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Diener GL, Spahn G, Hofmann GO. Occupational Stress as a Possible Risk Factor for Rotator Cuff Damage - Systematic Review and Meta-analysis. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:289-295. [PMID: 36473486 DOI: 10.1055/a-1957-6140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE In September 2021, the Federal Ministry of Labour and Social Affairs in Germany (BMAS) recommended recognising rotator cuff lesions caused by occupational long-term overhead work, repetitive movements, hand-arm-vibration and carrying and lifting heavy loads as an occupational disease. To gain a more detailed understanding of the correlation between occupational risk factors and lesions of the rotator cuff, a systematic literature review was carried out to determine their influence on the development of rotator cuff disease. MATERIAL AND METHOD A systematic literature review was used to search in the databases PubMed, Cochrane and Web-of-Science for papers dealing with occupational shoulder load and associated shoulder disorders. The influence of overhead work, repetitive movements, hand-arm-vibrations and carrying and lifting heavy loads were examined. RESULTS 58 studies were read in full text, of which 13 papers were included in the meta-analysis. In all risk factors, a significant association can be found with the strongest dose-response relationship in "overhead work" and "repetitive movements": overhead work: 2.23 (95% CI 1.98-2.52), repetitive movements: 2.17 (95% CI 1.92-2.46), hand-arm-vibration: 1.59 (95% CI 1.13-2.23), carrying and lifting heavy loads: 1.57 (95% CI 1.15-2.15). CONCLUSION Although a significant effect could be shown in our study for all the four risk factors examined, due to the low number of studies with high-quality study design and insufficient pathophysiological explanation for the development of a rotator cuff disease in these mechanical activities, no reliable correlation can currently be established.
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Affiliation(s)
- Greta-Linn Diener
- Praxisklinik für Unfallchirurgie und Orthopädie, Eisenach, Deutschland
| | - Gunter Spahn
- Praxisklinik für Unfallchirurgie und Orthopädie, Eisenach, Deutschland
- Klinik für Unfall,- Hand- und Wiederherstellungschirurgie, Universitatsklinikum Jena, Jena, Deutschland
| | - Gunther O Hofmann
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena, Jena, Deutschland
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Kliniken Bergmannstrost, Halle, Deutschland
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Tedesco A, Sharma AK, Acharya N, Rublev G, Hashmi S, Wu HH, Lee YP, Scolaro J, Bhatia N. The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes. JBJS Rev 2024; 12:01874474-202404000-00004. [PMID: 38619394 DOI: 10.2106/jbjs.rvw.23.00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
» Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.» Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.» Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.» Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.» Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.
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Affiliation(s)
- Amanda Tedesco
- School of Medicine, University of California, Irvine, Irvine, California
| | - Abhinav K Sharma
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Nischal Acharya
- School of Medicine, University of California, Irvine, Irvine, California
| | - George Rublev
- David Tvildiani Medical University, Tbilisi, Georgia
| | - Sohaib Hashmi
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Hao-Hua Wu
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Yu-Po Lee
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - John Scolaro
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Nitin Bhatia
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
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Ramos-Barbero M, Rufino-Palomares EE, Serrano-Carmona S, Hernández-Yera M, García-Salguero L, Lupiáñez JA, Pérez-Jiménez A. Effect of Nutraceutical Factors on Hepatic Intermediary Metabolism in Wistar Rats with Induced Tendinopathy. Int J Mol Sci 2024; 25:629. [PMID: 38203800 PMCID: PMC10779845 DOI: 10.3390/ijms25010629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/27/2023] [Accepted: 12/30/2023] [Indexed: 01/12/2024] Open
Abstract
Tendinopathy (TP) is a complex clinical syndrome characterized by local inflammation, pain in the affected area, and loss of performance, preceded by tendon injury. The disease develops in three phases: Inflammatory phase, proliferative phase, and remodeling phase. There are currently no proven treatments for early reversal of this type of injury. However, the metabolic pathways of the transition metabolism, which are necessary for the proper functioning of the organism, are known. These metabolic pathways can be modified by a number of external factors, such as nutritional supplements. In this study, the modulatory effect of four dietary supplements, maslinic acid (MA), hydroxytyrosol (HT), glycine, and aspartate (AA), on hepatic intermediary metabolism was observed in Wistar rats with induced tendinopathy at different stages of the disease. Induced tendinopathy in rats produces alterations in the liver intermediary metabolism. Nutraceutical treatments modify the intermediary metabolism in the different phases of tendinopathy, so AA treatment produced a decrease in carbohydrate metabolism. In lipid metabolism, MA and AA caused a decrease in lipogenesis at the tendinopathy and increased fatty acid oxidation. In protein metabolism, MA treatment increased GDH and AST activity; HT decreased ALT activity; and the AA treatment does not cause any alteration. Use of nutritional supplements of diet could help to regulate the intermediary metabolism in the TP.
