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Quadriceps strengthening exercises are part of the treatment of patellofemoral pain (PFP), but the heavy resistance exercises may aggravate knee pain. Blood flow restriction (BFR) training may provide a low-load quadriceps strengthening method to treat PFP.Seventy-nine participants were randomly allocated to a standardised quadriceps strengthening (standard) or low-load BFR. Both groups performed 8 weeks of leg press and leg extension, the standard group at 70% of 1 repetition maximum (1RM) and the BFR group at 30% of 1RM. Interventions were compared using repeated-measures analysis of variance for Kujala Patellofemoral Score, Visual Analogue Scale for 'worst pain' and 'pain with daily activity', isometric knee extensor torque (Newton metre) and quadriceps muscle thickness (cm). Subgroup analyses were performed on those participants with painful resisted knee extension at 60°.Sixty-nine participants (87%) completed the study (standard, n=34; BFR, n=35). The BFR group had a 93% greater reduction in pain with activities of daily living (p=0.02) than the standard group. Participants with painful resisted knee extension (n=39) had greater increases in knee extensor torque with BFR than standard (p0.01). No between-group differences were found for change in Kujala Patellofemoral Score (p=0.31), worst pain (p=0.24), knee extensor torque (p=0.07) or quadriceps thickness (p=0.2). No difference was found between interventions at 6 months.Compared with standard quadriceps strengthening, low load with BFR produced greater reduction in pain with daily living at 8 weeks in people with PFP. Improvements were similar between groups in worst pain and Kujala score. The subgroup with painful resisted knee extension had larger improvements in quadriceps strength from BFR.12614001164684.

The aim of this study was to investigate interactions between variants within genes encoding components of the collagen fibril and components of cell-signaling pathways within the extracellular matrix, and determine the relative contribution of these variants to Achilles tendinopathy risk in a polygenic model. A total of 339 asymptomatic control participants and 179 participants clinically diagnosed with Achilles tendinopathy were genotyped for variants within six genes encoding components of the collagen fibril and three genes encoding components of cell-signaling pathways. Logistic regression, stepwise selection, and receiver operating characteristic curve (ROC) analysis was used to select and evaluate genetic interactions and determine the relative contribution of these variants to overall genetic risk. The strongest, best fit polygenic risk model included the variables sex, three COL27A1 variants (rs4143245; rs1249744; rs946053), COL5A1 rs12722, CASP8 rs1045485, and CASP8 rs2824129 with an area under the ROC curve of 0.737 and the maximum sum of sensitivity and specificity indicators equal to 134%. Significant interactions between genes encoding components of the collagen fibril and genes encoding components of the cell-signaling pathways modify risk of Achilles tendinopathy.

The protection of an athlete's health and preventing injuries and illnesses in sport are top priorities for the IOC and its Medical Commission. The IOC therefore partners with selected research centres around the world and supports research in the field of sports medicine. This has enabled the IOC to develop an international network of expert scientists and clinicians in sports injury and disease prevention research. The IOC wants to promote injury and disease prevention and the improvement of physical health of the athlete by: (1) establishing long-term research programmes on injury and disease prevention (including studies on basic epidemiology, risk factors, injury mechanisms and intervention), (2) fostering collaborative relationships with individuals, institutions and organisations to improve athletes' health, (3) implementing and collaborating with applied, ongoing and novel research and development within the framework and long-term strategy of the IOC and (4) setting up knowledge translation mechanisms to share scientific research results with the field throughout the Olympic Movement and sports community and converting these results into concrete actions to protect the health of the athletes. In 2009, the IOC also identified four research centres that had an established track record in research, educational and clinical activities to achieve these ambitions: (1) the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Australia; (2) the Sport Injury Prevention Research Centre (SIPRC), Canada; (3) the Clinical Sport and Exercise Medicine Research (CSEM), South Africa and (4) the Oslo Sports Trauma Research Center (OSTRC), Norway. This paper highlights the work carried out by these four IOC Centres of Excellence over the past 6 years and their contribution to the world of sports medicine.

Patellar tendinopathy disrupts athletic careers in several sports and is resistant to many forms of conservative treatment. Outcome after conservative treatment has been minimally investigated, and the effect of these treatments on the pathology of overuse tendinopathy are not well understood. The clinical assessment of patellar tendinopathy appears straightforward, but evidence suggests that the importance of imaging and palpation in diagnosis and ongoing assessment may be overestimated. There is a lack of clinically relevant research on which to base treatment. However, the principles of management for patellar tendinopathy derived from clinical experience include load modification, musculotendinous rehabilitation, and intervention to improve the shock absorbing capacity of the limb. The role of electrophysical agents, massage, and stretching in the treatment of patellar tendinopathy are also discussed. The progression of treatment is based on clinical grounds due to a lack of reliable subjective and objective tools to assess recovery. The failure of some conservative programs could be due to either athlete compliance or practitioner expertise. The management of patellar tendinopathy is complex, and if the physiotherapist addresses all the principles of treatment, the chance of success could be increased.

