Normative ultrasound values for Achilles tendon thickness in the general population and patients with Achilles tendinopathy: A large international cross-sectional study.

The objective of the study was to obtain adjusted ultrasonographic reference values of the Achilles tendon thickness (maximum anterior-posterior distance) in adults without (previous) Achilles tendinopathy (AT) and to compare these reference values with AT patients. Six hundred participants were consecutively included, comprising 500 asymptomatic individuals and 100 patients with clinically diagnosed chronic AT. The maximum tendon thickness was assessed using Ultrasound Tissue Characterization. A multiple quantile regression model was developed, incorporating covariates (personal characteristics) that were found to have a significant impact on the maximum anterior-posterior distance of the Achilles tendon. A 95% reference interval (RI) was derived (50th, 2.5th-97.5th percentile). In asymptomatic participants median (95% RI) tendon thickness was 4.9 (3.8-6.9) mm for the midportion region and 3.7 (2.8-4.8) mm for the insertional region. Age, height, body mass index, and sex had a significant correlation with maximum tendon thickness. Median tendon thickness for the midportion region was calculated with the normative equation -2.1 + AGE × 0.021 + HEIGHT × 0.032+ BMI × 0.028 + SEX × 0.05. For the insertional region, the normative equation was -0.34 + AGE × 0.010+ HEIGHT × 0.018 + BMI × 0.022 + SEX × -0.05. In the equations, SEX is defined as 0 for males and 1 for females. Mean (95% CI) difference in tendon thickness compared to AT patients was 2.7 mm (2.3-3.2, p < 0.001) for the midportion and 1.4 mm (1.1-1.7, p < 0.001) for the insertional region. Compared to the asymptomatic population 73/100 (73%) AT patients exhibited increased tendon thickening, with values exceeding the 95% RI. This study presents novel reference values for the thickness of midportion and insertional region of the Achilles tendon, which were adjusted for personal characteristics. Our novel web-based openly accessible calculator for determining normative Achilles tendon thickness (www.achillestendontool.com) will be a useful resource in the diagnostic process. Trial registration number: This trial is registered in the Netherlands Trial Register (NL9010).

Low socioeconomic status is associated with worse treatment outcomes in patients with Achilles tendinopathy.

OBJECTIVE: To assess whether there is a difference in symptom severity at baseline and 24 weeks follow-up between conservatively managed patients with Achilles tendinopathy (AT) with low socioeconomic status (SES) compared with those with high SES. METHODS: In this prospective cohort study, 200 patients with AT were included and treated according to current guidelines. We linked a neighbourhood SES indicator based on income, employment and education level and divided the patient population into quintiles, with Q1 being the highest SES and Q5 the lowest. Symptom severity at baseline and follow-up was assessed using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Treatment adherence was not measured. We used a general linear model and the mean VISA-A scores at baseline and at 6, 12 and 24 weeks follow-up were compared between Q1 (n=45) and Q5 (n=39), while adjusting for age, sex, body mass index (BMI), Ankle Activity Score, symptom duration and baseline VISA-A score. RESULTS: Patients had a median age of 51 years and median BMI of 25.4, 40% were female. 74%, 70% and 58% of the participants completed the VISA-A at 6, 12 and 24 weeks, respectively. VISA-A scores at baseline were similar for Q1 and Q5 (43.9 and 41.8, p=0.591). At 24 weeks, there was a mean (95% CI) difference of 11.2 (1.0 to 21.3, p=0.032) points in favour of Q1 on the VISA-A score. CONCLUSION: AT patients with low SES may have worse outcomes when treated using the current guidelines. The difference in VISA-A score at 24 weeks is larger than the minimal clinically important difference and might be clinically relevant, but comes with uncertainty due to the large dispersion in the data. Clinicians need to consider the impact of social inequality when developing and implementing treatment plans.

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.

Are we asking the right questions to people with Achilles tendinopathy? The best questions to distinguish mild versus severe disability to improve your clinical management.

