Dr. Alison Grimaldi Publications

Browse through Dr. Alison Grimaldi's peer reviewed and invited publications. For some there are also full text papers available (open access).

An examination of imaging findings in patients with clinically diagnosed gluteal tendinopathy: a secondary analysis of a randomised clinical trial.

Grimaldi, A., Nasser, A., Mellor, R., & Vicenzino, B. (2025). An examination of imaging findings in patients with clinically diagnosed gluteal tendinopathy: a secondary analysis of a randomised clinical trial. Archives of Orthopaedic and Trauma Surgery, 145(1). https://doi.org/10.1007/s00402-025-05964-z

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ABSTRACT

Objectives

To report tendon pathology present on imaging and relationships to pain, function and disability in participants with gluteal tendinopathy (GT) who participated in a multi-centre randomised clinical trial.

Materials and methods

Imaging findings were examined in 204 participants with GT. Magnetic Resonance Images (MRI) and x-ray were evaluated against pre-determined criteria by experienced radiologists, blind to clinical findings, who reported on location of tendon pathology, presence and severity of tendon tears and location and presence of calcification. Severity of changes seen on MRI were scored and analyses for relationships to pain, function and disability were performed.

Results

Information on location and severity of tendon pathology was available for 202 (99%) of the 204 LEAP trial participants. Tendon pathology was commonly present in both the gluteus medius (GMed) and gluteus minimus (GMin) tendons (130/202; 64%), with tears in one or both tendons in 85 (42%) participants. Of 99 tears across both tendons, 77 (78%) were partial-thickness and 22 (22%) were full-thickness in nature. The anterior aspect of the GMed tendon and the posterior aspect of the GMin tendon were most afflicted. Calcifications at the lateral ilium or greater trochanter were evident on x-ray in 73 (36%) participants. Pain, function and disability were not associated with the severity of changes on MRI.

Conclusion

In a clinical trial of people with GT, a substantial number of participants had multiple tendons affected, as well as concomitant tendon tears and calcification. MRI detected changes were not associated with levels of pain, function or disability.

Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence

Grimaldi, A., Ganderton, C., & Nasser, A. (2025). Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence. Musculoskeletal Science and Practice, 76, 103253. https://doi.org/10.1016/j.msksp.2025.103253

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Introduction

Gluteal tendinopathy is a prevalent and impactful condition. For many decades clinical practice has been guided by ‘myths’ that developed around clinical beliefs. It's time to examine these myths and engage with the substantial evidence base.

Purpose

This masterclass aims to: (i) engage with the evidence to refute the most common myths associated with gluteal tendinopathy and trochanteric pain, and (ii) provide clinicians with guidance around contemporary, evidence-based clinical practice.

Implications

It is time to put aside traditional beliefs that focused on anti-inflammatory treatments, including rest and corticosteroid injections as first line management for trochanteric pain. Contemporary management of tendinopathy takes an active approach that empowers the individual to manage their own condition through education, load management, progressive exercise and optimisation of their general health. The body of evidence for gluteal tendinopathy supports health professionals in employing such principles with greater confidence.

Current and future advances in practice: tendinopathies of the hip

Grimaldi, A., Mellor, R., Nasser, A., Vicenzino, B., & Hunter, D. J. (2024). Current and future advances in practice: tendinopathies of the hip. Rheumatology Advances in Practice, 8(2), rkae022. https://doi.org/10.1093/rap/rkae022

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Tendinopathy describes persistent tendon pain and loss of function related to mechanical loading. Two common hip tendinopathies seen in practice are gluteal tendinopathy and proximal hamstring tendinopathy. Both conditions can be frustrating for patients and clinicians due to the delay in diagnosis, significant disability caused and lack of response to common treatments. Tendinopathy is a clinical diagnosis and can most often be made using findings from the patient interview and pain provocation tests, without the need for imaging. Specific education and progressive exercise offer a low-risk and effective option for gluteal tendinopathy and result in greater rates of treatment success than corticosteroid injection, both in the short term (8 weeks) and at 1 year. Proximal hamstring tendinopathy is a common, but less researched, and under-recognized cause of persistent ischial pain. As research on proximal hamstring tendinopathy is limited, this review summarizes the available evidence on diagnosis and treatment following similar principles to other well-researched tendinopathies.

The Victorian Institute of Sport Questionnaire - gluteal tendinopathy (VISA-G)

Nasser, A., & Grimaldi, A. (2024). Clinimetrics: The Victorian Institute of Sport Questionnaire - gluteal tendinopathy (VISA-G). Journal of Physiotherapy, 70(2), 153. https://doi.org/10.1016/j.jphys.2024.02.009

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The Victorian Institute of Sport Questionnaire – gluteal tendinopathy (VISA-G) is a freely available, eight-item, self-reported scale designed to evaluate the severity of disabilityassociated with gluteal tendinopathy on a 0 to 100 scale, where 100 indicates no hip-related disability. The questionnaire includes one item related to usual pain (item 1), four items related to pain on tendon loading (items 2, 3, 4 and 6), one item related to difficulty in moving after sitting (item 5) and two items related to activity participation (items 7 and 8).¹ Items 1 to 7 are each scored out of 10 points. For item 8, patients are directed to complete one of three sections, contributing a total of 30 points. These sections evaluate the ability to perform weight-bearing activities such as walking, shopping or running. A recent systematic review of six studies appraised the VISA-G using the Consensus-based Standards for the Selection of Health Measurement Instruments and found that the questionnaire had moderate-quality evidence of: sufficient responsiveness (pre–post intervention); low-quality evidence of sufficient reliability, measurement error and comprehensibility; and very low-quality evidence of sufficient comprehensiveness; relevance and responsiveness in comparison with other outcome measures. Structural validity and internal consistency were rated as indeterminate. The minimum clinically important change of the VISA-G was 29 out of 100 in patients 12 months following hip abductor repair when using a global rating of change of ‘moderately better’ as an anchor (or 22 out of 100 using ‘somewhat better’ as an anchor).

ICON 2020-International Scientific Tendinopathy Symposium Consensus: the development of a core outcome set for gluteal tendinopathy

Fearon, A. M., Grimaldi, A., Mellor, R., Nasser, A. M., Fitzpatrick, J., Ladurner, A., & Vicenzino, B. (2024). ICON 2020—International Scientific Tendinopathy Symposium Consensus: the development of a core outcome set for gluteal tendinopathy. British Journal of Sports Medicine, 58(5), 245–254. https://doi.org/10.1136/bjsports-2023-107150

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Gluteal tendinopathy (GT) is common and can be debilitating and challenging to manage. A lack of condition specific and appropriate outcome measures compromise evidence synthesis for treatment and limits clinical guideline development. Our objective was to develop a core outcome measurement set for GT (COS-GT). Participants were patients with GT and expert health professionals (HPs). A scoping review identified measures used in GT research, which were mapped to the nine International Scientific Tendinopathy Symposium Consensus core domains, and included in two surveys of HPs. The first survey identified the feasible and true measures for each domain. The second survey refined the list which a patient focus group then considered. Meeting online, HPs reached consensus (agreement ≥70%) on the most appropriate COS-GT measures. 34 HPs and seven patients were recruited. 57 measures were mapped to the nine core domains. Six measures did not proceed past survey one. Of those that progressed, none had adequate clinimetric properties for a COS-GT. Thus, participants decided on interim measures: the global rating of change, pain at night, time to pain onset with single limb stance, pain with stair walking, pain self-efficacy and hip abduction strength. HP participants additionally recommended that pain over the last week, the European Quality of Life-5 dimensions-5 levels and the Victorian Institute of Sport Assessment-Gluteal be considered in clinical trials, as they currently provide best easures of the relevant tendinopathy domains. In conclusion this interim COS-GT should guide outcome measure selection in clinical practice and future research trials in patients with GT.

Education plus exercise for persistent gluteal tendinopathy improves quality of life and is cost-effective compared with corticosteroid injection and wait and see: economic evaluation of a randomised trial

Wilson, R., Abbott, J. H., Mellor, R., Grimaldi, A., Bennell, K., & Vicenzino, B. (2022). Education plus exercise for persistent gluteal tendinopathy improves quality of life and is cost-effective compared with corticosteroid injection and wait and see: economic evaluation of a randomised trial. Journal of Physiotherapy, 69(1), 35–41. https://doi.org/10.1016/j.jphys.2022.11.007

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Question

For patients with gluteal tendinopathy, what is the cost utility from health system and societal perspectives of three management approaches: education plus exercise, ultrasound-guided corticosteroid injection or wait and see?

