Effect of a physiotherapy-directed rehabilitation programme on patients with multidirectional instability of the glenohumeral joint: a multimodal interventional MRI study protocol.

INTRODUCTION: Altered neuromuscular control of the scapula and humeral head is a typical feature of multidirectional instability (MDI) of the glenohumeral joint, suggesting a central component to this condition. A previous randomised controlled trial showed MDI patients participating in the Watson Instability Program 1 (WIP1) had significantly improved clinical outcomes compared with a general shoulder strength programme. The aim of this paper is to outline a multimodal MRI protocol to identify potential ameliorative effects of the WIP1 on the brain. METHODS AND ANALYSIS: Thirty female participants aged 18-35 years with right-sided atraumatic MDI and 30 matched controls will be recruited. MDI patients will participate in 24 weeks of the WIP1, involving prescription and progression of a home exercise programme. Multimodal MRI scans will be collected from both groups at baseline and in MDI patients at follow-up. Potential brain changes (primary outcome 1) in MDI patients will be probed using region-of-interest (ROI) and whole-brain approaches. ROIs will depict areas of functional alteration in MDI patients during executed and imagined shoulder movements (MDI vs controls at baseline), then examining the effects of the 24-week WIP1 intervention (baseline vs follow-up in MDI patients only). Whole-brain analyses will examine baseline versus follow-up voxel-wise measures in MDI patients only. Outcome measures used to assess WIP1 efficacy will include the Western Ontario Shoulder Index and the Melbourne Instability Shoulder Score (primary outcomes 2 and 3). Secondary outcomes will include the Tampa Scale for Kinesiophobia, Short Form Orebro, Global Rating of Change Score, muscle strength, scapular upward rotation, programme compliance and adverse events. DISCUSSION: This trial will establish if the WIP1 is associated with brain changes in MDI. ETHICS AND DISSEMINATION: Participant confidentiality will be maintained with publication of results. Swinburne Human Research Ethics Committee (Ref: 20202806-5692). TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trial Registry (ACTRN12621001207808).

Epidemiology of quadriceps muscle strain injuries in elite male Australian football players.

OBJECTIVE: To describe the epidemiology of quadriceps muscle strain injury (QMSI) in elite Australian Football League (AFL) players, explore recovery milestones and determine whether recovery is impacted by factors such as injury type (index vs. re-injury), the primary muscle injured and the mechanism of injury. MEASURES: All QMSI data reported to the Soft Tissue Injury Registry of the AFL from the 2014 to 2020 seasons were evaluated. Player demographic data, circumstances of injury, MRI reports and recovery outcomes following injury were extracted. Descriptive statistics and frequency distributions are presented. Recovery outcomes for injury type, primary muscle injured and the mechanism of injury were compared using univariate analyses. RESULTS: There were 164 QMSIs from 122 players reported (134 index; 30 re-injuries). Almost all (91.3%) QMSIs involved the rectus femoris. Half (48.4%) of the QMSIs occurred during kicking and most commonly affected the dominant kicking leg (72%). The majority occurred at training (64.6%). All re-injuries involved the rectus femoris, most occurred from kicking (63.0%) and within 6 months of the preceding injury (70%). The mean return to play (RTP) time was 25.4 days (95%CI = 22.6-28.2) and rectus femoris injuries took around 14 days longer to RTP than vastii injuries (p = 0.001). QMSIs with a kicking mechanism took the longest to RTP of all injury mechanisms. CONCLUSION: In AFL players, QMSIs occur mostly in the dominant leg from a kicking mechanism. Rectus femoris injuries are more prevalent and result in longer RTP time frames. Re-injuries exclusively involved the rectus femoris, primarily from kicking.

Traumatic muscle injury.

