Fatigue responses of human triceps surae muscles during repetitive maximal isometric contractions

Muscle Strength Preservation During Repeated Sets of Fatiguing Resistance Exercise: A Secondary Analysis

ABSTRACT

Nuzzo, JL. Muscle strength preservation during repeated sets of fatiguing resistance exercise: A secondary analysis. J Strength Cond Res 38(6): 1149-1156, 2024-During sustained or repeated maximal voluntary efforts, muscle fatigue (acute strength loss) is not linear. After a large initial decrease, muscle strength plateaus at approximately 40% of baseline. This plateau, which likely reflects muscle strength preservation, has been observed in sustained maximal isometric and repeated maximal isokinetic contractions. Whether this pattern of fatigue occurs with traditional resistance exercise repetitions with free weights and weight stack machines has not been overviewed. Here, the aim was to determine whether the number of repetitions completed across 4 or more consecutive repetitions-to-failure tests exhibits the same nonlinear pattern of muscle fatigue. A secondary analysis was applied to data extracted as part of a recent meta-analysis on repetitions-to-failure tests. Studies were eligible if they reported mean number of repetitions completed in 4-6 consecutive repetitions-to-failure tests at a given relative load. Twenty-nine studies were included. Overall, the results show that the number of repetitions completed in consecutive repetitions-to-failure tests at a given load generally decreases curvilinearly. The numbers of repetitions completed in sets 2, 3, 4, 5, and 6 were equal to approximately 70, 55, 50, 45, and 45% of the number of repetitions completed in set 1, respectively. Longer interset rest intervals typically attenuated repetition loss, but the curvilinear pattern remained. From the results, a chart was created to predict the number of repetitions across 6 sets of resistance exercise taken to failure based on the number of repetitions completed in set 1. The chart is a general guide and educational tool. It should be used cautiously. More data from a variety of exercises, relative loads, and interset rest intervals are needed for more precise estimates of number of repetitions completed during repeated sets of fatiguing resistance exercise.

In vivo human medial gastrocnemius fascicle behaviour and belly gear during submaximal eccentric contractions are not affected by concentric fatiguing exercise

Changes in muscle geometry and belly gearing during eccentric contractions influence fibre strain and susceptibility to muscle damage. They are modulated by the interaction between connective tissues and intracellular-intrafascicular fluid pressures and external pressures from neighbouring structures. Fatiguing exercise triggers fluid shifts (muscle swelling) and muscle activation changes that may influence these modulators. Our purpose was to measure medial gastrocnemius (MG) geometric changes in vivo during eccentric contractions before and after maximal concentric muscle work to test the hypothesis that fatigue would reduce fascicle rotation and muscle gear and provoke greater fascicle strain. Submaximal eccentric plantar flexor contractions at 40% and 60% of maximal eccentric torque were performed on an isokinetic dynamometer at 5°.s-1 before and immediately after the fatiguing exercise. MG fascicles and muscle-tendon junction were captured using ultrasonography during contractions, allowing quantification of geometric changes, whole-MG length, and belly gear (Δmuscle length/Δfascicle length). Triceps surae (TS) activation was estimated using surface electromyography and the distribution of activations between synergistic muscles was then determined. After exercise, concentric torque decreased ∼39% and resting muscle thickness increased by 4%, indicating muscle fatigue and swelling, respectively. While soleus (Sol) activation and the Sol/TS ratio increased, no changes in MG, MG/TS ratio or fascicle rotation during the contraction were detected. Thus, fascicle lengthening and belly gear remained unaltered. Changes in muscle thickness during contraction was also similar before and after exercise, suggesting that changes in muscle shape were relatively unaffected by the exercise. Consequently, the muscle maintained mechanical integrity after the fatiguing muscle work.

Faster triceps surae muscle cyclic contractions alter muscle activity and whole body metabolic rate

Hundred years ago, Fenn demonstrated that when a muscle shortens faster, its energy liberation increases. Fenn's results were the first of many that led to the general understanding that isometric muscle contractions are energetically cheaper than concentric contractions. However, this evidence is still primarily based on single fiber or isolated (ex vivo) muscle studies and it remains unknown whether this translates to whole body metabolic rate. In this study, we specifically changed the contraction velocity of the ankle plantar flexors and quantified the effects on triceps surae muscle activity and whole body metabolic rate during cyclic plantar flexion (PF) contractions. Fifteen participants performed submaximal ankle plantar flexions (∼1/3 s activation and ∼2/3 s relaxation) on a dynamometer at three different ankle angular velocities: isometric (10° PF), isokinetic at 30°/s (5-15° PF), and isokinetic at 60°/s (0-20° PF) while target torque (25% MVC) and cycle frequency were kept constant. In addition, to directly determine the effect of ankle angular velocity on muscle kinematics we collected gastrocnemius medialis muscle fascicle ultrasound data. As expected, increasing ankle angular velocity increased gastrocnemius medialis muscle fascicle contraction velocity and positive mechanical work (P < 0.01), increased mean and peak triceps surae muscle activity (P < 0.01), and considerably increased net whole body metabolic rate (P < 0.01). Interestingly, the increase in triceps surae muscle activity with fast ankle angular velocities was most pronounced in the gastrocnemius lateralis (P < 0.05). Overall, our results support the original findings from Fenn in 1923 and we demonstrated that greater triceps surae muscle contraction velocities translate to increased whole body metabolic rate.NEW & NOTEWORTHY Single muscle fiber studies or research on isolated (ex vivo) muscles demonstrated that faster concentric muscle contractions yield increased energy consumption. Here we translated this knowledge to muscle activation and whole body metabolic rate. Increasing ankle angular velocity increased triceps surae contraction velocity and mechanical work, increasing triceps surae muscle activity and substantially elevating whole body metabolic rate. Additionally, we demonstrated that triceps surae muscle activation strategy depends on the mechanical demands of the task.

