Publications by authors named "Sean Docking"

41 Publications

Prevalence and pain distribution of anterior knee pain in college basketball players.

J Athl Train 2021 Jul 30. Epub 2021 Jul 30.

1La Trobe Sport and Exercise Medicine Research Centre; College of Science, Health and Engineering; La Trobe University; Australia.

Context: Causes of anterior knee pain (AKP) in jumping athletes include patellofemoral pain and patellar tendinopathy. Differential diagnosis of AKP is challenging, with variation in clinical presentations. No previous research has used pain location to describe AKP in basketball athletes.

Objectives: To describe the prevalence and pain distribution of AKP in college basketball. To report the prevalence of focal inferior pole pain using two outcome measures.

Design: Cross-sectional study Setting: University and college basketball facilities in Alberta, Canada.

Patients Or Other Participants: 242 collegiate basketball athletes Main Outcome Measure(s): The single leg decline squat test (SLDS) was used to capture pain location using pain mapping (dichotomised into focal/diffuse) and pain severity (numerical rating scale). The Oslo Sports Trauma Research Centre Knee questionnaire (OSTRC-Knee) and adapted version for patellar tendinopathy (OSTRC-P) were used to report the prevalence of anterior knee pain (AKP) and patellar tendinopathy respectively. Focal inferior pole pain during the SLDS was used to classify patellar tendinopathy.

Results: Of the 242 players (138 women, 104 men), 146 (60%) reported pain with the SLDS [unilateral n=64, (26%); bilateral n=82 (34%)]. 101 (43%) reported knee pain using the OSTRC-Knee. Pain mapping captured variability in pain location. Diffuse pain was more prevalent [left 70%; right 72%] than focal pain [left 30%; right 28%]. There was low prevalence of patellar tendinopathy with either outcome measure; OSTRC-P [n=21, 8.7%] and inferior pole pain during the SLDS [n=25, 10.3%] Conclusions: Diffuse AKP was common in Canadian basketball players, however pain mapped to the inferior pole of the patella was not. Few players reported tendinopathy using the OSTRC-P, suggesting that patellar tendinopathy was not a primary knee pain presentation in this jumping cohort. Pain location rather than presence or severity of pain alone may better describe the clinical presentations of AKP in jumping athletes.
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http://dx.doi.org/10.4085/1062-6050-0604.20DOI Listing
July 2021

Nearly 40% of adolescent athletes report anterior knee pain regardless of maturation status, age, sex or sport played.

Phys Ther Sport 2021 Sep 27;51:29-35. Epub 2021 Jun 27.

La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia; Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Clayton, VIC, Australia; Cabrini Institute, Cabrini Health, Malvern, VIC, Australia.

Objective: To report point prevalence of anterior knee pain (AKP) in adolescent athletes by (1) maturation status, (2) chronological age, (3) sex, and (4) primary sport.

Design: Cross-sectional.

Methods: Male and female participants aged 11-15 years were recruited from specialised sports programs for basketball, volleyball, Australian Rules Football and tennis. Standing height, sitting height, and body mass were measured and used to calculate maturity status. Past injury history, self-reported physical activity, and Victorian Institute of Sport Assessment Questionnaire Patellar Tendon (VISA-P) questionnaires were completed. Anterior knee pain was defined as any pain experienced on the anterior surface of the knee and recorded using a visual analogue scale (VAS). A single leg decline squat (SLDS) was performed for provocation of AKP.

Results: Two hundred and seventeen male and female adolescent athletes participated in this study. Twenty participants were excluded from data analysis. Point prevalence of AKP was 39% (N = 76). Average self-reported physical activity/week was 7.9 ± 4.1 h of their specialised sport and 2.0 ± 2.0 h of other physical activity/week. Maturation status, chronological age, sex nor primary sporting program was statistically significant in explaining the presence or absence of AKP.

Conclusion: Due to the right-skewed maturation sample, the authors cannot state conclusively that maturation status was not associated with AKP. Nearly 40% of this cohort reported AKP during a pain provocation test. The presence of AKP was not explained by maturation status, age, sex or primary sport program. Given the chronic nature of AKP and future morbidity reported, this high prevalence provides rationale for intervention or prevention studies targeting younger athletes.
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http://dx.doi.org/10.1016/j.ptsp.2021.06.005DOI Listing
September 2021

Differences in Biomechanical Loading Magnitude During a Landing Task in Male Athletes with and without Patellar Tendinopathy.

J Athl Train 2021 Apr 22. Epub 2021 Apr 22.

2Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC USA.

Context: Prior research has not established if overloading or underloading movement profiles are present in symptomatic and asymptomatic athletes with patellar tendon structural abnormality (PTA) compared to healthy athletes.

Objective: The purpose was to compare involved limb landing biomechanics between male athletes with and without patellar tendinopathy.

Design: Cross-sectional study Setting: Laboratory Patients or Other Participants: 43 males were grouped based on patellar tendon pain & ultrasound imaging of the proximal patellar tendon: symptomatic with PTA (SYM-PTA; n=13; 20±2yrs; 1.8±0.1m; 84±5kg), asymptomatic with PTA (ASYM-PTA; n=15; 21±2yrs; 1.8±0.1m; 82±13kg), and healthy control (CON; n=15; 20±2yrs; 1.8±0.1m; 79±12kg).

Main Outcome Measures: 3D biomechanics were collected during double-limb jump-landing. Kinematic (knee flexion angle (KF)) and kinetic (vertical ground reaction force (VGRF); internal knee extension moment (KEM); patellar tendon force (FPT)) variables were analyzed as continuous waveforms during the stance phase for the involved limb. Mean values were calculated for each 1% of stance, normalized over 202 data points (0-100%), and plotted with 95% confidence intervals. Statistical significance was defined as a lack of 95% CI overlap for ≥ 6 consecutive data points.

Results: SYM-PTA had lesser KF than CON throughout the stance phase. ASYM-PTA had lesser KF than CON in the early and late stance phase. SYM-PTA group had lesser KEM and FPT than CON in early stance, as well as ASYM-PTA in mid-stance.

Conclusions: Male athletes with SYM-PTA demonstrated a patellar tendon load-avoidance profile compared to ASYM-PTA and CON athletes. ASYM-PTA did not show evidence of overloading compared to CON. Our findings support the need for individualized treatments for athletes with tendinopathy to maximize load-capacity.