Traumatic muscle injury represents a collection of skeletal muscle pathologies caused by trauma to the muscle tissue and is defined as damage to the muscle tissue that can result in a functional deficit. Traumatic muscle injury can affect people across the lifespan and can result from high stresses and strains to skeletal muscle tissue, often due to muscle activation while the muscle is lengthening, resulting in indirect and non-contact muscle injuries (strains or ruptures), or from external impact, resulting in direct muscle injuries (contusion or laceration). At a microscopic level, muscle fibres can repair focal damage but must be completely regenerated after full myofibre necrosis. The diagnosis of muscle injury is based on patient history and physical examination. Imaging may be indicated to eliminate differential diagnoses. The management of muscle injury has changed within the past 5 years from initial rest, immobilization and (over)protection to early activation and progressive loading using an active approach. One challenge of muscle injury management is that numerous medical treatment options, such as medications and injections, are often used or proposed to try to accelerate muscle recovery despite very limited efficacy evidence. Another challenge is the prevention of muscle injury owing to the multifactorial and complex nature of this injury.

Effects of foot orthoses and footwear interventions on impairments and quality of life in people with hip pain: A systematic review.

BACKGROUND: Foot orthoses and footwear interventions are advocated for the management of lower limb musculoskeletal conditions including the hip, but much of the research is focused on knee disorders. The aim of this systematic review was to synthesise the literature that investigates the use of foot orthoses or footwear in people with hip-related pain. METHODS: MEDLINE, EMBASE, CINAHL, AMED and SPORTDiscus were searched from inception to March 2023. Randomised controlled trials (RCT), cohort and pre-post studies reporting on footwear and foot orthoses interventions, in participants with hip-related pain, were eligible for inclusion. Outcomes included pain, physical function, and quality of life (QoL). Effect sizes were calculated where sufficient data were available. Reporting quality was assessed using the Cochrane Risk of Bias Tool (Rob-2) and the Joanna Briggs Institute Checklist. The overall quality of evidence was rated according to the Grading of Recommendations, Assessment, Development, and Evaluations framework. RESULTS: Of the seven included studies (n = 266 participants), there was one RCT, one cohort and five single-group pre-post designs. Interventions included customised and non-customised arch supports, heel lifts, and footwear modifications, used in the following hip conditions: trochanteric pain, non-specific hip pain, hip osteoarthritis, and leg length dysfunction following total hip arthroplasty. Meta-analysis was possible for outcomes in two studies, demonstrating moderate improvement in pain following foot orthoses use. Overall certainty of evidence ranged from very low to low. CONCLUSION: Single-group pre-post study designs describe positive relationships between foot orthoses and footwear use and improvements in hip pain, function, and QoL. However, these results were not supported by the only available RCT. Given this is a relatively inexpensive and non-invasive treatment approach, further rigorous studies are warranted.

Quantifying demands on the hamstrings during high-speed running: A systematic review and meta-analysis.

INTRODUCTION: Hamstring strain injury (HSI) remains a performance, economic, and player availability burden in sport. High-speed running (HSR) is cited as a common mechanism for HSI. While evidence exists regarding the high physical demands on the hamstring muscles in HSR, meta-analytical synthesis of related activation and kinetic variables is lacking. METHODS: A systematic search of Medline, Embase, Scopus, CINAHL, SportDiscus, and Cochrane library databases was conducted in accordance with the PRISMA 2020 guidelines. Studies reporting hamstring activation (electromyographic [EMG]) or hamstring muscle/related joint kinetics were included where healthy adult participants ran at or beyond 60% of maximum speed (activation studies) or 4 m per second (m/s) (kinetic studies). RESULTS: A total of 96 studies met the inclusion criteria. Run intensities were categorized as "slow," "moderate," or "fast" in both activation and kinetic based studies with appropriate relative, and raw measures, respectively. Meta-analysis revealed pooled mean lateral hamstring muscle activation levels of 108.1% (95% CI: 84.4%-131.7%) of maximal voluntary isometric contraction (MVIC) during "fast" running. Meta-analysis found swing phase peak knee flexion internal moment and power at 2.2 Newton meters/kilogram (Nm/kg) (95% CI: 1.9-2.5) and 40.3 Watts/kilogram (W/kg) (95% CI: 31.4-49.2), respectively. Hip extension peak moment and power was estimated as 4.8 Nm/kg (95% CI: 3.9-5.7) and 33.1 W/kg (95% CI: 17.4-48.9), respectively. CONCLUSIONS: As run intensity/speed increases, so do the activation and kinetic demands on the hamstrings. The presented data will enable clinicians to incorporate more objective measures into the design of injury prevention and return-to-play decision-making strategies.

