Determining intracortical, corticospinal and alpha motoneurone excitability in athletes with patellar tendinopathy compared to asymptomatic controls.

BACKGROUND: Lower capacity to generate knee extension maximal voluntary force (MVF) has been observed in individuals affected with patellar tendinopathy (PT) compared to asymptomatic controls. This MVF deficit is hypothesized to emanate from alterations in corticospinal excitability (CSE). The modulation of CSE is intricately linked to the excitability levels at multiple sites, encompassing neurones within the corticospinal tract (CST), intracortical neurones within the primary motor cortex (M1), and the alpha motoneurone. The aim of this investigation was to examine the excitability of intracortical neurones, CST neurones, and the alpha motoneurone, and compare these between volleyball and basketball athletes with PT and matched asymptomatic controls. METHOD: Nineteen athletes with PT and 18 asymptomatic controls participated in this cross-sectional study. Transcranial magnetic stimulation was utilized to assess CST excitability, corticospinal inhibition (silent period, and short-interval cortical inhibition). Peripheral nerve stimulation was used to evaluate lumbar spine and alpha motoneurone excitability, including the evocation of lumbar-evoked potentials and maximal compound muscle action potential (MMAX ), and CSE with central activation ratio (CAR). Knee extension MVF was also assessed. RESULTS: Athletes with PT exhibited longer silent period duration and greater electrical stimulator output for MMAX , as well as lower MVF, compared to asymptomatic controls (p < 0.05). CONCLUSION: These findings indicate volleyball and basketball athletes with PT exhibit reduced excitability of the alpha motoneurone or the neuromuscular junction, which may be linked to lower MVF. Subtle alterations at specific sites may represent compensatory changes to excitability aiming to maintain efferent drive to the knee extensors.

TENDINopathy Severity assessment-Achilles (TENDINS-A): evaluation of reliability and validity in accordance with COSMIN recommendations.

OBJECTIVE: To evaluate the construct validity (structural validity and hypothesis testing), reliability (test-retest reliability, measurement error and internal consistency) and minimal important change (MIC) of the 13-item TENDINopathy Severity assessment-Achilles (TENDINS-A). METHODS: Participants with Achilles pain completed an online survey including: demographics, TENDINS-A, Foot and Ankle Outcome Score (FAOS) and Victorian Institute of Sport Assessment-Achilles (VISA-A). Exploratory factor analysis (EFA) assessed dimensionality. Confirmatory factor analysis (CFA) assessed structural validity (root mean square error of approximation (RMSEA); Comparative Fit Index (CFI); Tucker-Lewis Index (TLI); standardised root measure square (SRMS)). Correlations between TENDINS-A and the FAOS or VISA-A assessed hypothesis testing. Intraclass correlation (ICC) assessed test-retest reliability. Cronbach's alpha assessed internal consistency. SE of the measurement (SEM) assessed measurement error. A distribution-based approach assessed MIC. RESULTS: 79 participants (51% female) with a mean (SD) age=42.6 (13.0) years, height=175.0 (11.7) cm and body mass=82.0 (19.1) kg were included. EFA identified three meaningful factors, proposed as pain, symptoms and function. The best model identified using CFA for TENDINS-A had structural validity (RMSEA=0.101, CFI=0.959, TLI=0.947, SRMS=0.068), which included three factors (pain, symptoms and function), but excluded three items from the original TENDINS-A. TENDINS-A exhibited moderate positive correlation with FAOS (r=0.598, p<0.001) and a moderate negative correlation with VISA-A (r=-0.639, p<0.001). Reliability of the TENDINS-A was excellent (ICC=0.930; Cronbach's α=0.808; SEM=6.54 units), with an MIC of 12 units. CONCLUSIONS: Our evaluation of the revised 10-item TENDINS-A determined it has construct validity and excellent reliability, compared with the VISA-A and FAOS which lack content and construct validity. The TENDINS-A is recommended as the preferred patient-reported outcome measure to assess disability in people with Achilles tendinopathy.

The acute effects of higher versus lower load duration and intensity on morphological and mechanical properties of the healthy Achilles tendon: a randomized crossover trial.

