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.

Where is Your Pain? Achilles Tendinopathy Pain Location on Loading Is Different to Palpation, Imaging and Recall Location.

OBJECTIVE: To describe and compare pain maps reported during Achilles tendon loading exercises with recall pain location, in people with pain on palpation in their Achilles tendon and tendon pathology on imaging. DESIGN: Cross-sectional analysis of baseline RCT. METHOD: Participants were recruited from a larger Achilles tendinopathy clinical trial. Inclusion criteria were at least 2-month self-reported history of Achilles tendinopathy, midtendon palpation pain, and pathology on ultrasound tissue characterization. Participants were asked to identify their Achilles tendon pain location on a pain map with 8 prespecified locations while at rest prior to loading (recall pain), and subsequently during tendon loading exercises (loading pain). Participants could select multiple locations or select "other" if the locations did not represent their pain. RESULTS: Ninety-three participants were included (93% of participants from a clinical trial). The locations of pain on loading were diverse; all 8 pain locations (and an "other" option) were represented within this sample. Twenty-five percent of participants did not report pain with loading (n = 23 of 93). Of the 70 participants with loading pain, recall pain location differed to loading pain location in 40% (n = 28 of 70) of the participants. CONCLUSION: Palpation pain location, recall pain location, or location of pathology on imaging were not valid proxies for load-related pain in the Achilles tendon. How different pain locations respond to treatment is unknown. Some pathologies (eg, plantaris) have clear pain locations (eg, medial tendon), and assessing pain location may assist differential diagnosis. J Orthop Sports Phys Ther 2024;54(1):1-9. Epub 7 December 2023. doi:10.2519/jospt.2023.12131.

Warming-up for the Latest on Diagnosing and Managing Tendinopathy.

SYNOPSIS: JOSPT is starting 2024 on a high, with a tendinopathy-focused edition that showcases more of the high-quality tendinopathy research you know and love in systematic reviews, original research articles, a consensus paper, and editorials. As any athlete knows, a good warm-up is crucial to performing well at the main event. Here, we help you warm up and prime your brain to take on all the content of this tendinopathy-focused issue of the Journal. J Orthop Sports Phys Ther 2024;54(1):1-2. Epub 5 December 2023. doi:10.2519/jospt.2023.12440.

The Tendinopathy Game Changers: Five Papers From the Last 5 Years That Might Change How You Manage Tendons.

SYNOPSIS: The clinical and scientific understanding of tendinopathy has substantially advanced since the Fifth International Scientific Tendinopathy Symposium in 2019. This editorial aims to highlight some of the fantastic tendinopathy research from the past 5 years. We have selected what we consider the "best paper" for each year from 2019 to 2023, which might change how you treat tendons. Selecting only 5 papers was not easy. Did your favorite papers make the cut? Or do you think we missed some key studies? We encourage you to tell us what you think using the social media hashtag #JOSPTtendon. J Orthop Sports Phys Ther 2024;54(1):1-3. Epub 16 November 2023. doi:10.2519/jospt.2023.12372.

Does lower-limb osteoarthritis alter motor cortex descending drive and voluntary activation? A systematic review and meta-analysis.

Purpose: The aim of the study was to quantify motor cortex descending drive and voluntary activation (VA) in people with lower-limb OA compared to controls. Methods: A systematic review and meta-analysis according to the PRISMA guidelines was carried out. Seven databases were searched until 30 December 2022. Studies assessing VA or responses to transcranial magnetic stimulation (TMS; i.e. motor evoked potential, intracortical facilitation, motor threshold, short-interval intracortical inhibition, and silent period) were included. Study quality was assessed using Joanna Briggs Institute criteria and evidence certainty using GRADE. The meta-analysis was performed using RevMan inverse variance, mixed-effect models. Results: Eighteen studies were included, all deemed low-quality. Quadriceps VA was impaired with knee OA compared to healthy controls (standardised mean difference (SMD) = 0.84, 95% CI = -1.12-0.56, low certainty). VA of the more symptomatic limb was impaired (SMD = 0.42, 95% CI = -0.75-0.09, moderate certainty) compared to the other limb in people with hip/knee OA. As only two studies assessed responses to TMS, very low-certainty evidence demonstrated no significant difference between knee OA and healthy controls for motor evoked potential, intracortical facilitation, resting motor threshold or short-interval intracortical inhibition. Conclusions: Low-certainty evidence suggests people with knee OA have substantial impairments in VA of their quadriceps muscle when compared to healthy controls. With moderate certainty we conclude that people with hip and knee OA had larger impairments in VA of the quadriceps in their more painful limb compared to their non-affected/other limb.