Trial Registry: ClinicalTrials.gov (#XXX).
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http://dx.doi.org/10.4085/1062-6050-0548.20DOI Listing
April 2021

Physical Activity and Investigation With Magnetic Resonance Imaging Partly Explain Variability in the Prevalence of Patellar Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals.

J Orthop Sports Phys Ther 2021 05 28;51(5):216-231. Epub 2021 Mar 28.

Objective: To estimate the pooled prevalence of, and factors associated with, the presence of patellar tendon abnormalities observed on imaging in people without symptoms.

Design: Systematic review with stratified meta-analysis and meta-regression.

Literature Search: We searched Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science from 1980 to August 2020.

Study Selection Criteria: We included studies that reported the prevalence of asymptomatic patellar tendon abnormalities on imaging. We excluded studies of participants with current tendon pain, a history of tendon pain, or other systemic conditions.

Data Synthesis: Stratification and meta-regression of studies based on study-level descriptive statistics (mean age, body mass index, proportion of female participants, physical activity participation, imaging modality) were performed using a random-effects model to account for between-study heterogeneity. Risk of bias was assessed using the modified Newcastle-Ottawa scale.

Results: Meta-analysis of 64 studies (7125 limbs from 4616 participants) found significant between-study heterogeneity (I≥90%, <.01), which precluded a summary prevalence estimate. Heterogeneity was partially explained by studies that included participants who were physically active and studies that assessed tendon abnormalities using magnetic resonance imaging compared to ultrasound (<.05). Mean age, body mass index, proportion of female participants, and sample size did not explain the remaining heterogeneity.

Conclusion: There was substantial variability in the reported prevalence of asymptomatic patellar tendon abnormalities. A clear and valid method is needed to assess and report the presence of patellar tendon abnormalities to increase research capacity and establish the clinical value of imaging the patellar tendon. .
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http://dx.doi.org/10.2519/jospt.2021.10054DOI Listing
May 2021

Explaining Variability in the Prevalence of Achilles Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals.

J Orthop Sports Phys Ther 2021 05 28;51(5):232-252. Epub 2021 Mar 28.

Objective: To estimate the prevalence of, and factors associated with, Achilles tendon abnormalities observed on imaging in asymptomatic individuals.

Design: Systematic review with stratified meta-analysis and meta-regression.

Literature Search: Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science were searched from 1980 to August 2020.

Study Selection Criteria: We included studies that reported the prevalence of Achilles tendon abnormalities, observed with any imaging modality, in an asymptomatic population. We excluded studies if participant mean age was younger than 12 years or if participants had current/previous lower-limb tendon injuries/symptoms or other systemic conditions.

Data Synthesis: Random-effects proportion meta-analysis was used to estimate prevalence. We used meta-regression for continuous variables (mean age and body mass index [BMI], sample size, proportion of female participants) and stratified categorical variables (imaging modality and participation in physical activity) to explain between-study heterogeneity.

Results: We included 91 studies (10 156 limbs, 5841 participants). The prevalence of Achilles tendon abnormalities on imaging ranged from 0% to 80% per participant. Between-study heterogeneity was high (I>90%, <.001), precluding data pooling. Between-study heterogeneity was partly explained by participant mean BMI (slope, 2.8% per 1-unit increase in BMI; 95% confidence interval: 0.57%, 5.03%; = .015) and participation in physical activity per limb, and mean age of 40 years old or older ( = .022) per participant.

Conclusion: There was substantial variability in the prevalence of Achilles tendon abnormalities on imaging in asymptomatic individuals. Higher prevalence of abnormalities was associated with older age (40 years old or older), higher BMI, and participation in physical activity. A large proportion of heterogeneity remains unaccounted for, likely due to variations in abnormality definitions and study design. .
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http://dx.doi.org/10.2519/jospt.2021.9970DOI Listing
May 2021

Assessment of trunk lateral flexion range of movement using a novel method in first class cricket players.

J Athl Train 2021 Mar 3. Epub 2021 Mar 3.

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia

Objectives: Lateral flexion range of movement (LF ROM) is used to assess and monitor recovery of side strain injury in athletes. This study established a reliable and pragmatic measure of LF ROM and investigated the stability of the measure over time in athletes.

Design: 1) Cross-sectional reliability study and 2) Cohort longitudinal study.

Setting: Elite cricket teams in COUNTRY-AAA and COUNTRY-BBB Participants: Cricket players Methods: 1) The intra- and inter-rater reliability of two methods of measuring LF ROM were assessed (distance to the floor or distance to fibular head). Ten healthy first-class cricket bowlers were tested by three experienced physiotherapists. Intra-class correlations (2,1) were calculated for absolute agreement for all 3 testers. 2) Professional cricket fast bowlers were recruited from COUNTRY-AAA and COUNTRY-BBB domestic and international competitions. Lateral flexion range of movement was measured monthly during the pre- and competitive season. A one-way repeated measures analysis of variance was performed to identify difference within the pre-season, within the competitive season, and between competitive seasons.

Main Outcome Measures: Lateral flexion range of movement towards and away from the bowling arm.

Results: Both methods had good intra- and inter-test reliability (ICC>0.84). As LF ROM to the floor was easier for clinicians it was used for the longitudinal study. Lateral flexion range of movement did not significantly alter throughout the pre- and competitive season or between seasons (p>0.05).

Conclusions: This new method of describing LF ROM demonstrates good intra- and inter-rater reliability and stability over time and can be used as an outcome measure in side-strain injury.
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http://dx.doi.org/10.4085/564-20DOI Listing
March 2021

Considerations for multi-centre conditioned pain modulation (CPM) research; an investigation of the inter-rater reliability, level of agreement and confounders for the Achilles tendon and Triceps Surae.

Br J Pain 2021 Feb 17;15(1):91-101. Epub 2020 Apr 17.

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia.

Objective: This study aimed to investigate the inter-rater reliability of the conditioned pain modulation (CPM) effect.

Methods: The reliability between two examiners assessing the CPM effect via pressure pain thresholds and induced using the cold pressor test of 28 healthy volunteers at the mid-portion Achilles tendon (AT) and Triceps Surae musculotendinous junction was performed. Reliability was calculated using intraclass correlation coefficient (ICC). Confounders were assessed using multivariable generalised estimating equations (GEEs). Bias in the level of agreement was assumed if the confidence intervals (CIs) of the mean difference in Bland-Altman plots did not cross the line of equality.