OBJECTIVE: Determine the capacity of individual items on the Tendinopathy Severity Assessment - Achilles (TENDINS-A), Foot and Ankle Outcome Score (FAOS), and Victorian Institute of Sports Assessment - Achilles (VISA-A) to differentiate patients with mild and severe tendon-related disability in order to provide clinicians the best questions when they are consulting patients with Achilles tendinopathy. DESIGN: Cross-sectional. PARTICIPANTS: Seventy participants with Achilles tendinopathy (61.4% mid-portion only, 31.4% insertional only, 7.2% both). OUTCOME MEASURES: The discrimination index was determined for each TENDINS-A, FAOS, and VISA-A item to determine if items could discriminate between mild and severe disability. A Guttman analysis for polytomous items was conducted. RESULTS: All 62 tems from the TENDINS-A, FAOS, and VISA-A were ranked with the best items relating to pain with physical tendon loading, time for pain to settle following aggravating activities and time for the tendon to 'warm-up' following inactivity. CONCLUSIONS: Pain with loading the Achilles tendon, time for pain to settle following aggravating activity, as well as time taken for the tendon symptoms to subside after prolonged sitting or sleeping are the best questions indicative of the severity of disability in patients with Achilles tendinopathy. These questions can assist clinicians with assessing baseline severity and monitoring treatment response.

Comparison of weekly training load and acute:chronic workload ratio methods to estimate change in training load in running.

CONTEXT: Before examining the impact of training load on injury risk in runners, it is important to gain insight in the differences between methods that are used to measure change in training load. OBJECTIVE: To investigate differences between four methods to calculate change in training load: (1) weekly training load; (2) acute:chronic workload ratio (ACWR), coupled rolling average (RA); (3) ACWR, uncoupled RA; (4) ACWR, exponentially weighted moving averages (EWMA). DESIGN: Descriptive epidemiology study. SETTING: This study is part of a randomized-controlled trial on running injury prevention among recreational runners. Runners received a baseline questionnaire and a request to share GPS training data. PARTICIPANTS: Runners who registered for running events (distances 10-42.195 kilometers) in the Netherlands. MAIN OUTCOME MEASURES: Primary outcome measure was the predefined significant increase in training load (weekly training loads ≥30% progression and ACWRs ≥1.5), based on training distance. Proportional Venn diagrams visualized the differences between the methods. RESULTS: 430 participants (73.3% men; age 44.3 years) shared their GPS training data with in total 22,839 training sessions. For the weekly training load, coupled RA, uncoupled RA, and EWMA method, respectively 33.4% (95% CI 32.8-34.0), 16.2% (95% CI 15.7-16.6), 25.8% (95% CI 25.3-26.4), and 18.9% (95% CI 18.4-19.4) of the training sessions were classified as significant increase in training load. Of the training sessions with significant increase in training load, 43.0% expressed in the weekly training load method showed a difference with the coupled RA and EWMA method. Training sessions with significant increase in training load based on the coupled RA method showed 100% overlap with the uncoupled RA and EWMA method. CONCLUSIONS: The difference in change in training load measured by weekly training load and ACWR methods was high. To validate an appropriate measure of change in training load in runners, future research on the association between training loads and RRI risk is needed.

Epidemiology of insertional and midportion Achilles tendinopathy in runners: A prospective cohort study.

