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ObjectivesLumbar bone stress injury (‘bone stress injury’) is common in junior fast bowlers. The repetitive loading of cricket fast bowling may cause bone marrow oedema (BMO), detectable on MRI, before the bowler suffers from symptomatic bone stress injury. We investigated the temporal relationship between BMO, bone stress injury, along with bowling workload correlates, in elite junior fast bowlers throughout a cricket season.Methods65 junior fast bowlers were prospectively monitored for one 8-month cricket season. For research purposes, participants had up to six MRI scans at set times in the season; findings were withheld from them and their clinicians. Standard practices for bowling workload monitoring and injury diagnosis were followed.Results15 (23%) participants developed bone stress injury during the study. All 15 of these participants had BMO detected on at least one of the preceding MRI scans, including the scan immediately prior to diagnosis. The risk of BMO progressing to bone stress injury during the season was greatest for participants with BMO present 2 weeks prior to the national championship tournament (period of high load) (RR=18.9, OR=44.8). Both bone stress injury and BMO were associated with bowling a higher percentage of days in training and having a shorter bowling break during the season. The number of balls bowled and acute-to-chronic workload were not associated with imaging abnormalities or injury.ConclusionThe presence of BMO on MRI in asymptomatic junior cricket fast bowlers confers a very high risk for bone stress injury. The risk may be managed by MRI screening and monitoring bowling frequency.

ObjectiveThe public health benefits of injury prevention programmes are maximised when programmes are widely adopted and adhered to. Therefore, these programmes require appropriate implementation support. This study evaluated implementation activity outcomes associated with the implementation of FootyFirst, an exercise training injury prevention programme for community Australian football, both with (FootyFirst+S) and without (FootyFirst+NS) implementation support.MethodAn evaluation plan based on the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) Sports Setting Matrix was applied in a controlled ecological evaluation of the implementation of FootyFirst. RE-AIM dimension-specific (range: 0–2) and total RE-AIM scores (range: 0–10) were derived by triangulating data from a number of sources (including surveys, interviews, direct observations and notes) describing FootyFirst implementation activities. The mean dimension-specific and total scores were compared for clubs in regions receiving FootyFirst+S and FootyFirst+NS, through analysis of variance.ResultsThe mean total RE-AIM score forclubs in the FootyFirst+S regions was 2.4 times higher than for clubs in the FootyFirst+NS region (4.73 vs 1.94; 95% CI for the difference: 1.64 to 3.74). Similarly, all dimension-specific scores were significantly higher for clubs in the FootyFirst+S regions compared with clubs in the FootyFirst+NS region. In all regions, the dimension-specific scores were highest for reach and adoption, and lowest for implementation.ConclusionImplementing exercise training injury prevention programmes in community sport is challenging. Delivering programme content supported by a context-specific and evidence-informed implementation plan leads to greater implementation activity, which is an important precursor to injury reductions.

Background Previous injury is a strong risk factor for recurrent lower limb injury in athletic populations, yet the association between previous injury and a subsequent injury different in nature or location is rarely considered. Objective To systematically review data on the risk of sustaining a subsequent lower limb injury different in nature or location following a previous injury. Methods Eight medical databases were searched. Studies were eligible if they reported lower limb injury occurrence following any injury of a different anatomical site and/or of a different nature, assessed injury risk, contained athletic human participants and were written in English. Two reviewers independently applied the eligibility criteria and performed the risk of bias assessment. Meta-analysis was conducted using a random effects model. Results Twelve studies satisfied the eligibility criteria. Previous history of an ACL injury was associated with an increased risk of subsequent hamstring injury (three studies, RR=2.25, 95% CI 1.34 to 3.76), but a history of chronic groin injury was not associated with subsequent hamstring injury (three studies, RR=1.14, 95% CI 0.29 to 4.51). Previous lower limb muscular injury was associated with an increased risk of sustaining a lower limb muscular injury at a different site. A history of concussion and a variety of joint injuries were associated with an increased subsequent lower limb injury risk. Conclusions The fact that previous injury of any type may increase the risk for a range of lower limb subsequent injuries must be considered in the development of future tertiary prevention programmes. Systematic review registration number CRD42016039904 (PROSPERO).

Objective Implementation of effective population-level injury prevention interventions requires broad multiagency partnerships. Different stakeholders address this from varying perspectives, and potential conflicts in priorities need to be addressed for such partnerships to be effective. The researcher-led National Guidance for Australian football Partnerships and Safety (NoGAPS) project involved the engagement and participation of seven non-academic partners, including government health promotion and safety agencies; peak sports professional and advocacy bodies and health insurance organisations. Design The partnership9s ongoing development was assessed by each partner completing the Victorian Health Promotion Foundation Partnership Analysis Tool (VPAT) annually over 2011–2015. Changes in VPAT scores were compared through repeated measures analysis of variance. Results Overall, mean total VPAT scores increased significantly over the 5-year period (125.1–141.2; F 5,30 =4.61, p=0.003), showing a significant improvement in how the partnership was functioning over time. This was largely driven by significant increases in several VPAT domains: ‘determining the need for a partnership’ (F 5,30 =4.15, p=0.006), ‘making sure the partnership works’ (F 5,30 =2.59, p=0.046), ‘planning collaborative action’ (F 5,30 =5.13, p=0.002) and ‘minimising the barriers to the partnership’ (F 5,30 =6.66, p Conclusion This is the first study to assess the functioning of a multiagency partnership to address sport injury prevention implementation. For NoGAPS, the engagement of stakeholders from the outset facilitated the development of new and/or stronger links between non-academic partners. Partners shared the common goal of ensuring the real-world uptake of interventions and research evidence-informed recommendations. Effective multiagency partnerships have the potential to influence the implementation of policies and practices beyond the life of a research project.

Background Musculoskeletal symptoms limit adherence to exercise interventions for individuals with type 2 diabetes. People with diabetes may be susceptible to tendinopathy due to chronically elevated blood glucose levels. Therefore, we aimed to investigate this potential association by systematically reviewing and meta-analysing case–control, cross-sectional, and studies that considered both of these conditions. Methods Nine medical databases and hand searching methods were used without year limits to identify all relevant English language articles that considered diabetes and tendinopathy. Two authors applied exclusion criteria and one author extracted data with verification by a second author. Meta-analysis was conducted using a random effects model. Results were expressed as odds ratio (OR), mean difference or standardised mean difference with a confidence intervals (95% CI). Heterogeneity was assessed by I 2 . Findings 31 studies were included in the final analysis of which 26 recruited people with diabetes and five recruited people with tendinopathy. Tendinopathy was more prevalent in people with diabetes (17 studies, OR 3·67, 95% CI 2·71 to 4·97), diabetes was more prevalent in people with tendinopathy (5 studies, OR 1·28, 95% CI 1·10 to 1·49), people with diabetes and tendinopathy had a longer duration of diabetes than people with diabetes only (6 studies, mean difference 5·26 years, 95% CI 4·15 to 6·36) and people with diabetes had thicker tendons than controls (9 studies, standardised mean difference 0·79 95% CI 0·47 to 1·12). Interpretation These findings provide strong evidence that diabetes is associated with higher risk of tendinopathy. This is clinically relevant as tendinopathy may affect adherence to exercise interventions for diabetes.

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

Tendon pain and dysfunction are the presenting clinical features of tendinopathy. Research has investigated many treatment options, but consistent, positive, clinical outcomes remain elusive. We know that treatment should be active (eg, exercise-based), and that a consistent and ongoing investment in rehabilitation is required. It is important to maximise this investment by understanding (and conveying to patients) treatments that do not help. The following 10 points highlight treatment approaches to avoid as they do not improve lower limb tendinopathy. 1. Don’t rest completely. Rest decreases the load tolerance of tendon, and complete rest decreases tendon stiffness within 2 weeks.1 It also decreases strength and power in the muscle attached to the tendon and the function of the kinetic chain,2 and likely changes the motor cortex, leaving the person less able to tolerate load at multiple levels. Treatment should initially reduce painful, high tendon load (point 2) and introduce beneficial loads (eg, isometrics3). Once pain is low and stable (consistent …

Objective Ultrasound (US) imaging has revealed distinct types of greyscale abnormalities in the patellar and Achilles tendons, including diffusely thickened tendons and tendons containing a hypoechoic region. The relationship between these greyscale abnormalities and their clinical relevance is unknown. This study investigated the temporal sequence in greyscale abnormalities as well as the relationship between greyscale abnormalities, Doppler flow and pain. Methods Patellar tendon pain (single leg decline squat test) and ultrasound imaging (greyscale (normal, diffuse thickening, hypoechoic), presence of Doppler flow) were assessed bilaterally among 58 volleyball players at monthly intervals during a 5-month season. The probability of transition between the greyscale ultrasound groups was calculated for each month and totalled over the season (prospective) and the relationship between these groups and the presence and intensity of pain and the presence of Doppler flow were investigated (cross-sectional investigation). Results Tendons with normal US were more likely to transition to diffuse thickening than to a hypoechoic region. Tendons containing a hypoechoic region were more likely to transition to diffuse thickening rather than to a normal US appearance. Hypoechoic regions were more likely to be painful (59%) and contain Doppler flow (42%) than tendons with diffuse thickening (pain in 43% and Doppler flow in 6%). Conclusions The transitions identified between normal, diffusely thickened tendons and those containing a hypoechoic region suggests that these greyscale US changes may represent different phases of tendon pathology. Tendons containing a hypoechoic region are more likely to be painful and contain Doppler flow than diffusely thickened tendons.