Design

Economic evaluation alongside a three-group, parallel, randomised clinical efficacy trial.

Participants

People aged between 35 and 70 years with image-confirmed gluteal tendinopathy were recruited via advertisements.

Interventions

Education plus exercise, consisting of 14 visits to a physiotherapist, with detailed instruction on tendinopathy management, twice weekly supervised exercise sessions, daily home exercises, a handout and a CD; corticosteroid injection, consisting of one ultrasound-guided injection and a handout on general tendon care; and 'wait and see', consisting of one visit to a physiotherapist with assurance and advice on staying active whilst respecting pain.

Outcome measures

Economic outcome measures were quality-adjusted life years (QALYs) calculated from EuroQol EQ-5D-3L using Australian population preference weights, and total economic costs obtained from participant-reported data collected over the 1-year follow-up period. Missing data (<12% per group) were imputed. Linear regression was used to estimate incremental QALYs and costs between interventions; uncertainty was assessed by calculating 90% confidence intervals, cost-effectiveness acceptability curves and confidence ellipses.

Results

A total of 204 individuals (82% women) were enrolled. Incremental cost-effectiveness ratio favoured education plus exercise over corticosteroid injection (AU$12,719 and $5,592 on societal and health system perspectives, respectively) and over wait and see ($29,258 and $3,444 on societal and health system perspectives, respectively). Complete case analysis and varying the direct intervention costs did not change the (imputed analysis) results, with the exception that corticosteroid injection was less cost-effective.

Conclusion

Education plus exercise for gluteal tendinopathy improves health-related quality of life and is cost-effective compared with corticosteroid injection and wait and see for treating gluteal tendinopathy.

Mediators and moderators of education plus exercise on perceived improvement in individuals with gluteal tendinopathy: an exploratory analysis of a three-arm randomised trial

Mellor, R., Kasza, J., Grimaldi, A., Hodges, P., Bennell, K., & Vicenzino, B. (2022). Mediators and moderators of education Plus Exercise on perceived improvement in individuals with gluteal tendinopathy: an exploratory analysis of a 3-Arm randomized trial. Journal of Orthopaedic and Sports Physical Therapy, 52(12), 826–836. https://doi.org/10.2519/jospt.2022.11261

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OBJECTIVE

To investigate mediators and moderators of effects of an education-plus-exercise program compared to corticosteroid injections or wait and see on perceived improvement in individuals with gluteal tendinopathy.

METHODS

Exploratory analysis from a clinical trial (n = 204) comparing education plus exercise, corticosteroid injection, and wait and see on global rating of change at 52 weeks. Potential mediators measured at baseline and 8 weeks were hip active abduction range, abductor muscle torque, pain self-efficacy, pain constancy, and patient-specific function. Potential moderators at baseline were Victorian Institute of Sport Assessment for gluteal tendinopathy, menopausal status, symptom duration, magnetic resonance imaging-determined tendon pathology, and pain catastrophizing.

RESULTS

There is evidence from mediation analysis that the beneficial effect of education plus exercise on global rating of change relative to corticosteroid injection or wait and see may be due to changes in patient-specific function (indirect effect relative risk; 95% CI: 1.14 [1.05-1.29], 1.29 [1.12-1.58], respectively), pain constancy (1.12 [1.03-1.27], 1.2 [1.08-1.41]), and pain self-efficacy (1.1 [1.02-1.25], 1.18 [1.04-1.44])-not active hip movement/muscle torque. Moderation analysis did not support our included patient characteristics.

CONCLUSION

Education plus exercise is likely to improve global rating of change for persons with gluteal tendinopathy relative to corticosteroid injection and wait and see through improvements in patient-specific function, pain self-efficacy, and reduced pain constancy. We found no evidence of differences in the effect of education plus exercise in patient subgroups based on disability, menopausal status, symptom duration, tendon pathology, or pain catastrophizing. J Orthop Sports Phys Ther 2022;52(12):826-836. Epub: 17 October 2022. doi:10.2519/jospt.2022.11261.

Outcome measures in the management of gluteal tendinopathy: a systematic review of their measurement properties

Nasser, A. M., Fearon, A. M., Grimaldi, A., Vicenzino, B., Mellor, R., Spencer, T., & Semciw, A. I. (2022). Outcome measures in the management of gluteal tendinopathy: a systematic review of their measurement properties. British Journal of Sports Medicine, 56(15), 877–887. https://doi.org/10.1136/bjsports-2021-104548

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Objective

Evaluate properties of outcome measures for gluteal tendinopathy.

Design

Multistage scoping/systematic review.

Data sources

Cochrane, PubMed, Embase, Scopus, Web of Science, PEDro, CINAHL, SPORTDISCUS were searched (December 2021) to identify measures used to evaluate gluteal tendinopathy. Measures were mapped to the core health domains for tendinopathy. Medline, CINAHL, Embase and PubMed were searched (December 2021) for studies evaluating measurement properties of gluteal tendinopathy outcome measures captured in the initial search. Both reviews included studies that evaluated a treatment in participants with gluteal tendinopathy, diagnosed by a professional. Consensus-based-Standards for the Selection of Health Instruments methodology were followed-including bias assessment and synthesis of findings.

Results

Six studies reported on the Victorian Institute of Sport Assessment-Gluteal Tendinopathy (VISA-G). One study reported on the Hip Outcome Score (HOS)-activities of daily living (ADL) and Sport.The VISA-G had moderate-quality evidence of sufficient construct validity (known group) and responsiveness (pre-post intervention), low-quality evidence of sufficient reliability, measurement error, comprehensibility and insufficient construct validity (convergent), and very low-quality evidence of sufficient comprehensiveness, relevance and responsiveness (comparison with other outcome measures).Both the HOS(ADL) and HOS(Sport) had very low-quality evidence of sufficient reliability, relevance and insufficient construct validity and comprehensiveness. The HOS(ADL) had very low-quality evidence of sufficient comprehensibility and insufficient measurement error. The HOS(Sport) had very low quality evidence of inconsistent comprehensibility and sufficient measurement error.

Conclusion

Rigorously validated outcome measures for gluteal tendinopathy are lacking. The VISA-G is the preferred available option to capture the disability associated with gluteal tendinopathy.

No Difference in Hip Muscle Volumes and Fatty Infiltration in Those With Hip-Related Pain Compared to Controls

Retchford, T. H., Tucker, K. J., Hart, H. F., Semciw, A. I., Weinrauch, P., Grimaldi, A., Cowan, S. M., Crossley, K. M., & Kemp, J. L. (2022). No difference in hip muscle volumes and fatty infiltration in those with Hip-Related Pain compared to controls. International Journal of Sports Physical Therapy, 17(5), 851–862. https://doi.org/10.26603/001c.36528

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Background

Little is known about muscle morphology in people with hip-related pain, without signs of femoro-acetabular impingement syndrome (FAIS). Identifying changes in hip muscle volume, fatty infiltrate and establishing relationships between muscle volume and strength, may provide insight into potential early treatment strategies.

Purposes

To: (i) compare the volumes and fatty infiltrate of gluteus maximus, gluteus medius, gluteus minimis, tensor fascia latae and quadratus femoris between symptomatic and less-symptomatic sides of participants with hip-related pain; (ii) compare the volumes and fatty infiltrate of hip muscles between healthy controls and symptomatic participants; and (iii) explore relationships of hip muscle volumes to muscle strength and patient-reported outcome measures in people with hip-related pain.

Study design

Cross-sectional study.

Methods

Muscle volume and fatty infiltrate (from magnetic resonance imaging), hip muscle strength, patient-reported symptoms, function and quality of life (QOL) were determined for 16 participants with hip-related pain (no clinical signs of FAIS; 37±9 years) and 15 controls (31±9 years). Using One Way Analysis of Co-Variance tests, muscle volume and fatty infiltrate was compared between the symptomatic and less-symptomatic sides in participants with hip-related pain as well as between healthy controls and symptomatic participants. In addition, hip muscle volume was correlated with hip muscle strength, hip-reported symptoms, function and QOL.

