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Carroll CC, Campbell NW, Lewis RL, Preston SE, Garrett CM, Winstone HM, Barker AC, Vanos JM, Stouder LS, Reyes C, Fortino MA, Goergen CJ, Hass ZJ, Campbell WW. Greater Protein Intake Emphasizing Lean Beef Does Not Affect Resistance Training-Induced Adaptations in Skeletal Muscle and Tendon of Older Women: A Randomized Controlled Feeding Trial. J Nutr 2024:S0022-3166(24)00169-X. [PMID: 38604504 DOI: 10.1016/j.tjnut.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/22/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Although experimental research supports that resistance training (RT), especially with greater dietary protein intake, improves muscle mass and strength in older adults, comparable research on tendons is needed. OBJECTIVES We assessed the effects of a protein-rich diet emphasizing lean beef, compared with 2 control diets, on RT-induced changes in skeletal muscle and tendon size and strength in older women. METHODS We randomly assigned women [age: 66 ± 1 y, body mass index (BMI): 28 ± 1] to groups that consumed 1) 0.8 g total protein/kg body weight/day from mixed food sources (normal protein control, n = 16); 2) 1.4 g/kg/d protein from mixed food sources (high protein control, n = 17); or 3) 1.4 g/kg/d protein emphasizing unprocessed lean beef (high protein experimental group, n = 16). Participants were provided with all foods and performed RT 3 times/wk, 70% of 1-repetition maximum for 12 wk. We measured quadriceps muscle volume via magnetic resonance imaging (MRI). We estimated patellar tendon biomechanical properties and cross-sectional area (CSA) using ultrasound and MRI. RESULTS Dietary intake did not influence RT-induced increases in quadriceps strength (P < 0.0001) or muscle volume (P < 0.05). We noted a trend for an RT effect on mean tendon CSA (P = 0.07), with no differences among diets (P > 0.05). Proximal tendon CSA increased with RT (P < 0.05) with no difference between dietary groups (P > 0.05). Among all participants, midtendon CSA increased with RT (P ≤ 0.05). We found a decrease in distal CSA in the 0.8 g group (P < 0.05) but no change in the 1.4 g group (P > 0.05). Patellar tendon MRI signal or biomechanical properties were unchanged. CONCLUSIONS Our findings indicated that greater daily protein intake, emphasizing beef, did not influence RT-induced changes in quadriceps muscle strength or muscle volume of older women. Although we noted trends in tendon CSA, we did not find a statistically significant impact of greater daily protein intake from beef on tendon outcomes. This trial was registered at clinicaltrials.gov as NCT04347447.
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Affiliation(s)
- Chad C Carroll
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States.
| | - Nathan Wc Campbell
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Rebecca L Lewis
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Sarah E Preston
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Chloe M Garrett
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Hannah M Winstone
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Anna C Barker
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Johnny M Vanos
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Lucas S Stouder
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Camila Reyes
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Matthew A Fortino
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States
| | - Craig J Goergen
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, United States; Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, United States
| | - Zachary J Hass
- School of Nursing, Purdue University, West Lafayette, IN, United States; School of Industrial Engineering, Purdue University, West Lafayette, IN, United States; Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, United States
| | - Wayne W Campbell
- Department of Nutrition Science, Purdue University, West Lafayette, IN, United States
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Patel SH, Campbell NWC, Emenim CE, Farino DO, Damen FW, Rispoli JV, Goergen CJ, Haus JM, Sabbaghi A, Carroll CC. Patellar tendon biomechanical and morphologic properties and their relationship to serum clinical variables in persons with prediabetes and type 2 diabetes. J Orthop Res 2024. [PMID: 38400550 DOI: 10.1002/jor.25816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/08/2024] [Accepted: 01/27/2024] [Indexed: 02/25/2024]
Abstract