A COL5A1 gene variant was shown to be associated with chronic Achilles tendinopathy in a South African population. The aim of this case-control genetic association study was to investigate the BstUI and DpnII restriction fragment length polymorphisms (RFLP) in a second population from Australia and to identify a predisposing haplotype for Achilles tendinopathy in both populations.85 Australian and 93 South African patients with tendinopathy, as well as 210 Australian and 132 white South African control subjects were genotyped for the BstUI (rs12722) and DpnII (rs13946) RFLP, as well as markers rs10858286, rs3196378, rs11103544, rs4504708 and rs3128575.The BstUI RFLP (p0.001) and marker rs3196378 (p = 0.016) were associated with chronic Achilles tendinopathy in Australian subjects. Individuals within both populations with a CC genotype for the BstUI RFLP had a significantly decreased risk of developing tendinopathy versus any other genotypes (Australian odds ratio 0.42, 95% CI 0.20 to 0.86, p = 0.017). The TC inferred haplotype (rs12722, rs3196378) was found to be overrepresented (global p = 0.008) in the South African tendinopathy group compared with all other haplotypes.The BstUI RFLP is associated with chronic Achilles tendinopathy in a second population and a region within the COL5A1 3' untranslated region may predispose individuals to an increased risk of developing chronic Achilles tendinopathy.

Background: This study investigated changes in tendon vascularity in 102 (67 men and 35 women) volleyball players over a 6 month competitive season. Methods: Athletes were examined with both grey scale ultrasound and standardised colour Doppler settings. Vessel length and pain were measured each month on five separate occasions. Vascular tendons were divided into (i) those that were vascular on all occasions (persistent vascularity) and (ii) those that were vascular on more than two but less than five occasions (intermittent vascularity). Results: A total of 41 of the 133 abnormal tendons were vascular on two or more occasions. Of these, 16 had persistent vascularity and 25 had intermittent vascularity. There was no significant difference in the prevalence of vascularity between men and women. None of the tendons had a pattern of vascularity over the season that could be clearly interpreted as the onset or resolution of vascularity. Subjects with changes in both tendons were more likely to have persistent vascularity (p = 0.045). Vessels were longer in tendons with persistent vascularity (p

Background: Conservative treatment of patellar tendinopathy has been minimally investigated. Effective validated treatment protocols are required. Objectives: To investigate the immediate (12 weeks) and long term (12 months) efficacy of two eccentric exercise programmes for the treatment of patellar tendinopathy. Methods: This was a prospective randomised controlled trial of 17 elite volleyball players with clinically diagnosed and imaging confirmed patellar tendinopathy. Participants were randomly assigned to one of two treatment groups: a decline group and a step group. The decline group were required to perform single leg squats on a 25° decline board, exercising into tendon pain and progressing their exercises with load. The step group performed single leg squats on a 10 cm step, exercising without tendon pain and progressing their exercises with speed then load. All participants completed a 12 week intervention programme during their preseason. Outcome measures used were the Victorian Institute of Sport Assessment (VISA) score for knee function and 100 mm visual analogue scale (VAS) for tendon pain with activity. Measures were taken throughout the intervention period and at 12 months. Results: Both groups had improved significantly from baseline at 12 weeks and 12 months. Analysis of the likelihood of a 20 point improvement in VISA score at 12 months revealed a greater likelihood of clinical improvements in the decline group than the step group. VAS scores at 12 months did not differ between the groups. Conclusions: Both exercise protocols improved pain and sporting function in volleyball players over 12 months. This study indicates that the decline squat protocol offers greater clinical gains during a rehabilitation programme for patellar tendinopathy in athletes who continue to train and play with pain.

Overuse injury to the patellar tendon (patellar tendinopathy) is a major reason for interrupted training and competition for elite athletes. In both sexes, the prevalence of unilateral and bilateral tendinopathy has been shown to differ. It has been proposed that bilateral pathology may have a different aetiology from unilateral pathology. Investigation of risk factors that may be unique to unilateral and bilateral patellar tendinopathy in female athletes may reveal insights into the aetiology of this condition.To examine whether anthropometry, body composition, or muscle strength distinguished elite female basketball players with unilateral or bilateral patellar tendinopathy.Body composition, anthropometry, and muscle strength were compared in elite female basketball players with unilateral (n = 8), bilateral (n = 7), or no (n = 24) patellar tendinopathy. Body composition was analysed using a dual energy x ray absorptiometer. Anthropometric measures were assessed using standard techniques. Knee extensor strength was measured at 180 degrees /s using an isokinetic dynamometer. z scores were calculated for the unilateral and bilateral groups (using the no tendinopathy group as controls). z scores were tested against zero.The tibia length to stature ratio was approximately 1.3 (1.3) SDs above zero in both the affected and non-affected legs in the unilateral group (p0.05). The waist to hip ratio was 0.66 (0.78) SD above zero in the unilateral group (p0.05). In the unilateral group, leg lean to total lean ratio was 0.42 (0.55) SD above zero (p0.07), the trunk lean to total lean ratio was 0.63 (0.68) SD below zero (p0.05), and leg fat relative to total fat was 0.47 (0.65) SD below zero (p0.09). In the unilateral group, the leg with pathology was 0.78 (1.03) SD weaker during eccentric contractions (p0.07).Unilateral patellar tendinopathy has identifiable risk factors whereas bilateral patellar tendinopathy may not. This suggests that the aetiology of these conditions may be different. However, interpretation must respect the limitation of small subject numbers.

Objective:Patellar tendinopathy has been reported to be associated with many intrinsic risk factors. Few have been fully investigated. This cross-sectional study examined the anthropometric and physical performance results of elite junior basketball players with normal or abnormal patellar tendons to see if any measures were associated with changes in tendon morphology.Methods:Agility, leg strength, endurance, and flexibility were measured in 71 male and 64 female players. A blinded radiologist ultrasonographically examined their patellar tendons and athletes were grouped as having normal or abnormal tendons. One-way ANOVA was used to test for differences in anthropometric and physical performance data for athletes whose tendons were normal or abnormal (unilateral or bilateral tendinopathy) on ultrasound.Results:Results show that females with abnormalities in their tendons had a significantly better vertical jump (50.9±6.8 cm) than those with normal tendons (46.1±5.4 cm) (p = 0.02). This was not found in males. In males, the mean sit and reach in those with normal tendons (13.2±6.7 cm) was greater (pConclusion:Flexibility and vertical jump ability are associated with patellar tendinopathy and the findings warrant consideration when managing young, jumping athletes.

Background Ballet loads the hip joint in extreme ranges of movement (ROM). Abnormal bony morphology and joint laxity may enable this movement, but predispose dancers to hip injury. Objective To compare hip injury and bony morphology between ballet dancers and non-dancing athletes, and to investigate relationships between these factors and clinical features. Design Blinded, case-control study. Participants 49 professional ballet dancers and 49 age- and sex-matched non-dancing athletes. Setting Professional ballet company and sporting clubs. Assessment of Risk Factors Lateral centre edge angles, anterior and superior alpha angles, femoral neck-shaft angles and acetabular version angles measured with 3.0-Tesla magnetic resonance imaging (3-T MRI), ROM and hypermobility testing. Main Outcome Measurements Cartilage, labral, ligamentum teres (LT) lesions and effusion scored on MRI, and HAGOS (Copenhagen Hip and Groin Outcome Score). Results Cartilage defect and labral tear prevalence was similar in dancers and athletes (p>0.05); LT tears were more prevalent in dancers compared to athletes (p=0.001). Dancers had higher neck-shaft angles (p=0.002); lower acetabular version angles (p=0.003); lower superior alpha angles (p 0.01 for all). All 6 dancers with cam morphology (α angle >50°) measured anteriorly had cartilage defects, and 5 had labral tears; a trend not observed in athletes. Joint effusions were larger in dancers compared to athletes (p=0.009), and the only factor related to lower HAGOS pain and sports/recreation scores in female dancers (p=0.001 for both). Conclusions Professional ballet dancers had a high incidence of LT tear, and hip bony morphology that may allow extreme motion. Dancers with cam morphology had cartilage defects, but joint effusion was the only correlate with symptoms. Longitudinal studies are required to determine the clinical sequelae.

