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Patellar Tendinitis in Elite Soccer PlayersAlthough many in the United States may argue that baseball or football hold the title of most popular sport in the world, Soccer reigns supreme. It is estimated that half of the global population are followers of the sport. This 4-billion-person following is the most concentrated in Europe and the Americas. The sport has been traced back to early Second Century Ancient China, but has also been speculated as originating with the Romans, Greeks, or Japanese.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"?What Are The Most Popular Sports In The World? - ","id":"4536385","type":"webpage","issued":{},"URL":"","accessed":{"date-parts":[["2017","11","27"]]},"citation-label":"4536385"}]1In addition to the large number of individuals that follow the sport of soccer, there is an estimated 260 million soccer players worldwide. The nature of the sport and its physical demands contribute to many injuries, both acute and chronic. Most research and evidence has been focused on acute injuries such as knee, ankle, hamstring, as well as traumatic injuries that may threaten the career or life of the individual. These have risen to the forefront due to their impact on playing careers as well as financial burdens placed on professional clubs or organizations.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Epidemiology of patellar tendinopathy in elite male soccer players.","id":"4536349","page":"1906-1911","type":"article-journal","volume":"39","issue":"9","author":[{"family":"H?gglund","given":"Martin"},{"family":"Zwerver","given":"Johannes"},{"family":"Ekstrand","given":"Jan"}],"issued":{"date-parts":[["2011","9"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546511408877","PMID":"21642599","citation-label":"4536349","Abstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described. PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded. RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture. CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy.","CleanAbstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described.PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors.STUDY DESIGN: Cohort study; Level of evidence, 2.METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded.RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture.CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy."}]2Among these injuries are those that involve tendon. Tendon is a relatively avascular tissue composed mostly of type I collagen. Its primary function is to connect muscle to bone, with parallel fibers that are able to withstand and respond to stresses placed upon it. Acute injuries of tendon can include partial or complete ruptures, while chronic injuries are called tendinopathies until further specification occurs. A tendinopathy is noticeable when there is an increase in pain in the area of a tendon and also a decrease in general performance either due to the pain or to impairments in the tendon’s function. Often these injuries are associated with inflammation, also known as tendinitis.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Tendon injury: from biology to tendon repair.","id":"4536381","page":"223-233","type":"article-journal","volume":"11","issue":"4","author":[{"family":"Nourissat","given":"Geoffroy"},{"family":"Berenbaum","given":"Francis"},{"family":"Duprez","given":"Delphine"}],"issued":{"date-parts":[["2015","4"]]},"container-title":"Nature Reviews. Rheumatology","container-title-short":"Nat Rev Rheumatol","journalAbbreviation":"Nat Rev Rheumatol","DOI":"10.1038/nrrheum.2015.26","PMID":"25734975","citation-label":"4536381","Abstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries.","CleanAbstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries."}]3Breaking down the composition of tendon further, there is a hierarchical fibrillar arrangement that includes type I collagen molecules align into fibrils. These fibrils form fibers, then fascicles, and lastly the tendon unit (appendix A). These collagen fibrils are abundant in the extra cellular matrix, and contribute to the overall strength of the tissue. Other associated molecules include proteoglycans, elastin, glycoproteins and these are integral in the fibrillogenesis of type I collagen.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Tendon injury: from biology to tendon repair.","id":"4536381","page":"223-233","type":"article-journal","volume":"11","issue":"4","author":[{"family":"Nourissat","given":"Geoffroy"},{"family":"Berenbaum","given":"Francis"},{"family":"Duprez","given":"Delphine"}],"issued":{"date-parts":[["2015","4"]]},"container-title":"Nature Reviews. Rheumatology","container-title-short":"Nat Rev Rheumatol","journalAbbreviation":"Nat Rev Rheumatol","DOI":"10.1038/nrrheum.2015.26","PMID":"25734975","citation-label":"4536381","Abstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries.","CleanAbstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries."}]3The collagenous component of tendon can be responsible for up to 95% of the dry weight of the tissue. The properties of collagen only allow for approximately 10% strain, detailing the stiffness of the tissue. This trait is beneficial because it prevents excessive forces being placed on bone causing bone failure.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"sakai.unc.edu/access/content/group/bcd666ac-2c6d-4eae-b4c5-38a53a54ff85/Course Unit Materials/Unit 5 - Tendon/TendinitisPaper.pdf","id":"4538082","type":"article-journal","issued":{},"citation-label":"4538082"}]4 Tendons connect to muscles via a myotendinous junction called an enthesis. This is a fibrocartilaginous tissue that is rich in type II collagen. This area of the tendon is dissimilar to other portions of the tissue, creating different responses to stresses, both in normal conditions and in pathological.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Tendon injury: from biology to tendon repair.","id":"4536381","page":"223-233","type":"article-journal","volume":"11","issue":"4","author":[{"family":"Nourissat","given":"Geoffroy"},{"family":"Berenbaum","given":"Francis"},{"family":"Duprez","given":"Delphine"}],"issued":{"date-parts":[["2015","4"]]},"container-title":"Nature Reviews. Rheumatology","container-title-short":"Nat Rev Rheumatol","journalAbbreviation":"Nat Rev Rheumatol","DOI":"10.1038/nrrheum.2015.26","PMID":"25734975","citation-label":"4536381","Abstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries.","CleanAbstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries."}]3 Tendinopathy is a term used for chronic tendon injury of unspecified nature that includes symptoms of pain, decreased strength, decreased range of motion, and point tenderness along the affected structure. This injury included microscopic tears along the tendon with collagen fibril disorganization, increased extracellular matrix content, neovascularization, and hypercellularity. These changes can alter the properties of the tendon, which elicits pain. There is no consensus on the pathogenesis of this injury; however, one hypothesis is that there is failed healing and degeneration of the tissue.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Tendon injury: from biology to tendon repair.","id":"4536381","page":"223-233","type":"article-journal","volume":"11","issue":"4","author":[{"family":"Nourissat","given":"Geoffroy"},{"family":"Berenbaum","given":"Francis"},{"family":"Duprez","given":"Delphine"}],"issued":{"date-parts":[["2015","4"]]},"container-title":"Nature Reviews. Rheumatology","container-title-short":"Nat Rev Rheumatol","journalAbbreviation":"Nat Rev Rheumatol","DOI":"10.1038/nrrheum.2015.26","PMID":"25734975","citation-label":"4536381","Abstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries.","CleanAbstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries."}]3Diagnosis of the condition can be achieved by a subjective and objective exam, with pain elicited in the site of injury as well as palpable inflammation or crepitus possible upon palpation. Observation of functional movement may demonstrate discrepancies in load bearing, as compared bilaterally, decreased range of motion (tight quadriceps and hamstrings), decreased strength (most often in the quadriceps), and decreased overall power. The onset of pain is often at the start of physical activity, however, the pain becomes more constant with greater injuries or with prolonged episodes of injury.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Find @ UNC","id":"4451203","type":"webpage","issued":{},"URL":"","accessed":{"date-parts":[["2017","11","2"]]},"citation-label":"4451203"}]5Imaging can be completed to confirm or refute initial diagnosis. The imaging methods of choice are ultrasound and MRI. Ultrasound is capable of locating lesions within the tendon via the use of the soundhead and connected monitor (Appendix B). These changes are most common just inferior to the inferior pole of the patella, indicating the site of injury of the patellar tendon. Other findings may be thickening of the tissue, calcifications present, and even bony discrepancies at the inferior pole of the patella. Although this imaging cannot determine any intraarticular issues, its specificity and sensitivity for patellar tendinopathy are 94% and 58%, respectively.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Find @ UNC","id":"4451203","type":"webpage","issued":{},"URL":"","accessed":{"date-parts":[["2017","11","2"]]},"citation-label":"4451203"}]5MRI is able to highlight intraarticular issues as well as the changes in tendon and bone witnessed by the ultrasound (Appendix C). The main limitations of MRI are the high cost associated with the examination, the limited availability of equipment, and also the time necessary for the results. The sensitivity of MRI for patellar tendinopathy is 78%, while the specificity is 86%, noting that the MRI has higher validity than that of the ultrasound making it the more recommended imaging procedure. However, the likelihood of getting an MRI for every athlete that is suspected to have patellar tendinopathy is very slim.5Neovascularization is also present in many cases of patellar tendinopathy. Often, these new, abnormal vessels arise from the Hoffa fat pad, located posterior and inferior to the inferior pole of the patella. This phenomenon can contribute to the symptoms of patellar tendinopathy in that nerve receptors, such as mechanoreceptors and glutamate NMDA receptors, are present in these vessels. Studies have also shown that neovascularization promotes pain transmission through a neural in-growth within the tendon, described as an inflammatory response to the injury. Currently, it is unknown whether the vascular or nerve component are the prominent factor in tendinopathy.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The role of tendon microcirculation in Achilles and patellar tendinopathy.","id":"1140960","page":"18","type":"article-journal","volume":"3","author":[{"family":"Knobloch","given":"Karsten"}],"issued":{"date-parts":[["2008","4","30"]]},"container-title":"Journal of Orthopaedic Surgery and Research","container-title-short":"J Orthop Surg Res","journalAbbreviation":"J Orthop Surg Res","DOI":"10.1186/1749-799X-3-18","PMID":"18447938","PMCID":"PMC2397381","citation-label":"1140960","Abstract":"Tendinopathy is of distinct interest as it describes a painful tendon disease with local tenderness, swelling and pain associated with sonographic features such as hypoechogenic texture and diameter enlargement. Recent research elucidated microcirculatory changes in tendinopathy using laser Doppler flowmetry and spectrophotometry such as at the Achilles tendon, the patellar tendon as well as at the elbow and the wrist level. Tendon capillary blood flow is increased at the point of pain. Tendon oxygen saturation as well as tendon postcapillary venous filling pressures, determined non-invasively using combined Laser Doppler flowmetry and spectrophotometry, can quantify, in real-time, how tendon microcirculation changes over with pathology or in response to a given therapy. Tendon oxygen saturation can be increased by repetitive, intermittent short-term ice applications in Achilles tendons; this corresponds to 'ischemic preconditioning', a method used to train tissue to sustain ischemic damage. On the other hand, decreasing tendon oxygenation may reflect local acidosis and deteriorating tendon metabolism. Painful eccentric training, a common therapy for Achilles, patellar, supraspinatus and wrist tendinopathy decreases abnormal capillary tendon flow without compromising local tendon oxygenation. Combining an Achilles pneumatic wrap with eccentric training changes tendon microcirculation in a different way than does eccentric training alone; both approaches reduce pain in Achilles tendinopathy. The microcirculatory effects of measures such as extracorporeal shock wave therapy as well as topical nitroglycerine application are to be studied in tendinopathy as well as the critical question of dosage and maintenance. Interestingly it seems that injection therapy using color Doppler for targeting the area of neovascularisation yields to good clinical results with polidocanol sclerosing therapy, but also with a combination of epinephrine and lidocaine.","CleanAbstract":"Tendinopathy is of distinct interest as it describes a painful tendon disease with local tenderness, swelling and pain associated with sonographic features such as hypoechogenic texture and diameter enlargement. Recent research elucidated microcirculatory changes in tendinopathy using laser Doppler flowmetry and spectrophotometry such as at the Achilles tendon, the patellar tendon as well as at the elbow and the wrist level. Tendon capillary blood flow is increased at the point of pain. Tendon oxygen saturation as well as tendon postcapillary venous filling pressures, determined non-invasively using combined Laser Doppler flowmetry and spectrophotometry, can quantify, in real-time, how tendon microcirculation changes over with pathology or in response to a given therapy. Tendon oxygen saturation can be increased by repetitive, intermittent short-term ice applications in Achilles tendons; this corresponds to 'ischemic preconditioning', a method used to train tissue to sustain ischemic damage. On the other hand, decreasing tendon oxygenation may reflect local acidosis and deteriorating tendon metabolism. Painful eccentric training, a common therapy for Achilles, patellar, supraspinatus and wrist tendinopathy decreases abnormal capillary tendon flow without compromising local tendon oxygenation. Combining an Achilles pneumatic wrap with eccentric training changes tendon microcirculation in a different way than does eccentric training alone; both approaches reduce pain in Achilles tendinopathy. The microcirculatory effects of measures such as extracorporeal shock wave therapy as well as topical nitroglycerine application are to be studied in tendinopathy as well as the critical question of dosage and maintenance. Interestingly it seems that injection therapy using color Doppler for targeting the area of neovascularisation yields to good clinical results with polidocanol sclerosing therapy, but also with a combination of epinephrine and lidocaine."}]6Patellar tendinopathy is not the most prominent injury in soccer, with various resources stating either ligamentous injury to the ankle or knee or hamstring strains as the top offenders. However, patellar tendinopathy or “jumper’s knee”, as some have coined it, is prevalent in the sport.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Prevent Common Injuries in Soccer: Knee Injuries - U.S. Soccer","id":"4537953","type":"webpage","issued":{},"URL":"","accessed":{"date-parts":[["2017","11","27"]]},"citation-label":"4537953"}]7 Volleyball and basketball have higher incidence rates of patellar tendinopathy due to the increased jumping activity throughout participation as well as the hard playing surface. Soccer players are predisposed to this injury by another mechanism that is prolonged, repetitive stress of the quadriceps and patellar tendon withstood throughout the physical demands of the sport.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Epidemiology of patellar tendinopathy in elite male soccer players.","id":"4536349","page":"1906-1911","type":"article-journal","volume":"39","issue":"9","author":[{"family":"H?gglund","given":"Martin"},{"family":"Zwerver","given":"Johannes"},{"family":"Ekstrand","given":"Jan"}],"issued":{"date-parts":[["2011","9"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546511408877","PMID":"21642599","citation-label":"4536349","Abstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described. PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded. RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture. CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy.","CleanAbstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described.PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors.STUDY DESIGN: Cohort study; Level of evidence, 2.METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded.RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture.CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy."}]2There is limited evidence regarding predispositions to patellar tendinopathy. Some sources report that males are at a greater risk, as well as those that are taller, with greater body mass, Type II Diabetes, and reduced dorsiflexion range of motion.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Tendon injury: from biology to tendon repair.","id":"4536381","page":"223-233","type":"article-journal","volume":"11","issue":"4","author":[{"family":"Nourissat","given":"Geoffroy"},{"family":"Berenbaum","given":"Francis"},{"family":"Duprez","given":"Delphine"}],"issued":{"date-parts":[["2015","4"]]},"container-title":"Nature Reviews. Rheumatology","container-title-short":"Nat Rev Rheumatol","journalAbbreviation":"Nat Rev Rheumatol","DOI":"10.1038/nrrheum.2015.26","PMID":"25734975","citation-label":"4536381","Abstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries.","CleanAbstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries."},{"title":"Epidemiology of patellar tendinopathy in elite male soccer players.","id":"4536349","page":"1906-1911","type":"article-journal","volume":"39","issue":"9","author":[{"family":"H?gglund","given":"Martin"},{"family":"Zwerver","given":"Johannes"},{"family":"Ekstrand","given":"Jan"}],"issued":{"date-parts":[["2011","9"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546511408877","PMID":"21642599","citation-label":"4536349","Abstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described. PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded. RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture. CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy.","CleanAbstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described.PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors.STUDY DESIGN: Cohort study; Level of evidence, 2.METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded.RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture.CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy."}]2,3 Other contributors are high amounts of physical activity, especially jumping or weight training, and also activities on hard surfaces such as basketball and volleyball.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Epidemiology of patellar tendinopathy in elite male soccer players.","id":"4536349","page":"1906-1911","type":"article-journal","volume":"39","issue":"9","author":[{"family":"H?gglund","given":"Martin"},{"family":"Zwerver","given":"Johannes"},{"family":"Ekstrand","given":"Jan"}],"issued":{"date-parts":[["2011","9"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546511408877","PMID":"21642599","citation-label":"4536349","Abstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described. PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded. RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture. CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy.","CleanAbstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described.PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors.STUDY DESIGN: Cohort study; Level of evidence, 2.METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded.RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture.CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy."}]2 Another possible relationship is colder temperatures weather and their impact on the number of incidences of patellar tendinitis. This was observed in the Hagglund et al study without significance, however it could be further studied to determine its influence.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Epidemiology of patellar tendinopathy in elite male soccer players.","id":"4536349","page":"1906-1911","type":"article-journal","volume":"39","issue":"9","author":[{"family":"H?gglund","given":"Martin"},{"family":"Zwerver","given":"Johannes"},{"family":"Ekstrand","given":"Jan"}],"issued":{"date-parts":[["2011","9"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546511408877","PMID":"21642599","citation-label":"4536349","Abstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described. PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded. RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture. CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy.","CleanAbstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described.PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors.STUDY DESIGN: Cohort study; Level of evidence, 2.METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded.RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture.CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy."}]2The prevalence of patellar tendinitis in elite soccer players was studied by Hagglund et al. Their sample included three prospective cohort studies, including 51 European professional teams over the course of 2001-2009. All players on these teams were invited to participate in the study resulting in 2229 participants. Within this cohort, 137 patellar tendon injuries were reported, representing 1.5% of all injuries recorded in the study. Of this number, four of these affected the distal aspect of the patellar tendon, leaving 133 proximal injuries. The median days missed post-injury was five, with 75% of players returning in 12 days. Additionally, 20% of these injuries were recurrences.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Epidemiology of patellar tendinopathy in elite male soccer players.","id":"4536349","page":"1906-1911","type":"article-journal","volume":"39","issue":"9","author":[{"family":"H?gglund","given":"Martin"},{"family":"Zwerver","given":"Johannes"},{"family":"Ekstrand","given":"Jan"}],"issued":{"date-parts":[["2011","9"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546511408877","PMID":"21642599","citation-label":"4536349","Abstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described. PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded. RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture. CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy.","CleanAbstract":"BACKGROUND: Patellar tendinopathy is common among athletes in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus. The epidemiology in soccer is not well described.PURPOSE: This study was undertaken to investigate and describe the epidemiology of patellar tendinopathy in elite male soccer players and evaluate potential risk factors.STUDY DESIGN: Cohort study; Level of evidence, 2.METHODS: Between 2001 and 2009, the authors followed 51 European elite soccer clubs (2229 players) from 3 different cohorts: the Swedish First League cohort (SWE) and Union of European Football Associations (UEFA) Champions League cohort (UCL), both playing on natural grass; and the Artifical Turf cohort (ART), playing on third-generation artificial turf. Individual player exposure in training and matches and time-loss injuries were recorded.RESULTS: In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries and corresponding to an incidence of 0.12 injuries/1000 hours. Each season, 2.4% of players were affected, with most injuries (61%) resulting in absence up to 1 week or less. Twenty percent of tendinopathies were recurrent complaints. No significant difference in season prevalence (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.60-1.44; P = .74) or incidence (rate ratio [RR] 1.20; 95% CI, 0.82-1.75; P = .36) was observed between teams playing on artificial turf and natural grass, respectively. Multivariate logistic regression showed that a high total exposure hours (OR, 1.02 per 10-hour increase; 95% CI, 1.00-1.04; P = .033) was a significant risk factor for patellar tendinopathy, and increased body mass was borderline significant (OR, 1.15 per 5-kg increase; 95% CI, 1.00-1.33; P = .055). In addition, 2 acute partial tendon ruptures were recorded, but no total rupture.CONCLUSION: Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. Exposure to artificial turf did not increase the prevalence or incidence of injury. High total amount of exposure was identified as a risk factor for patellar tendinopathy."}]2The primary focus of treating a tendinopathy is to decrease pain. This is often achieved through the use of topical analgesics and/or non-steroidal anti-inflammatories. Once the pain has been decreased to a manageable level, the introduction of functional rehabilitation begins. Exercises that are eccentric in nature have been the most popular choice in this treatment regimeADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Tendon injury: from biology to tendon repair.","id":"4536381","page":"223-233","type":"article-journal","volume":"11","issue":"4","author":[{"family":"Nourissat","given":"Geoffroy"},{"family":"Berenbaum","given":"Francis"},{"family":"Duprez","given":"Delphine"}],"issued":{"date-parts":[["2015","4"]]},"container-title":"Nature Reviews. Rheumatology","container-title-short":"Nat Rev Rheumatol","journalAbbreviation":"Nat Rev Rheumatol","DOI":"10.1038/nrrheum.2015.26","PMID":"25734975","citation-label":"4536381","Abstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries.","CleanAbstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries."}]3; however, in recent years, studies have argued its efficacy.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness.","id":"2152551","page":"267-286","type":"article-journal","volume":"43","issue":"4","author":[{"family":"Malliaras","given":"Peter"},{"family":"Barton","given":"Christian J"},{"family":"Reeves","given":"Neil D"},{"family":"Langberg","given":"Henning"}],"issued":{"date-parts":[["2013","4"]]},"container-title":"Sports medicine (Auckland, N.Z.)","container-title-short":"Sports Med","journalAbbreviation":"Sports Med","DOI":"10.1007/s40279-013-0019-z","PMID":"23494258","citation-label":"2152551"}]8 Mallaiaras et al stated that up to 45% of individuals with tendinitis completing an eccentric exercise intervention strategy do not respond to the treatment. Their conclusion urged the need for physical therapists to use a combined approach of eccentric and concentric loading to achieve greater outcomes. Additionally, those in the elite athlete population may benefit greatly from heavy load training in order to elicit tendon adaptation to prevent recurrence.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness.","id":"2152551","page":"267-286","type":"article-journal","volume":"43","issue":"4","author":[{"family":"Malliaras","given":"Peter"},{"family":"Barton","given":"Christian J"},{"family":"Reeves","given":"Neil D"},{"family":"Langberg","given":"Henning"}],"issued":{"date-parts":[["2013","4"]]},"container-title":"Sports medicine (Auckland, N.Z.)","container-title-short":"Sports Med","journalAbbreviation":"Sports Med","DOI":"10.1007/s40279-013-0019-z","PMID":"23494258","citation-label":"2152551"}]8In order to play through patellar tendinitis, athletes will try almost anything to decrease the pain and maintain their functional capacity. Patellar tendon straps are a common “band-aid” strategy that have been shown to significantly decrease pain in some studies. The theory behind this is that the pressure exerted on the tendon by the strap during flexion and extension can reduce the amount of tensile force the tendon experiences.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Patellar tendon straps decrease pre-landing quadriceps activation in males with patellar tendinopathy.","id":"4544032","page":"13-19","type":"article-journal","volume":"24","author":[{"family":"Rosen","given":"Adam B"},{"family":"Ko","given":"Jupil"},{"family":"Simpson","given":"Kathy J"},{"family":"Brown","given":"Cathleen N"}],"issued":{"date-parts":[["2017","3"]]},"container-title":"Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine","container-title-short":"Phys Ther Sport","journalAbbreviation":"Phys Ther Sport","DOI":"10.1016/j.ptsp.2016.09.007","PMID":"28160657","citation-label":"4544032","Abstract":"OBJECTIVE: To determine if patellar tendon straps altered quadriceps' muscle activity during a drop-jump landing in males with and without patellar tendinopathy. DESIGN: Case-control. SETTINGS: Biomechanics Research Laboratory. PARTICIPANTS: Twenty recreationally-active males participated: ten (age?=?21.3?±?2.4 years, height?=?182.8?±?5.3?cm, mass?=?81.7?±?8.6?kg) with patellar tendinopathy; ten (age?=?22.0?±?1.6 years, height?=?185.7?±?4.5?cm, mass?=?82.2?±?9.8?kg) were healthy with no history of tendinopathy. MAIN OUTCOME MEASURES: Electromyography (EMG) data for the vastus medialis (VM), rectus femoris (RF), and vastus lateralis (VL) muscles were collected. Five 2-legged 40?cm drop-jumps were performed wearing a patellar tendon strap and 5 with no-strap in a counterbalanced order. Root-mean square EMG (REMG) values of the VM, RF, and VL were averaged for a pre-landing and post-landing interval. Multiple mixed-model two-way ANOVAs were performed to determine the effect of tendinopathy and strapping condition on REMG values for each muscle. RESULTS: For the pre-landing interval, all participants displayed lesser VL EMG activation (0.44?±?0.19%, 0.53?±?0.27%, respectively; p?=?0.007, d?=?0.39) in the no-strap compared with the strap condition. CONCLUSIONS: When wearing a strap, all participants demonstrated lower VL activation prior to landing which may be helpful in reducing tensile stress at the tendon. These effects may be clinically important in modulating pain in those with patellar tendinopathy. Copyright ? 2016 Elsevier Ltd. All rights reserved.","CleanAbstract":"OBJECTIVE: To determine if patellar tendon straps altered quadriceps' muscle activity during a drop-jump landing in males with and without patellar tendinopathy.DESIGN: Case-control.SETTINGS: Biomechanics Research Laboratory.PARTICIPANTS: Twenty recreationally-active males participated: ten (age?=?21.3?±?2.4 years, height?=?182.8?±?5.3?cm, mass?=?81.7?±?8.6?kg) with patellar tendinopathy; ten (age?=?22.0?±?1.6 years, height?=?185.7?±?4.5?cm, mass?=?82.2?±?9.8?kg) were healthy with no history of tendinopathy.MAIN OUTCOME MEASURES: Electromyography (EMG) data for the vastus medialis (VM), rectus femoris (RF), and vastus lateralis (VL) muscles were collected. Five 2-legged 40?cm drop-jumps were performed wearing a patellar tendon strap and 5 with no-strap in a counterbalanced order. Root-mean square EMG (REMG) values of the VM, RF, and VL were averaged for a pre-landing and post-landing interval. Multiple mixed-model two-way ANOVAs were performed to determine the effect of tendinopathy and strapping condition on REMG values for each muscle.RESULTS: For the pre-landing interval, all participants displayed lesser VL EMG activation (0.44?±?0.19%, 0.53?±?0.27%, respectively; p?=?0.007, d?=?0.39) in the no-strap compared with the strap condition.CONCLUSIONS: When wearing a strap, all participants demonstrated lower VL activation prior to landing which may be helpful in reducing tensile stress at the tendon. These effects may be clinically important in modulating pain in those with patellar tendinopathy.Copyright ? 2016 Elsevier Ltd. All rights reserved."}]9 Further, a study on cadaveric specimens demonstrated that there was less pressure placed on the infrapatellar fat pad and a decrease in patellofemoral contact area and contact pressure, thus decreasing knee pain.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The influence of patellar bracing on patellar and knee load-distribution and kinematics: an experimental cadaver study.","id":"2867793","page":"135-141","type":"article-journal","volume":"16","issue":"2","author":[{"family":"Bohnsack","given":"Michael"},{"family":"Halcour","given":"Andre"},{"family":"Klages","given":"Phillip"},{"family":"Wilharm","given":"Arne"},{"family":"Ostermeier","given":"Sven"},{"family":"Rühmann","given":"Oliver"},{"family":"Hurschler","given":"Christof"}],"issued":{"date-parts":[["2008","2"]]},"container-title":"Knee Surgery, Sports Traumatology, Arthroscopy","container-title-short":"Knee Surg Sports Traumatol Arthrosc","journalAbbreviation":"Knee Surg Sports Traumatol Arthrosc","DOI":"10.1007/s00167-007-0428-3","PMID":"18000652","citation-label":"2867793","Abstract":"The aim of this study was to analyze the biomechanical consequences of patella bracing in order to evaluate possible mechanisms supporting its clinical application. The hypothesis is that the patellar bracing reduces patellofemoral pressure by influencing patellar and knee kinematics, and load distribution. Physiologic isokinetic knee extension motions were simulated on ten human knee cadaver specimens using a knee kinematic simulator. Joint kinematics were evaluated using an ultrasound-based motion analysis system and patellofemoral contact pressure was measured using a thin-film piezoresistive pressure measuring system. Infrapatellar tissue pressure was analyzed using a closed sensor-cell. Three different patella braces were fitted to the knee cadavers and their influence on the kinematic and kinetic biomechanical parameters were evaluated and compared to the physiologic situation. Patellar bracing resulted in a significant (p = 0.05) proximalization of the patella up to 3 mm. Depending on the type of brace used, a decrease in the infrapatellar fat pad pressure was found and the patellofemoral contact area was decreased significantly (p = 0.05) between 60 degrees of knee flexion and full extension (maximum 22%). Patella bracing significantly (p = 0.05) reduced the patellofemoral contact pressure an average of 10%, as well as the peak contact pressure which occurred. Patellar bracing significantly influences patella biomechanics in a reduction of the patellofemoral contact area and contact pressure as well as a decrease in the infrapatellar tissue pressure. The application of infrapatellar straps is suggested for the treatment and prevention of anterior knee pain, especially in high level sports.","CleanAbstract":"The aim of this study was to analyze the biomechanical consequences of patella bracing in order to evaluate possible mechanisms supporting its clinical application. The hypothesis is that the patellar bracing reduces patellofemoral pressure by influencing patellar and knee kinematics, and load distribution. Physiologic isokinetic knee extension motions were simulated on ten human knee cadaver specimens using a knee kinematic simulator. Joint kinematics were evaluated using an ultrasound-based motion analysis system and patellofemoral contact pressure was measured using a thin-film piezoresistive pressure measuring system. Infrapatellar tissue pressure was analyzed using a closed sensor-cell. Three different patella braces were fitted to the knee cadavers and their influence on the kinematic and kinetic biomechanical parameters were evaluated and compared to the physiologic situation. Patellar bracing resulted in a significant (p = 0.05) proximalization of the patella up to 3 mm. Depending on the type of brace used, a decrease in the infrapatellar fat pad pressure was found and the patellofemoral contact area was decreased significantly (p = 0.05) between 60 degrees of knee flexion and full extension (maximum 22%). Patella bracing significantly (p = 0.05) reduced the patellofemoral contact pressure an average of 10%, as well as the peak contact pressure which occurred. Patellar bracing significantly influences patella biomechanics in a reduction of the patellofemoral contact area and contact pressure as well as a decrease in the infrapatellar tissue pressure. The application of infrapatellar straps is suggested for the treatment and prevention of anterior knee pain, especially in high level sports."