Results: The inter-rater reliability of the CPM effect was poor to moderate in the AT (ICC 95% CI = 0.00-0.66) and Triceps Surae (ICC 95% CI = 0.00-0.69). However, when accounting for confounders within the GEE, there were no differences between testers and Bland-Altman plots reported good agreement between testers. Habitual completion of running-related physical activity was a confounder for both the AT parallel-paradigm (p = 0.017) and sequential-paradigm (p = 0.029). Testing order was a confounder for the AT (p = 0.023) and Triceps Surae (p = 0.014) parallel-paradigm.

Conclusion: This study suggests the CPM effect may be site specific (i.e. differences between the AT and Triceps Surae exist). In addition, differences in the reliability between examiners are likely due to the influence of confounders and not examiner technique and therefore appropriate analysis should be used in research investigating the CPM effect.
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http://dx.doi.org/10.1177/2049463720912208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882768PMC
February 2021

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

Phys Ther Sport 2021 May 19;49:51-61. Epub 2020 Sep 19.

La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia. Electronic address:

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.
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http://dx.doi.org/10.1016/j.ptsp.2020.09.008DOI Listing
May 2021

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.

J Sci Med Sport 2021 May 4;24(5):441-447. Epub 2020 Nov 4.

School of Physiotherapy, The University of Notre Dame Australia, Fremantle, WA, Australia.

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.
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http://dx.doi.org/10.1016/j.jsams.2020.10.015DOI Listing
May 2021

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

Br J Sports Med 2021 May 28;55(9):486-492. Epub 2020 Sep 28.

Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.

Objectives: To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy.

Methods: This was a parallel-group randomised superiority trial at a single centre (La Trobe University Health Sciences Clinic, Discipline of Podiatry, Melbourne, Victoria, Australia). One hundred participants (52 women and 48 men, mean age 45.9, SD 9.4 years) with clinically diagnosed and ultrasonographically confirmed mid-portion Achilles tendinopathy were randomly allocated to either a (1) heel lifts (n=50) or (2) eccentric exercise (n=50) group. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 12 weeks. Differences between groups were analysed using intention to treat with analysis of covariance.

Results: There was 80% follow-up of participants (n=40 per group) at 12 weeks. The mean VISA-A score improved by 26.0 points (95% CI 19.6 to 32.4) in the heel lifts group and by 17.4 points (95% CI 9.5 to 25.3) in the eccentric exercise group. On average, there was a between-group difference in favour of the heel lifts for the VISA-A (adjusted mean difference 9.6, 95% CI 1.8 to 17.4, p=0.016), which approximated, but did not meet our predetermined minimum important difference of 10 points.

Conclusion: In adults with mid-portion Achilles tendinopathy, heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks. However, there is uncertainty in the estimate of effect for this outcome and patients may not experience a clinically worthwhile difference between interventions.

Trial Registration Number: ACTRN12617001225303.
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http://dx.doi.org/10.1136/bjsports-2019-101776DOI Listing
May 2021

Landing biomechanics are not immediately altered by a single-dose patellar tendon isometric exercise protocol in male athletes with patellar tendinopathy: A single-blinded randomized cross-over trial.

Phys Ther Sport 2020 Nov 12;46:177-185. Epub 2020 Sep 12.

Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Orthopedics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Objectives: To a) determine the acute effects of a single-dose patellar tendon isometric exercise protocol on involved limb landing biomechanics in individuals with patellar tendinopathy and asymptomatic patellar tendon pathology, and b) determine if individuals with patellar tendinopathy demonstrated changes in pain following a single-dose patellar tendon isometric exercise protocol.

Design: Single-blinded randomized cross-over trial.

Setting: Laboratory; PARTICIPANTS: 28 young male athletes with symptomatic (n = 13, age: 19.62 ± 1.61) and asymptomatic (n = 15, age: 21.13 ± 1.88) patellar tendinopathy.

Main Outcome Measures: Participants completed a single-dose patellar tendon isometric exercise protocol and a sham-TENS protocol, randomized and separated by 7-10 days. Pain-levels during a single-limb decline squat (SLDS) and three-dimensional biomechanics were collected during a double-limb jump-landing task before and after each intervention protocol. A mixed-model repeated measures ANOVA was conducted to compare change scores for all dependent variables.

Results: There were no group × intervention interactions for change in pain (F = 0.555, p = 0.463). There was one significant group × intervention interaction for vertical ground reaction force (VGRF) (F = 5.33, p = 0.029). However, post-hoc testing with Bonferroni correction demonstrated no statistical significance for group (SYM: t = -1.679, p = 0.119; ASYM: t = -1.7, p = 0.107) or intervention condition (isometric: t = -2.58, p = 0.016; sham-TENS: 0.72, p = 0.460). There were no further significant group × intervention interactions (p > 0.05).

Conclusions: A single-dose patellar tendon isometric exercise protocol did not have acute effects on landing biomechanics or pain levels in male athletes with patellar tendinopathy or asymptomatic patellar tendon pathology.
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http://dx.doi.org/10.1016/j.ptsp.2020.09.003DOI Listing
November 2020

Self-reported jumpers' knee is common in elite basketball athletes - But is it all patellar tendinopathy?

Phys Ther Sport 2020 May 23;43:58-64. Epub 2020 Jan 23.

La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Australia. Electronic address:

Objectives: To describe the prevalence and pain location of self-reported patellar tendinopathy and patellar tendon abnormality in a male elite basketball population.

Design: Cross-sectional.

Setting: Pre-season tournament.

Participants: Sixty male athletes from the Australian National Basketball League.

Main Outcome Measures: Self-reported patellar tendinopathy (PT) using the Oslo Sports Trauma Research Centre Overuse Questionnaire (OSTRC). Pain location using pain mapping (dichotomised: focal/diffuse) and severity during the single leg decline squat. Ultrasound tissue characterisation scans of both patellar tendons.

Results: Thirteen participants (22.7%) self-reported PT. Only 3 who reported PT had localised inferior pole pain. Thirty athletes reported pain during the decline squat, 15 described focal pain; 10 diffuse pain (5 missing data). Those with diffuse pain had greater years played [Md = 21 (13-24), n = 10 than focal pain (Md = 12 (7-26), n = 15), p = 0.042, r = 0.3]. Bilateral tendon abnormality was found in 45% of athletes and 15% had unilateral tendon abnormality.

