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Tendinopathy – State of Play Orthopaedic Research UK – Conference Highlights

21 Nov, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective –A BJSM blog series

By Dr Farrah Jawad

Orthopaedic Research UK arranged a one-day Tendinopathy conference in London last week – Tendinopathy: state of play. The event brought together field leaders from sports and exercise medicine, physiotherapy and surgery “to address tendinopathy from the cellular level to the sporting arena.” It aimed to share the latest research and encourage discussion among clinicians.

tendonopathy-runHere are some key findings, highlighted in the speaker presentations.

Epidemiology of Achilles Tendinopathy in UK runners and the role of soleus in tendinopathy and rehabilitation – Mr Seth O’Neill, Physiotherapy Lecturer, Department of Medical and Social Care Education, University of Leicester

  • Calf stretching may make the tendon-muscle unit more pliable
  • Healthy controls seem to have less pliable tendons (cause or effect?)
  • Soleus is very important in the running population as it contributes a large force during this activity. Its strength can reduce with age, which may be implicated in the onset of tendinopathy.
  • Plantarflexor weakness has been demonstrated in Achilles tendinopathy patients
  • Plantarflexion function and mechanistic studies may be targets for interventional studies.
  • The contralateral limb should not be used in studies as a comparison to the tendinopathic side, as it is not an adequate control.

Tendon Loading and Implications for Injury – Dr Steve Pearson, Senior Lecturer in Human and Applied Physiology, University of Salford

  • Potential mechanisms of tendinopathy may include: tendon overload or underload (these terms are difficult to define as they mean different things to different individuals), poor mechanics, insufficient recovery
  • The superficial region of the Achilles tendon tends to undergo greater strain compared to the deep region – could this result in tendon maladaptation?
  • It is possible that the increased water in tendinopathic tendons has a protective effect.
  • Time under tension may be the most important factor in rehabilitation.
  • Eccentric loading has shown benefits over other tendon loading protocols for clinical outcomes but not necessarily tendon structure.

Can new ultrasound imaging modalities influence the management of Achilles Tendinopathy? – Dr Bhavesh Kumar, Consultant in Sport and Exercise Medicine, Institute of Sport, Exercise and Health, University College London

  • The limitations of ultrasound for tendons are that: hypoechoic areas can be difficult to delineate, ultrasound may be operator dependent and distinguishing between tears and tendinosis can be difficult.
  • This is where Ultrasound Tissue Characterisation (UTC) can have a role
  • There may not be value in monitoring structural changes compared with monitoring clinical severity, as pain symptoms may resolve earlier.
  • UTC appears to detect pre-symptomatic Achilles tendon changes; there may be value in screening certain cohorts.
  • UTC may be able to detect occult tendinopathic changes within clinically normal tendons that are not visible on ultrasound imaging.
  • There is a poor correlation between pain and structural pathology.

Plantaris – Its role in the athlete – assessment and management – Mr James Calder, Consultant Orthopaedic Surgeon, Fortius Clinic, London

  • Medially located Achilles tendon pain may be due to plantaris
  • Plantaris tendon is present in around 98%1
  • The insertion of plantaris may be slightly varied among different individuals2
  • Plantaris effect may be compressive, related to neuroinflammatory mediation or result in less capacity for elongation.
  • Excising the plantaris tendon in elite athletes with non-insertional Achilles tendinopathy may have a role3
  • Plantaris should be investigated as a possible cause of Achilles pain.
  • Heavy slow resistance may help when plantaris is involved, and surgery may be considered if conservative treatment fails.

Neural Aspects of Achilles Tendinopathy – Dr Polly Baker, Consultant in Sport and Exercise Medicine and Honorary Research Fellow, University of Brighton

  • Hypoxic tissue produces vascular endothelial growth factor (VEGF) which leads to neovascularisation and stimulates axonal outgrowth.
  • There seems to be an upregulation in pain in Achilles tendinopathy
  • Ongoing pain may be due to nociception or persistent inflammation, or psychological factors
  • Nerve injury may also cause neovascularisation
  • Neural assessment gives an understanding of the aetiology, and should be an essential part of examining patients with Achilles tendinopathy.

Is Tendinopathy and Inflammatory Condition? – Professor Andy Carr, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford

  • Immune cells are players in tendon repair – inflammation is an important contributor in tendinopathy
  • Perhaps clinicians should avoid using emotive terms such as “degeneration” to describe tendon changes
  • Tendon cells do not turn over; the tendon we make in adolescence stays with us for life.
  • Tendon cells may behave in a semi-inflammatory fashion
  • Neurosensitisation may be an important factor in nociception
  • Central sensitisation is implicated by both upregulation of glutamate and increased sensitisation to glutamate.
  • Steroid injections switch off “good” and “bad” inflammation.
  • In the future, there may be anti-inflammatory medications which may be available for tendinopathy
  • Platelet-rich plasma (PRP) may be bad for tissues – apoptosis has been observed in histological tendon samples.

How do our models of tendinopathy help us treat patients? – Dr Jonathan Rees, Consultant in Rheumatology and Sports Medicine, Honorary Senior Lecturer, Addenbrooke’s Hospital

  • Cook and Purdam’s continuity model4,5 and Fu’s failed healing response model6 are easy to understand
  • Modulation of the inflammatory response may be a potential option
  • Neovascularisation is described in osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, diabetic neuropathy, malignancy, ischaemia. To say that tendon degeneration alone is causing neovascularisation without an inflammatory mechanism does not make sense
  • Macrophages, T and B lymphocytes are seen in chronic Achilles tendinopathy using monoclonal antibodies to CD68, CD3 and CD20 – inflammation is implicated7,8.
  • Current models may not have the complete story.

Tendinopathy: physiotherapy and rehabilitation – Dr Bruce Paton, Clinical Specialist Physiotherapist, Lower Limb Extended Scope Practitioner, University College Hospital

Optimum rehabilitation goals are to restore:

  • the load function of the tendon
  • adequate tendon stiffness
  • adequate stretch-shortening behaviour
  • load dissipation
  • an effective kinetic chain
  • a pain-free state.

