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.

What Contributes to Athlete Performance Health? A Concept Mapping Approach.

BACKGROUND: In high-performance sport, athlete performance health encompasses a state of optimal physical, mental, and social wellbeing related to an athlete's sporting success. The aim of this study was to identify the priority areas for achieving athlete performance health in Australia's high-performance sport system (HPSS). METHODS: Participants across five socioecological levels of Australia's HPSS were invited to contribute to this study. Concept mapping, a mixed-methods approach incorporating qualitative and quantitative data collection, was used. Participants brainstormed ideas for what athlete performance health requires, sorted the ideas into groups based on similar meaning and rated the importance, and ease of achieving each idea on a scale from 1 (not important/easiest to overcome) to 5 (extremely important/hardest to overcome). RESULTS: Forty-nine participants generated 97 unique statements that were grouped into 12 clusters following multidimensional scaling and hierarchical cluster analysis. The three clusters with highest mean importance rating were (mean importance rating (1-5), mean ease of overcoming (1-5)): 'Behavioral competency' (4.37, 2.30); 'Collaboration and teamwork' (4.19, 2.65); 'Valuing athlete wellbeing' (4.17, 2.77). The 12 clusters were grouped into five overarching domains: Domain one-Performance health culture; Domain two-Integrated strategy; Domain three-Operational effectiveness; Domain four-Skilled people; Domain five-Leadership. CONCLUSION: A diverse sample of key stakeholders from Australia's HPSS identified five overarching domains that contribute to athlete performance health. The themes that need to be addressed in a strategy to achieve athlete performance health in Australia's HPSS are 'Leadership', 'Skilled people', 'Performance health culture', 'Operational effectiveness', and 'Integrated strategy'.

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

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

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

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

Isometric Exercise to Reduce Pain in Patellar Tendinopathy In-Season: Is It Effective "on the Road"?

OBJECTIVE: To investigate the effectiveness of an isometric squat exercise using a portable belt, on patellar tendon pain and function, in athletes during their competitive season. DESIGN: Case series with no requirements to change any aspect of games or training. The object of this pragmatic study was to investigate this intervention in addition to "usual management." A control or sham intervention was considered unacceptable to teams. SETTING: In-season. PARTICIPANTS: A total of 25 male and female elite and subelite athletes from 5 sports. INTERVENTION: 5 × 30-second isometric quadriceps squat exercise using a rigid belt completed over a 4-week period. MAIN OUTCOME MEASURES: (1) single-leg decline squat (SLDS)-a pain provocation test for the patellar tendon (numerical rating score of pain between 0 and 10), (2) VISA-P questionnaire assessing patellar tendon pain and function, and (3) self-reported adherence with completing the exercise over a 4-week period. RESULTS: Baseline SLDS pain was high for these in-season athletes, median 7.5/10 (range 3.5-9) and was significantly reduced over the 4-week intervention (P < 0.001, ES r = 0.580, median change 3.5). VISA-P scores improved after intervention (P < 0.001, ES r = 0.568, mean change 12.2 ± 8.9, percentage mean change 18.8%, where minimum clinical important difference of relative change for VISA-P is 15.4%-27%). Adherence was high; athletes reported completing the exercise 5 times per week. CONCLUSIONS: This pragmatic study suggests that a portable isometric squat reduced pain in-season for athletes with patellar tendinopathy (PT). This form of treatment may be effective, but clinical trials with a control group are needed to confirm the results.

Oral Supplementation of Specific Collagen Peptides Combined with Calf-Strengthening Exercises Enhances Function and Reduces Pain in Achilles Tendinopathy Patients.

The current pilot study investigates whether oral supplementation of specific collagen peptides improves symptoms and tendon vascularisation in patients with chronic mid-portion Achilles tendinopathy in combination with structured exercise. Participants were given a placebo or specific collagen peptides (TENDOFORTE®) in combination with a bi-daily calf-strengthening program for 6 months. Group AB received specific collagen peptides for the first 3 months before crossing over to placebo. Group BA received placebo first before crossing over to specific collagen peptides. At baseline (T1), 3 (T2) and 6 (T3) months, Victorian Institute of Sports Assessment⁻Achilles (VISA-A) questionnaires and microvascularity measurements through contrast-enhanced ultrasound were obtained in 20 patients. Linear mixed modeling statistics showed that after 3 months, VISA-A increased significantly for group AB with 12.6 (9.7; 15.5), while in group BA VISA-A increased only by 5.3 (2.3; 8.3) points. After crossing over group AB and BA showed subsequently a significant increase in VISA-A of, respectively, 5.9 (2.8; 9.0) and 17.7 (14.6; 20.7). No adverse advents were reported. Microvascularity decreased in both groups to a similar extent and was moderately associated with VISA-A (Rc²:0.68). We conclude that oral supplementation of specific collagen peptides may accelerate the clinical benefits of a well-structured calf-strengthening and return-to-running program in Achilles tendinopathy patients.