}]10 Another study, by Villar et al, utilized a patellar strap in 37 military service members with anterior knee pain, finding that 25 of these individuals had significant decreases in symptoms. Those that did not have these positive outcomes were found to have severe degenerative changes in the patellofemoral cartilage, needing more invasive methods of intervention for significant improvements. Perhaps if these individuals were provided with a patellar strap at initial onset of symptoms, their degenerative changes may have been prevented or slowed.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"From the Department of Orthopaedic Surgery, Southampton General Hospital,","id":"4544686","type":"article-journal","author":[{"family":"Southampton"},{"family":"Hants"}],"issued":{},"citation-label":"4544686"}]11Therapeutic modalities have often been used in conjunction with a rehabilitation program to treat tendinopathy. These include iontophoresis, ultrasound, dry-needling, extracorporeal shock wave therapy (ESWT), and low-level laser therapy. Literature on dry needling suggests that the physical break-up of degenerative changes and the bleeding that ensues can help to promote healing. ESWT is less understood, but it has been used in clinical trials for the last 10 years. A study in 2007 showed a significant decrease in pain at one month, continuing to improve for two years, with the addition of ESWT.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Management of chronic tendon injuries.","id":"4556251","page":"486-490","type":"article-journal","volume":"87","issue":"7","author":[{"family":"Childress","given":"Marc A"},{"family":"Beutler","given":"Anthony"}],"issued":{"date-parts":[["2013","4","1"]]},"container-title":"American Family Physician","container-title-short":"Am Fam Physician","journalAbbreviation":"Am Fam Physician","PMID":"23547590","citation-label":"4556251","Abstract":"Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.","CleanAbstract":"Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise."}]12Platelet-rich plasma (PRP) injections have been used to treat various musculoskeletal conditions, including tendinopathy. Although this was introduced in the 1970s, there has been a recent increase in use, especially in the athletic population. In 2013, 86,000 athletes in the United States were treated with PRP.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The systemic effects of platelet-rich plasma injection.","id":"2474185","page":"186-193","type":"article-journal","volume":"41","issue":"1","author":[{"family":"Wasterlain","given":"Amy S"},{"family":"Braun","given":"Hillary J"},{"family":"Harris","given":"Alex H S"},{"family":"Kim","given":"Hyeon-Joo"},{"family":"Dragoo","given":"Jason L"}],"issued":{"date-parts":[["2013","1"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546512466383","PMID":"23211708","citation-label":"2474185"}]13 This method of enhancing the healing process can be used in conjunction with other conservative methods of treatment as well as with surgical intervention. Location of injection is found either by the use of ultrasound imaging or palpating to find the most sensitive and painful area of the tissue.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Platelet-rich therapies for musculoskeletal soft tissue injuries.","id":"2776163","page":"CD010071","type":"article-journal","issue":"4","author":[{"family":"Moraes","given":"Vinícius Y"},{"family":"Lenza","given":"Mário"},{"family":"Tamaoki","given":"Marcel Jun"},{"family":"Faloppa","given":"Flávio"},{"family":"Belloti","given":"Jo?o Carlos"}],"issued":{"date-parts":[["2014","4","29"]]},"container-title":"Cochrane Database of Systematic Reviews","container-title-short":"Cochrane Database Syst Rev","journalAbbreviation":"Cochrane Database Syst Rev","DOI":"10.1002/14651858.CD010071.pub3","PMID":"24782334","citation-label":"2776163"}]14The way in which this intervention works is by concentrating the platelets and growth factors in blood via the use of a centrifuge, as previously stated. These growth factors include platelet derived growth factor (PDGF), insulin-like growth factor (IGF), fibroblast growth factor (FGF), transforming growth factor- β (TGF- β), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), and endothelial cell growth factor (ECGF). These naturally produced healing aids are increased in number and then reintroduced into the area of tissue with the most need. This therapy has a very low negative outcome, with only 2-5% of patients reporting adverse symptoms or events. Common side effects include tenderness and pain, often resolving in 48 hours.14In 2010, the World Anti-Doping Agency (WADA) placed PRP on the banned list, highlighting IGF as concerning as it could be used as an ergogenic substance. The committee stated that this therapy could give athletes an unfair advantage, however, there was an exception for tendon injections as long as there was a therapeutic use documented. In 2011, all uses of PRP were allowed after there was no evidence in the therapy’s impact on performance enhancement. This decision was based on the lack of evidence as a whole in regard to PRP’s systemic effect. Wasterlain et al sought to determine the effects of the therapy to either support or refute WADA’s concerns.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The systemic effects of platelet-rich plasma injection.","id":"2474185","page":"186-193","type":"article-journal","volume":"41","issue":"1","author":[{"family":"Wasterlain","given":"Amy S"},{"family":"Braun","given":"Hillary J"},{"family":"Harris","given":"Alex H S"},{"family":"Kim","given":"Hyeon-Joo"},{"family":"Dragoo","given":"Jason L"}],"issued":{"date-parts":[["2013","1"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546512466383","PMID":"23211708","citation-label":"2474185"}]13The study by Wasterlain et al found that there were significant increases in the systemic circulation of growth factors, including IGF, VEGF, and FGF after PRP injection. Additionally, there was an increase in Human Growth Hormone (HGH) 24 hours post injection. The amount of increase is comparable to the amount of increase seen after exercising or HGH injection. Due to this, there is a potential controversy in using this treatment method in elite athletes under the standards of WADA.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The systemic effects of platelet-rich plasma injection.","id":"2474185","page":"186-193","type":"article-journal","volume":"41","issue":"1","author":[{"family":"Wasterlain","given":"Amy S"},{"family":"Braun","given":"Hillary J"},{"family":"Harris","given":"Alex H S"},{"family":"Kim","given":"Hyeon-Joo"},{"family":"Dragoo","given":"Jason L"}],"issued":{"date-parts":[["2013","1"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546512466383","PMID":"23211708","citation-label":"2474185"}]13ESWT has been used in patellar tendinopathy with some success. This treatment is thought to produce tissue-healing effects through regeneration and repair while also inhibiting pain receptors.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double-Blinded Randomized Study.","id":"4564899","page":"89-96","type":"article-journal","volume":"27","issue":"2","author":[{"family":"Thijs","given":"Karin M"},{"family":"Zwerver","given":"Johannes"},{"family":"Backx","given":"Frank J G"},{"family":"Steeneken","given":"Victor"},{"family":"Rayer","given":"Stephan"},{"family":"Groenenboom","given":"Petra"},{"family":"Moen","given":"Maarten H"}],"issued":{"date-parts":[["2017","3"]]},"container-title":"Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine","container-title-short":"Clin J Sport Med","journalAbbreviation":"Clin J Sport Med","DOI":"10.1097/JSM.0000000000000332","PMID":"27347857","citation-label":"4564899","Abstract":"OBJECTIVE: To evaluate the effectiveness of a combined treatment of focused shockwave therapy (ESWT) and eccentric training compared with sham-shockwave therapy (placebo) and eccentric training in participants with patellar tendinopathy (PT) after 24 weeks. DESIGN: Randomized controlled trial. SETTING: Sports medicine departments of a university hospital and a general hospital in the Netherlands. PARTICIPANTS: Fifty-two physically active male and female participants with a clinical diagnosis of PT (mean age: 28.6 years; range, 18-45) were randomly allocated to the ESWT (n = 22) or sham shockwave (n = 30). INTERVENTIONS: Extracorporeal shockwave therapy and sham shockwave were applied in 3 sessions at 1-week intervals with a piezoelectric device. All participants were instructed to perform eccentric exercises (3 sets of 15 repetitions twice a day) for 3 months on a decline board at home. MAIN OUTCOME MEASURES: The Victorian Institute of Sport Assessment-Patella (VISA-P) scores (primary), pain scores during functional knee loading tests, and Likert score (secondary) were registered at baseline and at 6, 12, and 24 weeks after the start with the ESWT or sham-shockwave treatment. RESULTS: No significant differences for the primary and secondary outcome measures were found between the groups. In the ESWT/eccentric group, the VISA-P increased from 54.5 ± 15.4 to 70.9 ± 17.8, whereas the VISA-P in the sham-shockwave/eccentric group increased from 58.9 ± 14.6 to 78.2 ± 15.8 (between-group change in VISA-P at 24 weeks -4.8; 95% confidence interval, -12.7 to 3.0, P = 0.150). CONCLUSIONS: This study showed no additional effect of 3 sessions ESWT in participants with PT treated with eccentric exercises. The results should be interpreted with caution because of small sample size and considerable loss to follow-up, particularly in the ESWT group.","CleanAbstract":"OBJECTIVE: To evaluate the effectiveness of a combined treatment of focused shockwave therapy (ESWT) and eccentric training compared with sham-shockwave therapy (placebo) and eccentric training in participants with patellar tendinopathy (PT) after 24 weeks.DESIGN: Randomized controlled trial.SETTING: Sports medicine departments of a university hospital and a general hospital in the Netherlands.PARTICIPANTS: Fifty-two physically active male and female participants with a clinical diagnosis of PT (mean age: 28.6 years; range, 18-45) were randomly allocated to the ESWT (n = 22) or sham shockwave (n = 30).INTERVENTIONS: Extracorporeal shockwave therapy and sham shockwave were applied in 3 sessions at 1-week intervals with a piezoelectric device. All participants were instructed to perform eccentric exercises (3 sets of 15 repetitions twice a day) for 3 months on a decline board at home.MAIN OUTCOME MEASURES: The Victorian Institute of Sport Assessment-Patella (VISA-P) scores (primary), pain scores during functional knee loading tests, and Likert score (secondary) were registered at baseline and at 6, 12, and 24 weeks after the start with the ESWT or sham-shockwave treatment.RESULTS: No significant differences for the primary and secondary outcome measures were found between the groups. In the ESWT/eccentric group, the VISA-P increased from 54.5 ± 15.4 to 70.9 ± 17.8, whereas the VISA-P in the sham-shockwave/eccentric group increased from 58.9 ± 14.6 to 78.2 ± 15.8 (between-group change in VISA-P at 24 weeks -4.8; 95% confidence interval, -12.7 to 3.0, P = 0.150).CONCLUSIONS: This study showed no additional effect of 3 sessions ESWT in participants with PT treated with eccentric exercises. The results should be interpreted with caution because of small sample size and considerable loss to follow-up, particularly in the ESWT group."}]15 The acoustic waves produced can increase growth factor production due to the capillary rupturing that occurs. In addition, the mechanical pressure can increase cell membrane permeability, further aiding the healing process. Looking to the research, studies promote the use of this modality in combination with an eccentric exercise regime. In order to treat, the device is placed on the most painful point on the patellar tendon when the knee is extended.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double-Blinded Randomized Study.","id":"4564899","page":"89-96","type":"article-journal","volume":"27","issue":"2","author":[{"family":"Thijs","given":"Karin M"},{"family":"Zwerver","given":"Johannes"},{"family":"Backx","given":"Frank J G"},{"family":"Steeneken","given":"Victor"},{"family":"Rayer","given":"Stephan"},{"family":"Groenenboom","given":"Petra"},{"family":"Moen","given":"Maarten H"}],"issued":{"date-parts":[["2017","3"]]},"container-title":"Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine","container-title-short":"Clin J Sport Med","journalAbbreviation":"Clin J Sport Med","DOI":"10.1097/JSM.0000000000000332","PMID":"27347857","citation-label":"4564899","Abstract":"OBJECTIVE: To evaluate the effectiveness of a combined treatment of focused shockwave therapy (ESWT) and eccentric training compared with sham-shockwave therapy (placebo) and eccentric training in participants with patellar tendinopathy (PT) after 24 weeks. DESIGN: Randomized controlled trial. SETTING: Sports medicine departments of a university hospital and a general hospital in the Netherlands. PARTICIPANTS: Fifty-two physically active male and female participants with a clinical diagnosis of PT (mean age: 28.6 years; range, 18-45) were randomly allocated to the ESWT (n = 22) or sham shockwave (n = 30). INTERVENTIONS: Extracorporeal shockwave therapy and sham shockwave were applied in 3 sessions at 1-week intervals with a piezoelectric device. All participants were instructed to perform eccentric exercises (3 sets of 15 repetitions twice a day) for 3 months on a decline board at home. MAIN OUTCOME MEASURES: The Victorian Institute of Sport Assessment-Patella (VISA-P) scores (primary), pain scores during functional knee loading tests, and Likert score (secondary) were registered at baseline and at 6, 12, and 24 weeks after the start with the ESWT or sham-shockwave treatment. RESULTS: No significant differences for the primary and secondary outcome measures were found between the groups. In the ESWT/eccentric group, the VISA-P increased from 54.5 ± 15.4 to 70.9 ± 17.8, whereas the VISA-P in the sham-shockwave/eccentric group increased from 58.9 ± 14.6 to 78.2 ± 15.8 (between-group change in VISA-P at 24 weeks -4.8; 95% confidence interval, -12.7 to 3.0, P = 0.150). CONCLUSIONS: This study showed no additional effect of 3 sessions ESWT in participants with PT treated with eccentric exercises. The results should be interpreted with caution because of small sample size and considerable loss to follow-up, particularly in the ESWT group.","CleanAbstract":"OBJECTIVE: To evaluate the effectiveness of a combined treatment of focused shockwave therapy (ESWT) and eccentric training compared with sham-shockwave therapy (placebo) and eccentric training in participants with patellar tendinopathy (PT) after 24 weeks.DESIGN: Randomized controlled trial.SETTING: Sports medicine departments of a university hospital and a general hospital in the Netherlands.PARTICIPANTS: Fifty-two physically active male and female participants with a clinical diagnosis of PT (mean age: 28.6 years; range, 18-45) were randomly allocated to the ESWT (n = 22) or sham shockwave (n = 30).INTERVENTIONS: Extracorporeal shockwave therapy and sham shockwave were applied in 3 sessions at 1-week intervals with a piezoelectric device. All participants were instructed to perform eccentric exercises (3 sets of 15 repetitions twice a day) for 3 months on a decline board at home.MAIN OUTCOME MEASURES: The Victorian Institute of Sport Assessment-Patella (VISA-P) scores (primary), pain scores during functional knee loading tests, and Likert score (secondary) were registered at baseline and at 6, 12, and 24 weeks after the start with the ESWT or sham-shockwave treatment.RESULTS: No significant differences for the primary and secondary outcome measures were found between the groups. In the ESWT/eccentric group, the VISA-P increased from 54.5 ± 15.4 to 70.9 ± 17.8, whereas the VISA-P in the sham-shockwave/eccentric group increased from 58.9 ± 14.6 to 78.2 ± 15.8 (between-group change in VISA-P at 24 weeks -4.8; 95% confidence interval, -12.7 to 3.0, P = 0.150).CONCLUSIONS: This study showed no additional effect of 3 sessions ESWT in participants with PT treated with eccentric exercises. The results should be interpreted with caution because of small sample size and considerable loss to follow-up, particularly in the ESWT group."}]15 Manual therapy is a common treatment used in addition to modalities, bracing, and therapeutic exercises. Under this umbrella is the method of deep friction massage (DFM), developed by Dr. Cyriax as a way to facilitate healing. The process in which this occurs is by increasing fibroblastic activity, breaking down adhesions within the collagen, and promoting optimal alignment of the fibers. Ideally, this will result in decreased pain, increased function, and enhanced healing.