The Achilles tendon (AT) exhibits volume changes related to fluid flow under acute load which may be linked to changes in stiffness. Fluid flow provides a mechanical signal for cellular activity and may be one mechanism that facilitates tendon adaptation. This study aimed to investigate whether isometric intervention involving a high level of load duration and intensity could maximize the immediate reduction in AT volume and stiffness compared with interventions involving a lower level of load duration and intensity. Sixteen healthy participants (12 males, 4 females; age 24.4±9.4 years, body mass 70.9±16.1 kg, height 1.7±0.1 m) performed three isometric interventions of varying levels of load duration (2 s and 8 s) and intensity (35% and 75% maximal voluntary isometric contraction) over a 3 week period. Freehand 3D ultrasound was used to measure free AT volume (at rest) and length (at 35%, 55% and 75% of maximum plantarflexion force) pre- and post-interventions. The slope of the force-elongation curve over these force levels represented individual stiffness (N mm-1). Large reductions in free AT volume and stiffness resulted in response to long-duration high-intensity loading whilst less reduction was produced with a lower load intensity. In contrast, no change in free AT volume and a small increase in AT stiffness occurred with lower load duration. These findings suggest that the applied load on the AT must be heavy and sustained for a long duration to maximize immediate volume reduction, which might be an acute response that enables optimal long-term tendon adaptation via mechanotransduction pathways.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial.

OBJECTIVES: To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy. METHODS: This was a parallel-group randomised superiority trial at a single centre (La Trobe University Health Sciences Clinic, Discipline of Podiatry, Melbourne, Victoria, Australia). One hundred participants (52 women and 48 men, mean age 45.9, SD 9.4 years) with clinically diagnosed and ultrasonographically confirmed mid-portion Achilles tendinopathy were randomly allocated to either a (1) heel lifts (n=50) or (2) eccentric exercise (n=50) group. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 12 weeks. Differences between groups were analysed using intention to treat with analysis of covariance. RESULTS: There was 80% follow-up of participants (n=40 per group) at 12 weeks. The mean VISA-A score improved by 26.0 points (95% CI 19.6 to 32.4) in the heel lifts group and by 17.4 points (95% CI 9.5 to 25.3) in the eccentric exercise group. On average, there was a between-group difference in favour of the heel lifts for the VISA-A (adjusted mean difference 9.6, 95% CI 1.8 to 17.4, p=0.016), which approximated, but did not meet our predetermined minimum important difference of 10 points. CONCLUSION: In adults with mid-portion Achilles tendinopathy, heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks. However, there is uncertainty in the estimate of effect for this outcome and patients may not experience a clinically worthwhile difference between interventions. TRIAL REGISTRATION NUMBER: ACTRN12617001225303.

The Efficacy of Higher Versus Lower Dose Exercise in Rotator Cuff Tendinopathy: A Systematic Review of Randomized Controlled Trials.

OBJECTIVES: To compare the effectiveness and harms of higher exercise dose, including higher exercise load or higher volume, with lower exercise dose (lower load or lower volume) in individuals with rotator cuff tendinopathy. DESIGN: Systematic review. DATA SOURCES: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL from inception to March 2019. STUDY SELECTION: Randomized controlled trials comparing higher versus lower dose exercise that investigated function and pain (overall, activity, night) and adverse event outcomes were independently determined by 2 reviewers. DATA EXTRACTION: Two authors independently extracted data and assessed risk of bias using the Cochrane tool. The primary endpoint was at least 6 weeks to 3 months (other endpoints included up to 6 weeks and beyond 3 months) and the Grades of Recommendation, Assessment, Development and Evaluation was used to assess evidence certainty. DATA SYNTHESIS: Three trials (N=283), none at low risk of bias for all domains, were included. Low-certainty evidence (1 trial, N=102) indicated improved function (20 points [95% confidence interval, 12-28] on a 0-100 point scale) with higher load and volume exercise at 3 months, but little or no clinically important between-group difference in activity or night pain (overall pain not reported). Very low-certainty evidence (1 trial, N=120) indicated higher load exercise conferred no function benefits over lower load exercise at 6 weeks. Very low-certainty evidence (1 trial, N=61) indicated benefit of uncertain clinical importance in function with higher versus lower volume exercise at 3 months and clinically important benefit at more than 3 months (pain outcomes not reported). The risk of adverse events was uncertain. CONCLUSIONS: There are few studies that have investigated higher dose exercise for rotator cuff tendinopathy. There was low to very low certainty and conflicting evidence regarding the value of higher exercise dose in individuals with rotator cuff tendinopathy.

Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Synthesize evidence regarding effectiveness of progressive and resisted or non-progressive and non-resisted exercise compared with placebo or no treatment, in rotator cuff related pain. DATA SOURCES: English articles, searched in Cochrane CENTRAL, MEDLINE, EMBASE and CINAHL databases up until May 19, 2020. METHODS: Randomized controlled trials in people with rotator cuff related pain comparing either progressive and resisted exercise or non-progressive and non-resisted exercise, with placebo or no treatment were included. Data extracted independently by two authors. Risk of bias appraised with the Cochrane Collaboration tool. RESULTS: Seven trials (468 participants) were included, four trials (271 participants) included progressive and resisted exercise and three trials (197 participants) included non-progressive or non-resisted exercise. There was uncertain clinical benefit for composite pain and function (15 point difference, 95% CI 9 to 21, 100-point scale) and pain outcomes at >6 weeks to 6 months with progressive and resisted exercise compared to placebo or no treatment (comparison 1). For non-progressive or non-resisted exercise there was no significant benefit for composite pain and function (4 point difference, 95% CI -2 to 9, 100-point scale) and pain outcomes at >6 weeks to 6 months compared to placebo or no treatment (comparison 2). Adverse events were seldom reported and mild. CONCLUSIONS: There is uncertain clinical benefit for all outcomes with progressive and resisted exercise and no significant benefit with non-progressive and non-resisted exercise, versus no treatment or placebo at >6 weeks to 6 months. Findings are low certainty and should be interpreted with caution.

ICON 2019-International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients.

BACKGROUND: The absence of any agreed-upon tendon health-related domains hampers advances in clinical tendinopathy research. This void means that researchers report a very wide range of outcome measures inconsistently. As a result, substantial synthesis/meta-analysis of tendon research findings is almost futile despite researchers publishing busily. We aimed to determine options for, and then define, core health-related domains for tendinopathy. METHODS: We conducted a Delphi study of healthcare professionals (HCP) and patients in a three-stage process. In stage 1, we extracted candidate domains from clinical trial reports and developed an online survey. Survey items took the form: 'The 'candidate domain' is important enough to be included as a core health-related domain of tendinopathy'; response options were: agree, disagree, or unsure. In stage 2, we administered the online survey and reported the findings. Stage 3 consisted of discussions of the findings of the survey at the ICON (International Scientific Tendinopathy Symposium Consensus) meeting. We set 70% participant agreement as the level required for a domain to be considered 'core'; similarly, 70% agreement was required for a domain to be relegated to 'not core' (see Results next). RESULTS: Twenty-eight HCP (92% of whom had >10 years of tendinopathy experience, 71% consulted >10 cases per month) and 32 patients completed the online survey. Fifteen HCP and two patients attended the consensus meeting. Of an original set of 24 candidate domains, the ICON group deemed nine domains to be core. These were: (1) patient rating of condition, (2) participation in life activities (day to day, work, sport), (3) pain on activity/loading, (4) function, (5) psychological factors, (6) physical function capacity, (7) disability, (8) quality of life and (9) pain over a specified time. Two of these (2, 6) were an amalgamation of five candidate domains. We agreed that seven other candidate domains were not core domains: range of motion, pain on clinician applied test, clinical examination, palpation, drop out, sensory modality pain and pain without other specification. We were undecided on the other five candidate domains of physical activity, structure, medication use, adverse effects and economic impact. CONCLUSION: Nine core domains for tendon research should guide reporting of outcomes in clinical trials. Further research should determine the best outcome measures for each specific tendinopathy (ie, core outcome sets).

ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T).

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.

Immediate and Short-Term Effects of Short- and Long-Duration Isometric Contractions in Patellar Tendinopathy.

