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Spinal pain is a significant global health issue, affecting millions and ranking as one of the leading causes of disability worldwide. Despite the wide scope of research conducted on spinal and associated pain, the lack of standardised core outcome measures poses challenges for comparing and synthesising research data. Core Outcome Sets (COSs) are intended to harmonise assessment and facilitate comparison across studies. This review aimed to identify, map, and examine published core outcome sets (COSs) designed for the assessment of spinal pain-including cervical, thoracic, lumbar-and spinal-related limb, trunk, abdomen, or pelvic pain. It also sought to synthesise consistent outcome domains across these COSs, categorising them by anatomical region and measurement type, including patient-reported, physical, biological, psychological, social, and environmental measures. This systematic review followed PRISMA guidelines and was registered with PROSPERO. A comprehensive literature search of 13 electronic databases and grey literature sources was conducted from 2000 to April 2025. Two independent reviewers assessed study eligibility and quality using predefined criteria. Data extraction was performed to identify core outcome domains, and a thematic analysis was conducted to categorise domains based on anatomical regions, patient-reported outcomes, performance measures, and biopsychosocial factors. Thirteen studies met inclusion criteria, addressing core outcome sets for cervical (n = 4), thoracolumbar (n = 1), and lumbar (n = 8) spinal regions. Patient-reported outcome measures were the most frequently recommended outcome type. The most commonly endorsed domains were physical function n = 9 (100%), pain intensity n = 8 (88.9%), participation in work or daily activities n = 7 (77.8%), and disability n = 6 (66.7%). However, few studies incorporated psychological, social, environmental, or physiological domains, highlighting critical gaps in the multidimensional assessment of spinal pain. This systematic review identified key domains in current use and significant gaps in biopsychosocial and biological measurement. Findings will support researchers, clinicians, and policymakers in selecting appropriate outcomes for spinal pain research and practice. A Delphi study to develop an internationally agreed \"Essential Universal Set\" for spinal pain, inclusive of multidimensional biopsychosocial domains, is a sound next step.

The calf-raise test is used by clinicians and researchers in sports medicine to assess properties of the calf muscle-tendon unit. The test generally involves repetitive concentric–eccentric muscle action of the plantar-flexors in unipedal stance and is quantified by the number of raises performed. Although the calf-raise test appears to have acceptable reliability and face validity, and is commonly used for medical assessment and rehabilitation of injuries, no universally acceptable test parameters have been published to date. A systematic review of the existing literature was conducted to investigate the consistency as well as universal acceptance of the evaluation purposes, test parameters, outcome measurements and psychometric properties of the calf-raise test. Nine electronic databases were searched during the period May 30th to September 21st 2008. Forty-nine articles met the inclusion criteria and were quality assessed. Information on study characteristics and calf-raise test parameters, as well as quantitative data, were extracted; tabulated; and statistically analysed. The average quality score of the reviewed articles was 70.4 ± 12.2% (range 44–90%). Articles provided various test parameters; however, a consensus was not ascertained. Key testing parameters varied, were often unstated, and few studies reported reliability or validity values, including sensitivity and specificity. No definitive normative values could be established and the utility of the test in subjects with pathologies remained unclear. Although adapted for use in several disciplines and traditionally recommended for clinical assessment, there is no uniform description of the calf-raise test in the literature. Further investigation is recommended to ensure consistent use and interpretation of the test by researchers and clinicians.

This study used subject-specific measures of three-dimensional (3D) free Achilles tendon geometry in conjunction with a finite element method to investigate the effect of variation in subject-specific geometry and subject-specific material properties on tendon stress during submaximal isometric loading. Achilles tendons of eight participants (Aged 25–35years) were scanned with freehand 3D ultrasound at rest and during a 70% maximum voluntary isometric contraction. Ultrasound images were segmented, volume rendered and transformed into subject-specific 3D finite element meshes. The mean (±SD) lengths, volumes and cross-sectional areas of the tendons at rest were 62±13mm, 3617±984mm3 and 58±11mm2 respectively. The measured tendon strain at 70% MVIC was 5.9±1.3%. Subject-specific material properties were obtained using an optimisation approach that minimised the difference between measured and modelled longitudinal free tendon strain. Generic geometry was represented by the average mesh and generic material properties were taken from the literature. Local stresses were subsequently computed for combinations of subject-specific and generic geometry and material properties. For a given geometry, changing from generic to subject-specific material properties had little effect on the stress distribution in the tendon. In contrast, changing from generic to subject-specific geometry had a 26-fold greater effect on tendon stress distribution. Overall, these findings indicate that the stress distribution experienced by the living free Achilles tendon of a young and healthy population during voluntary loading are more sensitive to variation in tendon geometry than variation in tendon material properties.