Loading programmes:

  • Concentric – some evidence that this may be effective9
  • Eccentric – best treatment available.10,11 Clears majority of midsubstance but not all
  • Isometrics – give some short-term pain relief and cortical inhibition, and may be good for reactive/compressive tendinopathy12
  • Heavy slow resistance – seems to be effective in patellar tendinopathy,13 now also evidence in Achilles tendinopathy.

Other rehabilitation considerations:

  • Possibly the kinetic chain
  • Neurodynamics have a role
  • Address psychosocial factors such as fear avoidance
  • Mixed evidence for pushing through pain
  • Address metabolic factors such as obesity.

What evidence do we need to translate into practice to better manage tendinopathy – and how? – Dr Dylan Morrissey, Consultant Physiotherapist and Clinical Reader, National Institute for Health Research

  • Need to consider evidence based on physical activity vs exercise vs sport – there may be differing evidence for the elite level athletes vs weekend warriors vs the sedentary.
  • A case study illustrating the importance of thinking around the problem and expecting the unexpected.


The Orthopaedic Research UK’s Tendinopathy conference was informative and thought-provoking.   Tendinopathy is a frequently encountered clinical problem which can prove challenging to manage.  Hopefully the conference will become a regular event in the sport and exercise medicine calendar.


  1. Saxena A, Bareither D. Magnetic resonance and cadaveric findings of the incidence of plantaris tendon.   Foot Ankle Int. 2000 Jul;21(7):570-2.
  2. van Sterkenburg MN1, Kerkhoffs GM, Kleipool RP, Niek van Dijk C. The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study.  J Anat. 2011 Mar;218(3):336-41.
  3. James D F Calder Richard Freeman Noel Pollock.  Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes.  Br J Sports Med 2015;49:1532-1534.
  4. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.  Br J Sports Med. 2009 Jun;43(6):409-16.
  5. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?  Br J Sports Med. 2016 Oct;50(19):1187-91.
  6. Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM. Deciphering the pathogenesis of tendinopathy: a three-stages process.  Sports Med Arthrosc Rehabil Ther Technol. 2010 Dec 13;2:30.
  7. Rees JD, Stride M, Scott A. Tendons–time to revisit inflammation.  Br J Sports Med. 2014 Nov;48(21):1553-7.
  8. Rees JD. The role of inflammatory cells in tendinopathy: is the picture getting any clearer?  Br J Sports Med. 2016 Feb;50(4):201-2.
  9. Wetke E, Johannsen F, Langberg H. Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid injections in a clinical setting.  Scand J Med Sci Sports. 2015 Aug;25(4):e392-9.
  10. Frohm A, Saartok T, Halvorsen K, Renström P. Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols.  Br J Sports Med. 2007 Jul;41(7):e7. Epub 2007 Feb 8.
  11. Habets B, van Cingel RE. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols.  Scand J Med Sci Sports. 2015 Feb;25(1):3-15.
  12. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.  Br J Sports Med. 2015 Oct;49(19):1277-83.
  13. Kongsgaard M1, Qvortrup K, Larsen J, Aagaard P, Doessing S, Hansen P, Kjaer M, Magnusson SP. Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training.  Am J Sports Med. 2010 Apr;38(4):749-56.

Dr Farrah Jawad is a registrar in Sport and Exercise Medicine in London.  She has previously worked in the Tendinopathy clinic at the Institute of Sport, Exercise and Health in London and currently works at Homerton University Hospital.  She has recently completed her MSc in Performing Arts Medicine at UCL, for which she has been nominated for the Dean’s Prize.  Farrah co-ordinates the BJSM Trainee Perspective blog.

Physiotherapy and treating golfers: practical tips and experience based principles

12 Aug, 16 | by BJSM

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport

By Nigel Tilley @nigel_tilley

Physiotherapist on European Tour/ETPI; Team GB Golf Physio Rio 2016; European Ryder cup team physio 2016

Identifying the cause of an injury is often key to the effective assessment and management of a condition/problem.  All too often practitioners jump to the ‘hands-on’ objective assessment & identification of structural issues.

Take time to stand back and speak to the player in detail to get an insight into their history and what has led them to arriving in front of you.  Always remember though that first and foremost you are treating the person not the injury.  As a general rule most problems we see on tour can relate to a few simple issues and is likely to be similar with most club/amateur golfers you will see in your day to day practice.  Think about these things and use these questions to help you identify the problem:

kettle ball golf1) VOLUME – Have they hit more balls recently, been practicing more, playing more?  Have they been practicing a certain shot? Have they had a change in their routine? Have they started a new exercise programme or increased their workload suddenly? Have they been hitting off hard mats or suddenly gone from doing nothing for a month to hitting 300 balls a day for a week?

2) TECHNIQUE –  Have they changed anything in their technique recently? Grip, Swing biomechanics, equipment, footwear?  Have they been pulling a cart or carrying a bag when they may normally have used a buggy.

3) ACUTE TRAUMA – have they hit a shot from thick rough, caught a tree root, forced a shot too hard, lifted something (heavy bags and equipment in/out of house and car)

4) A combination of any or all of the above.  Such as a player who has recently changed shafts in their woods and made some swing changes due to poor form. But the poor form and desire to practice and ‘imbed the new swing’ changes means instead of hitting 50-100 practice balls a day they are now hitting 300 a day (a 300% increase) on tissues that are potentially not used to tolerating those loads in that intensity.

Of course there are many other potential triggers and causes of injury in golfers, but more often than not the presenting player will usually identify a specific trigger to the start of their symptoms.  The solution often lies with the cause.  Whilst we may direct acute treatment plans to the structures we believe are involved, the key to success is identifying the cause.  More often than not education is vital to enable the player to both resolve their problem and prevent its return.  We work hard on encouraging players to use practice and training logs (practice time, balls hit, number of swings, effort used, practice putting and chipping times etc) to ensure they don’t have volume and training spikes (and troughs!!). Educating players on periods of high vulnerability and injury risk, such as when they are making technique or equipment changes and to take care that they are not linked with large spikes in practice volume is hugely important.

There are 3 key areas you can get patients to work on to reduce injury potential and benefit their game.

Develop/maintain mobility in 3 key areas

The Thoracic spine

Golf requires a lot of rotation.  The thoracic spine provides a lot of this rotation.  If it is stiff the rotation (or rotational forces) end up going elsewhere. Often this means the Lumbar spine (which is not designed well to do this) and can lead to injury or technique faults.