Knee flexion not hip extension strength is persistently reduced following hamstring strain injury in Australian Football athletes: Implications for Periodic Health Examinations.

OBJECTIVES: Determine whether clinically feasible tests of isometric lower limb strength and range of motion (ROM) in Australian Football (AF) athletes are useful in Periodic Health Examinations to identify persistent deficits following hamstring strain injury (HSI). DESIGN: Case-control. METHODS: Thirty-seven male, semi-professional AF athletes (mean±SD; age, 20.2±2.9years; height, 1.7±0.5m; mass, 81±9.2kg) participated, ten athletes (37%) reported HSI within the previous three seasons of competition. Comparisons of pre-season isometric knee flexion and hip extension strength variables (peak force, torque and torque normalised to body mass) and hip, knee and ankle ROM measures were made between athletes with and without past-history of HSI using linear mixed-effect models. A logistic regression evaluated whether any of the outcome measures could differentiate athletes with a past-history of HSI. RESULTS: Knee flexion peak force, torque and torque normalised to body mass were significantly reduced in athletes with a past-history of HSI (coefficient, 95% CI) (-44.8N, -86.3 to -3.3), (-22.2Nm, -40.5 to -3.7) and (-0.2Nmkg-1, -0.4 to 0.0) respectively. Knee flexion peak torque normalised to body mass (Nmkg-1) approached significance as a test was able to differentiate athletes with history of HSI (p=0.068). There were no differences between groups for any hip extension strength or lower limb ROM outcome measures. CONCLUSIONS: Deficits in isometric peak knee flexion strength persist for up to three seasons following HSI in AF athletes. Isometric knee flexion strength testing may be a clinically feasible option for Periodic Health Examinations and inform tertiary injury prevention strategies.

Knee flexion strength is significantly reduced following competition in semi-professional Australian Rules football athletes: Implications for injury prevention programs.

OBJECTIVES: To evaluate strength and flexibility measures pre- and post- Australian Football (AF) competition to determine their potential utility as secondary prevention measures. DESIGN: Cohort study. SETTING: Semi-professional AF club. PARTICIPANTS: Ten male AF athletes (mean ±â€¯SD; age, 21.3 ±â€¯2.2 years; height, 186.1 ±â€¯6.3 cm; weight, 83.5 ±â€¯8.6 kg). MAIN OUTCOME MEASURES: Maximal unilateral isometric knee flexion strength performed in 45 degrees of hip flexion and 30 degrees of knee flexion, flexibility measures of hip and knee extension and ankle dorsiflexion. All outcome measures were evaluated pre-match to determine baseline measurements and repeated acutely post-match and at 26, 50 and 74 h following. Comparisons were made between baseline measures and all other time points. RESULTS: Knee flexion strength was significantly reduced at a group level acutely (-122.8N, 95%CI -156.2 to -89.4, p = 0.000) and at 26 h (-89.6N, 95%CI -122.9 to -56.2, p = 0.000) following competition. Hamstring flexibility was significantly reduced at all time periods following competition (all p < 0.05), however these values were not clinically meaningful. CONCLUSIONS: Knowledge that unilateral isometric knee flexion strength returns to pre-competition levels by 50 h following match-play in AF athletes is valuable for planning recovery time frames and may inform implementation of secondary prevention strategies.

Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy / Gestión de la carga en las tendinopatías: progresión clínica para tendinopatías de Aquiles y rotuliana

Achilles and patellar tendons are commonly affected by tendinopathy. Injury to these tendons can severely impact upon sports, recreational and everyday activities. Eccentric musculotendinous loading has become the dominant conservative intervention strategy for Achilles and patellar tendinopathy over the last two decades. Eccentric loading involves isolated, slow lengthening muscle contractions. Systematic reviews have evaluated the evidence for eccentric muscle loading in Achilles and patellar tendinopathy, concluding that outcomes are promising but high-quality evidence is lacking. Eccentric loading may not be effective for all patients (athletes and non-athletes) affected by tendinopathy. It is possible that in athletes, eccentric work is an inadequate load on the muscle and tendon. A rehabilitation program aiming to increase tendon load tolerance must obviously include strength exercises, but should also add speed and energy storage and release. The aim of this paper is to document a rehabilitation protocol for Achilles and patellar tendinopathy. It consists of simple and pragmatic exercises designed to incorporate progressive load to the tendon: isometric work, strength, functional strength, speed and jumping exercises to adapt the tendon to the ability to store and release energy. This article would be the first step for an upcoming multicentre randomized controlled trial to investigate its efficacy (AU)