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Affiliation(s)
- Marta Ramos-Barbero
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, 18071 Granada, Spain; (M.R.-B.); (L.G.-S.); (J.A.L.)
| | - Eva E. Rufino-Palomares
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, 18071 Granada, Spain; (M.R.-B.); (L.G.-S.); (J.A.L.)
| | | | - Manuel Hernández-Yera
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, 18071 Granada, Spain; (M.R.-B.); (L.G.-S.); (J.A.L.)
| | - Leticia García-Salguero
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, 18071 Granada, Spain; (M.R.-B.); (L.G.-S.); (J.A.L.)
| | - José Antonio Lupiáñez
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, 18071 Granada, Spain; (M.R.-B.); (L.G.-S.); (J.A.L.)
| | - Amalia Pérez-Jiménez
- Department of Zoology, Faculty of Science, University of Granada, 18071 Granada, Spain
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谢 淘, 仲 鹤, 金 瑛, 刘 修, 陈 方, 向 宽, 吴 术. [Research on Runx2 gene induced differentiation of human amniotic mesenchymal stem cells into ligament fibroblasts in vitro and promotion of tendon-bone healing in rabbits]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:1523-1532. [PMID: 38130197 PMCID: PMC10739672 DOI: 10.7507/1002-1892.202306010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
Objective To investigate whether the Runx2 gene can induce the differentiation of human amniotic mesenchymal stem cells (hAMSCs) to ligament fibroblasts in vitro and promote the tendon-bone healing in rabbits. Methods hAMSCs were isolated from the placentas voluntarily donated from healthy parturients and passaged, and then identified by flow cytometric identification. Adenoviral vectors carrying Runx2 gene (Ad-Runx2) and empty vector adenovirus (Ad-NC) were constructed and viral titer assay; then, the 3rd generation hAMSCs were transfected with Ad-Runx2 (Ad-Runx2 group) or Ad-NC (Ad-NC group). The real-time fluorescence quantitative PCR and Western blot were used to detect Runx2 gene and protein expression to verify the effectiveness of Ad-Runx2 transfection of hAMSCs; and at 3 and 7 days after transfection, real-time fluorescence quantitative PCR was further used to detect the expressions of ligament fibroblast-related genes [vascular endothelial growth factor (VEGF), collagen type Ⅰ, Fibronectin, and Tenascin-C]. The hAMSCs were used as a blank control group. The hAMSCs, hAMSCs transfected with Ad-NC, and hAMSCs were mixed with Matrigel according to the ratio of 1 : 1 and 1 : 2 to construct the cell-scaffold compound. Cell proliferation was detected by cell counting kit 8 (CCK-8) assay, and the corresponding cell-scaffold compound with better proliferation were taken for subsequent animal experiments. Twelve New Zealand white rabbits were randomly divided into 4 groups of sham operation group (Sham group), anterior cruciate ligament reconstruction group (ACLR group), anterior cruciate ligament reconstruction+hAMSCs transfected with Ad-NC-scaffold compound group (Ad-NC group), and anterior cruciate ligament reconstruction+hAMSCs transfected with Ad-Runx2-scaffold compound group (Ad-Runx2 group), with 3 rabbits in each group. After preparing the ACL reconstruction model, the Ad-NC group and the Ad-Runx2 group injected the optimal hAMSCs-Matrigel compunds into the bone channel correspondingly. The samples were taken for gross, histological (HE staining and sirius red staining), and immunofluorescence staining observation at 1 month after operation to evaluate the inflammatory cell infiltration as well as collagen and Tenascin-C content in the ligament tissues. Results Flow cytometric identification of the isolated cells conformed to the phenotypic characteristics of MSCs. The Runx2 gene was successfully transfected into hAMSCs. Compared with the Ad-NC group, the relative expressions of VEGF and collagen type Ⅰ genes in the Ad-Runx2 group significantly increased at 3 and 7 days after transfection ( P<0.05), Fibronectin significantly increased at 3 days ( P<0.05), and Tenascin-C significantly increased at 3 days and decreased at 7 days ( P<0.05). CCK-8 detection showed that there was no significant difference ( P>0.05) in the cell proliferation between groups and between different time points after mixed culture of two ratios. So the cell-scaffold compound constructed in the ratio of 1∶1 was selected for subsequent experiments. Animal experiments showed that at 1 month after operation, the continuity of the grafted tendon was complete in all groups; HE staining showed that the tissue repair in the Ad-Runx2 group was better and there were fewer inflammatory cells when compared with the ACLR group and the Ad-NC group; sirius red staining and immunofluorescence staining showed that the Ad-Runx2 group had more collagen typeⅠ and Ⅲ fibers, tending to form a normal ACL structure. However, the fluorescence intensity of Tenascin-C protein was weakening when compared to the ACLR and Ad-NC groups. Conclusion Runx2 gene transfection of hAMSCs induces directed differentiation to ligament fibroblasts and promotes tendon-bone healing in reconstructed anterior cruciate ligament in rabbits.