BACKGROUND: Achilles tendinopathy (AT) is a common problem among runners. There is only limited evidence for risk factors for AT, and most studies have not defined the AT subcategories. No study has compared the incidence and risk factors between insertional AT and midportion AT, though they are considered distinct. This study aimed to assess incidence and risk factors of AT based on data from a large prospective cohort. The secondary aim was to explore differences in risk factors between insertional and midportion AT. METHODS: Participants were recruited from among registered runners at registration for running events. Questionnaires were completed at baseline, 1 month before the event, 1 week before the event, and 1 month after the event. Information concerning demographics, training load, registered events, and running-related injuries were collected at baseline. The follow-up questionnaires collected information about new injuries. A pain map was used to diagnose midportion and insertional AT. The primary outcome was the incidence of AT. Multivariable logistic regression analysis was applied to identify risk factors for the onset. RESULTS: We included 3379 participants with a mean follow-up of 20.4 weeks. The incidence of AT was 4.2%. The proportion of insertional AT was 27.7% and of midportion AT was 63.8%; the remaining proportion was a combined type of insertional and midportion AT. Men had a significantly higher incidence (5%, 95% confidence interval (95%CI): 4.1%-6.0%) than women (2.8%, 95%CI: 2.0%-3.8%). AT in the past 12 months was the most predominant risk factor for new-onset AT (odds ratio (OR) = 6.47, 95%CI: 4.27 -9.81). This was similar for both subcategories of AT (insertional: OR = 5.45, 95%CI: 2.51-11.81; midportion: OR = 6.96, 95%CI: 4.24-11.40). Participants registering for an event with a distance of 10/10.55 km were less likely to develop a new-onset AT (OR = 0.59, 95%CI: 0.36-0.97) or midportion AT (OR = 0.47, 95%CI: 0.23 -0.93). Higher age had a significant negative association with insertional AT (OR = 0.97, 95%CI: 0.94-1.00). CONCLUSION: The incidence of new-onset AT among recreational runners was 4.2%. The proportion of insertional and midportion AT was 27.7% and 63.8%, respectively. AT in the past 12 months was the predominant risk factor for the onset of AT. Risk factors varied between insertional and midportion AT, but we could not identify clinically relevant differences between the 2 subtypes.

There is a Lack of Clinical Homogeneity in Lower-Limb Tendinopathy Trials: A Scoping Review.

OBJECTIVE: It is unclear if clinical trials of treatments for lower-limb tendinopathies include clinically homogeneous participant populations (an assumption for pooling in meta-analyses). We assessed the recruitment setting and participant characteristics used in randomized controlled trials (RCTs) that were investigating any treatment for lower-limb tendinopathies. DESIGN: Scoping review. METHODS: We conducted a systematic literature search in the PubMed, Embase, Cochrane CENTRAL, and Web of Science databases. All RCTs that were investigating treatments for lower-limb tendinopathies in an adult population (≥18 years) were eligible for inclusion. At least 2 authors conducted independent screening and selection of full-text papers, and extracted data from included studies. RESULTS: Of 18 341 records, 342 RCTs (21 897 participants) were eligible for inclusion and data extraction. The most common diagnoses were plantar fasciopathy (n = 195, 57%), Achilles tendinopathy (n = 82, 24%), and patellar tendinopathy (n = 41, 12%). Secondary care (n = 144, 42%) was the most reported recruitment setting, followed by an open setting (n = 44, 13%). In 93 (27%) RCTs, the recruitment setting was not described. We found high heterogeneity in participant characteristics (eg, symptom duration, age, body mass index, and the Victorian Institute of Sport Assessment [VISA] questionnaire score) within and between recruitment settings. CONCLUSION: Our results question whether clinical homogeneity can be adequately assumed in clinical trials of lower-limb tendinopathies due to the lack of clear reporting of the recruitment setting and the variability within and between recruitment settings of key participant characteristics. These findings threaten assumptions for meta-analyses in lower-limb tendinopathies. J Orthop Sports Phys Ther 2024;54(1):1-10. Epub 5 December 2023. doi:10.2519/jospt.2023.11722.

Measuring Ultrasonographic Thickness of the Achilles Tendon Insertion Is Less Reliable Than the Midportion in Healthy Tendons and Patients With Tendinopathy.