Las tendinopatías de Aquiles y rotuliana son muy frecuentes. Las lesiones en estos tendones pueden afectar severamente a las actividades deportivas, recreativas y cotidianas. En las últimas 2 décadas, los ejercicios excéntricos se han convertido en la principal intervención conservadora para tratar las tendinopatías de Aquiles y rotuliana. Los ejercicios excéntricos no son efectivos en todos los pacientes afectados por tendinopatías (atletas y no atletas). Es posible que en atletas, la carga que genera el trabajo excéntrico sobre el músculo y el tendón sea insuficiente. Un programa de rehabilitación que tenga por objetivo aumentar la tolerancia del tendón a la carga debe, obviamente, incluir ejercicios de fuerza, pero también debe agregar ejercicios de velocidad y ejercicios que aumenten la capacidad para almacenar y liberar energía. Este trabajo muestra un protocolo de rehabilitación para las tendinopatías de Aquiles y rotuliana. Consiste en ejercicios simples y pragmáticos diseñados para incorporar carga progresiva al tendón: mediante trabajo isométrico, fuerza, fuerza funcional, velocidad y ejercicios pliométricos que aumenten en el tendón la capacidad de almacenar y liberar energía. Este trabajo es el primer paso para diseñar un ensayo clínico aleatorizado y multicéntrico que permita evaluar su eficacia (AU)

Effects of Altering Trunk Position during Landings on Patellar Tendon Force and Pain.

PURPOSE: This study aimed to verify the immediate effects of altering sagittal plane trunk position during jump landings on lower limb biomechanics, patellar tendon force, and pain of athletes with and without patellar tendinopathy. METHODS: Twenty-one elite male athletes were categorized into three groups: athletes with patellar tendinopathy (TG; n = 7), asymptomatic athletes with patellar tendon abnormalities (n = 7), and asymptomatic athletes without tendon abnormalities (CG; n = 7). A biomechanical evaluation was conducted while the athletes performed drop landings from a bench in a self-selected trunk position (SS). Afterward, the athletes were randomly assigned to land with either a flexed trunk position (FLX) or an extended trunk position (EXT). Variables of interest for this study included sagittal plane peak kinematics, kinetics, patellar tendon force, and pain during the landing tasks. RESULTS: Peak patellar tendon force, knee extensor moment, and knee pain decreased in the FLX landing compared with the SS landing, regardless of group. In addition, peak patellar tendon force, knee extensor moment, and vertical ground reaction force were smaller in the FLX landing compared with the EXT landing. The TG had smaller peak ankle dorsiflexion compared with the CG during jump landings, regardless of trunk position. CONCLUSIONS: Landing with greater trunk flexion decreased patellar tendon force in elite jumping athletes. An immediate decrease in knee pain was also observed in symptomatic athletes with a more flexed trunk position during landing. Increasing trunk flexion during landing might be an important strategy to reduce tendon overload in jumping athletes.

El continuum de la patología de tendón: concepto actual e implicaciones clínicas / The continuum of tendon pathology: Current view and clinical implications

El modelo del continuum fue propuesto por Cook y Purdam en 2009 con el propósito de mejorar la comprensión del complejo marco que rodea la patología del tendón. El concepto se basa en las características de los tres estados tisulares del tendón: tendón reactivo, tendinopatía desestructurada y tendinopatía degenerativa. El concepto del continuum se diferencia de las otras propuestas por su visión de cambio continuo de la estructura del tejido tendinoso. Cada fase tiene una presentación clínica característica y un tratamiento específico. Estudios histológicos, por la imagen y clínicos corroboran con evidencia el abordaje de esta patología mediante el concepto del modelo de continuum (AU)

Cook and Purdam first proposed the Continuum model in 2009, with the aim of improving the understanding of the complexity of tendon pathologies. The Continuum is based on three states of tendon structure: reactive tendon, tendon disrepair and degenerative tendon. In contrast to other proposals, the Continuum model describes continuous changes in tendon structure. Each state of tendon structure represents a particular clinical presentation and requires a particular type of management. Evidence seen in histopathological studies, imaging and clinical studies all support the Continuum model for the analysis of tendon pathologies (AU)

Asymptomatic players with a patellar tendon abnormality do not adapt their landing mechanics when fatigued.