Conclusion: Elite male basketball athletes self-reporting PT had heterogeneity in pain location. When focal pain with loading was used as a primary definition of PT, 'jumpers' knee' was not common in this cohort. This study found that abnormality of the patellar tendon was common and did not correlate with symptoms.
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http://dx.doi.org/10.1016/j.ptsp.2020.01.012DOI Listing
May 2020

Improved reporting of overuse injuries and health problems in sport: an update of the Oslo Sport Trauma Research Center questionnaires.

Br J Sports Med 2020 Apr 14;54(7):390-396. Epub 2020 Feb 14.

Department of Public and Occupational Health, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands.

In 2013, the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O) was developed to record the magnitude, symptoms and consequences of overuse injuries in sport. Shortly afterwards, a modified version of the OSTRC-O was developed to capture all types of injuries and illnesses-The Oslo Sports Trauma Research Center Questionnaire on Health Problems (OSTRC-H). Since then, users from a range of research and clinical environments have identified areas in which these questionnaires may be improved. Therefore, the structure and content of the questionnaires was reviewed by an international panel consisting of the original developers, other user groups and experts in sports epidemiology and applied statistical methodology. Following a review panel meeting in October 2017, several changes were made to the questionnaires, including minor wording alterations, changes to the content of one question and the addition of questionnaire logic. In this paper, we present the updated versions of the questionnaires (OSTRC-O2 and OSTRC-H2), assess the likely impact of the updates on future data collection and discuss practical issues related to application of the questionnaires. We believe this update will improve respondent adherence and improve the quality of collected data.
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http://dx.doi.org/10.1136/bjsports-2019-101337DOI Listing
April 2020

Landing Biomechanics, But Not Physical Activity, Differ in Young Male Athletes With and Without Patellar Tendinopathy.

J Orthop Sports Phys Ther 2020 Mar 6;50(3):158-166. Epub 2020 Jan 6.

Objective: To examine differences in biomechanical and physical activity load in young male athletes with and without patellar tendinopathy.

Design: Cross-sectional cohort study.

Methods: Forty-one young male athletes (15-28 years of age) were categorized into 3 distinct groups: symptomatic athletes with patellar tendon abnormalities (PTA) (n = 13), asymptomatic athletes with PTA (n = 14), and a control group of asymptomatic athletes without PTA (n = 14). Participants underwent a laboratory biomechanical jump-landing assessment and wore an accelerometer for 1 week of physical activity monitoring.

Results: The symptomatic group demonstrated significantly less patellar tendon force loading impulse in the involved limb compared with both the control and asymptomatic groups (<.05), with large effects ( = 0.91-1.40). There were no differences in physical activity between the 3 groups (>.05).

Conclusion: Young male athletes with symptomatic patellar tendinopathy demonstrated smaller magnitudes of patellar tendon force loading impulse during landing compared to both asymptomatic athletes with patellar tendinopathy and healthy control participants. However, these 3 distinct groups did not differ in general measures of physical activity. Future investigations should examine whether comprehensively monitoring various loading metrics may be valuable to avoid both underloading and overloading patterns in athletes with patellar tendinopathy. .
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http://dx.doi.org/10.2519/jospt.2020.9065DOI Listing
March 2020

How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: A narrative review.

J Musculoskelet Neuronal Interact 2019 09;19(3):300-310

La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Australia.

Understanding how tendons adapt to load is crucial to understanding how training can improve performance, minimise the risk of injury and aid rehabilitation. Adaptation is the positive response of an organism or tissue to benefit its function. In tendons, numerous tissue responses to load have been identified . Changes in tendon dimensions, structure on imaging, mechanical properties, and blood flow have been reported in response to mechanical stimuli. However, research has focused on tissue level changes with little understanding of how changes at the tissue level affect the person, their athletic performance or injury risk. Tendons can have a paradoxical response to load, load can induce positive adaptation, however it is also a major factor in the development of tendon pathology and pain. Tendon pathology is a risk factor for developing symptoms, yet the high rate of asymptomatic pathology suggests that the pathological tendon must adapt to be able to tolerate load. Similarly, there is mounting evidence to suggest that tendon remodelling or repair is not necessary for a positive clinical outcome following rehabilitation, suggesting that the tendon must adapt via other mechanisms. This narrative review synthesises evidence of how normal and pathological tendons adapts to load, and how this relates to adaptation of load capacity and function of the individual.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737558PMC
September 2019

MRI findings are associated with time to return to play in first class cricket fast bowlers with side strain in Australia and England.

J Sci Med Sport 2019 Sep 7;22(9):992-996. Epub 2019 Jun 7.

La Trobe Sport and Exercise Medicine Research Centre La Trobe University, Australia.

Objectives: To investigate the reliability of reporting and relationship between MRI parameters at injury and time to return to play (RTP) in first class cricket fast bowlers with side strain in Australia and England.

Design: Cohort study.

Methods: Eighty MRI scans of side strain injuries to 57 fast bowlers were sourced. Ten scans were reported by three experienced radiologists to determine intra- and inter-rater reliability. The relationship between six MRI parameters (muscle injured, presence of a muscle tear, rib level of injury, presence of blood fluid products/haematoma, periosteal stripping, rib oedema) and time to RTP was investigated with 39 scans reported by a single radiologist with known intra-rater reliability. The association between parameters and time to RTP was analysed with an ordinal logistic regression model.

Results: Recovery time was prolonged with a mean of 39days (standard deviation: 14days) and 44% of bowlers requiring more than 6weeks to RTP. Reliability levels between parameters varied widely. The presence or absence of a muscle tear was the only MRI parameter associated with time to RTP. Players with a muscle tear were 8 times more likely to take more than 6weeks to RTP. The multifactorial model was predictive of recovery time in only 53% of this cohort, leaving 47% of total variance in time to RTP unexplained.

Conclusions: The presence of a muscle tear was associated with time to RTP in cricket fast bowlers with side strain injury in first class cricket in Australia and England.
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http://dx.doi.org/10.1016/j.jsams.2019.05.020DOI Listing
September 2019

Extracorporeal Shock Wave Therapy Immediately Affects Achilles Tendon Structure and Widespread Pressure Pain Thresholds in Healthy People: A Repeated-Measures Observational Study.

