Dr. Hanjabam Barun, Sports & Exercise Medicine Specialist

24/08/2025

💡 The present study highlights maximal muscle strength, and in part rate of force development, as powerful predictors of physical function in patients with advanced knee osteoarthritis and may be used as simple, valuable measures when evaluating patients' physical function.

👉🏻 This is from the new paper "Muscle strength is a key predictor of physical function in advanced knee osteoarthritis" by Izadi et al 2025

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Disclaimer: Sharing a study is NOT an endorsement. You should read the original research yourself and be critical.

24/08/2025

What are the latest guidelines for Achilles Tendinopathy?

Chimenti et al. (2024) published an extensive update of the Clinical Practice Guidelines (CPG) for Achilles Tendinopathy. It’s open access so I’d recommend reading it in full (reference below).

Exercise should be a first line treatment and should be combined with education about tendinopathy, pain and load management.

Rehab should be progressive and can include all contraction types - eccentric, heavy slow resistance, isometric and plyometrics where tolerated.

Those with irritable symptoms and low load tolerance may benefit from lower-level exercises initially with education and interventions to help reduce pain.

Patient’s with high load tolerance and low irritability may be able to start with higher levels of load, for example progressing from 15RM to 6RM over approximately 12 weeks (see Beyer et al. 2015).

It should be noted that in many areas there was minimal evidence or contradictory findings. In some areas, such as stretching, no evidence update was provided so previous recommendations from the 2018 CPG were retained.

Shockwave therapy was not included in this review as it was considered outside of typical scope of practice. However, Iontophoresis was included and recommended with moderate evidence (grade B) despite it not being used widely in practice.

🗣️What do you think? Anything you’d add or change?

Reference:
Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024. J Orthop Sports Phys Ther. 2024 Dec;54(12):CPG1-CPG32. doi: 10.2519/jospt.2024.0302. PMID: 39611662.

24/08/2025

💡Check out this Editor's Choice article:

🔎The Role of Adipokines in Health and Disease

by Clemente‑Suárez, V. J., et al. (2023). Biomedicines, 11(5), 1290.

Full text here ➡️ https://shorturl.at/3Zmhq

📜 Adipokines, secreted by adipose tissue, act as active endocrine mediators affecting inflammation and multiple pathologies. Read more to learn about the role of adipokines in health and disease as well as the important functions and effects of these cytokines.

24/08/2025

🦵 Tibial nerve origin and pathway
• Branches from the sciatic nerve slightly above the popliteal fossa
• Runs behind the knee
• Passes through the tarsal tunnel around the medial malleolus

🦶 Plantar nerve branching
• Branches to the medial and lateral plantar nerves around the tarsal tunnel
• Pe*****te into the fascia of the abductor hallucis muscle
• Run from the sole to the toes
• Innervate the sensory of the anterior part of the plantar

⚪ Medial calcaneal nerve
• Branches from the posterior tibial nerve at the proximal end of the tarsal tunnel
• Pierces the flexor retinaculum
• Innervates the sensory of the medial calcaneus

🏗️ Tarsal tunnel structure
• Composed of a rigid bone at the bottom
• Covered by the flexor retinaculum

📍 Structures passing through the tarsal tunnel
• Tibialis posterior tendon
• Flexor digitorum longus tendon
• Posterior tibial artery and veins
• Posterior tibial nerve
• Flexor hallucis longus tendon

🔗 Neurovascular relation
• Posterior tibial nerve runs with the posterior tibial artery and veins in the tarsal tunnel

⚠️ Clinical relevance
• Because of these anatomical features, the posterior tibial nerve may be damaged at the tarsal tunnel (tarsal tunnel syndrome: TTS)
• TTS was first reported by Keck and Lam in 1962 [1, 2]

24/08/2025

🦵 Genu Valgum (Knock Knee)

Considered to be a normal alignment of the lower extremity in children from 2 to 6 years of age.

📉 By about 6 or 7 years of age, the physiological valgus should begin to decrease.

🧑‍⚕️ By young adulthood, the extent of valgus angulation at the knee should be only about 5° to 7°.

➡️ In genu valgum, the mechanical axes of the lower extremities are displaced laterally.

⚠️ If the extent of genu valgum exceeds 30° and persists beyond 8 years of age, structural changes may occur.

🔧 Increased external torque → medial knee joint structures subjected to abnormal tensile/distraction stress.

🔩 Lateral structures subjected to abnormal compressive stress.

🦿 The patella may be laterally displaced → predisposed to subluxation.