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

Anterior knee pain is a common presenting complaint amongst adolescent athletes. We hypothesised that patellar tendinopathy may occur at a younger age than is generally recognised. Thus, we studied the patellar tendons in 134 elite 14- to 18-year-old female (n=64) and male (n=70) basketball players and 29 control swimmers (17 female, 12 male) clinically and with ultrasonography. We found that of 268 tendons, 19 (7%) had current patellar tendinopathy on clinical grounds (11% in males, 2% in females). Twenty-six percent of the basketball players' patellar tendons contained an ultrasonographic hypoechoic region. Ultrasonographic abnormality was more prevalent in the oldest tertile of players (17-18 years) than the youngest tertile (14-15.9 years). Of tendons categorised clinically as 'Never patellar tendinopathy', 22% had an ultrasonographic hypoechoic region nevertheless. This study indicates that patellar tendinopathy can occur in 14- to 18-year-old basketball players. Ultrasonographic tendon abnormality is 3 times as common as clinical symptoms.

IN BRIEF: Patellar tendinopathy causes substantial morbidity in both professional and recreational athletes. The condition is most common in athletes of jumping sports such as basketball and volleyball, but it also occurs in soccer, track, and tennis athletes. The disorder arises most often from collagen breakdown rather than inflammation, a tendinosis rather than a tendinitis. Physicians must address the degenerative pathology underlying patellar tendinopathy because regimens that seek to minimize (nonexistent) inflammation would appear illogical. Suggestions for applying the ‘tendinosis paradigm’ to patellar tendinopathy management include conservative measures such as load reduction, strengthening exercises, and massage. Surgery should be considered only after a long-term and appropriate conservative regimen has failed.

Overuse tendinopathies are common in primary care. Numerous investigators worldwide have shown that the pathology underlying these conditions is tendinosis or collagen degeneration. This applies equally in the Achilles, patellar, medial and lateral elbow, and rotator cuff tendons. If physicians acknowledge that overuse tendinopathies are due to tendinosis, as distinct from tendinitis, they must modify patient management in at least eight areas. These include adaptation of advice given when counseling, interaction with the physical therapist and athletic trainer, interpretation of imaging, choice of conservative management, and consideration of whether surgery is an option.

OBJECTIVE: To report the appearances of ultrasound (US) and magnetic resonance imaging (MRI) before and after surgery for chronic patellar tendinopathy and to correlate postoperative appearances with clinical outcome. DESIGN: A 12-month prospective longitudinal study and a retrospective study, each part using different patients. Prospective study included clinical assessment, ultrasound, and MRI all performed before and 12 months after surgery. Retrospective study included ultrasound and clinical assessment only (i.e., no MRI) 24 to 67 months after surgery. SETTING: Institutional athlete study group in Australia (Victorian Institute of Sport Tendon Study Group). PATIENTS: In the prospective study, 13 patients (all male; 15 tendons) who underwent patellar tenotomy; in the retrospective study, 17 different patients (18 tendons) who had undergone identical surgery. MAIN OUTCOME MEASURES: Ultrasound and MRI appearances and clinical assessment at baseline and 12 months after surgery (prospective study). Ultrasound appearance and clinical assessment 24 to 67 months after surgery (retrospective study). Dimensions of abnormal regions on imaging were measured. Clinical assessment included categorical rating and numerical Victorian Institute of Sport Assessment (VISA) score. RESULTS: In the prospective study, preoperative ultrasound and MRI appearances confirmed the clinical diagnosis of patellar tendinopathy. Postoperative ultrasound and MRI also revealed abnormalities consistent with patellar tendinopathy. Despite this, 11 of 15 (73%) tendons were rated clinically as either good or excellent. Imaging modalities were unable to distinguish tendons rated as good or excellent from those rated poor at 12 months. In the retrospective study, ultrasound images revealed abnormalities despite full clinical recovery. There was no correlation between dimension of ultrasound abnormality and either VISA score or time since surgery. CONCLUSION: After open patellar tenotomy, MRI and ultrasound findings remain abnormal despite clinical recovery. Thus, clinicians ought to base postoperative management of patients undergoing patellar tenotomy on clinical grounds rather than imaging findings. At present, there appears to be no role for routine postoperative imaging of patients recovering slowly after patellar tenotomy. However, this is not to suggest that imaging cannot play a role in special circumstances.

