Athletes participating in elite sports are exposed to high training loads and increasingly saturated competition calendars. Emerging evidence indicates that poor load management is a major risk factor for injury. The International Olympic Committee convened an expert group to review the scientific evidence for the relationship of load (defined broadly to include rapid changes in training and competition load, competition calendar congestion, psychological load and travel) and health outcomes in sport. We summarise the results linking load to risk of injury in athletes, and provide athletes, coaches and support staff with practical guidelines to manage load in sport. This consensus statement includes guidelines for (1) prescription of training and competition load, as well as for (2) monitoring of training, competition and psychological load, athlete well-being and injury. In the process, we identified research priorities.

https://bjsm.bmj.com/content/bjsports/50/17/1030.full.pdf

How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear. Level of Evidence: Level II, systematic review. See the Guidelines for Authors for a complete description of levels of evidence.

/pdf/treatment-of-tendinopathy-what-works-what-does-not-and-what-qjygrkz8kh.pdf

Treatment of tendinopathy: what works, what does not, and what is on the horizon.

A randomized-controlled single-blind trial was conducted to investigate the clinical, structural and functional effects of peritendinous corticosteroid injections (CORT), eccentric decline squat training (ECC) and heavy slow resistance training (HSR) in patellar tendinopathy. Thirty-nine male patients were randomized to CORT, ECC or HSR for 12 weeks. We assessed function and symptoms (VISA-p questionnaire), tendon pain during activity (VAS), treatment satisfaction, tendon swelling, tendon vascularization, tendon mechanical properties and collagen crosslink properties. Assessments were made at 0 weeks, 12 weeks and at follow-up (half-year). All groups improved in VISA-p and VAS from 0 to 12 weeks (Po0.05). VISA-p and VAS improvements were maintained at follow-up in ECC and HSR but deteriorated in CORT (Po0.05). In CORT and HSR, tendon swelling decreased ( � 13 � 9% and � 12 � 13%, Po0.05) and so did vascularization ( � 52 � 49% and � 45 � 23%, Po0.01) at 12 weeks. Tendon mechanical properties were similar in healthy and injured tendons and were unaffected by treatment. HSR yielded an elevated collagen network turnover. At the half-year follow-up, treatment satisfaction differed between groups, with HSR being most satisfied. Conclusively, CORT has good short-term but poor long-term clinical effects, in patellar tendinopathy. HSR has good short- and long-term clinical effects accompanied by pathology improvement and increased collagen turnover.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0838.2009.00949.x

Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy

The adaptive response of connective tissue to loading requires increased synthesis and turnover of matrix proteins, with special emphasis on collagen. Collagen formation and degradation in the tendon increases with both acute and chronic loading, and data suggest that a gender difference exists, in that females respond less than males with regard to an increase in collagen formation after exercise. It is suggested that estrogen may contribute toward a diminished collagen synthesis response in females. Conversely, the stimulation of collagen synthesis by other growth factors can be shown in both animal and human models where insulin-like growth factor 1 (IGF-I) and transforming growth factor-beta-1 (TGF-beta-1) expression increases to accompany or precede an increase in procollagen expression and collagen synthesis. In humans, it can be demonstrated that an increase in the interstitial concentration of TGF-beta, PGE2, IGF-I plus its binding proteins and interleukin-6 takes place after exercise. The increase in IGF-I expression in tendon includes the isoform that has so far been thought only to exist in skeletal muscle (mechano growth factor). The increase in IGF-I and procollagen expression showed a similar response whether the tendon was stimulated by concentric, isometric or eccentric muscle contraction, suggesting that strain rather that stress/torque determines the collagen-synthesis stimulating response seen with exercise. The adaptation time to chronic loading is longer in tendon tissue compared with contractile elements of skeletal muscle or the heart, and only with very prolonged loading are significant changes in gross dimensions of the tendon observed, suggesting that habitual loading is associated with a robust change in the size and mechanical properties of human tendons. An intimate interplay between mechanical signalling and biochemical changes in the matrix is needed in tendon, such that chemical changes can be converted into adaptations in the morphology, structure and material properties.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0838.2009.00986.x

From mechanical loading to collagen synthesis, structural changes and function in human tendon.

