Article Text

Evidence based journal watch

Statistics from


Professor Martin P Schwellnus, University of Cape Town, South Africa

Background: Non-steroidal anti-inflammatory drugs (non-selective and cyclooxygenase-2-specific) have been shown to impair bone formation, but whether they have a negative effect on tendon-to-bone healing is not known.

Research question/s: Do traditional non-selective non-steroidal anti-inflammatory drugs and cyclooxygenase-2-specific non-steroidal anti-inflammatory drugs negatively affect tendon-to-bone healing.

Methodology:Subjects:180 rats that underwent acute rotator cuff repairs.:Experimental procedure:In the 14 day post-operative period rats were randomly assigned to one of three groups: Control (CON = 60, receiving standard rat chow), Indomethacin (3 mg/kg/day, traditional non-selective anti-inflammatory drug) (IND = 60), or Celecoxib (10 mg/kg/day, cyclooxygenase-2-specific non-steroidal anti-inflammatory drug) (CEL = 60). Animals were sacrificed at 2, 4 and 8 weeks, and tissue was analysed.:Measures of outcome:Tissue analysis by gross inspection, biomechanical testing, histological analysis, collagen formation and maturation (polarised light microscopy).

Main finding/s:

Embedded Image

  • Failure to heal: failure to heal was evident in four tendons in the CEL and one tendon in the IND group.

  • Collagen organisation and maturation: there was significantly less collagen organisation and maturation in the IND and CEL groups compared with CON at 4 and 8 weeks (p<0.001).


  • In an animal study of tendon-bone healing following rotator cuff repair, both a traditional non-selective as well as a cyclooxygenase-2-specific non-steroidal anti-inflammatory drugs inhibited tendon-to-bone healing.

  • The common practice of administering non-steroidal anti-inflammatory drugs following tendon-bone repairs should be carefully considered.

Evidence based rating: 8.5/10

Clinical interest rating: 8/10

Type of study: Randomised, controlled, clinical trial (animal model)

Methodological considerations: Animal study, requires clinical trials in humans

Keywords: Non-steroidal anti-inflammatory drug (NSAID), healing, tendon-to-bone, rotator cuff, shoulder, animals


Background: Females undergoing military training have an increased risk of developing bone stress injuries but the risk factors for these injuries requires investigation.

Research question/s:

Which pre-training characteristics can identify women who are at an increased risk of developing stress fractures during military training?


Subjects: 2962 women (age 17–33 yrs) undergoing basic training.: Experimental procedure:Prior to the onset of 13 weeks of training, all the subjects completed a baseline questionnaire highlighting exercise and menstrual status and underwent performance on a timed run (a measure of aerobic fitness), and anthropometric measurements. All the recruits were followed over the basic training period, and all bone stress injuries were documented using clinical, radiological or bone scan criteria.: Measures of outcome:Odds ratio (all bone stress injuries, pelvic or femoral bone stress injuries).

Main finding/s:

Embedded Image

  • Incidence of injury in 13 weeks of training: 152 recruits (5.1%) had 181 confirmed lower extremity stress fractures (most common sites: tibia = 25%, metatarsals = 22%, pelvis = 22%, and femur = 20%).

  • No menses during the past year was also significantly associated with the occurrence of any stress fracture (OR = 3.79) and with pelvic or femoral stress fractures (OR = 5.85) during boot camp.

Conclusion/s: In female military recruits undergoing 13 weeks of basic military training, low endurance fitness (slow running times for ¾ or 1 mile) and amenorrhea in the last year are risk factors for stress fractures including pelvic and femoral stress fractures.

Evidence based rating: 7/10

Clinical interest rating: 8/10

Type of study: Prospective cohort study

Methodological considerations: Recall bias (menstrual history)

Keywords: Stress fractures, bone stress injuries, menstrual status, fitness, military, women


Background: Early loading of a ruptured Achilles tendon may prevent detrimental alterations in muscle and may favorably influence maturation of collagen fibers within the tendon.