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Cyriax's deep friction massage application parameters: Evidence from a cross-sectional study with physiotherapists.","id":"4564947","page":"92-97","type":"article-journal","volume":"32","author":[{"family":"Chaves","given":"Paula"},{"family":"Sim?es","given":"Daniela"},{"family":"Pa?o","given":"Maria"},{"family":"Pinho","given":"Francisco"},{"family":"Duarte","given":"José Alberto"},{"family":"Ribeiro","given":"Fernando"}],"issued":{"date-parts":[["2017","12"]]},"container-title":"Musculoskeletal science & practice","container-title-short":"Musculoskelet Sci Pract","journalAbbreviation":"Musculoskelet Sci Pract","DOI":"10.1016/j.msksp.2017.09.005","PMID":"28934644","citation-label":"4564947","Abstract":"BACKGROUND: Deep friction massage is one of several physiotherapy interventions suggested for the management of tendinopathy. OBJECTIVES: To determine the prevalence of deep friction massage use in clinical practice, to characterize the application parameters used by physiotherapists, and to identify empirical model-based patterns of deep friction massage application in degenerative tendinopathy. DESIGN: observational, analytical, cross-sectional and national web-based survey. METHODS: 478 physiotherapists were selected through snow-ball sampling method. The participants completed an online questionnaire about personal and professional characteristics as well as specific questions regarding the use of deep friction massage. Characterization of deep friction massage parameters used by physiotherapists were presented as counts and proportions. Latent class analysis was used to identify the empirical model-based patterns. Crude and adjusted odds ratios and 95% confidence intervals were computed. RESULTS: The use of deep friction massage was reported by 88.1% of the participants; tendinopathy was the clinical condition where it was most frequently used (84.9%) and, from these, 55.9% reported its use in degenerative tendinopathy. The \"duration of application\" parameters in chronic phase and \"frequency of application\" in acute and chronic phases are those that diverge most from those recommended by the author of deep friction massage. CONCLUSION: We found a high prevalence of deep friction massage use, namely in degenerative tendinopathy. Our results have shown that the application parameters are heterogeneous and diverse. This is reflected by the identification of two application patterns, although none is in complete agreement with Cyriax's description. Copyright ? 2017 Elsevier Ltd. All rights reserved.","CleanAbstract":"BACKGROUND: Deep friction massage is one of several physiotherapy interventions suggested for the management of tendinopathy.OBJECTIVES: To determine the prevalence of deep friction massage use in clinical practice, to characterize the application parameters used by physiotherapists, and to identify empirical model-based patterns of deep friction massage application in degenerative tendinopathy.DESIGN: observational, analytical, cross-sectional and national web-based survey.METHODS: 478 physiotherapists were selected through snow-ball sampling method. The participants completed an online questionnaire about personal and professional characteristics as well as specific questions regarding the use of deep friction massage. Characterization of deep friction massage parameters used by physiotherapists were presented as counts and proportions. Latent class analysis was used to identify the empirical model-based patterns. Crude and adjusted odds ratios and 95% confidence intervals were computed.RESULTS: The use of deep friction massage was reported by 88.1% of the participants; tendinopathy was the clinical condition where it was most frequently used (84.9%) and, from these, 55.9% reported its use in degenerative tendinopathy. The \"duration of application\" parameters in chronic phase and \"frequency of application\" in acute and chronic phases are those that diverge most from those recommended by the author of deep friction massage.CONCLUSION: We found a high prevalence of deep friction massage use, namely in degenerative tendinopathy. Our results have shown that the application parameters are heterogeneous and diverse. This is reflected by the identification of two application patterns, although none is in complete agreement with Cyriax's description.Copyright ? 2017 Elsevier Ltd. All rights reserved."}]16 This treatment is not without its limitations, specifically the variance between the clinicians providing the intervention. These include pressure, frequency, duration, and the number of treatment sessions.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Cyriax's deep friction massage application parameters: Evidence from a cross-sectional study with physiotherapists.","id":"4564947","page":"92-97","type":"article-journal","volume":"32","author":[{"family":"Chaves","given":"Paula"},{"family":"Sim?es","given":"Daniela"},{"family":"Pa?o","given":"Maria"},{"family":"Pinho","given":"Francisco"},{"family":"Duarte","given":"José Alberto"},{"family":"Ribeiro","given":"Fernando"}],"issued":{"date-parts":[["2017","12"]]},"container-title":"Musculoskeletal science & practice","container-title-short":"Musculoskelet Sci Pract","journalAbbreviation":"Musculoskelet Sci Pract","DOI":"10.1016/j.msksp.2017.09.005","PMID":"28934644","citation-label":"4564947","Abstract":"BACKGROUND: Deep friction massage is one of several physiotherapy interventions suggested for the management of tendinopathy. OBJECTIVES: To determine the prevalence of deep friction massage use in clinical practice, to characterize the application parameters used by physiotherapists, and to identify empirical model-based patterns of deep friction massage application in degenerative tendinopathy. DESIGN: observational, analytical, cross-sectional and national web-based survey. METHODS: 478 physiotherapists were selected through snow-ball sampling method. The participants completed an online questionnaire about personal and professional characteristics as well as specific questions regarding the use of deep friction massage. Characterization of deep friction massage parameters used by physiotherapists were presented as counts and proportions. Latent class analysis was used to identify the empirical model-based patterns. Crude and adjusted odds ratios and 95% confidence intervals were computed. RESULTS: The use of deep friction massage was reported by 88.1% of the participants; tendinopathy was the clinical condition where it was most frequently used (84.9%) and, from these, 55.9% reported its use in degenerative tendinopathy. The \"duration of application\" parameters in chronic phase and \"frequency of application\" in acute and chronic phases are those that diverge most from those recommended by the author of deep friction massage. CONCLUSION: We found a high prevalence of deep friction massage use, namely in degenerative tendinopathy. Our results have shown that the application parameters are heterogeneous and diverse. This is reflected by the identification of two application patterns, although none is in complete agreement with Cyriax's description. Copyright ? 2017 Elsevier Ltd. All rights reserved.","CleanAbstract":"BACKGROUND: Deep friction massage is one of several physiotherapy interventions suggested for the management of tendinopathy.OBJECTIVES: To determine the prevalence of deep friction massage use in clinical practice, to characterize the application parameters used by physiotherapists, and to identify empirical model-based patterns of deep friction massage application in degenerative tendinopathy.DESIGN: observational, analytical, cross-sectional and national web-based survey.METHODS: 478 physiotherapists were selected through snow-ball sampling method. The participants completed an online questionnaire about personal and professional characteristics as well as specific questions regarding the use of deep friction massage. Characterization of deep friction massage parameters used by physiotherapists were presented as counts and proportions. Latent class analysis was used to identify the empirical model-based patterns. Crude and adjusted odds ratios and 95% confidence intervals were computed.RESULTS: The use of deep friction massage was reported by 88.1% of the participants; tendinopathy was the clinical condition where it was most frequently used (84.9%) and, from these, 55.9% reported its use in degenerative tendinopathy. The \"duration of application\" parameters in chronic phase and \"frequency of application\" in acute and chronic phases are those that diverge most from those recommended by the author of deep friction massage.CONCLUSION: We found a high prevalence of deep friction massage use, namely in degenerative tendinopathy. Our results have shown that the application parameters are heterogeneous and diverse. This is reflected by the identification of two application patterns, although none is in complete agreement with Cyriax's description.Copyright ? 2017 Elsevier Ltd. All rights reserved."}]16 The essential principles of DFM, as developed by Dr. Cyriax, include the following:ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Cyriax's friction massage: A review.","id":"4564960","page":"16-22","type":"article-journal","volume":"4","issue":"1","author":[{"family":"Chamberlain","given":"G J"}],"issued":{"date-parts":[["1982"]]},"container-title":"The Journal of Orthopaedic and Sports Physical Therapy","container-title-short":"J Orthop Sports Phys Ther","journalAbbreviation":"J Orthop Sports Phys Ther","DOI":"10.2519/jospt.1982.4.1.16","PMID":"18810110","citation-label":"4564960","Abstract":"This article reviews the existing literature on connective tissue in an attempt to provide additional substantiation for the use of Dr. James Cyriax's friction massage. J Orthop Sports Phys Ther 1982;4(1):16-22.","CleanAbstract":"This article reviews the existing literature on connective tissue in an attempt to provide additional substantiation for the use of Dr. James Cyriax's friction massage. J Orthop Sports Phys Ther 1982;4(1):16-22."}]17 1. Location must be found through palpation2. Friction is applied perpendicular to the fiber arrangement3. Therapist’s fingers and the patient’s skin must move as one. No sliding across the skin.4. The application must be deep and have a sufficient sweep5. The patient must be at rest in a comfortable positionAn exercise program focusing on a combination of eccentric and concentric strengthening exercises as well as functional movement training to return to pain-free sport is the ideal rehabilitation protocol (Appendix D). The most common exercise to focus on eccentric loading of the Quadriceps and patellar tendon is that of single leg squats on a decline board (Appendix E). Some studies have speculated at the mechanism of eccentric loading and its impact on tendon healing, stating that the lengthening of the muscle while contracting essentially squeezes out the blood flow in the new vessels in the tissue in combination with collagen synthesis, growth factor production, and changes in normal tendon blood flow.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Neovascularity in patellar tendinopathy and the response to eccentric training: a case report using Power Doppler ultrasound.","id":"4536361","page":"602-605","type":"article-journal","volume":"18","issue":"6","author":[{"family":"McCreesh","given":"Karen M"},{"family":"Riley","given":"Sara J"},{"family":"Crotty","given":"James M"}],"issued":{"date-parts":[["2013","12"]]},"container-title":"Manual Therapy","container-title-short":"Man Ther","journalAbbreviation":"Man Ther","DOI":"10.1016/j.math.2012.09.001","PMID":"23022320","citation-label":"4536361","Abstract":"This report describes the case of an amateur soccer player with chronic patellar tendinopathy who underwent ultrasound imaging before and after engaging in an 8-week programme of eccentric exercise. On initial assessment, greyscale ultrasound imaging demonstrated tendon thickening and reduced echogenicity, while Power Doppler imaging demonstrated a large amount of neovascularity. After 8 weeks of an eccentric loading programme, the patient reported significantly improved symptoms and functional scores, while follow-up imaging demonstrated improvement in the echo appearance of the tendon and complete resolution of the neovascularity. The association between neovascularity and symptoms in tendinopathy research is conflicting, with a paucity of research in the area of patellar tendinopathy. While further research is needed to clarify the significance of greyscale and Power Doppler ultrasound changes in relation to symptoms in patellar tendinopathy, ultrasound imaging was shown to be a useful adjunct to diagnosis and outcome assessment in this case. Copyright ? 2012 Elsevier Ltd. All rights reserved.","CleanAbstract":"This report describes the case of an amateur soccer player with chronic patellar tendinopathy who underwent ultrasound imaging before and after engaging in an 8-week programme of eccentric exercise. On initial assessment, greyscale ultrasound imaging demonstrated tendon thickening and reduced echogenicity, while Power Doppler imaging demonstrated a large amount of neovascularity. After 8 weeks of an eccentric loading programme, the patient reported significantly improved symptoms and functional scores, while follow-up imaging demonstrated improvement in the echo appearance of the tendon and complete resolution of the neovascularity. The association between neovascularity and symptoms in tendinopathy research is conflicting, with a paucity of research in the area of patellar tendinopathy. While further research is needed to clarify the significance of greyscale and Power Doppler ultrasound changes in relation to symptoms in patellar tendinopathy, ultrasound imaging was shown to be a useful adjunct to diagnosis and outcome assessment in this case.Copyright ? 2012 Elsevier Ltd. All rights reserved."}]18Best practice for physical therapists is to make all attempts at non-invasive treatment methods prior to recommending a return to a physician for injection or surgery. When reaching this impasse with patients, an injection may be the next most-feasible treatment option. High Volume Image Guided Injection (HVIGI) can be utilized in these cases, where the visual guide may help to remove neovascularization and decrease the amount of nerve ingrowth. The syringe is guided by ultrasound imaging, injecting Bupivacaine, Hydrocortisone, and Saline. Corticosteroid injections have been used as a “quick-fix” intervention for patients with patellar tendinopathy, especially athletes. The process of these medications is to decrease inflammation by inhibiting proinflammatory cytokine synthesis. These have demonstrated some short-term effects, however, there are no long-term effects associated with an injection. Potential adverse outcomes include tendon rupture. This in combination with the lack of effect duration has deterred many physicians and patients from using this method.14Recommendations for injections include avoiding injecting directly into the tendon, refraining from strenuous activity for several weeks post-treatment, and repeating the intervention no sooner than three to four weeks after.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Predictors of short-term work-related disability among active duty US Navy personnel: a cohort study in patients with acute and subacute low back pain.","id":"4271100","page":"806-816","type":"article-journal","volume":"12","issue":"9","author":[{"family":"Hiebert","given":"Rudi"},{"family":"Campello","given":"Marco A"},{"family":"Weiser","given":"Sherri"},{"family":"Ziemke","given":"Gregg W"},{"family":"Fox","given":"Bryan A"},{"family":"Nordin","given":"Margareta"}],"issued":{"date-parts":[["2012","9"]]},"container-title":"The Spine Journal","container-title-short":"Spine J","journalAbbreviation":"Spine J","DOI":"10.1016/j.spinee.2011.11.012","PMID":"22227177","citation-label":"4271100"}]19 Adverse effects observed with corticosteroid injection include impaired healing and the increased risk of rupture. The most common drug used in these situations is Dexamethosone. A study by Zhang et al sought to discover the effects of Dexamethosone on tendon stem cells as they are key players in the tendon healing process. Their study found that the introduction of Dexamethosone actually caused the stem cells to proliferate at lower rates and also induced non-tendon stem cell differentiation. Within these stem cells were those of bone, fatty tissue, and cartilage-like tissues. This alteration is a factor in the weakening of the healing tendon and adds to the increased risk of rupture.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The effects of dexamethasone on human patellar tendon stem cells: implications for dexamethasone treatment of tendon injury.","id":"4580687","page":"105-110","type":"article-journal","volume":"31","issue":"1","author":[{"family":"Zhang","given":"Jianying"},{"family":"Keenan","given":"Camille"},{"family":"Wang","given":"James H-C"}],"issued":{"date-parts":[["2013","1"]]},"container-title":"Journal of Orthopaedic Research","container-title-short":"J Orthop Res","journalAbbreviation":"J Orthop Res","DOI":"10.1002/jor.22193","PMID":"22886634","PMCID":"PMC3498577","citation-label":"4580687","Abstract":"Injection of Dexamethasone (Dex) is commonly used in clinics to treat tendon injury such as tendinopathy because of its anti-inflammatory capabilities. However, serious adverse effects have been reported as a result of Dex treatment, such as impaired tendon healing and tendon rupture. Using both in vitro and in vivo approaches, this study was to determine the effects of Dex treatment on the proliferation and differentiation of human tendon stem cells (hTSCs), which can directly impact tendon healing. We found that Dex treatment stimulated cell proliferation at lower concentrations (< 1,000?nM), whereas a high concentration (1,000?nM) decreased cell proliferation. Moreover, at all concentrations used (5, 10, 100, and 1,000?nM), Dex treatment induced non-tenocyte differentiation of hTSCs, as evidenced by a change in cell shape, a nearly complete suppression of collagen type I expression, and an upregulation of non-tenocyte related genes (PPARγ and Sox-9), which was especially evident when higher concentrations (>10?nM) of Dex were used. Implantation of Dex-treated hTSCs for a short time (3 weeks) resulted in the extensive formation of fatty tissues, cartilage-like tissues, and bony tissues. These findings suggest that Dex treatment in clinics may cause a paradoxical effect on the injured tendons it is supposed to treat: by inducing non-tenocyte differentiation of hTSCs, Dex treatment depletes the stem cell pool and leads to the formation of non-tendinous tissues (e.g., fatty and cartilage-like tissues), which make tendon susceptible to rupture. Copyright ? 