Posterior Shoulder Instability in Tennis Players: Aetiology, Classification, Assessment and Management.

Background: Micro-traumatic posterior shoulder instability (PSI) is an often missed and misdiagnosed pathology presenting in tennis players. The aetiology of micro-traumatic PSI in tennis players is multifactorial, including congenital factors, loss of strength and motor control, and sport-specific repetitive microtrauma. Repetitive forces placed on the dominant shoulder, particularly combinations of flexion, horizontal adduction, and internal rotation contribute to the microtrauma. These positions are characteristic for kick serves, backhand volleys, and the follow-through phase of forehands and serves. The aim of this clinical commentary is to present an overview of the aetiology, classification, clinical presentation, and treatment of micro-traumatic PSI, with a particular focus on tennis players. Level of Evidence: 5.

Gluteal Muscle Size and Quality in Professional Ballet Dancers Compared to Non-Dancing Athletes.

INTRODUCTION: Professional ballet dancers load their hips in extreme ranges of motion and commonly report hip pain. Evaluating gluteal muscle size and quality may help guide exercise programs. Objectives of this study were to compare gluteal muscle size and quality (fatty infiltration) in ballet dancers compared to athletes; and to investigate the relationship between gluteal muscle size and quality, and reports of hip-related pain. METHODS: This study was a case-control design. Professional ballet dancers (current and retired, n = 49, mean age 35 years, range 19-63) and age and sex-matched athletes (current and retired, n = 49) underwent magnetic resonance imaging of both hips. Muscle cross-sectional areas (CSA) were obtained at standardized landmarks for gluteus maximus (GMax) and gluteus medius (GMed). Full muscle volume was calculated for gluteus minimus (GMin). Fatty infiltration was rated using the Goutallier classification system. Muscle size was compared between groups using linear mixed models. Fatty infiltration was compared using a mixed model binary logistic regression. Hip-related pain, participation status, limb side and sex were included as covariates. RESULTS: Ballet dancers had significantly larger GMax (upper P < .01, middle P < .01, lower P = .01) and GMed (level of anterior inferior iliac spine P < .01, greater sciatic foramen P < .01) CSA and larger GMin volume (P < .01), when normalized to weight. There was no difference in fatty infiltration ratings between dancers and non-dancing athletes. Retired dancers and athletes reporting hip-related pain were more likely to have fatty infiltration in GMax lower (P = .04). CONCLUSION: Gluteal muscles are larger in ballet dancers compared to athletes suggesting high-level loading of these muscles. There is no relationship between hip-related pain and gluteal muscle size. Dancers and athletes have comparable muscle quality.

Towards development of a core outcome set in proximal hamstring tendinopathy - A systematic review of measurement instruments and their clinimetric properties.