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.

Hip rotation muscle strength is implicated in the progression of early post-traumatic osteoarthritis: A longitudinal evaluation up to 5 years following ACL reconstruction.

INTRODUCTION: Following ACL reconstruction (ACLR), deficits in hip muscle strength and relationships to future outcomes are unknown. METHODS: 111 participants one year after ACLR, completed hip external rotation (ER) and internal rotation (IR) strength assessment. At 1 (n = 111) and 5 (n = 74) years post-ACLR, participants completed a battery of functional, symptomatic (Knee Osteoarthritis Outcome Score (KOOS)) and structural assessments (radiography, magnetic resonance imaging (MRI)). Cartilage health of the patellofemoral and tibiofemoral compartments was assessed with the semiquantitative MRI Osteoarthritis Knee Score. Hip rotation strength was compared between-limbs, and relationships between hip strength at 1 year and functional, symptomatic and cartilage outcomes at 1 and 5 years were investigated with regression models. RESULTS: The index (ACLR) limb had weaker hip ER (but not IR) strength compared to the contralateral side (standardised mean difference ER = -0.33 (95%CI -0.60, -0.07; IR = -0.11 (95%CI -0.37, 0.15). Greater hip ER and IR strength was associated with superior function at 1 and 5 years, and better KOOS-Patellofemoral symptoms at 5 years. Greater hip ER strength was associated with lower odds of worsening tibiofemoral cartilage lesions at 5 years (odds ratio 0.01, 95%CI 0.00, 0.41). CONCLUSION: Hip rotation strength may play a role in worsening function, symptoms and cartilage health after ACLR.

Efficacy of Telehealth for Movement-Evoked Pain in People With Chronic Achilles Tendinopathy: A Noninferiority Analysis.

OBJECTIVE: The purpose of this study was to compare the efficacy of physical therapy delivered via an all telehealth or hybrid format with an all in-person format on movement-evoked pain for individuals with chronic Achilles tendinopathy (AT). METHODS: Sixty-six individuals with chronic AT participated (age, 43.4 [SD = 15.4] years; 56% female; body mass index, 29.9 [SD = 7.7] kg/m2). Participants completed all in-person visits from the initiation of recruitment in September 2019 to March 16, 2020 (in-person group). From March 17 to July 15, 2020, participants completed all telehealth visits (telehealth group). From July 16, 2020, to enrollment completion in December 2020, participants could complete visits all in-person, all telehealth, or a combination of in-person and telehealth (hybrid group) based on their preference. A physical therapist provided 6 to 7 visits, including an exercise program and patient education. Noninferiority analyses of the telehealth and hybrid groups compared with the in-person group were completed for the primary outcome of movement-evoked pain during single-limb heel raises. RESULTS: All groups demonstrated decreases in movement-evoked pain beyond the minimal clinically important difference from baseline to 8 weeks (2 out of 10 on a numeric pain rating scale). Lower bounds of the 95% CIs for mean differences between groups did not surpass the preestablished noninferiority margin (2 out of 10) for movement-evoked pain in both the telehealth and hybrid groups (telehealth vs in-person: 0.45 [-1.1 to 2.0]; hybrid vs in-person: 0.48 [-1.0 to 1.9]). CONCLUSION: Individuals with chronic AT who completed a tendon-loading program with patient education through a telehealth or hybrid format had no worse outcomes for pain than those who received the same intervention through in-person visits. IMPACT: Physical therapist-directed patient care delivered via telehealth may enhance accessibility to best practice AT rehabilitation, including exercise and education. Use of telehealth technology may also provide an opportunity to prioritize patient preference for physical therapy visit format. LAY SUMMARY: If you are a patient with chronic AT, physical therapist-directed patient care delivered via telehealth may improve your accessibility to best practice AT rehabilitation, including exercise and education. Use of telehealth technology may also prioritize your preferences regarding the format of the physical therapy visit.