Am J Phys Med Rehabil 2019 09;98(9):806-810

From the Chinese University of Hong Kong, Pond Cres, Ma Liu Shui, Hong Kong (HTL); and La Trobe Sport & Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia (SD, MG, CB, JC, ER).

Objective: Extracorporeal shockwave therapy is a common clinical treatment for tendinopathy, yet negative effects on tendon structure have been shown in animal studies. This study aimed to investigate the effect of extracorporeal shockwave therapy in healthy participants (i.e., no Achilles tendon pain or pathology).

Design: This study examined the effect of three bouts of weekly extracorporeal shockwave therapy for 3 wks in 13 healthy participants. Outcomes measures assessed were as follows: (a) Achilles tendon structure, quantified using ultrasound tissue characterization (before and 3 hrs after extracorporeal shockwave therapy), (b) pressure pain thresholds, over the Achilles tendon and common extensor tendon origin (before, immediately after, and 3 hrs after extracorporeal shockwave therapy), and (c) hop pain (before and immediately after extracorporeal shockwave therapy).

Results: There was a significant reduction in echo type I (P < 0.05) and increase in echo type II (P < 0.05) at 3 hrs after the first extracorporeal shockwave therapy session that recovered to baseline levels before week 2. There were no significant changes in ultrasound tissue characterization echo pattern observed in subsequent sessions. There were increased pressure pain thresholds immediately after extracorporeal shockwave therapy at the common extensor tendon origin but no significant change at the Achilles tendon. Pressure pain thresholds returned to baseline at 3 hrs after extracorporeal shockwave therapy. There were no significant changes in pressure pain threshold in subsequent sessions.

Conclusions: Extracorporeal shockwave therapy resulted in transient changes to tendon structure and widespread hyperalgesia.
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http://dx.doi.org/10.1097/PHM.0000000000001203DOI Listing
September 2019

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

J Foot Ankle Res 2019 21;12:20. Epub 2019 Mar 21.

1Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria 3086 Australia.

Background: Mid-portion Achilles tendinopathy is a common musculoskeletal condition characterised by degeneration of the Achilles tendon, which causes pain and disability. Multiple non-surgical treatments have been advocated for this condition including calf muscle eccentric exercise and in-shoe heel lifts. Although adherence is challenging, there is evidence to suggest that calf muscle eccentric exercise is effective in decreasing pain and improving function in people with Achilles tendinopathy. Heel lifts reduce ankle joint dorsiflexion and Achilles tendon strain, however their efficacy in the management of Achilles tendinopathy is unclear. This article describes the design of a parallel-group randomised trial comparing the efficacy of heel lifts to calf muscle eccentric exercise for Achilles tendinopathy.

Methods: Ninety-two participants with Achilles tendinopathy will be randomised to one of two groups: (i) a heel lift group that will receive pre-fabricated 12 mm in-shoe heel lifts (Clearly Adjustable®), or (ii) an exercise group that will be advised to carry out a calf muscle eccentric exercise program (twice a day, 7 days a week, for 12 weeks). Outcome measures will be obtained at baseline, 2, 6 and 12 weeks; the primary endpoint for assessing efficacy being 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. Secondary outcome measures will include thickness and integrity of the Achilles tendon (using ultrasound tissue characterisation [UTC]), participant perception of treatment effect on pain and function (using the 7-point Patient Global Impression of Change scale), severity of pain at the Achilles tendon (using a 100 mm visual analogue scale) in the previous week, health status (using the EuroQol-5D-5L™ questionnaire), physical activity levels (using the 7-day Recall Physical Activity Questionnaire) and calf muscle function (using the standing heel rise test). Data will be analysed using the intention to treat principle.

Discussion: The HEALTHY trial (Heel lifts versus calf muscle eccentric Exercise for AchiLles TendinopatHY) is the first randomised trial to compare the efficacy of heel lifts to calf muscle eccentric exercise in reducing pain and improving function in people with Achilles tendinopathy. A pragmatically designed trial was developed to ensure that if the interventions are found to be effective, the findings can be readily implemented in clinical practice.

Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12617001225303. Registered on August 22nd, 2017.
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http://dx.doi.org/10.1186/s13047-019-0325-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6429802PMC
July 2019

Diagnostic accuracy of imaging modalities in the detection of clinically diagnosed de Quervain's syndrome: a systematic review.

Skeletal Radiol 2019 Nov 19;48(11):1715-1721. Epub 2019 Mar 19.

La Trobe Sport and Exercise Medicine Research Centre; College of Science, Health and Engineering, La Trobe University, Bundoora, Australia.

Objectives: To collate and synthesise the literature to provide estimates of the diagnostic accuracy of imaging modalities, and summarise the reported imaging findings associated with de Quervain's syndrome.

Materials And Methods: A systematic search was performed in seven databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PROSPERO, Web of Science, and ProQuest Dissertations & Theses Global). Two reviewers independently performed screening, data extraction and quality assessment using a modified Quality Assessment of Diagnostic Accuracy Studies-2. Measures of diagnostic accuracy were summarised for different modalities and imaging findings.

Results: Twenty-two studies were included, reporting ultrasound, magnetic resonance imaging, X-ray and scintigraphy findings. Reported imaging findings included sheath effusion, retinaculum thickening, subcutaneous oedema, tenosynovitis, hypervascularity, increased tendon size, bony erosion, apposition, calcific lesions and increased uptake on scintigraphy. The most commonly reported imaging findings related to the tendon sheath, with a sensitivity ranging from 0.45 to 1.00 for thickening, and 0.29 to 1.00 for effusions. The risk of bias of studies is largely unclear owing to a lack of reported detail.

Conclusions: The accuracy of imaging in the diagnosis of de Quervain's syndrome is unable to be determined because of the quality of the studies included. Ultrasound is the most frequently studied imaging modality and may be the modality of choice in clinical practice. Further research involving both symptomatic and asymptomatic participants and clear definitions of abnormal findings are required to better evaluate the effectiveness of imaging in identifying de Quervain's syndrome.
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http://dx.doi.org/10.1007/s00256-019-03195-zDOI Listing
November 2019

Identification and differentiation of gluteus medius tendon pathology using ultrasound and magnetic resonance imaging.

Musculoskelet Sci Pract 2019 06 7;41:1-5. Epub 2019 Feb 7.

Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, 2617, Australia; Research Institute for Sport and Exercise, University of Canberra, 2617, Australia.

Background: It has been suggested that imaging findings play a role in directing treatment for Greater Trochanteric Pain Syndrome. Structural diagnoses associated with Greater Trochanter Pain Syndrome include gluteal tendinosis, and partial- or full-thickness gluteal tendon tears. However, few studies have compared imaging to confirmed tendon pathology observed during surgery.

Objective: To investigate the ability of magnetic resonance and ultrasound imaging to identify the presence of a pathological gluteus medius tendon in comparison to surgical and histological findings.

Study Design: Cross-sectional study.

Methods: 26 participants undergoing gluteal tendon reconstruction surgery or hip arthroplasty were included. Prior to surgery, participants underwent both magnetic resonance (MR) (n = 23) and ultrasound (US) (n = 25) imaging. A radiologist (MR) and nuclear physicians (US) classified the gluteus medius tendon as normal, tendinosis (no tear), partial-thickness tear, or full-thickness tear.

Results: Ultrasound identified 17 out of the 19 pathological gluteus medius tendons correctly. However, 5 of the 6 normal tendons were incorrectly identified as exhibiting pathology on ultrasound. Magnetic resonance rated 11 out of 17 pathological tendons as abnormal, with 4 out of 6 normal tendons identified correctly. Both imaging modalities were poor at identifying and differentiating between tendinosis and partial-thickness tears.

Conclusion: Both imaging modalities showed a reasonable ability to identify tendon pathology. While limited by sample size, these early findings suggest that both imaging modalities may be limited in identifying specific pathoanatomical diagnoses, such as partial-thickness tears. These limitations may misdirect treatment.
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http://dx.doi.org/10.1016/j.msksp.2019.01.011DOI Listing
June 2019

Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis.

Br J Sports Med 2019 Sep 13;53(17):1070-1077. Epub 2019 Jan 13.

School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.

Objective: To assess the effectiveness of heavy eccentric calf training (HECT) in comparison with natural history, traditional physiotherapy, sham interventions or other exercise interventions for improvements in pain and function in mid-portion Achilles tendinopathy.

Design: A systematic review and meta-analysis were conducted as per the PRISMA guidelines.

Data Sources: PUBMED, CINAHL (Ovid) and CINAHL (EBSCO) were searched from inception until 24 September 2018.

Eligibility Criteria: Randomised controlled trials comparing HECT to natural history, sham exercise, traditional physiotherapy and other exercise interventions were included. Primary outcome assessing pain and function was the Victorian Institute of Sports Assessment-Achilles.

Results: Seven studies met the inclusion criteria. This review suggests HECT may be superior to both natural history, mean difference (MD) (95% CI) of 20.6 (11.7 to 29.5, one study) and traditional physiotherapy, MD (95% CI) of 17.70 (3.75 to 31.66, two studies). Following removal of one study, at high risk of bias, due to pre-planned sensitivity analysis, this review suggests HECT may be inferior to other exercise interventions, MD (95% CI) of -5.65 (-10.51 to -0.79, three studies). However, this difference is unlikely to be clinically significant.

Conclusion: Current evidence suggests that HECT may be superior to natural history and traditional physiotherapy while HECT may be inferior to other exercise interventions. However, due to methodological limitations, small sample size and a lack of data we are unable to be confident in the results of the estimate of the effect, as the true effect is likely to be substantially different.

Systematic Review Registry: PROSPERO registration number: CRD4201804493 PROTOCOL REFERENCE: This protocol has been published open access: Murphy M, Travers MJ, Gibson, W. Is heavy eccentric calf training superior to natural history, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy? 2018; 7: 58.
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http://dx.doi.org/10.1136/bjsports-2018-099934DOI Listing
September 2019

Quantification of Achilles and patellar tendon structure on imaging does not enhance ability to predict self-reported symptoms beyond grey-scale ultrasound and previous history.

J Sci Med Sport 2019 Feb 27;22(2):145-150. Epub 2018 Jul 27.

La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Australia; Faculty of Science and Technology, Federation University Australia, Australia.

Background: Tendon pathology on imaging has been associated with an increased risk of developing symptoms. This evidence is based on classifying the tendon as normal or pathological. It is unclear whether the extent of tendon pathology is associated with the development or severity of symptoms.

Objectives: To investigate whether the presence and extent of tendon pathology on ultrasound tissue characterisation (UTC), or a previous history of symptoms, were associated with the development of symptoms over a football season.

Methods: 179 male Australian football players underwent UTC imaging of their Achilles and/or patellar tendon at the start of the pre-season. Players completed monthly OSTRC overuse questionnaires to quantify the presence and severity of Achilles and/or patellar tendon symptoms. Risk factor analysis was performed to identify associations between imaging and the development of symptoms.

Results: A pathological Achilles tendon increased the risk of developing symptoms (RR=3.2, 95%CI 1.7-5.9). Conversely, a pathological patellar tendon was not significantly associated with the development of symptoms (RR=1.8, 95%CI 0.9-3.7). Quantification of tendon structure using UTC did not enhance the ability to identify athletes who developed symptoms. Previous history of symptoms was the strongest predictor for the development of symptoms (Achilles RR=3.0 95%CI 1.8-4.8; patellar RR=3.7 95%CI 2.2-6.1).

Conclusion: Tendon pathology was associated with the development of self-reported symptoms; however previous history of symptoms was a stronger risk factor. The extent of disorganisation quantified by UTC should not be used as a marker for the presence or severity of current and future symptoms.
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http://dx.doi.org/10.1016/j.jsams.2018.07.016DOI Listing
February 2019

EVALUATING THE PROGRESS OF MID-PORTION ACHILLES TENDINOPATHY DURING REHABILITATION: A REVIEW OF OUTCOME MEASURES FOR SELF- REPORTED PAIN AND FUNCTION.

Int J Sports Phys Ther 2018 Apr;13(2):283-292

School of Physiotherapy, University of Notre Dame Australia, Fremantle, Australia.

Introduction: Management of mid-portion Achilles tendinopathy is a challenge for both clinicians and researchers. Alteration in tendon structure, muscle performance and pain processing mechanisms have been suggested as mechanisms driving improvement in pain and function. However, few trials have used consistent outcome measures to track changes in pain and function.