OBJECTIVE: To find measurement instruments for proximal hamstring tendinopathy, map them to outcome domains, and evaluate their measurement properties. METHODS: There were three phases. Phase one involved a search of MEDLINE, CINAHL, EMBASE, SPORTSDISCUS and PUBMED (February 2022) to identify measurement instruments used in proximal hamstring tendinopathy research. In phase two we mapped these measurement instruments to the International Tendinopathy Scientific Consensus (ICON) core outcome domains. The third phase involved conducting a second search (same databases/census date) to identify studies that evaluated measurement properties of measurement instruments in participants with proximal hamstring tendinopathy. Measurement properties were then evaluated following the Consensus-based-Standards for the Selection of Health Instruments methodology -including risk of bias assessment and synthesis of findings. RESULTS: Twenty-eight different measurement instruments were identified in phase one. These were mapped to six of nine ICON domains in phase two. In phase three, there was only one instrument that had been evaluated for its measurement properties (4 studies, n = 302) - the Victorian Institute of Sport Assessment - Proximal Hamstring Tendinopathy (VISA-H). For the VISA-H there was moderate-quality evidence of sufficient construct validity, low-quality evidence of sufficient responsiveness, reliability and measurement error, very low-quality evidence of sufficient relevance and comprehensibility and very low-quality evidence of insufficient comprehensiveness. CONCLUSION: The VISA-H - mapped to the ICON disability domain - is the only one of the 28 different measurement instruments identified that was validated in this population. Caution in applying it is warranted given it is supported by lower quality evidence.

The impact of previous musculoskeletal injury on running gait variability: A systematic review.

BACKGROUND: Growing evidence suggests that identifying movement variability alterations in pathological vs. healthy gait may further understanding of injury mechanisms related to gait biomechanics; however, in the context of running and musculoskeletal injuries the role of movement variability remains unclear. RESEARCH QUESTION: What is the impact of a previous musculoskeletal injury on running gait variability? METHODS: Medline, CINAHL, Embase, Cochrane library and SPORTDiscus were searched from inception until February 2022. Eligibility criteria were (a) included a musculoskeletal injury group, (b) compared running biomechanics data to a control group, (c) measured movement variability for at least one dependent variable, (d) provided a statistical between-group comparison of variability outcomes. Exclusion criteria were neurological conditions impacting gait, upper body musculoskeletal injuries and age < 18 years old. A summative synthesis was performed instead of a meta-analysis due to methodological heterogeneity. RESULTS: Seventeen case-control studies were included. The most common deviations in variability observed among the injured groups were: (1) high and low knee-ankle/foot coupling variability and (2) low trunk-pelvis coupling variability. Significant (p < 0.05) between-group differences in movement variability were identified in 8 of 11; 73% of studies of runners with injury-related symptoms, and 3 of 7; 43% of studies of recovered or asymptomatic populations. SIGNIFICANCE: This review identified limited to strong evidence that running variability is altered in adults with a recent history of injury for specific joint couplings only. Individuals with ankle instability or pain employed altered running strategies more often than those who have recovered from injury. Altered variability strategies have been proposed to contribute to future running-related injuries, therefore these findings are relevant to clinicians managing active populations.

Comparison between a targeted exercise program and a sham intervention on gluteal muscle activity in people with hip osteoarthritis: Analysis of secondary outcomes from a randomised clinical trial.

BACKGROUND: People with hip osteoarthritis (OA) typically display altered gluteus minimus (GMin) and gluteus medius (GMed) activity during gait, in addition to reduced walking speed and stride length. It is unknown if current rehabilitation programs address changes in gluteal muscle activity in people with hip OA. RESEARCH QUESTION: Can a targeted gluteal intervention restore normal gluteal muscle segment activity during gait in people with hip OA? METHODS: This study presents secondary outcomes from a multi-site, double-blinded clinical trial in which participants with radiologically confirmed mild-moderate hip OA were randomised into a targeted gluteal or sham intervention for 12-weeks following baseline testing. Electromyography (EMG) outcomes were only conducted at a single site and data were collected from 22 participants. Intramuscular electrodes were inserted into two segments of GMin (anterior, posterior) and three segments of GMed (anterior, middle, posterior) to record average amplitude, peak amplitude and time to peak (TTP) during the first 60 % of the gait cycle (stance phase) at baseline and post-intervention. RESULTS: Following the targeted gluteal intervention, posterior GMin displayed a decrease in average (P = 0.032, ES=1.04) and peak (P = 0.017, ES=1.17) muscle activity during late stance phase with a shift to an earlier TTP (P = 0.034, ES=1.02). There were no further significant changes between groups for other outcome measures. Similar trends for an earlier TTP were observed for the posterior segment of GMed following the targeted intervention (P = 0.095, ES=0.87). The earlier TTP in the posterior segments of both GMin and GMed post-intervention resembled patterns observed in a healthy young population. SIGNIFICANCE: A targeted gluteal intervention can positively impact activity in posterior GMin during gait in people with hip OA when compared to a sham intervention.

