Effectiveness of an anti-inflammatory diet versus low-fat diet for knee osteoarthritis: the FEAST randomised controlled trial protocol.

INTRODUCTION: Chronic inflammation plays a key role in knee osteoarthritis pathophysiology and increases risk of comorbidities, yet most interventions do not typically target inflammation. Our study will investigate if an anti-inflammatory dietary programme is superior to a standard care low-fat dietary programme for improving knee pain, function and quality-of-life in people with knee osteoarthritis. METHODS AND ANALYSIS: The eFEct of an Anti-inflammatory diet for knee oSTeoarthritis study is a parallel-group, assessor-blinded, superiority randomised controlled trial. Following baseline assessment, 144 participants aged 45-85 years with symptomatic knee osteoarthritis will be randomly allocated to one of two treatment groups (1:1 ratio). Participants randomised to the anti-inflammatory dietary programme will receive six dietary consultations over 12 weeks (two in-person and four phone/videoconference) and additional educational and behaviour change resources. The consultations and resources emphasise nutrient-dense minimally processed anti-inflammatory foods and discourage proinflammatory processed foods. Participants randomised to the standard care low-fat dietary programme will receive three dietary consultations over 12 weeks (two in-person and one phone/videoconference) consisting of healthy eating advice and education based on the Australian Dietary Guidelines, reflecting usual care in Australia. Adherence will be assessed with 3-day food diaries. Outcomes are assessed at 12 weeks and 6 months. The primary outcome will be change from baseline to 12 weeks in the mean score on four Knee injury and Osteoarthritis Outcome Score (KOOS4) subscales: knee pain, symptoms, function in daily activities and knee-related quality of life. Secondary outcomes include change in individual KOOS subscale scores, patient-perceived improvement, health-related quality of life, body mass and composition using dual-energy X-ray absorptiometry, inflammatory (high-sensitivity C reactive protein, interleukins, tumour necrosis factor-α) and metabolic blood biomarkers (glucose, glycated haemoglobin (HbA1c), insulin, liver function, lipids), lower-limb function and physical activity. ETHICS AND DISSEMINATION: The study has received ethics approval from La Trobe University Human Ethics Committee. Results will be presented in peer-reviewed journals and at international conferences. TRIAL REGISTRATION NUMBER: ACTRN12622000440729.

Effectiveness of Technology-Enabled, Low Carbohydrate Dietary Interventions, in the Prevention or Treatment of Type 2 Diabetes Mellitus in Adults: A Systematic Literature Review of Randomised Controlled and Non-Randomised Trials.

Evidence suggests that low carbohydrate dietary (LCD) approaches can improve glycaemic control and may result in type 2 diabetes mellitus (T2DM) remission. This systematic literature review (SLR) aimed to assess the effectiveness of technology-enabled LCD interventions in the management of people with prediabetes or T2DM. Data sources included Medline, Embase, CINAHL, and Web of Science. Randomised (RCTs) or non-randomised (non-RCTs) controlled trials investigating the effect of technology-enabled LCDs (<130 g/day) or very low carbohydrate diets (VLCDs < 50 g/day) on glycosylated haemoglobin A1c (HbA1c) for at least three months and published in English between 2009 and 2023 were included. Risk of bias assessment, data extraction, and synthesis were conducted using standard tools and procedures. Six studies (two RCTs and four non-RCTs, total sample, n = 1519) were identified and included in the SLR. Two studies examining LCDs reported significant reductions in mean HbA1c (0.4% and -1.2%) and weight loss (-3.8 kg and -7.5 kg) at one year. Three studies examining VLCDs reported significant reductions in mean HbA1c (-0.8% to -1.3%) and weight loss (-12 kg to -14 kg) up to two years. Technology-enabled LCD or VLCD interventions can be a novel approach in helping people with prediabetes or T2DM self-manage their condition and possibly achieve remission. However, further research is required to determine the sustainability, effectiveness, and safety of this approach.

Effectiveness of a Digitally Delivered Continuous Care Intervention (Defeat Diabetes) on Type 2 Diabetes Outcomes: A 12-Month Single-Arm, Pre-Post Intervention Study.