OBJECTIVE: To compare patellar tendon sonographic findings in active, currently asymptomatic, elite athletes with those in nonathletic controls. DESIGN: Cross-sectional cohort study with convenience control sample. SETTING: The Victorian Institute of Sport Tendon Study Group, an institutional elite athlete study group in Australia. PATIENTS AND PARTICIPANTS: Two hundred elite male and female athletes from the sports of basketball, cricket, netball, and Australian rules football. Forty athletes who had current symptoms of jumper's knee were excluded from analysis, leaving 320 subject tendons in athletes who were currently asymptomatic. Twenty-seven nonathletic individuals served as controls. MAIN OUTCOME MEASURE: Sonographic patellar tendon appearance. We measured the dimensions of subject tendons and noted the presence or absence of hypoechoic regions and tendon calcification. Dimensions of hypoechoic regions were measured, and approximate cross-sectional areas were calculated. Chi-squared analysis was used to test the prevalence of hypoechoic regions in subjects and controls and men and women. RESULTS: In currently asymptomatic subjects, hypoechoic regions were more prevalent in athlete tendons (22%) than in controls (4%), in male subject tendons (30%) than in female subjects (14%), and in basketball players (32%) than in other athletes (9%) (all p < 0.01). Bilateral tendon abnormalities were equally prevalent in men and women but more prevalent in basketball players (15%) than in other athletes (3%) (p < 0.05). Sonographic hypoechoic regions were present in 35 of 250 (14%) patellar tendons in athletes who had never had anterior knee pain. CONCLUSIONS: Patellar tendon sonographic hypoechoic areas were present in asymptomatic patellar tendons of a proportion of elite athletes but rarely present in controls. This has implications for clinicians managing athletes with anterior knee pain.

SUMMARY The patellar tendon donor site of 20 patients who underwent anterior cruciate ligament (ACL) reconstruction using the patellar tendon tissue as autograft was examined with high resolution 7.5 MHz ultrasound. The patients were randomly divided into four groups and studied at 3, 6, 9 or 12 months postoperatively. The size of the postoperative tendon defect was measured just distal to the lower pole of the patella. The size of the tendon defect diminished progressively from a mean of 109 mm2 at 3 months to a mean of 23 mm2 at 12 months. Increasing echogenicity was first noticed 12 months after tendon repair. Seven patients developed clinical features postoperatively of jumper's knee (patellar tendinosis). There were no ultrasound signs that differentiated these patients from asymptomatic patients. It is concluded that ultrasound provides objective evidence of patellar tendon healing after ACL reconstruction: the surgical defect diminished in size and became echogenic after a period of 12 months.

Symptoms of jumper's knee (patellar tendinosis) are not easily quantified and this may explain why there are no evidence-based guidelines for managing the condition. A simple, practical questionnaire-based index of severity would facilitate jumper's knee research and subsequently, clinical management. Thus we devised and tested the Victorian Institute of Sport Assessment (VISA) questionnaire. The brief questionnaire assesses (i) symptoms, (ii) simple tests of function and (iii) ability to play sport. Six of the eight questions are scored on a visual analogue scale from 0–10 with 10 representing optimal health. The maximal VISA score for an asymptomatic, fully performing individual is 100 points and the theoretical minimum is 0 points. We found the VISA scale to have excellent short-term test-retest, and inter-tester reliability (both, r>0.95) as well as good short-term (one week) stability (r=0.87). Mean (SD) of the VISA scores ranged from 95 (8) points in asymptomatic control subjects to 55 (12) points in patients who presented to a sports medicine clinic with jumper's knee and 22 (17) points in patients before surgery for chronic jumper's knee. Six- and twelve-months after surgery VISA scores returned to 49 (15) and 75 (17) points respectively, mirroring clinical recovery. We conclude that the VISA score is a reliable index of the severity of jumper's knee that has potential to aid clinicians and researchers.