The hips

Having good range of internal and external rotation in the hips is important to facilitate a full and efficient swing through correct loading and weight transference through the feet and up the chain during the golf swing.  Limitations in hip rotation have been shown to be linked with increased low back pain in golfers.

The shoulders

Golf is an asymmetrical sport requiring different movements and actions from the lead and non-lead upper and lower limbs.  A right handed golfer will require greater range of external rotation of the right shoulder than the left and subsequently more adduction of the left than the right during the swing.  Having a good range of movement in both shoulders helps both technique and reducing excess forces to other areas of the body during the swing.

Develop stability and control through range

Flexibility is obviously important in golfers but it is equally as important to be able to safely control that movement through the range and as part of the kinetic chain.  Having a stable base from which to create and transmit forces from the ground up through the kinetic chain to the hands is vital for efficient and maximal power creation & use.  Being able to control and brake the forces involved in the golf swing is as important as being able to create them.

Understand a players physical capabilities and limitations

It is important for both you and the patient to have an understanding of the golf swing and what is required of the body to perform the golf swing.  A player can either build a golf swing around what their body can do OR can look to change their physical limitations or improve their capabilities to fit the swing they want.  Developing a good relationship with a PGA teaching professional will help you both to understand & identify swing faults & link this to your physical assessment & subsequently with your treatment & management.

The underlying aim of what we do with players in rehabilitation and conditioning work, is ‘to make them strong, make them robust and make them stable’.  Evidence really is pointing towards the use of strength and conditioning programmes and making people strong as the key tool in both injury prevention & performance enhancement.  A large amount of the injuries we see in golf are tendinopathies.  The immediate requirement of a player presenting to you the day before he plays an important game with an acute tendinopathy is to make sure they play if that’s what they want.  Our acute management of that issue may include strappings, tapings, soft tissue techniques etc etc.  But fundamental to the long term management of this is identifying the cause, ensuring the right education is given to the player and most important of all that an appropriate and structured loading programme is used for the tendon/tissues as the foundation of their management plan.

resistence training golf

Players need to develop an underlying stable athletic foundation and to develop tissue resilience that can tolerate the forces being placed upon them.  The use of strength and conditioning as part of professional golfers training is well and truly engrained and is becoming more widely used and accepted amongst amateur golfers.  The golf swing requires a large mix of explosive power, strength, stability, flexibility, and athleticism.  The modern day professional golfer really is now seen as an athlete. Their training reflects this.  We should be encouraging all golfers we see from beginners to elite to develop that mindset and look to improve their general athleticism.   As physiotherapists we are ideally placed to deal with the complex acute and chronic injuries, rehabilitation and strength and conditioning & performance needs of golfers.


CABRI, J., SOUSA, J.P., KOTS,M. and BARREIROS, J. (2009) Golf-related injuries: a systematic review. European Journal of Sports Science, 9(6), 353-366

EVANS, K., REFSHAUGE, K.M., ADAMS, R. and ALIPRANDI, L. (2005). Predictors of low back pain in young elite golfers: a preliminary study. Physical Therapy in Sport, 6, 122-130

FRADKIN, A.J., SHERMAN, C.A. AND FINCH, C.F. (2004). Improving golf performance with a warm up conditioning programme. British Journal of Sports Medicine, 38, 762-765

GLUCK, G.S., BENDO, J.A. and SPIVAK, J.M. (2008). The lumbar spine and low back pain in golf: a literature review of swing biomechanics and injury prevention. The Spine Journal, 8, 778-788

GOSHEGER, G., LIEM, D. and LUDWIG, K. (2003). Injuries and overuse syndromes in golf. American Journal of Sports Medicine, 31(3), 438-443

HOSEA, T.M., GATT, C.J. and CALLI N.A. (1990). Biomechanical analysis of the golfer’s back. In COCHRAN, A.J. (Editor) Science and Golf I: Proceedings of the World Scientific Congress of Golf. London: E&FN Spon, 43-48

HOSEA, T.M. and GATT, C.J. (1996). Back pain in golf. Clinical Sports Medicine, 15, 37-53

LAURENSEN, J.B., BERTELSEN, D.M. AND ANDERSON, L.B. (2014). The effectiveness of exercise interventions to prevent sports injrueis: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48 (11), 871-7

LINDSAY, D.M, and HORTON, J.F. (2002). Comparison of spine motion in elite golfers with and without low back pain. Journal of Sports Sciences, 20, 599-605

LINDSAY, D.M, and HORTON, J.F. (2006). Trunk rotation strength and endurance in healthy normals and elite male golfers with and without low back pain. North American Journal of Sports Physical Therapy, 1(2), 80-89

MCHARDY, A., POLLARD, H. and LUO, K. (2006). Golf injuries. Sports Medicine, 36(2), 171-187

METZ, J.P. (1999). Managing golf injuries: technique and equipment changes to aid treatment. Physician and Sports Medicine, 27, 41-58

Myotendinous injuries call for proposals – NBA and GE Healthcare Orthopedics and Sports Medicine Collaboration

11 Aug, 16 | by BJSM

NBA call for proposals

In June 2015, the NBA and GE Healthcare launched the NBA & GE Healthcare Orthopedics and Sports Medicine Collaboration, a strategic partnership aimed at engaging leading clinical researchers who have demonstrated excellence in orthopedics, sports medicine, radiology, and related disciplines. The NBA, GE Healthcare, and additional partners will provide funding for research that supports the mission of the collaboration.

The mission is to address high-priority clinical questions regarding the prevention, diagnosis, and treatment of acute and overuse injuries among NBA athletes, and to apply such findings to basketball players and the general population.

A series of Calls for Proposals (CFP) will be consecutively released by the NBA & GE Healthcare Orthopedics and Sports Medicine Collaboration, with each CFP strategically focused on a class of acute or overuse injuries affecting NBA athletes. The first CFP was released in 2015 and focused on the natural history, diagnosis, treatment, and prevention of tendinopathy. To learn more about the Tendinopathy CFP and awardees, and to register for notifications of upcoming CFP releases, please visit the NBA & GEHC collaboration CFP website.