Low-carbohydrate dietary approaches can lead to improvements in blood glucose levels and weight loss, as well as a reduction and/or cessation in medication use in people with type 2 diabetes (T2D). Recent technological advances have led to the development of health-related applications (apps), including a high proportion dedicated to the management of diabetes. The Defeat Diabetes Program is a smartphone- and web-based app that provides guidance on a low-carbohydrate dietary approach for T2D and was designed to be used in conjunction with standard care in the medical management of T2D. The primary aim of this protocol is to provide the rationale and design of a single-arm 12-month pre-post intervention clinical trial using the Defeat Diabetes Program in an Australian community-based cohort of people with T2D who were referred by their general practitioner (GP). The study seeks to engage the GP community to help demonstrate whether the results of using a low-carbohydrate dietary approach for T2D can be achieved by the Defeat Diabetes Program in their patients. This protocol describes (1) the rationale for the selection of primary and secondary outcome measures, (2) the sampling procedures and methodological steps used to identify eligible participants and collect data, and (3) the approach followed to involve and educate GPs to support the trial.

An anti-inflammatory diet intervention for knee osteoarthritis: a feasibility study.

BACKGROUND: Knee osteoarthritis has an inflammatory component that is linked to pain and joint pathology, yet common non-surgical and non-pharmacological interventions (e.g., exercise, calorie restricting diets) do not typically target inflammation. We aimed to evaluate the feasibility of a telehealth delivered anti-inflammatory diet intervention for knee osteoarthritis. METHODS: This 9-week single-arm feasibility study recruited participants aged 40-85 years with symptomatic knee osteoarthritis (inclusion criteria: average pain ≥4/10 or maximal pain ≥5/10 during past week). All participants received a telehealth-delivered anti-inflammatory dietary education intervention involving 1:1 consultations at baseline, 3- and 6-week follow-up. The diet emphasised nutrient-dense wholefoods and minimally processed anti-inflammatory foods and discouraged processed foods considered to be pro-inflammatory. The primary outcome of feasibility was assessed via: i) eligibility, recruitment and retention rates; ii) self-reported dietary adherence; iii) adverse events; and iv) treatment satisfaction. Post-intervention interviews evaluated the acceptability of the dietary intervention delivered via telehealth. Secondary outcomes included changes in self-reported body mass, Knee injury and Osteoarthritis Outcome Score (KOOS), health-related quality of life (EuroQoL-5D), analgesic use and global rating of change. Worthwhile effects were determined by the minimal detectable change (MDC) for all five KOOS-subscales (pain, symptoms, activities of daily living, sport/recreation, quality of life) being contained within the 95% confidence interval. RESULTS: Forty-eight of seventy-three (66%) individuals screened were eligible and 28 enrolled over 2 months (82% female, mean age 66 ± 8 years, body mass index 30.7 ± 4.8 kg.m-2). Six participants withdrew prior to final follow-up (21% drop-out). Of those with final follow-up data, attendance at scheduled telehealth consultations was 99%. Self-reported adherence to diet during the 9-week intervention period: everyday = 27%, most of time = 68% and some of time = 5%. Two minor adverse events were reported. Change scores contained the MDC within the 95% confidence interval for all five KOOS subscales. Suggestions to improve study design and limit drop-out included an initial face-to-face consultation and more comprehensive habitual dietary intake data collection. CONCLUSION: This study supports the feasibility of a full-scale randomised controlled trial to determine the efficacy of a primarily telehealth-delivered anti-inflammatory dietary education intervention in adults with symptomatic knee osteoarthritis. TRIAL REGISTRATION: ACTRN12620000229976 prospectively on 25/2/2020.

Contact-Related Strain of Quadratus Femoris, Obturator Externus, and Inferior Gemellus in an Australian Football Player: A Case Report.

CONTEXT: Muscle injuries of the hip stabilizers are considered rare in sport. OBJECTIVE: This report presents a previously unreported case of a contact injury resulting in acute strain of quadratus femoris, obturator externus, and inferior gemellus in an amateur Australian rules football player. DESIGN: Level 4-case report. CASE PRESENTATION: A player was tackled ipsilateral to the injured leg, while in hip flexion in a lunged position. The case describes the diagnostic process, initial management, and return to play for this athlete. RESULTS: Following rehabilitation, the player was able to return to sport at 8 weeks without ongoing issues. CONCLUSIONS: A literature search for sports-related contact injuries to either muscle returned only one result. All other documented cases of injury to these muscle groups are confined to noncontact mechanisms or delayed presentations. Despite conventional teaching, the action of the deep external rotators of the hip appears to be positionally dependent. Knowledge of this type of injury and mechanism may be useful for future clinical reasoning and differential diagnosis in patients with this type of presentation.

