ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials.

OBJECTIVE: To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research. DESIGN: Scoping review. LITERATURE SEARCH: We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors. STUDY SELECTION: Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation. DATA SYNTHESIS: We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field. RESULTS: Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct. CONCLUSION: There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

Oxford consensus on primary cam morphology and femoroacetabular impingement syndrome: part 1-definitions, terminology, taxonomy and imaging outcomes.

INTRODUCTION: Primary cam morphology is a mostly benign bony prominence that develops at the femoral head-neck junction of the hip, but it is highly prevalent in many athlete populations. In the small proportion of athletes for whom it is not benign, the resulting hip osteoarthritis can be debilitating. Clinicians, athletes, patients and researchers do not yet agree on important primary cam morphology elements. We aimed to ascertain and improve the level of agreement on primary cam morphology definitions, terminology, taxonomy and imaging outcome measures. METHODS: To collect and aggregate informed opinions, an expert panel-the Young Athlete's Hip Research Collaborative-rated primary cam morphology definition, terminology, taxonomy and imaging outcome statements through an online Delphi exercise followed by an online meeting to explore areas of tension and dissent. Reporting followed Conducting and REporting DElphi Studies. RESULTS: A diverse and inclusive Delphi panel (n=65 for rounds 1 and 2, representing 18 countries; 6 stakeholder groups; 40% women) agreed on 35 of 47 statements in 4 domains, while surfacing areas of tension and dissent. This Delphi panel agreed on four key issues essential to moving research and clinical care forward around primary cam morphology. They agreed on: (1) definition, confirming its conceptual attributes (tissue type, size, location, shape and ownership); (2) terminology-use 'morphology' and not terms with a negative connotation like 'lesion', 'abnormality' or 'deformity'; (3) taxonomy, distinguishing between primary and secondary cam morphology, and (4) imaging outcomes, a continuous bone/cartilage alpha angle on radial femoral head-neck MRI for primary cam morphology aetiology research. CONCLUSION: This consensus provides athletes, patients, clinicians and researchers with a strong foundation to guide more precise communication, better clinical decision-making and higher value research about primary cam morphology and its natural history.

Oxford consensus on primary cam morphology and femoroacetabular impingement syndrome: part 2-research priorities on conditions affecting the young person's hip.

INTRODUCTION: Primary cam morphology is highly prevalent in many athlete populations, causing debilitating hip osteoarthritis in some. Existing research is mired in confusion partly because stakeholders have not agreed on key primary cam morphology elements or a prioritised research agenda. We aimed to inform a more rigorous, inclusive and evidence-based approach to research on primary cam morphology and its natural history by working towards agreement on a set of research priorities for conditions affecting the young person's hip. METHODS: An international expert panel-the Young Athlete's Hip Research (YAHiR) Collaborative-rated research priority statements through an online two-round Delphi exercise and met online to explore areas of tension and dissent. Panellists ranked the prioritised research statements according to the Essential National Health Research (ENHR) ranking strategy. Reporting of results followed REPRISE (REporting guideline for PRIority SEtting of health). RESULTS: A diverse Delphi panel (n=65, Delphi rounds 1 and 2; three ENHR strategy surveys: n=49; n=44; n=42) from 18 countries representing six stakeholder groups, prioritised and ranked 18 of 38 research priority statements. The prioritised statements outlined seven research domains: (1) best practice physiotherapy, (2) rehabilitation progression and return to sport, (3) exercise intervention and load management, (4) primary cam morphology prognosis and aetiology, (5) femoroacetabular impingement syndrome prognosis and aetiology, (6) diagnostic criteria, and (7) screening. The panel recommended areas of tension and dissent for the research community to focus on immediately. CONCLUSION: While informing more rigorous, inclusive and evidence-based research, this consensus is a roadmap for researchers, policy-makers and funders to implement research dedicated to reducing the cost and burden of hip disease related to primary cam morphology.

Primary cam morphology; bump, burden or bog-standard? A concept analysis.

BACKGROUND: Cam morphology, a distinct bony morphology of the hip, is prevalent in many athletes, and a risk factor for hip-related pain and osteoarthritis. Secondary cam morphology, due to existing or previous hip disease (eg, Legg-Calve-Perthes disease), is well-described. Cam morphology not clearly associated with a disease is a challenging concept for clinicians, scientists and patients. We propose this morphology, which likely develops during skeletal maturation as a physiological response to load, should be referred to as primary cam morphology. The aim of this study was to introduce and clarify the concept of primary cam morphology. DESIGN: We conducted a concept analysis of primary cam morphology using articles that reported risk factors associated with primary cam morphology; we excluded articles on secondary cam morphology. The concept analysis method is a rigorous eight-step process designed to clarify complex 'concepts'; the end product is a precise definition that supports the theoretical basis of the chosen concept. RESULTS: We propose five defining attributes of primary cam morphology-tissue type, size, site, shape and ownership-in a new conceptual and operational definition. Primary cam morphology is a cartilage or bony prominence (bump) of varying size at the femoral head-neck junction, which changes the shape of the femoral head from spherical to aspherical. It often occurs in asymptomatic male athletes in both hips. The cartilage or bone alpha angle (calculated from radiographs, CT or MRI) is the most common method to measure cam morphology. We found inconsistent reporting of primary cam morphology taxonomy, terminology, and how the morphology is operationalised. CONCLUSION: We introduce and clarify primary cam morphology, and propose a new conceptual and operational definition. Several elements of the concept of primary cam morphology remain unclear and contested. Experts need to agree on the new taxonomy, terminology and definition that better reflect the primary cam morphology landscape-a bog-standard bump in most athletic hips, and a possible hip disease burden in a selected few.