Tendon biomechanical properties and fibril organization are altered in patients with diabetes compared to healthy individuals, yet few biomarkers have been associated with in vivo tendon properties. We investigated the relationships between in vivo imaging-based tendon properties, serum variables, and patient characteristics across healthy controls (n = 14, age: 45 ± 5 years, body mass index [BMI]: 24 ± 1, hemoglobin A1c [HbA1c]: 5.3 ± 0.1%), prediabetes (n = 14, age: 54 ± 5 years, BMI: 29 ± 2; HbA1c: 5.7 ± 0.1), and type 2 diabetes (n = 13, age: 55 ± 3 years, BMI: 33 ± 2, HbA1c: 6.7 ± 0.3). We used ultrasound speckle-tracking and measurements from magnetic resonance imaging (MRI) to estimate the patellar tendon in vivo tangent modulus. Analysis of plasma c-peptide, interleukin-1β (IL-1β), IL-6, IL-8, tumor necrosis factor-α (TNF-α), adiponectin, leptin, insulin-like growth factor 1 (IGF-1), and C-reactive protein (CRP) was completed. We built regression models incorporating statistically significant covariates and indicators for the clinically defined groups. We found that tendon cross-sectional area normalized to body weight (BWN CSA) and modulus were lower in patients with type 2 diabetes than in healthy controls (p < 0.05). Our regression analysis revealed that a model that included BMI, leptin, high-density lipoprotein (HDL), low-density lipoprotein (LDL), age, and group explained ~70% of the variability in BWN CSA (R2 = 0.70, p < 0.001). For modulus, including the main effects LDL, groups, HbA1c, age, BMI, cholesterol, IGF-1, c-peptide, leptin, and IL-6, accounted for ~54% of the variability in modulus (R2 = 0.54, p < 0.05). While BWN CSA and modulus were lower in those with diabetes, group was a poor predicter of tendon properties when considering the selected covariates. These data highlight the multifactorial nature of tendon changes with diabetes and suggest that blood variables could be reliable predictors of tendon properties.
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Affiliation(s)
- Shivam H Patel
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Nathan W C Campbell
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Chinonso E Emenim
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Dominick O Farino
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Frederick W Damen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Joseph V Rispoli
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Craig J Goergen
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Jacob M Haus
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Arman Sabbaghi
- Head of Clinical Methods, Unlearn.AI, San Francisco, California, USA
| | - Chad C Carroll
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
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Jiang XJ, Shen JJ, Huang JF, Tong PJ. Reconstruction of Myerson type III chronic Achilles tendon ruptures using semitendinosus tendon and gracilis tendon autograft. J Orthop Surg (Hong Kong) 2020; 27:2309499019832717. [PMID: 30808253 DOI: 10.1177/2309499019832717] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Reconstruction of Myerson type III (defect size more than 5 cm) chronic Achilles tendon ruptures (CATRs) is a surgical challenge due to its large Achilles tendon defect. This study aims to describe our operative technique for Myerson type III CATR and its clinical outcomes. PATIENTS AND METHODS From May 2012 to April 2015, we treated seven patients (6 males, 1 female) with Myerson type III CATR using semitendinosus tendon and gracilis tendon autograft. The mean age was 47.3 years (range: 37-56). Patients were followed for a mean time of 31.3 months. All patients' defect size between Achilles ends after debridement was more than 5 cm and hence classified as Myerson type III. The clinical outcomes were evaluated by visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Achilles tendon total rupture score (ATRS), and the Short Form 36 (SF-36). RESULTS All patients reported good postoperative clinical outcomes. The average AOFAS score increased from 54.29 points (range: 46-65 points) preoperatively to 97.57 points (range: 90-100 points) at last follow-up. The average ATRS increased from 51.43 points (range: 40-61 points) preoperatively to 92.71 points (range: 83-100 points) at last follow-up. And the average VAS for pain was 0 at the last follow-up. The mean value of SF-36 physical increased from 32.14 points (range: 25-35 points) to 90 points (range: 80-95 points). And the mean value of SF-36 mental was improved from 37.14 points (range: 32-40 points) to 90.86 points (range: 84-96 points). CONCLUSIONS Semitendinosus tendon combined gracilis tendon autograft is a safe and effective technique in the reconstruction of Myerson type III CATR.