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Affiliation(s)
- 淘 谢
- 遵义医科大学附属医院骨科(贵州遵义 563000)Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China
| | - 鹤鹤 仲
- 遵义医科大学附属医院骨科(贵州遵义 563000)Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China
| | - 瑛 金
- 遵义医科大学附属医院骨科(贵州遵义 563000)Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China
| | - 修齐 刘
- 遵义医科大学附属医院骨科(贵州遵义 563000)Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China
| | - 方 陈
- 遵义医科大学附属医院骨科(贵州遵义 563000)Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China
| | - 宽 向
- 遵义医科大学附属医院骨科(贵州遵义 563000)Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China
| | - 术红 吴
- 遵义医科大学附属医院骨科(贵州遵义 563000)Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China
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van Dam L, Terink R, Mensink M, de Vos RJ, Zwerver J. The JUMPFOOD study: additional effect of hydrolyzed collagen and vitamin C to exercise treatment for patellar tendinopathy (jumper's knee) in athletes-study protocol for a double-blind randomized controlled trial. Trials 2023; 24:768. [PMID: 38017500 PMCID: PMC10685530 DOI: 10.1186/s13063-023-07783-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 11/06/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Patellar tendinopathy (PT) is a common problem in jumping athletes. Management can be challenging and treatment outcome is not always successful. In combination with tendon loading exercises, hydrolyzed collagen/vitamin C supplementation appears to have a promising effect on the recovery of tendinopathy. The aim of this study is to evaluate whether the use of oral supplementation of hydrolyzed collagen and vitamin C in combination with progressive tendon loading exercises (PTLE) is superior to PTLE and placebo on VISA-P score (which rates pain, function, sports participation) after 24 weeks for athletes with PT. METHODS The JUMPFOOD study is a double-blinded, two-armed randomized controlled trial, in which the effectiveness of oral supplementation of hydrolyzed collagen/vitamin C combined with PTLE compared to PTLE with placebo on pain and recovery of function in athletes with PT will be investigated. Seventy-six athletes aged 16-40 years, with symptoms of PT for at least 12 weeks, who play sports at least once a week will be included. All participants will receive education, advice with regard to load management and a PTLE program according to the Dutch guidelines for anterior knee pain. In addition, the intervention group will receive daily 10 g hydrolyzed collagen and 40 mg vitamin C supplementation for 24 weeks whereas the control group receives 10 g maltodextrin placebo supplementation. Measurements will take place at baseline and at 12 and 24 weeks' follow-up. Primary outcome is the VISA-P score, which evaluates pain, function, and sports participation. For secondary outcome measures, data with regard to pain during functional tests, flexibility measurements, blood withdrawals, imaging characteristics of the tendon, and health questionnaires will be collected. During the follow-up period, participants will register sports participation, amount of training and tendon load, pain during sports, co-medication, and side-effects in a digital weekly diary. DISCUSSION The JUMPFOOD study is the first large RCT to study the effectiveness of hydrolyzed collagen/vitamin C supplementation in combination with the PTLE program in athletes with patellar tendinopathy. If supplementation of collagen/vitamin C appears to be effective, this treatment can be implemented in daily sports medicine practice to improve the treatment outcome of patients with PT. TRIAL REGISTRATION ClinicalTrials.gov NCT05407194. Registered on 7 June 2022.
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Affiliation(s)
- L van Dam
- Department of Sports Medicine, SportsValley, Hospital Gelderse Vallei, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands.
- Division of Human Nutrition and Health, Wageningen University & Research (WUR), Wageningen, The Netherlands.