OBJECTIVES: Isometric muscle contractions are used in the management of patellar tendinopathy to manage pain and improve function. Little is known about whether long- or short-duration contractions are optimal to improve pain. This study examined the immediate and short-term (4 weeks) effects of long- and short-duration isometric contraction on patellar tendon pain, and tendon adaptation. DESIGN: Repeated measures within groups. SETTING: Clinical primary care. PATIENTS: Participants (n = 16, males) with patellar tendinopathy. INTERVENTION: Short-duration (24 sets of 10 seconds) or long-duration (6 sets of 40 seconds) isometric knee extension loading (85% maximal voluntary contraction), for 4 weeks. MAIN OUTCOME MEASURE: Immediate change in pain with single-leg decline squat (SLDS) and hop, as well as change in pain and tendon adaptation [within-session anterior-posterior (AP) strain] were assessed over 4 weeks. RESULTS: Pain was significantly reduced after isometric loading on both SLDS (P < 0.01) and hop tests (P < 0.01). Pain and quadriceps function improved over the 4 weeks (P < 0.05). There was significant AP strain at each measurement occasion (P < 0.01). Although transverse strain increased across the training period from ∼14% to 22%, this was not significant (P = 0.08). CONCLUSIONS: This is the first study to show that short-duration isometric contractions are as effective as longer duration contractions for relieving patellar tendon pain when total time under tension is equalized. This finding provides clinicians with greater options in prescription of isometric loading and may be particularly useful among patients who do not tolerate longer duration contractions. The trend for tendon adaptation over the short 4-week study period warrants further investigation.

Changes on Tendon Stiffness and Clinical Outcomes in Athletes Are Associated With Patellar Tendinopathy After Eccentric Exercise.

OBJECTIVE: Eccentric exercise is commonly used as a form of loading exercise for individuals with patellar tendinopathy. This study investigated the change of mechanical properties and clinical outcomes and their interrelationships after a 12-week single-legged decline-board exercise with and without extracorporeal shockwave therapy (ESWT). DESIGN: Randomized controlled trial. SETTING: Outpatient clinic of a university. PARTICIPANTS: Thirty-four male in-season athletes with patellar tendinopathy for more than 3 months were randomized into exercise and combined groups. INTERVENTIONS: The exercise group received a 12-week single-legged decline-squat exercise, and the combined group performed an identical exercise program in addition to a weekly session of ESWT in the initial 6 weeks. MAIN OUTCOME MEASURES: Tendon stiffness and strain were examined using ultrasonography and dynamometry. Visual analog scale and Victoria Institute of Sports Assessment-patella (VISA-p) score were used to assess pain and dysfunction. These parameters were measured at preintervention and postintervention. RESULTS: Significant time effect but no significant group effect on the outcome measures; significant reduction in tendon stiffness (P = 0.02) and increase in tendon strain (P = 0.00); and reduction of intensity of pain (P = 0.00) and dysfunction (P = 0.00) were observed. Significant correlations between changes in tendon stiffness and VISA-p score (ρ = -0.58, P = 0.05); alteration in tendon strain, pain intensity (ρ = -0.63, P = 0.03); and VISA-p score (ρ = 0.60, P = 0.04) were detected after the exercise program. CONCLUSIONS: Eccentric exercise-induced modulation on tendon mechanical properties and clinical symptoms are associated in athletes with patellar tendinopathy.

Adaptation of Tendon Structure and Function in Tendinopathy With Exercise and Its Relationship to Clinical Outcome.

CONTEXT: Exercise is seen as the most evidence-based treatment for managing tendinopathy and although the type of exercise used to manage tendinopathy may induce adaptation in healthy tendons, it is not clear whether these adaptations occur in tendinopathy and if so whether they are associated with improved clinical outcomes. OBJECTIVE: The aim of the study was to synthesize available evidence for adaptation of the Achilles tendon to eccentric exercise and the relationship between adaptation (change in tendon thickness) and clinical outcomes among people with Achilles tendinopathy. EVIDENCE ACQUISITION: The search was performed in September 2018 in several databases. Studies investigating the response (clinical outcome and imaging on ultrasound/magnetic resonance imaging) of pathological tendons (tendinopathy, tendinosis, and partial rupture) to at least 12 weeks of eccentric exercise were included. Multiple studies that investigated the same interventions and outcome were pooled and presented in effect size estimates, mean difference, and 95% confidence intervals if measurement scales were the same, or standard mean difference and 95% confidence intervals if measurements scales were different. Where data could not be pooled the studies were qualitatively synthesized based on van Tulder et al. EVIDENCE SYNTHESIS: Eight studies met the inclusion and exclusion criteria and were included in the review. There was strong evidence that Achilles tendon thickness does not decrease in parallel with improved clinical outcomes. CONCLUSIONS: Whether a longer time to follow-up is more important than the intervention (ie, just the time per se) for a change in tendon thickness remains unknown. Future studies should investigate whether exercise (or other treatments) can be tailored to optimize tendon adaptation and function, and whether this relates to clinical outcomes.