Results

No differences in all the studied muscle volumes or fatty infiltrate were identified between the symptomatic and less-symptomatic hips of people with hip-related pain; or between people with and without hip-related pain. Greater GMED volume on the symptomatic side was associated with less symptoms and better function and QOL (ρ=0.522-0.617) for those with hip-related pain. Larger GMAX volume was associated with greater hip abduction and internal rotation strength, larger GMED volume was associated with greater hip extension strength, and larger QF volume was associated with greater hip abduction strength (rho=0.507-0.638).

Conclusion

People with hip-related pain and no clinical signs of FAIS have hip muscle volumes that are not significantly different than those of matched pain-free controls or their less-symptomatic hip. Larger GMED muscle volume was associated with fewer symptoms and greater strength.

Proximal Hamstring Tendinopathy: A Systematic Review of Interventions

Nasser, A. M., Vicenzino, B., Grimaldi, A., Anderson, J., & Semciw, A. I. (2021). Proximal Hamstring Tendinopathy: A Systematic Review of Interventions. International Journal of Sports Physical Therapy, 16(2), 288–305. https://doi.org/10.26603/001c.21250

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Background

Proximal hamstring tendinopathy affects athletic and non-athletic populations and is associated with longstanding buttock pain. The condition is common in track and field, long distance running and field-based sports. Management options need to be evaluated to direct appropriate clinical management.

Purpose/hypothesis

To evaluate surgical and non-surgical interventions used in managing proximal hamstring tendinopathy.

Study design

Systematic review.

Methods

Electronic databases were searched to January 2019. Studies (all designs) investigating interventions for people with proximal hamstring tendinopathy were eligible. Outcomes included symptoms, physical function, quality of life and adverse events. Studies were screened for risk of bias. Reporting quality was assessed using the Cochrane Risk of Bias Tool (Randomized Controlled Trials [RCT]) and the Joanna Briggs Institute Checklist (Case Series). Effect sizes (Standard mean difference or Standard paired difference) of 0.2, 0.5 and 0.8 were considered as small, medium and large respectively. Overall quality of evidence was rated according to GRADE guidelines.

Results

Twelve studies (2 RCTs and 10 case series) were included (n=424; males 229). RCTs examined the following interventions: platelet-rich plasma injection (n=1), autologous whole-blood injection (n=1), shockwave therapy (n=1) and multi-modal intervention (n=1). Case series included evaluation of the following interventions: platelet-rich plasma injection (n=3), surgery (n=4), corticosteroid injection (n=2), multi-modal intervention + platelet-rich plasma injection (n=1). Very low-level evidence found shockwave therapy was more effective than a multi-modal intervention, by a large effect on improving symptoms (-3.22 SMD; 95% CI -4.28, -2.16) and physical function (-2.42 SMD; 95% CI-3.33, -1.50) in the long-term. There was very low-level evidence of no difference between autologous whole-blood injection and platelet-rich plasma injection on physical function (0.17 SMD; 95% CI -0.86, 1.21) to (0.24 SMD; 95% CI -0.76, 1.24) and quality of life (-0.04 SMD; 95%CI -1.05, 0.97) in the medium-term. There was very low-quality evidence that surgery resulted in a large reduction in symptoms (-1.89 SPD; 95% CI -2.36, -1.41) to (-6.02 SPD; 95% CI -8.10, -3.94) and physical function (-4.08 SPD; 95%CI -5.53, -2.63) in the long-term.

Conclusions

There is insufficient evidence to recommend any one intervention over another. A pragmatic approach would be to initially trial approaches proven successful in other tendinopathies.

Proximal hamstring tendinopathy; expert physiotherapists' perspectives on diagnosis, management and prevention

Nasser, A. M., Pizzari, T., Grimaldi, A., Vicenzino, B., Rio, E., & Semciw, A. I. (2020). Proximal hamstring tendinopathy; expert physiotherapists’ perspectives on diagnosis, management and prevention. Physical Therapy in Sport, 48, 67–75. https://doi.org/10.1016/j.ptsp.2020.12.008

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Objectives

To explore and summarise expert physiotherapists' perceptions on their assessment, management and prevention of proximal hamstring tendinopathy (PHT).

Methods

We conducted semi-structured interviews with expert physiotherapists until data saturation was met (n = 13). Interviews were transcribed verbatim and data were analysed systematically and organised into categories and sub-categories according to study aims.

Results

Experts report using a clinical reasoning-based approach, incorporating information from the patient interview and results of clinical load-based provocation tests, in the physical examination to diagnose PHT. Experts manage the condition through education and progressive loading targeting the hamstring unit and kinetic chain, avoiding provocative activities in positions of compression in early-mid stage rehab and a gradated and controlled return to sport. Passive therapies including injection therapies and surgery were believed to have limited utility. Prevention of recurrence primarily involved continuation of hamstring and kinetic chain strengthening programs and management of physical workload.

Conclusion

Experts rely on a combination of information from the patient interview and a battery of pain provocation tests to diagnose PHT. Education and graded exercise of the hamstring group and synergists, minimising early exposure to hip flexion, were the foundation of management of the condition.

Foot exercise plus education versus wait and see for the treatment of plantar heel pain (FEET Trial): a protocol for a feasibility study

Smith, M. M. F., Collins, N. J., Mellor, R., Grimaldi, A., Elliott, J., Hoggarth, M., Weber, K. A., & Vicenzino, B. (2020). Foot exercise plus education versus wait and see for the treatment of plantar heel pain (FEET trial): a protocol for a feasibility study. Journal of Foot and Ankle Research, 13(1), 20. https://doi.org/10.1186/s13047-020-00384-1

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Background

Plantar heel pain (PHP) is present in a wide range of individuals and creates significant burden to quality of life and participation in physical activity. The high recurrence rates and persistence of PHP suggests current management options may not address all potentially modifiable factors associated with the condition. Reports of intrinsic foot muscle (IFM) atrophy in individuals with PHP, together with biomechanical evidence of their important contribution to optimal foot function, suggests that an intervention focused on IFM training may be beneficial in managing PHP. We will test the feasibility of a prospective, assessor-blinded, parallel-group, randomised clinical trial that compares foot exercise plus education to brief advice in individuals with PHP.

Methods

Twenty participants with PHP will be randomly allocated to one of two groups for a 12-week intervention period: (i) foot exercise plus education, or (ii) brief advice. The foot exercise plus education group will attend eight sessions with a physiotherapist and receive detailed education on self-management strategies as well as a progressive exercise program for the IFMs. The brief advice group will attend one session with a physiotherapist and receive brief information about self-management strategies and reassurance. Outcome measures will be obtained at baseline and the primary end-point of 12 weeks. Primary outcomes will be the feasibility of conducting a full-scale randomised clinical trial (RCT), and the credibility and acceptability of the foot exercise plus education intervention. Secondary outcomes will explore treatment effects, which will consist of pain, physical function, physical activity level, pain self-efficacy, perceived treatment effect, magnetic resonance and ultrasound image measurement of IFM morphology, ultrasound imaging measurement of plantar fascia thickness, IFM motor performance, foot posture, foot mobility, ankle dorsiflexion range of motion, toe flexor and plantar flexor strength/endurance.

Discussion

To reduce the burden of PHP on individuals and society, there is a need to establish effective treatments that are feasible and accepted by patients and health professionals. This trial will be the first to evaluate the feasibility of conducting a full-scale RCT, as well as the credibility, acceptability, and treatment effects, of education and foot exercise for PHP. The findings of this study will inform the development of a full-scale RCT.

International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British Journal of Sports Medicine

Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., De Vos, R., Fu, S. N., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S., Malliaras, P., Auliffe, S. M., Oei, E. H. G., Purdam, C. R., Rees, J. D., Rio, E. K., Silbernagel, K. G., . . . Zwerver, J. (2019). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British Journal of Sports Medicine, 54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885

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The authors of this paper, a group of international clinical and research experts from different disciplines, aimed to achieve a consensus in terminology for persistent tendon disorders. The group ran a Delphi and consensus process that culminated in a face-to-face meeting at the fifth International Scientific Tendinopathy Symposium (ISTS) in Groningen, the Netherlands, on 26 September 2018 (placeholder for sentence about the other two papers and accompanying editorial if they get accepted). Here, they present the resulting consensus statements on terminology for persistent tendon pain.