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Affiliation(s)
- Xian-Jun Jiang
- 1 The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, China.,2 Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Jian-Jian Shen
- 3 Department of Orthopaedics, Affiliated Cixi Hospital of Wenzhou Medical University, Cixi, China
| | - Jie-Feng Huang
- 1 The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, China.,2 Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Pei-Jian Tong
- 1 The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, China.,2 Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
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Lenskjold A, Kongsgaard M, Larsen JO, Nielsen RH, Kovanen V, Aagaard P, Kjaer M, Magnusson SP. The influence of physical activity during youth on structural and functional properties of the Achilles tendon. Scand J Med Sci Sports 2013; 25:25-31. [DOI: 10.1111/sms.12143] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2013] [Indexed: 12/22/2022]
Affiliation(s)
- A. Lenskjold
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - M. Kongsgaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - J. O. Larsen
- Department of Neuroscience and Pharmacology; University of Copenhagen; Copenhagen Denmark
| | - R. H. Nielsen
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - V. Kovanen
- Gerontology Research Center, Department of Health Sciences; University of Jyväskylä; Jyväskylä Finland
| | - P. Aagaard
- Institute of Sports Exercise and Clinical Biomechanics, SDU Muscle Research Cluster (SMRC); University of Southern Denmark; Odense Denmark
| | - M. Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - S. P. Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
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Freund W, Faust S, Birklein F, Gaser C, Wunderlich AP, Müller M, Billich C, Juchems MS, Schmitz BL, Grön G, Schütz UH. Substantial and reversible brain gray matter reduction but no acute brain lesions in ultramarathon runners: experience from the TransEurope-FootRace Project. BMC Med 2012; 10:170. [PMID: 23259507 PMCID: PMC3566943 DOI: 10.1186/1741-7015-10-170] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 12/21/2012] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND During the extremely challenging 4,487 km ultramarathon TransEurope-FootRace 2009, runners showed considerable reduction of body weight. The effects of this endurance run on brain volume changes but also possible formation of brain edema or new lesions were explored by repeated magnetic resonance imaging (MRI) studies. METHODS A total of 15 runners signed an informed consent to participate in this study of planned brain scans before, twice during, and about 8 months after the race. Because of dropouts, global gray matter volume analysis could only be performed in ten runners covering three timepoints, and in seven runners who also had a follow-up scan. Scanning was performed on three identical 1.5 T Siemens MAGNETOM Avanto scanners, two of them located at our university. The third MRI scanner with identical sequence parameters was a mobile MRI unit escorting the runners. Volumetric 3D datasets were acquired using a magnetization prepared rapid acquisition gradient echo (MPRAGE) sequence. Additionally, diffusion-weighted (DWI) and fluid attenuated inversion recovery (FLAIR) imaging was performed. RESULTS Average global gray matter volume as well as body weight significantly decreased by 6% during the race. After 8 months, gray matter volume returned to baseline as well as body weight. No new brain lesions were detected by DWI or FLAIR imaging. CONCLUSIONS Physiological brain volume reduction during aging is less than 0.2% per year. Therefore a volume reduction of about 6% during the 2 months of extreme running appears to be substantial. The reconstitution in global volume measures after 8 months shows the process to be reversible. As possible mechanisms we discuss loss of protein, hypercortisolism and hyponatremia to account for both substantiality and reversibility of gray matter volume reductions. Reversible brain volume reduction during an ultramarathon suggests that extreme running might serve as a model to investigate possible mechanisms of transient brain volume changes. However, despite massive metabolic load, we found no new lesions in trained athletes participating in a multistage ultramarathon.See related commentary http://www.biomedcentral.com/1741-7015/10/171.