Connective tissue injury in calf muscle tears and return to play: MRI correlation.

OBJECTIVE: The aim of our study was to assess a group of patients with calf muscle tears and evaluate the integrity of the connective tissue boundaries and interfaces. Further, we propose a novel MRI grading system based on integrity of the connective tissue and assess any correlation between the grading score and time to return to play. We have also reviewed the anatomy of the calf muscles. MATERIALS AND METHODS: We retrospectively evaluated 100 consecutive patients with clinical suspicion and MRI confirmation of calf muscle injury. We evaluated each calf muscle tear with MRI for the particular muscle injured, location of injury within the muscle and integrity of the connective tissue structure at the interface. The muscle tears were graded 0-3 depending on the degree of muscle and connective tissue injury. The time to return to play for each patient and each injury was found from the injury records and respective sports doctors. RESULTS: In 100 patients, 114 injuries were detected. Connective tissue involvement was observed in 63 out of 100 patients and failure (grade 3 injury) in 18. Mean time to return to play with grade 0 injuries was 8 days, grade 1 tears was 17 days, grade 2 tears was 25 days and grade 3 tears was 48 days (p<0.001). CONCLUSION: The integrity of the connective tissue can be used to estimate and guide the time to return to play in calf muscle tears.

Distal Musculotendinous T Junction Injuries of the Biceps Femoris: An MRI Case Review.

BACKGROUND: Injury to the distal musculotendinous T junction (DMTJ) of the biceps femoris is a distinct clinical entity that behaves differently from other hamstring injuries due to its complex, multicomponent anatomy and dual innervation. Injury in this region demonstrates a particularly high rate of recurrence, even with prolonged rehabilitation times. PURPOSE: To describe the anatomy of the DMTJ of the biceps femoris and analyze the injury patterns seen on magnetic resonance imaging (MRI) to aid prognosis and rehabilitation and minimize the risk of recurrence. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Acute injury to the DMTJ of the biceps femoris was identified in 106 MRI examinations from 55 patients at a single institution. Each injury was classified as involving the long head, the short head, or both components of the DMTJ, with each component individually graded. Injuries were classified as recurrent if there was a previous MRI demonstrating an acute injury to the DMTJ or if there was scarring present at the site of an acute injury. RESULTS: Of the 106 acute injuries to the DMTJ of the biceps femoris, isolated injury to the long head component was the most common (51%), with both components involved in [round 42.5% to 43%] of cases. Isolated injury to the short head component accounted for 7% of cases. The recurrence rate for reinjury to the DMTJ was 54% in this series. The date of prior injury was known in 45 of 57 recurrent cases, with 34 of these reoccurring within 3 months (76%) and 40 reoccurring within 12 months (89%). The recurrent injury was of a higher grade than the prior injury in 22 of 44 instances (50%), the same grade in 16 instances (36%), and a lower grade in 6 instances (14%). Thus, 86% of recurrent injuries were of the same or higher grade than prior injury. CONCLUSION: These results suggest that high-risk muscle injuries, such as that to the DMTJ of the biceps femoris, should be evaluated using MRI to determine the structural components involved and to assess the extent and severity of injury.

'Serious thigh muscle strains': beware the intramuscular tendon which plays an important role in difficult hamstring and quadriceps muscle strains.

Why do some hamstring and quadriceps strains take much longer to repair than others? Which injuries are more prone to recurrence? Intramuscular tendon injuries have received little attention as an element in 'muscle strain'. In thigh muscles, such as rectus femoris and biceps femoris, the attached tendon extends for a significant distance within the muscle belly. While the pathology of most muscle injures occurs at a musculotendinous junction, at first glance the athlete appears to report pain within a muscle belly. In addition to the musculotendinous injury being a site of pathology, the intramuscular tendon itself is occasionally injured. These injuries have a variety of appearances on MRIs. There is some evidence that these injuries require a prolonged rehabilitation time and may have higher recurrence rates. Therefore, it is important to recognise the tendon component of a thigh 'muscle strain'.

Which Extrinsic and Intrinsic Factors are Associated with Non-Contact Injuries in Adult Cricket Fast Bowlers?