2012 Orthopaedic Research Society.","CleanAbstract":"Injection of Dexamethasone (Dex) is commonly used in clinics to treat tendon injury such as tendinopathy because of its anti-inflammatory capabilities. However, serious adverse effects have been reported as a result of Dex treatment, such as impaired tendon healing and tendon rupture. Using both in vitro and in vivo approaches, this study was to determine the effects of Dex treatment on the proliferation and differentiation of human tendon stem cells (hTSCs), which can directly impact tendon healing. We found that Dex treatment stimulated cell proliferation at lower concentrations (10?nM) of Dex were used. Implantation of Dex-treated hTSCs for a short time (3 weeks) resulted in the extensive formation of fatty tissues, cartilage-like tissues, and bony tissues. These findings suggest that Dex treatment in clinics may cause a paradoxical effect on the injured tendons it is supposed to treat: by inducing non-tenocyte differentiation of hTSCs, Dex treatment depletes the stem cell pool and leads to the formation of non-tendinous tissues (e.g., fatty and cartilage-like tissues), which make tendon susceptible to rupture.Copyright ? 2012 Orthopaedic Research Society."}]20A recent study by Blomgran, Hammerman, and Aspenberg found that the introduction of systemic dexamethasone early in the remodeling phase in rats that underwent an Achilles transection demonstrated an improvement in tendon healing. This was observed through better collagen alignment and also the reduction in number of cytotoxic T cells. Cytotoxic T cells have been shown to delay fracture healing in both mice and humans, so their limitation may potentially have a significant effect on tendon healing. The relationship between systemic and local introduction of corticosteroids is unknown; however, these findings suggest that there may be more benefit to local injection than was previously discovered.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Systemic corticosteroids improve tendon healing when given after the early inflammatory phase.","id":"4577677","page":"12468","type":"article-journal","volume":"7","issue":"1","author":[{"family":"Blomgran","given":"Parmis"},{"family":"Hammerman","given":"Malin"},{"family":"Aspenberg","given":"Per"}],"issued":{"date-parts":[["2017","9","29"]]},"container-title":"Scientific reports","container-title-short":"Sci Rep","journalAbbreviation":"Sci Rep","DOI":"10.1038/s41598-017-12657-0","PMID":"28963482","PMCID":"PMC5622078","citation-label":"4577677","Abstract":"Inflammation initiates tendon healing and then normally resolves more or less completely. Unresolved inflammation might disturb the remodeling process. We hypothesized that suppression of inflammation during the early remodeling phase by systemic dexamethasone treatment can improve healing. 36 rats underwent?Achilles tendon transection and were randomized to dexamethasone or saline on days 0-4 after surgery (early inflammatory phase), and euthanasia day 7. Another 54 rats received injections days 5-9 (early remodeling phase) and were euthanized day 12 for mechanical, histological and flow cytometric evaluation. Dexamethasone treatment days 0-4 reduced the cross-sectional area, peak force and stiffness by day 7 to less than half (p?< ?0.001 for all), while material properties (peak stress and elastic modulus) were not significantly affected. In contrast, dexamethasone treatment days 5-9 increased peak force by 39% (p?=?0.002) and stiffness by 58% (p?< ?0.001). The cross-sectional area was reduced by 42% (p?< ?0.001). Peak stress and elastic modulus were more than doubled (p?< ?0.001 for both). Semi-quantitative histology at day 12 showed that late dexamethasone treatment improved collagen alignment, and flow cytometry revealed reduced numbers of CD8a+ cytotoxic T cells in the tendon callus. These results suggest that downregulation of lingering inflammation during the early remodeling phase can improve healing.","CleanAbstract":"Inflammation initiates tendon healing and then normally resolves more or less completely. Unresolved inflammation might disturb the remodeling process. We hypothesized that suppression of inflammation during the early remodeling phase by systemic dexamethasone treatment can improve healing. 36 rats underwent?Achilles tendon transection and were randomized to dexamethasone or saline on days 0-4 after surgery (early inflammatory phase), and euthanasia day 7. Another 54 rats received injections days 5-9 (early remodeling phase) and were euthanized day 12 for mechanical, histological and flow cytometric evaluation. Dexamethasone treatment days 0-4 reduced the cross-sectional area, peak force and stiffness by day 7 to less than half (p?< ?0.001 for all), while material properties (peak stress and elastic modulus) were not significantly affected. In contrast, dexamethasone treatment days 5-9 increased peak force by 39% (p?=?0.002) and stiffness by 58% (p?< ?0.001). The cross-sectional area was reduced by 42% (p?< ?0.001). Peak stress and elastic modulus were more than doubled (p?< ?0.001 for both). Semi-quantitative histology at day 12 showed that late dexamethasone treatment improved collagen alignment, and flow cytometry revealed reduced numbers of CD8a+ cytotoxic T cells in the tendon callus. These results suggest that downregulation of lingering inflammation during the early remodeling phase can improve healing."}]21Should conservative methods be unsuccessful, surgical intervention may be recommended. Approximately 10% of athletes choose to undergo surgery after their symptoms persist through prior interventions.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Arthroscopic patellar release for treatment of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population.","id":"4580692","page":"486","type":"article-journal","volume":"18","issue":"1","author":[{"family":"Lang","given":"Gernot"},{"family":"Pestka","given":"Jan M"},{"family":"Maier","given":"Dirk"},{"family":"Izadpanah","given":"Kaywan"},{"family":"Südkamp","given":"Norbert"},{"family":"Ogon","given":"Peter"}],"issued":{"date-parts":[["2017","11","22"]]},"container-title":"BMC Musculoskeletal Disorders","container-title-short":"BMC Musculoskelet Disord","journalAbbreviation":"BMC Musculoskelet Disord","DOI":"10.1186/s12891-017-1851-3","PMID":"29166934","PMCID":"PMC5700547","citation-label":"4580692","Abstract":"BACKGROUND: Arthroscopic patellar release (APR) is utilized for minimally invasive surgical treatment of patellar tendinopathy. Evidence regarding long-term success following the procedure is limited. Also, the influence of age and preoperative performance level, are incompletely understood. The aim of this study was to investigate whether APR translates into sustained pain relief over a long-term follow-up in athletes undergoing APR. Furthermore, we analyzed if age influences clinical and functional outcome measures in APR. METHODS: Between 1998 and 2010, 30 competitive and recreational athletes were treated with APR due to chronic refractory patellar tendinopathy. All data were analyzed retrospectively. Demographic data, such as age or level of performance prior to injury were extracted. Clinical as well as functional outcome measures (Swedish Victorian Institute of sport assessment for patella (VISA-P), the modified Blazina score, pain level following exercise, return to sports, and subjective knee function were assessed pre- and postoperatively. RESULTS: In total, 30 athletes were included in this study. At follow-up (8.8?±?2.82?years), clinical and functional outcome measures such as the mean Blazina score, VISA-P, VAS, and subjective knee function revealed significant improvement compared to before surgery (P?< ?0.001). The mean time required for return to sports was 4.03?±?3.18?months. After stratification by age, patients younger than 30?years of age yielded superior outcome in the mean Blazina score and pain level when compared to patients ≥30?years (P?=?0.0448). At 8?years of follow-up, patients yielded equivalent clinical and functional outcome scores compared to our previous investigation after four years following APR. CONCLUSION: In summary, APR can be regarded a successful, minimally invasive, and sustained surgical technique for the treatment of patella tendinopathy in athletes. Younger age at surgery may be associated with improved clinical and functional outcome following APR.","CleanAbstract":"BACKGROUND: Arthroscopic patellar release (APR) is utilized for minimally invasive surgical treatment of patellar tendinopathy. Evidence regarding long-term success following the procedure is limited. Also, the influence of age and preoperative performance level, are incompletely understood. The aim of this study was to investigate whether APR translates into sustained pain relief over a long-term follow-up in athletes undergoing APR. Furthermore, we analyzed if age influences clinical and functional outcome measures in APR.METHODS: Between 1998 and 2010, 30 competitive and recreational athletes were treated with APR due to chronic refractory patellar tendinopathy. All data were analyzed retrospectively. Demographic data, such as age or level of performance prior to injury were extracted. Clinical as well as functional outcome measures (Swedish Victorian Institute of sport assessment for patella (VISA-P), the modified Blazina score, pain level following exercise, return to sports, and subjective knee function were assessed pre- and postoperatively.RESULTS: In total, 30 athletes were included in this study. At follow-up (8.8?±?2.82?years), clinical and functional outcome measures such as the mean Blazina score, VISA-P, VAS, and subjective knee function revealed significant improvement compared to before surgery (P?CONCLUSION: In summary, APR can be regarded a successful, minimally invasive, and sustained surgical technique for the treatment of patella tendinopathy in athletes. Younger age at surgery may be associated with improved clinical and functional outcome following APR."}]22 Unfortunately, surgery may have as low as a 50% positive response rate in those with patellar tendinopathy.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population.","id":"4580696","page":"204","type":"article-journal","volume":"18","issue":"1","author":[{"family":"Barker-Davies","given":"Robert M"},{"family":"Nicol","given":"Alastair"},{"family":"McCurdie","given":"I"},{"family":"Watson","given":"James"},{"family":"Baker","given":"Polly"},{"family":"Wheeler","given":"Patrick"},{"family":"Fong","given":"Daniel"},{"family":"Lewis","given":"Mark"},{"family":"Bennett","given":"Alexander N"}],"issued":{"date-parts":[["2017","5","22"]]},"container-title":"BMC Musculoskeletal Disorders","container-title-short":"BMC Musculoskelet Disord","journalAbbreviation":"BMC Musculoskelet Disord","DOI":"10.1186/s12891-017-1564-7","PMID":"28532478","PMCID":"PMC5441076","citation-label":"4580696","Abstract":"BACKGROUND: Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%. High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT). METHODS: RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited. INCLUSION CRITERIA: male, 18-55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment. DISCUSSION: Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment. TRIAL REGISTRATION: EudraCT: 2015-003587-36 3 Dec 2015.","CleanAbstract":"BACKGROUND: Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%. High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT).METHODS: RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited.INCLUSION CRITERIA: male, 18-55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment.DISCUSSION: Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment.TRIAL REGISTRATION: EudraCT: 2015-003587-36 3 Dec 2015."}]23 A minimally invasive method to treat patellar tendinopathy is the Arthroscopic Patellar Release (APR). This procedure is completed with an arthroscopic ablation probe to complete the focal synovectomy in the area of the inferior pole and the proximal portion of the tendon. Should there be involvement of Hoffa’s Fat Pad, the hypertrophic areas would be removed as well. Lastly, the ablation probe denervates the transitional zone at the inferior pole and in other symptomatic areas.22Evidence has shown that surgical intervention is useful in treating recalcitrant cases of patellar tendinitis. These patients most often have the greatest pain levels and decreases in function at the time of surgery, compared to those that responded to conservative management. Some studies have shown that an open procedure gains greater positive outcomes as compared to arthroscopic.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Treatment options for patellar tendinopathy: a?systematic review.","id":"4564987","page":"861-872","type":"article-journal","volume":"33","issue":"4","author":[{"family":"Everhart","given":"Joshua S"},{"family":"Cole","given":"Devon"},{"family":"Sojka","given":"John H"},{"family":"Higgins","given":"John D"},{"family":"Magnussen","given":"Robert A"},{"family":"Schmitt","given":"Laura C"},{"family":"Flanigan","given":"David C"}],"issued":{"date-parts":[["2017","4"]]},"container-title":"Arthroscopy","container-title-short":"Arthroscopy","journalAbbreviation":"Arthroscopy","DOI":"10.1016/j.arthro.2016.11.007","PMID":"28110807","citation-label":"4564987","Abstract":"PURPOSE: To compare the efficacy of common invasive and noninvasive patellar tendinopathy (PT) treatment strategies. METHODS: A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SPORTDiscus. Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up. Methodological quality and reporting bias were evaluated with a modified Coleman score and Begg's and Egger's tests of bias, respectively. RESULTS: A total of 15 studies were included. Reporting quality was high (mean Coleman score 86.0, standard deviation 9.7), and there was no systematic evidence of reporting bias. Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P?= .004). Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%). Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches. Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery. Finally, steroid injection provided no benefit (20%, 95% CI?-20% to 60%). CONCLUSIONS: Initial treatment of PT can consist of eccentric squat-based therapy, shockwave, or PRP as monotherapy or an adjunct to accelerate recovery. Surgery or shockwave can be considered for patients who fail to improve after 6?months of conservative treatment. Corticosteroid therapy should not be used in the treatment of PT. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies. Copyright ? 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.","CleanAbstract":"PURPOSE: To compare the efficacy of common invasive and noninvasive patellar tendinopathy (PT) treatment strategies.METHODS: A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SPORTDiscus. Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up. Methodological quality and reporting bias were evaluated with a modified Coleman score and Begg's and Egger's tests of bias, respectively.RESULTS: A total of 15 studies were included. Reporting quality was high (mean Coleman score 86.0, standard deviation 9.7), and there was no systematic evidence of reporting bias. Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P?= .004). Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%). Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches. Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery. Finally, steroid injection provided no benefit (20%, 95% CI?-20% to 60%).CONCLUSIONS: Initial treatment of PT can consist of eccentric squat-based therapy, shockwave, or PRP as monotherapy or an adjunct to accelerate recovery. Surgery or shockwave can be considered for patients who fail to improve after 6?months of conservative treatment. Corticosteroid therapy should not be used in the treatment of PT.LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.Copyright ? 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved."}]24Other risk factors for tendon injury include prednisone, Fluoroquinolones, and Statins. Many individuals, especially those in the latter part of their lives, are prescribed prednisone to manage systemic diseases. Diseases most often correlated to atraumatic Achilles tendon rupture are rheumatoid arthritis, hyperparathyroidism, lupus erythematosus, gout, and chronic renal failure. This is due not only to the effects from the condition, but also the long-term use of steroids, such as prednisone.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Achilles tendon rupture as a result of oral steroid therapy.","id":"4580585","page":"355-358","type":"article-journal","volume":"92","issue":"6","author":[{"family":"Hersh","given":"Bryan L"},{"family":"Heath","given":"Nicholas S"}],"issued":{"date-parts":[["2002","6"]]},"container-title":"Journal of the American Podiatric Medical Association","container-title-short":"J Am Podiatr Med Assoc","journalAbbreviation":"J Am Podiatr Med Assoc","PMID":"12070236","citation-label":"4580585","Abstract":"Spontaneous Achilles tendon rupture associated with long-term oral steroid use is not uncommon, particularly in older patients who use these drugs daily to treat systemic diseases. Rupture often results in a large defect, which complicates surgical repair. The authors review Achilles tendon rupture associated with systemic and local steroid use and present a case of rupture due to chronic oral steroid use in a patient with Addison's disease.","CleanAbstract":"Spontaneous Achilles tendon rupture associated with long-term oral steroid use is not uncommon, particularly in older patients who use these drugs daily to treat systemic diseases. Rupture often results in a large defect, which complicates surgical repair. The authors review Achilles tendon rupture associated with systemic and local steroid use and present a case of rupture due to chronic oral steroid use in a patient with Addison's disease."