| | - R Terink
- Department of Sports Medicine, SportsValley, Hospital Gelderse Vallei, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands
| | - M Mensink
- Division of Human Nutrition and Health, Wageningen University & Research (WUR), Wageningen, The Netherlands
| | - R J de Vos
- Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - J Zwerver
- Department of Sports Medicine, SportsValley, Hospital Gelderse Vallei, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Liu J, Wang W, Wang Z, Wu Q, Zhu Y, Wu W, Zhou Q. The Association between Dietary Habits and Rapid Postoperative Recovery of Rotator Cuff Repair. Nutrients 2023; 15:4587. [PMID: 37960241 PMCID: PMC10648498 DOI: 10.3390/nu15214587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Some nutritional factors have been suggested to improve postoperative outcomes in rotator cuff (RC) repair, but dietary effects on the recovery speed after the surgery remain undefined. To investigate the potential roles of dietary habits in this context, we analyzed the 12-month follow-up data of 55 patients with RC repair and found that these patients could be categorized into a rapid recovery group (n = 35) and slow recovery group (n = 20) according to their postoperative recovery patterns. Group-based logistic analysis revealed that habitual intakes of meat (OR = 1.84, 95%CI, 1.22-2.76, p = 0.003), fruits (OR = 2.33, 95%CI, 1.26-5.67, p = 0.01), and wheat-flour foods (OR = 1.62, 95%CI, 1.2-2.25, p = 0.002) were significantly associated with rapid recovery. Moreover, among all intakes of wheat-flour foods, intakes of steamed and boiled flour products were also associated with rapid recovery. Further mediation analysis showed that eosinophilic granulocytes (EOs) significantly mediated the association between rapid RC recovery and the habitual intakes of meat (mediation proportion = 17.5%, P-mediation < 0.0001), fruits (17.9%, p < 0.0001), and wheat-flour foods (11.4%, p < 0.0001). Thus, our study suggests that certain dietary habits play beneficial roles in the context of postoperative recovery for RC repair.
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Affiliation(s)
- Jiaxin Liu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China; (J.L.); (W.W.); (Y.Z.)
- State Key Laboratory of Genetic Engineering and MOE Key Laboratory of Contemporary Anthropology, Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai 200438, China; (Z.W.); (Q.W.)
- Rugao Research Institute of Longevity and Aging, Fudan University, Rugao 226500, China
| | - Wei Wang
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China; (J.L.); (W.W.); (Y.Z.)
| | - Zhifeng Wang
- State Key Laboratory of Genetic Engineering and MOE Key Laboratory of Contemporary Anthropology, Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai 200438, China; (Z.W.); (Q.W.)
- Rugao Research Institute of Longevity and Aging, Fudan University, Rugao 226500, China
| | - Qingyun Wu
- State Key Laboratory of Genetic Engineering and MOE Key Laboratory of Contemporary Anthropology, Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai 200438, China; (Z.W.); (Q.W.)
- Rugao Research Institute of Longevity and Aging, Fudan University, Rugao 226500, China
| | - Yunli Zhu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China; (J.L.); (W.W.); (Y.Z.)
| | - Weicheng Wu
- State Key Laboratory of Genetic Engineering and MOE Key Laboratory of Contemporary Anthropology, Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai 200438, China; (Z.W.); (Q.W.)
- Rugao Research Institute of Longevity and Aging, Fudan University, Rugao 226500, China
| | - Qi Zhou
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China; (J.L.); (W.W.); (Y.Z.)
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Baart AM, Terink R, Naeff M, Naeff E, Mensink M, Alsma J, Witteman BJM, Zwerver J. Factors associated with lower limb tendinopathy in a large cohort of runners: a survey with a particular focus on nutrition. BMJ Open Sport Exerc Med 2023; 9:e001570. [PMID: 37180970 PMCID: PMC10174009 DOI: 10.1136/bmjsem-2023-001570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives Lower limb tendinopathy (LLT) is highly prevalent in runners. Treatment can be challenging, and knowledge of risk factors may be valuable to develop preventive or treatment interventions for LLT. The aims of this study were (1) to assess the prevalence of three common LLTs (Achilles tendinopathy (AT), patellar tendinopathy and plantar fasciopathy) in a large cohort of Dutch and Belgian runners and (2) to investigate its association with potential risk factors, with a particular focus on nutritional factors in the habitual diet. Methods A total of 1993 runners were included in the study. They completed two online questionnaires: a general questionnaire on running habits and injuries and a Food Frequency Questionnaire. Runners with and without LLT were compared regarding personal characteristics, running characteristics and nutritional factors. Results The point prevalence for the three LLTs was 6%; 33% of the runners reported LLT in the past and 35% had either a current or past LLT. AT was the most prevalent type of LLT, and prevalence rates for all types of LLT were higher in men than women. Positive associations with LLT were observed for age and running years (men and women), running level and running distance (men). No associations between LLT and nutritional factors were observed. Conclusion One-third of this population of runners had ever experienced an LLT. These tendinopathies were associated with gender, age and running load, but not with nutritional factors.
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Affiliation(s)
- A Mireille Baart
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
- Sports Valley, Department of Sports Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Rieneke Terink
- Sports Valley, Department of Sports Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Mannes Naeff
- Sports Valley, Department of Sports Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Eelke Naeff
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marco Mensink
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
| | - Jelmer Alsma
- Rotterdam Marathon Study Group, Rotterdam, The Netherlands
| | - Ben J M Witteman
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Johannes Zwerver
- Sports Valley, Department of Sports Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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