimen without loading into dorsiflexion. This was done as 3x15 reps, twice a day, 7 days/week, for 12 weeks. Pain during Achilles-tendon-loading activity (VAS) and patient’s satisfaction (back to previous activity) were evaluated.

Results: At follow-up (mean 4 months) 18 patients (67%, 23/34 tendons) were satisfied and back to their previous tendon-loading activity. Their mean VAS had decreased from 69.9 (SD 18.9) to 21 (SD 20.6) (p<0.001). Nine patients (11 tendons) were not satisfied with the treatment, although their VAS was significantly reduced from 77.5 (8.6) to 58.1 (14.8) (p<0.01).

Conclusion: In this short-term pilot study this new model of painful eccentric calf-muscle training showed promising clinical results in 67% of the patients.

Animals and urban informality in sacred spaces: bull-calf trafficking in Simhachalam Temple, Vishakapatnam

Religion and Urbanism contributes to an expanded understanding of 'sustainable cities' in South Asia by demonstrating the multiple, and often conflicting ways in which religion enables or challenges socially equitable and ecologically sustainable urbanisation in the region. In particular, this collection focuses on two aspects that must inform the sustainable cities discourse in South Asia: the intersections of religion and urban heritage, and religion and various aspects of informality.

This book makes a much-needed contribution to the nexus between religion and urban planning for researchers, postgraduate students and policy makers in Sustainable Development, Development Studies, Urban Studies, Religious Studies, Asian Studies, Heritage Studies and Urban and Religious Geography.

Clinical features of patellar tendinopathy and their implications for rehabilitation

This study investigated the clinical features of patellar tendinopathy (PT), with focus on individuals with unilateral and bilateral PT. A cross-sectional study design was employed to compare individuals with unilateral (n = 14) or bilateral (n = 13) PT and those without PT (control, n = 31). Features assessed included thigh strength (normalized peak knee extensor torque) and flexibility (sit-and-reach and active knee extension), calf endurance (heel-rise test), ankle flexibility (dorsiflexion), alignment measures (arch height and leg length difference), and functional measures (hop for distance and 6 m hop test). Groups were matched for age and height; however, unilateral and bilateral PT had greater mass with a higher body mass index (BMI) than control. Also, bilateral PT performed more sport hours per week than both unilateral PT and control. Unilateral PT had less thigh strength than control and bilateral PT, whereas bilateral PT had more thigh flexibility than control and unilateral PT. Both unilateral and bilateral PT had altered alignment measures compared to control. Features that predicted symptoms in PT were lower thigh flexibility and strength, whereas those that predicted function were higher thigh strength and lower ankle flexibility.  These findings indicate that unilateral and bilateral PT represent distinct entities, and that thigh strength appears particularly important in PT as it predicted both symptoms and function in PT.

The effect of topical wheatgrass cream on chronic plantar fasciitis: a randomized, double-blind, placebo-controlled trial

Objectives: To investigate the efficacy of a topical wheatgrass cream for improving pain and function in patients with chronic plantar fasciitis.

Design: Randomized, double-blind, placebo-controlled trial.

Setting: Eighty participants with chronic plantar fasciitis were randomly assigned to a treatment group (wheatgrass cream) or a control group (placebo cream). All participants applied a cream twice daily for 6 weeks. Follow up was conducted at 6 and 12 weeks.

Main outcome measures: Visual Analogue Scale (VAS) for daily first-step pain and the Foot Health Status Questionnaire (FHSQ) for overall foot function. Secondary measures of foot posture, calf muscle strength and range of ankle dorsiflexion were also assessed.

Results: No significant differences were found between groups with respect to main outcomes of first-step pain or foot function at any time. Both groups improved significantly from baseline to 6 weeks, and these improvements were maintained at 12 weeks.

Conclusions: The topical application of wheatgrass cream is no more effective than a placebo cream for the treatment of chronic plantar fasciitis.

Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players

Patellar tendon injury, a chronic overuse injury characterised by pain during tendon loading, is common in volleyball players and may profoundly restrict their ability to compete. This cross-sectional study investigated the association between performance factors and the presence of patellar tendon injury. These performance factors (sit and reach flexibility, ankle dorsiflexion range, jump height, ankle plantarflexor strength, years of volleyball competition and activity level) were measured in 113 male and female volleyball players. Patellar tendon health was determined by measures of pain and ultrasound imaging. The association between these performance factors and patellar tendon health (normal tendon, abnormal imaging without pain, abnormal imaging with pain) was investigated using analysis of variance. Only reduced ankle dorsiflexion range was associated with patellar tendinopathy (p < 0.05). As coupling between ankle dorsiflexion and eccentric contraction of the calf muscle is important in absorbing lower limb force when landing from a jump, reduced ankle dorsiflexion range may increase the risk of patellar tendinopathy.