International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients

Vicenzino, B., De Vos, R., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B. K., Fu, S. N., Silbernagel, K. G., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S., Malliaras, P., Auliffe, S. M., Oei, E. H. G., Purdam, C., Rees, J. D., Rio, E. K., Scott, A., . . . Zwerver, J. (2019). ICON 2019—International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients. British Journal of Sports Medicine, 54(8), 444–451. https://doi.org/10.1136/bjsports-2019-100894

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Background

The absence of any agreed-upon tendon health-related domains hampers advances in clinical tendinopathy research. This void means that researchers report a very wide range of outcome measures inconsistently. As a result, substantial synthesis/meta-analysis of tendon research findings is almost futile despite researchers publishing busily. We aimed to determine options for, and then define, core health-related domains for tendinopathy.

Methods

We conducted a Delphi study of healthcare professionals (HCP) and patients in a three-stage process. In stage 1, we extracted candidate domains from clinical trial reports and developed an online survey. Survey items took the form: 'The 'candidate domain' is important enough to be included as a core health-related domain of tendinopathy'; response options were: agree, disagree, or unsure. In stage 2, we administered the online survey and reported the findings. Stage 3 consisted of discussions of the findings of the survey at the ICON (International Scientific Tendinopathy Symposium Consensus) meeting. We set 70% participant agreement as the level required for a domain to be considered 'core'; similarly, 70% agreement was required for a domain to be relegated to 'not core' (see Results next).

Results

Twenty-eight HCP (92% of whom had >10 years of tendinopathy experience, 71% consulted >10 cases per month) and 32 patients completed the online survey. Fifteen HCP and two patients attended the consensus meeting. Of an original set of 24 candidate domains, the ICON group deemed nine domains to be core. These were: (1) patient rating of condition, (2) participation in life activities (day to day, work, sport), (3) pain on activity/loading, (4) function, (5) psychological factors, (6) physical function capacity, (7) disability, (8) quality of life and (9) pain over a specified time. Two of these (2, 6) were an amalgamation of five candidate domains. We agreed that seven other candidate domains were not core domains: range of motion, pain on clinician applied test, clinical examination, palpation, drop out, sensory modality pain and pain without other specification. We were undecided on the other five candidate domains of physical activity, structure, medication use, adverse effects and economic impact.

Conclusion

Nine core domains for tendon research should guide reporting of outcomes in clinical trials. Further research should determine the best outcome measures for each specific tendinopathy (ie, core outcome sets).

International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T)

Rio, E. K., Auliffe, S. M., Kuipers, I., Girdwood, M., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., Fu, S. N., Grimaldi, A., De Vos, R., Lewis, J. S., Maffulli, N., Malliaras, P., Magnusson, S. P., Oei, E. H. G., Purdam, C. R., Rees, J. D., Scott, A., . . . Zwerver, J. (2019). ICON PART-T 2019–International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T). British Journal of Sports Medicine, 54(11), 627–630. https://doi.org/10.1136/bjsports-2019-100957

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ABSTRACT

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.

Physiotherapy management of Greater Trochanteric Pain Syndrome (GTPS): an international survey of current physiotherapy practice Physiotherapy

French, H., Woodley, S., Fearon, A., O’Connor, L., & Grimaldi, A. (2019). Physiotherapy management of greater trochanteric pain syndrome (GTPS): an international survey of current physiotherapy practice. Physiotherapy, 109, 111–120. https://doi.org/10.1016/j.physio.2019.05.002

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Objectives

This study aimed to establish and compare current physiotherapy management of GTPS in Australia, New Zealand (NZ) and Ireland.

Design

Cross-sectional observational survey of physiotherapists.

Methods

An online survey was distributed to registered musculoskeletal physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; median and interquartile ranges were calculated for numerical data. Inter-country comparisons were made using Chi-squared analyses for nominal/ordinal data and Kruskal-Wallis tests for numerical data. Statistical significance was set at P<0.05.

Results/findings

Valid responses were received from 361 physiotherapists, 61% were female and 80% worked in private practice. Overall, consistency in treatment of GTPS was observed across the three countries. All physiotherapists used education and exercise (most commonly strengthening and neuromuscular control) primarily targeting the gluteal muscles. Other interventions included massage (90%), stretching (53%), range of motion (40%), thermal modalities (50%), taping (38%) and electrotherapy (25%), whilst 40% commonly recommended up to 2 to 3 corticosteroid injections per patient/per annum. Physiotherapists used pain severity scales as their primary outcome measure (79%). Single leg stance was the most common physical measure used (68%), and global rating scores or standardised physical measures were less commonly used.

Conclusion

This international survey established the physiotherapy management of GTPS. Education used in conjunction with exercise is in line with current evidence, but a proportion of clinicians use adjunct treatments without clear rationale or supporting evidence. Results indicate the need to further define optimal management of GTPS using robust methodologies such as randomised controlled trials.

An international survey of current physiotherapy practice in diagnosis and knowledge translation of greater trochanteric pain syndrome (GTPS)

French, H., Grimaldi, A., Woodley, S., O’Connor, L., & Fearon, A. (2019). An international survey of current physiotherapy practice in diagnosis and knowledge translation of greater trochanteric pain syndrome (GTPS). Musculoskeletal Science and Practice, 43, 122–126. https://doi.org/10.1016/j.msksp.2019.06.002

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ABSTRACT

Purpose

To evaluate how physiotherapists across three countries (Australia, New Zealand (NZ) and Ireland) diagnose greater trochanteric pain syndrome (GTPS) using clinical tests and imaging findings, and how physiotherapists update their knowledge regarding GTPS.

Design

Cross-sectional observational study of physiotherapists.

Methods

An online survey was distributed to registered physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; medians and interquartile ranges were calculated for numerical data. Comparisons between the three countries were made using Chi-squared analyses for nominal/ordinal data and Kruskal Wallis tests for numerical data. Statistical significance was set at p < 0.05.

Results/findings

Valid responses were received from 361 physiotherapists; 61% were female and 79.8% worked in private practice. Most respondents were very confident in diagnosing GTPS (67.9%) and incorporated a range of symptoms and tests, including validated tests, in their diagnosis. However, many physiotherapists were not commonly using some available validated diagnostic tests (e.g. FABER and FADER-R). Approximately 30% of physiotherapists used imaging to inform assessment, with ultrasound being most preferred. Physiotherapists rated hands-on experience as most valuable for updating their knowledge of GTPS, followed by courses.

Conclusion

While most clinicians appear to be using current evidence in their assessment of patients with GTPS, a proportion use suboptimal methods and/or a limited range of diagnostic tests, suggesting that despite their confidence in diagnosis, further knowledge translation may be required. Future research should determine the best methods of facilitating knowledge acquisition and translation of research into practice.

(EDITORIAL) Is exercise therapy for femoroacetabular impingement in or out of FASHIoN? We need to talk about current best practice for the non-surgical management of FAI syndrome.

Kemp, Joanne L., et al. “Is Exercise Therapy for Femoroacetabular Impingement in or out of FASHIoN? We Need to Talk about Current Best Practice for the Non-Surgical Management of FAI Syndrome.” British Journal of Sports Medicine, vol. 53, no. 19, 1 Oct. 2019, pp. 1204–1205, bjsm.bmj.com/content/53/19/1204.long, https://doi.org/10.1136/bjsports-2018-100173. Accessed 17 June 2020.

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A survey of physiotherapy practice (2018) in the United Kingdom for patients with greater trochanteric pain syndrome

Stephens, G., O’Neill, S., French, H. P., Fearon, A., Grimaldi, A., O’Connor, L., Woodley, S., & Littlewood, C. (2019). A survey of physiotherapy practice (2018) in the United Kingdom for patients with greater trochanteric pain syndrome. Musculoskeletal Science and Practice, 40, 10–20. https://doi.org/10.1016/j.msksp.2019.01.004

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Purpose

Greater Trochanteric Pain syndrome (GTPS) is a debilitating condition causing lateral hip pain. It affects up to 23.5% of women and 8% of men between 50 and 75 years old. Sufferers report comparable quality of life and functional performance to patients with end stage osteoarthritis of the hip. Understanding of optimal management strategies for GTPS remains limited. Hence, the purpose of this cross-sectional survey was to describe current UK physiotherapy practice so as to understand current practice and inform the systematic development of a physiotherapy intervention.