Methods: Seventy-eight clubs were targeted for implementation of an online injury surveillance system (approximately 4000 athletes) in five community Australian football leagues concurrently enrolled in a larger injury prevention project (National Guidance for Australian Football Partnerships and Safety (NoGAPS)). System implementation was evaluated quantitatively, using the RE-AIM framework, and qualitatively via semi-structured interviews with targeted-users (mainly sports trainers). Results: Across the 78 clubs, there was 69% reach (informed about/trained in use of injury surveillance system), 44% adoption (set up an online account with intention of recording injuries), 23% implementation (used system to record injuries throughout season) and 9% maintenance (used system over two consecutive seasons). Reach and adoption were highest in those leagues receiving concurrent support for the delivery of the NoGAPS injuryprevention trainingprogram(FootyFirst). Interviewees identified several barriers and facilitators to implementation including personal (e.g. belief in the importance of injury surveillance), sociocontextual (e.g. understaffing and athlete underreporting) and systems factors (e.g. the time taken to upload injury data into the online surveillance system). Discussion: The injury surveillance system was implemented andmaintained by only a small proportion of clubs. Outcomeswere best in those leagues receiving concurrent support for the delivery of FootyFirst, suggesting that engagement with club personnel and organisations at all levels can enhance use of injury surveillance systems in community sport. Interview findings suggest that increased implementation could also be achievedby educating club personnel on the importance of recording injuries, asking leagues to create clearer injury surveillance guidelines, increasing club staffing, better remunerating those who conduct surveillance and offering flexible surveillance systems in a range of accessible formats. By increasing the use of surveillance systems, datawill better reflect the target population and increase our understanding of the injury problem in community sport.

Background Type XI collagen, which is expressed in developing tendons and is encoded by the COL11A1 , COL11A2 and COL2A1 genes, shares structural and functional homology with type V collagen, which plays an important role in collagen fibril assembly. We investigated the association of these three polymorphisms with Achilles tendinopathy (AT) and whether these polymorphisms interact with COL5A1 to modulate the risk of AT. Methods 184 participants diagnosed with chronic AT (TEN) and 338 appropriately matched asymptomatic controls (CON) were genotyped for the three polymorphisms. Results Although there were no independent associations with AT, the TCT pseudohaplotype constructed from rs3753841 (T/C), rs1676486 (C/T) and rs1799907 (T/A) was significantly over-represented (p=0.006) in the TEN (25.9%) compared with the CON (17.1%) group. The TCT(AGGG) pseudohaplotypes constructed using these type XI collagen polymorphisms and the functional COL5A1 rs71746744 (-/AGGG) polymorphism were also significantly over-represented (p Discussion The genes encoding structural and functionally related type XI ( COL11A1 and COL11A2 ) and type V ( COL5A1 ) collagens interact with one another to collectively modulate the risk for AT. Although there are no immediate clinical applications, the results of this study provide additional evidence that interindividual variations in collagen fibril assembly might be an important molecular mechanism in the aetiology of chronic AT.