BACKGROUND: The high prevalence of injury amongst cricket fast bowlers exposes a great need for research into the risk factors associated with injury. Both extrinsic (environment-related) and intrinsic (person-related) risk factors are likely to be implicated within the high prevalence of non-contact injury amongst fast bowlers in cricket. Identifying and defining the relative importance of these risk factors is necessary in order to optimize injury prevention efforts. OBJECTIVE: The objective of this review was to assess and summarize the scientific literature related to the extrinsic and intrinsic factors associated with non-contact injury inherent to adult cricket fast bowlers. METHOD: A systematic review was performed in compliance with the PRISMA guidelines. This review considered both experimental and epidemiological study designs. Studies that included male cricket fast bowlers aged 18 years or above, from all levels of play, evaluating the association between extrinsic/intrinsic factors and injury in fast bowlers were considered for inclusion. The three-step search strategy aimed at finding both published and unpublished studies from all languages. The searched databases included MEDLINE via PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Controlled Trials Register in the Cochrane Library, Physiotherapy Evidence Database (PEDro), ProQuest 5000 International, ProQuest Health and Medical Complete, EBSCO MegaFile Premier, Science Direct, SPORTDiscus with Full Text and SCOPUS (prior to 28 April 2015). Initial keywords used were 'cricket', 'pace', 'fast', 'bowler', and 'injury'. Papers which fitted the inclusion criteria were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). RESULTS: A total of 16 studies were determined to be suitable for inclusion in this systematic review. The mean critical appraisal score of the papers included in this study was 6.88 (SD 1.15) out of a maximum of 9. The following factors were found to be associated with injury: bowling shoulder internal rotation strength deficit, compromised dynamic balance and lumbar proprioception (joint position sense), the appearance of lumbar posterior element bone stress, degeneration of the lumbar disc on magnetic resonance imaging (MRI), and previous injury. Conflicting results were found for the association of quadratus lumborum (QL) muscle asymmetry with injury. Technique-related factors associated with injury included shoulder-pelvis flexion-extension angle, shoulder counter-rotation, knee angle, and the proportion of side-flexion during bowling. Bowling workload was the only extrinsic factor associated with injury in adult cricket fast bowlers. A high bowling workload (particularly if it represented a sudden upgrade from a lower workload) increased the subsequent risk to sustaining an injury 1, 3 or 4 weeks later. CONCLUSION: Identifying the factors associated with injury is a crucial step which should precede the development of, and research into, the effectiveness of injury prevention programs. Once identified, risk factors may be included in pre-participation screening tools and injury prevention programs, and may also be incorporated in future research projects. Overall, the current review highlights the clear lack of research on factors associated with non-contact injury, specifically in adult cricket fast bowlers. SYSTEMATIC REVIEW REGISTRATION NUMBER: Johanna Briggs Institute Database of Systematic Reviews and Implementation Reports 1387 (Olivier et al., JBI Database Syst Rev Implement Rep 13(1):3-13. doi: 10.11124/jbisrir-2015-1387 , 2015).