Methods

An online survey was developed and distributed via Twitter, the interactive Chartered Society of Physiotherapy website, Musculoskeletal Association of Chartered Physiotherapists and the professional networks of the authors via email. Responses were collected over a four-week period, this was finalised in April 2018.

Results

A total of 409 surveys were submitted; 382 were eligible for use. Nearly all physiotherapists were either somewhat, or very confident diagnosing (372/382; 97.4%) and treating (372/382; 97.4%) patients with GTPS. The management strategies most commonly used were: education on load management (377/381; 98.7%) and self-management strategies (375/381; 98.4%). Strengthening exercises (376/382; 98.4%) were commonly used and targeted to the hip abductors (355/379; 93.7%). Most frequently these exercises were delivered using a combination of home exercise programme (380/380; 100%) and one-to-one exercise sessions (344/377; 91.2%).

Conclusion

The data from this large survey highlights that physiotherapists in the UK most commonly use education on load management and self-management strategies, alongside strengthening exercises targeting the hip abductors for patients with GTPS.

Clinical features of people with hip-related pain, but no clinical signs of femoroacetabular impingement syndrome

Retchford, T. H., Tucker, K. J., Weinrauch, P., Cowan, S. M., Grimaldi, A., Kemp, J. L., & Crossley, K. M. (2018). Clinical features of people with hip-related pain, but no clinical signs of femoroacetabular impingement syndrome. Physical Therapy in Sport, 34, 201–207. https://doi.org/10.1016/j.ptsp.2018.10.007

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Objectives

Identifying impairments in hip range of motion (ROM) and muscle strength in people with hip-related pain, without signs of femoro-acetabular impingement syndrome (FAIS).

Study aims

To determine if hip strength and ROM i) differs between the symptomatic and less-symptomatic hip of people with hip-related pain; and between people with hip-related pain and healthy controls; and ii) are associated with hip-related Quality of Life and pain.

Design

Cross-sectional study.

Setting

University laboratory.

Participants

Thirty participants with hip-related pain who were awaiting hip arthroscopy (22 women; age = 37 ± 10yrs), 32 healthy controls (19 women; age = 30 ± 10yrs).

Main outcome measures

Hip ROM, muscle strength, pain intensity and the Hip disability and Osteoarthritis Outcome Score (HOOS) were assessed.

Results

Less hip flexion ROM (p = 0.004), and extension (p = 0.004), abduction (p = 0.001) and internal rotation (IR) (p = 0.048) strength were measured on the symptomatic compared to non-symptomatic side. Hip-related pain participants had lower hip abduction strength (p = 0.045), and less flexion (p < 0.001), IR (p = 0.027) and external rotation (ER) (p = 0.019) ROM compared to controls. Less ER ROM (p = 0.03-0.04), and greater abduction (p = 0.03-0.04) and adduction strength (p = 0.02) were associated with better patient reported outcome measures.

Conclusions

Specific impairments in hip ROM and strength were identified in people with hip-related pain but no FAIS.

Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial

Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H., & Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. British Journal of Sports Medicine, 52(22), 1464–1472. https://doi.org/10.1136/bjsports-2018-k1662rep

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Objective

To compare the effects of a programme of load management education plus exercise, corticosteroid injection use, and no treatment on pain and global improvement in individuals with gluteal tendinopathy.

Design

Prospective, three arm, single blinded, randomised clinical trial.

Setting

Brisbane and Melbourne, Australia.

Participants

Individuals aged 35-70 years, with lateral hip pain for more than 3 months, at least 4/10 on the pain numerical rating scale, and gluteal tendinopathy confirmed by clinical diagnosis and MRI; and with no corticosteroid injection use in previous 12 months, current physiotherapy, total hip replacement, or neurological conditions.

Interventions

A physiotherapy led education and exercise programme of 14 sessions over 8 weeks (EDX; n=69), one corticosteroid injection (CSI; n=66), and a wait and see approach (WS; n=69).

Main outcomes

Primary outcomes were patient reported global rating of change in hip condition (on an 11 point scale, dichotomised to success and non-success) and pain intensity in the past week (0=no pain, 10=worst pain) at 8 weeks, with longer term follow-up at 52 weeks.

Results

Of 204 randomised participants (including 167 women; mean age 54.8 years (SD 8.8)), 189 (92.6%) completed 52 week follow-up. Success on the global rating of change was reported at 8 weeks by 51/66 EDX, 38/65 CSI, and 20/68 WS participants. EDX and CSI had better global improvement scores than WS (risk difference 49.1% (95% CI 34.6% to 63.5%), number needed to treat 2.0 (95% CI 1.6 to 2.9); 29.2% (13.2% to 45.2%), 3.4 (2.2 to 7.6); respectively). EDX had better global improvement scores than CSI (19.9% (4.7% to 35.0%); 5.0 (2.9 to 21.1)). At 8 weeks, reported pain on the numerical rating scale was mean score 1.5 (SD 1.5) for EDX, 2.7 (2.4) for CSI, and 3.8 (2.0) for WS. EDX and CSI participants reported less pain than WS (mean difference -2.2 (95% CI -2.89 to -1.54); -1.2 (-1.85 to -0.50); respectively), and EDX participants reported less pain than CSI (-1.04 (-1.72 to -0.37)). Success on the global rating of change was reported at 52 weeks by 51/65 EDX, 36/63 CSI, and 31/60 WS participants; EDX was better than CSI (20.4% (4.9% to 35.9%); 4.9 (2.8 to 20.6)) and WS (26.8% (11.3% to 42.3%); 3.7 (2.4 to 8.8)). Reported pain at 52 weeks was 2.1 (2.2) for EDX, 2.3 (1.9) for CSI, and 3.2 (2.6) for WS; EDX did not differ from CSI (-0.26 (-1.06 to 0.55)), but both treatments did better than WS (1.13 (-1.93 to -0.33); 0.87 (-1.68 to -0.07); respectively).

Conclusions

For gluteal tendinopathy, education plus exercise and corticosteroid injection use resulted in higher rates of patient reported global improvement and lower pain intensity than no treatment at eight weeks. Education plus exercise performed better than corticosteroid injection use. At 52 week follow-up, education plus exercise led to better global improvement than corticosteroid injection use, but no difference in pain intensity. These results support EDX as an effective management approach for gluteal tendinopathy.

Gluteal tendinopathy and hip osteoarthritis: Different pathologies, different hip biomechanics.

Allison, K., Hall, M., Hodges, P. W., Wrigley, T. V., Vicenzino, B., Pua, Y., Metcalf, B., Grimaldi, A., & Bennell, K. L. (2018). Gluteal tendinopathy and hip osteoarthritis: Different pathologies, different hip biomechanics. Gait & Posture, 61, 459–465.

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BACKGROUND

Gluteal tendinopathy (GT) and hip osteoarthritis (OA) are the most common causes of hip pain and associated disability in older adults. Pain and altered walking biomechanics are common to both conditions. This study aimed to compare three-dimensional walking biomechanics between individuals with unilateral, symptomatic GT and HOA.

METHODS

Sixty individuals with symptomatic unilateral GT confirmed by magnetic-resonance-imaging and 73 individuals with symptomatic unilateral HOA (Kellgren-Lawrence Grade ≥ 2) underwent three-dimensional gait analysis. Maximum and minimum values of the external sagittal hip moment, the first peak, second peak and mid-stance minimum of the hip adduction moment (HAM), sagittal plane hip excursion and hip joint angles, pelvic obliquity and trunk lean, at the three HAM time points during stance phase of walking were compared between groups.

RESULTS

Compared to individuals with HOA, those with GT exhibited a greater hip peak extension moment (P < 0.001) and greater HAM throughout the stance phase of walking (P = 0.01-P < 0.001), greater hip adduction (P < 0.001) and internal rotation (P < 0.01-P < 0.001) angles and lower hip flexion angles and excursion (P = 0.02 - P < 0.001). Individuals with HOA exhibited a greater forward trunk lean (P ≤ 0.001) throughout stance, and greater ipsilateral trunk lean in the frontal plane (P < 0.001) than those with GT.