Musculoskeletal Physical Therapy After COVID-19: Time for a New "Normal".

In late 2019, a previously unknown coronavirus, SARS-CoV-2 (the coronavirus that causes COVID-19), was reported in Wuhan, China. Similar to the polio virus epidemic, the fear, uncertainty, and collective response associated with COVID-19 have disrupted daily life on a global scale. In this editorial, we argue that it is time for musculoskeletal physical therapists to grasp the opportunity provided by the COVID-19 pandemic to provide care that is (1) primarily active, (2) focused on self-efficacy and self-management, and (3) far less reliant on passive therapies. J Orthop Sports Phys Ther 2021;51(1):5-7. doi:10.2519/jospt.2021.0102.

Better reporting standards are needed to enhance the quality of hop testing in the setting of ACL return to sport decisions: a narrative review.

BACKGROUND/AIM: There is a lack of consistency in return to sport (RTS) assessments, in particular hop tests to predict who will sustain a reinjury following anterior cruciate ligament (ACL) reconstruction. Inconsistent test battery content and methodological heterogeneity might contribute to variable associations between hop test performance and subsequent injury. Our aim was to investigate whether commonly used hop tests are administered in a consistent manner and in accordance with reported guidelines. METHODS: We conducted a narrative review of studies that examined whether hop testing could differentiate RTS pass rates, reinjury and rerupture in athletes after ACL reconstruction. Our specific focus was on the methodological procedures of hop testing as this component is widely used to evaluate patients' function and readiness to RTS. MAIN FINDINGS: Substantial variation exists in RTS hop test administration, scoring and interpretation. Authors often failed to report important details of methods such as warm up activities, randomisation, number of trials, rest periods and landing requirements. CONCLUSION: We recommend researchers provide clearer descriptions of how hop tests are performed to increase standardisation and promote accurate data collection. Absence of reporting to describe test methods and using different test procedures makes it difficult to compare study findings.

The strength of association between psychological factors and clinical outcome in tendinopathy: A systematic review.

OBJECTIVE: Tendinopathy is often a disabling, and persistent musculoskeletal disorder. Psychological factors appear to play a role in the perpetuation of symptoms and influence recovery in musculoskeletal pain. To date, the impact of psychological factors on clinical outcome in tendinopathy remains unclear. Therefore, the purpose of this systematic review was to investigate the strength of association between psychological factors and clinical outcome in tendinopathy. METHODS: A systematic review of the literature and qualitative synthesis of published trials was conducted. Electronic searches of ovid MEDLINE, ovid EMBASE, PsychINFO, CINAHL and Cochrane Library was undertaken from their inception to June 2020. Eligibility criteria included RCT's and studies of observational design incorporating measurements of psychological factors and pain, disability and physical functional outcomes in people with tendinopathy. Risk of Bias was assessed by two authors using a modified version of the Newcastle Ottawa Scale. High or low certainty evidence was examined using the GRADE criteria. RESULTS: Ten studies of observational design (6-cross sectional and 4 prospective studies), involving a sample of 719 participants with tendinopathy were included. Risk of bias for the included studies ranged from 12/21 to 21/21. Cross-sectional studies of low to very low level of certainty evidence revealed significant weak to moderate strength of association (r = 0.24 to 0.53) between psychological factors and clinical outcomes. Prospective baseline data of very low certainty evidence showed weak strength of association between psychological factors and clinical outcome. However, prospective studies were inconsistent in showing a predictive relationship between baseline psychological factors on long-term outcome. Cross sectional studies report similar strengths of association between psychological factors and clinical outcomes in tendinopathy to those found in other musculoskeletal conditions. CONCLUSION: The overall body of the evidence after applying the GRADE criteria was low to very low certainty evidence, due to risk of bias, imprecision and indirectness found across included studies. Future, high quality longitudinal cohort studies are required to investigate the predictive value of baseline psychological factors on long-term clinical outcome.

Residual deficits in reactive strength indicate incomplete restoration of athletic qualities following anterior cruciate ligament reconstruction in professional soccer players.