}]25Fluoroquinolones, antibiotics often taken for respiratory infections or urinary tract infections, have been shown to significantly effect tendon in a negative way. Examples of these are ciproflaxin, levofloxacin, and olfolaxicin. This medication can cause tendinitis or even tendon rupture. The occurrence of rupture is rare, but it is important to know that the risk is there for individuals taking these medications. Proposed mechanisms of effect on tendon tissue include direct injury via apoptosis or necrosis, promotion of local release of harmful substances such as nitric oxide and free radicals, inhibition of topoisomerase II which causes toxicity within the mitochondria, and other effects on the extracellular matrix such as collagen degradation.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Fluoroquinolone-Associated Tendinopathy: Does Levofloxacin Pose the Greatest Risk?","id":"4580591","page":"679-693","type":"article-journal","volume":"36","issue":"6","author":[{"family":"Bidell","given":"Monique R"},{"family":"Lodise","given":"Thomas P"}],"issued":{"date-parts":[["2016","6","11"]]},"container-title":"Pharmacotherapy","container-title-short":"Pharmacotherapy","journalAbbreviation":"Pharmacotherapy","DOI":"10.1002/phar.1761","PMID":"27138564","citation-label":"4580591","Abstract":"Fluoroquinolone antibiotics recently have gained increased national attention due to safety concerns. A well-described and serious adverse event associated with receipt of fluoroquinolones is tendinitis and tendon rupture. These tendon injuries can result in long-term sequelae, including chronic pain and mobility restrictions, and may warrant surgery. Due to the severity of these adverse events, a black box warning is included in the product labeling of all fluoroquinolones. In light of the mounting concerns surrounding fluoroquinolone-associated toxicities, the purpose of this clinical review is to provide a comprehensive summary of the risk of tendinopathy associated with levofloxacin, one of the most widely prescribed antibiotics in the United States, across in vitro, animal, and clinical studies, relative to other antibiotics. As part of this review, clinical presentation and onset, proposed mechanisms, patient-specific risk factors, and management of fluoroquinolone-induced tendon injury are summarized. Data were obtained from a comprehensive PubMed literature search and a review of U.S. Food and Drug Administration documents. Although tendinopathy is considered a fluoroquinolone class-wide toxicity, data from in vitro studies, animal studies, patient-level analyses, and large national and international surveillance reports suggest that levofloxacin, as well as its parent compound ofloxacin, possess higher propensities to cause tendon damage relative to other fluoroquinolones. Risk with ofloxacin and levofloxacin appears to be exposure dependent, with higher doses and longer durations being most commonly associated with tendinopathy. Other well-described patient risk factors for fluoroquinolone-associated tendinopathy include older age (older than 60 yrs), receipt of concomitant corticosteroid therapy, presence of renal dysfunction, and history of solid organ transplantation. Given widespread use of levofloxacin across patient care settings, knowledge of both patient- and drug-specific characteristics associated with increased risk of tendinitis and tendon rupture can promote safe use of levofloxacin and other fluoroquinolones. ? 2016 Pharmacotherapy Publications, Inc.","CleanAbstract":"Fluoroquinolone antibiotics recently have gained increased national attention due to safety concerns. A well-described and serious adverse event associated with receipt of fluoroquinolones is tendinitis and tendon rupture. These tendon injuries can result in long-term sequelae, including chronic pain and mobility restrictions, and may warrant surgery. Due to the severity of these adverse events, a black box warning is included in the product labeling of all fluoroquinolones. In light of the mounting concerns surrounding fluoroquinolone-associated toxicities, the purpose of this clinical review is to provide a comprehensive summary of the risk of tendinopathy associated with levofloxacin, one of the most widely prescribed antibiotics in the United States, across in vitro, animal, and clinical studies, relative to other antibiotics. As part of this review, clinical presentation and onset, proposed mechanisms, patient-specific risk factors, and management of fluoroquinolone-induced tendon injury are summarized. Data were obtained from a comprehensive PubMed literature search and a review of U.S. Food and Drug Administration documents. Although tendinopathy is considered a fluoroquinolone class-wide toxicity, data from in vitro studies, animal studies, patient-level analyses, and large national and international surveillance reports suggest that levofloxacin, as well as its parent compound ofloxacin, possess higher propensities to cause tendon damage relative to other fluoroquinolones. Risk with ofloxacin and levofloxacin appears to be exposure dependent, with higher doses and longer durations being most commonly associated with tendinopathy. Other well-described patient risk factors for fluoroquinolone-associated tendinopathy include older age (older than 60 yrs), receipt of concomitant corticosteroid therapy, presence of renal dysfunction, and history of solid organ transplantation. Given widespread use of levofloxacin across patient care settings, knowledge of both patient- and drug-specific characteristics associated with increased risk of tendinitis and tendon rupture can promote safe use of levofloxacin and other fluoroquinolones.? 2016 Pharmacotherapy Publications, Inc."}]26A case of fluoroquinolone induced tendon rupture occurred with a 47-year-old runner presenting to the Emergency Department with bilateral knee pain and the inability to walk. Two weeks prior to the injury, the patient was taking ciproflaxin for an acquired respiratory infection. He stated that he fell all of a sudden while descending the stairs causing significant anterior knee pain and then he could not get up. The observation showed superiorly riding patellae, inflammation, a gap between the inferior poles, and lack of knee extension. X rays showed bilateral patella alta and an Insall-Salvati ratio >1.5. This lead to the diagnosis of bilateral patellar tendon rupture.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Spontaneous bilateral patellar tendon rupture: case report and review of fluoroquinolone-induced tendinopathy.","id":"4580589","page":"678-681","type":"article-journal","volume":"4","issue":"7","author":[{"family":"Rosa","given":"Bárbara"},{"family":"Campos","given":"Pedro"},{"family":"Barros","given":"André"},{"family":"Karmali","given":"Samir"},{"family":"Gon?alves","given":"Ricardo"}],"issued":{"date-parts":[["2016","7"]]},"container-title":"Clinical case reports","container-title-short":"Clin Case Rep","journalAbbreviation":"Clin Case Rep","DOI":"10.1002/ccr3.592","PMID":"27386128","PMCID":"PMC4929805","citation-label":"4580589","Abstract":"The present case emphasizes the importance of adhering to strict indications when prescribing fluoroquinolones. Although rare, drug-induced tendinopathy is not confined to fluoroquinolones. The patient's and physician's awareness should be increased to reduce fluoroquinolones-associated morbidity, particularly in patients with previously described risk factors.","CleanAbstract":"The present case emphasizes the importance of adhering to strict indications when prescribing fluoroquinolones. Although rare, drug-induced tendinopathy is not confined to fluoroquinolones. The patient's and physician's awareness should be increased to reduce fluoroquinolones-associated morbidity, particularly in patients with previously described risk factors."}]27A potential differential diagnosis that is often overlooked is that of Recurrent Anterior Peroneal Nerve Entrapment Syndrome (Appendix G shows the location of the affected nerve). Tenderness may be experienced along the lateral border of the patellar tendon, but there is also peroneal muscle and nerve involvement. The muscles may have an increase in tone and neurodynamic restrictions of the peroneal nerve may be present. Looking distally, examination of the cuboid could show a subluxation, which may be treated with the cuboid whip maneuver. Once this is completed with successful return to normal position of the cuboid, the patient may have a decrease in symptoms. To further promote the eradication of the syndrome, stretches for the peroneal musculature can help to decrease the tightness and return the patient to pain-free activity.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The anterior recurrent peroneal nerve entrapment syndrome: a patellar tendinopathy differential diagnosis case report.","id":"4564923","page":"611-614","type":"article-journal","volume":"18","issue":"6","author":[{"family":"Rousseau","given":"Eric"}],"issued":{"date-parts":[["2013","12"]]},"container-title":"Manual Therapy","container-title-short":"Man Ther","journalAbbreviation":"Man Ther","DOI":"10.1016/j.math.2012.10.003","PMID":"23102854","citation-label":"4564923","Abstract":"Patellar tendinopathy which is a cause of pain in the inferior patellar region is a relatively common pathology among sports enthusiasts. This paper describes a new pain syndrome identified from clinical observations which is a differential diagnosis to patellar tendinopathy. The pattern is specific and recognizable among many individuals, and it should be considered as its own entity. The new syndrome is discussed in terms of the pain experienced, the diagnostic criteria, treatment and the rationale to explain it. As it is a differential diagnosis to patellar tendinopathy, many sports enthusiasts might benefit from this diagnosis. If identified correctly, treatment might be directed to the correct structures and with the appropriate modalities, ensuring the patients a fast return to their past occupations without pain and without unwarranted treatments. Copyright ? 2012 Elsevier Ltd. All rights reserved.","CleanAbstract":"Patellar tendinopathy which is a cause of pain in the inferior patellar region is a relatively common pathology among sports enthusiasts. This paper describes a new pain syndrome identified from clinical observations which is a differential diagnosis to patellar tendinopathy. The pattern is specific and recognizable among many individuals, and it should be considered as its own entity. The new syndrome is discussed in terms of the pain experienced, the diagnostic criteria, treatment and the rationale to explain it. As it is a differential diagnosis to patellar tendinopathy, many sports enthusiasts might benefit from this diagnosis. If identified correctly, treatment might be directed to the correct structures and with the appropriate modalities, ensuring the patients a fast return to their past occupations without pain and without unwarranted treatments.Copyright ? 2012 Elsevier Ltd. All rights reserved."}]28Other differential diagnoses include Osgood-Schlatter Disease, Iliotibial Band Friction Syndrome, and giant cell tumor of the patellar tendon sheath.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Find @ UNC","id":"4170391","type":"webpage","URL":"","accessed":{"date-parts":[["2017","9","6"]]},"citation-label":"4170391"},{"title":"Giant cell tumor of the patellar tendon sheath: A rare case of anterior knee pain.","id":"4580931","page":"e1690","type":"article-journal","volume":"9","issue":"9","author":[{"family":"K?l??aslan","given":"?mer Faruk"},{"family":"Kat?","given":"Yusuf Alper"},{"family":"Kose","given":"Ozkan"},{"family":"Erol","given":"Bekir"},{"family":"Sezgin Alikanoglu","given":"Arsenal"}],"issued":{"date-parts":[["2017","9","16"]]},"container-title":"Cureus","container-title-short":"Cureus","journalAbbreviation":"Cureus","DOI":"10.7759/cureus.1690","PMID":"29158998","PMCID":"PMC5690290","citation-label":"4580931","Abstract":"Giant cell tumor of the tendon sheath (GCTTS) is a benign, proliferative lesion of the synovium of the joint, the bursa, and the tendon sheath. We report a case of intra-articular, localized GCTTS arising from the patellar tendon, which is a rare cause of anterior knee pain. The diagnosis may be delayed due to non-specific symptoms and normal plain radiographic findings. Magnetic resonance imaging (MRI) is diagnostic to detect the lesion, but several other clinical entities and lesions should be evaluated in the differential diagnosis. The treatment of choice is a total excision of the lesion without leaving residual tumor tissue, in order to reduce the risk of recurrence. We present a patient with GCTTS of the patellar tendon and discuss its clinical and radiographic characteristics, differential diagnosis, pathology, and treatment.","CleanAbstract":"Giant cell tumor of the tendon sheath (GCTTS) is a benign, proliferative lesion of the synovium of the joint, the bursa, and the tendon sheath. We report a case of intra-articular, localized GCTTS arising from the patellar tendon, which is a rare cause of anterior knee pain. The diagnosis may be delayed due to non-specific symptoms and normal plain radiographic findings. Magnetic resonance imaging (MRI) is diagnostic to detect the lesion, but several other clinical entities and lesions should be evaluated in the differential diagnosis. The treatment of choice is a total excision of the lesion without leaving residual tumor tissue, in order to reduce the risk of recurrence. We present a patient with GCTTS of the patellar tendon and discuss its clinical and radiographic characteristics, differential diagnosis, pathology, and treatment."}]29,30 To differentiate between these conditions, the aforementioned diagnostic tools may be used (Ultrasound and/or MRI) as well as a thorough subjective and objective examination. Although giant cell tumors are benign, they cause anterior knee pain when they affect the patellar tendon. These growths are often palpable, leading to referrals to specialists for official diagnosis through imaging and needle aspiration biopsy. If diagnosed, removal via surgical excision is generally successful, with some incidences of local recurrence.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Giant cell tumor of the patellar tendon sheath: A rare case of anterior knee pain.","id":"4580931","page":"e1690","type":"article-journal","volume":"9","issue":"9","author":[{"family":"K?l??aslan","given":"?mer Faruk"},{"family":"Kat?","given":"Yusuf Alper"},{"family":"Kose","given":"Ozkan"},{"family":"Erol","given":"Bekir"},{"family":"Sezgin Alikanoglu","given":"Arsenal"}],"issued":{"date-parts":[["2017","9","16"]]},"container-title":"Cureus","container-title-short":"Cureus","journalAbbreviation":"Cureus","DOI":"10.7759/cureus.1690","PMID":"29158998","PMCID":"PMC5690290","citation-label":"4580931","Abstract":"Giant cell tumor of the tendon sheath (GCTTS) is a benign, proliferative lesion of the synovium of the joint, the bursa, and the tendon sheath. We report a case of intra-articular, localized GCTTS arising from the patellar tendon, which is a rare cause of anterior knee pain. The diagnosis may be delayed due to non-specific symptoms and normal plain radiographic findings. Magnetic resonance imaging (MRI) is diagnostic to detect the lesion, but several other clinical entities and lesions should be evaluated in the differential diagnosis. The treatment of choice is a total excision of the lesion without leaving residual tumor tissue, in order to reduce the risk of recurrence. We present a patient with GCTTS of the patellar tendon and discuss its clinical and radiographic characteristics, differential diagnosis, pathology, and treatment.","CleanAbstract":"Giant cell tumor of the tendon sheath (GCTTS) is a benign, proliferative lesion of the synovium of the joint, the bursa, and the tendon sheath. We report a case of intra-articular, localized GCTTS arising from the patellar tendon, which is a rare cause of anterior knee pain. The diagnosis may be delayed due to non-specific symptoms and normal plain radiographic findings. Magnetic resonance imaging (MRI) is diagnostic to detect the lesion, but several other clinical entities and lesions should be evaluated in the differential diagnosis. The treatment of choice is a total excision of the lesion without leaving residual tumor tissue, in order to reduce the risk of recurrence. We present a patient with GCTTS of the patellar tendon and discuss its clinical and radiographic characteristics, differential diagnosis, pathology, and treatment."}]30In conclusion, patellar tendinopathy can be a debilitating condition for elite soccer players, causing them to lose training and match time. In order to treat these athletes most effectively to gain long-term results, a combination of medication, modalities, manual therapy, rehabilitation, and potentially surgical intervention must be administered.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Management of chronic tendon injuries.","id":"4556251","page":"486-490","type":"article-journal","volume":"87","issue":"7","author":[{"family":"Childress","given":"Marc A"},{"family":"Beutler","given":"Anthony"}],"issued":{"date-parts":[["2013","4","1"]]},"container-title":"American Family Physician","container-title-short":"Am Fam Physician","journalAbbreviation":"Am Fam Physician","PMID":"23547590","citation-label":"4556251","Abstract":"Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.","CleanAbstract":"Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise."}]12 The rehabilitation component should include eccentric, concentric, and functional exercises to improve strength and biomechanics in attempt to prevent future patellar tendinopathies.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness.","id":"2152551","page":"267-286","type":"article-journal","volume":"43","issue":"4","author":[{"family":"Malliaras","given":"Peter"},{"family":"Barton","given":"Christian J"},{"family":"Reeves","given":"Neil D"},{"family":"Langberg","given":"Henning"}],"issued":{"date-parts":[["2013","4"]]},"container-title":"Sports medicine (Auckland, N.Z.)","container-title-short":"Sports Med","journalAbbreviation":"Sports Med","DOI":"10.1007/s40279-013-0019-z","PMID":"23494258","citation-label":"2152551"}]8 An alternative treatment is the injection of PRP, enhancing the healing process through eliciting growth factor production.