s / Osteoarthritis and Cartilage 21 (2013) S63–S312 S95 162 DOES KNEE EXTERNAL ROTATION DIFFER ACCORDING TO FRONTAL PLANE KNEE ALIGNMENT AND THE PRESENCE OF PATELLOFEMORAL OSTEOARTHRITIS AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? A.G. Culvenor y, A.G. Schache z, B.T. Vicenzino y, N.J. Collins z, J.L. Cook x, M.G. Pandy z, K.M. Crossley y. yUniv. of Queensland, Brisbane, Australia; zUniv. of Melbourne, Parkville, Australia; xMonash Univ., Melbourne, Australia Purpose: Patellofemoral (PF) osteoarthritis (OA) and anterior cruciate ligament reconstruction (ACLR) have both been shown to be associated with frontal plane knee malalignment and greater tibial external rotation. However, little is known about frontal plane malalignment and knee external rotation in people with PF OA after ACLR. The aim of this study was to evaluate the association between frontal plane knee alignment and tibial rotation angle during walking and running in people with and without PF OA after ACLR. Methods: Thirty-six individuals from an ACLR database who were 9 years after hamstring graft ACLR with either radiographic PF OA (with no, or less, concomitant tibiofemoral OA; n1⁄418; 56% male; age 47 10 years; BMI 27.3 3.8kg$m-2) or no OA (n1⁄418; 61% male; age 40 9 years; BMI 26.6 4.1kg$m-2) participated in a cross-sectional study. Knee rotation in the ACLR knee was measured in a gait laboratory using a point-cluster technique and a three-dimensional motion analysis system (VICON) during gait (2 speeds: walking at self-selected speed and running at 2.5-3.5 m.sec-1). Weight-bearing frontal plane knee alignment was measured with a digital inclinometer, and participants were classified as having either varus or valgus alignment using a previously validated formula. Repeated-measures analysis of covariance (covariates: age, gender, BMI) with speed (walk, run) and event (initial contact, point of maximum knee flexion during stance, toe-off) as within-subject factors, and OA status (PF OA, no OA) and frontal plane alignment (varus, valgus) as between-subject factors, was used to assess the interaction between PF OA and frontal plane alignment on tibial external rotation angle. Post-hoc tests were conducted where indicated (a1⁄40.05). Results: Significant interactions were found between PF OA and frontal plane alignment on tibial rotation angle during walking and running (F(1,29) 1⁄4 9.32, p 1⁄4 0.005). Post-hoc tests revealed that in individuals with valgus alignment, those with PF OA demonstrated a mean 5 (95% CI: 0 to 10) more tibial external rotation than those without OA across both gait speeds (Figure 1) with a moderate effect size (standardised mean difference (SMD)1⁄40.53). For individuals with varus alignment, those with PF OA had a mean 3 (-1 to 6) less tibial external rotation than those without OA with a smaller effect size (SMD1⁄40.38). Conclusions: Nine years after ACLR a significant interaction effect between PF OA and frontal plane alignment on tibial external rotation angle exists during walking and running. Greater tibial external rotation in those with PF OA with valgus aligned knees may be clinically important, given that a rotational shift of similar magnitude has been suggested to be sufficient to cause acceleration of cartilage degeneration. Further prospective studies are required to determine if this relationship indicates altered movement patterns due to PF OA, or if it may be a risk factor for PF OA development after ACLR. Ă 163 DIFFERENT ALTERATIONS IN THE SIT TO STAND MOVEMENT PATTERN IN WOMEN WITH EARLY AND ESTABLISHED MEDIAL COMPARTMENT KNEE OSTEOARTHRITIS I.A. Baert y,z, A. Mahmoudian y, I. Jonkers y, F. Staes y, F.P. Luyten x, S. Truijen k,z, S.M. Verschueren y. yKU Leuven, Heverlee, Belgium; zArtesis Univ. Coll. of Antwerp, Merksem, Belgium; xUZ KU Leuven, Leuven, Belgium; kUniv. of Antwerp, Antwerpen, Belgium Purpose: Several gait alterations including a greater loading of the medial compartment have been documented in patients with moderate to severe knee osteoarthritis (OA), but not in knee OA patients with beginning joint degeneration (early knee OA). The Sit to Stand (STS) movement is a mechanically more demanding task, requiring greater joint forces and moments, and is considered as one of the most difficult activities of daily life for patients with knee OA. Therefore, the aim of this study was to assess whether early knee OA patients did show an altered movement strategy in the more demanding STS movement compared to established knee OA patients and healthy controls. Methods: A novel classification system, incorporating Magnetic Resonance Imaging, was used to identify patients with early knee OA. Thirteen female subjects with symptomatic early medial compartment knee OA,16 female subjects with establishedmedial compartment knee OA (Kellgren and Lawrence grade 2+) and 16 asymptomatic female control subjects volunteered for the study. A 3D motion analysis system and force platform were used to capture the movement pattern during the STS task. Outcome measures included spatiotemporal variables (duration of movement angular velocity), kinematic variables (joint angles) and kinetic variables (joint moments). Differences between groups were analyzed using a one-way analysis of variance. Results: The duration of the STS movement and the knee angular flexion velocity were not significantly different between the three groups. Early OA subjects showed no significant differences in kinematic variables during the STS movement. In contrast, the established OA group had a smaller knee flexion range ofmotion (61.0 degrees versus 67,4 degrees), related to significantmore remaining knee flexion after reaching the final standing posture (15.7 degrees versus 9.9 degrees). They also showed significantly less knee abduction (11.5 degrees versus 14.4 degrees) and a significantly higher maximal knee adduction angle (6.7 degrees versus 1.9 degrees). Both OA groups showed different alterations in kinetic variables during the STS movement. Early OA patients showed a significantly higher peak hip flexion moment (0.28 Nm/kg versus 0.17 Nm/kg) and established OA patients showed a significantly larger KAM impulse (0.04 Nm/kg versus -0.02 Nm/kg) compared to controls. Conclusions: Differences in the STS movement kinematics and kinetics that were only present in patients with established knee OA and not in patients with early knee OA are most likely a consequence of structural degeneration in medial compartment knee OA and reflect mechanical overload of the medial compartment. On the other hand, the higher peak hip flexion moment during the STS movement that was present in the early stage of knee OA could reflect a compensatory mechanism in order to avoid an increase in peak knee flexion moment on their diseased knee. Higher knee flexion moments would entail higher force demand for the quadriceps, higher overall joint compression forces and, subsequently, an increase in pain. In contrast with the findings in gait analysis, early OA patients did show an adaptation in their STS movement strategy compared to healthy controls which supports the relevance of classification of early knee OA. 164 BIOMECHANICAL FACTORS RELATED TO RESPONSE TO LATERAL WEDGE INSOLES G.J. Chapman y, M.J. Parkes z, L.M. Forsythe z, D.T. Felson z, R.K. Jones y. yUniv. of Salford, Salford, United Kingdom; zUniv. of Manchester, Manchester, United Kingdom Purpose: Lateral wedge insoles reduce the external knee adduction moment (EKAM), however approximately 30% of patients have a paradoxical increase in EKAM. Identifying and understanding why these patients increase EKAM is critical for prescribing the correct treatment for these patients. Evidence suggests ankle biomechanics may play a key role in reducing EKAM as lateral wedge insoles have been shown to shift the centre of foot pressure (COFP) laterally, increasing ankle eversionmoment and shorten the lever arm separating ground reaction force (GRF) from knee thus reducing the EKAM. To date, patients have