CONCLUSION

Despite presence of pain in both conditions, hip kinematics and kinetics differ between individuals with symptomatic unilateral GT and those with symptomatic unilateral HOA. These condition-specific impairments may be targets for optimization of management of HOA and GT.

Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: a cross-sectional study.

Plinsinga, M., Coombes, B., Mellor, R., Nicolson, P., Grimaldi, A., Hodges, P., Bennell, K., & Vicenzino, B. (2018). Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: A cross‐sectional study. European Journal of Pain, 22(6), 1124–1133. https://doi.org/10.1002/ejp.1199

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ABSTRACT

BACKGROUND

Gluteal tendinopathy is the most common lower limb tendinopathy presenting to general practice. It has a high prevalence amongst middle-aged women and impacts on daily activities, work participation and quality of life. The aim was to compare physical and psychological characteristics between subgroups of severity of pain and disability.

METHODS

A multicentre cross-sectional cohort of 204 participants (mean age 55 years, 82% female) who had a clinical diagnosis of gluteal tendinopathy with magnetic resonance imaging confirmation were assessed. A range of physical and psychosocial characteristics were recorded. Pain and disability were measured with the VISA-G questionnaire. A cluster analysis was used to identify mild, moderate and severe subgroups based on total VISA-G scores. Between-group differences were then evaluated with a MANCOVA, including sex and study site as covariates, followed by a Bonferroni post hoc test. Significance was set at 0.05.

RESULTS

There were significantly higher pain catastrophizing and depression scores in the more severe subgroups. Lower pain self-efficacy scores were found in the severe group compared to the moderate and mild groups. Greater waist girth and body mass index (BMI), lower activity levels and poorer quality of life were reported in the severe group compared to the mild group. Hip abductor muscle strength and hip circumference did not differ between subgroups of severity.

CONCLUSIONS

Individuals with severe gluteal tendinopathy present with psychological distress, poorer quality of life, greater BMI and waist girth. Given these features, the consideration of psychological factors in more severe patients may be important to optimize patient outcomes and reduce healthcare utilization.

SIGNIFICANCE

Patients with severe gluteal tendinopathy exhibit greater psychological distress, poorer quality of life and greater waist girth and BMI when compared to less severe cases. This implies that clinicians ought to consider psychological factors in the management of more severe gluteal tendinopathy.

Hip abductor muscle activity during walking in individuals with gluteal tendinopathy.

Allison, K., Salomoni, S. E., Bennell, K. L., Wrigley, T. V., Hug, F., Vicenzino, B., Grimaldi, A., & Hodges, P. W. (2017). Hip abductor muscle activity during walking in individuals with gluteal tendinopathy. Scandinavian Journal of Medicine and Science in Sports, 28(2), 686–695. https://doi.org/10.1111/sms.12942

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The external hip adduction moment during walking is greater in individuals with gluteal tendinopathy (GT) than pain-free controls. Although this likely represents a greater demand on the hip abductor muscles implicated in GT, no study has investigated activation of these muscles in GT. For this purpose, fine wire electrodes were inserted into the segments of the gluteus minimus and medius muscles, and surface electrodes placed on the tensor fascia lata, upper gluteus maximus, and vastus lateralis muscles of eight individuals with, and eight without, GT. Participants underwent six walking trials. Individual muscle patterns were compared between groups using a wavelet-based linear effects model and muscle synergy analysis performed using non-negative matrix factorization to evaluate muscle activation patterns, within-and between-participant variability. Compared to controls, individuals with GT exhibited a more sustained initial burst of the posterior gluteus minimus and middle gluteus medius muscle segments. Two muscle synergies were identified; Synergy-1 activated in early-mid stance and Synergy-2 in early stance. In GT participants, posterior gluteus minimus and posterior gluteus medius and tensor fascia lata contributed more to Synergy-1 active during the period of single leg support. Participants with GT exhibited reduced within-participant variability of posterior gluteus medius and reduced between-participant variability of anterior gluteus minimus and medius and upper gluteus maximus. In conclusion, individuals with GT exhibit modified muscle activation patterns of the hip abductor muscles during walking, with potential relevance for gluteal tendon loading.

Iliocapsularis: Technical application of fine-wire electromyography, and direction specific action during maximum voluntary isometric contractions.

Lawrenson, P., Grimaldi, A., Crossley, K., Hodges, P., Vicenzino, B., & Semciw, A. I. (2017). Iliocapsularis: Technical application of fine-wire electromyography, and direction specific action during maximum voluntary isometric contractions. Gait & Posture, 54, 300–303. https://doi.org/10.1016/j.gaitpost.2017.03.027

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ABSTRACT

The iliocapsularis muscle of the anterior hip may play an important role in hip function, but no electromyographic (EMG) recordings have been made. This muscle provides the most substantial muscular attachment to the anterior hip capsule and is hypothesised to have a dynamic role to limit capsular impingement and to augment joint stability. Current understanding of the function of iliocapsularis is based on limited cadaveric and radiographic studies. Located deep over the hip joint it would require intramuscular fine-wire EMG to evaluate its activity directly with limited cross-talk from overlying muscles. The primary aim of this study was to describe a new technique for insertion of intramuscular EMG electrodes into iliocapsularis and to report its activation during different directions of hip maximum voluntary isometric contraction (MVIC). Fifteen healthy volunteers (10M, mean age (SD) 22 (2) years) who were free from hip pain were recruited for electrode insertion and to perform MVIC's in six directions at 0° and three directions at 90° of hip flexion. Intramuscular electrodes were successfully inserted into the iliocapsularis muscle with guidance from real-time ultrasound imaging. The greatest muscle activity occurred during resisted hip flexion at 90° (Median (IQR); 100.0 (1.2) % MVIC) and lowest activity during hip extension, 0° (0.5 (0.3) % MVIC). These findings have implications for our understanding of iliocapsularis' functional role. This paper provides the first report of intramuscular electrode insertion into iliocapsularis with guided technical instructions for future EMG investigations in other populations and tasks.

Exercise interventions for the prevention and treatment of groin pain and injury in athletes: A critical and systematic review.

Charlton, P. C., Drew, M. K., Mentiplay, B. F., Grimaldi, A., & Clark, R. A. (2017). Exercise Interventions for the Prevention and Treatment of groin Pain and Injury in Athletes: A Critical and Systematic review. Sports Medicine, 47(10), 2011–2026. https://doi.org/10.1007/s40279-017-0742-y

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ABSTRACT

BACKGROUND

Groin injury is a common musculoskeletal complaint for athletes competing in a variety of sports. The extent to which exercise interventions incorporating external load are an appropriate option for the treatment and prevention of groin injury in athletes is not yet clear.

OBJECTIVES

The aim of this review was to describe and evaluate exercise therapy interventions and outcomes for the treatment and prevention of groin injury with specific attention to application of external load.

DATA SOURCES

The databases Medline, PubMed, SPORTDiscus, Web of Science, and Cochrane were searched on 18 April 2016.

STUDY ELIGIBILITY CRITERIA

This review was registered as PROSPERO CRD42016037752 and a systematic search was conducted with the following inclusion criteria: any study design evaluating exercise interventions for the prevention or treatment of groin pain in athletes.

DATA ANALYSIS

Two independent authors screened search results, performed data extraction, assessed risk of bias using the modified Downs and Black appraisal tool and determined strength and level of evidence. Reporting standards for exercise interventions were assessed using the Consensus for Exercise Reporting Template (CERT).

RESULTS

A total of 1320 titles were identified with 14 studies satisfying the inclusion criteria, four (29%) of which demonstrated low risk of bias. Ten (71%) studies utilised external load as a component of the exercise intervention. Reporting standards for exercise intervention scores ranged from 0 to 63%.

CONCLUSION

There is limited evidence from level 2 and 3 studies indicating exercise therapy may reduce the incidence and hazard risk of sustaining a groin injury in athletes. There is strong evidence from level 4 studies indicating exercise therapy is beneficial as a treatment for groin injury in athletes in terms of symptom remission, return to sport and recurrence outcomes. However, there are limited studies with low risk of bias, and exercise interventions for the treatment of groin injury are poorly described.