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The systemic effects of platelet-rich plasma injection.","id":"2474185","page":"186-193","type":"article-journal","volume":"41","issue":"1","author":[{"family":"Wasterlain","given":"Amy S"},{"family":"Braun","given":"Hillary J"},{"family":"Harris","given":"Alex H S"},{"family":"Kim","given":"Hyeon-Joo"},{"family":"Dragoo","given":"Jason L"}],"issued":{"date-parts":[["2013","1"]]},"container-title":"The American Journal of Sports Medicine","container-title-short":"Am J Sports Med","journalAbbreviation":"Am J Sports Med","DOI":"10.1177/0363546512466383","PMID":"23211708","citation-label":"2474185"},{"title":"Platelet-Rich Plasma Injections as a Treatment for Refractory Patellar Tendinosis: A Meta-Analysis of Randomised Trials.","id":"4292856","page":"165-171","type":"article-journal","volume":"29","issue":"3","author":[{"family":"Dupley","given":"Leanne"},{"family":"Charalambous","given":"Charalambos P"}],"issued":{"date-parts":[["2017","9","1"]]},"container-title":"Knee surgery & related research","container-title-short":"Knee Surg Relat Res","journalAbbreviation":"Knee Surg Relat Res","DOI":"10.5792/ksrr.16.055","PMID":"28854761","PMCID":"PMC5596405","citation-label":"4292856","Abstract":"Purpose: Patellar tendinosis (PT) is a common condition amongst athletes. In this study, we perform a meta-analysis on randomised controlled trials (RCTs) to evaluate the use of platelet-rich plasma (PRP) for refractory PT. Methods: A literature search was undertaken in various databases from their year of inception to October 2015. The primary outcome measure was the Victorian Institute of Sports Assessment-Patella (VISA-P) score. Results: We identified 2 RCTs comparing PRP injections to alternative treatment options (extracorporeal shockwave therapy [ESWT] and dry needling of the tendon). Meta-analysis showed no significant difference in mean VISA-P scores between PRP injection and control at early assessment (2 or 3 months; estimated difference in means, 11.9; standard error [SE], 7.4; 95% confidence interval [CI], -2.7 to 26.4; p=0.109). However, PRP was statistically better than control with regards to VISA-P scores at longer follow-up (6 months or longer; estimated difference in means, 12.7; SE, 4.4; 95% CI, 4.1 to 21.3; p=0.004). Conclusions: There is a paucity of RCTs evaluating the role of PRP in PT. Our results suggest that, based on limited evidence, PRP is superior over other established non-surgical treatments (dry needling and ESWT) for refractory PT. Larger RCTs may allow better characterisation of the role of PRP in this condition.","CleanAbstract":"Purpose: Patellar tendinosis (PT) is a common condition amongst athletes. In this study, we perform a meta-analysis on randomised controlled trials (RCTs) to evaluate the use of platelet-rich plasma (PRP) for refractory PT.Methods: A literature search was undertaken in various databases from their year of inception to October 2015. The primary outcome measure was the Victorian Institute of Sports Assessment-Patella (VISA-P) score.Results: We identified 2 RCTs comparing PRP injections to alternative treatment options (extracorporeal shockwave therapy [ESWT] and dry needling of the tendon). Meta-analysis showed no significant difference in mean VISA-P scores between PRP injection and control at early assessment (2 or 3 months; estimated difference in means, 11.9; standard error [SE], 7.4; 95% confidence interval [CI], -2.7 to 26.4; p=0.109). However, PRP was statistically better than control with regards to VISA-P scores at longer follow-up (6 months or longer; estimated difference in means, 12.7; SE, 4.4; 95% CI, 4.1 to 21.3; p=0.004).Conclusions: There is a paucity of RCTs evaluating the role of PRP in PT. Our results suggest that, based on limited evidence, PRP is superior over other established non-surgical treatments (dry needling and ESWT) for refractory PT. Larger RCTs may allow better characterisation of the role of PRP in this condition."}]13,31 Should there be little to no improvement with these conservative methods, injections of corticosteroids have shown some success; however, care must be taken to not inject directly into the tendon to decrease the risk of rupture.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The effects of dexamethasone on human patellar tendon stem cells: implications for dexamethasone treatment of tendon injury.","id":"4580687","page":"105-110","type":"article-journal","volume":"31","issue":"1","author":[{"family":"Zhang","given":"Jianying"},{"family":"Keenan","given":"Camille"},{"family":"Wang","given":"James H-C"}],"issued":{"date-parts":[["2013","1"]]},"container-title":"Journal of Orthopaedic Research","container-title-short":"J Orthop Res","journalAbbreviation":"J Orthop Res","DOI":"10.1002/jor.22193","PMID":"22886634","PMCID":"PMC3498577","citation-label":"4580687","Abstract":"Injection of Dexamethasone (Dex) is commonly used in clinics to treat tendon injury such as tendinopathy because of its anti-inflammatory capabilities. However, serious adverse effects have been reported as a result of Dex treatment, such as impaired tendon healing and tendon rupture. Using both in vitro and in vivo approaches, this study was to determine the effects of Dex treatment on the proliferation and differentiation of human tendon stem cells (hTSCs), which can directly impact tendon healing. We found that Dex treatment stimulated cell proliferation at lower concentrations (< 1,000?nM), whereas a high concentration (1,000?nM) decreased cell proliferation. Moreover, at all concentrations used (5, 10, 100, and 1,000?nM), Dex treatment induced non-tenocyte differentiation of hTSCs, as evidenced by a change in cell shape, a nearly complete suppression of collagen type I expression, and an upregulation of non-tenocyte related genes (PPARγ and Sox-9), which was especially evident when higher concentrations (>10?nM) of Dex were used. Implantation of Dex-treated hTSCs for a short time (3 weeks) resulted in the extensive formation of fatty tissues, cartilage-like tissues, and bony tissues. These findings suggest that Dex treatment in clinics may cause a paradoxical effect on the injured tendons it is supposed to treat: by inducing non-tenocyte differentiation of hTSCs, Dex treatment depletes the stem cell pool and leads to the formation of non-tendinous tissues (e.g., fatty and cartilage-like tissues), which make tendon susceptible to rupture. Copyright ? 2012 Orthopaedic Research Society.","CleanAbstract":"Injection of Dexamethasone (Dex) is commonly used in clinics to treat tendon injury such as tendinopathy because of its anti-inflammatory capabilities. However, serious adverse effects have been reported as a result of Dex treatment, such as impaired tendon healing and tendon rupture. Using both in vitro and in vivo approaches, this study was to determine the effects of Dex treatment on the proliferation and differentiation of human tendon stem cells (hTSCs), which can directly impact tendon healing. We found that Dex treatment stimulated cell proliferation at lower concentrations (10?nM) of Dex were used. Implantation of Dex-treated hTSCs for a short time (3 weeks) resulted in the extensive formation of fatty tissues, cartilage-like tissues, and bony tissues. These findings suggest that Dex treatment in clinics may cause a paradoxical effect on the injured tendons it is supposed to treat: by inducing non-tenocyte differentiation of hTSCs, Dex treatment depletes the stem cell pool and leads to the formation of non-tendinous tissues (e.g., fatty and cartilage-like tissues), which make tendon susceptible to rupture.Copyright ? 2012 Orthopaedic Research Society."}]20 Finally, surgical intervention has been successful in cases of recalcitrant tendinopathies due to their lack of response to conservative methods.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Arthroscopic patellar release for treatment of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population.","id":"4580692","page":"486","type":"article-journal","volume":"18","issue":"1","author":[{"family":"Lang","given":"Gernot"},{"family":"Pestka","given":"Jan M"},{"family":"Maier","given":"Dirk"},{"family":"Izadpanah","given":"Kaywan"},{"family":"Südkamp","given":"Norbert"},{"family":"Ogon","given":"Peter"}],"issued":{"date-parts":[["2017","11","22"]]},"container-title":"BMC Musculoskeletal Disorders","container-title-short":"BMC Musculoskelet Disord","journalAbbreviation":"BMC Musculoskelet Disord","DOI":"10.1186/s12891-017-1851-3","PMID":"29166934","PMCID":"PMC5700547","citation-label":"4580692","Abstract":"BACKGROUND: Arthroscopic patellar release (APR) is utilized for minimally invasive surgical treatment of patellar tendinopathy. Evidence regarding long-term success following the procedure is limited. Also, the influence of age and preoperative performance level, are incompletely understood. The aim of this study was to investigate whether APR translates into sustained pain relief over a long-term follow-up in athletes undergoing APR. Furthermore, we analyzed if age influences clinical and functional outcome measures in APR. METHODS: Between 1998 and 2010, 30 competitive and recreational athletes were treated with APR due to chronic refractory patellar tendinopathy. All data were analyzed retrospectively. Demographic data, such as age or level of performance prior to injury were extracted. Clinical as well as functional outcome measures (Swedish Victorian Institute of sport assessment for patella (VISA-P), the modified Blazina score, pain level following exercise, return to sports, and subjective knee function were assessed pre- and postoperatively. RESULTS: In total, 30 athletes were included in this study. At follow-up (8.8?±?2.82?years), clinical and functional outcome measures such as the mean Blazina score, VISA-P, VAS, and subjective knee function revealed significant improvement compared to before surgery (P?< ?0.001). The mean time required for return to sports was 4.03?±?3.18?months. After stratification by age, patients younger than 30?years of age yielded superior outcome in the mean Blazina score and pain level when compared to patients ≥30?years (P?=?0.0448). At 8?years of follow-up, patients yielded equivalent clinical and functional outcome scores compared to our previous investigation after four years following APR. CONCLUSION: In summary, APR can be regarded a successful, minimally invasive, and sustained surgical technique for the treatment of patella tendinopathy in athletes. Younger age at surgery may be associated with improved clinical and functional outcome following APR.","CleanAbstract":"BACKGROUND: Arthroscopic patellar release (APR) is utilized for minimally invasive surgical treatment of patellar tendinopathy. Evidence regarding long-term success following the procedure is limited. Also, the influence of age and preoperative performance level, are incompletely understood. The aim of this study was to investigate whether APR translates into sustained pain relief over a long-term follow-up in athletes undergoing APR. Furthermore, we analyzed if age influences clinical and functional outcome measures in APR.METHODS: Between 1998 and 2010, 30 competitive and recreational athletes were treated with APR due to chronic refractory patellar tendinopathy. All data were analyzed retrospectively. Demographic data, such as age or level of performance prior to injury were extracted. Clinical as well as functional outcome measures (Swedish Victorian Institute of sport assessment for patella (VISA-P), the modified Blazina score, pain level following exercise, return to sports, and subjective knee function were assessed pre- and postoperatively.RESULTS: In total, 30 athletes were included in this study. At follow-up (8.8?±?2.82?years), clinical and functional outcome measures such as the mean Blazina score, VISA-P, VAS, and subjective knee function revealed significant improvement compared to before surgery (P?CONCLUSION: In summary, APR can be regarded a successful, minimally invasive, and sustained surgical technique for the treatment of patella tendinopathy in athletes. Younger age at surgery may be associated with improved clinical and functional outcome following APR."},{"title":"Open Patellar Tendon Tenotomy, Debridement, and Repair Technique Augmented With Platelet-Rich Plasma for Recalcitrant Patellar Tendinopathy.","id":"4536370","page":"e447-e453","type":"article-journal","volume":"6","issue":"2","author":[{"family":"Kruckeberg","given":"Bradley M"},{"family":"Chahla","given":"Jorge"},{"family":"Ferrari","given":"Marcio B"},{"family":"Sanchez","given":"George"},{"family":"Moatshe","given":"Gilbert"},{"family":"LaPrade","given":"Robert F"}],"issued":{"date-parts":[["2017","4","17"]]},"container-title":"Arthroscopy techniques","container-title-short":"Arthrosc Tech","journalAbbreviation":"Arthrosc Tech","DOI":"10.1016/j.eats.2016.10.025","PMID":"28580266","PMCID":"PMC5443616","citation-label":"4536370","Abstract":"Patellar tendinopathy is a disabling condition that frequently affects the athletic population, especially athletes undergoing repetitive impact forces as a result of jumping and landing activities. Most cases are initially treated conservatively, but if symptoms persist, surgical treatment is warranted. Options for surgical treatment include both arthroscopic and open techniques. The purpose of this Technical Note is to detail our open patellar tendon tenotomy, debridement, and repair technique augmented with platelet-rich plasma.","CleanAbstract":"Patellar tendinopathy is a disabling condition that frequently affects the athletic population, especially athletes undergoing repetitive impact forces as a result of jumping and landing activities. Most cases are initially treated conservatively, but if symptoms persist, surgical treatment is warranted. Options for surgical treatment include both arthroscopic and open techniques. The purpose of this Technical Note is to detail our open patellar tendon tenotomy, debridement, and repair technique augmented with platelet-rich plasma."}]22,32Prior to any season’s initiation, a thorough physical examination with subjective health history must be administered to determine predispositions, health concerns, etc. Within this, careful consideration must be taken in regards to tendon health if the athlete has completed a dose of antibiotics within the last 90 days due to its influence on tendon strength.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Fluoroquinolone-Associated Tendinopathy: Does Levofloxacin Pose the Greatest Risk?","id":"4580591","page":"679-693","type":"article-journal","volume":"36","issue":"6","author":[{"family":"Bidell","given":"Monique R"},{"family":"Lodise","given":"Thomas P"}],"issued":{"date-parts":[["2016","6","11"]]},"container-title":"Pharmacotherapy","container-title-short":"Pharmacotherapy","journalAbbreviation":"Pharmacotherapy","DOI":"10.1002/phar.1761","PMID":"27138564","citation-label":"4580591","Abstract":"Fluoroquinolone antibiotics recently have gained increased national attention due to safety concerns. A well-described and serious adverse event associated with receipt of fluoroquinolones is tendinitis and tendon rupture. These tendon injuries can result in long-term sequelae, including chronic pain and mobility restrictions, and may warrant surgery. Due to the severity of these adverse events, a black box warning is included in the product labeling of all fluoroquinolones. In light of the mounting concerns surrounding fluoroquinolone-associated toxicities, the purpose of this clinical review is to provide a comprehensive summary of the risk of tendinopathy associated with levofloxacin, one of the most widely prescribed antibiotics in the United States, across in vitro, animal, and clinical studies, relative to other antibiotics. As part of this review, clinical presentation and onset, proposed mechanisms, patient-specific risk factors, and management of fluoroquinolone-induced tendon injury are summarized. Data were obtained from a comprehensive PubMed literature search and a review of U.S. Food and Drug Administration documents. Although tendinopathy is considered a fluoroquinolone class-wide toxicity, data from in vitro studies, animal studies, patient-level analyses, and large national and international surveillance reports suggest that levofloxacin, as well as its parent compound ofloxacin, possess higher propensities to cause tendon damage relative to other fluoroquinolones. Risk with ofloxacin and levofloxacin appears to be exposure dependent, with higher doses and longer durations being most commonly associated with tendinopathy. Other well-described patient risk factors for fluoroquinolone-associated tendinopathy include older age (older than 60 yrs), receipt of concomitant corticosteroid therapy, presence of renal dysfunction, and history of solid organ transplantation. Given widespread use of levofloxacin across patient care settings, knowledge of both patient- and drug-specific characteristics associated with increased risk of tendinitis and tendon rupture can promote safe use of levofloxacin and other fluoroquinolones. ? 