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.

Patellofemoral joint (PFJ) osteoarthritis (OA) is a prevalent disease capable of being a potent source of knee symptoms. Although anterior cruciate ligament (ACL) injury and reconstruction (ACLR) are well-established risk factors for the development of tibiofemoral joint OA, PFJ OA after ACL reconstruction has gone largely unrecognised. This is despite the high prevalence of anterior knee pain after ACLR, which can reduce the capacity for physical activity and quality of life. The susceptibility of the PFJ to degenerative change after ACLR may have implications for current rehabilitation strategies. This review summarises the evidence describing the prevalence of PFJ OA after ACLR and examines why this compartment may be at increased risk of early onset OA after ACLR. Strategies that address the modifiable factors for risk of PFJ OA may aid in alleviating joint loads and symptoms for people after ACLR.

Achilles tendinopathy (AT) is a degenerative condition for which several risk factors have been implicated including components of the inflammatory pathway. The aim was to assess functional variants within genes encoding components of the apoptosis signaling cascade and the effectiveness of a polygenic apoptosis profile to capture tendinopathy (TEN) risk. A total of 358 unaffected control (CON) participants [159 South Africa (SA CON) and 199 Australia (AUS CON)] and 166 affected AT (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 AT. A receiver operator characteristic (ROC) curve was plotted to determine the effectiveness of a model to capture AT risk. This study indicates the independent association of CASP8_rs1045485 and CASP8_rs3834129 as well as their haplotype with AT risk and the identification of an optimal model which included genetic loci CASP8_rs384129 and CASP8_rs1045485 together with sex to capture AT risk in both SA and AUS. Collectively, these results further implicate the apoptosis signaling cascade as one of the biological pathways involved in the development of AT.

Summary. Re-study of the fauna recovered in 1969 during excavations by John Campbell in front of the West Entrance to Robin Hood Cave, Creswell Crags, Derbyshire, England, shows it to include components of different ages. Arctic hare is the only species certainly exploited by humans and it is suggested that the position and character of cut-marks preserved on bone surfaces documents the processing and possible consumption of uncooked meat. It has not been possible to identify the time(s) of year when these hares died. Radiocarbon results for cut-marked bones are important for dating the Creswellian.

A reindeer antler object found in Northamptonshire possesses the characteristic traits of a Lyngby axe. Such implements are themselves characteristic of the Late Glacial of northern Europe but hitherto unknown in Britain. A direct radiocarbon accelerator date of 10, 320±150 BP (OxA–803) confirms the typological dating and places it amongst a small number of finds which link Britain with the Ahrensburgian phase in Europe. The function of the axe cannot be determined, but consideration of its features throws some light on this problem.

Understanding adaption to load is essential for prevention and treatment of tendinopathy/tendinosis. Cytokine release in response to load is one mechanism involved in mechanotransduction. The cytokine tumor necrosis factor alpha (TNF-α) is implicated in tendinosis and can induce apoptotic effects via tumor necrosis factor receptor 1 (TNFR1). The complete absence of information concerning the TNF-α system in Achilles tendon is a limitation as mid-portion Achilles tendinosis is very frequent. Purpose: To examine expression patterns of TNF-α and its two receptors (TNFR1 and TNFR2) in human Achilles tendinosis and control tissue and to biochemically confirm the presence of TNF-α in tendinosis tissue. Methods: TNF-α and TNFR1 mRNA were detected via in situ hybridization. TNF-α, TNFR1, and TNFR2 were demonstrated immunohistochemically. Apoptosis markers were utilized. ELISA was used to detect TNF-α. Results: TNF-α and TNFR1 mRNA was detected in tenocytes of both tendinosis and control tendons. Tenocytes from both groups displayed specific immunoreactions for TNF-α, TNFR1, and TNFR2. The widened/rounded tenocytes of tendinosis samples exhibited the most intense immunoreactions. Apoptosis was detected in only a subpopulation of the tenocytes in tendinosis tissue. TNF-α was measurable in tendinosis tissue. Inflammatory cells were not seen. Conclusion: This is the first evidence of the existence of the TNF-α system in the human Achilles tendon. Findings are confirmed at mRNA and protein levels as well as biochemically. The TNF-α system was in principle confined to the tenocytes. The connection between tenocyte morphology and the expression pattern of TNF-α, TNFR1, and TNFR2 suggests that the TNF-α system may be involved in tenocyte activation in Achilles tendinosis.