Musculoskeletal tissues, including tendons, are sensitive to their mechanical environment, with both excessive and insufficient loading resulting in reduced tissue strength. Tendons appear to be particularly sensitive to mechanical strain magnitude, and there appears to be an optimal range of tendon strain that results in the greatest positive tendon adaptation. At present, there are no tools that allow localized tendon strain to be measured or estimated in training or a clinical environment. In this paper, we first review the current literature regarding Achilles tendon adaptation, providing an overview of the individual technologies that so far have been used in isolation to understand in vivo Achilles tendon mechanics, including 3D tendon imaging, motion capture, personalized neuromusculoskeletal rigid body models, and finite element models. We then describe how these technologies can be integrated in a novel framework to provide real-time feedback of localized Achilles tendon strain during dynamic motor tasks. In a proof of concept application, Achilles tendon localized strains were calculated in real-time for a single subject during walking, single leg hopping, and eccentric heel drop. Data was processed at 250 Hz and streamed on a smartphone for visualization. Achilles tendon peak localized strains ranged from ∼3 to ∼11% for walking, ∼5 to ∼15% during single leg hop, and ∼2 to ∼9% during single eccentric leg heel drop, overall showing large strain variation within the tendon. Our integrated framework connects, across size scales, knowledge from isolated tendons and whole-body biomechanics, and offers a new approach to Achilles tendon rehabilitation and training. A key feature is personalization of model components, such as tendon geometry, material properties, muscle geometry, muscle-tendon paths, moment arms, muscle activation, and movement patterns, all of which have the potential to affect tendon strain estimates. Model personalization is important because tendon strain can differ substantially between individuals performing the same exercise due to inter-individual differences in these model components.Musculoskeletal tissues, including tendons, are sensitive to their mechanical environment, with both excessive and insufficient loading resulting in reduced tissue strength. Tendons appear to be particularly sensitive to mechanical strain magnitude, and there appears to be an optimal range of tendon strain that results in the greatest positive tendon adaptation. At present, there are no tools that allow localized tendon strain to be measured or estimated in training or a clinical environment. In this paper, we first review the current literature regarding Achilles tendon adaptation, providing an overview of the individual technologies that so far have been used in isolation to understand in vivo Achilles tendon mechanics, including 3D tendon imaging, motion capture, personalized neuromusculoskeletal rigid body models, and finite element models. We then describe how these technologies can be integrated in a novel framework to provide real-time feedback of localized Achilles tendon strain during dynamic motor tasks. In a proof of concept application, Achilles tendon localized strains were calculated in real-time for a single subject during walking, single leg hopping, and eccentric heel drop. Data was processed at 250 Hz and streamed on a smartphone for visualization. Achilles tendon peak localized strains ranged from ∼3 to ∼11% for walking, ∼5 to ∼15% during single leg hop, and ∼2 to ∼9% during single eccentric leg heel drop, overall showing large strain variation within the tendon. Our integrated framework connects, across size scales, knowledge from isolated tendons and whole-body biomechanics, and offers a new approach to Achilles tendon rehabilitation and training. A key feature is personalization of model components, such as tendon geometry, material properties, muscle geometry, muscle-tendon paths, moment arms, muscle activation, and movement patterns, all of which have the potential to affect tendon strain estimates. Model personalization is important because tendon strain can differ substantially between individuals performing the same exercise due to inter-individual differences in these model components.