Research question/s: Does immediate weight-bearing produce faster rehabilitation for patients after a rupture of the Achilles tendon whether they undergo surgical repair or not?

Methodology:Subjects:96 patients with Achilles tendon rupture (aged 28–69 years).:Experimental procedure:Two independent clinical trials were conducted. In trial 1, all subjects (n = 48) underwent surgical repair followed by random allocation to a control (SurgCon = 25) or immediate weight-bearing mobilisation (SurgIWBM = 23). In trial 2, all subjects (n = 48) underwent non-operative treatment (below knee plaster cast or slab) followed by random allocation to a control (NonCon = 26) or immediate weight-bearing mobilisation (NonIWBM = 22). All the patients were reviewed at 3, 6 and 12 months.:Measures of outcome:Time to return to normal activity, percent returning to sport, EuroQol health status.

Main finding/s:

Embedded Image

  • Trial 1: following operative repair of a ruptured Achilles tendon, there was a significantly greater improved functional outcome for patients mobilised fully weight-bearing after surgical repair—immediate weight-bearing did not predispose the patients to a higher complication rate.

  • Trial 2: following non-operative treatment of an acute Achilles tendon rupture, there was no evidence of a functional benefit from immediate weight-bearing mobilisation.

Conclusion/s: In patients with acute Achilles tendon rupture who undergo surgical repair, immediate weight-bearing mobilisation results in better functional outcomes compared with no immediate mobilisation.

Evidence based rating: 7.5/10

Clinical interest rating: 8/10

Type of study: Randomised, controlled, clinical trial

Methodological considerations: Well-conducted study

Keywords: Achilles rupture, non-operative treatment, operative treatment, immediate weight bearing mobilisation


Background: In a chronic disease rehabilitation programme constant load exercise (CLE) training is commonly used, but an alternative approach that allows high-intensity exercise to be performed is interval exercise (IE).

Research question/s: Does IE training induce similar positive changes in the morphological and biochemical characteristics of the vastus lateralis muscle in patients undergoing pulmonary rehabilitation when compared to changes following CLE training?

Methodology:Subjects:19 patients with stable advanced COPD (FEV1, 40 ± 4% predicted).: Experimental procedure:All the subjects were assessed and then randomly assigned to either an interval exercise group (IE = 10, 124 ± 15% of baseline peak work rate (Wpeak)) with 30 s work periods interspersed with 30 s rest periods for 45 min/d) or a constant load exercise group (CL = 9, 75 ± 5% Wpeak for 30 min/d). Subjects exercised 3 d/wk for 10 weeks. Needle biopsies of the right vastus lateralis muscle were performed before and after rehabilitation.: Measures of outcome:Skeletal muscle adaptations (Cross sectional areas of type I and IIa muscle fibers (um2), capillary-to-fiber ratio, citrate synthase activity (μmol/min/g)), exercise capacity (peak workload change), symptoms during training (ratings of dyspnea and leg discomfort (% at Wpeak)).

Main finding/s: Skeletal muscle adaptations: following training in both groups, there was significant increase in cross-sectional areas of type I and IIa fibers, capillary-to-fiber ratio, and some change in citrate synthase activity (p  =  0.097).

  • Exercise capacity: in both groups there was a significant improvement in Wpeak.

  • The magnitude of changes in all the above variables was not significantly different compared to that incurred after CLE training.


Embedded Image

A 10-week (3/week) high-intensity interval training programme is as effective as constant load training to improve muscle function in patients undergoing pulmonary rehabilitation; however, interval training is associated with fewer symptoms during training.

Evidence based rating: 8/10

Clinical interest rating: 8/10

Type of study: Randomised, controlled, clinical trial

Methodological considerations: Well-conducted study

Keywords: Interval training, constant load training, exercise, obstructive lung disease, pulmonary rehabilitation

View Abstract

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.