The reliability of a maximal isometric hip strength and simultaneous surface EMG screening protocol in elite, junior rugby league athletes.

Charlton, P. C., Mentiplay, B. F., Grimaldi, A., Pua, Y., & Clark, R. A. (2016). The reliability of a maximal isometric hip strength and simultaneous surface EMG screening protocol in elite, junior rugby league athletes. Journal of Science and Medicine in Sport, 20(2), 139–145. https://doi.org/10.1016/j.jsams.2016.06.008

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ABSTRACT

OBJECTIVES

Firstly, to describe the reliability of assessing maximal isometric strength of the hip abductor and adductor musculature using a hand-held dynamometry (HHD) protocol with simultaneous wireless surface electromyographic (sEMG) evaluation of the gluteus medius (GM) and adductor longus (AL). Secondly, to describe the correlation between isometric strength recorded with the HHD protocol and a laboratory standard isokinetic device.

DESIGN

Reliability and correlational study.

METHODS

A sample of 24 elite, male, junior, rugby league athletes, age 16-20 years participated in repeated HHD and isometric Kin-Com (KC) strength testing with simultaneous sEMG assessment, on average (range) 6 (5-7) days apart by a single assessor. Strength tests included; unilateral hip abduction (ABD) and adduction (ADD) and bilateral ADD assessed with squeeze (SQ) tests in 0 and 45° of hip flexion.

RESULTS

HHD demonstrated good to excellent inter-session reliability for all outcome measures (ICC(2,1)=0.76-0.91) and good to excellent association with the laboratory reference KC (ICC(2,1)=0.80-0.88). Whilst intra-session, inter-trial reliability of EMG activation and co-activation outcome measures ranged from moderate to excellent (ICC(2,1)=0.70-0.94), inter-session reliability was poor (all ICC(2,1)<0.50).

CONCLUSIONS

Isometric strength testing of the hip ABD and ADD musculature using HHD may be measured reliably in elite, junior rugby league athletes. Due to the poor inter-session reliability of sEMG measures, it is not recommended for athlete screening purposes if using the techniques implemented in this study.

(EDITORIAL) Conservative management of lateral hip pain: the future holds promise. British Journal of Sports Medicine.

Grimaldi, Alison. (2017). “Conservative Management of Lateral Hip Pain: The Future Holds Promise.” British Journal of Sports Medicine, vol. 51, no. 2, pp. 72–73, https://doi.org/10.1136/bjsports-2016-096600.

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Kinematics and kinetics during stair ascent in individuals with gluteal tendinopathy.

Allison, K., Vicenzino, B., Bennell, K. L., Wrigley, T. V., Grimaldi, A., & Hodges, P. W. (2016). Kinematics and kinetics during stair ascent in individuals with Gluteal Tendinopathy. Clinical Biomechanics, 40, 37–44.

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BACKGROUND

Individuals with gluteal tendinopathy commonly report lateral hip pain and disability during stair ascent. This study aimed to compare kinematics and kinetics between individuals with and without gluteal tendinopathy during a step up task.

METHODS

35 individuals with unilateral gluteal tendinopathy and 35 pain-free controls underwent three-dimensional motion analysis of stance phase during stair ascent. An analysis of covariance was performed to compare hip, pelvis and trunk kinematic and kinetic variables between groups. A K-means cluster analysis was performed to identify subgroups from the entire group (n=70) based on the characteristics of the external hip adduction moment. Finally, a Newcombe-Wilson test was performed to evaluate the relationship between group and cluster codes and a 3×2 ANOVA to investigate the differences in kinematics between groups and cluster codes.

FINDINGS

Individuals with gluteal tendinopathy exhibited a greater hip adduction moment impulse during stair ascent (ES=0.83), greater internal rotation impulse during the first 50% stance phase (ES=0.63) and greater contralateral trunk lean throughout stance than controls (ranging from ES=0.67-0.93). Three subgroups based on hip adduction moment characteristics were identified. Individuals with GT were 4.5 times more likely to have a hip adduction moment characteristic of a large impulse and greater lateral pelvic translation at heel strike than the subgroup most likely to contain controls.

INTERPRETATION

Individuals with GT exhibit greater hip adduction moment impulse and alterations in trunk and pelvic kinematics during stair ascent. Findings provide a basis to consider frontal plane trunk and pelvic control in the management of gluteal tendinopathy.

Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain.

Grimaldi, A., Mellor, R., Nicolson, P., Hodges, P., Bennell, K., & Vicenzino, B. (2016). Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. British Journal of Sports Medicine, 51(6), 519–524. https://doi.org/10.1136/bjsports-2016-096175

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PURPOSE

Gluteal tendinopathy (GT) is a source of lateral hip pain, yet common clinical diagnostic tests have limited validity. Patients with GT are often misdiagnosed, resulting in inappropriate management, including surgery. This study determined the diagnostic utility of clinical tests for GT, using MRI as the reference standard.

METHODS

65 participants with lateral hip pain were examined to evaluate the ability of clinical tests to detect MRI-determined GT (an increase in intratendinous signal intensity on T2-weighted images). Palpation of the greater trochanter and several clinical pain provocation tests applying compressive and tensile loads on the gluteal tendons were investigated. MRI of the painful hip was examined by a radiologist, blind to clinical findings.

RESULTS

Pain reported within 30 s of standing on the affected limb conclusively moves a (nominal) 50% pretest probability of GT presence on MRI to a post-test probability of 98% (specificity 100%, positive likelihood ratio ∼12), whereas no pain on palpation (80% sensitivity) would rule out its presence. 20 participants (31%) had GT on MRI but clinically negative (ie, not positive on palpation and another test).

CONCLUSIONS

Keeping in mind that the sample size was small (ie, possibly underpowered for indices of diagnostic utility with low precision), the results of this study indicate that a patient who reports lateral hip pain within 30 s of single-leg-standing is very likely to have GT. Patients with lateral hip pain who are not palpably tender over the greater trochanter are unlikely to have MRI-detected GT.

Single leg stance control in individuals with symptomatic gluteal tendinopathy.

Allison, K., Bennell, K. L., Grimaldi, A., Vicenzino, B., Wrigley, T. V., & Hodges, P. W. (2016). Single leg stance control in individuals with symptomatic gluteal tendinopathy. Gait & Posture, 49, 108–113.

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BACKGROUND

Lateral hip pain during single leg loading, and hip abductor muscle weakness, are associated with gluteal tendinopathy, but it has not been shown how or whether kinematics in single leg stance differ in those with gluteal tendinopathy.

PURPOSE

To compare kinematics in preparation for, and during, single leg stance between individuals with and without gluteal tendinopathy, and the effect of hip abductor muscle strength on kinematics.

METHODS

Twenty individuals with gluteal tendinopathy and 20 age-matched pain-free controls underwent three-dimensional kinematic analysis of single leg stance and maximum isometric hip abductor strength testing. Maximum values of hip adduction, pelvic obliquity (contralateral pelvis rise/drop), lateral pelvic translation (ipsilateral/contralateral shift) and ipsilateral trunk lean during preparation for leg lift and average values in steady single leg stance, were compared between groups using an analysis of covariance, with and without anthropometric characteristics and strength as covariates.

RESULTS

Individuals with gluteal tendinopathy demonstrated greater hip adduction (standardized mean difference (SMD)=0.70, P=0.04) and ipsilateral pelvic shift (SMD=1.1, P=0.002) in preparation for leg lift, and greater hip adduction (SMD=1.2, P=0.002) and less contralateral pelvic rise (SMD=0.86, P=0.02) in steady single leg stance than controls. When including strength as a covariate, only between-group differences in lateral pelvic shift persisted (SMD=1.7, P=0.01).

CONCLUSION

Individuals with gluteal tendinopathy use different frontal plane kinematics of the hip and pelvis during single leg stance than pain-free controls. This finding is not influenced by pelvic dimension or the potentially modifiable factor of body mass index, but is by hip abductor muscle weakness.

Femoral shaft torsion in injured and uninjured ballet dancers and its association with other hip measures: a cross-sectional study.