INTRODUCTION: Ultrasound is the preferred imaging method in the diagnostic process of Achilles tendinopathy (AT). Ultrasound tissue characterization (UTC) is a frequently used, standardized and valid method to assess tendon geometry in AT patients. It is unknown whether UTC is reliable for measuring Achilles tendon thickness. The aim of the study was to assess intra- and inter-rater reliability of Achilles tendon thickness measurements using UTC in both asymptomatic individuals and patients with AT, and to evaluate if the reliability of thickness measurements differs between the midportion and insertional area. METHODS: Exactly 50 patients with AT and 50 asymptomatic individuals were included. Using the conventional US and standardized UTC procedure maximum thickness was measured in the midportion and insertion region. To determine inter- and intra-rater reliabilities, the intraclass correlation coefficient (ICC) was used. RESULTS: The ICC values for inter- and intra-rater reliability were classified as "excellent," for the AT group (0.93 [95% CI: 0.88-0.96] and 0.95 [0.92-0.97]) and asymptomatic participants (0.91 [0.87-0.94] and 0.94 [0.92-0.96]). The reliability of measuring tendon thickness in the midportion region was "excellent," with both inter-rater (0.97 [0.95-0.98]) and intra-rater (0.98 [0.96-0.99]) ICC values indicating high levels of agreement. In the insertional region, ICC values for inter-rater (0.79 [0.69-0.87]) and intra-rater (0.89 [0.84-0.93]) reliability were "moderate to good." CONCLUSION: We showed excellent reliability for measuring the US thickness of the midportion and good reliability of measuring the insertional region in patients with AT. Significantly lower ICCs were observed for the reliability of thickness measurements in the insertional region when compared with the midportion.

Association Between Physical Tests and Patients-Reported Outcomes in Athletes Performing Exercise Therapy for Patellar Tendinopathy: A Secondary Analysis of the JUMPER Study.

BACKGROUND: Physical tests are commonly used in patellar tendinopathy to aid the clinical diagnosis, assess the prognosis, and monitor treatment. However, it is still unknown whether these physical measures are associated with patient-reported outcomes after exercise therapy. PURPOSE: To identify the prognostic value of baseline physical test results and to determine the association between physical response after exercise therapy and clinical improvement over 24 weeks. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study recruited 76 consecutive athletes with patellar tendinopathy who were randomized to 2 different programs of exercise therapy for 24 weeks. Athletes underwent a range of physical tests before and during exercise therapy (12 and 24 weeks), including isometric muscle strength (quadriceps and hip abductors), muscle flexibility (quadriceps, hamstrings, soleus, and gastrocnemius), vertical jump height, and visual analog scale (VAS) scores by palpation, after 3 jump trials, and after single-leg squat (VAS-SLS). The Victorian Institute of Sports Assessment-Patella (VISA-P) questionnaire was used as the primary patient-reported outcome. Linear mixed-effect models were used to assess the prognostic value of baseline physical tests. The change in VISA-P score was further dichotomized into clinical responsiveness (≥14 points) and nonresponsiveness (<14 points). Multiple linear and logistic regression models were performed to evaluate associations between physical response and clinical improvement. RESULTS: Of the 76 included patients, 67 (88%) had complete follow-ups. The estimated mean VISA-P score increased by 23 points (95% CI, 19-28 points) after 24 weeks. No association was found between any baseline physical test results and a 24-week change in VISA-P score (all Pinteraction > .2, using the likelihood ratio test). Improvement in VAS-SLS after exercise therapy was not associated with VISA-P improvement after adjustment (ß = -1.76; P = .01; Bonferroni-corrected P = .10; R2 = 36.3%). No associations were found between changes in other physical test results and clinical improvement (all P > .05). CONCLUSION: In patients with patellar tendinopathy, physical test results including strength and flexibility in the lower limb, jump performance, and pain levels during pain-provoking tests were not identified as prognostic factors for patient-reported outcomes after exercise therapy. Similarly, changes in physical test results were not associated with changes in patient-reported outcomes after adjustments. These results do not support using physical test results to estimate prognosis or monitor treatment response. REGISTRATION: NCT02938143 (ClinicalTrials.gov identifier).

TENDINopathy Severity Assessment - Achilles (TENDINS-A): Development and Content Validity Assessment of a New Patient-Reported Outcome Measure for Achilles Tendinopathy.