Extrinsic and intrinsic factors associated with non-contact injury in adult pace bowlers: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: Review question: which extrinsic and intrinsic factors are associated with non-contact injury in adult cricket pace bowlers?Review objective: the objective of this review is to determine the extrinsic and intrinsic factors associated with non-contact injury in adult pace bowlers. BACKGROUND: Cricket is generally considered to be a sport of low injury risk compared to other sports. In cricket, the pace bowler strives towards the adoption of a bowling technique with a relatively low injury threat that will, at the same time, allow for a fast (>120km/hr) and accurate delivery to the opposing batsman. However, of all the various roles of the cricket player, the pace bowler has the highest risk of injury, especially for low back and lower limb (lower quarter) injury. The reason for this high risk of injury is due to the inherent, high-load biomechanical nature of the pace bowling action. The high prevalence of injury amongst pace bowlers highlights the great need for research into factors associated with injury.Both extrinsic and intrinsic factors work in combination to predispose the bowler to injury. Extrinsic or environment-related factors include bowling workload (the numbers of overs a bowler bowls), player position (first, second or third change) and time of play (morning or afternoon). A high bowling workload has been linked with a higher risk of injury in pace bowlers. Foster et al. found in an observational study that bowling too many overs in a single spell or bowling too many spells may increase the pace bowler's risk of sustaining a low back injury. In another observational study, Dennis et al. found that an exceptionally high bowling workload as well as an uncommonly low bowling workload is associated with injury risk. The major extrinsic factors for bowling injury identified by Orchard et al. are a high number of match overs bowled in the previous week, number of days of play and bowling second (batting first) in a match. Extrinsic factors are known to make the bowler more susceptible to injury, especially in the presence of intrinsic factors.Intrinsic, or person-related, factors include muscle strength, flexibility, balance and biomechanics. Intrinsic, strength-related factors, such as shoulder depression, horizontal flexion strength for the preferred limb and quadriceps power in the non-preferred limb are also significantly related to back injuries in fast bowlers. Both upper limb and lower limb-related intrinsic factors are known to be associated with injury. A prospective study by Dennis et al. aimed to identify the risk factors for injury in adolescent cricket fast bowlers. Their findings concluded that bowlers with a hip internal rotation range of motion of ≤30° on the leg ipsilateral to the bowling arm were at a significantly reduced risk of injury compared with bowlers with >40° of rotation. Moreover, bowlers with ankle dorsiflexion lunge of 12.1-14.0 cm on the leg contralateral to the bowling arm were at a significantly increased risk of injury compared to bowlers with a lunge of >14 cm. Reduced hamstring flexibility was also associated with lumbar disc abnormalities. Bowling-related biomechanical risk factors for injury have been established such as trunk rotation of the shoulders by to a more side-on position during the delivery stride. Portus et al. also reported that shoulder counter-rotation was significantly higher in bowlers who reported lumbar spine stress fractures, while the non-trunk injured group displayed a more flexed knee at front foot contact and ball release. In addition to the above kinematic risk factors, there are high ground reaction forces associated with the power phase - between the front foot placement and ball release components of the pace bowling action. A combination of kinematic bowling related issues as described above and high ground reaction forces may predispose the bowler to injury.Morton et al. conducted a systematic review on pace bowlers between the ages of 13.7 and 22.5 years on risk factors and successful interventions for cricket-related low back pain. Young cricketers between the ages of 13 and 18 years are different to adults in terms of their physiology which impacts on their predisposition to injury and phases of healing. Young cricketers may differ from an adult population in that young pace bowlers who sustain injuries during their bowling career may have given up on the sport by the time they approach adulthood, and the composition of the adult pace bowler population group is therefore affected by natural selection which may cause this group to differ from the original population. Caution is thus advised when generalizing findings from this young population group to adult pace bowlers which emphasizes the need for studies amongst adult pace bowlers. Furthermore, the review by Morton et al. included articles that specifically investigated factors associated with low back pain. However, due to the interconnectedness between the spine and the lower limbs, kinematic variables affecting the spine will also affect the load placed on the lower limbs with subsequent risk of injury. The interdependent mechanical interactions in a linked segment system such as the system of motion of the low back can be caused by movement coordination patterns in other body segments. The systematic review by Morton et al. only included intrinsic factors while the proposed review will also look at extrinsic factors. Therefore, the primary objective of this review is to determine extrinsic and intrinsic factors associated with non-contact injury in adult pace bowlers.

Hamstring injuries: prevention and treatment-an update.

Despite increased knowledge of hamstring muscle injuries, the incidence has not diminished. We now know that not all hamstring injuries are the same and that certain types of injuries require prolonged rehabilitation and return to play. The slow stretch type of injury and injuries involving the central tendon both require longer times to return to play. A number of factors have been proposed as being indicators of time taken to return to play, but the evidence for these is conflicting. Recurrence rates remain high and it is now thought that strength deficits may be an important factor. Strengthening exercise should be performed with the hamstrings in a lengthened position. There is conflicting evidence regarding the efficacy of platelet-rich plasma injection in the treatment of hamstring injuries so at this stage we cannot advise their use. Various tests have been proposed as predictors of hamstring injury and the use of the Nordboard is an interesting addition to the testing process. Prevention of these injuries is the ultimate aim and there is increasing evidence that Nordic hamstring exercises are effective in reducing the incidence.

Doha agreement meeting on terminology and definitions in groin pain in athletes.