Game-play affects hamstring but not adductor muscle fibre mechanics in elite U20 basketball athletes.

Muscle tendon unit fibre mechanics of hamstring and adductor strain injuries are not well studied, with factors such as fatigue promoted as risk factors in the absence of mechanistic evidence. In this study, musculoskeletal modelling was used to estimate fibre mechanics of four hamstring (biceps femoris long head, biceps femoris short head, semimembranosus and semitendinosus) and four adductor (adductor brevis, adductor longus, adductor magnus and gracilis) muscles during an anticipated cut task. The cut task was performed by 10 healthy elite male U20 basketball players both before and immediately after they played in one (of four) competitive basketball game. Biceps femoris long head produced significantly lower (p = 0.032) submaximal force post-game in the latter part of swing (30.7% to 35.0% of stride), though its peak force occurred later (37%) and remained unchanged. Semimembranosus produced significantly lower (p = 0.006) force post-game (32.9% to 44.9% of stride), which encompassed the instance of peak force (39%). Neither fibre velocity nor fibre length of the investigated muscles were significantly affected by game-play. These finding suggest that if fatigue is a factor in hamstring and adductor muscle strain injuries and is brought about by game-play, it is unlikely through the fibre mechanisms investigated in this study.

Effects of a targeted resistance intervention compared to a sham intervention on gluteal muscle hypertrophy, fatty infiltration and strength in people with hip osteoarthritis: analysis of secondary outcomes from a randomised clinical trial.

BACKGROUND: People with hip osteoarthritis are typically offered a combination of education and exercise to address muscle atrophy and weakness. Limited evidence exists to assess the efficacy of exercise programs on muscle structure or function in this population. The aim of this study was to evaluate the effects of targeted resistance exercise on gluteal muscle hypertrophy and strength in people with mild-to-moderate hip osteoarthritis. METHODS: Twenty-seven participants with radiologically confirmed hip osteoarthritis recruited from a single site of a multi-site, double-blind clinical trial were randomly allocated to receive a 12-week targeted gluteal intervention or sham intervention. Magnetic resonance imaging and hand-held dynamometry were used to determine change in gluteal muscle volume, fatty infiltration and hip muscle strength. For gluteal muscle volume and strength outcomes mixed model analyses of variance (ANOVA) were conducted. A general linear model (ANOVA) analysis with fixed effects parameter estimates was used to assess the impact of sex on gluteal muscle size and strength of the affected limb only. For muscle fat index a mixed method ANOVA was used to assess the differences between groups and over time. RESULTS: In the targeted intervention group, gluteus minimus volume increased from baseline to post-intervention in both limbs (pooled mean difference: 0.06 cm3/kg, 95% confidence interval: 0.01 to 0.11) while no change occurred in the sham group (time x group effect: P = 0.025). Gluteus medius, gluteus maximus and tensor fascia lata volume did not change significantly over time. Hip strength (abduction, adduction, flexion, extension, external and internal rotation) improved similarly in both groups (time main effect: P ≤ 0.042). There was a consistent, albeit non-significant, pattern of reduced fatty infiltration after the targeted intervention. CONCLUSION: Targeted resistance exercise resulted in gluteus minimus hypertrophy, but improvements in hip strength occurred in both groups. Clinicians delivering hip osteoarthritis rehabilitation programs might consider implementing a targeted exercise program to attenuate disease associated changes within gluteal muscles. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ID: ACTRN12617000970347. Registered prospectively on 5 July 2017.