The calcite figurine of a human couple in coitus said to be from Ain Sakhri in Judea has been interpreted as a symbol of fertility reflecting the economic and social concerns of the Natufian period. This paper presents a critical history surrounding its discovery, an evaluation of its archaeological context and a description of the piece itself, in order to address the broader issues surrounding its interpretation.

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

Purpose: Risk factors associated with a clinical presentation of patellar tendinopathy are patellar tendon ultrasonographic abnormality (PTA) and excessive loading. It remains unknown whether characteristics of an athlete's landing technique contribute to this excessive patellar tendon loading. This study investigated whether asymptomatic athletes with and without PTA had different landing strategies and hypothesized that asymptomatic athletes with a PTA would create higher patellar tendon loading and a different lower-limb landing strategy compared with athletes with normal patellar tendons. Methods: Seven athletes with no previous history or clinical signs of patellar tendon injury with a PTA were matched to athletes with normal patellar tendons (controls). Participants performed five successful trials of a stop-jump task, which involved a simultaneous two-foot horizontal and then vertical landing. During each trial, the participants' ground reaction forces and lower-limb electromyographic data were recorded, the three-dimensional kinematics measured, and the peak patellar tendon force calculated by dividing the net knee joint moment by the patellar tendon moment arm. Results: Significant between-group differences in landing technique were mostly observed during the horizontal landing phase. Participants with a PTA created similar patellar tendon loading to the controls, but with altered sequencing, by landing with significantly greater knee flexion and extending their hips while the controls flexed their hips as they landed, reflecting a different muscle recruitment order compared with the PTA group. Conclusions: The crucial part in the development of PTA and, in turn, patellar tendinopathy may not be the magnitude of the patellar tendon load but rather the loading patterns. This research provides clinicians with important landing assessment criteria against which to identify athletes at risk of developing patellar tendinopathy.

Background Adiposity is a modifiable factor that has been implicated in tendinopathy. As tendon pain reduces physical activity levels and can lead to weight gain, associations between tendon pathology and adiposity must be studied in individuals without tendon pain. Therefore, the purpose of this study was to determine whether fat distribution was associated with asymptomatic Achilles tendon pathology. Methods The Achilles tendons of 298 individuals were categorised as normal or pathological using diagnostic ultrasound. Fat distribution was determined using anthropometry (waist circumference, waist hip ratio [WHR]) and dual-energy x-ray absorptiometry. Results Asymptomatic Achilles tendon pathology was more evident in men (13%) than women (5%) (p = 0.007). Men with tendon pathology were older (50.9 ± 10.4, 36.3 ± 11.3, p < 0.001), had greater WHR (0.926 ± 0.091, 0.875 ± 0.065, p = 0.039), higher android/gynoid fat mass ratio (0.616 ± 0.186, 0.519 ± 0.142, p = 0.014) and higher upper-body/lower body fat mass ratio (2.346 ± 0.630, 2.022 ± 0.467, p = 0.013). Men older than 40 years with a waist circumference >83 cm had the greatest prevalence of tendon pathology (33%). Women with tendon pathology were older (47.4 ± 10.0, 36.0 ± 10.3, p = 0.008), had less total fat (17196 ± 3173 g, 21626 ± 7882 g, p = 0.009), trunk fat (7367 ± 1662 g, 10087 ± 4152 g, p = 0.003) and android fat (1117 ± 324 g, 1616 ± 811 g, p = 0.005). They had lower central/peripheral fat mass ratios (0.711 ± 0.321 g, 0.922 ± 0.194 g, p = 0.004) than women with normal tendons. Women with tendon pathology were more often menopausal (63%, 13%, p = 0.002). Conclusions Men with Achilles tendon pathology were older and had a central fat distribution. Women with tendon pathology were older and had a peripheral fat distribution. An interaction between age and waist circumference was observed among men.