Can we really say getting stronger makes your tendon feel better? No current evidence of a relationship between change in Achilles tendinopathy pain or disability and changes in Triceps Surae structure or function when completing rehabilitation: A systematic review.

OBJECTIVES: Determine if improvements in pain and disability in patients with mid-portion Achilles tendinopathy relate to changes in muscle structure and function whilst completing exercise rehabilitation. DESIGN: A systematic review exploring the relationship between changes in pain/disability and muscle structure/function over time, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS: Six online databases and the grey literature were searched from database inception to 16th December 2022 whereas clinical trial registries were searched from database inception to 11th February 2020. We included clinical studies where participants received exercise rehabilitation (±placebo interventions) for mid-portion Achilles tendinopathy if pain/disability and Triceps Surae structure/function were measured. We calculated Cohen's d (95 % confidence intervals) for changes in muscle structure/function over time for individual studies. Data were not pooled due to heterogeneity. Study quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS: Seventeen studies were included for synthesis. No studies reported the relationship between muscle structure/function and pain/disability changes. Twelve studies reported muscle structure/function outcome measures at baseline and at least one follow-up time-point. Three studies reported improvements in force output after treatment; eight studies demonstrated no change in structure or function; one study did not provide a variation measure, precluding within group change over time calculation. All studies were low quality. CONCLUSIONS: No studies explored the relationship between changes in tendon pain and disability and changes in muscle structure and function. It is unclear whether current exercise-based rehabilitation protocols for mid-portion Achilles tendinopathy improve muscle structure or function. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (registration number: CRD42020149970).

The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial.

ABSTRACT: Exercise is the standard of care for Achilles tendinopathy (AT), but 20% to 50% of patients continue to have pain following rehabilitation. The addition of pain science education (PSE) to an exercise program may enhance clinical outcomes, yet this has not been examined in patients with AT. Furthermore, little is known about how rehabilitation for AT alters the fear of movement and central nervous system nociceptive processing. Participants with chronic AT (N = 66) were randomized to receive education about AT either from a biopsychosocial (PSE) or from a biomedical (pathoanatomical education [PAE]) perspective. Simultaneously, all participants completed an exercise program over 8 weeks. Linear mixed models indicated that there were no differences between groups in (1) movement-evoked pain with both groups achieving a clinically meaningful reduction (mean change [95% CI], PSE: -3.0 [-3.8 to -2.2], PAE = -3.6 [-4.4 to -2.8]) and (2) self-reported function, with neither group achieving a clinically meaningful improvement (Patient-Reported Outcomes Measurement Information System Physical Function-PSE: 1.8 [0.3-3.4], PAE: 2.5 [0.8-4.2]). After rehabilitation, performance-based function improved (number of heel raises: 5.2 [1.6-8.8]), central nervous system nociceptive processing remained the same (conditioned pain modulation: -11.4% [0.2 to -17.3]), and fear of movement decreased (Tampa Scale of Kinesiophobia, TSK-17: -6.5 [-4.4 to -8.6]). Linear regression models indicated that baseline levels of pain and function along with improvements in self-efficacy and knowledge gain were associated with a greater improvement in pain and function, respectively. Thus, acquiring skills for symptom self-management and the process of learning may be more important than the specific educational approach for short-term clinical outcomes in patients with AT.

Fifteen minutes of high intensity running can impair performance on concussion testing; Implications for on-field diagnosis in sport.