Background—Palpation is an important clinical test for jumper’s knee. Objectives—To (a) test the reproducibility of palpation tenderness, (b) evaluate the sensitivity and specificity of palpation in subjects with clinical symptoms of jumper’s knee, and (c) determine whether tenderness to palpation may serve as a useful screening test for patellar tendinopathy. The yardstick for diagnosis of patellar tendinopathy was ultrasonographic abnormality. Methods—In 326 junior symptomatic and asymptomatic athletes’ tendons, palpation was performed by a single examiner before ultrasonographic examination by a certified ultrasound radiologist. In 58 tendons, palpation was performed twice to test reliability. Tenderness to palpation was scored on a scale from 0 to 3 where 0 represented no pain, and 1, 2, and 3 represented mild, moderate, and severe tenderness respectively. Results—Patellar tendon palpation was a reliable examination for a single examiner (Pearson r = 0.82). In symptomatic tendons, the positive predictive value of palpation was 68%. As a screening examination in asymptomatic subjects, the positive predictive value of tendon palpation was 36‐38%. Moderate and severe palpation tenderness were better predictors of ultrasonographic tendon pathology than absent or mild tenderness (p

Background To date, there have been very few attempts at setting broad-based sports injury prevention public health activity. A staged and evidence-informed approach towards developing and delivering a new lower limb injury prevention program (FootyFirst) for community-level Australian football. The National Guidance for Australian football Partnerships for Safety (NoGAPS) study is one of the first large-scale studies to use a controlled, ecological design to assess the effectiveness of a sports injury prevention intervention at the population-level. The aim of this talk is to present the population-level evaluation of FootyFirst Methods FootyFirst was implemented during the 2012 and 2013 football seasons and its impact on injury rate evaluated through a controlled ecological study design applied to three distinct geographic regions (R1-3). Each region received a different combination of program + delivery mode: Region 1 (R1)-Full FootyFirst program + fully supported delivery in both 2012 and 2013; R2-Full FootyFirst program + unsupported delivery (both 2012 and 2013); R3-No FootyFirst + no delivery in 2012 (control), full FootyFirst program + full delivery in 2013. For each region, the numbers of hospital-treated (admissions and emergency department presentations) sports injury cases at the hospitals serving those regions were obtained from routine data collections. The in-football season monthly number of lower limb injuries (#LLI) during 2006–2013 was modelled by an intervention time series. The sports injury data was “interrupted” at the beginning of 2012, to coincide with the starting of the FootyFirst delivery, and a second inter accounted for an administrative data change. The model was used to assess changes in slope of the trend lines pre- and post-intervention using a generalised least squares method. Results There was a significant decline in #LLI after the first delivery of FootyFirst only for R1 (pre-FootyFirst monthly increase of 0.15 cases; post-FootyFirst monthly decline of 2.62 cases; effect p = 0.005).The administrative data change led to an increase in the number of cases in all regions. Conclusions After adjusting for seasonal effects, there was a significant reduction in #LLI treated in hospitals in the region where FootyFirst was accompanied by full implementation support.

Introduction Many athletes with patellar tendinopathy are still participating in sports but have symptoms during or after activities. It is hard to decrease pain in-season with current treatments; eccentric exercises in-season have resulted in worsening of symptoms [Fredberg, 2008; Visnes, 2007]. Other exercise programs (isometric and isotonic exercises) have the potential to decrease pain while continuing sport activities [Kongsgaard, 2010; Naugle 2012]. The aim of this study was to compare an isometric against an isotonic exercise protocol designed to decrease patellar tendon pain in-season. Methods Jumping athletes with patellar tendinopathy playing at least 3 times per week participated in this study. They were randomised into an isometric exercise or isotonic exercise group. The exercise programs consisted of 4 exercise sessions per week for 4 weeks. The exercise sessions consisted of 5 sets of 45 second isometric holds for the isometric group and 4 sets of 8 repetitions heavy slow resistance for the isotonic group; both exercises were performed on a leg extension machine. Pain during a Single Leg Decline Squat (SLDS) on a Numeric Rating Scale (0–10) was used as the main outcome measure. Participants kept a diary in which they scored the pre and post exercise pain scores when they performed an exercise session. A Generalised Estimating Equations (GEE) model was run with participants (id) as subject variable; main and interaction effects were determined for the factors time and type of intervention. Results Preliminary results (n = 15) showed a significant improvement of both groups over time (Wald chi-square = 657.4, df =13, p ≤ 0.001). Both groups improved but showed a significantly different effect over time (interaction effect time by intervention, Wald chi-square = 3897.7, df =13, p ≤ 0. 001). This difference seems to take place in week 2 and 3 (Figure 1). There was no difference between groups (Wald chi-square = 0.438, df =1, p = 0.508). Discussion Preliminary results showed that both isometric and isotonic exercises result in a decrease in pain in athletes with patellar tendinopathy symptoms over a 4 week period in-season. This is one of the first in-season studies that makes a direct comparison between exercise protocols for patellar tendinopathy and to our knowledge the first study to investigate isometric exercises in a clinical setting. A decrease in pain score in week 2 and increase in week 3 of the isometric group might possibly be explained by a fast decrease in pain which might have resulted in an increase in activities and a related increase in pain. Isometric and isotonic exercise programs are promising easy-to-use exercises to reduce pain from patellar tendinopathy for athletes in-season. References Fredberg et al. Am J Sports Med. 2008;36:451–460 Kongsgaard et al. Am J Sports Med. 2010;38:749–756 Naugle et al. J Pain. 2012;13(12):1139–1150 Visnes H et al. Br J Sports Med. 2007;41(4):217–223

Introduction Increases in tendon dimensions, such as anteroposterior (AP) diameter and cross-sectional area, is a frequently described feature of tendinopathy. Increased AP diameter has been associated with hypoechogenecity on ultrasound suggesting that pathology and tendon thickness are related. 1 Ultrasound changes, an indication of matrix disorganisation, can only be qualitatively interpreted. Ultrasound tissue characterisation, UTC, captures a 3-dimensional image of the tendon and categorises the tendon into four echo-types based on the stability of pixel brightness over contiguous transverse images. 2 The modality removes the reliance on subjective interpretation and quantifies structure into aligned fibrillar structure (echo-type I+II) and disorganised structure (echo-type III+IV). This study investigated the relationship between the amount of disorganised tissue and the size of the Achilles and patellar tendon. The amount of aligned fibrillar structure in a pathological tendon was compared to normal tendon to determine if pathological tendon has a compromised tendon structure. Methods 91 participants who had their Achilles and/or patellar tendons scanned as part of their clinical management or previous research project were recruited. An algorithm to classify the tendon as normal or pathological was developed based on previously described grey-scale features of tendinopathy (hypoechogenicity, diffuse or whole tendon thickening). Based on UTC algorithms, the total mean cross-sectional area (mCSA), mCSA of aligned fibre structure (echo-type I+II) and disorganised structure (echo-type III+IV) were compared in the pathological and normal tendon using a Mann-Whitney U test. A linear regression between AP diameter, total mean CSA and the mean CSA of disorganised tissue was performed in pathological tendons. Results As expected, both the pathological Achilles and patellar tendon exhibited significantly larger total mCSA, AP diameter and mCSA of disorganised tissue compared to the normal tendon (p Discussion This study found that tendon dimensions were positively correlated with the amount of disorganisation and that the pathological tendon contained an increased amount of aligned fibrillar structure. In combination, these findings suggest that the pathological Achilles and patellar tendon compensate for an area of disorganisation by increasing tendon dimensions to maintain a sufficient aligned fibrillar structure. A lack of remodelling is not apparent within the pathological Achilles or patellar tendon. Treatments that strengthen the already sufficient levels of aligned fibrillar structure may be better than regenerating areas of disorganisation. References 1 Malliaras, et al . Scand J Med Sci Sports. 2012;22:149–155 2 van Schie, et al . BJSM . 2010;44:1153–1159

Introduction Ciprofloxacin, a commonly prescribed fluoroquinolone antibiotic, has been shown to have a deleterious effect on the tendon extracellular matrix. The aims of this study were to determine the effects of short term exposure of ciprofloxacin on 1) tenocyte metabolism, 2) glycosaminoglycan content, and 3) mRNA expression levels of extracellular proteoglycans, and to correlate these changes with the production of newly synthesised proteoglycans in explant cultures of equine tendon. Methods Normal superficial digital flexor tendon from 6 yr old Thoroughbred horses were incubated for 4 days in DMEM alone (control), or DMEM containing up to 300 µg/ml ciprofloxacin (CPX). The effect of CPX on the metabolism of tenocytes was determined by lactate production and Alamar blue assay and glycosaminoglycan content was determined by a dimethylene blue assay. Levels of gene expression of aggrecan, versican, decorin, biglycan and fibromodulin were determined by quantitative PCR. The production of newly synthesised proteoglycans was determined by 35 S-sulfate incorporation at the end of the treatment period. Results Higher levels of CPX (≥100 µg/ml) reduced tenocyte metabolism by 30–40% as measured by lactate production and Alamar blue assay. There was no change in glycosaminoglycan content nor mRNA expression levels of aggrecan, versican, decorin, biglycan or fibromodiulin in CPX-treated tendon explants compared with control. However, CPX suppressed the synthesis of both 35 S-labelled large and small proteoglycans in a dose dependent manner. Discussion The suppression of newly synthesised proteoglycans in tendon explants treated with CPX suggests that these changes are driven by changes in metabolism rather than expression of its associated genes.