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Affiliation(s)
- Wolfgang Freund
- Department of Diagnostic and Interventional Radiology, University Hospitals Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
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Tardioli A, Malliaras P, Maffulli N. Immediate and short-term effects of exercise on tendon structure: biochemical, biomechanical and imaging responses. Br Med Bull 2012; 103:169-202. [PMID: 22279080 DOI: 10.1093/bmb/ldr052] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Introduction Tendons are metabolically active structures, and their biochemical, biomechanical and structural properties adapt to chronic exercise. However, abnormal adaptations may lead to the development of tendinopathy and pain. Acute and subacute adaptations might contribute to tendon pathology. Sources of data A systematic search of peer-reviewed articles was performed using a wide range of electronic databases. A total of 61 publications were selected. Areas of agreement Exercise induces acute responses in collagen turnover, blood flow, glucose, lactate and other inflammatory products (e.g. prostaglandins and interleukins). Mechanical properties are influenced by activity duration and intensity. Acute bouts of exercise affect tendon structure, with some of the changes resembling those reported in pathological tendons. Areas of controversy Given the variation in study designs, measured parameters and outcomes, it remains debatable how acute exercise influences overall tendon properties. There is discrepancy regarding which investigation modality and settings provide optimal assessment of each parameter. Growing points There is a need for greater homogeneity between study designs, including subject consortium and age, exercise protocols and time frames for parameter assessing. Areas timely for developing research Innovative methods, measuring each parameter simultaneously, would allow a greater understanding of how and when changes occur. This methodology is key to revealing pathological processes and pathways that alter tendon properties according to various activities. Optimal tendon properties differ between activities: more compliant tendons are beneficial for slow stretch shortening cycle (SSC) activities such as countermovement jumps, whereas stiffer tendons are considered beneficial for fast SSC movements such as sprinting.
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Affiliation(s)
- Alex Tardioli
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry,Mile End Hospital, London, UK
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Schütz UHW, Schmidt-Trucksäss A, Knechtle B, Machann J, Wiedelbach H, Ehrhardt M, Freund W, Gröninger S, Brunner H, Schulze I, Brambs HJ, Billich C. The TransEurope FootRace Project: longitudinal data acquisition in a cluster randomized mobile MRI observational cohort study on 44 endurance runners at a 64-stage 4,486 km transcontinental ultramarathon. BMC Med 2012; 10:78. [PMID: 22812450 PMCID: PMC3409063 DOI: 10.1186/1741-7015-10-78] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 07/19/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The TransEurope FootRace 2009 (TEFR09) was one of the longest transcontinental ultramarathons with an extreme endurance physical load of running nearly 4,500 km in 64 days. The aim of this study was to assess the wide spectrum of adaptive responses in humans regarding the different tissues, organs and functional systems being exposed to such chronic physical endurance load with limited time for regeneration and resulting negative energy balance. A detailed description of the TEFR project and its implemented measuring methods in relation to the hypotheses are presented. METHODS The most important research tool was a 1.5 Tesla magnetic resonance imaging (MRI) scanner mounted on a mobile unit following the ultra runners from stage to stage each day. Forty-four study volunteers (67% of the participants) were cluster randomized into two groups for MRI measurements (22 subjects each) according to the project protocol with its different research modules: musculoskeletal system, brain and pain perception, cardiovascular system, body composition, and oxidative stress and inflammation. Complementary to the diverse daily mobile MR-measurements on different topics (muscle and joint MRI, T2*-mapping of cartilage, MR-spectroscopy of muscles, functional MRI of the brain, cardiac and vascular cine MRI, whole body MRI) other methods were also used: ice-water pain test, psychometric questionnaires, bioelectrical impedance analysis (BIA), skinfold thickness and limb circumference measurements, daily urine samples, periodic blood samples and electrocardiograms (ECG). RESULTS Thirty volunteers (68%) reached the finish line at North Cape. The mean total race speed was 8.35 km/hour. Finishers invested 552 hours in total. The completion rate for planned MRI investigations was more than 95%: 741 MR-examinations with 2,637 MRI sequences (more than 200,000 picture data), 5,720 urine samples, 244 blood samples, 205 ECG, 1,018 BIA, 539 anthropological measurements and 150 psychological questionnaires. CONCLUSIONS This study demonstrates the feasibility of conducting a trial based centrally on mobile MR-measurements which were performed during ten weeks while crossing an entire continent. This article is the reference for contemporary result reports on the different scientific topics of the TEFR project, which may reveal additional new knowledge on the physiological and pathological processes of the functional systems on the organ, cellular and sub-cellular level at the limits of stress and strain of the human body. Please see related articles: http://www.biomedcentral.com/1741-7015/10/76 and http://www.biomedcentral.com/1741-7015/10/77.