2016 Pharmacotherapy Publications, Inc.","CleanAbstract":"Fluoroquinolone antibiotics recently have gained increased national attention due to safety concerns. A well-described and serious adverse event associated with receipt of fluoroquinolones is tendinitis and tendon rupture. These tendon injuries can result in long-term sequelae, including chronic pain and mobility restrictions, and may warrant surgery. Due to the severity of these adverse events, a black box warning is included in the product labeling of all fluoroquinolones. In light of the mounting concerns surrounding fluoroquinolone-associated toxicities, the purpose of this clinical review is to provide a comprehensive summary of the risk of tendinopathy associated with levofloxacin, one of the most widely prescribed antibiotics in the United States, across in vitro, animal, and clinical studies, relative to other antibiotics. As part of this review, clinical presentation and onset, proposed mechanisms, patient-specific risk factors, and management of fluoroquinolone-induced tendon injury are summarized. Data were obtained from a comprehensive PubMed literature search and a review of U.S. Food and Drug Administration documents. Although tendinopathy is considered a fluoroquinolone class-wide toxicity, data from in vitro studies, animal studies, patient-level analyses, and large national and international surveillance reports suggest that levofloxacin, as well as its parent compound ofloxacin, possess higher propensities to cause tendon damage relative to other fluoroquinolones. Risk with ofloxacin and levofloxacin appears to be exposure dependent, with higher doses and longer durations being most commonly associated with tendinopathy. Other well-described patient risk factors for fluoroquinolone-associated tendinopathy include older age (older than 60 yrs), receipt of concomitant corticosteroid therapy, presence of renal dysfunction, and history of solid organ transplantation. Given widespread use of levofloxacin across patient care settings, knowledge of both patient- and drug-specific characteristics associated with increased risk of tendinitis and tendon rupture can promote safe use of levofloxacin and other fluoroquinolones.? 2016 Pharmacotherapy Publications, Inc."}]26 Another risk factor includes the long-term use of oral corticosteroids to treat systemic conditions, placing those athletes on high alert for tendinopathies or rupture.ADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Achilles tendon rupture as a result of oral steroid therapy.","id":"4580585","page":"355-358","type":"article-journal","volume":"92","issue":"6","author":[{"family":"Hersh","given":"Bryan L"},{"family":"Heath","given":"Nicholas S"}],"issued":{"date-parts":[["2002","6"]]},"container-title":"Journal of the American Podiatric Medical Association","container-title-short":"J Am Podiatr Med Assoc","journalAbbreviation":"J Am Podiatr Med Assoc","PMID":"12070236","citation-label":"4580585","Abstract":"Spontaneous Achilles tendon rupture associated with long-term oral steroid use is not uncommon, particularly in older patients who use these drugs daily to treat systemic diseases. Rupture often results in a large defect, which complicates surgical repair. The authors review Achilles tendon rupture associated with systemic and local steroid use and present a case of rupture due to chronic oral steroid use in a patient with Addison's disease.","CleanAbstract":"Spontaneous Achilles tendon rupture associated with long-term oral steroid use is not uncommon, particularly in older patients who use these drugs daily to treat systemic diseases. Rupture often results in a large defect, which complicates surgical repair. The authors review Achilles tendon rupture associated with systemic and local steroid use and present a case of rupture due to chronic oral steroid use in a patient with Addison's disease."}]25 Prevention of these injuries is just as important as successful management for both the athlete and their associated club. ResourcesADDIN F1000_CSL_BIBLIOGRAPHY1. ?What Are The Most Popular Sports In The World? - . Available at: . Accessed November 27, 2017.2. H?gglund M, Zwerver J, Ekstrand J. Epidemiology of patellar tendinopathy in elite male soccer players. Am J Sports Med 2011;39(9):1906-1911. doi:10.1177/0363546511408877.3. Nourissat G, Berenbaum F, Duprez D. Tendon injury: from biology to tendon repair. Nat Rev Rheumatol 2015;11(4):223-233. doi:10.1038/nrrheum.2015.26.4. Gross MT: Chronic tendinitis: Pathomechanics of injury, factors affecting the healing response, and treatment. J Orthop Sports Phys Ther 16:148-161,19925. Figeuroa D, Figueroa F, Calvo R. Patellar tendinopathy: diagnosis and treatment. J of the Am Acad of Orthop Surg. 2016;24:184-1926. Knobloch K. The role of tendon microcirculation in Achilles and patellar tendinopathy. J Orthop Surg Res 2008;3:18. doi:10.1186/1749-799X-3-18.7. Prevent Common Injuries in Soccer: Knee Injuries - U.S. Soccer. Available at: . Accessed November 27, 2017.8. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes?: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013;43(4):267-286. doi:10.1007/s40279-013-0019-z.9. Rosen AB, Ko J, Simpson KJ, Brown CN. Patellar tendon straps decrease pre-landing quadriceps activation in males with patellar tendinopathy. Phys Ther Sport 2017;24:13-19. doi:10.1016/j.ptsp.2016.09.007.10. Bohnsack M, Halcour A, Klages P, et al. The influence of patellar bracing on patellar and knee load-distribution and kinematics: an experimental cadaver study. Knee Surg Sports Traumatol Arthrosc 2008;16(2):135-141. doi:10.1007/s00167-007-0428-3.11. Villar R. Patellofemoral pain and the infrapatellar brace: a military view. Am J Sports Med 1985;13(5):313-31512. Childress MA, Beutler A. Management of chronic tendon injuries. Am Fam Physician 2013;87(7):486-490.13. Wasterlain AS, Braun HJ, Harris AHS, Kim H-J, Dragoo JL. The systemic effects of platelet-rich plasma injection. Am J Sports Med 2013;41(1):186-193. doi:10.1177/0363546512466383.14. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev 2014;(4):CD010071. doi:10.1002/14651858.CD010071.pub3.15. Thijs KM, Zwerver J, Backx FJG, et al. Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double-Blinded Randomized Study. Clin J Sport Med 2017;27(2):89-96. doi:10.1097/JSM.0000000000000332.16. Chaves P, Sim?es D, Pa?o M, Pinho F, Duarte JA, Ribeiro F. Cyriax’s deep friction massage application parameters: Evidence from a cross-sectional study with physiotherapists. Musculoskelet Sci Pract 2017;32:92-97. doi:10.1016/j.msksp.2017.09.005.17. Chamberlain GJ. Cyriax’s friction massage: A review. J Orthop Sports Phys Ther 1982;4(1):16-22. doi:10.2519/jospt.1982.4.1.16.18. McCreesh KM, Riley SJ, Crotty JM. Neovascularity in patellar tendinopathy and the response to eccentric training: a case report using Power Doppler ultrasound. Man Ther 2013;18(6):602-605. doi:10.1016/j.math.2012.09.001.19. Sanchez-Yamomoto D, Bush T, Bursitis and Tendinitis; Injection therapy basics; corticosteroids often relieve symptoms when other treatments do not. J Musculoskeletal Medicine. 2002; 19 (1):13-2020. Zhang J, Keenan C, Wang JH-C. The effects of dexamethasone on human patellar tendon stem cells: implications for dexamethasone treatment of tendon injury. J Orthop Res 2013;31(1):105-110. doi:10.1002/jor.22193.21. Blomgran P, Hammerman M, Aspenberg P. Systemic corticosteroids improve tendon healing when given after the early inflammatory phase. Sci Rep 2017;7(1):12468. doi:10.1038/s41598-017-12657-0.22. Lang G, Pestka JM, Maier D, Izadpanah K, Südkamp N, Ogon P. Arthroscopic patellar release for treatment of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population. BMC Musculoskelet Disord 2017;18(1):486. doi:10.1186/s12891-017-1851-3.23. Barker-Davies RM, Nicol A, McCurdie I, et al. Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population. BMC Musculoskelet Disord 2017;18(1):204. doi:10.1186/s12891-017-1564-7.24. Everhart JS, Cole D, Sojka JH, et al. Treatment options for patellar tendinopathy: a?systematic review. Arthroscopy 2017;33(4):861-872. doi:10.1016/j.arthro.2016.11.007.25. Hersh BL, Heath NS. Achilles tendon rupture as a result of oral steroid therapy. J Am Podiatr Med Assoc 2002;92(6):355-358.26. Bidell MR, Lodise TP. Fluoroquinolone-Associated Tendinopathy: Does Levofloxacin Pose the Greatest Risk? Pharmacotherapy 2016;36(6):679-693. doi:10.1002/phar.1761.27. Rosa B, Campos P, Barros A, Karmali S, Gon?alves R. Spontaneous bilateral patellar tendon rupture: case report and review of fluoroquinolone-induced tendinopathy. Clin Case Rep 2016;4(7):678-681. doi:10.1002/ccr3.592.28. Rousseau E. The anterior recurrent peroneal nerve entrapment syndrome: a patellar tendinopathy differential diagnosis case report. Man Ther 2013;18(6):611-614. doi:10.1016/j.math.2012.10.003.29. Hertling D, Kessler RM. Management of common musculoskeletal disorders: physical therapy principles and methods. Philadelphia: Lippincott Williams & Wilkins; 2006.30. K?l??aslan ?F, Kat? YA, Kose O, Erol B, Sezgin Alikanoglu A. Giant cell tumor of the patellar tendon sheath: A rare case of anterior knee pain. Cureus 2017;9(9):e1690. doi:10.7759/cureus.1690.31. Dupley L, Charalambous CP. Platelet-Rich Plasma Injections as a Treatment for Refractory Patellar Tendinosis: A Meta-Analysis of Randomised Trials. Knee Surg Relat Res 2017;29(3):165-171. doi:10.5792/ksrr.16.055.32. Kruckeberg BM, Chahla J, Ferrari MB, Sanchez G, Moatshe G, LaPrade RF. Open Patellar Tendon Tenotomy, Debridement, and Repair Technique Augmented With Platelet-Rich Plasma for Recalcitrant Patellar Tendinopathy. Arthrosc Tech 2017;6(2):e447-e453. doi:10.1016/j.eats.2016.10.025.33. Bianchi S, Martinoli C, Abdelwahab IF. Ultrasound of tendon tears. Part 1: general considerations and upper extremity. Skeletal Radiol 2005;34(9):500-512. doi:10.1007/s00256-005-0956-1.34. Rutland M, O’Connell D, Brismée J-M, Sizer P, Apte G, O’Connell J. Evidence-supported rehabilitation of patellar tendinopathy. N Am J Sports Phys Ther 2010;5(3):166-178.Appendix A – Tendon CompositionADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Tendon injury: from biology to tendon repair.","id":"4536381","page":"223-233","type":"article-journal","volume":"11","issue":"4","author":[{"family":"Nourissat","given":"Geoffroy"},{"family":"Berenbaum","given":"Francis"},{"family":"Duprez","given":"Delphine"}],"issued":{"date-parts":[["2015","4"]]},"container-title":"Nature Reviews. Rheumatology","container-title-short":"Nat Rev Rheumatol","journalAbbreviation":"Nat Rev Rheumatol","DOI":"10.1038/nrrheum.2015.26","PMID":"25734975","citation-label":"4536381","Abstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries.","CleanAbstract":"Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries."}]3center9181Appendix B – Ultrasound Image of Patellar TendinitisADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Ultrasound of tendon tears. Part 1: general considerations and upper extremity.","id":"4564930","page":"500-512","type":"article-journal","volume":"34","issue":"9","author":[{"family":"Bianchi","given":"Stefano"},{"family":"Martinoli","given":"Carlo"},{"family":"Abdelwahab","given":"Ibrahim Fikry"}],"issued":{"date-parts":[["2005","9"]]},"container-title":"Skeletal Radiology","container-title-short":"Skeletal Radiol","journalAbbreviation":"Skeletal Radiol","DOI":"10.1007/s00256-005-0956-1","PMID":"15999281","citation-label":"4564930","Abstract":"The role of ultrasound (US) in assessing musculoskeletal disorders is persistently increasing because of its low cost, readiness, noninvasiveness, and possibility of allowing a dynamic examination. Secondary to increased sport practice, tendon tears are more frequently observed in daily medical practice. They deserve early diagnosis to allow proper treatment that can limit functional impairment. The aim of this review article is twofold: to illustrate the US appearance of normal tendons and to describe the US findings of the most common tendon tears.","CleanAbstract":"The role of ultrasound (US) in assessing musculoskeletal disorders is persistently increasing because of its low cost, readiness, noninvasiveness, and possibility of allowing a dynamic examination. Secondary to increased sport practice, tendon tears are more frequently observed in daily medical practice. They deserve early diagnosis to allow proper treatment that can limit functional impairment. The aim of this review article is twofold: to illustrate the US appearance of normal tendons and to describe the US findings of the most common tendon tears."}]33center24354Appendix C – MRI Imaging of Patellar Tendinitis***Figueroacenter376359204606415949Appendix D – Evidence Based Rehabilitation ProtocolADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Evidence-supported rehabilitation of patellar tendinopathy.","id":"4492857","page":"166-178","type":"article-journal","volume":"5","issue":"3","author":[{"family":"Rutland","given":"Marsha"},{"family":"O'Connell","given":"Dennis"},{"family":"Brismée","given":"Jean-Michel"},{"family":"Sizer","given":"Phil"},{"family":"Apte","given":"Gail"},{"family":"O'Connell","given":"Janelle"}],"issued":{"date-parts":[["2010","9"]]},"container-title":"North American journal of sports physical therapy : NAJSPT","container-title-short":"N Am J Sports Phys Ther","journalAbbreviation":"N Am J Sports Phys Ther","PMID":"21589672","PMCID":"PMC2971642","citation-label":"4492857","Abstract":"Chronic tendinopathy is a common musculoskeletal disorder that frequently affects athletes who train and compete at all levels. This Clinical Commentary presents a review of the etiology, incidence, and contributory factors related specifically to patellar tendinopathy. Examination and differential diagnosis considerations are provided, and an evidence-based, staged rehabilitation program is described.","CleanAbstract":"Chronic tendinopathy is a common musculoskeletal disorder that frequently affects athletes who train and compete at all levels. This Clinical Commentary presents a review of the etiology, incidence, and contributory factors related specifically to patellar tendinopathy. Examination and differential diagnosis considerations are provided, and an evidence-based, staged rehabilitation program is described."}]34Appendix E – Eccentric Loading with Decline SquatsADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Management of chronic tendon injuries.","id":"4556251","page":"486-490","type":"article-journal","volume":"87","issue":"7","author":[{"family":"Childress","given":"Marc A"},{"family":"Beutler","given":"Anthony"}],"issued":{"date-parts":[["2013","4","1"]]},"container-title":"American Family Physician","container-title-short":"Am Fam Physician","journalAbbreviation":"Am Fam Physician","PMID":"23547590","citation-label":"4556251","Abstract":"Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.","CleanAbstract":"Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise."}]12center352134Appendix F – Open Surgical ProcedureADDIN F1000_CSL_CITATION<~#@#~>[{"title":"Spontaneous bilateral patellar tendon rupture: case report and review of fluoroquinolone-induced tendinopathy.","id":"4580589","page":"678-681","type":"article-journal","volume":"4","issue":"7","author":[{"family":"Rosa","given":"Bárbara"},{"family":"Campos","given":"Pedro"},{"family":"Barros","given":"André"},{"family":"Karmali","given":"Samir"},{"family":"Gon?alves","given":"Ricardo"}],"issued":{"date-parts":[["2016","7"]]},"container-title":"Clinical case reports","container-title-short":"Clin Case Rep","journalAbbreviation":"Clin Case Rep","DOI":"10.1002/ccr3.592","PMID":"27386128","PMCID":"PMC4929805","citation-label":"4580589","Abstract":"The present case emphasizes the importance of adhering to strict indications when prescribing fluoroquinolones. Although rare, drug-induced tendinopathy is not confined to fluoroquinolones. The patient's and physician's awareness should be increased to reduce fluoroquinolones-associated morbidity, particularly in patients with previously described risk factors.","CleanAbstract":"The present case emphasizes the importance of adhering to strict indications when prescribing fluoroquinolones. Although rare, drug-induced tendinopathy is not confined to fluoroquinolones. The patient's and physician's awareness should be increased to reduce fluoroquinolones-associated morbidity, particularly in patients with previously described risk factors."}]27center416560center601980Appendix G - Recurrent Anterior Peroneal Nerve LocationADDIN F1000_CSL_CITATION<~#@#~>[{"title":"The anterior recurrent peroneal nerve entrapment syndrome: a patellar tendinopathy differential diagnosis case report.","id":"4564923","page":"611-614","type":"article-journal","volume":"18","issue":"6","author":[{"family":"Rousseau","given":"Eric"}],"issued":{"date-parts":[["2013","12"]]},"container-title":"Manual Therapy","container-title-short":"Man Ther","journalAbbreviation":"Man Ther","DOI":"10.1016/j.math.2012.10.003","PMID":"23102854","citation-label":"4564923","Abstract":"Patellar tendinopathy which is a cause of pain in the inferior patellar region is a relatively common pathology among sports enthusiasts. This paper describes a new pain syndrome identified from clinical observations which is a differential diagnosis to patellar tendinopathy. The pattern is specific and recognizable among many individuals, and it should be considered as its own entity. The new syndrome is discussed in terms of the pain experienced, the diagnostic criteria, treatment and the rationale to explain it. As it is a differential diagnosis to patellar tendinopathy, many sports enthusiasts might benefit from this diagnosis. If identified correctly, treatment might be directed to the correct structures and with the appropriate modalities, ensuring the patients a fast return to their past occupations without pain and without unwarranted treatments. Copyright ? 2012 Elsevier Ltd. All rights reserved.","CleanAbstract":"Patellar tendinopathy which is a cause of pain in the inferior patellar region is a relatively common pathology among sports enthusiasts. This paper describes a new pain syndrome identified from clinical observations which is a differential diagnosis to patellar tendinopathy. The pattern is specific and recognizable among many individuals, and it should be considered as its own entity. The new syndrome is discussed in terms of the pain experienced, the diagnostic criteria, treatment and the rationale to explain it. As it is a differential diagnosis to patellar tendinopathy, many sports enthusiasts might benefit from this diagnosis. If identified correctly, treatment might be directed to the correct structures and with the appropriate modalities, ensuring the patients a fast return to their past occupations without pain and without unwarranted treatments.Copyright ? 2012 Elsevier Ltd. All rights reserved."}]28 ................
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