The association between tibial morphology and tibial stress fractures or tibial stress syndrome was examined in triathletes with an unusually high incidence of these injuries. A cross-sectional study design examined associations between tibial geometry from MRI images and training and injury data between male and female triathletes and between stress fracture (SF) and non-stress fracture (NSF) groups. Fifteen athletes (7 females, 8 males) aged 17–23 years who were currently able to train and race were recruited from the New Zealand Triathlete Elite Development Squad. Geometric measurements were taken at 5 zones along the tibia using MRI and compared between symptomatic and asymptomatic tibiae subjects. SF tibiae displayed either oedema within the cancellous bone and/or stress fracture on MRI. When collapsed across levels, symptomatic tibiae had thicker medial cortices (F1,140=9.285, p=0.003), thicker lateral cortices (F1,140=10.129, p=0.002) and thinner anterior cortices (F1,140=14.517, p=0.000) than NSF tibiae. Only medial cortex thickness in SF tibia was significantly different (F4,140=3.358, p=0.012) at different levels. Follow-up analysis showed that athletes showing oedema within the cancellous bone and/or stress fracture on MRI had, within 2 years of analysis, subsequently taken time off training and racing due a tibial stress fracture. The thinner anterior cortex in SF tibiae is associated with a stress reaction in these triathletes.

Athletes commonly sustain injuries to the triceps surae muscle-tendon unit. The calf-raise test (CRT) is frequently employed in sports medicine for the detection and monitoring of such injuries. However, despite being widely-used, a recent systematic review found no universal consensus relating to the test's purpose, parameters, and standard protocols. The purpose of this paper is to provide a clinical perspective on the anatomo-physiological bases underpinning the CRT and to discuss the utilisation of the test in relation to the structure and function of the triceps surae muscle-tendon unit. Structured narrative review. Nine electronic databases were searched using keywords and MESH headings related to the CRT and the triceps surae muscle-tendon unit anatomy and physiology. A hand-search of reference lists and relevant journals and textbooks complemented the electronic search. There is evidence supporting the clinical use of the CRT to assess soleus and gastrocnemius, their shared aponeurosis, the Achilles tendon, and the combined triceps surae muscle-tendon unit. However, employing the same clinical test to assess all these structures and their associated functions remains challenging. Further refinement of the CRT for the triceps surae muscle-tendon unit is needed. This is vital to support best practice utilisation, standardisation, and interpretation of the CRT in sports medicine.

Adventure racing is a wilderness multisport endurance event with the potential for significant injury and illness; however specific contributing factors have not been extensively studied. A prospective cross-sectional study was conducted that collected data during the 2005 Adventure Racing World Championship on pre-, in- and post-race injury and illness and determined pre-race training volumes and health profiles in 184 athletes (46 teams of 4 athletes). In the 6 months prior to the event, 79.9% of athletes reported an injury or illness. Fifty-nine cases of injury or illness were recorded during the race; representing an overall rate of 2.5 injuries per 1000 race-hours and 1.0 illness per 1000 race-hours. This incidence could be considered low compared to some sports, but the rate is tempered by the time on course exposure of 16,774 race-hours. Respiratory conditions were the single-most common condition resulting in race withdrawal. There was a moderate, but not statistically significantly, association (OR = 4.61, p = 0.083, 95% CI 0.82–26.08) between pre-race illness and in-race illness. Forty-four (95%) teams responded to a post-race questionnaire with 30% of the athletes reporting a new injury and 12% reporting a new illness in the week following the race. Understanding contributing factors to injury and illness during adventure racing will aid implementation of race medical coverage, preventative strategies and increase participation and performance.