Tendinopathy is characterized by pain in the tendon and impaired performance sometimes associated with swelling of the tendon. Its diagnosis is usually clinical but ultrasonography and magnetic resonance imaging can refine the diagnosis. Tendinopathy is highly prevalent and is one of the most frequently self reported musculoskeletal diseases in physical workers and sports people. Nevertheless, it is very difficult to carry out general epidemiologic studies on tendinopathy because of the varying sports cultures and sports habits in different countries. The aetiology of tendinopathy seems to be multi-factorial, involving intrinsic and extrinsic factors. The role of inflammation is still debated but the absence of inflammatory cells does not mean that inflammatory mediators are not implicated. Different theories have been advanced to explain pain and chronicity mechanisms, but these mechanisms remain largely unknown. "Conventional "treatments are generally employed empirically to fight pain and inflammation but they do not modify the histological structure of the tendon. However, these treatments are not completely satisfactory and the recurrence of symptoms is common. Currently, eccentric training remains the treatment of choice for tendinopathy, even though some studies are contradictory. Moreover, many interesting new treatments are now being developed to treat tendinopathy, but there is little evidence to support their use in clinical practice. Key pointsThe word "tendinopathy "is the correct term for the clinical diagnosis of pain accompanied by impaired performance, and sometimes swelling in the tendon.The aetiology of tendinopathy seems to be a multi-factorial process, involving promoting factors that are intrinsic or extrinsic, working either alone or in combination.US (with color Doppler) and MRI are usually prescribed when tendinopathy is unresponsive to treatment and entails lingering symptoms.Eccentric training is currently considered to be the most efficient treatment for tendinopathy; nevertheless, in order to be effective, this treatment needs specific modalities: slow speed, low intensity and gradual intensification, with minimum 20 to 30 sessions of exercises often being needed.Many interesting new treatments are now being developed to treat tendinopathy, but currently there is little evidence to support their use in clinical practice.

Current Opinions on Tendinopathy

The aim was to compare the efficacy and safety of two 
eccentric rehabilitation protocols for patients with 
symptomatic patellar tendinopathy. A new eccentric 
overload training device was compared to the present 
standard eccentric rehabilitation program on a decline 
board.
 Design: Prospective, randomised clinical trial.
Setting: Sports rehabilitation clinic, university sports 
laboratory supplemented with home exercises.
 Patients: 20 competitive and recreational 
athletes, all with clinical diagnosis of patellar 
tendinopathy, verified by MRI or ultrasound imaging.
Interventions: A 12-week rehabilitation period, either, 
with bilateral eccentric overload strength training using 
the Bromsman® device twice a week, or unilateral 
eccentric body load training using a decline board twice 
a week supplemented with daily home exercises. Outcome measures: The primary outcome was pain and 
function, assessed by the Swedish VISA-P score. Secondary 
outcome measures were isokinetic muscle torque, dynamic 
function, and muscle flexibility as well as pain level 
estimations using Visual Analogue Scale (VAS). Side 
effects were registered.
 Results: Both treatment groups improved in short 
term according to the VISA-P scores during the 12-week 
rehabilitation period. However, there were no significant 
differences between the groups in terms of pain and 
function. After a three months rehabilitation period, the 
majority of the patients could be regarded as improved 
enough to be able to return to training and sports. No 
serious side effects were detected in either group.
 Conclusion: In patients with patellar tendinopathy 
pain, two-legged eccentric overload training twice per 
week, using the new device (Bromsman®), were as efficient 
and safe as the present standard daily eccentric one-
legged rehabilitation-training regimen using a decline 
board.

/pdf/eccentric-treatment-for-patellar-tendinopathy-a-prospective-5fpyxut685.pdf

Eccentric treatment for patellar tendinopathy - a prospective randomised short-term pilot study of two rehabilitation protocols

Studies have shown that reduced neuromuscular control or strength increases the risk of acute injuries. It is hypothesized that a non-functional movement pattern can predispose for injuries. In the present paper a detailed description of a test battery consisting of nine different tests to screen athletic movement pattern is provided. The aim was to evaluate the inter- and intra-rater reliability of the test battery on a group of male elite soccer players. Twenty-six healthy elite soccer players (17–28 years) were screened. Eighteen participated at a second occasion 7 days later. No significant difference (P 5 0.31) was found between test occasion 1 (LS means 18.3, 95% confidence interval 14.9–21.7) and test occasion 2 (18.0, 14.4–21.7) in the mean total score of the test battery. No significant difference in the inter-rater reliability was found between the eight physiotherapists at the two test occasions. The intra-class correlation coefficient was 0.80 and 0.81, respectively. The test battery showed good interand intra-rater reliability. The screening battery is easy to use for familiarized professionals and requires minimal equipment. However, further studies are needed to confirm the validity of the test battery in injury prevention, rehabilitation and performance enhancement.

A nine-test screening battery for athletes: a reliability study.