Objectives: 1) To identify all outcomes measures used in trials utilizing exercise-based interventions for mid-portion Achilles tendinopathy (AT) that assess self-reported pain and function and to report on the reliability and validity of the identified measures, and 2) Propose measures to optimally assess self-reported pain and function in patients with AT.

Design: Literature Review.

Data Sources: Three major electronic databases were searched from inception until May 2016 for studies using isometric, eccentric or isotonic loading protocols for mid-portion AT.

Eligibility Criteria: Randomized and non-randomized trials of isometric, eccentric or isotonic loading in people with mid-portion AT.

Results: Forty-six studies were included and all outcome measures assessing self-reported pain and function were extracted. While a variety of outcome measures have been used, few have provided reliability data. There is evidence to suggest that the Victorian Institute of Sports Assessment- Achilles (VISA-A) is the only valid and reliable measure of self-reported pain and function for people with mid-portion AT. No other outcome measures have been validated in mid-portion AT.

Conclusion: The VISA-A remains the gold standard for assessing pain and function in mid-portion AT. However, while the validity or reliability of the Numerical Rating Scale (NRS) of pain during a functional task has not been established it may be a better measure of immediate treatment effect.

Level Of Evidence: 5.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063067PMC
April 2018

Reduced Levels of Aligned Fibrillar Structure Are Not Associated With Achilles and Patellar Tendon Symptoms.

Clin J Sport Med 2020 11;30(6):550-555

La Trobe Sport and Exercise Medicine Research Center, College of Science, Health and Engineering; La Trobe University; Australia; and.

Objective: To investigate whether the mean cross-sectional area (mCSA) of aligned fibrillar structure (AFS) was associated with the presence and severity of symptoms.

Design: Prospective cohort study.

Participants: One hundred seventy-five elite male Australian football players completed monthly Oslo Sports Trauma Research Center overuse injury questionnaires for both the Achilles and patellar tendon over the season to ascertain the presence and severity of symptoms. At the start of the preseason, participants underwent ultrasound tissue characterization (UTC) imaging of the Achilles and patellar tendon.

Main Outcome Measures: Images were classified as normal or abnormal based on gray-scale ultrasound. Based on UTC quantification, the mCSA of AFS was compared between those with and without current symptoms.

Results: No difference in the mCSA of AFS was observed between those with or without tendon symptoms (P < 0.05). Similar to previous findings, 80% to 92% of abnormal tendons had similar amounts of mCSA of AFS compared with normal tendon. If reduced mCSA of AFS was present, it was not associated with the presence or severity of symptoms.

Conclusions: The prevalence, development, or severity of symptoms was not associated with decreased levels of AFS in the Achilles or patellar tendon. This suggests that a lack of structural integrity is not linked to symptoms and questions the rationale behind regenerative medicine. Most tendons are able to compensate for areas of disorganization and maintain tissue homeostasis.
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http://dx.doi.org/10.1097/JSM.0000000000000644DOI Listing
November 2020

EVALUATING THE PROGRESS OF MID-PORTION ACHILLES TENDINOPATHY DURING REHABILITATION: A REVIEW OF OUTCOME MEASURES FOR MUSCLE STRUCTURE AND FUNCTION, TENDON STRUCTURE, AND NEURAL AND PAIN ASSOCIATED MECHANISMS.

Int J Sports Phys Ther 2018 Jun;13(3):537-551

School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia.

Introduction: Alterations in tendon structure and muscle performance have been suggested as mechanisms driving improvement in pain and function with mid-portion Achilles tendinopathy (AT). However, few trials have used consistent outcome measures to track differences in muscle structure and function, tendon structure and neural and pain associated mechanisms.

Objectives: 1) Identify the outcomes measures used in trials utilising loading protocols for mid-portion AT that assess muscle structure and function, tendon structure and neural and pain associated mechanisms in order to report on the reliability of the identified measures, and 2) Propose a summary of measures for assessment of muscle structure and function, tendon structure and neural and pain associated mechanisms in patients with AT.

Design: Literature Review.

Data Sources: Three electronic databases were searched from inception until May 2016 for studies using loading protocols for mid-portion AT.

Eligibility Criteria: Randomized and non-randomized trials of loading protocols for mid-portion AT.

Results: Twenty-eight studies were included; seven assessed muscle, 21 assessed tendon and two assessed neural and pain associated mechanisms. Evidence suggests that isokinetic dynamometry, eccentric-concentric heel raise tests, single leg drop counter-movement jumps or hopping are the most reliable ways to assess muscular adaptation. Assessment of tendon structure is unlikely to have any benefit given it does not appear to correlate to clinical outcomes. The neural and pain associated mechanisms have not been thoroughly investigated.

Conclusion: Further research needs to be done to determine the role of muscle, tendon and neural adaptations using reliable outcome measures during the management of mid-portion AT.

Level Of Evidence: Level Five.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044591PMC
June 2018

Pain mapping of the anterior knee: injured athletes know best.

Scand J Pain 2018 07;18(3):409-416

La Trobe Sport and Exercise Medicine Centre (LASEM), La Trobe University, Bundoora VIC, Australia.

Background and aims Research investigating differences in pain location and distribution across conditions is lacking. Mapping a patient's pain may be a useful way of understanding differences in presentations, however the use of pain mapping during a pain provocation task has not been investigated. The aim of this study was to assess the reliability of patient and clinician rated pain maps during a pain provocation task for the anterior knee. Methods Participants were recruited from a larger study of professional Australian rules football players (n=17). Players were invited to participate if they reported a current or past history of patellar tendon pain. No clinical diagnosis was performed for this reliability study. Participants were asked to point on their own knee where they usually experienced pain, which was recorded by a clinician on a piloted photograph of the knee using an iPad. Participants then completed a single leg decline squat (SLDS), after which participants indicated where they experienced pain during the task with their finger, which was recorded by a clinician. Participants then recorded their own self-rated pain map. This process was repeated 10 min later. Pain maps were subjectively classified into categories of pain location and spread by two raters. Pain area was quantified by the number of pixels shaded. Intra- and inter-rater reliability (between participants and clinicians) were analysed for pain area, similarity of location as well as subjective classification. Results Test-retest reliability was good for participants (intraclass correlation coefficients [ICC]=0.81) but only fair for clinicians (ICC=0.47) for pain area. There was poor agreement between participants and clinicians for pain area (ICC=0.16) and similarity of location (Jaccard index=0.19). Clinicians had good inter- and intra-rater reliability of classification of pain spread (k=0.75 and 0.67). Conclusions Participant completed pain maps were more reliable than clinician pain maps. Clinicians were reliable at classifying pain based on location and type of spread. Implications Clinicians should ask patients to complete their own pain maps following a pain provocation test, to elicit the most reliable and consistent understanding of their pain perception.
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http://dx.doi.org/10.1515/sjpain-2018-0046DOI Listing
July 2018

Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis.