Background This study examines the effect of progressive increases in footwear minimalism on injury incidence and pain perception in recreational runners. Methods One hundred and three runners with neutral or mild pronation were randomly assigned a neutral (Nike Pegasus 28), partial minimalist (Nike Free 3.0 V2) or full minimalist shoe (Vibram 5-Finger Bikila). Runners underwent baseline testing to record training and injury history, as well as selected anthropometric measurements, before starting a 12-week training programme in preparation for a 10 km event. Outcome measures included number of injury events, Foot and Ankle Disability (FADI) scores and visual analogue scale pain rating scales for regional and overall pain with running. Results 99 runners were included in final analysis with 23 injuries reported; the neutral shoe reporting the fewest injuries (4) and the partial minimalist shoe (12) the most. The partial minimalist shoe reported a significantly higher rate of injury incidence throughout the 12-week period. Runners in the full minimalist group reported greater shin and calf pain. Conclusions Running in minimalist footwear appears to increase the likelihood of experiencing an injury, with full minimalist designs specifically increasing pain at the shin and calf. Clinicians should exercise caution when recommending minimalist footwear to runners otherwise new to this footwear category who are preparing for a 10 km event.

The tendon conditioning effect is transient, but the time course of recovery from conditioning is not known. This study examined the time-course recovery of three-dimensional (3D) Achilles tendon (AT) deformation immediately following a standardised AT conditioning protocol. Randomised crossover. Ten healthy male adults (age: 24±5 years; height: 175.8±4.1cm; body mass: 78.4±6.3kg) attended the laboratory on 6 occasions. ATs were scanned using freehand 3D ultrasound during a 50% maximal voluntary isometric contraction (MVIC) of the plantarflexors immediately prior to and following the conditioning protocol (10×25s plantarflexion contractions at 50% MVIC), and then at either 15, 30, 60, 90 or 120min post-conditioning, randomised by session. Free AT longitudinal strain was significantly increased from 3.13±0.19% pre-conditioning to 7.49±0.20% immediately post-conditioning and was accompanied by a corresponding reduction in free AT transverse strain from −5.35±0.48% to −10.16±0.49% (p<0.001). There were no significant differences in free AT longitudinal or transverse strains at 60min relative to 0min post-conditioning, or between pre-conditioning strains and strains measured at 2h (p>0.05). The free AT undergoes a creep response during conditioning which is recoverable within 2h following conditioning. Recovery from conditioning has the potential to be a source of error during in vivo measurement of AT mechanical properties. The time window in which the free AT longitudinal and transverse strains could be achieved without a large confounding effect of creep recovery is 0–60min post-conditioning.

Spinal pain is a significant global health issue, affecting millions and ranking as one of the leading causes of disability worldwide. Despite the wide scope of research conducted on spinal and associated pain, the lack of standardised core outcome measures poses challenges for comparing and synthesising research data. Core Outcome Sets (COSs) are intended to harmonise assessment and facilitate comparison across studies. This review aimed to identify, map, and examine published core outcome sets (COSs) designed for the assessment of spinal pain-including cervical, thoracic, lumbar-and spinal-related limb, trunk, abdomen, or pelvic pain. It also sought to synthesise consistent outcome domains across these COSs, categorising them by anatomical region and measurement type, including patient-reported, physical, biological, psychological, social, and environmental measures. This systematic review followed PRISMA guidelines and was registered with PROSPERO. A comprehensive literature search of 13 electronic databases and grey literature sources was conducted from 2000 to April 2025. Two independent reviewers assessed study eligibility and quality using predefined criteria. Data extraction was performed to identify core outcome domains, and a thematic analysis was conducted to categorise domains based on anatomical regions, patient-reported outcomes, performance measures, and biopsychosocial factors. Thirteen studies met inclusion criteria, addressing core outcome sets for cervical (n = 4), thoracolumbar (n = 1), and lumbar (n = 8) spinal regions. Patient-reported outcome measures were the most frequently recommended outcome type. The most commonly endorsed domains were physical function n = 9 (100%), pain intensity n = 8 (88.9%), participation in work or daily activities n = 7 (77.8%), and disability n = 6 (66.7%). However, few studies incorporated psychological, social, environmental, or physiological domains, highlighting critical gaps in the multidimensional assessment of spinal pain. This systematic review identified key domains in current use and significant gaps in biopsychosocial and biological measurement. Findings will support researchers, clinicians, and policymakers in selecting appropriate outcomes for spinal pain research and practice. A Delphi study to develop an internationally agreed \"Essential Universal Set\" for spinal pain, inclusive of multidimensional biopsychosocial domains, is a sound next step.