Myotendinous injuries are common issues in competitive athletes and can impair performance, limit playing time, and disrupt a career. Such injuries are often referred to as “muscle strains, tears, ruptures, or pulls.” Prevention programs for some specific myotendinous injuries have been described for varying levels of play; however, there is little evidence supporting many of these strategies. When an acute muscle injury occurs, the best techniques for clinical assessment, choice and timing of imaging modalities, treatment, and return-to-play strategies are unclear.

Questions to be addressed in this CFP:

  • How can the impact of acute myotendinous injuries on athletic participation be reduced?
  • What is the efficacy of prevention programs?
  • What specific prevention, assessment, and treatment techniques are needed for different injury sites (e.g. hamstring vs. gastrocnemius/soleus)?
  • What is the correlation between imaging and clinical assessment?
  • Which interventions are effective for treatment?
  • What are the risk factors associated with an initial injury?
  • What are the risk factors for re-injury?

To read about specific areas of research interest please go to the NBA & GEHC collaboration website.


This CFP will award a total of $1,500,000 over a three-year period to support preclinical and clinical research addressing important unanswered questions regarding myotendinous injury diagnosis, treatment, and prevention in elite basketball athletes. The maximum amount for an individual grant is $300,000 including direct and indirect costs for the entire project period. More focused, impactful projects requiring less support are encouraged.


Completed applications and proposals must be received no later than 5:00 pm EDT on September 8, 2016.

Scientific peer review and programmatic review is intended to be complete in November of 2016.

This CFP with complete instructions and forms for applying are available at the NBA & GEHC collaboration Myotendinous Injury CFP website (

Struggling to provide evidence-based care to your patients? A knowledge broker can help: Case study of the Achilles Tendinopathy Toolkit

24 Apr, 16 | by BJSM

By Alison Hoens

It isn’t easy. You want to provide your patients the most effective treatment but you are faced with a mountain of information from an insurmountable number of sources through endless links in your Google search. It isn’t just the volume of information; interpretation is thwarted by differences in methodologies and confusing statistics.  You are not alone in feeling overwhelmed. Increasingly healthcare is recognizing the need for expertise to help with ‘Knowledge Translation’ (KT) and calling upon Knowledge Brokers (KB) to navigate clinicians through the ‘forest of dense content’ to reach the destination of ‘practice bliss’.

KB communicationKnowledge translation has been described with > 125 terms ! But no matter what term is used, the message is the same – knowledge is not enough. Simply producing and disseminating knowledge does not lead to a change in practice. Shockingly, research suggests that it takes 17 years to get 14% of research findings adopted into practice1.  Further, typical strategies to support evidence-informed practice (EIP), such as providing educational materials or didactic lectures, elicit a meager average 10% change in practice2.

A relatively new KT strategy to support EIP is the use of a knowledge broker. A knowledge broker is an intermediary who bridges the gap between evidence and practice and functions as a catalyst to link researchers, clinicians, and decision makers to facilitate co-creation or synthesis, translation, dissemination, and implementation of evidence to change practice3. Essentially, the knowledge broker’s main roles are to act as an: 1) information manager 2) linking agent 3) capacity builder 4) facilitator and 5) evaluator4 (those interested in learning more about these roles can check out a video abstract for our recent manuscript HERE). Indeed, Meyer et al (2010) states that knowledge brokers do more than transfer knowledge, they transform knowledge such that Brokered knowledge is knowledge made more robust, more accountable, more usable; knowledge that ‘serves locally’ …” (pg. 123)5. Basically, a knowledge broker helps, with experts from research and clinical realms, to find, interpret and reshape knowledge so that it can be used more readily in the hands of a clinician.

Practical experience – A KB’s secrets!

I serve as the Physical Therapy Knowledge Broker (PT KB) situated within the Department of Physical Therapy at the University of British Columbia (UBC). Reflecting the breadth of stakeholders, the position is jointly funded by the University, the  provincial professional body (Physiotherapy Association of British Columbia) and the research institutes of two large health regions ( Providence Health Care and Vancouver Coastal Health).

This 0.5 FTE position has enabled partnerships between more than 335 researchers, clinicians and decision makers to enable approximately 2.5 million dollars of funding for 19 rehabilitation relevant research projects and the development of 23 resources and tools to support evidence-informed practice. These resources have been accessed over 164,000 times by physiotherapists throughout the world and have been shared through 24 webinars and more than 50 presentations locally, nationally and internationally. All resources are freely accessible HERE.

Turning Achilles research into changes in clinical management

An example of the KB role in successfully transforming knowledge to “make it more useable” is the Achilles Tendinopathy Toolkit ( Co-created with research and clinical experts, and recently updated to include new literature, the toolkit includes: (1) a summary of the evidence, clinical implications and ‘take home messages’ for nonpharmacologic interventions such as manual therapy, exercise, low level laser therapy, orthotics, shock wave, ultrasound, taping etc;  (2) an algorithm to guide the sequence of interventions; (3) and appendices including (a) exercise programmes (b) low level laser dosage calculation (c) tabulated details for each article reviewed and (d) a review of common medical interventions. It has been accessed over 85,000 times by therapists throughout the world. Moreover, a recent cross-sectional study demonstrated favourable findings regarding the impact of this KT strategy on the knowledge and attitudes of British Columbia physical therapists6.

The PT KB position provides an opportunity to enable researchers, clinicians, patients, and decision-makers to unite in efforts to support clinicians in the feasible provision of individualized evidence-informed care to our patients.

Your turn

So, what can you do today to support your EIP? Try out some of our free resources at and advocate for developing KB positions in your healthcare communities.