OBJECTIVE: To develop a new patient-reported outcome measure (PROM) assessing TENDINopathy Severity of the Achilles (TENDINS-Achilles) and evaluate its content validity. DESIGN: Mixed-methods, modified Delphi. METHODS: We performed 1 round of semistructured one-on-one interview responses with professionals and patients, for initial item generation. This was followed by 1 round of survey responses for professionals and a final round of semistructured one-on-one interviews with patients. The work culminated in a PROM to quantify Achilles tendinopathy severity under the core health domain of disability. Participants identified 3 subdomains contributing to the severity of disability of Achilles tendinopathy: pain, symptoms, and functional capacity. RESULTS: All 8 patient participants invited to participate were enrolled. Forty professional participants (50% women, six different continents) were invited to participate and 30 were enrolled (75% response rate). Therefore, a total of 30 professionals and 8 patients were included within this study. Following 3 rounds of qualitative or quantitative feedback, this study has established the content validity of TENDINS-A (good relevance, comprehensibility, and comprehensiveness) as a new PROM to assess the severity of Achilles tendinopathy, which assesses aspects of pain, symptoms, and functional capacity. CONCLUSION: TENDINS-A has established content validity and is appropriate for use with clinical and research populations. We recommend users interpret TENDINS-A results cautiously, until further testing evaluates the most appropriate scoring scale, reliability, construct validity, criterion validity, and responsiveness of TENDINS-A. Until these psychometric properties are established, we suggest using TENDINS-A alongside existing tools. J Orthop Sports Phys Ther 2023;53(11):1-16. Epub: 24 August 2023. doi:10.2519/jospt.2023.11964.

Do physical tests have a prognostic value in chronic midportion Achilles tendinopathy?

OBJECTIVES: To determine whether baseline physical tests have a prognostic value on patient-reported outcomes in Achilles tendinopathy. DESIGN: Prospective cohort study, secondary analysis of data from a randomized trial. METHODS: Patients with chronic midportion Achilles tendinopathy performed a progressive calf muscle exercise program. At baseline and after 2, 6, 12 and 24 weeks, patients completed the Victorian Institute of Sports Assessment-Achilles questionnaire and performed the following physical tests: ankle dorsiflexion range of motion with a bent knee or an extended knee, calf muscle strength, jumping height and pain on palpation (Visual Analogue Scale; 0-100) and after 10 hops (Visual Analogue Scale-10-hops). Associations between baseline test results and improvement (Victorian Institute of Sports Assessment-Achilles scores) were determined using a Mixed Linear Model. RESULTS: 80 patients were included. The mean Victorian Institute of Sports Assessment-Achilles score improved 20 points (95 % confidence interval, 16-25, P < .001) after 24 weeks. There were significant associations between the baseline ankle dorsiflexion range of motion with a bent knee (ß 0.2, 95 % confidence interval 0.001 to 0.3, P = .049), the baseline pain provocation tests (Visual Analogue Scale palpation: ß -0.2; 95 % confidence interval: -0.4 to -0.1; P < .001, Visual Analogue Scale-10-hops: ß -0.3; 95 % confidence interval: -0.4 to -0.2; P < .001) and the change in the Victorian Institute of Sports Assessment-Achilles score. CONCLUSIONS: In patients with chronic midportion Achilles tendinopathy, easy-to-perform pain provocation tests have a clinically relevant prognostic value on patient-reported improvement. Patients with less pain during pain provocation tests at baseline have a better improvement in pain, function and activities after 24 weeks than patients with high baseline pain scores.

Terminating Corticosteroid Injection in Tendinopathy? Hasta la Vista, Baby.