High volume injection with and without corticosteroid in chronic midportion achilles tendinopathy.

BACKGROUND: High volume injection (HVI) shows promising results in the treatment of chronic midportion Achilles tendinopathy (AT). HVI consists of a large volume of saline with a small amount of corticosteroid and local anesthetic. OBJECTIVE: To determine the effect of corticosteroid in HVI in AT. METHODS: A total of 28 men (18-59 years) with chronic (>3 months) AT were included in a double-blinded RCT and followed for 24 weeks. All performed eccentric training and randomized to either (a) HVI injection with corticosteroid or (b) HVI injection without corticosteroid. Outcomes included self-reported function (VISA-A score) and pain (VAS score) and ultrasound imaging (tendon thickness, Doppler flow). RESULTS: VISA-A and VAS score improved in both groups at all time-points (P < 0.05). VISA-A improvement was significantly greater in HVI with corticosteroid (mean ± SEM; 6-weeks = 31 ± 3 points; 12-weeks = 32 ± 5 points) vs HVI without corticosteroid (6 weeks = 14 ± 3; 12-weeks = 17 ± 3) at 6 and 12 weeks (P < 0.05), but not at 24 weeks. Decrease in VAS scores was significantly greater in HVI with corticosteroid (6 weeks = 55 ± 3 mm; 12 weeks = 53 ± 5 mm) vs HVI without corticosteroid (6 weeks = 16 ± 3 mm; 12 weeks = 25 ± 5 mm) at 6 and 12 weeks (P < 0.05) but not at 24 weeks. Tendon thickness decreased significantly in both groups at all time-points (P < 0.05), but more in the HVI with corticosteroid vs HVI without corticosteroid at 6 and 12 weeks (P < 0.05) but not at 24 weeks. CONCLUSION: High volume injection with or without corticosteroid in combination with eccentric training seems effective in AT. HVI with corticosteroid showed a better short-term improvement than HVI without corticosteroid indicating a short-term effect of corticosteroid in HVI treatment of AT.

Incidence of Tendinopathy in Team Sports in a Multidisciplinary Sports Club Over 8 Seasons.

Tendinopathy is a critical medical condition that often hinders level of participation for professional and young athletes in many sports. The purpose of the study was to describe the incidence and severity of tendinopathy in a multi-sport club with professional and youth teams. We performed a retrospective epidemiological study. Incidence of tendinopathy in players (n = 3839; 8-38 years, professional and youth) was reviewed over 8 seasons (2008-2016) in 5 team sports: football, basketball, handball, roller hockey, and futsal. Team physicians diagnosed and classified tendinopathies according to anatomical location, sport types, playing category, sex, playing surface, lost training time, and severity (time to return to play). Injuries were coded using OSICS-10, and incidence of tendinopathies were calculated as the number of injuries per 100 players per season. The total relative frequency of tendinopathy (versus total injuries) was 22% (843/3839) over 8 seasons from 360 in youth and 483 in professional teams. The incidence of injury was the highest in professional basketball [69.9, 95%CI: (58.0-81.4)] followed by professional roller hockey [64.4, 95%CI: (47.3-85.6)], and professional futsal [36.2, 95%CI: (27.3-47.1)]. The most incidences commonly affected tendons were the patellar [11.7, 95%CI: (10.0-13.5)] and Achilles [10.3, 95%CI: (8.5-12.5)]. Tendinopathies represent a significant number of injuries in team sports and are more common in professional than youth teams, especially basketball and roller hockey. Additional studies are needed to understand associated time-loss and impact on performance, and to develop prevention strategies for high risk sports.

Patellar Tendinopathy and Potential Risk Factors: An International Database of Cases and Controls.