  1. Balas E, Boren S. Managing Clinical Knowledge for Health Care Improvement. In: van Bemmel JH, McCray AT, eds. Yearbook of Medical Informatics. Stuttgart: Schattauer Verlagsgesellschaft mbH, 2000:65–70.
  2. Straus SE, Tetroe JM, Graham ID, editors. Knowledge translation in health care: moving from evidence to practice. Chichester (UK): Wiley Blackwell; 2009.
  3. Hoens, A. and Li, L.C. 2014, The knowledge broker’s “Fit” in the world of knowledge translation, Physiotherapy Canada: 66:3:223-227.
  4. Glegg S & Hoens A. Role domains of knowledge brokering: A model for the healthcare setting. Journal of Neurologic Physiotherapy. Journal of Neurologic Physical Therapy. 2016;40: 115–123). org/10.1097/NPT.0000000000000122. Video abstract:
  5. Meyer M. The rise of the knowledge broker. Science Communication 32, 1 (2010) 118-127. DOI : 10.1177/1075547009359797.
  6. Ezzat AM, Schneeberg A, Huisman ES, White LD, Kennedy C, Levesque LA, Scott A, Hoens AM. Is it effective? A cross-sectional evaluation of a toolkit to support evidence-informed management of Achilles Tendinopathy. Disability and Rehabilitation. DOI10.3109/09638288.2016.1160447


Alison Hoens holds two positions:  (1) Physical Therapy Knowledge Broker within the Department of Physical Therapy, Faculty of Medicine and (2) Research, Education and Practice Coordinator for Physiotherapy at Providence Health Care. At Providence Health Care she is responsible for research, education and evidence-based practice support for over 120 Physiotherapists and Rehabilitation Assistants across the spectrum of acute, rehabilitation and residential care settings. In her role as Knowledge Broker she facilitates partnerships between researchers, clinicians and decision makers for rehabilitation relevant research and the development of resources and tools to support evidence-informed practice.


Bad for your heart = bad for your tendons, potential for early detection of high cholesterol?

11 Dec, 15 | by BJSM

musculoskeletal running manCongrats to BJSM co-authors Ben Tilley, Jill Cook (@ProfJillCook), Sean Docking and Jamie Gaida whose article “Is higher serum cholesterol associated with altered tendon structure or tendon pain? A systematic review” was featured by mainstream media.

The review included 17 tendon studies with data from more than 2000 people. As profiled in the Globe and Mail, individuals with abnormal blood cholesterol levels were more likely to have tendon pain or altered tendon structure.

“The most interesting finding was that the pattern of cholesterol changes seen with tendinopathy was similar to that which increases cardiovascular disease risk. It seems that what is bad for your heart is bad for your tendons.” …The researchers theorize that cholesterol deposits lead to inflammation of the tendons, and this leads to structural changes that make the area vulnerable to injury and pain. …“However, the more important benefit of identifying a link between cholesterol and tendinopathy is the potential for early detection of high cholesterol, and management of cardiovascular disease risk, in those presenting with tendon pain.”

Click here to read the original Globe and Mail article

Click here to read the original BJSM article

BJSM Virtual Conference – Tendons

20 Jun, 15 | by BJSM

A monthly round-up of podcasts and articles 

By Steffan Griffin (@lifestylemedic)

If you were hoping for further additions to the cluster series (previously on hamstring and shoulder injuries), fear not, here it is. We have simply changed the (now-monthly) series’ name from “cluster” to “virtual conference” to better reflect its provision of sleek and sexy resources.

Whether you fancy becoming a 24-hour expert or need to stay awake on your commute to & from work, enjoy these great contributors to BJSM podcasts and publications.

Tennis Player Preparing to Serve --- Image by © Royalty-Free/Corbis

Tennis Player preparing to serve

This month’s focus is on the key academic and clinical entity of tendons, featuring some of the world’s most respected authorities on the matter.

1. “Mechanotherapy” and why it’s important for clinicians, with Karim Khan

A podcast centred on the “the most important fundamental concept that underpins rehabilitation exercises” – containing nuggets of information including why ‘rest doesn’t work’ and the evidence-base underpinning the theory. For best results, combine listening to reading the paper

2. The continuum model of tendinopathy, with Jill Cook

Is tendon pathology a continuum? Prof Jill Cook explains and answers questions relating to this famous pathology model to explain the clinical presentation of load-induced tendinopathy (Accompanying paper can be found at

3.Tendons: Where does pain fit in the continuum model? with Chris Littlewood

So now you’re familiar/brushed up on the tendinopathy continuum, do you have any questions about the connection between pain and pathology in tendons? Chris Littlewood, who has expertise as a clinician and researcher in the rotator cuff, asks questions of Craig Purdam and Ebonie Rio in this fantastic podcast.

4. Time to revisit inflammation in tendons, with Jon Rees

So inflammation is completely out of the window, right? Although widely accepted that chronic tendinopathy is caused by a degenerative process devoid of inflammation, the evidence for non-inflammatory degenerative processes alone as the cause of tendinopathy is surprisingly weak. In this podcast, Jon Rees tells Jill Cook why the role of inflammation offers potential opportunities in treating chronic tendinopathies and should be explored further.

5. Managing tendinopathies, with Jill Cook and Hakan Alfredson

Cook and Alfredson focus on the management aspect of tendinopathy, with practical pointers and a tip to consider the time-course of tendon injury when making treatment decisions. It fits nicely with Hakan Alfredson’s ‘treating tendinopathy’ podcast; here they discuss the clinical challenge of whether to opt for exercise treatment, new ‘biological therapies’ like platelet-rich plasma (PRP), or surgery.

 6. The pathogenesis of tendinopathy and tendon healing, with Michael Kjaer

This great podcast discusses seven models of tendinopathy, and the important difference between mid-tendon and insertional tendinopathy. We also hear about the healing capacity of tendons, the (absence of a) link between tendinopathy and tendon rupture, and various interventions that are used in an attempt to promote tendon healing – a real one-stop shop for those short on time!

7. The brain and mind in chronic pain, with Lorimer Moseley

A man needing no introduction, this podcast discusses the important difference between pain and nociception, with thoughts on how pain science can help clinicians working in sports medicine. You’ll hear him share the best, and worst, ways to explain pain to patients, with thoughtful reflections along with a big dob of humour and humility.

So there we go, the first official virtual conference, all for free! As always, let us know your thoughts via our various social media channels – Twitter (@BJSM_BMJ), Facebook and Google+. Feedback is appreciated and valued!

International Scientific Tendinopathy Symposium 2014 winner of clinically relevant research by a young investigator: Congrats to Ebonie Rio

13 Nov, 14 | by BJSM

runners-kneeThe BJSM £1500 prize for best clinically relevant research by a young investigator was awarded at the International Scientific Tendon Symposium. The winner was Ebonie Rio for her paper: Exercise reduces pain immediately and affects cortical inhibition in patellar tendinopathy (co-authors Dawson Kidgell and Jill Cook).