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Affiliation(s)
- Uwe H W Schütz
- Department of Diagnostic and Interventional Radiology, University Hospital of Ulm, Germany.
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Freund W, Weber F, Billich C, Schuetz UH. The foot in multistage ultra-marathon runners: experience in a cohort study of 22 participants of the Trans Europe Footrace Project with mobile MRI. BMJ Open 2012; 2:e001118. [PMID: 22619270 PMCID: PMC3364457 DOI: 10.1136/bmjopen-2012-001118] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 04/24/2012] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES 67 runners participated in the Trans Europe FootRace 2009 (TEFR09), a 4487 km (2789 mi) multistage ultra-marathon covering the south of Europe (Bari, Italy) to the North Cape. Reports on ultra-marathons are lacking, but the literature reports overuse injuries in athletes, especially to the Achilles tendon (AT), ankle or hind foot. Bone oedema may be related to exposure and is present in fatigue fractures. Therefore, the aim of this study was to determine prospectively if sustained maximal load during an ultra-marathon leads to damage to the foot. DESIGN AND PARTICIPANTS In a cohort study, repeated scanning of the 22 athletes participating in the study was performed before and during (approximately every 1000 km) the race. Using the obtained fat saturated inversion recovery sequence, two experienced readers blinded to the clinical data rated the images regarding foot lesions. Statistical analysis included regression analysis and computation of the inter-rater reliability. SETTING The TEFR09 course. MRI scanning was performed according to prearranged schedules for every participant, using a mobile 1.5 Tesla MRI unit on a trailer following the race. PRIMARY OUTCOME MEASURES MRI data such as AT diameter, bone or tendon lesions, subcutaneous, plantar fascia or intraosseous oedema. RESULTS The 22 study participants did not differ significantly from the total of the 67 TEFR09 runners regarding height, weight and age. The AT diameter increased significantly from 6.8 to 7.8 mm as did intraosseous signal, bone lesions and subcutaneous oedema. However, finishers differed only regarding plantar aponeurosis and subcutaneous oedema from participants aborting the TEFR09. Inter-rater reliability was 0.88-0.98. CONCLUSION Under the extreme stress of the TEFR09, an increase of the AT diameter as well as bone signal are thought to be adaptive since only subcutaneous oedema and plantar fascia oedema were related to abortion of the race. TRIAL REGISTRATION NUMBER University of Ulm, Germany Ethics Committee Number 78/08-UBB/se.
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Affiliation(s)
- Wolfgang Freund
- Department of Diagnostic and Interventional Radiology, University Hospitals, Ulm, Germany
| | - Frank Weber
- Department of Neurology, German Armed Forces Hospital, Ulm, Germany
| | - Christian Billich
- Department of Diagnostic and Interventional Radiology, University Hospitals, Ulm, Germany
| | - Uwe H Schuetz
- Department of Diagnostic and Interventional Radiology, University Hospitals, Ulm, Germany
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