BACKGROUND: Heterogeneous taxonomy of groin injuries in athletes adds confusion to this complicated area. AIM: The 'Doha agreement meeting on terminology and definitions in groin pain in athletes' was convened to attempt to resolve this problem. Our aim was to agree on a standard terminology, along with accompanying definitions. METHODS: A one-day agreement meeting was held on 4 November 2014. Twenty-four international experts from 14 different countries participated. Systematic reviews were performed to give an up-to-date synthesis of the current evidence on major topics concerning groin pain in athletes. All members participated in a Delphi questionnaire prior to the meeting. RESULTS: Unanimous agreement was reached on the following terminology. The classification system has three major subheadings of groin pain in athletes: 1. Defined clinical entities for groin pain: Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain. 2. Hip-related groin pain. 3. Other causes of groin pain in athletes. The definitions are included in this paper. CONCLUSIONS: The Doha agreement meeting on terminology and definitions in groin pain in athletes reached a consensus on a clinically based taxonomy using three major categories. These definitions and terminology are based on history and physical examination to categorise athletes, making it simple and suitable for both clinical practice and research.

Cricket fast bowling workload patterns as risk factors for tendon, muscle, bone and joint injuries.

OBJECTIVE: To assess workload-related risk factors for injuries to particular tissue types in cricket fast bowlers. DESIGN: 235 fast bowlers who bowled in 14600 player innings over a period of 15 years were followed in a prospective cohort risk factor study to compare overs bowled in each match (including preceding workload patterns) and injury risk in the 3-4 weeks subsequent to the match. Injuries were categorised according to the affected tissue type as either: bone stress, tendon injuries, muscle strain or joint injuries. Workload risk factors were examined using binomial logistic regression multivariate analysis, with a forward stepwise procedure requiring a significance of <0.05. RESULTS: High acute match workload and high previous season workload were risk factors for tendon injuries, but high medium term (3-month workload) was protective. For bone stress injuries, high medium term workload and low career workload were risk factors. For joint injuries, high previous season and career workload were risk factors. There was little relationship between muscle injury and workload although high previous season workload was slightly protective. CONCLUSIONS: The level of injury risk for some tissue types varies in response to preceding fast bowling workload, with tendon injuries most affected by workload patterns. Workload planning may need to be individualised, depending on individual susceptibility to various injury types. This study supports the theory that tendons are at lowest risk with consistent workloads and susceptible to injury with sudden upgrades in workload. Gradual upgrades are recommended, particularly at the start of a bowler's career to reduce the risk of bone stress injury.

Fast bowling match workloads over 5-26 days and risk of injury in the following month.

OBJECTIVES: This study examined whether high match fast bowling workloads in the short to medium term were associated with increased bowling injury rates. DESIGN: Prospective cohort study. METHODS: Over a 15 year period, workload patterns for 235 individual fast bowlers during time periods from 5 to 26 days were examined to consider whether there was an increased injury rate during the month (28 days) subsequent to the workload. RESULTS: Fast bowlers who bowled more than 50 match overs in a 5 day period had a significant increase in injury over the next month compared to bowlers who bowled 50 overs or less RR 1.54 (95% CI 1.04-2.29). For periods ranging from 12 to 26 days, there was no statistically-significant increase in injury over the next month from exceeding thresholds of certain amounts of overs, although bowlers who bowled more than 100 overs in 17 days had a non-significant increase in injury over the next month RR 1.78 (95% CI 0.90-3.50). CONCLUSION: There were no statistically-significant increases in subsequent injury risk for high workloads for periods of 12-26 days, although exceeding 100 overs in 17 days (or less) was associated with higher injury rates. Compression of cricket fixtures is likely to have only a minimal contribution to increased fast bowling injury rates being seen in the T20 era (along with sudden workload increases due to transferring between forms of the game, which has been previously established as a major contributor).

Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme.

Recurrent hamstring injuries are a major problem in sports such as football. The aim of this paper was to use a clinical example to describe a treatment strategy for the management of recurrent hamstring injuries and examine the evidence for each intervention. A professional footballer sustained five hamstring injuries in a relatively short period of time. The injury was managed successfully with a seven-point programme-biomechanical assessment and correction, neurodynamics, core stability, eccentric strengthening, an overload running programme, injection therapies and stretching/relaxation. The evidence for each of these treatment options is reviewed. It is impossible to be definite about which aspects of the programme contributed to a successful outcome. Only limited evidence is available in most cases; therefore, decisions regarding the use of different treatment modalities must be made by using a combination of clinical experience and research evidence.