Introduction Patellar tendinopathy (PT) affects the ability to jump and land due to pain and associated corticospinal changes to motor patterning. Whilst eccentric exercise is commonly used in rehabilitation, it can be painful to complete. 1 Tendinopathy is especially problematic in competitive season, during which there are constant time and performance pressures. 2 Where eccentric exercise has been completed in the competitive season, there has been poor adherence due to pain and either no benefit [Visnes, 2005] or worse outcomes [Fredberg, 2008]. There is a need for interventions that reduce pain immediately, enabling participation in sport yet do not negatively impact on muscle fatigue, which may affect performance. The purpose of this study was to compare an acute bout of either isometric or isotonic muscle contractions on patellar tendon pain and function and maximal voluntary isometric leg extension torque. Methods This was a single blinded, randomised cross over study compared the effect of a bout of isometric and isotonic muscle contractions on patellar tendon pain, quadriceps strength and measures of corticospinal excitability and inhibition. Outcome measures were single leg decline squat pain (SLDS) for tendon pain, transcranial magnetic stimulation for corticospinal excitability and inhibition and maximal voluntary isometric contraction (MVIC) torque for quadriceps strength. Data were analysed using a split-plot in time repeated measures ANOVA. Results Six volleyball players with PT participated (mean SLDS pain was 7.5/10 (range 7–8), mean cortical inhibition ratio was 27.53% ± 13.0). Isometric muscle contractions significantly reduced SLDS pain immediately (mean 0.16/10 range 0–1; p Discussion Compared to isotonic contractions, a single strength training bout of isometric contractions reduced patellar tendon pain immediately and for at least 45 min post intervention and increased MVIC. The reduction in pain was paralleled by a reduction cortical inhibition, providing insight into potential mechanisms. The clinical implications are that isometric muscle contractions may be used to reduce pain without associated muscle fatigue in PT. References 1 Alfredson H, Pietila T, Jonsson P, Lorentzon R. Am J Sports Med. 1998;26(3):360–6 2 Cook J, Purdam C. Br J Sports Med. 2014;48(7):506–9 3 Visnes H, Hoksrud A, Cook J, Bahr R. Clin J Sports Med . 2005;15(4):227–34 4 Fredberg U, Bolvig L, Andersen NT. Am . J Sports Med. 2008;36(3):451–60 5 Weier AT, Pearce AJ, Kidgell DJ. Acta Physiol . 2012;206(2):109–19

Introduction Musculoskeletal pain (MSK) is known to cause neuroplasticity and changes to muscle representation and motor control.1 Patellar tendinopathy (PT) is a MSK pain that can persist for many years and causes dysfunction in the patellar tendon. Local tissue changes fail to explain tendon pain because pathology may or may not cause pain. Importantly, it is not known how the central nervous system modulates or interprets tendon pain and whether it is similar to other chronic/persistent pain conditions. Corticospinal excitability is an important determinant for muscle function and differences between healthy and tendinopathic participants may correlate with altered muscle function associated with tendinopathy. The corticospinal changes in people with tendon pathology and no pain may contribute to our understanding of the “chicken or the egg” in pathology and pain. This study investigated whether there were corticospinal excitability differences between people with and without tendon pain and tendon pathology. Methods Thirty jumping athletes (n = 6 women, n = 24 men) aged over 18 years with and without PT participated in the study. PT was diagnosed clinically. Ultrasound was used to assess for the presence of tendon abnormality. Objective measures of SLDS pain (numerical rating score out of ten) and maximal voluntary isometric leg extension torque were recorded. The VISA-P questionnaire was administered. Single pulse transcranial magnetic stimulation (TMS) was applied over the motor area projecting to the quadriceps muscle group to obtain measures of corticospinal excitability. Surface EMG was placed on the rectus femoris muscle to record the motor evoke potentials (MEP). Stimulus-response curves were obtained and the slope and peak values were used to establish the strength of projection. Results of tendinopathic and healthy individuals were compared. Within participant analysis was conducted to investigate the cortical changes associated with either unilateral or bilateral pain. People with tendon pathology were analysed separately to controls to determine the effect of pathology on corticospinal excitability. Results Pilot data only (n = 11) is provided at this time with a full data set currently being analysed (n = 30). The mean VISA-P was 97.5 for healthy (n = 4) and 57.75 for people with PT (n = 7). The mean SLDS was 7.5/10 for people with PT. PT increased cortical excitability, evidenced by a steeper slope in the stimulus response curve of people with PT compared with healthy people (p = 0.029, Cohen’s d = 3.08). Figure 1 shows an example of a control participant and a participant with PT. The x axis is the percentage stimulator output. These changes were positively related to symptom duration (r2= 0.57) – the longer the duration of symptoms, the more pronounced the increase in cortical excitability. Discussion People with PT have increased corticospinal excitability affecting motor control. Differences identified indicate that symptom duration impacts cortical excitability. It may be important to measure and consider these cortical changes in the rehabilitation of people with PT. Reference 1 Tsao H, Galea M, Hodges P. Eur J of Pain 2010;14:8,832–839

Introduction Patellar tendinopathy (jumper’s knee – pain in the tendon and dysfunction) has a high prevalence, especially in jumping athletes like volleyball players. Excess load on the patellar tendon through high volumes of training and competition is an important risk factor [Visnes, 2014]. Structural changes in the tendon are related with a higher risk of developing patellar tendinopathy [Cook, 2000]. The critical load that affects tendon structure is unknown. The aim of this study was to investigate patellar tendon structure on each day of a five day volleyball tournament in an adolescent population (16–18 years old). Methods The right patellar tendon of 41 players in the Australian Volleyball Schools Cup (AVSC) was scanned with Ultrasound Tissue Characterisation (UTC) on every day of the tournament (Monday-Friday). UTC can quantify structure of a tendon into four echo-types based on the stability of the echopattern. Hypoechoic abnormalities on grey-scale were also recorded at baseline. Generalised Estimating Equations (GEE) were used to test for change of echo-type I and II over the tournament. Echo-type was used as dependent variable; main effect of time (days of tournament) was determined. In a second analysis the interaction effect time by hypoechoic abnormality was determined. Results Participants played between 8 and 9 matches during the tournament. Hypoechoic abnormalities were recorded in 14 athletes. There was no significant change in echo-types over the 5 days of the study (echo-type I: Wald χ2 =4.603, df = 4, p = 0.331; echo-type II: Wald χ2 = 6.070, df=4, p = 0.194; see figure 1). Overall echopattern was stable across the tournament in participants without hypoechoic abnormalities while a (non-significant) decrease in echo-type I (less stable echopattern) over time (Wald χ2 = 3.853, df =4, p = 0.426) was seen in athletes with hypoechoic abnormalities (figure 2). Echo-type I was significantly lower in athletes with abnormalities (Wald χ2 = 16.545, df=1, p Discussion This study shows that patellar tendon structure of 16–18 year old volleyball players is not affected during 5 days of cumulative loading during a volleyball tournament. Subgroups might exist with a different response to load (e.g. existing hypoechoic abnormality). Further research should focus on different loads and subgroups. References Visnes et al. Scan J Med Sci Sports. 2014;[Epub] Cook et al. J Ultrasound Med. 2000;19:473–479

Introduction Greater trochanteric pain syndrome (GTPS) is common and can cause significant pain and dysfunction. 3 While both trochanteric bursae and gluteal tendons have been implicated in the pathology, 2,6 the underlying pathology remains controversial. Studies reporting on pathology are limited by sample size or methods, including lack of comparison specimens. Thus the aim of this study was to clarify the role of tendon and bursa pathology in GTPS. Methods Tendon and bursa specimens were obtained from 64 participants: 35 with GTPS and 29 control participants. Specimens were evaluated by a minimum of two investigators via light microscopy for histopathological and morphological differences. Immunohistochemistry methods were used to evaluate macrophages (CD68), inflammatory cells (CD45) and substance P. Tendon was evaluated used the Bonar score3. Bursa specimens were evaluated via a semi-quantitative scoring system. Second harmonic generation microscopy, via multiphoton excitation fluorescence (MPEF) was used to illustrate morphological findings (Figure 1). Results Higher levels of pathology were found in specimens from participants with GTPS vs controls. The stroma of the bursa score, mean (SD): GTPS 4.18 (1.65) vs. control 2.53 (1.61), p = 0.051. Bonar (tendon) score, mean (SD): GTPS 12.65 (2.0) vs. control 10.43 (4.83), p = 0.04. There was a higher frequency of SubP in bursa (9/12 vs 6/16, p = 0.047), but not the tendon (8/12 vs. 8/15, p = 0.484) of specimens from participants with GTPS vs controls. There was no evidence of increased frequency of macrophages or other inflammatory cells in the bursa or the tendon specimens from either group. Intra adipose septa were identified and found to be present more frequently in the stroma of bursa specimens of participants with GTPS than controls (27/31 vs 15.27, Fisher exact: p = 0.008), (Figure 1). Discussion Tendon pathology present in both groups, with higher degree of pathology in GTPS. More extensive bursa pathology was seen in the GTPS group, along with a higher frequency of SubP in the bursae from the GTPS than the OA group. This may explain why bursectomy appears to be a successful treatment for some people with GTPS. 1 The IAS has previously reported in rats, 5 but not to our knowledge, in humans. This well organised structure may play a role in bursa stabilisation and shear mitigation. Pathologically it may reduce the ability of the bursa stroma to mitigate compression forces over the tendon. References Baker, et al . Arthroscopy. 2007;23:827–832 Connell, et al . Eur Radiol . 2003;13:1339–1347 Fearon, et al . J Arthroplasty . 2014;29:383–386 Fearon, et al . J Sci Med Sport. 2013;doi: 10.1016/j.jsams.2013.07.008 Shaw, et al . J Anat . 2007;211:436–443 Spear, et al . Surg Clin N Amer . 1952;32:1217–1224