OBJECTIVES: Numerous risk factors have been identified for patellar tendinopathy (PT), often in small population studies. The aim was to use an international online questionnaire to generate a large database and identify significant risk factors. DESIGN: Case-control study. SETTING: Private practice and sporting teams recruited from England, Spain, and Italy with the questionnaire available in all 3 languages (equivalence between online and self-administration shown previously). All data were anonymized and password protected. PARTICIPANTS: Eight hundred twenty-five data sets collected between January 2012 and May 2014. ASSESSMENT OF RISK FACTORS: A total of 23.4% of participants had clinically diagnosed PT. A comparison between these participants and participants without PT was made. MAIN OUTCOME MEASURE: Association between the presence of PT and risk factors. RESULTS: Eight risk factors were included in the analysis based on a purposeful selection procedure: sex, hours of training, hamstring flexibility, previous patellar tendon rupture, previous knee injury, current/previous back pain, family history, and age. Four were found to have statistically significant odds ratios: female sex [0.70, 95% confidence interval (CI), 0.49-1.00, P = 0.05], hours of training (>20 hours 8.94, 95% CI, 4.68-17.08, P < 0.01), previous knee injury (2.10, 95% CI, 1.45-3.04, P < 0.01), and flexible hamstrings (0.61, 95% CI, 0.38-0.97, P = 0.04). There was a trend toward association for back pain (1.45, 95% CI, 0.99-2.14, P = 0.06) and a family history of tendon problems (1.51, 95% CI, 0.96-2.37, P = 0.08). CONCLUSIONS: Risk factors have been identified that are potentially modifiable to inform prevention and rehabilitation programs; future research is required to establish causal relationships. Identified risk factors require mechanistic investigation as they are not currently recognized in the literature.

Sonoelastography of the Achilles Tendon: Prevalence and Prognostic Value Among Asymptomatic Elite Australian Rules Football Players.

OBJECTIVE: To investigate the prevalence of sonographic abnormalities at the mid-Achilles tendon among a cohort of asymptomatic professional football players and to determine whether these sonographic abnormalities predict midportion Achilles tendon symptoms. DESIGN: Longitudinal study. SETTING: A single competitive season in the Australian Rules Football League. PARTICIPANTS: Forty-two elite Australian Rules football players. MAIN OUTCOME MEASURES: Using ultrasound and sonoelastography, 42 players were examined at baseline and again 9 months later (postseason) for the existence of intratendinous hypoechogenicity, delamination, softening, and neovascularization. The anterio-posterior (AP) thickness and cross-sectional area (CSA) were measured. Players reporting Achilles tendon pain or with Victorian Institute of Sports Assessment-Achilles scores below 80 at the end of the season were classified as symptomatic. RESULTS: At preseason, ultrasound and/or sonoelastographic abnormalities were found in 22 (22/42, 52.4%) asymptomatic players. Baseline AP thickness and CSA were significantly greater in symptomatic players at the end season than those in asymptomatic players (0.57 ± 0.05 cm vs 0.50 ± 0.03 cm; P < 0.001 and 0.67 ± 0.07 cm vs 0.57 ± 0.06 cm; P < 0.001, respectively). The presence of intratendinous softening and delaminations at baseline was associated with pain onset during the season (P = 0.046; P = 0.048, respectively). CONCLUSIONS: Ultrasound and sonoelastography-detected abnormalities were relatively common among the asymptomatic footballers. Greater AP thickness and CSA and also the presence of intratendinous softening and delaminations were associated with the increased risk of developing symptoms. CLINICAL RELEVANCE: Conventional ultrasound supplement with sonoelastography may be able to identify elite athletes at risk of Achilles tendon injury, which may, in turn, impact therapeutic decisions.

Development and validation of a questionnaire (FASH--Functional Assessment Scale for Acute Hamstring Injuries): to measure the severity and impact of symptoms on function and sports ability in patients with acute hamstring injuries.