SYNOPSIS: Two recent randomized-controlled trials showed promising results of local corticosteroid injections combined with exercise therapy for Achilles tendinopathy and plantar fasciopathy. Should clinicians go back to using corticosteroid injections to treat tendinopathy? Are corticosteroids back (baby)? In this viewpoint we critically appraise the new evidence and humbly share our clinical reasoning when advising athletes about corticosteroid injections in practice. Our goal is to help clinicians decide what to do and what to recommend to patients. We prioritize the risk for higher recurrence rates and tendon rupture when weighing the reasonable treatment options for tendinopathy, and recommend against using corticosteroid injections. The best systematic review evidence shows that local corticosteroid injections are not effective for tendinopathies after the first few weeks, and produce worse long-term outcomes compared to other treatments. For now, we consider corticosteroid injections remain terminated. J Orthop Sports Phys Ther 2023;53(11):1-4. Epub: 28 July 2023. doi:10.2519/jospt.2023.11875.

Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis.

BACKGROUND: Ankle osteoarthritis is debilitating and usually affects relatively young people, often as a result of previous ankle traumas, frequently occurring in sports. Platelet-rich plasma (PRP) injections for ankle osteoarthritis have shown no evidence of benefit over the course of 26 weeks. Previous studies on PRP for knee osteoarthritis showed that clinically significant improvements with PRP occurred between 6 to 12 months in the absence of initial benefit. No studies have evaluated the effect of PRP from 6 to 12 months in ankle osteoarthritis. PURPOSE: To assess the efficacy of PRP injections in ankle osteoarthritis over the course of 52 weeks. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In this 52-week follow-up trial, 100 patients with ankle osteoarthritis were randomized to a PRP group or placebo (saline) group. Patients received 2 intra-articular talocrural injections: at inclusion and after 6 weeks. Patient-reported outcome measures were used to assess pain, function, quality of life, and indirect costs over 52 weeks. RESULTS: Two patients (2%) were lost to follow-up. The adjusted between-group difference for the patient-reported American Orthopaedic Foot & Ankle Society score over 52 weeks was -2 points (95% CI, -5 to 2; P = .31) in favor of the placebo group. No significant between-group differences were observed for any of the secondary outcome measures. CONCLUSION: For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections. REGISTRATION: NTR7261 (Netherlands Trial Register).

Factors Associated With Running-Related Injuries in Recreational Runners With a History of Running Injuries.

OBJECTIVE: To identify the incidence and characteristics associated with a higher injury risk in recreational runners who suffered a running-related injury (RRI) in the previous 12 months. DESIGN: Prospective cohort study among recreational runners who registered for a Dutch running event (5-42.2 km) and suffered an RRI in the 12 months before inclusion. SETTING: Open population. PARTICIPANTS: Recreational runners with a previous reported injury. ASSESSMENT OF RISK FACTORS: At baseline, information on demographics, training characteristics, health complaints, and RRI history was collected. MAIN OUTCOME MEASURES: With 3 follow-up questionnaires (2 weeks before, 1 day after, and 1 month after the running event), the occurrence of new RRIs was registered. RESULTS: In total, 548 participants (55.1%) sustained a new RRI during follow-up. In total, 20.5% of the new RRIs was located at the same anatomical location as the previous RRI. Runners who registered for a marathon had a higher chance to sustain a new RRI [odd ratio (OR) 1.72; 95% confidence intervals (CIs), 1.17-2.53]. Also previous RRIs in the upper leg (OR 1.59; 95% CI, 1.15-2.19) and lower leg (OR 1.61; 95% CI, 1.18-2.21) were associated with an increased injury risk. CONCLUSIONS: Especially being a marathon runner and the anatomical location of previous RRIs seem to be associated with the injury risk in recreational runners with a previous RRI.

Risk Factors for Musculoskeletal Injury in CrossFit: A Systematic Review.