Introduction Up to 30% of Achilles tendinopathy presents in non-active individuals [Rolf 1997] and an association between adiposity and tendinopathy has been highlighted [Gaida 2009a]. Inactivity and adiposity are both associated with unfavourable serum lipid parameters. Individuals with Achilles tendinopathy have a dyslipidaemic profile [Gaida 2009b] and the extreme cholesterol levels seen in familial hypercholesterolaemia are associated with a 6-fold increased lifetime prevalence of Achilles tendon pain (47% versus 7%) [Beeharry, 2006]. It is unknown whether an association exists between lipid parameters and tendon structure in the general population. Methods Serum lipids and Achilles tendon structure were measured in healthy participants. Lipid parameters included total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG). Glucose (GLU) was also measured. Ultrasound tissue characterisation (UTC) was used to quantify Achilles tendon structure; echo-types I (green) and II (blue) were used for analysis. Height, weight and waist circumference were measured. Physical activity level and history of Achilles tendon pain were recorded via questionnaire. Results The 67 participants recruited included 42 men and 25 women (Table 1). The physical activity level was 113 ± 442 min/week. Sixteen participants (24%) reported a history of Achilles tendon pain. There were no statistically significant correlations between echo-types I/II and any of the lipid measures (Table 3, Figure 1). Discussion This study did not show an association between cholesterol and tendon structure. While there was significant variability in the UTC measured tendon structure, the lipid results were relatively homogenous. For example, TC results were clustered between 4.0 and 6.0 mmol/L, suggesting that a vast majority of the participants are fundamentally “normal”. Thus, cholesterol at this level is not correlated with altered tendon structure. References Beeharry et al . Ann Rheum Dis, 2006;65(3):312–5 Gaida et al . Arthritis Rheum , 2009a;27;61(6):840–9 Gaida et al . Med Sci Sports Exerc , 2009b; 31;41(6):1194–7 Rolf et al . Foot Ankle Int. 1997;18(9):565–9

Introduction Type 1 diabetes mellitus (T1DM) occurs when insulin-producing cells are destroyed by an autoimmune response, resulting in hyperglycaemia. Hyperglycaemia accelerates collagen cross-linking in tendons, which can deteriorate tendon structure and predispose to tendon injury (Reddy 2003). Tendon pathology has been observed in the type 2 DM (T2DM) population (Akturk et al . 2007; Papanas et al . 2009), however little is known about T1DM and tendon pathology. This review examines whether there is an association between T1DM and lower limb tendon pathology. Methods Five databases were comprehensively searched for English language journal articles that reported on three key domains: (i) T1DM, (ii) lower limb, and (iii) tendon pathology. Reference lists of included studies or reviews were manually inspected for relevant papers. Articles were excluded if they were: case reports; animal models; conference abstracts; or did not provide T1DM data. Results The search yield of 593 papers was evaluated by title and abstract and 38 papers were read in full text. Only one article met all inclusion criteria (Figure 1). Three potentially eligible articles pooled tendon outcome data for T1DM and T2DM individuals (Bolton et al . 2005; D’Ambrogi et al . 2005; Giacomozzi et al . 2005). Original data was sought from the authors, but was no longer available. The one included article was a cross-sectional study that reported the prevalence of T1DM among individuals with midportion Achilles tendinopathy. This study reviewed electronic medical records from GP practices in the Netherlands, where all reasons for visit are recorded on a computerised registration system. The prevalence of T1DM in those with Achilles tendinopathy (1.8%, 95% CI, 0 to 4.5) was the same as in the general Dutch population (0.8%, CI, NA) (de Jonge et al . 2011). Discussion The main finding of this review was no difference in the prevalence of T1DM between individuals with tendinopathy and the general population. The review highlighted two other key points: (i) there is very limited published data on tendon pain or structure in T1DM, and (ii) despite profound difference in T1/T2DM pathophysiology and co-morbidities, data are commonly combined. Articles that pooled T1DM and T2DM tendon data did not meet the review inclusion criteria. An effort was made to obtain original T1DM data, which was unsuccessful. These studies found DM individuals had significantly thicker Achilles tendons (p et al . 2005; Giacomozzi et al . 2005), but similar flexor hallucis longus tendon thickness (p > 0.05) (Bolton et al . 2005) compared to controls. However, the influence of T1DM on tendon structure in these studies is unknown. The interest in investigating T1DM and T2DM separately comes from the differing pathophysiological causes of DM and exposure to hyperglycaemia. Other characteristics more specific to T2DM may predispose tendons to pathological changes, such as insulin resistance (Gaida et al . 2009b), elevated lipids (Beeharry et al . 2006) and adiposity (Gaida et al . 2009a). References Akturk et al . Exp clin endocrinol. 2007;115:92–6 Beeharry et al . Ann Rheum Dis. 2006;65:312–5 Bolton et al . Clin Biomech. 2005;20:540–6 D’Ambrogi et al . Diabetic Med. 2005;22:1713–9 de Jonge et al . Brit J Sport Med. 2011;45: 1026–8 Gaida et al . Arthritis Rheum. 2009a; 61:840–9 Gaida et al . Med Sci Sport Exer. 2009b; 41:1194–7 Giacomozzi et al . Clin biomech. 2005;20:532–9 Papanas et al , Exp clin endocrinol. 2009;117:645–8 Reddy, J Orthopaed Res. 2003;21:738–43

Background Although sports clubs have a responsibility to protect their players with a safe training and playing environment, little is known about actual safety policies and procedures adopted by community sports clubs. Currently, there is no definitive macro-level sport safety policy available for clubs to implement in Australia. Community sports clubs use micro-policies around issues deemed relevant to their club, which are sourced from various agencies. Objective This presentation will describe the full range of safety resources (policy documents, guidelines, action plans, research papers, fact sheets, posters, and procedures) as developed and disseminated online by key sports safety agencies in Australia. The gaps and duplications in the set of safety resources will also be identified. Finally, a recommendation around the safety needs of community sports clubs with regards to a macro sports safety policy that covers all relevant aspects which can easily be implemented and adopted will be made. Design Document analysis as a qualitative research method. Sources Online sport safety documents from key sport safety agencies in Australia. Main outcome measurements To determine the relevant sport safety resources available online to community sport clubs through key sport safety agencies. Results A collated list of recommended sport safety policies and procedures as developed and disseminated online by key sport safety agencies in Australia, for use by community sports clubs. An analysis of the gaps in current sports safety policy is also discussed. Conclusions Sport safety policies and procedures are currently provided in the form of micro-polices that cover single issues (SunSmart, blood rule, concussion policy etc). It is recommended that key sport safety agencies collaborate to develop a macro-level policy around sport safety that comprehensively covers the full spectrum of safety under one plan that can be easily accessed, adapted and implemented in a variety of community sports club settings.

Background Hyperglycaemia accelerates collagen cross-linking in tendons, which may manifest as an increased thickness or as an altered response to load. Type 1 diabetes mellitus (T1DM) is a unique population exhibiting hyperglycaemia independent of obesity and low physical activity. Ultrasound tissue characterisation (UTC) quantifies the structural integrity of a tendon based on the alignment of collagen, represented as echo-types (I-IV). Objective To measure achilles tendon response to a 10km run among individuals with T1DM and controls. Design In this case-control study, UTC scans were taken at day 0, 2, 4 after a 10 km run. Analysis of UTC scans was performed in a blinded fashion. Setting Social running club for people with T1DM. Participants Individuals with T1DM (n=7) were diagnosed 13±12 years ago. Control participants (n=10) had no diagnosis or family history of T1DM. Participants all regularly ran ≥5 km in a recreational capacity with an average weekly distance of 18±3 km. VISA-A scores were 94±11 (T1DM) and 94±10 (control). Risk factor assessment The independent variable was diagnosis of T1DM (yes/no). HbA1c and blood glucose were also measured. Main outcome measurements Tendon response to a 10km run measured with UTC was defined as the key outcome variable before data collection. Results Baseline structure was the same in control and T1DM groups for all UTC four echo-types (I-IV) and for anteroposterior thickness (P>.05). Furthermore, no significant differences were observed within each group in response to the run. Conclusions A novel finding that Achilles tendon baseline structure and response to a 10 km run over 4-days is the same in controls and T1DM. This suggests that T1DM individuals who are regularly physically active do not undergo the same structural changes to their Achilles tendon as previously demonstrated in the general diabetic population.

BACKGROUND: Altered expression of several cytokines and growth factors has been shown in biopsies of tendinopathy tissue. Biopsy studies are however challenged by capacity to obtain i) healthy tiss ...

Background Developing injury prevention programs for community sport is challenging. The injury issues and interventions must be grounded in science and be both meaningful to, and implementable by, those involved in community sport. Objective This presentation will detail the multi-stage iterative process used to develop FootyFirst, a community-Australian Football (AF) specific lower limb injury prevention program. Design The scientific literature, clinical experience, expert and end-user consultations, community trials, theory-informed discussion, and graphic design and editorial expertise, were combined to develop FootyFirst. Setting Community-AF. Results Lower limb injuries were identified as the major injury concern and it was established that a combination of balance and control, eccentric hamstring, plyometric and strength exercises could be efficacious in preventing such injuries. The multi-disciplinary research team used evidence from the scientific literature, clinical experience and knowledge of the community-AF context in an iterative process to create and trial the exercises and progressions that were included in the first draft of FootyFirst. This draft was further refined through a Delphi process in which AF-specific lower limb injury prevention experts agreed on the appropriateness of including the proposed exercises in FootyFirst. Potential end-user groups (community-AF players, coaches, fitness coaches, sports trainers and administrators) provided feedback about the fit between FootyFirst and the implementation context including potential barriers and facilitators to widespread program adoption and implementation. Trials of FootyFirst were conducted to ensure it could be understood and delivered by community-AF coaches and completed by players. The research team then reviewed the entire program during discussions focused around the Diffusion of Innovations principles of relative advantage, compatibility, complexity, trialability and observability before expert graphic designers and editors were engaged to develop FootyFirst resources. Conclusions The content-to-context process detailed in this presentation was successfully used to develop FootyFirst, an evidence-informed, expert-endorsed, context-specific community-AF lower limb injury prevention program.