OBJECTIVE: To develop a condition-specific patient-reported outcome measure, the Functional Assessment Scale for Acute Hamstring Injuries (FASH), de novo in three languages, following distinct and rigorous methodology for content generation, analysis and validation and to assess its psychometric properties. BACKGROUND: To our knowledge, there is no patient-reported functional scale specific for acute hamstring injuries. METHODS: The development of the scale followed specific guidelines, as well as de novo construction in three languages (Greek, English and German). Item generation was accomplished by selecting three different sources of items: literature review, focus group and key informant interviews. Content analysis was conducted by an expert committee. The 21 items selected as appropriate were tested through a structured content analytic method and item-content validity coefficient, and 10 were retained for the FASH. The validation and assessment of its psychometric properties followed theConsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) recommendations to ensure quality, in a convenience sample of 140 participants. RESULTS: The face validity was adequate and tested by expert committees, authors and participants. Content validity was characterised as well addressed and conducted independently by experts and through specific content validation procedures. The dimensionality analysis indicated a one-factor solution explaining the 95.8% of total variance. Known group validity was demonstrated by significant differences between patients and controls (p<0.001). The FASH exhibited very good test-retest reliability (intraclass correlation coefficient=0.9, p<0.001), internal consistency (α=0.98) and responsiveness (3.81 and 5.23 using baseline and pooled SD, respectively; standardised response mean (SRD)=4.68). CONCLUSION: This study provides initial evidence for psychometric properties of the first scale assessing hamstring injuries.

Medial tibial pain pressure threshold algometry in runners.

PURPOSE: Pressure algometry (PA) may provide an objective and standardised tool in assessing palpation pain over the tibia. The purpose of this study was to analyse the intra-rater repeatability of PA and to determine whether tibial tenderness in healthy runners differ from runners with medial tibial stress syndrome (MTSS). METHODS: Pressure algometry was performed on 20 asymptomatic runners (40 legs) and 9 MTSS patients (14 symptomatic legs) at standardised locations along the medial border of the tibia. Intra-rater reliability was assessed in 10 randomly selected asymptomatic runners through repeated measurements 2 weeks later. RESULTS: Intra-rater reliability was moderate to excellent (ICC 0.53-0.90) in asymptomatic runners. Pain pressure threshold (PPT) was significantly reduced at 2/9-5/9 of the distance from the medial malleolus to the medial tibial condyle (p = 0.002-0.022). There was evidence of a statistically significant association between both height and weight, and PPT from the 3/9 (r = 0.416, p = 0.008) to 7/9 (r = 0.334, p = 0.035) and 3/9 (r = 0.448, p = 0.004) to 6/9 (r = 0.337, p = 0.034) area, respectively. In both MTSS patients and healthy runners, there was evidence of lower PPT in females compared to males (p = 0.0001-0.049) and a negative association between age and PPT (p = 0.001-0.033). MTSS patients had significantly lower PPT at the 3/9 site (p = 0.048) compared to asymptomatic runners. CONCLUSION: Pain pressure threshold algometry can be incorporated into MTSS clinical assessment to objectively assess pain and monitor progress. The presence of reduced medial tibial PPT in asymptomatic runners suggests that clinicians may not need to await resolution of medial tibia tenderness before allowing return to sport in MTSS patients.

Sensitivity to change and responsiveness of provocative load tests among athletes with patellar tendinopathy.

BACKGROUND: Pain provocation tests are recommended for assessing pain severity and as an outcome measure for individuals with patellar tendinopathy. OBJECTIVE: To evaluate floor and ceiling effects, sensitivity to change, and responsiveness cut-offs of two provocative load tests among athletes with patellar tendinopathy. METHODS: Athletes (N = 41) performed six repetitions for the single leg decline squat (SLDS) and resisted knee extension (KE) at baseline and 12 weeks. Participants rated their pain during each test on a visual analog scale (VAS). Sensitivity to change was assessed by calculating effect size (ES) and the standardized response mean (SRM). The responsiveness cut-offs were assessed using a combination of anchor and distribution- based methods to determine the minimal clinically important difference (MCID) for each test. RESULTS: A floor or ceiling effect was observed in only a small number of participants for both tests except for KE, for which approximately one third of participants had a floor effect at week 12. There was higher sensitivity to change for SLDS (ES: 1.93/SRM: 1.43) compared with KE (ES:0.96/SRM: 1.09). The MCID corresponded to a decrease of 1.6 points for SLDS and 1.0 for KE, while the distribution-based method estimated 1.2 points for SLDS and 1.1 for KE. CONCLUSION: This study found moderate to high sensitivity to change and established MCID values for the SLDS and KE test in athletes with patellar tendinopathy before and after rehabilitation. Both tests may be useful as pain on loading outcomes as athletes progress with their rehabilitation, but the KE test results in higher floor effects and has lower sensitivity to change.