Little is known about health variables and if these variables could increase the risk of injuries among adolescent elite athletes. The primary aim was to present overall data on self-perceived stress, nutrition intake, self-esteem, and sleep, as well as gender and age differences, on two occasions among adolescent elite athletes. A secondary aim was to study these health variables as potential risk factors on injury incidence. A questionnaire was e-mailed to 340 adolescent elite athletes on two occasions during a single school year: autumn semester and spring semester. The results show that during autumn semester, the recommended intake of fruits, vegetables, and fish was not met for 20%, 39%, and 43% of the adolescent elite athletes, respectively. The recommended amount of sleep during weekdays was not obtained by 19%. Multiple logistic regression showed that athletes sleeping more than 8 h of sleep during weekdays reduced the odds of injury with 61% (OR, 0.39; 95% CI, 0.16-0.99) and athletes reaching the recommended nutrition intake reduced the odds with 64% (OR, 0.36; 95% CI, 0.14-0.91). Our findings suggest that nutrition intake and sleep volume are of importance in understanding injury incidence.

Too little sleep and an unhealthy diet could increase the risk of sustaining a new injury in adolescent elite athletes.

Many risk factors for injury are presented in the literature, few of those are however consistent and the majority is associated with adult and not adolescent elite athletes. The aim was to identify risk factors for injury in adolescent elite athletes, by applying a biopsychosocial approach. A total of 496 adolescent elite athletes (age range 15-19), participating in 16 different sports, were monitored repeatedly over 52 weeks using a valid questionnaire about injuries, training exposure, sleep, stress, nutrition, and competence-based self-esteem. Univariate and multiple Cox regression analyses were used to calculate hazard ratios (HR) for risk factors for first reported injury. The main finding was that an increase in training load, training intensity, and at the same time decreasing the sleep volume resulted in a higher risk for injury compared to no change in these variables (HR 2.25, 95% CI, 1.46-3.45, P<.01), which was the strongest risk factor identified. In addition, an increase by one score of competence-based self-esteem increased the hazard for injury with 1.02 (HR 95% CI, 1.00-1.04, P=.01). Based on the multiple Cox regression analysis, an athlete having the identified risk factors (Risk Index, competence-based self-esteem), with an average competence-based self-esteem score, had more than a threefold increased risk for injury (HR 3.35), compared to an athlete with a low competence-based self-esteem and no change in sleep or training volume. Our findings confirm injury occurrence as a result of multiple risk factors interacting in complex ways.

Multiple factors explain injury risk in adolescent elite athletes : applying a biopsychosocial perspective

Background: Self-administrated patient outcome scores are increasingly recommended for evaluation of primary outcome in clinical studies. The VISA-P score, developed at the Victorian Institute of Sport Assessment in Melbourne, Australia, is a questionnaire developed for patients with patellar tendinopathy and the patients assess severity of symptoms, function and ability to participate in sport. The aim of this study was to translate the questionnaire into Swedish and to study the reliability and validity of the translated questionnaire and resultant scores. Methods: The questionnaire was translated into Swedish according to internationally recommended guidelines for cross-cultural adaptation of self-report measures. The reliability and validity were tested in three different populations. The populations used were healthy students (n = 17), members of the Swedish male national basketball team (n = 17), considered as a population at risk, and a group of non-surgically treated patients (n = 17) with clinically diagnosed patellar tendinopathy. The questionnaire was completed by 51 subjects altogether. Results: The translated VISA-P questionnaire showed very good test-retest reliability (ICC = 0.97). The mean (± SD) of the VISA-P score, at both the first and second test occasions was highest in the healthy student group 83 (± 13) and 81 (± 15), respectively. The score of the basketball players was 79 (± 24) and 80 (± 23), while the patient group scored significantly (p < 0.05) lower, 48 (± 20) and 52 (± 19). Conclusions: The translated version of the VISA-P questionnaire was linguistically and culturally equivalent to the original version. The translated score showed good reliability.

/pdf/psychometric-properties-of-a-swedish-translation-of-the-visa-174wqt2jo9.pdf

Anna Frohm

Papers

Eccentric treatment for patellar tendinopathy - a prospective randomised short-term pilot study of two rehabilitation protocols

A nine-test screening battery for athletes: a reliability study.

Too little sleep and an unhealthy diet could increase the risk of sustaining a new injury in adolescent elite athletes.

Multiple factors explain injury risk in adolescent elite athletes : applying a biopsychosocial perspective

Psychometric properties of a Swedish translation of the VISA-P outcome score for patellar tendinopathy