The objective of this systematic review was to identify potential risk factors for injury in CrossFit participants. Embase, Medline, Web of Science, Cochrane, CINAHL, Google Scholar, and SportDiscuss databases were all searched up to June 2021. Cohort studies that investigated risk factors for CrossFit injuries requiring medical attention or leading to time loss in sports were included. A best-evidence synthesis was performed combining all the outcomes from prospective cohort studies. From 9,452 publications identified, we included three prospective cohort studies from which two had a low risk of bias and one a high risk of bias. The studies examined 691 participants of whom 172 sustained an injury. There was limited evidence that switching between prescribed and scaled loads during training is associated with increased injury risk and that increased duration of participation is a protective factor for injury. This could mean that novice CrossFit athletes and those increasing their training load should have closer supervision by CrossFit coaches. These risk factors should be considered when developing preventive interventions.

Pathways driving tendinopathy and enthesitis: siblings or distant cousins in musculoskeletal medicine?

Tendinopathy and enthesitis share clinical, anatomical, and molecular parallels. However, their relationship is complex, presenting challenges in diagnosis and treatment. The biomechanics underlying these pathologies, together with relative immune and stromal contributions to pathology, are characterised by crucial comparative elements. However, methodologies used to study enthesitis and tendinopathy have been divergent, which could account for discrepancies in how these conditions are perceived and treated. In this Review, we summarise key clinical parallels between these two common presentations in musculoskeletal medicine and address factors that currently preclude development of more effective therapeutics. Furthermore, we describe molecular similarities and disparities that govern pathological mechanisms in tendinopathy and enthesitis, thus informing translational studies and treatment strategies.

Accelerated menopausal changes as human disease model 'FOCUM' for the development of osteoarthritis and other degenerative disorders: protocol for a prospective cohort study.

INTRODUCTION: The incidence of degenerative disorders, including osteoarthritis (OA), increases rapidly in women after menopause. However, the influence of the menopause is still insufficiently investigated due to the slowness of menopausal transition. In this study, a novel human model is used in which it is expected that menopausal-related changes will occur faster. This is the Females discontinuing Oral Contraceptives Use at Menopausal age model. The ultimate aim is to link these changes to OA and other degenerative disorders, including cardiovascular diseases, diabetes, osteoporosis and tendinopathies. METHODS AND ANALYSIS: This is a pilot observational prospective cohort study with 2 years of follow-up. Fifty women aged 50-60 who use oral contraceptive (OC) and have the intention to stop are included. Measurements are performed once before stopping OC, and four times thereafter at 6 weeks, 6 months, 1 year and 2 years. At every time point, a questionnaire is filled in and a sample of blood is drawn. At the first and final time points, a physical examination, hand radiographs and a MRI scan of one knee are performed. The primary OA outcome is progression of the MRI Osteoarthritis Knee Score. Secondary OA outcomes are the development of clinical knee and hand OA, development of knee OA according to the MRI definition, and progression of radiographic features for hand OA. Principal component analysis will be used to assess which changes occur after stopping OC. Univariate and multivariate generalised estimating equation models will be used to test for associations between these components and OA. ETHICS AND DISSEMINATION: The study has been approved by the Medical Ethics Committee of the Erasmus MC University Medical Center Rotterdam (MEC-2019-0592). All participants must give informed consent before data collection. Results will be disseminated in national and international journals. TRIAL REGISTRATION NUMBER: NL70796.078.19.

Do High-Volume Injections Affect the Ultrasonographic Neovascularization in Chronic Achilles Tendinopathy? A Randomized Placebo-Controlled Clinical Trial.