Hafiz, E., Hiller, C. E., Nicholson, L. L., Nightingale, E. J., Grimaldi, A., & Refshauge, K. M. (2016). Femoral Shaft Torsion in Injured and Uninjured Ballet Dancers and Its Association with Other Hip Measures: A Cross-sectional Study. Journal of Dance Medicine & Science, 20(1), 3–10. https://doi.org/10.12678/1089-313x.20.1.3

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ABSTRACT

Low range femoral torsion, termed "lateral shaft torsion," has been associated with greater range of hip external rotation and turnout in dancers. It is also hypothesized that achieving greater turnout at the hip minimizes torsion at the knee, shank, ankle, and foot, and consequently reduces incidence of lower limb injuries. The primary aims of this study were to investigate: 1. differences in range of femoral shaft torsion between dancers with and without lower limb injuries; and 2. the relationship between femoral shaft torsion, hip external rotation range, and turnout. A secondary aim was to examine the relationship between femoral shaft torsion and other hip measures: hip strength, lower limb joint hypermobility, hip stability, and foot progression angle, as explanatory variables. Demographic, dance, and injury data were collected, along with physical measures of femoral shaft torsion, hip rotation range of motion, and turnout. Hip strength, control, lower limb hypermobility, and foot progression angle were also measured. Eighty female dancers, 50 with lower limb injury (20.7 ± 4.8 years of age) and 30 without lower limb injury (17.8 ± 4.1 years of age), participated in the study. There was no difference in range of femoral shaft torsion between the groups (p = 0.941). Femoral shaft torsion was weakly correlated with range of hip external rotation (r = -0.034, p = 0.384) and turnout (r = -0.066, p = 0.558). Injured dancers had a significantly longer training history than non-injured dancers (p = 0.001). It was concluded that femoral shaft torsion does not appear to be associated with the overall incidence of lower limb injury in dancers or to be a primary factor influencing extent of turnout in this population.

Kinematics and kinetics during walking in individuals with gluteal tendinopathy.

Allison, K., Wrigley, T. V., Vicenzino, B., Bennell, K. L., Grimaldi, A., & Hodges, P. W. (2016). Kinematics and kinetics during walking in individuals with gluteal tendinopathy. Clinical Biomechanics, 32, 56–63. https://doi.org/10.1016/j.clinbiomech.2016.01.003

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ABSTRACT

BACKGROUND

Lateral hip pain during walking is a feature of gluteal tendinopathy but little is known how walking biomechanics differ in individuals with gluteal tendinopathy. This study aimed to compare walking kinematics and kinetics between individuals with and without gluteal tendinopathy.

METHODS

Three-dimensional walking-gait analysis was conducted on 40 individuals aged 35 to 70 years with unilateral gluteal tendinopathy and 40 pain-free controls. An analysis of covariance was used to compare kinematic and kinetic variables between groups. Linear regression was performed to investigate the relationship between kinematics and external hip adduction moment in the gluteal tendinopathy group.

FINDINGS

Individuals with gluteal tendinopathy demonstrated a greater hip adduction moment throughout stance than controls (standardized mean difference ranging from 0.60 (first peak moment) to 0.90 (second peak moment)). Contralateral trunk lean at the time of the first peak hip adduction moment was 1.2 degrees greater (P=0.04), and pelvic drop at the second peak hip adduction moment 1.4 degrees greater (P=0.04), in individuals with gluteal tendinopathy. Two opposite trunk and pelvic strategies were also identified within the gluteal tendinopathy group. Contralateral pelvic drop was significantly correlated with the first (R=0.35) and second peak (R=0.57) hip adduction moment, and hip adduction angle with the second peak hip adduction moment (R=-0.36) in those with gluteal tendinopathy.

INTERPRETATION

Individuals with gluteal tendinopathy exhibit greater hip adduction moments and alterations in trunk and pelvic kinematics during walking. Findings provide a basis to consider frontal plane pelvic control in the management of gluteal tendinopathy.

Exercise and load modification versus corticosteroid injection versus‘wait and see’ for persistent gluteus medius/minimus tendinopathy (the LEAP trial): a protocol for a randomised clinical trial.

Mellor, R., Grimaldi, A., Wajswelner, H., Hodges, P., Abbott, J. H., Bennell, K., & Vicenzino, B. (2016). Exercise and load modification versus corticosteroid injection versus ‘wait and see’ for persistent gluteus medius/minimus tendinopathy (the LEAP trial): a protocol for a randomised clinical trial. BMC Musculoskeletal Disorders, 17(1), 196. https://doi.org/10.1186/s12891-016-1043-6

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BACKGROUND

Lateral hip pain is common, particularly in females aged 40-60 years. The pain can affect sleep and daily activities, and is frequently recalcitrant. The condition is often diagnosed as trochanteric bursitis, however radiological and surgical studies have revealed that the most common pathology is gluteus medius/minimus tendinopathy. Patients are usually offered three treatment options: (a) corticosteroid injection (CSI), (b) physiotherapy, or (c) reassurance and observation. Research on Achilles and patellar tendons has shown that load modification and exercise appears to be more effective than other treatments for managing tendinopathy, however, it is unclear whether a CSI, or a load modification and exercise-based physiotherapy approach is more effective in gluteal tendinopathy. This randomised controlled trial aims to compare the efficacy on pain and function of a load modification and exercise-based programme with a CSI and a 'wait and see' approach for gluteal tendinopathy.

METHODS

Two hundred one people with gluteal tendinopathy will be randomly allocated into one of three groups: (i) CSI; (ii) physiotherapist-administered load modification and exercise intervention; and (iii) wait and see approach. The CSI therapy will consist of one ultrasound (US) guided CSI around the affected tendons and advice on tendon care. Education about load modification will be delivered in physiotherapy clinics and the exercise programme will be both home-based and supervised. The group allocated the wait and see approach will receive basic tendon care advice and reassurance in a single session by a trial physiotherapist. Outcomes will be evaluated at baseline, 4, 8, 12, 26 and 52 weeks using validated global rating of change, pain and physical function scales, psychological measures, quality of life and physical activity levels. Hip abductor muscle strength will be measured at baseline and 8 weeks. Economic evaluation will be performed to investigate the cost-effectiveness of the active interventions compared with the wait and see approach. Analyses will be conducted on an intention-to-treat basis using logistic and linear mixed regression models and the economic evaluation will report incremental cost-utility ratios. The trial reporting will comply with CONSORT guidelines.

DISCUSSION

This study will provide clinicians with directly applicable evidence of the relative efficacy of three common approaches to the management of gluteal tendinopathy.

Hip abductor muscle weakness in individuals with gluteal tendinopathy.

Allison, K., Vicenzino, B., Wrigley, T. V., Grimaldi, A., Hodges, P. W., & Bennell, K. L. (2015). Hip Abductor Muscle Weakness in Individuals with Gluteal Tendinopathy. Medicine & Science in Sports & Exercise, 48(3), 346–352. https://doi.org/10.1249/mss.0000000000000781

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ABSTRACT

Purpose:

This study aimed to compare hip abductor muscle strength between individuals with symptomatic, unilateral gluteal tendinopathy (GT), and asymptomatic controls.

Methods:

Fifty individuals with GT age between 35 and 70 yr and 50 sex- and age-comparable controls were recruited from the community. Maximal isometric strength (torque normalized to body mass) of the hip abductors was recorded in the supine position using an instrumented manual muscle tester. A two-way mixed ANCOVA, with covariates of self-reported pain during testing and pain limiting maximum effort, was used to compare hip abductor strength of the symptomatic and asymptomatic hip between GT and control individuals. Data were expressed as mean and SD, with the pairwise comparisons expressed as mean differences and 95% confidence intervals.

Results:

Individuals with GT demonstrated significantly lower hip abductor torque of both their symptomatic and asymptomatic hip than healthy controls (both P G 0.05), with mean strength deficits of 0.35 NImIkgj1 (32%) on the symptomatic hip and 0.25 N.m.kg-1 (23%) on the asymptomatic hip. In individuals with GT, the symptomatic hip was significantly weaker than the asymptomatic hip with a mean strength deficit of 0.09 N.m.kg-1 (11%) (P G 0.05).

Conclusions:

People with unilateral GT demonstrate significant weakness of the hip abductor muscles bilaterally when compared with healthy controls. Although it is not clear whether hip weakness precedes GT or is a consequence of the condition, the findings provide a basis to consider hip abductor muscle weakness in the treatment plan for management of GT.

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