The judging panel consisted of Prof Malcolm Collins (scientist, South Africa), Dr. Guy Simoneau (physiotherapist, Canada), Dr Hazel Screen (scientist, Britain), and Dr Jon Rees (rheumatologist, Britain). Fourteen potential papers were ranked on abstract before the conference and the top 4 were judged on their research presentation. 

We caught up with Ebonie Rio to learn more about her, and the award’s impact:

Can you share your academic background with the BJSM blog community?

I have a Bachelor’s of Applied Science in Human Movement, a Bachelors of Physiotherapy (hons), a Master’s of Sports Physiotherapy, and am currently a PhD candidate, in Monash University’s Monash Tendon Research group (Australia), in the Department of Physiotherapy. My Clinical experience involves time at the Australian Institute of Sport, Physio for Disney’s The Lion King (Melbourne and Shanghai), Australian Ballet Company, Victorian Institute of Sport, 2006 Commonwealth Games, 2010 Winter Olympics, and the  2012 Paralympics.

What was your favourite session of ISTS 2014?

I really enjoyed listening to Jo Gibson and her very clinically relevant presentation on management and evidence relating to central sensitisation for upper limb disorders.

Why are you excited to have won the award?

I am so grateful to BJSM and the committee for the award. It is such an honour as the standard of research presented was fantastic and there are so many wonderful young researchers emerging.  I am excited as it will allow us to forge ahead with one of the many project ideas on our whiteboard!

Thanks Ebonie, we look forward to your future publications!

Customised foot orthoses for Achilles tendinopathy RCT: responding to the critics

3 Nov, 14 | by BJSM

By Dr Shannon E Munteanu, Lisa A Scott, Daniel R Bonanno, Dr Karl B Landorf, Dr Tania Pizzari, Prof Jill Cook, Prof Hylton B Menz
-achillesOur group’s randomised controlled trial (RCT) that evaluated the effectiveness of customised foot orthoses for Achilles tendinopathy was recently published in the British Journal of Sports Medicine. The abstract can be viewed here, and the full text of the study protocol can be viewed here.
As with any RCT that provides unfavourable results for a commonly-used intervention, our trial has attracted some degree of criticism on blogs and social media. Rather than entering into ongoing debates across multiple platforms, we have instead summarised our responses to these criticisms below.
Criticism #1: The sham orthoses were not ‘biomechanically inert’
In order to measure the treatment-specific effectiveness of an intervention, controlled trials often use placebo groups to compare the experimental intervention to – the best example being the use of inert pills in pharmaceutical trials. However, this is not possible when evaluating interventions which have a physical or mechanical effect (i.e. those commonly used for musculoskeletal disorders). In these trials, the control group is provided with a ‘sham’ intervention, which can be defined as “a treatment or procedure that is performed as a control and that is similar to but omits a key therapeutic element of the treatment or procedure under investigation” (note the added emphasis). Put simply, a sham intervention is not a placebo.
Our trial published in the British Journal of Sports Medicine compared the effectiveness of customised orthoses to sham orthoses for people with Achilles tendinopathy undergoing an eccentric exercise program. The sham orthosis was a contoured, vacuum-moulded device constructed from 4.0 mm thick ethylene vinyl acetate (EVA) with a density of 90 kg/m3 (i.e. very soft) and had an identical covering fabric to the customised orthosis. The sham device was selected based on a previous study which showed that it produced only small effects on plantar pressure (10% reduction in peak pressure under the heel) while still being considered a credible intervention by participants.
After this study was published, the following comment was made in relation to the selection of control interventions in orthotic studies:
“…the best you can do is to minimise the influence that the control orthoses have upon the variable of interest” (link).
We agree. However, since the publication of our RCT, some have argued that the sham device was not actually a sham because it was not biomechanically ‘inert’, for example:
“There is no such thing as a “sham” foot orthosis, and the sooner this is recognised the better” (link)
“Not sham orthoses at all. This study actually compared two different types of orthoses” (link)
“Does this mean they are completely “inert” and will not change any kinetic parameters at the foot-orthosis interface?” (link)
These comments represent a misunderstanding of what a sham intervention is. It is obvious that no device placed in the shoe can be truly biomechanically inert. However, at no stage have we claimed that the sham device used in our trial was inert – we have simply argued (and have evidence to show) that they have as minimal effect as possible while still being considered a credible intervention. Credibility of the sham is critically important when evaluating a real intervention against a sham intervention, otherwise resentful demoralisation comes into effect in the sham group, which might bias the findings.
Interestingly, a previous RCT that evaluated the effectiveness of customised orthoses for pes cavus also used a sham device for the control group (an insole made from 3-mm latex foam). This device had similar effects on plantar pressure to our sham device (reductions in pressure-time integrals of 9%, 11% and 6% in the rearfoot, forefoot and midfoot, respectively). However, the response to this trial could not have been more different, and no criticism has been made of this sham device. The fact that this study found customised orthoses were more effective than sham devices may explain the different responses to these two trials.
If there are any lingering doubts that the sham orthoses had minimal mechanical effects and were markedly different to the customised orthoses, we provide the following movie for your perusal:
<iframe width=”420″ height=”315″ src=”//” frameborder=”0″ allowfullscreen></iframe>
Criticism #2: The customised orthoses were not appropriately prescribed
Researchers conducting trials of customised orthoses are faced with the unavoidable dilemma of how to individualise or ‘customise’ the orthoses. This is a long-standing problem and arises because there are currently no evidence-based or consensus guidelines in relation to the prescription of foot orthoses – an issue that is explored in this commentary paper. An ambitious attempt to try and achieve this commenced in July 2009 but to date has produced no outcome (and has been described as an ‘epic fail’ by one of its proponents).
In our trial, the customised orthoses were individually prescribed based on an assessment of participants’ Foot Posture Index and bodyweight. At the time the study protocol was published, there was some concern regarding the lack of a heel lift (this is discussed later), but our approach attracted the following positive comments:     
“I am excited to see Shannon, Karl, Hylton and company trying to tackle this important subject since Achilles tendinitis is a very common injury in my sports medicine practice and it would be nice to see how the individuals all respond to the different protocols” (link)
“…they have made the effort to make the devices more custom than any other study that I have seen…If they have a pronated FPI, they get the medial heel skive, if neutral it is a basic shell, and if a supinated FPI they get a device to control supination as described in Josh Burns paper…the devices are made at a laboratory from slipper casts, so should be close to what many Podiatrists would prescribe” (link)
However, on the publication of the RCT results, the mood changed considerably:
 “Is giving everyone the same prescription even a true definition of a custom device? Not for me…” (link)
“It’s really hard for me to get excited about custom foot orthosis research unless the custom foot orthoses used in these studies are the types of foot orthoses used by those who are most experienced and expert at foot orthosis therapy” (link)
To reiterate – there are no evidence-based or expert consensus guidelines in relation to the prescription of foot orthoses. Until such guidelines are produced, there is no basis upon which to argue that our prescription approach was inappropriate.
Criticism #3: Why no heel lift?
Heel lifts are commonly recommended as a treatment for Achilles tendinopathy, based on the assumption that elevating the heel decreases Achilles tendon loading. In designing the trial, we considered adding a heel lift to the orthoses but eventually decided against this. This was criticised when the study protocol was published and again when the RCT results were published:
“I would have thought that if one was to design an experiment on custom foot orthoses for Achilles tendinopathy that one would have used a custom foot orthosis with a heel lift added to the orthosis since this is the type of custom foot orthosis that nearly every good sports podiatrist that I know of uses in their orthoses for patients with Achilles tendinopathy” (link)
“Of course there should have been heel lifts on the foot orthoses” (link)
“Clinically speaking I think it’s reasonable to say that most practitioners would incorporate a heel raise” (link)
So why no heel lifts?
Put simply, the evidence to support the use of heel lifts in Achilles tendinopathy is extremely limited. First, our systematic review revealed no trials of heel lifts as a treatment for AT. Second, the biomechanical evidence that heel elevation decreases Achilles tendon loads is not at all convincing. At the time the study was designed, three studies had examined the biomechanical effects of heel elevation on Achilles tendon loading:
         Reinschmidt and Nigg (1995) found no difference in plantarflexion moments when subjects ran in shoes which differed in heel height (2.1-3.3 cm), and concluded that “the results of this study did not support the speculation that changes in heel height would reduce the plantarflexion moments of the ankle joint, and thus, the Achilles tendon forces…the treatment or prevention of Achilles tendonitis with a raising of the heel is based on anecdotal evidence and not on research”
         Dixon and Kerwin (1998) assessed the effects of 7.5mm and 15mm heel lifts on Achilles tendon force during running, and found that Achilles tendon forces increased with greater heel elevation. They concluded that “the finding that increased heel lift may increase maximum Achilles tendon force suggests that caution is advised in the routine use of this intervention”
         Farris et al (2008) assessed the effects of 12 and 18mm heel lifts compared to a no-lift control condition in 6 female runners, and found no difference in peak Achilles tendon forces or maximum Achilles tendon strain between conditions, concluding that “Heel lifts alter ankle mechanics during running. However, this appears not to affect peak AT force or strain”
In the time between the commencement of our trial and its publication, one study has been published that suggested that heel lifts may have beneficial effects on Achilles tendon loading:
         Farris et al (2012) assessed the effects of 12 and 18mm heel lifts on Achilles tendon strain in ten female runners, and found that, compared to the control condition, strain reduced (by 1.9%) with the 18mm lift but did not change with the 12mm lift.
Would our prescription protocol have changed if this study had been published prior to the commencement of our trial? No – on balance, the evidence is not overly supportive of the use of heel lifts in Achilles tendinopathy. Interestingly, a recent biomechanical study found that contoured orthoses without a heel lift reduced Achilles tendon load in 12 runners, so it cannot be argued that orthoses must have a heel lift in order to be effective in the treatment of Achilles tendinopathy. Furthermore, even if there was good evidence to suggest that heel lifts reduce Achilles tendon loading, the question then arises: why not simply use a heel lift rather than incorporating a heel lift into a customised orthosis?
In summary, our trial is the most rigorously designed study so far undertaken to assess the effectiveness of customised orthoses in the treatment of Achilles tendinopathy in individuals undergoing an eccentric exercise program. We stand by our conclusion that foot orthoses, prescribed according to the protocol in this study, are no more effective than sham foot orthoses for this condition. We welcome further high-quality RCTs evaluating foot orthoses by other investigators, particularly if they believe that they can prescribe more effective foot orthoses.
Originally posted:


#Tendons2014 – Day 1 BJSM exclusive. Guest blog @DrPaulDijkstra. 5 highlights…

6 Sep, 14 | by Karim Khan

CelloThe 3rd International Scientific Tendinopathy Symposium: on donuts and female tenocytes… bridging science & practice.

The Jacqueline du Pré Music Building at St. Hilda’s College in Oxford is a very fitting venue for the 3rd International Scientific Tendinopathy Symposium. It’s a stone’s throw away from the Iffley Road track where Sir Roger Bannister broke the four-minute  60 years ago. For 800 years Oxford has led innovation and scientific rigor. In 1214, Roger Bacon taught at Oxford and “was instrumental in setting science on the path towards modernity, as an inductive study of nature, based on and tested by experiment”. (1) He developed the principles of experimental science in his Opus Majus, an encyclopaedia of current knowledge of the natural world completed in 1266.

This 3rd International Tendinopathy Symposium (#Tendons2014) links scientists and clinicians. This is not a new idea. Thomas Sydenham (1624 – 1689),  an Oxford-based physician and one of the fathers of the science of epidemiology, influenced medical teaching in Britain for centuries. He was a “champion of bedside experience” and believed “that medical progress could best be achieved by discarding the trappings of preconceived hypotheses…”(1)

Thus, bridging theory and practice is a tradition on the banks of the River Thames in Oxford; yesterday’s first day of #Tendons2014 provided a healthy dose of translational and basic science as well as clinical practice pearls.

Top 5 flavours of the day:

1. Tendon loading, tendon structure and tendon pain… with terms like ‘overuse’, ‘normal loading’ and ‘abnormal loading’ featured in numerous talks and discussions. What causes the pain? Is there abnormal neural ingrowth into the tendon proper and if so what is the clinical relevance? Abnormal loading / overuse cause hypoxia, heat shock and apoptosis resulting in tendinopathy though complex and highly individual cell mediated reactions.