Advances in the Non-Operative Management of Multidirectional Instability of the Glenohumeral Joint.

Multidirectional instability (MDI) of the glenohumeral joint refers to symptomatic subluxations or dislocations in more than one direction. The aetiology of MDI is multifactorial, which makes the classification of this condition challenging. A shoulder rehabilitation program is the initial recommended treatment for MDI, however available rehabilitation programs have varying levels of evidence to support their effectiveness. In 2016, we published the details of an evidence-based program for MDI that has been evaluated for efficacy in two single-group studies and a randomised controlled trial. In 2017, we published a clinical commentary on the aetiology, classification, and treatment of this condition. The aim of this paper is to provide an update on the components of these publications with a particular focus on new advances in the non-operative management of this condition.

Risk Factors for Quadriceps Muscle Strain Injuries in Sport: A Systematic Review.

OBJECTIVE: To identify risk factors for quadriceps muscle strain injury in sport. DESIGN: Risk factor systematic review. LITERATURE SEARCH: A systematic search was conducted in the MEDLINECINAHL, Embase, AMED, AUSPORT, SPORTDiscus, PEDro, and Cochrane Library databases (from inception to September 2021). STUDY SELECTION CRITERIA: Studies reporting prospective data to evaluate risk factors related to index and/or recurrent quadriceps muscle strain injury. DATA SYNTHESIS: A risk-of-bias assessment (using a modified Quality in Prognosis Studies tool) was performed, and we used best-evidence synthesis to qualitatively synthesize the data to quantify relationships between risk factors and quadriceps muscle injury. RESULTS: Sixteen studies were included, capturing 2408 quadriceps injuries in 11 719 athletes. Meta-analyses were not performed due to clinical heterogeneity. The dominant kicking leg (over 3154 individuals, 1055 injuries), a previous history of quadriceps muscle injury (6208 individuals, 975 injuries), and a recent history of hamstring strain (4087 individuals, 581 injuries) were intrinsic factors associated with quadriceps injury. Extrinsic factors relating to the preseason period and competitive match play increased quadriceps injury risk; participating at higher levels of competition decreased quadriceps injury risk. Age, weight, and flexibility (intrinsic factors) had no association with quadriceps injury. CONCLUSION: Previous quadriceps injury, recent hamstring injury, the dominant kicking leg, and competitive match play were the strongest risk factors for future quadriceps muscle injury in sport. J Orthop Sports Phys Ther 2022;52(6):389-400. doi:10.2519/jospt.2022.10870.

Factors associated with overuse injury in cyclists: A systematic review.

OBJECTIVES: To identify risk factors associated with overuse injuries in cyclists. DESIGN: Systematic review. METHODS: Data sources: Medline, CINAHL, EMBASE, SPORTDiscus, and the Cochrane Library were systematically searched. Reference checking and citation tracking of included articles were undertaken. Grey literature searches and a review of key publications by known experts in the industry were conducted. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies evaluating the association between specific measures of the bike, the cyclist's body and load characteristics, and overuse pain or injury in cycling. RESULTS: Of the 3596 studies yielded in the search, 18 studies were included in the review with only 3 of these studies deemed to have a low risk of bias. The best evidence synthesis showed moderate evidence of a relationship between load and symptoms, as well as moderate evidence of no relationship between cycling overuse injury or pain and many measures traditionally used in bike fitting. Conflicting evidence of a relationship exists between seat height and symptoms. CONCLUSIONS: Cycling is popular on a world scale for transport and exercise with cyclists experiencing a high prevalence of overuse pain and injury. Many theories exist as to the cause of these symptoms, however there are limited high quality studies of risk factors for overuse injuries. This review highlights that there is no strong evidence relating any measure of the bike, body or load to cycling overuse pain or injury.