Sports Med 2018 Aug;48(8):1875-1891

La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia.

Background: Mid-portion Achilles tendinopathy is prevalent within both the athletic and non-athletic populations and loading protocols for Achilles tendinopathy are effective over time, though the rate of symptom change throughout rehabilitation is unknown.

Objective: The objective of this study was to determine the rate of change in pain and function over time in patients while completing a loading protocol for mid-portion Achilles tendinopathy.

Methods: A systematic review and longitudinal meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases PubMed, CINAHL (Ovid) and CINAHL (EBSCO) were searched for articles published from inception until 31 July, 2017. Our search focused on clinical trials and cohort studies examining changes in pain and function when completing a loading protocol for mid-portion Achilles tendinopathy. The primary outcome measure assessing pain and function was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire.

Results: A total of 31 separate cohorts (24 studies) were eligible, with follow-up ranging from 2 weeks to 6 months. The data were pooled to create the mean (standard deviation) of change from baseline at each time point. The data demonstrated an improvement in pain and function as early as 2 weeks that appeared to peak at 12 weeks with a mean (standard deviation) of 21.11 (6.61) points of change on the VISA-A.

Conclusion: The improvement in pain and function during rehabilitation suggests future research should be directed toward investigating contributing mechanisms as tendon structure on imaging does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following the inception of a loading protocol. Systematic Review Registry: PROSPERO registration number: CRD42017062737 ( https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=62737 ).
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http://dx.doi.org/10.1007/s40279-018-0932-2DOI Listing
August 2018

Clinical Improvements Are Not Explained by Changes in Tendon Structure on Ultrasound Tissue Characterization After an Exercise Program for Patellar Tendinopathy.

Am J Phys Med Rehabil 2018 10;97(10):708-714

From the Department of Sport and Exercise Medicine, University Medical Center Groningen, University of Groningen, the Netherlands (MvA, IvdA-S, JZ); School of Physiotherapy, Monash University, Frankston, Australia (MvA, ER, JC, SD); Department of Physiotherapy, Hanze University of Applied Sciences Groningen, the Netherlands (MvA); Centre of Expertise Primary Care Groningen (ECEZG), the Netherlands (MvA); La Trobe University Sport and Exercise Medicine Research Centre. Bundoora, Australia (ER, JC, SD); Australian Collaboration for Research into Sports Injury and Its Prevention (ACRISP), Federation University, Ballarat, Australia (ER, SD); and University of Canberra Research Institute for Sport and Exercise (UCRISE), Australia (JEG).

Objectives: The aim of this study was to investigate the effects of a 4-wk in-season exercise program of isometric or isotonic exercises on tendon structure and dimensions as quantified by ultrasound tissue characterization (UTC).

Design: This was a randomized clinical trial. Volleyball and basketball players (16-31 yrs, n = 29) with clinically diagnosed patellar tendinopathy were randomized to a 4-wk isometric or isotonic exercise program. The programs were designed to decrease patellar tendon pain. A baseline and 4-wk UTC scan was used to evaluate change in tendon structure.

Results: No significant change in tendon structure or dimensions on UTC was detected after the exercise program despite patellar tendinopathy symptoms improving. The percentage and mean cross-sectional area of aligned fibrillar structure (echo types I + II) (Z = -0.414, P = 0.679) as well as disorganized structure (echo types III + IV) (Z = -0.370, P = 0.711) did not change over the 4-wk exercise program. Change in tendon structure and dimensions on UTC did not differ significantly between the groups.

Conclusion: Structural properties and dimensions of the patellar tendon on UTC did not change after a 4-wk isometric or isotonic exercise program for athletes with patellar tendinopathy in-season, despite an improvement in symptoms. It seems that structural improvements are not required for a positive clinical outcome.
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http://dx.doi.org/10.1097/PHM.0000000000000951DOI Listing
October 2018

Characterising the proximal patellar tendon attachment and its relationship to skeletal maturity in adolescent ballet dancers.

Muscles Ligaments Tendons J 2017 Apr-Jun;7(2):306-314. Epub 2017 Sep 18.

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia.

Background: It is unknown how and when the proximal attachment of the patellar tendon matures; puberty may be key in ensuring normal tendon formation. The aim of this study was to investigate the features of the proximal patellar tendon attachment at different stages of skeletal maturity, to help gain an understanding of how and when the tendon attachment matures.

Methods: Sixty adolescent elite ballet students (ages 11-18) and eight mature adults participated. Peak height velocity (PHV) estimated skeletal maturity. Ultrasound tissue characterisation (UTC) scan was taken of the left knee and analysed for stability of echopattern. An image-based grading scale for greyscale ultrasound was developed to describe the tendon appearance. Anterior-posterior thickness was measured at the inferior pole of the patella, 1 and 2 centimetres distally. Outcomes were compared with skeletal maturity.

Results: Mid-portion patellar tendon thickness increased with skeletal maturity (p=0.001 at 1 cm and p=0.007 at 2 cm). There was more variance in structural appearance (greyscale classification and UTC echopattern) in pre and peri-PHV participants. Tendon attachment one-year post PHV appeared similar to mature tendons.

Conclusions: Early adolescence was associated with highly variable tendon appearance, whereas the tendon appeared mature after PHV. Adolescence may be a critical time for the formation of normal tendon attachment.

Level Of Evidence: IIb individual cohort study.
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http://dx.doi.org/10.11138/mltj/2017.7.2.306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725180PMC
September 2017

Adaptation of the pathological tendon: you cannot trade in for a new one, but perhaps you don't need to?

Br J Sports Med 2018 May 19;52(10):622-623. Epub 2017 Jul 19.

La Trobe Sports and Exercise Medicine (LASEM) Research Centre, La Trobe University, Bundoora, Australia.

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http://dx.doi.org/10.1136/bjsports-2016-097325DOI Listing
May 2018
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