An Upper Palaeolithic engraving of a female figure has recently been discovered on the base of a naturally hollowed limestone slab possibly used as a bowl or lamp, found in the cave of Courbet (Penne-Tarn, France) and preserved in the British Museum. The slab, decorated on the dished side with linear incisions, and the female figure are described in detail. The occurrence of a female engraving on a utilised slab is found to be unique to date but the relationship of the figure to the support is questioned and discussed. The female engraving is compared with others known from Germany, as well as Quercy and Périgord, France. On the basis of these comparisons and radiocarbon age estimates, the engraved slab is attributed to Magdalenian VI.

Objective To establish the relationship between the history of hip and groin injuries in elite junior football players prior to elite club recruitment and the incidence of hip and groin injuries during their elite career. Design Retrospective cohort study. Setting Analysis of existing data. Participants 500 Australian Football League (AFL) players drafted from 1999 to 2006 with complete draft medical assessment data. Assessment of risk factors Previous history of hip/groin injury, anthropometric and demographic information. Main outcome measurement The number of hip/groin injuries resulting in ≥1 missed AFL game. Results Data for 500 players were available for analysis. 86 (17%) players reported a hip/groin injury in their junior football years. 159 (32%) players sustained a hip/groin injury in the AFL. Players who reported a previous hip or groin injury at the draft medical assessment demonstrated a rate of hip/groin injury in the AFL >6 times higher (IRR 6.24, 95% CI 4.43 to 8.77) than players without a pre-AFL hip or groin injury history. Conclusions This study demonstrated that a hip or groin injury sustained during junior football years is a significant predictor of missed game time at the elite level due to hip/groin injury. The elite junior football period should be targeted for research to investigate and identify modifiable risk factors for the development of hip/groin injuries.

Objective: To compare the chemical levels and mRNA expression of proteoglycan and collagen in normal human patellar tendons and tendons exhibiting chronic overuse tendinopathy. Methods: Sulfated glycosaminoglycan and hydroxyproline content were investigated by spectrophotometric measurement using papain-digested samples. Deglycosylated proteoglycan core proteins were analysed by Western blot using specific antibodies. Total mRNA isolated from samples of frozen tendons was assayed by relative quantitative RT-PCR for decorin, biglycan, fibromodulin, versican, aggrecan, and collagens Type I, II and III and normalised to glyceraldehyde-3-phosphate dehydrogenase. Results: There was a significant increase in sulfated glycosaminoglycan content in pathologic tendons compared to normal. This was attributed to an increased deposition of the large aggregating proteoglycans versican and aggrecan and the small proteoglycans biglycan and fibromodulin, but not decorin. Aggrecan and versican were extensively degraded in both normal and pathologic tendons, biglycan was more fragmented in the pathologic tendons while predominantly intact fibromodulin and decorin were present in normal and pathologic tendons. There was a greater range in total collagen content but no change in the level of total collagen in pathologic tendons. There were no significant differences between the pathologic and normal tendon for all genes, however p values close to 0.05 indicated a trend in downregulation of Type I collagen and fibromodulin, and upregulation in versican and Type III genes in pathologic tissue. Conclusion: The changes in proteoglycan and collagen levels observed in patellar tendinopathy appear to be primarily due to changes in the metabolic turnover of these macromolecules. Changes in the expression of these macromolecules may not play a major role in this process.

Chronic painful insertional Achilles tendinopathy is seen in both physically active and non-active individuals. Painful eccentric training, where the patients load the Achilles tendon into full dorsiflexion, has shown good results in patients with mid-portion Achilles tendinosis. However, only 32% of patients with insertional Achilles tendinopathy had good clinical results with that type of eccentric training regimen.To investigate whether a new model of painful eccentric training had an effect on chronic painful insertional Achilles tendinopathy.27 patients (12 men, 15 women, mean age 53 years) with a total of 34 painful Achilles tendons with a long duration of pain (mean 26 months), diagnosed as insertional Achilles tendinopathy, were included. The patients performed a new model of painful eccentric training regimen without loading into dorsiflexion. This was done as 3x15 reps, twice a day, 7 days/week, for 12 weeks. Pain during Achilles-tendon-loading activity (VAS) and patient's satisfaction (back to previous activity) were evaluated.At follow-up (mean 4 months) 18 patients (67%, 23/34 tendons) were satisfied and back to their previous tendon-loading activity. Their mean VAS had decreased from 69.9 (SD 18.9) to 21 (SD 20.6) (p0.001). Nine patients (11 tendons) were not satisfied with the treatment, although their VAS was significantly reduced from 77.5 (8.6) to 58.1 (14.8) (p0.01).In this short-term pilot study this new model of painful eccentric calf-muscle training showed promising clinical results in 67% of the patients.