OBJECTIVE: High-volume injections (HVIs) are thought to target neovascularization in chronic midportion Achilles tendinopathy (AT), yet the mechanism has not been clarified. Therefore, we aim to evaluate whether a HVI decreases ultrasonographic Doppler flow in patients with chronic midportion AT. DESIGN: A double-blind, randomized, placebo-controlled clinical trial. SETTING: Sports medicine department at a district general hospital. PATIENTS: Sixty-two patients with clinically diagnosed chronic midportion AT were included and randomized into the intervention group (HVI-group, n = 30) and placebo group (n = 32). INTERVENTION: A daily calf-muscle exercise program combined with either (1) a HVI (HVI-group: 50 mL) or (2) a placebo-injection (placebo-group: 2 mL) with a mixture of saline and lidocaine. MAIN OUTCOME MEASURES: Primary outcome was the surface area quantification (SAQ) score (%) of the Doppler flow during a 24-week follow-up period. Secondary outcome was the association between SAQ scores and symptoms [Victorian Institute of Sports Assessment-Achilles (VISA-A)]. Outcomes were measured before, directly after, and 1 hour after the injection and at 2, 6, 12, and 24 weeks of follow-up. RESULTS: There was no significant between-group difference at 24 weeks [-0.1%; 95% confidence interval (CI), -4.9 to 4.7] or at any of the other time points. Change in SAQ score did not correlate with the change in VISA-A score (P = 0.93). CONCLUSION: A HVI does not affect Doppler flow in patients with chronic midportion AT. Also, changes in Doppler flow were not associated with the clinical outcome. These findings challenge the theoretical basis of a HVI. TRIAL REGISTRATION: NCT02996409.

Feasibility and usability of GPS data in exploring associations between training load and running-related knee injuries in recreational runners.

BACKGROUND: The purpose of the present study was to explore the feasibility of collecting GPS data and the usability of GPS data to evaluate associations between the training load and onset of running-related knee injuries (RRKIs). METHODS: Participants of the INSPIRE-trial, a randomized-controlled trial on running injury prevention, were asked to participate in this study. At baseline, demographic variables were collected. Follow-up questionnaires assessed information on RRKIs. Participants with a new reported RRKI and uninjured participants were sent a GPS export request. Weekly GPS-based training distances were used to calculate Acute:Chronic Workload Ratios (ACWRs). RESULTS: A total of 240 participants (62.7%) tracked their running training sessions with the use of a GPS-enabled device or platform and were willing to share their GPS data. From the participants (N = 144) who received a GPS export request, 50.0% successfully shared their data. The majority (69.4%) of the shared GPS data were usable for analyses (N = 50). GPS data were used to present weekly ACWRs of participants with and without an RRKI eight weeks prior to RRKI onset or running event. CONCLUSIONS: It seems feasible to collect GPS data from GPS-enabled devices and platforms used by recreational runners. The results indicate that GPS data is usable to calculate weekly ACWRs to evaluate associations between training load and onset of RRKIs in recreational runners. Therefore, GPS-based ACWR measures can be used for future studies to evaluate associations between training load and onset of RRIs.

Educational online prevention programme (the SPRINT study) has no effect on the number of running-related injuries in recreational runners: a randomised-controlled trial.

OBJECTIVES: The aim of this study was to examine the effectiveness of an enhanced online injury prevention programme on the number of running-related injuries (RRIs) in recreational runners. METHODS: We conducted a randomised-controlled trial in runners who registered for running events (distances: 10-42.195 km) in the Netherlands. Adult runners who provided informed consent were randomised into the intervention or control group. Participants in the intervention group received access to the online prevention programme, which included items to prevent RRIs. Participants in the control group followed their regular preparation for the running event. The primary outcome measure was the number of new RRIs from baseline to 1 month after the running event. To determine differences between injury proportions, univariate and multivariate logistic regression analyses were performed. RESULTS: This study included 4050 recreational runners (63.5% males; mean (SD) age: 42.3 (12.1) years) for analyses. During follow-up, 35.5% (95% CI: 33.5 to 37.6) of the participants in the intervention group sustained a new RRI compared with 35.4% (95% CI: 33.3 to 37.5) of the participants in the control group, with no between-group difference (OR: 1.03; 95% CI: 0.90 to 1.17). There was a positive association between the number of items followed in the injury prevention programme and the number of RRIs (OR: 1.05; 95% CI: 1.00 to 1.11). CONCLUSION: The enhanced online injury prevention programme had no effect on the number of RRIs in recreational runners, and being compliant with the programme paradoxically was associated with a slightly higher injury rate. Future studies should focus on individual targeted prevention with emphasis on the timing and application of preventive measures. TRIAL REGISTRATION NUMBER: NL7694.