Obesity and pronated foot type may increase the risk of chronic plantar heel pain : a matched case-control study

Background : Chronic plantar heel pain (CPHP) is one of the most common musculoskeletal disorders of the foot, yet its aetiology is poorly understood. The purpose of this study was to examine the association between CPHP and a number of commonly hypothesised causative factors.

Methods : Eighty participants with CPHP (33 males, 47 females, mean age 52.3 years, S.D. 11.7) were matched by age (± 2 years) and sex to 80 control participants (33 males, 47 females, mean age 51.9 years, S.D. 11.8). The two groups were then compared on body mass index (BMI), foot posture as measured by the Foot Posture Index (FPI), ankle dorsiflexion range of motion (ROM) as measured by the Dorsiflexion Lunge Test, occupational lower limb stress using the Occupational Rating Scale and calf endurance using the Standing Heel Rise Test.

Results : Univariate analysis demonstrated that the CPHP group had significantly greater BMI (29.8 ± 5.4 kg/m2 vs. 27.5 ± 4.9 kg/m2; P < 0.01), a more pronated foot posture (FPI score 2.4 ± 3.3 vs. 1.1 ± 2.3; P < 0.01) and greater ankle dorsiflexion ROM (45.1 ± 7.1° vs. 40.5 ± 6.6°; P < 0.01) than the control group. No difference was identified between the groups for calf endurance or time spent sitting, standing, walking on uneven ground, squatting, climbing or lifting. Multivariate logistic regression revealed that those with CPHP were more likely to be obese (BMI ≥ 30 kg/m2) (OR 2.9, 95% CI 1.4 – 6.1, P < 0.01) and to have a pronated foot posture (FPI ≥ 4) (OR 3.7, 95% CI 1.6 – 8.7, P < 0.01).

Conclusion : Obesity and pronated foot posture are associated with CPHP and may be risk factors for the development of the condition. Decreased ankle dorsiflexion, calf endurance and occupational lower limb stress may not play a role in CPHP.

Maternal 25-Hydroxyvitamin D and parathyroid hormone concentrations and offspring birth size

Context: There is inconsistent evidence that maternal 25-hydroxyvitamin D [25-(OH)D] deficiency may impair fetal growth.

Objective: The objective of the study was to examine the relationship between maternal 25-(OH)D and PTH concentrations at less than 16 and 28 wk gestation and offspring birth size.

Design: This was an observational study.

Setting: The study was set at a hospital antenatal clinic.

Participants: Women with singleton pregnancies, before 16 wk gestation, participated.

Interventions: No interventions were used.

Main Outcome Measure: Knee-heel length at birth was the main outcome measure.

Results: Altogether 374 of 475 (79%) women completed this study. We found no evident relationship between birth size measures and maternal 25-(OH)D or PTH at recruitment (∼11 wk). Gestation length was 0.7 wk (95% confidence interval −1.3, −0.1) shorter and knee-heel length was 4.3 mm smaller (−7.3, −1.3) in infants of 27 mothers with low 25-(OH)D (<28 nmol/liter) at 28–32 wk vs. babies whose mothers had higher concentrations. This latter difference was reduced to −2.7 mm (−5.4, −0.1) after adjustment for gestation length, suggesting some of the apparent growth deficit is explained by shorter gestation. There was no evidence that other birth measures were affected. Maternal PTH concentration at 28–32 wk was positively related to knee-heel length, birth weight, and mid-upper arm and calf circumferences. These associations were independent of 25-(OH)D concentration.

Conclusions: Low maternal 25-(OH)D in late pregnancy is associated with reduced intrauterine long bone growth and slightly shorter gestation. The long-term consequences for linear growth and health require follow-up. The positive relationship between maternal PTH and measures of infant size may relate to increased mineral demands by larger babies, but warrants further investigation.