The Assessment, Management and Prevention of Calf Muscle Strain Injuries: A Qualitative Study of the Practices and Perspectives of 20 Expert Sports Clinicians.

BACKGROUND: Despite calf muscle strain injuries (CMSI) being problematic in many sports, there is a dearth of research to guide clinicians dealing with these injuries. The aim of this study was to evaluate the current practices and perspectives of a select group of international experts regarding the assessment, management and prevention of CMSI using in-depth semi-structured interviews. RESULTS: Twenty expert clinicians working in elite sport and/or clinician-researchers specialising in the field completed interviews. A number of key points emerged from the interviews. Characteristics of CMSI were considered unique compared to other muscle strains. Rigor in the clinical approach clarifies the diagnosis, whereas ongoing monitoring of calf capacity and responses to loading exposure provides the most accurate estimate of prognosis. Athlete intrinsic characteristics, injury factors and sport demands shaped rehabilitation across six management phases, which were guided by key principles to optimise performance at return to play (RTP) while avoiding subsequent injury or recurrence. To prevent CMSI, periodic monitoring is common, but practices vary and data are collected to inform load-management and exercise selection rather than predict future CMSI. A universal injury prevention program for CMSI may not exist. Instead, individualised strategies should reflect athlete intrinsic characteristics and sport demands. CONCLUSIONS: Information provided by experts enabled a recommended approach to clinically evaluate CMSI to be outlined, highlighting the injury characteristics considered most important for diagnosis and prognosis. Principles for optimal management after CMSI were also identified, which involved a systematic approach to rehabilitation and the RTP decision. Although CMSI were reportedly difficult to prevent, on- and off-field strategies were implemented by experts to mitigate risk, particularly in susceptible athletes.

Past-season, pre-season and in-season risk assessment of groin problems in male football players: a prospective full-season study.

OBJECTIVE: We assessed past-season, pre-season and in-season risk factors to investigate their association with an in-season groin problem in male amateur football players. METHODS: Past-season groin-pain information and pre-season short-lever and long-lever adductor squeeze strength were obtained at baseline, together with anthropometrics (weight, lower limb lever length) and player age. In-season hip-related and groin-related sporting function was monitored every 4 weeks using the Sports and Recreation (Sport) subscale from the Hip And Groin Outcome Score questionnaire (HAGOS (Sport)). Groin problems, including time-loss groin injuries and groin pain irrespective of time loss, were collected over a 39-week competitive in-season. We estimated relative risk (RR), and 95% credibility interval (ICr) from logistic regressions fitted in a Bayesian framework. RESULTS: Players (n=245) suffering from groin pain during the past-season had 2.4 times higher risk of experiencing a groin problem in the new season (2.40 RR; 95% ICr 1.5 to 3.7). This risk was reduced by 35% (0.65 RR; 95% ICr 0.42 to 0.99) per unit (N·m/kg) increase in the long-lever adductor squeeze test. Player age, short-lever squeeze test and the HAGOS (Sport) scores were not associated with the risk of a groin problem. CONCLUSIONS: Past-season groin pain increased the risk of a groin problem in the new in-season. This risk was reduced by higher pre-season long-lever adductor squeeze strength. Past-season groin-pain information and long-lever adductor squeeze strength can be quickly obtained during pre-season to identify players with an elevated risk of in-season groin problems. This may be key to reduce these problems in the new season.

Does Menopausal Hormone Therapy, Exercise, or Both Improve Pain and Function in Postmenopausal Women With Greater Trochanteric Pain Syndrome? A 2 × 2 Factorial Randomized Clinical Trial.