🦶 Gravitational torque on the foot tends to produce pronation → stress on medial longitudinal arch and supporting structures.

⚖️ Abnormal weight-bearing on the posterior medial aspect of the calcaneus (valgus torque).

➕ Additional related changes:

Flat foot

Lateral tibial torsion

Lateral patellar subluxation

Lumbar spine contralateral rotation

~

🦵 Genu Varum (Bowleg)

🚶 A condition in which the knees are widely separated when the feet are together and the malleoli are touching.

👶 Some extent of genu varum is normal at birth and during infancy up to 3 or 4 years of age.

🔄 Physiological bowing is symmetrical and involves both the femur and tibia.

🦴 Cortical thickening on the medial concavity of femur and tibia may be present → due to increased compressive forces.

↘️ The patellae may be displaced medially.

❗ Commonly suggested causes:

Vitamin D deficiency

Renal rickets

Osteochondritis

Epiphyseal injury

[Joint Structure and Function, 5th Edition, p. 506]

24/08/2025

24/08/2025

📃Differences in lower limb kinematics and kinetics between individuals with posterior tibial tendon dysfunction and healthy controls during step-up and step-down tasks

🦶 Introduction

Posterior tibial tendon dysfunction (PTTD), also recently named progressive collapsing foot deformity, is a disabling disorder with multifactorial etiologies that leads to functional limitations.

It primarily affects 3.3% of women over 40 years of age and ~10% of individuals over 65 years.

Excessive tensile forces can lead to chronic inflammation, structural degeneration, and altered tendon collagen.

PTTD progresses to collapsed foot arch and altered gait biomechanics.

Previous studies focused on walking, but step-up and step-down tasks are also crucial daily activities.

👥 Participants

16 participants with PTTD and 16 healthy controls.

PTTD group: Stage I or II PTTD, medial ankle/foot pain, positive rise test, no fracture/surgery in past 12 months.

Control group: no recent injuries or surgeries, no pain or limitations.

Exclusion: neurological/systemic disease, subtalar stiffness, recent injections, history of foot/ankle surgery.

👇👇👇
Individuals with PTTD exhibited greater ankle eversion across all tasks.

Midfoot and ankle kinematic differences revealed a more pronated foot and ankle.

Altered mechanics may increase medial arch collapse and strain on posterior tibial tendon.

Smaller midfoot moments suggest reliance on passive structures.

Inclined surfaces exacerbate kinetic deficits and increase injury risk.

Knee/hip adaptations may predispose to osteoarthritis.

✅ Conclusions

Individuals with PTTD exhibit distinct biomechanical patterns compared to healthy controls.

Altered movements may increase stress on joints/tissues, worsening the condition.

Differences were consistent across step-down, inclined step-down, and step-up tasks.

Findings are crucial for rehabilitation strategies aimed at improving function, reducing pain, and preventing injuries.

👉Link to article in the comments

23/08/2025

𝗧𝗿𝘂𝗻𝗸 𝗠𝘂𝘀𝗰𝗹𝗲 𝗔𝗰𝘁𝗶𝘃𝗮𝘁𝗶𝗼𝗻 𝗼𝗳 𝗖𝗼𝗿𝗲 𝗘𝘅𝗲𝗿𝗰𝗶𝘀𝗲𝘀 𝗶𝗻 𝗦𝘂𝗯𝗷𝗲𝗰𝘁𝘀 𝘄𝗶𝘁𝗵 𝗮𝗻𝗱 𝘄𝗶𝘁𝗵𝗼𝘂𝘁 𝗖𝗵𝗿𝗼𝗻𝗶𝗰 𝗟𝗼𝘄 𝗕𝗮𝗰𝗸 𝗣𝗮𝗶𝗻 💡

👉 Chronic low back pain (CLBP) is a highly prevalent musculoskeletal condition, affecting approximately 20% of working-age individuals, with prevalence increasing steadily until the age of 60. It is a leading cause of disability worldwide and imposes a significant burden on healthcare systems and productivity (Meucci et al., 2015; Hoy et al., 2014). The majority of cases are nonspecific in origin, lacking a definitive pathological diagnosis (Deyo, 2002). Structural and functional alterations in trunk musculature, including atrophy and fatty infiltration of deep stabilizers such as the multifidus, have been strongly associated with CLBP (Ranger et al., 2017; Parkkola et al., 1993).