Neuromuscular mechanics and hopping training in elderly

Purpose: The present study examined the effects of repetitive hopping training on muscle activation profiles and fascicle–tendon interaction in the elderly.Methods: 20 physically active elderly men were randomly assigned for training (TG) and control groups (CG). TG performed supervised bilateral short contact hopping training with progressively increasing training volume. Measurements were performed before the training period (BEF) as well as after 2 weeks (2 W) and 11 weeks (11 W) of training. During measurements, the gastrocnemius medialis–muscle (GaM) fascicle and its outer Achilles tendon length changes during hopping were examined by ultrasonography together with electromyographic (EMG) activities of calf muscles, kinematics, and kinetics.Results: At 2 W, the ankle joint stiffness was increased by 21.0 ± 19.3 % and contact time decreased by 9.4 ± 7.8 % in TG. Thereafter, from 2–11 W the jumping height increased 56.2 ± 18.1 % in TG. Simultaneously, tendon forces increased 24.3 ± 19.0 % but tendon stiffness did not change. GaM fascicles shifted to shorter operating lengths after training without any changes in their length modifications during the contact phase of hopping. Normalized EMG amplitudes during hopping did not change with training.Conclusions: The present study shows that 11 W of hopping training improves the performance of physically active elderly men. This improvement is achieved with shorter GaM operating lengths and, therefore, increased fascicle stiffness and improved tendon utilization after training. Based on these results, hopping training could be recommended for healthy fit elderly to retain and improve rapid force production capacity. © 2014 Springer-Verlag Berlin Heidelberg

Neuromuscular mechanics and hopping training in elderly

Purpose: The present study examined the effects of repetitive hopping training on muscle activation profiles and fascicle–tendon interaction in the elderly. Methods: 20 physically active elderly men were randomly assigned for training (TG) and control groups (CG). TG performed supervised bilateral short contact hopping training with progressively increasing training volume. Measurements were performed before the training period (BEF) as well as after 2 weeks (2 W) and 11 weeks (11 W) of training. During measurements, the gastrocnemius medialis–muscle (GaM) fascicle and its outer Achilles tendon length changes during hopping were examined by ultrasonography together with electromyographic (EMG) activities of calf muscles, kinematics, and kinetics. Results: At 2 W, the ankle joint stiffness was increased by 21.0 ± 19.3 % and contact time decreased by 9.4 ± 7.8 % in TG. Thereafter, from 2–11 W the jumping height increased 56.2 ± 18.1 % in TG. Simultaneously, tendon forces increased 24.3 ± 19.0 % but tendon stiffness did not change. GaM fascicles shifted to shorter operating lengths after training without any changes in their length modifications during the contact phase of hopping. Normalized EMG amplitudes during hopping did not change with training. Conclusions: The present study shows that 11 W of hopping training improves the performance of physically active elderly men. This improvement is achieved with shorter GaM operating lengths and, therefore, increased fascicle stiffness and improved tendon utilization after training. Based on these results, hopping training could be recommended for healthy fit elderly to retain and improve rapid force production capacity.

Influence of vibration resistance training on knee extensor and plantar flexor size, strength, and contractile speed characteristics after 60 days of bed rest

Spaceflight and bed rest (BR) result in loss of muscle mass and strength. This study evaluated the effectiveness of resistance training and vibration-augmented resistance training to preserve thigh (quadriceps femoris) and calf (triceps surae) muscle cross-sectional area (CSA), isometric maximal voluntary contraction (MVC), isometric contractile speed, and neural activation (electromyogram) during 60 days of BR. Male subjects participating in the second Berlin Bed Rest Study underwent BR only [control (CTR), n = 9], BR with resistance training (RE; n = 7), or BR with vibration-augmented resistance training (RVE; n = 7). Training was performed three times per week. Thigh CSA and MVC torque decreased by 13.5 and 21.3%, respectively, for CTR (both P < 0.001), but were preserved for RE and RVE. Calf CSA declined for all groups, but more so (P < 0.001) for CTR (23.8%) than for RE (10.7%) and RVE (11.0%). Loss in calf MVC torque was greater (P < 0.05) for CTR (24.9%) than for RVE (12.3%), but not different from RE (14.8%). Neural activation at MVC remained unchanged in all groups. For indexes related to rate of torque development, countermeasure subjects were pooled into one resistance training group (RT, n = 14). Thigh maximal rate of torque development (MRTD) and contractile impulse remained unaltered for CTR, but MRTD decreased 16% for RT. Calf MRTD remained unaltered for both groups, whereas contractile impulse increased across groups (28.8%), despite suppression in peak electromyogram (12.1%). In conclusion, vibration exposure did not enhance the efficacy of resistance training to preserve thigh and calf neuromuscular function during BR, although sample size issues may have played a role. The exercise regimen maintained thigh size and MVC strength, but promoted a loss in contractile speed. Whereas contractile speed improved for the calf, the exercise regimen only partially preserved calf size and MVC strength. Modification of the exercise regimen seems warranted.