OBJECTIVES: To examine the effects of 15 min of high intensity treadmill running on concussion testing assessed by the King-Devick test. DESIGN: Prospective Cohort Study. METHODS: Participants self-selected to either a running or a control group. At baseline both groups were assessed using the King-Devick concussion test. The running group then completed 15-minutes of treadmill running at rating of perceived exertion of 7-9/10 while the control group sat quietly. Both groups repeated the King-Devick test following that 15-minute period. RESULTS: Participants (n = 84 men, 53 women) were divided in two groups; running or control. Both groups, on average, had significant improvement after 15 min (suggesting a learning effect). Comparisons between the baseline and re-assessment scores indicated impaired performance was more common following high intensity treadmill running (n = 23 participants, 34.3%) compared to the control group (n = 10 participants, 14.3%, p = 0.006, OR = 3.44 [95%CI 1.40-8.50]). Four participants in the running group worsened their score at reassessment by more than 3 s compared to no participants in the control group. CONCLUSIONS: After 15 min of high intensity treadmill running, 1 in 3 participants scored a slower time at follow-up or committed a mistake compared to baseline. Implications for clinical practise include: the recommendation that baseline tests be conducted at rest and after high intensity exercise to provide accurate comparisons to assist in clinical decision making; and a cut-off of >3 s may be a clinically useful difference between resting baseline and re-assessment using the King-Devick test.

The relationship between kinesiophobia and self-reported outcomes and physical function differs between women and men with femoroacetabular impingement syndrome.

BACKGROUND: There is no evidence whether kinesiophobia affects women and men with femoroacetabular impingement (FAI) syndrome differently. OBJECTIVE: To explore the association between kinesiophobia, quality of life (QoL), pain, and physical function in people with FAI syndrome, and to compare the level of kinesiophobia between women and men with FAI syndrome. METHODS: One-hundred-fifty participants with FAI syndrome (51% women) completed assessment of the following: kinesiophobia with the Tampa Scale for Kinesiophobia; patient reported outcome measures (PROMs) (pain, physical function, health- and hip-related QoL); physical function (side bridge, hop for distance, and one leg rise); and active hip range of motion (flexion, external rotation, internal rotation). RESULTS: Greater kinesiophobia was correlated with worse hip-related QoL (rho=-0.58; p<0.001), self-reported physical function (rho=-0.42; p<0.001), health-related QoL (rho=-0.46; p<0.001), and pain levels (rho=-0.46; p<0.001). In women, kinesiophobia was also associated with worse physical function (hop for distance r=-0.38; p=0.001 and side bridge rho=-0.24; p=0.036) explaining 36% of the variation of the hip-related QoL, 29% of the health-related QoL, and 27% of the self-reported physical function. In men, kinesiophobia explained 35%, 12%, and 10%, respectively. CONCLUSION: In people with FAI syndrome, greater kinesiophobia was associated with worse PROMs, but not with hip range of motion. No sex-related differences in mean kinesiophobia scores were found. In women, an association was found between kinesiophobia and worse performance in physical tests. These findings might indicate that kinesiophobia plays a more important role in the clinical presentation of women with FAI syndrome than men.

Implicit Motor Imagery of the Foot and Hand in People with Achilles Tendinopathy: A Left Right Judgement Study.

OBJECTIVE: To determine if impairment in motor imagery processes is present in Achilles tendinopathy (AT), as demonstrated by a reduced ability to quickly and accurately identify the laterality (left-right judgement) of a pictured limb. Additionally, this study aimed to use a novel data pooling approach to combine data collected at 3 different sites via meta-analytical techniques that allow exploration of heterogeneity. DESIGN: Multi-site case-control study. METHODS: Three independent studies with similar protocols were conducted by separate research groups. Each study-site evaluated left/right judgement performance for images of feet and hands using Recognise© software and compared performance between people with AT and healthy controls. Results from each study-site were independently collated, then combined in a meta-analysis. RESULTS: In total, 126 participants (40 unilateral, 22 bilateral AT cases, 61 controls) were included. There were no differences between AT cases and controls for hand image accuracy and reaction time. Contrary to the hypothesis, there were no differences in performance between those with AT and controls for foot image reaction time, however there were conflicting findings for foot accuracy, based on four separate analyses. There were no differences between the affected and unaffected sides in people with unilateral AT. CONCLUSIONS: Impairments in motor imagery performance for hands were not found in this study, and we found inconsistent results for foot accuracy. This contrasts to studies in persistent pain of limbs, face and knee osteoarthritis, and suggests that differences in pathoetiology or patient demographics may uniquely influence proprioceptive representation.