Background In determining the effectiveness of sports injury prevention programs (IPP), an assessment of program fidelity is needed. This includes considering whether the intervention was delivered and adhered to as it was intended. Evaluation of program fidelity prevents incorrect conclusions being made about the effects of an IPP and can provide information on why it was successful, or not. Program fidelity for IPPs in sport has generally been limited to self-reported measures around frequency of participation. However, for exercise-based IPPs, performing the exercises as they were originally prescribed is important to maximise injury prevention benefits. Therefore, observing the actual exercise performance could give important insight when evaluating overall IPP fidelity. Objective The aim of this study was to develop an observational tool for exercise-based IPPs and assess its inter-rater reliability. This was trialled in the context of FootyFirst, an IPP in Australian Football. Design The essential performance criteria of each FootyFirst exercise were described in terms of their technique, volume and intensity, in line with exercise prescription guidelines. The expert FootyFirst development team were consulted until consensus was reached on details of each exercise. Each criterion was evaluated by observing player performance and responding with a yes/no answer. Setting Community Australian football clubs. Participants Players participating in FootyFirst as part of regular training; two independent raters. Main outcome measurements Inter-rater reliability of tool and correct performance of FootyFirst exercises. Results The observational tool was trialled at eight clubs for 70 observations. The raters agreed on 61 observations (K=0.718, P Conclusions The FootyFirst Observational Tool has high inter-rater reliability. This can be used to monitor the quality of exercise performance when assessing overall program fidelity.

Background This study evaluated the time course of recovery of transverse strain in the Achilles and patellar tendons following a bout of resistance exercise. Methods Seventeen healthy adults underwent sonographic examination of the right patellar (n=9) or Achilles (n=8) tendons immediately prior to and following 90 repetitions of weight–bearing exercise. Quadriceps and gastrocnemius exercise were performed against an effective resistance of 175% and 250% body weight, respectively. Sagittal tendon thickness was determined 20 mm from the tendon enthesis and transverse strain was repeatedly monitored over a 24 hour recovery period. Results Resistance exercise resulted in an immediate decrease in Achilles (t7=10.6, P Discussion Despite structural and biochemical differences between the Achilles and patellar tendons, 1 the mechanisms underlying transverse creep–recovery in vivo appear similar and are highly time dependent. Primary recovery required about 7 hours in healthy tendons, with full recovery requiring up to 24 hours. These in vivo recovery times are similar to those reported for axial creep recovery of the vertebral disc in vitro, 2 and may be used clinically to guide physical activity to rest ratios in healthy adults. Optimal ratios for high–stress tendons in clinical populations, however, remain unknown and require further attention in light of the knowledge gained in this study.

Introduction A predominant feature of tendinopathy is a change in the appearance and organisation of the extracellular matrix including greater amounts of the large aggregating proteoglycans, aggrecan and versican. We have shown that in patellar tendinopathy these large proteoglycans are also rapidly degraded so that mainly fragments remain in the tissue.1 This catabolism of large proteoglycans is likely to be mediated by a number of matrix-degrading proteinases such as the matrix metalloproteinases (MMPs) and the aggrecanases (ADAMTSs). The aim of this work was to investigate whether in patellar tendinopathy there is a change in the gene expression of the matrix proteinases involved in proteoglycan catabolism including the MMPs and ADAMTSs, as well as their inhibitors, the tissue inhibitor of metalloproteinases (TIMPs). Methods Total mRNA isolated from ∼100mg tissue samples of normal (n=9) and pathologic (n=12) tendon was assayed by relative quantitative RT-PCR for MMP (-1, -2, -3, -9, and -13), ADAMTS (-1, -4, -5), and TIMP (-1, -2, -3, and -4), and normalised to GAPDH. Results Expression of mRNA for MMP-9 and TIMP-1 was significantly up-regulated in pathologic tendons (p=0.019 and p=0.013, respectively). A trend toward a down-regulation of expression of MMP-3 was observed in pathologic tendons (p=0.06). There were no significant changes in ADAMTS-1, -4, or -5 gene expressions. Discussion These results suggest that the elevated expression of MMP-9 and TIMP-1 genes is likely to reflect the changes in collagen metabolism in pathologic tendons. However, these results also suggest that the proteolysis of proteoglycans in the pathologic tendons is not likely to be affected at the gene expression level of proteinases and their inhibitors. These observations are consistent with others, who showed no difference in the expression of ADAMTS-1, -4, and -5 genes between human Achilles tendons with chronic pain and normal tendons.23 Therefore, it is likely that proteoglycan catabolism is elevated by the activation of ADAMTSs and possibly MMPs and not by increased gene expression. This activation may be driven by growth factors and cytokines such as IL-1α, TGF-β and TNF-α, which are shown to be increased in overuse tendinopathy. However, the details of the mechanisms of these regulatory processes warrant further investigation.

Introduction The breakdown of the extracellular matrix (ECM) is well recognised in tendinopathy and likely the cause of degenerative tendon tears. Tendinopathy and degenerative tears can be hard and expensive to treat. Understanding the cellular processes that lead to ECM breakdown will likely lead to improved treatments. With this in mind, the gene transcript profile for extracellular matrix remodelling of tendon specimens from people with greater trochanteric pain syndrome (GTPS) and associated gluteal tendon tears were compared to an age and sex matched reference group. Methods Tendon specimens were collected from six participants undergoing gluteal tendon reconstruction for long standing (mean duration=41 months) GTPS, and four participants from an age-matched reference group (REF) of hip OA patients asymptomatic for GTPS. Specimens were collected using sterile technique and were stored at −80°C. RNA was isolated via laser capture micro-dissection (LCM) of areas of tendon that typified tendon rather than para-tendon or vessels within the specimen—identified using light microscopy and H&E staining. Specimens were tested using the SABiosciences array (PAHS-013). Immunohistochemistry was used to confirm the site of a subset of the expressed genes. Results We report on gene regulation changes of at least five fold that were seen in the GTPS group compared to the REF group. Genes involved in extracellular matrix modelling were both up regulated (MMP7) and down regulated (MMP3). The following cell adhesion genes were up regulated: ITGAV, NCAM1, ITGAM, while ITG3 was down regulated. The following genes involved in ECM synthesis were up regulated (LAMC1, COL1A1, COL5A1, Col6A1), while ADMATS1, LAMB3, VTN were down regulated. Conclusions This paper presents a novel method of tissue specimen selection (LCM), reducing the likelihood of RNA contamination from cells other than tenocytes. Further, these results suggest that there is increased cell activity and collagen production indicating that the tendon is continuing to actively remodel despite prolonged tissue damage. This supports the role of appropriate advice regarding tendon loading and compression, exercises to strengthen the musclo-tendinous unit, and ongoing support to patients. Recovery from tendinopathy may be possible—even in longstanding cases.

Introduction Effective treatment of hip pain leads to improved quality of life and population health. This is dependent on accurate differential diagnosis. While hip osteoarthritis (OA) diagnosis is well defined,1 the diagnosis of greater trochanteric pain syndrome (GTPS) is not. The aim of this study was to clinically define GTPS. Methods Forty one people with GTPS, ranging from mild to severe (11 not seeking treatment and 10 awaiting surgery), 20 with severe hip OA, and 23 age and sex matched asymptomatic participants (ASC) were recruited from public and private hospitals, and the community. Inclusion and exclusion criteria assured mutually exclusive groups. Assessment included the Harris Hip Score (HHS), a battery of passive and resisted tests (recording reproduction and location of pain), and the single leg stance test. Statistical analyses used include Fisher exact test, ANOVA, and recursive partitioning to develop two classification trees. The first classification tree was based on an undifferentiated hip pain response and the second was based on a clearly identified lateral hip pain response. Results The HHS domains of maximum walking distance and the ability to manipulate shoes and socks were the only domains to differentiate between the two symptomatic groups, (ANOVA: p=0.010 and p 30/60; and of 0.06 (0.00 to 0.26)—for the ability to manipulate shoes and socks, of having GTPS versus hip OA. The first classification tree resulted in a four branch tree for diagnosing GTPS, with a mean (se) sensitivity and specificity of 0.78 (0.058) and 0.28 (0.080) respectively. These branches included a positive Ober and passive to active medial rotation ratios. The second tree resulted in one branch, FABER, for diagnosing GTPS with a mean (se) sensitivity and specificity of 0.81 (0.019) and 0.82 (0.044) respectively. The single leg stance test did not differentiate between the two symptomatic groups. Discussion Three features differentiated people with GTPS from those with hip OA without reference to our inclusion criteria. These results provide clinicians with markers to aid with the sometimes difficult diagnosis of GTPS.2 When combined with greater trochanter palpation, this combination of features is likely to be more sensitive and specific than the FABER test result. We recommend that the clinical syndrome of GTPS be defined as a history of lateral hip pain in the absence of difficulty with manipulating shoes and socks, together with an examination of findings of pain reproduction on palpation of the greater trochanter (a previously recognised sign) and lateral hip pain with a FABER test. In patients who cannot differentiate the site of their pain, multiple pathologies should be considered. For research purposes or in cases of poor response to treatment, multiple pathologies should be considered and a hip x-ray should be undertaken to exclude joint pathology.