👉 Exercise therapy is widely regarded as a cornerstone in CLBP management, though evidence suggests its impact on pain and disability reduction remains modest (Hayden et al., 2021). Traditional rehabilitation programs often emphasize low-load motor control or stabilization exercises, but their effectiveness in reversing atrophy and restoring strength is debated (Tataryn et al., 2021; Steele et al., 2015). Progressive resistance training, in contrast, has demonstrated positive effects on muscle hypertrophy and anti-inflammatory pathways (Putman et al., 2004). However, the optimal exercise modalities for maximizing trunk muscle activation in CLBP remain unclear.

👉 Most previous electromyography (EMG)-based studies assessing trunk muscle activity during core exercises have been conducted in healthy individuals (Oliva-Lozano & Muyor, 2020). Whether these findings translate to patients with CLBP, who may have altered neuromuscular activation due to pain or inhibition, is not well established. Thus, the present study by Ylinen et al. (2024) aimed to identify which core exercises elicit the highest levels of trunk muscle activation in both CLBP patients and healthy controls.

📉 Summary of Methods and Findings

👬 The study employed a cross-sectional case-control design including 14 male patients with CLBP and 15 age-matched healthy controls. Surface electromyography (sEMG) was used to record activity of six trunk muscles during maximal voluntary isometric contractions (MVIC) and 11 core stailization exercises (s. illustration).

🏋️‍♂️ The participant performed 6 repetitions with the 10 RM load. Pace of performance was standardized using a metronome. EMG amplitudes were normalized to MVIC values and compared across groups using generalized estimating equations. Furthermore, patients rated their average pain during exercise test after the completion of each exercise.

🔑 Key findings demonstrated that trunk muscle activation varied substantially between exercises but showed 𝗻𝗼 𝘀𝗶𝗴𝗻𝗶𝗳𝗶𝗰𝗮𝗻𝘁 𝗱𝗶𝗳𝗳𝗲𝗿𝗲𝗻𝗰𝗲𝘀 𝗯𝗲𝘁𝘄𝗲𝗲𝗻 𝗖𝗟𝗕𝗣 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀 𝗮𝗻𝗱 𝗰𝗼𝗻𝘁𝗿𝗼𝗹𝘀.

✅The 𝗵𝗶𝗽 𝗳𝗹𝗲𝘅𝗶𝗼𝗻 𝗺𝗮𝗰𝗵𝗶𝗻𝗲 elicited the highest multifidus activation (70% (patients), 54% (healthy),

✅while the 𝗯𝗮𝗻𝗱 𝘀𝗶𝗱𝗲 𝗽𝘂𝗹𝗹 produced maximal lumbar erector spinae activation (55% (patients), 43% (healthy).

✅For the thoracic erector spinae, the 𝗯𝗮𝗻𝗱 𝘀𝗶𝗱𝗲 𝗽𝘂𝗹𝗹 and 𝘀𝗶𝗻𝗴𝗹𝗲-𝗮𝗿𝗺 𝗰𝗮𝗯𝗹𝗲 𝗽𝘂𝗹𝗹 𝗲𝘅𝗲𝗿𝗰𝗶𝘀𝗲𝘀 were the best exercises, inducing about 70% of MVIC.

✅For abdominal muscles, the 𝗿𝗼𝘁𝗮𝗿𝘆 𝗽𝗹𝗮𝗻𝗸 (52% -72%) were most effective. Exercises such as the broomstick rotation induced the lowest activity levels. Importantly, no exercise was universally superior across all trunk muscles.

✅ All exercise were experienced causing pain by at least one patient. 𝗠𝗼𝗿𝗲𝗼𝘃𝗲𝗿, 𝗻𝗼 𝘀𝗶𝗻𝗴𝗹𝗲 𝗲𝘅𝗲𝗿𝗰𝗶𝘀𝗲 𝘀𝘂𝗶𝘁𝗲𝗱 𝗮𝗹𝗹 𝗼𝗿 𝘄𝗮𝘀 𝗽𝗮𝗶𝗻𝗳𝘂𝗹 𝗳𝗼𝗿 𝗮𝗹𝗹 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀 𝘄𝗶𝘁𝗵 𝗟𝗕𝗣 𝗶𝗿𝗿𝗲𝘀𝗽𝗲𝗰𝘁𝗶𝘃𝗲 𝗼𝗳 𝘄𝗵𝗲𝘁𝗵𝗲𝗿 𝗶𝘁 𝘄𝗮𝘀 𝗮 𝗹𝗼𝘄 𝗼𝗿 𝗵𝗶𝗴𝗵 𝗹𝗼𝗮𝗱 𝗲𝘅𝗲𝗿𝗰𝗶𝘀𝗲.