Does isometric exercise result in exercise induced hypoalgesia in people with local musculoskeletal pain? A systematic review.

OBJECTIVE: The aim of this review was to investigate if exercise induced hypoalgesia (EIH) occurs following isometric muscle contraction in people with local musculoskeletal symptoms. DESIGN: Systematic review. DATA SOURCES: MEDLINE, EMBASE, CINAHL & SportDiscus electronic databases were searched (inception to April 2020). ELIGIBILITY CRITERIA: Two authors independently evaluated eligibility. Randomised controlled and crossover (repeated measures) trials that measured the effects of isometric exercise in participants with localised musculoskeletal pain during, and up to 2 hours after isometric exercise were included. Other inclusion criteria included comparison to another intervention, or comparison to healthy controls. Primary outcomes were experimentally induced pain thresholds and secondary outcomes included measures of pain sensitivity from clinical testing. RESULTS: 13 studies with data from 346 participants were included for narrative synthesis. EIH was reported in some upper and lower limb studies but there were no consistent data to show isometric exercises were superior to comparison interventions. CONCLUSION: There was no consistent evidence for EIH following isometric exercise in people with musculoskeletal pain. These findings are different to those reported in asymptomatic populations (where EIH is consistently demonstrated) as well as conditions associated with widespread symptoms such as fibromyalgia (where isometric exercise may induce hyperalgesia). Although well tolerated when prescribed, isometric exercise did not induce EIH consistently for people seeking care for local musculoskeletal symptoms. The variance in the dose, location of contraction and intensity of protocols included in this review may explain the inconsistent findings. Further work is required to better understand endogenous analgesia in musculoskeletal pain conditions.

Do people with unilateral mid-portion Achilles tendinopathy who participate in running-related physical activity exhibit a meaningful conditioned pain modulation (CPM) effect: a pilot study.

OBJECTIVES: Our primary objective was to report the presence of a conditioned pain modulation (CPM) effect in people with localised mid-portion Achilles tendinopathy and whether changes occur over a 12-week period. Our secondary objectives were to quantify the proportion of participants who present for tendinopathy research with previous interventions or co-morbidities, which may impact the CPM-effect and investigate modulating factors. DESIGN: Prospective, observational cohort pilot study. METHOD: 215 participants presented for this Achilles tendinopathy research and were screened for inclusion with nine being included. Included participants had the CPM-effect (cold-pressor test) assessed using pressure pain thresholds at the Achilles tendon and quantified as absolute, relative and meaningful change at baseline and 12-week follow-up. RESULTS: The most common reasons for exclusion were failure to meet a load-related diagnosis for Achilles tendinopathy (15.5%), presence of confounding other injury (14.1%) and previous injection therapy (13.6%). All participants had a meaningful CPM-effect at baseline and 12-week follow-up. The mean (SD, n) baseline relative CPM effect (reduction in PPTs) was -40.5 (32.7, 9) percent. Moderators of the CPM-effect as well as follow-up changes were not statistically analysed due to a small sample size. CONCLUSION: Based on these data, we would suggest that a homogenous population of patients with chronic, unilateral mid-portion Achilles tendinopathy and no other co-morbidities are likely to exhibit a meaningful CPM-effect. Impairments to endogenous analgesic mechanisms seen in people presenting with mid-portion Achilles tendinopathy may be due to other confounding variables.