Introduction The Achilles tendon is an elastic storage tendon that converts kinetic energy into mechanical energy and reduces the metabolic cost of high-speed locomotion. Numerous studies have shown that the tendon is responsive to mechanical stimuli with changes in CSA and collagen synthesis both in the short- and long-term.12 This mechano-responsiveness of the tendon has been implicated in the development of tendinopathy and detecting early and/or short-term changes may have a role in managing tendinopathy. Ultrasound tissue characterisation (UTC) uses contiguous ultrasound images to render a 3-dimensional image that allows semi-quantitative analysis of tendon structure. This novel ultrasound technique has been used to show short-term changes in tendon structure in response to maximal exercise in thoroughbred horses.3 This study aims to investigate short-term changes in the Achilles tendon in Australian football players in response to loading during competitive games. Methods 22 elite male Australian football players, some with history of tendinopathy (six and three players with a history of patellar and Achilles tendinopathy, respectively) were recruited. Players were scanned prior to the game and days 1, 2 and 4 post-game using UTC. A 1cm region at the midsubstance of the tendon was selected and the ultra-structure quantified into four echo-types based on the stability of the echopattern. Changes in the echopattern were compared over the 4 days using a related samples Friedmans two-way analysis of variance. If a significant difference in the median was observed, post-hoc (Wilcoxon signed rank test) analysis was performed to identify the differences between days 1, 2 and 4 and day 0. Results Preliminary data analysis showed differences in baseline tendon structure in players with and without a history of lower limb tendinopathy. Further analysis will examine differences between groups in change over the 4 days, and examine intrinsic (age, mass) and extrinsic factors (game load, GPS data) that are associated with change in UTC parameters. Conclusions This study demonstrated the changes seen in the Achilles tendons of athletes after intense loading. The factors that affect the magnitude of the response were elucidated.

The exercise or loading approaches to treatment of tendinopathy have been at the forefront of treatment options for the last 30 years. Prior to that, the predominance of the inflammatory model prescribed that rest, ice and anti-inflammatory medication was the only suitable approach. This approach was overwhelmingly unsuccessful; failure to recover and recurrence were common. In the 70′s Curwin and Stanish reported that eccentric loading was beneficial for tendinopathy, and although this received some notice in the clinical world, the Alfredson paper in 1995 resulted in an explosion of interest in eccentric load for tendinopathy. Since then much research has confirmed the benefits of eccentric exercise, however the reasons for its effectiveness have not been elucidated. The effectiveness appears to be specific to rehabilitation of active people; eccentric exercise in season, and in the inactive population was less successful. The specificity of eccentric-only exercise has also been questioned- although eccentric clearly has to be part of the programme, it has been shown to be effective when combined with concentric exercise and with quite high loads. Is there more progress to be made in the area of exercise-based rehabilitation? If the continuum model is correct, then consideration of loading in different stages is essential, remembering that the eccentric programme was shown to be most effective in chronic degenerative tendinopathy. Reactive tendinopathy is likely to require different loading regimes, as will the common clinical presentation of reactive on degenerative tendinopathy. Power and energy storage loads have not been considered in research, although clinically they are a critical part of rehabilitation. Research in these areas is likely to be complex and require multi-centre trials; it may be up to the people at this conference to prioritise this research as a group.

Introduction Achilles tendinopathy is a prevalent musculoskeletal injury in the young athletic population as well as older individuals. A high proportion of individuals develop symptoms within both Achilles tendons as well as an increased incidence of tendon rupture in the contralateral tendon post Achilles tendon rupture. Bilateral pathological changes have been reported in the literature in a number of animal studies,1 as well as pathological changes observed histologically and ultrasonographically in the asymptomatic tendon.23 Recent studies have suggested that these changes may be centrally mediated rather than alterations in gait, and may predispose the tendon to further degeneration and the development of symptoms. The current study examined changes in tendon structure in patients suffering from unilateral Achilles tendinopathy using ultrasound tissue characterisation (UTC) in both the symptomatic and asymptomatic tendon. UTC allows semi quantitative analysis of tendon structure by assessing the stability of the echopattern, which is closely related to the 3-D structure of the tendon. Methods 13 unilateral Achilles tendinopathy patients were recruited with various times of symptoms. Both Achilles tendons were scanned using UTC. UTC captures 600 contiguous transverse images over a distance of 12 cm and renders a three-dimensional image of the tendon. Tendon structure was quantified from the insertion to the musculotendinous junction using customised software that quantifies the stability of the echopattern and allows semi-quantification of tendon structure, which has previously been matched with pathological specimens. Tendon structure was compared between the symptomatic and asymptomatic tendon using a related-samples Wilcoxon signed rank test. Results No significant difference was observed for any of the four echo-types between the symptomatic and asymptomatic tendon (p=0.388, p=0.158, 0.624, p=0.824, respectively). Despite no differences being observed in the echopatterns, disorganisation within the asymptomatic group was diffusely scattered throughout the length of the tendon. Disorganisation in the symptomatic tendon was confined to focal lesions predominately characterised by echo-types representing extensive fibrillar disorganisation. Discussion Despite the overall echopattern of the tendon not differing between the two groups, the distribution of disorganisation within the tendon differed. However, as changes in tendon structure were not confined to the symptomatic tendon, treatments should aim to improve tendon structure in both limbs to minimise the risk of developing symptoms and potential tendon rupture.

Introduction Grading the extent of degenerative change in tendon is an important aspect of tendinopathy research. The Bonar score1 has been widely used for this purpose since 2004. This method provides valuable guidelines for tendinosis assessment but is not without limitations, and many groups have made modifications to the original method.2 It is common for researchers to evaluate the area of highest morphological change, however the method of defining this area, and the implications of using different methods, have not been documented. In this study, we asked whether selecting the level of greatest morphological change using different aspects of the score (degree of collagen disruption, the level of cell morphological change, or the degree of vascularity) would lead to similar or different Bonar scores. Methods Human tendon from people undergoing gluteal tendon reconstruction or hip arthroplasty was assessed in each part of this study. Two researchers experienced in using the Bonar score systematically reviewed each domain of the Bonar score while viewing tendon sections. By consensus, the appropriate level of magnification used for each domain was determined. The need for polarisation was also reviewed. Additional clauses of pathological acellularity and avascularity were added to the third. Hyper and hypo cellularity were defined, and, modification of the vascularity and cellularity scores were confirmed. Two researchers, with a third to resolve disputes evaluated 32 sections of tendon. Each domain within the Bonar score was evaluated in each of the following areas: the area of worst collagen disruption; the area scoring the highest vascularity; and thirdly the area scoring the highest tenocyte morphology change. Results A total of 84 areas of tendon were evaluated. The total Bonar score was highest in the areas of most cellular morphological (CM) changes (mean, (SD) 14.4 (1.50)) then highest collagen disruption (CD: 13.0 (2.56)), and lowest for the area of vascularity (VS) (11.6 (1.68), (regression: CD vs TM p=0.008, CM vs VS p Conclusions and recommendations This paper provides clarification of, and recommendations on the use of the commonly used Bonar score. Cellularity is best assessed using one FoV×100. In human tissue, hypo-cellularity ≤20 nuclei per HPF, Hyper-cellularity ≥30 nuclei per HPF. Normal=20 to 30 nuclei per HPF. Cell morphology was best assessed at ×200 magnification, over four FoV. Vascularity should be assessed at ×400 magnification, up to 10 FoV, and Ground substance was best assessed at ×100. When evaluating a FoV, a 20% rule should be applied. That is, if 20% of the tissue can be scored at the highest level, this score is applied to the entire FoV. To provide accurate/reliable assessment, tendon sections should be viewed by a minimum, of two researchers, simultaneously, but independently with the final score decided either by consensus, or a third assessor. These results suggest that using the area of maximum tenocyte morphological changes provides a justifiable score that is representative of the worst degree of tendinosis in the specimen. We believe our modified Bonar score provides clearer definitions of each grade and also specifies the level of magnification for each domain, producing a more robust assessment tool. Further evaluation of the Bonar score9s applicability to commonly used tendinopathy laboratory models should be carried out.

Introduction Achilles tendinopathy is a degenerative condition for which several risk factors have been implicated including components of the inflammatory pathway. The aims of this study was to evaluate (i) several functional variants within genes encoding components of the apoptosis signalling cascade and (ii) the effectiveness of a polygenic apoptosis profile to capture Achilles tendinopathy (TEN) risk. Methods A total of 358 unaffected control (CON) participants (159 South Africa (SA CON) and 199 Australia (AUS CON)) and 166 affected TEN participants (87 SA TEN and 79 AUS TEN) were genotyped for four variants ( CASP8 (rs384129), CASP8 (rs1045485) , NOS3 (rs1799983) and NOS2 (rs2779249)). Logistic regression was used to derive risk models for TEN and a receiver operator characteristic (ROC) curve was plotted to determine the effectiveness of the models to capture TEN risk. Results An independent association of CASP8 _rs1045485 and CASP8 _rs3834129, together with their haplotype was observed with TEN risk. The optimal risk model identified from the study included the two CASP8 genetic loci investigated ( CASP8 _rs384129 and CASP8 _rs1045485) together with sex to capture TEN risk in both SA and AUS participants collectively. Conclusions These findings further implicate the apoptosis signalling cascade as one of the important biological pathways involved in the development of Achilles tendinopathy.