CONTEXT: Deficits in plyometric abilities are common following anterior cruciate ligament reconstruction (ACLR). Vertical rebound tasks may provide a targeted evaluation of knee function. OBJECTIVE: Examine the utility of a vertical hop test to assess function following ACLR and establish factors associated with performance. DESIGN: Cross-sectional Setting: Rehabilitation Participants: Soccer players with a history of ACLR (N = 73) and matched controls (N = 195) Main outcome measures: 10 second vertical hop test including measures of jump height, reactive strength index (RSI) and asymmetry. We also examined possible predictors of hop performance including single leg vertical drop jump (SLDVJ), isokinetic knee extension strength, and the international knee documentation committee questionnaire. RESULTS: Significant between-limb differences were identified for the ACLR group only and asymmetry scores increased in those with a history of ACLR (P < 0.001) compared to controls. SLDVJ RSI and knee extension torque were significant predictors of 10 second hop height (R2 = 20.1%) and RSI (R2 = 47.1%). CONCLUSIONS: Vertical hop deficits are present following ACLR even after completing a comprehensive rehabilitation program. This may be due to reduced knee extension and reactive strength. Vertical hop tests warrant inclusion as part of return to sport test battery.

"It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away." A qualitative study exploring individuals' beliefs and experiences of Achilles tendinopathy.

BACKGROUND: Achilles tendinopathy (AT) is a common and often persistent musculoskeletal disorder affecting both athletic and non-athletic populations. Despite the relatively high incidence there is little insight into the impact and perceptions of tendinopathy from the individual's perspective. Increased awareness of the impact and perceptions around individuals' experiences with Achilles tendinopathy may provide crucial insights for the management of what is often a complex, persistent, and disabling MSK disorder. PURPOSE: To qualitatively explore the lived experiences of individuals with AT. DESIGN: A qualitative, interpretive description design was performed using semi-structured telephone interviews. METHODS: Semi-structured interviews were conducted on 15 participants (8 male and 7 female) with AT. Thematic analysis was performed using the guidelines laid out by Braun and Clarke. The study has been reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. RESULTS: Four main themes were identified from the data: 1) beliefs and perceptions surrounding AT: "If I'm over training or something, I don't really know", 2) the biopsychosocial impact of AT: "I think it restricts me in a lot of things that I would be able to do", 3) individuals' experiences with the management process: "You want it to happen now. You're doing all this stuff and it's just very slow progress", and 4) future prognosis and outlook in individuals with AT: "I see myself better". CONCLUSIONS: This study offers a unique insight into the profound impact and consequences of Achilles tendinopathy in a mixed sample of both athletic and non-athletic individuals. The findings of this study have important clinical implications. Specifically, it highlights the need for clinicians to recognize and adopt treatment approaches to embrace a more biopsychosocial approach for the management of tendinopathy.

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

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

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

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

Beyond the tendon: Experiences and perceptions of people with persistent Achilles tendinopathy.

BACKGROUND: Achilles tendinopathy (AT) is associated with persistent pain leading to a significant physical and psychological burden. Psychosocial factors are considered to be important mediators following exercise interventions. Despite the recognition of the importance of psychosocial variables in persistent MSK disorders, there is a distinct lack of qualitative research investigating psychosocial factors in AT. PURPOSE: To qualitatively explore the perceptions and experiences of people with AT prior to an intervention study. METHODOLOGY: A qualitative, interpretive description design was performed using semi-structured telephone interviews. The questioning route covered history of AT, perceived cause of AT, effect of AT pain, experience in managing AT, and perspective on prognosis of AT pain. Interviews were transcribed verbatim. The study has been reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. To facilitate the rigor of methodology and the transparency of the research process an audit trail was created. RESULTS: Eight participant's (Five male and three female). Four main themes were identified in the data: (i) pain as a feature of everyday life; (ii) experience with the management process; (iii) identifying with and self-managing AT, and (iv) looking to the future. CONCLUSIONS: This study suggests that persistent AT is associated with a significant psychosocial impact, particularly in terms of participation in daily life and valued activities. Better understanding the experiences and personal impacts of AT may enhance management of this persistent disorder, and facilitate individuals with AT complying with evidence-based approaches including exercise and pain reconceptualization.

A systematic review of the reliability of diagnostic ultrasound imaging in measuring tendon size: Is the error clinically acceptable?

BACKGROUND: Diagnostic ultrasound (US) is a commonly used imaging modality for visualising tendon pathology and morphology. In comparison to magnetic resonance imaging (MRI), diagnostic US is perceived to have a higher risk of error when evaluating tendon size. AIM: To systematically assess the evidence regarding the Intra rater and Inter rater reliability of diagnostic US measurements of tendon size. DATA SOURCES: Eight electronic databases were searched using an agreed set of keywords. Studies which investigated the reliability of tendon size (thickness or cross sectional area) using diagnostic US were eligible. RESULTS: Combined Inter rater and Intra rater ICC values for tendon thickness ranged from 0.45 to 0.99. Combined Inter rater and Intra rater ICC values for tendon cross-sectional area (CSA) ranged from 0.58 to 0.92. Overall, Intra rater ICC values (0.59-0.99) were marginally higher than Inter rater values (0.45-0.99) across all tendon sites. Percentage co-efficient of variation (CV%) for tendon thickness and CSA ranged from 0 to 35% across all tendons. Percentage standard error of the mean SEM% values for tendon thickness ranged from 3.33% to 7.39%. CONCLUSIONS: The findings of this review suggest diagnostic US measures of tendon size are reliable, both in terms of relative and absolute reliability. However, the findings must be considered in light of the presence of tendon abnormalities in a large percentage of asymptomatic populations.