Effect of Pain Education and Exercise on Pain and Function in Chronic Achilles Tendinopathy: Protocol for a Double-Blind, Placebo-Controlled Randomized Trial.

BACKGROUND: Achilles tendinopathy (AT) rehabilitation traditionally includes progressive tendon loading exercises. Recent evidence suggests a biopsychosocial approach that incorporates patient education on psychosocial factors and mechanisms of pain can reduce pain and disability in individuals with chronic pain. This is yet to be examined in individuals with AT. OBJECTIVE: This study aims to compare the effects on movement-evoked pain and self-reported function of pain education as part of a biopsychosocial approach with pathoanatomical education for people with AT when combined with a progressive tendon loading exercise program. METHODS: A single-site, randomized, double-blind, placebo-controlled clinical trial will be conducted in a university-based hospital in a laboratory setting and/or by telehealth. A total of 66 participants with chronic (>3 months) midportion or insertional AT will be randomized for the Tendinopathy Education of the Achilles (TEAch) study. All participants will complete progressive Achilles tendon loading exercises over 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. All participants will complete 6-7 one-to-one sessions with a physical therapist to progress exercises in a standardized manner over 8 weeks. During the last 4 weeks of the intervention, participants will be encouraged to maintain their home exercise program. Participants will be randomized to 1 of 2 types of education (pain education or pathoanatomic), in addition to exercise. Pain education will focus on the biological and psychological mechanisms of pain within a biopsychosocial framing of AT. Pathoanatomic education will focus on biological processes within a more traditional biomedical framework of AT. Evaluation sessions will be completed at baseline and 8-week follow-up, and self-reported outcome measures will be completed at the 12-week follow-up. Both groups will complete progressive Achilles loading exercises in 4 phases throughout the 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. Primary outcomes are movement-evoked pain during heel raises and self-reported function (patient-reported outcome measure information system-Physical Function). Secondary outcomes assess central nervous system nociceptive processing, psychological factors, motor function, and feasibility. RESULTS: Institutional review board approval was obtained on April 15, 2019, and study funding began in July 2019. As of March 2020, we randomized 23 out of 66 participants. In September 2020, we screened 267 individuals, consented 68 participants, and randomized 51 participants. We anticipate completing the primary data analysis by March 2022. CONCLUSIONS: The TEAch study will evaluate the utility of pain education for those with AT and the effects of improved patient knowledge on pain, physical function, and clinical outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19111.

Don't Assume the Control Group Is Normal-People with Asymptomatic Tendon Pathology Have Higher Pressure Pain Thresholds.

Objective: Pain pressure thresholds (PPT) are used to study peripheral and central pain processing. In the tendon, pathological changes may exist without pain. This pilot study aimed to compare PPT between individuals with normal tendons and asymptomatic tendon pathology, and between individuals with and without a history of tendon pain. Methods: The patellar, Achilles, and supraspinatus tendons of 128 asymptomatic participants were examined with ultrasound. Global PPT average was determined using a digital algometer at the patellar tendon, quadriceps muscle, L3 spinous process, and deltoid muscle insertion. Participants were separated into three groups: (1) healthy control group (no pathology, no history of pain), (2) tendon pathology at any site without a history of pain, (3) history of tendon pain anywhere. Results: There were 92 controls, seven with asymptomatic pathology and 29 with a history of tendon pain. Asymptomatic tendon pathology at any site (without a history of pain) was associated with globally increased PPTs compared with controls (P < 0.001, pathology N = 7, N = 92 controls). Matched pair analysis remained significant (P < 0.004). A history of tendon pain was associated with globally increased PPTs compared with the control group (P = 0.026). Matched pair analysis was not significant (P = 0.122). Conclusions: Asymptomatic tendon pathology is associated with higher PPTs. These findings point toward central nervous system adaptations but in a novel way-central desensitization. This challenges the validity of conclusions drawn from PPT studies that do not verify normal structure in the control group; artificial inflation of control group data may incorrectly indicate decreased PPTs in the comparison group.