💡 Conclusion

Ylinen and colleagues conclude that certain high-intensity, loadable exercises—particularly hip flexion machine, band side pull, single-arm cable pull, and rotary plank—are most effective for activating specific trunk muscles. The study suggests that there is no reason to stick only to low-load home exercises, as they activate the muscles less and were not better tolerated than high load exercises by patients with CLBP. 𝗢𝗻𝗰𝗲 𝗮𝗴𝗮𝗶𝗻, 𝗶𝘁 𝗶𝘀 𝗰𝗹𝗲𝗮𝗿 𝘁𝗵𝗮𝘁 𝗲𝘅𝗲𝗿𝗰𝗶𝘀𝗲 𝗿𝗼𝘂𝘁𝗶𝗻𝗲𝘀 𝘀𝗵𝗼𝘂𝗹𝗱 𝗯𝗲 𝘁𝗮𝗶𝗹𝗼𝗿𝗲𝗱 𝘁𝗼 𝘁𝗵𝗲 𝗶𝗻𝗱𝗶𝘃𝗶𝗱𝘂𝗮𝗹 𝗽𝗮𝘁𝗶𝗲𝗻𝘁, 𝗮𝘀 𝘁𝗵𝗲𝗿𝗲 𝗶𝘀 𝗻𝗼 𝗼𝗻𝗲-𝘀𝗶𝘇𝗲-𝗳𝗶𝘁𝘀-𝗮𝗹𝗹 𝘀𝘆𝘀𝘁𝗲𝗺.

📒 References

Deyo, R. A. (2002). Diagnostic evaluation of LBP: reaching a specific diagnosis is often impossible. Archives of Internal Medicine, 162(13), 1444–1447. https://doi.org/10.1001/archinte.162.13.1444

Hayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., & van Tulder, M. W. (2021). Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews, 9(9), CD009790. https://doi.org/10.1002/14651858.CD009790.pub2

Hoy, D., March, L., Brooks, P., et al. (2014). The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Annals of the Rheumatic Diseases, 73(6), 968–974. https://doi.org/10.1136/annrheumdis-2013-204428

Meucci, R. D., Fassa, A. G., & Faria, N. M. X. (2015). Prevalence of chronic low back pain: systematic review. Revista de Saúde Pública, 49, 1. https://doi.org/10.1590/S0034-8910.2015049005874

Oliva-Lozano, J. M., & Muyor, J. M. (2020). Core muscle activity during physical fitness exercises: A systematic review. International Journal of Environmental Research and Public Health, 17(12), 4306. https://doi.org/10.3390/ijerph17124306

Parkkola, R., Rytökoski, U., & Kormano, M. (1993). Magnetic resonance imaging of the discs and trunk muscles in patients with chronic low back pain and healthy control subjects. Spine, 18(7), 830–836. https://doi.org/10.1097/00007632-199306000-00004

Putman, C. T., Xu, X., Gillies, E., MacLean, I. M., & Bell, G. J. (2004). Effects of strength, endurance and combined training on myosin heavy chain content and fibre-type distribution in humans. European Journal of Applied Physiology, 92(4–5), 376–384. https://doi.org/10.1007/s00421-004-1104-7

Ranger, T. A., Cicuttini, F. M., Jensen, T. S., et al. (2017). Is the size and composition of the paraspinal muscles associated with low back pain? A systematic review. The Spine Journal, 17(5), 1729–1748. https://doi.org/10.1016/j.spinee.2017.07.002

Steele, J., Bruce-Low, S., & Smith, D. (2015). A review of the clinical value of isolated lumbar extension resistance training for chronic low back pain. PM&R, 7(2), 169–187. https://doi.org/10.1016/j.pmrj.2014.10.009

Tataryn, N., Simas, V., Catterall, T., Furness, J., & Keogh, J. W. L. (2021). Posterior-chain resistance training compared to general exercise and walking programmes for the treatment of chronic low back pain in the general population: A systematic review and meta-analysis. Sports Medicine - Open, 7(1), 17. https://doi.org/10.1186/s40798-021-00306-w

Ylinen, J., Pasanen, T., Heinonen, A., Kivistö, H., Kautiainen, H., & Multanen, J. (2024). Trunk muscle activation of core stabilization exercises in subjects with and without chronic low back pain. Journal of Back and Musculoskeletal Rehabilitation, 37(6), 897–908. https://doi.org/10.3233/BMR-230043