Evidence for an additional effect of whole-body vibration above resistive exercise alone in preventing bone loss during prolonged bed rest

SUMMARY: The addition of whole-body vibration to high-load resistive exercise may provide a better stimulus for the reduction of bone loss during prolonged bed rest (spaceflight simulation) than high-load resistive exercise alone. INTRODUCTION: Prior work suggests that the addition of whole-body vibration to high-load resistive exercise (RVE) may be more effective in preventing bone loss in spaceflight and its simulation (bed rest) than resistive exercise alone (RE), though this hypothesis has not been tested in humans. METHODS: Twenty-four male subjects as part of the 2nd Berlin Bed Rest Study performed RVE (n = 7), RE (n = 8) or no exercise (control, n = 9) during 60-day head-down tilt bed rest. Whole-body, spine and total hip dual X-ray absorptiometry (DXA) measurements as well as peripheral quantitative computed tomography measurements of the tibia were conducted during bed rest and up to 90 days afterwards. RESULTS: A better retention of bone mass in RVE than RE was seen at the tibial diaphysis and proximal femur (p ≤ 0.024). Compared to control, RVE retained bone mass at the distal tibia and DXA leg sub-region (p ≤ 0.020), but with no significant difference to RE (p ≥ 0.10). RE impacted significantly (p = 0.038) on DXA leg sub-region bone mass only. Calf muscle size was impacted similarly by both RVE and RE. On lumbar spine DXA, whole-body DXA and calcium excretion measures, few differences between the groups were observed. CONCLUSIONS: Whilst further countermeasure optimisation is required, the results provide evidence that (1) combining whole-body vibration and high-load resistance exercise may be more efficient than high-load resistive exercise alone in preventing bone loss at some skeletal sites during and after prolonged bed rest and (2) the effects of exercise during bed rest impact upon bone recovery up to 3 months afterwards.

Greater association of peak neuromuscular performance with cortical bone geometry, bone mass and bone strength than bone density : a study in 417 older women

BACKGROUND: We evaluated which aspects of neuromuscular performance are associated with bone mass, density, strength and geometry. METHODS: 417 women aged 60-94years were examined. Countermovement jump, sit-to-stand test, grip strength, forearm and calf muscle cross-sectional area, areal bone mineral content and density (aBMC and aBMD) at the hip and lumbar spine via dual X-ray absorptiometry, and measures of volumetric vBMC and vBMD, bone geometry and section modulus at 4% and 66% of radius length and 4%, 38% and 66% of tibia length via peripheral quantitative computed tomography were performed. The first principal component of the neuromuscular variables was calculated to generate a summary neuromuscular variable. Percentage of total variance in bone parameters explained by the neuromuscular parameters was calculated. Step-wise regression was also performed. RESULTS: At all pQCT bone sites (radius, ulna, tibia, fibula), a greater percentage of total variance in measures of bone mass, cortical geometry and/or bone strength was explained by peak neuromuscular performance than for vBMD. Sit-to-stand performance did not relate strongly to bone parameters. No obvious differential in the explanatory power of neuromuscular performance was seen for DXA aBMC versus aBMD. In step-wise regression, bone mass, cortical morphology, and/or strength remained significant in relation to the first principal component of the neuromuscular variables. In no case was vBMD positively related to neuromuscular performance in the final step-wise regression models. CONCLUSION: Peak neuromuscular performance has a stronger relationship with leg and forearm bone mass and cortical geometry as well as proximal forearm section modulus than with vBMD.

The PREPARE pilot RCT of home-based progressive resistance exercises for venous leg ulcers

OBJECTIVE: To establish the feasibility of conducting a home-based progressive resistance exercise programme to improve calf muscle pump function in community-based patients with venous leg ulcers. METHOD: Participants were randomised to receive a 12-week progressive resistance exercise programme using heel raises in addition to compression. The control was usual care in addition to compression. Randomisation was stratified by ulcer duration and ulcer size. Air plethysmography was used to determine changes in calf muscle pump function from baseline. Changes in ulcer parameters were measured using the SilhouetteMobile device. RESULTS: Forty participants were randomised. There were significantly greater improvements in ejection fraction of the calf muscle in the exercise group compared with the control (usual care) group (mean difference 18.5%, 95% CI 0.03 to 36.6%, p<0.05). Other parameters improved in the exercise group but the mean differences were not significant. Adherence with prescribed exercises was 81% and there was no significant difference in the numbers reporting adverse events. There were also no significant differences in ulcer healing parameters (change in area, percentage change in area, number healed at 12 weeks, time to healing). CONCLUSION: A community-based randomised trial of progressive resistance exercise is feasible. The prescribed exercises appeared to increase ejection fraction, but the effect of exercise on ulcer healing requires further investigation.