BACKGROUND: Greater trochanteric pain syndrome (GTPS) is a debilitating chronic condition, most prevalent in postmenopausal women. A positive association between high estrogen levels and tendon health may exist, and postmenopausal women have reduced estrogen. Menopausal hormone therapy (MHT) may reduce the incidence of tendon abnormality, particularly when combined with exercise. PURPOSE: To determine the effect of MHT and exercise on tendon pain and function in postmenopausal women with GTPS. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Postmenopausal women (N = 132; n = 12, lost to follow-up) with GTPS were randomized into MHT and placebo transdermal cream groups combined with tendon-specific or sham exercise. All groups received education about avoiding gluteal tendon compression and load management throughout 12 weeks of intervention. The primary outcome was the Victorian Institute of Sport Assessment for gluteal tendinopathy (VISA-G), and secondary outcomes were measured at baseline and at 12 and 52 weeks. The Global Rating of Change was assessed at 12 and 52 weeks. A linear mixed-effects model was used to assess differences. Body mass index (BMI) was included as a covariate. RESULTS: All participant groups improved over time (baseline vs 12 weeks, P < .001; baseline vs 52 weeks, P < .001). There was no difference among exercise groups measured by all outcomes (VISA-G: baseline, P = .97, mean difference [MD] = 0.10; 12 weeks, P = .49, MD = 2.15; 52 weeks, P = .32, MD = -3.08). There was a significant interaction effect between cream and BMI; therefore, the population was stratified by BMI levels (<25, <30, ≥30). The MHT groups (with exercise and education) had significantly better VISA-G outcomes (baseline, P = .04, MD = -11.20, 95% CI = -21.70 to -0.70; 12 weeks, P < .001, MD = -20.72, 95% CI = -31.22 to -10.22; 52 weeks, P = .002, MD = -16.71, 95% CI = -27.21 to -6.22) and secondary measure scores as compared with placebo at all time points when BMI was <25. CONCLUSION: MHT or placebo combined with tendon-specific or sham exercise plus education reduced pain and increased function for this population. For women with a BMI <25, MHT with any exercise plus education was better than placebo. A targeted exercise or sham exercise strategy is effective when prescribed with education about avoiding gluteal tendon compression and load management. REGISTRATION: ACTRN12614001157662 (Australian New Zealand Clinical Trials Registry).

Screening Hamstring Injury Risk Factors Multiple Times in a Season Does Not Improve the Identification of Future Injury Risk.

PURPOSE: To determine if eccentric knee flexor strength and biceps femoris long head (BFlh) fascicle length were associated with prospective hamstring strain injury (HSI) in professional Australian Football players, and if more frequent assessments of these variables altered the association with injury risk. METHODS: Across two competitive seasons, 311 Australian Football players (455 player seasons) had their eccentric knee flexor strength during the Nordic hamstring exercise and BFlh architecture assessed at the start and end of preseason and in the middle of the competitive season. Player age and injury history were also collected in preseason. Prospective HSIs were recorded by team medical staff. RESULTS: Seventy-four player seasons (16%) sustained an index HSI. Shorter BFlh fascicles (<10.42 cm) increased HSI risk when assessed at multiple time points only (relative risk [RR], 1.9; 95% confidence interval [CI], 1.2-3.0). Neither absolute (N) nor relative (N·kg-1) eccentric knee flexor strength was associated with HSI risk, regardless of measurement frequency (RR range, 1.0-1.1); however, between-limb imbalance (>9%), when measured at multiple time points, was (RR, 1.8; 95% CI, 1.1-3.1). Prior HSI had the strongest univariable association with prospective HSI (RR, 2.9; 95% CI, 1.9-4.3). Multivariable logistic regression models identified a combination of prior HSI, BFlh architectural variables and between-limb imbalance in eccentric knee flexor strength as optimal input variables; however, their predictive performance did not improve with increased measurement frequency (area under the curve, 0.681-0.726). CONCLUSIONS: More frequent measures of eccentric knee flexor strength and BFlh architecture across a season did not improve the ability to identify which players would sustain an HSI.