Ultrasonography (US) is used to visualise tendon structure. However, its capacity to detect early disintegration, to reproducibly monitor progress of pathology or repair, and to objectively evaluate effect of therapies and exercise is poor. Furthermore, US is not able to reliably assess tissue integrity as its limits of resolution means that every US image is a mixture of reflections (of relatively large structures like secondary tendon bundles, fasciculi) and interfering echoes (generated by smaller entities like fibrils and cells) that cannot be discriminated by the eye. Therefore, a method for computerised ‘ultrasound tissue characterisation’ (UTC) was created. A high-resolution probe is fixed in a tracking device and moves automatically along a tendon9s long axis, collecting transverse images at even distances of 0.2 mm. By compounding contiguous transverse images, a 3-D ultrasound data-block is created that can be used for (A) tomographic visualisation in 3 planes of view plus a 3-D rendered view, and for (B) tissue characterisation and quantification of 3-D architecture of the tendon matrix. Dedicated UTC-Algorithms can discriminate four different echo-types, namely: echo-type I, generated by reflections at intact and aligned tendon bundles, echo-type II, generated by reflections at discontinuous or wavy tendon bundles, echo-type III, generated by interfering echoes from mainly fibrillar components, and echo-type IV, generated by mainly cellular components and fluid in amorphous tissue. Initially, UTC was validated by precisely matching UTC-processed images with corresponding tendon specimens, sampled from isolated flexor tendons in the horse. These four echo-types appeared to be highly correlated with histo-morphological characteristics, showing the discriminative power of UTC for tissue characterisation. Since 2005, UTC is implemented for human Achilles and patellar tendons and has been used in multiple research projects too. Some relevant observations in these studies are: Inter-and intra-observer reproducibility of both data-collection and analysis appeared to be high (ICC over 0.90), indicating an excellent reliability for longitudinal monitoring. Observational studies of UTC parameters related to age revealed that Achilles tendons of young persons (24–30 years of age) are characterised by 80–85% echo-type I, 10–15% echo-type II and only 2–5% type III plus IV echoes. Initial deterioration, mostly asymptomatic, was characterised by increasing percentages of echo-types II (remodelling or fibrosis) and/or III plus IV (fibrillar and cellular disintegration), mainly localised in the postero-medial quadrant of the Achilles tendon. In patients with diabetes type II and in persons with lateral foot-landing pattern, the Achilles tendons demonstrated significantly more changes on UTC compared to matched controls. Patients suffering tendinopathy (avg. age 45 years) have significantly higher percentages of echo-types II, III and/or IV, compared with a matching group of asymptomatic control persons.1 Significant increases of echo-type II and III can be observed in normal tendons 24–48 h after maximal loads: these changes appear reversible within 4 days.2 On the other hand, preliminary results in a group of high-performance athletes indicate that athletes with persistent changes on UTC are at risk of developing symptoms within the same season. Ultra-structural effects of rehabilitation exercises can be quantitatively evaluated within 14 days. It is concluded that UTC is utmost suitable for (a) detection of in-situ tendon responses to load, (b) early diagnosis of injury or degeneration, (c) staging of histo-pathological stage of lesions, and for (d) objective evaluation of longitudinal effects of regenerative therapies.

Background There is an increasing momentum to develop, widely implement and evaluate evidence-based injury prevention programmes in sport. However, navigating the literature to evaluate the evidence, and bridging the gap between the research environment and the real-world implementation context, is challenging. Aims/Objectives/Purpose This study aimed to develop an evidence-based lower limb injury prevention exercise programme for implementation and evaluation in community Australian football. Methods Development of the programme involved a systematic review of the literature including consideration of compliance, cost, adverse effects, uptake and feasibility. The review was used to develop a draft exercise-based programme (FootyFirst) to prevent hamstring, hip/groin, knee and ankle injuries. The programme was presented to stakeholders in Australian football for feedback through a Delphi process and then field tested for feasibility. The final programme was then implemented in two football leagues under two conditions (fully supported and programme only), with a third league acting as a control. Results/Outcome The evidence-base for lower limb injury prevention strategies was limited, making direct extrapolation of research findings to programme content challenging. Three rounds of the Delphi process were required before consensus of the programme content was achieved. Further modifications were made after field testing. The programme was implemented in time for the 2012 season. Significance/Contribution to the Field Developing a comprehensive programme with a strong foundation in the published research evidence was challenging, requiring many modifications and extensive consultation to develop a programme with face validity and a strong probability of uptake. The effectiveness FootyFirst is currently being evaluated. This is an abstract of a presentation at Safety 2012, the 11th World Conference on Injury Prevention and Safety Promotion, 1-4 October 2012, Michael Fowler Center, Wellington, New Zealand. Full text does not seem to be available for this abstract.

Background A planned approach towards translating injury prevention research evidence and policy into sustained safety practice and behaviour changes is an often neglected component of the evidence to practice translation process. Aims/Objectives/Purpose This presentation will describe how evidence and theory-informed, context-specific implementation plans were developed for two sports injury prevention interventions aimed at community sport in Australia. Methods The seven tasks of Step 5 of the Intervention Mapping Protocol were used to develop implementation plans for both the Mayday neck and spinal injury prevention policy in rugby union and the FootyFirst exercise training programme to prevent leg injuries in Australian football. Results/Outcomes Although changes in sports participant behaviour were the desired end-goal of both interventions, it was recognised that sports coaches would be the primary programme adopters. Therefore, coach-delivered training to players was the important outcome. To encourage coach implementation of the Mayday safety procedure the key focus was on referee enforcement of a new local rugby by-law, supported by content changes to current mandatory coach education, and education resource production and dissemination. For FootyFirst, the key implementation strategies were the endorsement of the programme by opinion leaders, allocation of mentors to support community coaches to implement the programme, and the development of user-friendly implementation resources. Significance/Contribution to the Field These two case studies demonstrate a systematic approach for planning the implementation of injury prevention interventions that can lead to the development of context-specific, evidence and theory-informed implementation plans.

Evidence-based treatments exist for many sports injuries; for example, reconstruction of the anterior cruciate ligament (ACL) is clinically effective and has evidence to support it. Other injuries that have a more difficult, recurrent or variable time course to recovery, for example, muscle strains, tendon injuries and bone stress, have more limited evidence. Although a range of interventions exist for these problematic conditions in ‘conventional’ or ‘mainstream’ medicine, a plethora of gurus offer more exotic interventions and ‘promise’ quicker and better outcomes and return to sport. Gurus are successful in gathering clients for their interventions in a range of ways, but one ingredient is expectation. There is a wealth of information that shows clinical enthusiasm (‘Gee, he’s confident'), novelty (‘No one told me about this!’) and expense (‘The best money can buy’) relate to improved outcomes—usually by increasing expectation1—this is …

What is your first reaction when you find out your next patient has a long-term tendinopathy? I suspect you want to hide or get an urgent phone call that drags you away from the practice. You know that the person will have tried multiple interventions, probably had several injections, read all the literature about treatments for tendinopathy on the internet and want an immediate and lifelong cure. You also know that your assessment will take well into your next patient’s time allotment and even then it will remain difficult to prioritise treatments and to explain the rationale behind your plan to the patient. Even as a tendon researcher and part-time clinician whose practice consists solely of tendinopathy patients, my reactions to chronic tendinopathy patients are similar. Tendon is incredibly complex tissue that refuses to behave in any sort of structured reparative way or respond to clinical interventions …

Thank you to BJSM guest editor Steven Blair1 and all our January and February authors (http://bjsm.bmj.com/content/vol43/issue1; http://bjsm.bmj.com/content/vol43/issue2). If we apply Bono's battle cry “There has been a lot of talk, maybe too much talk”…to the subject of physical inactivity, we can now proclaim it's time for action. The January and February BJSM issues bring together global authorities and focus on practical steps. Medical clinicians will be interested in the analysis by Erica Frank and colleagues ( see page 124 ) of the activity levels of medical students and their propensity to prescribe physical activity (or not!).2 Is it time to add a physical activity question to the medical student selection process? Should the Medical College Admission Test ask for a shuttle run/beep test score? Barry Franklin and colleagues3 make a compelling case for …

Background:The role of apoptosis, or programmed cell death, has only recently been explored in tendon.Objective:To investigate the development of apoptosis after high strain loading of rat tendon.Methods:The right tibialis anterior tendons of three rats were prepared for mechanical loading, and left tendons were prepared identically as non-loaded controls. Tendon was loaded with 20% strain for six hours using a 1 Hz longitudinal sine wave signal. The following were used to assess apoptosis: (a) a monoclonal mouse antibody (F7-26) to label single stranded DNA breaks; (b) a rabbit polyclonal antibody that specifically recognises the cleaved form of caspase-3.Results:Light microscopy confirmed that the high strain protocol induced a stretch overload injury. Control tendons showed little or no staining with the F7-26 antibody, but the loaded tendons displayed numerous apoptotic cells. The percentage of apoptotic cells (20%) in the loaded tendon was significantly greater than in the control tendon (1%) (p = 0.000). The labelled cells colocalised with abnormal nuclear morphology, including nuclear fragmentation. The staining against cleaved caspase-3 was positive in loaded tendons only, and localised both to nucleus and cytoplasm.Conclusion:This experiment extends knowledge of human tendon apoptosis by showing that apoptosis can occur in response to short term, high strain mechanical loading. This is the first report of mechanical loading of intact tendon causing excessive apoptosis.