Appropriate loading results in healthy tendon adaptation via mechanotransduction/mechantherapy. What constitutes normal and abnormal load remains very complex and highly individual. What is quite clear is that appropriate loading stimulates healthy cell reaction, (including Tendon Stem Cell (TSC) differentiation into tenocytes) and tendon adaptation. Good evidence exists to suggest that the normal part of the tendon reacts to loading and grows to support the abnormal / tendinopathic part – ‘It’s about the donut, not the hole’ – Craig Purdam

2. I was surprise by the number of speakers still using the word ‘inflammation’ without clearly defining what they mean by it or necessarily understanding its role in clinical practice. There is no conclusive evidence that inflammation play a key role in tendinopathy and I haven’t heard anything today to convince me otherwise. (For more on this see Rees, Stride & Scott here)

3. Ultrasound Tissue Characterisation (UTC) was the topic of a number of oral and poster presentations. UTC is a novel imaging modality reporting 4 different echotypes representing different qualities of tendon structure. It is an interesting tool but with limited clinical application at the moment with certainly no link between pain and UTC structure.

4. Genetic researchers conclude that genetic testing has little or no role in identifying talent. With respect to injury, it should be used cautiously as part of the many factors influencing (i) (tendon) injury risk and (ii) an individual’s response to training. Finally, genetic testing should never be direct to the consumer (DTC) but always through appropriately qualified clinicians or geneticists. (@MCollinsSA but not active on twitter yet!).  (Editor – a top link on genes in sport broadly is @DavidEpstein podcast here)

5. The lid has been lifted from the ‘Plantaris tendon pot’… but still a lot of steam fogging the glasses… Note that of some of the ‘champions of bedside (trackside!) experience’ like Noel Pollock (@DrNoelPollock), Toby Smith, Lorenzo Masci and Hakan Alfredson are firm believers. Abberant (?) plantaris insertion complicating Achilles tendinopathy is certainly a real entity in elite Track and Field. Also, isolated plantaris tendinopathy might trigger a medial mid-portion Achilles Tendinopathy (perhaps irrespective of its distal insertion anatomy). Scraping of the ventral surface of the Achilles tendon and excision of the plantaris tendon remains one of the most prevalent surgical procedures in the British elite Track and Field cohort. Clearly the treatment approach remains speculative (no RCTs) but a clinical pearl is to put plantaris tendinopathy in your differential diagnosis when ‘straightforward midportion Achilles tendinopathy’ is not responding to appropriate Rx.

PS: The ‘donut’ refers to the apparent ‘hole’ within the donut which represents tendinopathy on an ultrasound scan. Of course there is no ‘hole’ in reality. The  ‘donut’ itself represents the tendon tissue surrounding the ‘hole’. Tomorrow’s blog will reveal the significance of female tenocytes…

Some reflections…

It is often “the simple, telling experiment” that provides the catalyst for substantial change in thinking and practice. On the 25th May 1940 Norman Heatley gave eight mice a lethal dose of streptococci bacteria – four of the eight were then given penicillin and they survived. In 1990 Heatley, a biochemist, became the first non-medic in the 800-year history of the University of Oxford to be awarded an honorary doctorate of medicine. (1)

There has been a lot of development in tendon science and the clinical practice application. We still lack ‘the simple, telling, tendon experiment’ though… I’m already looking forward to the 4th Symposium! Who knows…

@DrPaulDijkstra is an Associate Editor of BJSM, a regular guest blogger and sports physician at Aspetar, Qatar Orthopaedic and Sports Medicine Clinic. He served TeamGB at the 2008 and 2012 Olympic Games and TeamEngland at the Commonwealth Games in Glasgow in July-August.

BJSM is a sponsor of the 3rd International Scientific Tendinopathy Symposium (ISTS); The summary statement from the 2nd International Symposium (Vancouver, 2012) is here

Reference:  C. Keating, Great Medical Discoveries An Oxford Story Bodleian Library, Oxford, 2013

Hertford Bridge, also known as the Bridge of Sighs, links two parts of Hertford College at Oxford University and crosses New College Lane

Hertford Bridge, also known as the Bridge of Sighs, links two parts of Hertford College at Oxford University and crosses New College Lane

Concussion to groin pain: BJSM editors and authors contribute to a 200-strong clinician education event

17 May, 14 | by BJSM

BJSM editors and authors contributed to a 200-strong clinician education event run by the Faculty of Sport and Exercise Medicine of Ireland on Tuesday April 29.

Andy Franklyn-Miller argued the ‘compartment pressure’ syndrome was a misnomer for pathology that relates to relative overuse. His article can be found HERE  (OPEN ACESS) in BJSM and his podcast on the topic is among the top 5 of all time on BJSM podcasts (LISTEN HERE).

BJSM concussion cover 2014Eanna Falvey addressed the challenges of deciding on return to play in concussion and he challenged what many US newspapers are taking as gospel – that repeated concussion leads to chronic traumatic encephalopathy (CTE). BJSM’s 4th issue of 2014 addressed this question and Paul McCrory is on BJSM podcasts (LISTEN HERE).

Senior Associate Editor Peter Brukner (@PeterBrukner) reviewed the challenges of managing groin pain in sport. He argues that Copenhagen’s Per Holmich’s ‘entities’ approach is a useful one. You can see watch Per Holmich talk about history and clinical examination on YouTube (HERE) and read about the entities (HERE).

To close off the educational event, BJSM Editor in Chief Karim Khan reviewed the pathogenesis of tendinopathy arguing that collagen failure and abnormal tendon cells/matrix needs to be respected even if there are some biochemical changes that have loosely been linked to ‘inflammatory’ pathways. The new BJSM paper ‘Time to revisit inflammation”  (OPEN ACCESS)  is a thought-provoking contribution to tendinopathy management science by UK Professor Jonathan Rees. If you are interested in tendon injuries and their quality management, go to Oxford in September (2014). International Scientific Tendinopathy Symposium.

This event was part of a 10-city educational tour of UK supported by BJSM, McGraw-Hill publishers, and Aspetar Orthopaedic and Sports Medicine Hospital, Qatar.

What do you think? Tweet @BJSM_BMJ or email us ( thoughts.

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