This study aimed to explore how asymptomatic athletes with a patellar tendon abnormality (PTA), who are at high risk of developing patellar tendinopathy, alter their landing technique and net patellar tendon loads generated in response to fatigue. Seven asymptomatic players with a PTA performed five successful vertical stop-jump trials before and after a fatigue protocol. Fatigue protocol involved participants repeatedly performing sets of 30 submaximal jump exercises on a sledge apparatus followed by 30 s rest until the task failure criteria were reached. Three-dimensional ground reaction forces, lower limb kinematics and net peak patellar tendon force were recorded during the stop-jump task. No significant between-fatigue condition differences in net patellar tendon loading, or most secondary outcome variables were observed. Only some fatigue changes were seen during the vertical landing phase. Asymptomatic PTA participants did not modify their landing technique or net patellar tendon loading during a stop-jump task in response to fatigue. The lack of between-fatigue condition differences displayed by the asymptomatic PTA participants during both landing phases suggest that these individuals may not be capable of sufficient movement variability in their landing strategies to adapt to fatigue.

Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management.

Synopsis Proximal hamstring tendinopathy (PHT) typically manifests as deep buttock pain at the hamstring common origin. Both athletic and nonathletic populations are affected by PHT. Pain and dysfunction are often long-standing and limit sporting and daily functions. There is limited evidence regarding diagnosis, assessment, and management; for example, there are no randomized controlled trials investigating rehabilitation of PHT. Some of the principles of management established in, for example, Achilles and patellar tendinopathy would appear to apply to PHT but are not as well documented. This narrative review and commentary will highlight clinical aspects of assessment and management of PHT, drawing on the available evidence and current principles of managing painful tendinopathy. The management outline presented aims to guide clinicians as well as future research. J Orthop Sports Phys Ther 2016;46(6):483-493. Epub 15 Apr 2016. doi:10.2519/jospt.2016.5986.

Reliability of externally fixed dynamometry hamstring strength testing in elite youth football players.

OBJECTIVES: To investigate inter and intra-tester reliability of an externally fixed dynamometry unilateral hamstring strength test, in the elite sports setting. DESIGN: Reliability study. METHODS: Sixteen, injury-free, elite male youth football players (age=16.81±0.54 years, height=180.22±5.29cm, weight 73.88±6.54kg, BMI=22.57±1.42) gave written informed consent. Unilateral maximum isometric peak hamstring force was evaluated by externally fixed dynamometry for inter-tester, intra-day and intra-tester, inter-week reliability. The test position was standardised to correlate with the terminal swing phase of the gait running cycle. RESULTS: Inter and intra-tester values demonstrated good to high levels of reliability. The intra-class coefficient (ICC) for inter-tester, intra-day reliability was 0.87 (95% CI=0.75-0.93) with standard error of measure percentage (SEM%) 4.7 and minimal detectable change percentage (MDC%) 12.9. Intra-tester, inter-week reliability results were ICC 0.86 (95% CI, 0.74-0.93), SEM% 5.0 and MDC% 14.0. CONCLUSIONS: This study demonstrates good to high inter and intra-tester reliability of isometric externally fixed dynamometry unilateral hamstring strength testing in the regular elite sport setting involving elite male youth football players. The intra-class coefficient in association with the low standard error of measure and minimal detectable change percentages suggest that this procedure is appropriate for clinical and academic use as well as monitoring hamstring strength in the elite sport setting.

Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review.

Tendinopathy can be resistant to treatment and often recurs, implying that current treatment approaches are suboptimal. Rehabilitation programmes that have been successful in terms of pain reduction and return to sport outcomes usually include strength training. Muscle activation can induce analgesia, improving self-efficacy associated with reducing one's own pain. Furthermore, strength training is beneficial for tendon matrix structure, muscle properties and limb biomechanics. However, current tendon rehabilitation may not adequately address the corticospinal control of the muscle, which may result in altered control of muscle recruitment and the consequent tendon load, and this may contribute to recalcitrance or symptom recurrence. Outcomes of interest include the effect of strength training on tendon pain, corticospinal excitability and short interval cortical inhibition. The aims of this concept paper are to: (1) review what is known about changes to the primary motor cortex and motor control in tendinopathy, (2) identify the parameters shown to induce neuroplasticity in strength training and (3) align these principles with tendon rehabilitation loading protocols to introduce a combination approach termed as tendon neuroplastic training. Strength training is a powerful modulator of the central nervous system. In particular, corticospinal inputs are essential for motor unit recruitment and activation; however, specific strength training parameters are important for neuroplasticity. Strength training that is externally paced and akin to a skilled movement task has been shown to not only reduce tendon pain, but modulate excitatory and inhibitory control of the muscle and therefore, potentially tendon load. An improved understanding of the methods that maximise the opportunity for neuroplasticity may be an important progression in how we prescribe exercise-based rehabilitation in tendinopathy for pain modulation and potentially restoration of the corticospinal control of the muscle-tendon complex.

Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations.

Synopsis The hallmark features of patellar tendinopathy are (1) pain localized to the inferior pole of the patella and (2) load-related pain that increases with the demand on the knee extensors, notably in activities that store and release energy in the patellar tendon. While imaging may assist in differential diagnosis, the diagnosis of patellar tendinopathy remains clinical, as asymptomatic tendon pathology may exist in people who have pain from other anterior knee sources. A thorough examination is required to diagnose patellar tendinopathy and contributing factors. Management of patellar tendinopathy should focus on progressively developing load tolerance of the tendon, the musculoskeletal unit, and the kinetic chain, as well as addressing key biomechanical and other risk factors. Rehabilitation can be slow and sometimes frustrating. This review aims to assist clinicians with key concepts related to examination, diagnosis, and management of patellar tendinopathy. Difficult clinical presentations (eg, highly irritable tendon, systemic comorbidities) as well as common pitfalls, such as unrealistic rehabilitation time frames and overreliance on passive treatments, are also discussed. J Orthop Sports Phys Ther 2015;45(11):887-898. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5987.

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.

BACKGROUND: Few interventions reduce patellar tendinopathy (PT) pain in the short term. Eccentric exercises are painful and have limited effectiveness during the competitive season. Isometric and isotonic muscle contractions may have an immediate effect on PT pain. METHODS: This single-blinded, randomised cross-over study compared immediate and 45 min effects following a bout of isometric and isotonic muscle contractions. Outcome measures were PT pain during the single-leg decline squat (SLDS, 0-10), quadriceps strength on maximal voluntary isometric contraction (MVIC), and measures of corticospinal excitability and inhibition. Data were analysed using a split-plot in time-repeated measures analysis of variance (ANOVA). RESULTS: 6 volleyball players with PT participated. Condition effects were detected with greater pain relief immediately from isometric contractions: isometric contractions reduced SLDS (mean±SD) from 7.0±2.04 to 0.17±0.41, and isotonic contractions reduced SLDS (mean±SD) from 6.33±2.80 to 3.75±3.28 (p<0.001). Isometric contractions released cortical inhibition (ratio mean±SD) from 27.53%±8.30 to 54.95%±5.47, but isotonic contractions had no significant effect on inhibition (pre 30.26±3.89, post 31.92±4.67; p=0.004). Condition by time analysis showed pain reduction was sustained at 45 min postisometric but not isotonic condition (p<0.001). The mean reduction in pain scores postisometric was 6.8/10 compared with 2.6/10 postisotonic. MVIC increased significantly following the isometric condition by 18.7±7.8%, and was significantly higher than baseline (p<0.001) and isotonic condition (p<0.001), and at 45 min (p<0.001). CONCLUSIONS: A single resistance training bout of isometric contractions reduced tendon pain immediately for at least 45 min postintervention and increased MVIC. The reduction in pain was paralleled by a reduction in cortical inhibition, providing insight into potential mechanisms. Isometric contractions can be completed without pain for people with PT. The clinical implications are that isometric muscle contractions may be used to reduce pain in people with PT without a reduction in muscle strength.

Forearm position's alteration of radial-head impingement on wrist-extensor tendons.

CONTEXT: Lateral epicondylalgia, pain at the lateral elbow, is commonly associated with extensor carpi radialis brevis tendinopathy. The radial head, which abuts the extensor tendons and is elliptical in shape, may affect the extensor tendons during pronation of the forearm. Cadaverous studies have shown that the radial head may act as a cam in pronation, to offer a mechanical advantage to the common extensor tendon and to mitigate load on the origin of the extensor carpi radialis brevis tendon. OBJECTIVE: To determine the effect of radial-head position on the wrist-extensor tendons in vivo. DESIGN: Repeated-measures design. SETTING: Laboratory. PARTICIPANTS: 22 participants (12 male, 2 left-handed). MAIN OUTCOME MEASURES: Distance (mm) from subcutaneous fascia to radial head measured by ultrasound. RESULTS: The radial head in supination was significantly deeper than either pronation or midprone, indicating a smaller cam effect in supination. CONCLUSION: The authors recommend that the effect of radial-head position and its relationship to the area of tendon pathology be considered clinically in the rehabilitation of patients suffering from lateral epicondylalgia.