Shorter muscle fascicle operating lengths increase the metabolic cost of cyclic force production

During locomotion, force-producing limb muscles are predominantly responsible for an animal's whole body metabolic energy expenditure. Animals can change the length of their force-producing muscle fascicles by altering body posture (e.g., joint angles), the structural properties of their biological tissues over time (e.g., tendon stiffness), or the body's kinetics (e.g., body weight). Currently, it is uncertain whether relative muscle fascicle operating lengths have a measurable effect on the metabolic energy expended during cyclic locomotion-like contractions. To address this uncertainty, we quantified the metabolic energy expenditure of human participants, as they cyclically produced two distinct ankle moments at three ankle angles (90°, 105°, and 120°) on a fixed-position dynamometer using their soleus. Overall, increasing participant ankle angle from 90° to 120° (more plantar flexion) reduced minimum soleus fascicle length by 17% (both moment levels, P < 0.001) and increased metabolic energy expenditure by an average of 208% across both moment levels (both P < 0.001). For both moment levels, the increased metabolic energy expenditure was not related to greater fascicle positive mechanical work (higher moment level, P = 0.591), fascicle force rate (both P ≥ 0.235), or model-estimated active muscle volume (both P ≥ 0.122). Alternatively, metabolic energy expenditure correlated with average relative soleus fascicle length (r = -0.72, P = 0.002) and activation (r = 0.51, P < 0.001). Therefore, increasing active muscle fascicle operating lengths may reduce metabolic energy expended during locomotion.NEW & NOTEWORTHY During locomotion, active muscles undergo cyclic length-changing contractions. In this study, we isolated confounding variables and revealed that cyclically producing force at relatively shorter fascicle lengths increases metabolic energy expenditure. Therefore, muscle fascicle operating lengths likely have a measurable effect on the metabolic energy expenditure during locomotion.

Submaximal fatiguing contractions reduce stability of voluntary postural control more than maximal fatiguing contractions

BACKGROUND

It is well known that different exercise intensities for the ankle muscles can impair postural stability. However, it remains unclear whether it is low-intensity exercises (which primarily induce central fatigue) or high-intensity exercises (which primarily induce peripheral fatigue) that have a greater effect on voluntary postural control.

RESEARCH QUESTION

The aim of this study was to compare the effects of fatiguing exercises that induce either central or peripheral fatigue on voluntary postural stability.

METHODS

Following isometric maximum voluntary contraction (IMVC) tests, 12 volunteers randomly performed submaximal (40% IMVC) and maximal (100% IMVC) fatiguing contractions of the plantar flexors on a dynamometer. Before and after the fatiguing protocols, postural stability was assessed by measuring the centre of pressure trajectory during voluntary sways on a force plate. The electromyography activity of the right gastrocnemius medialis was recorded. To assess central and peripheral fatigue, electrical stimulations were applied both during and after the IMVC. The effects of the fatiguing protocols and the differences between the protocols were tested with a two-way repeated measures ANOVA test (fatigue × time).

RESULTS

Submaximal contractions induced a greater increase of sway area and medial-lateral sway cycle range than maximal contractions (P < 0.01). Voluntary activation decreased significantly more after submaximal contractions than maximal contractions (P < 0.01). Submaximal contractions induced a significantly greater reduction of IMVC than maximal contractions (P < 0.01). Resting twitch size was smaller after maximal contractions than submaximal contractions (P = 0.04).

SIGNIFICANCE

The outcome of this study suggests that training programmes for patients with balance issues should be based on training with maximal rather than submaximal load, to avoid deficits that might compromise postural stability.

A mathematical model-based approach to optimize loading schemes of isometric resistance training sessions

Individualized resistance training is necessary to optimize training results. A model-based optimization of loading schemes could provide valuable impulses for practitioners and complement the predominant manual program design by customizing the loading schemes to the trainee and the training goals. We compile a literature overview of model-based approaches used to simulate or optimize the response to single resistance training sessions or to long-term resistance training plans in terms of strength, power, muscle mass, or local muscular endurance by varying the loading scheme. To the best of our knowledge, contributions employing a predictive model to algorithmically optimize loading schemes for different training goals are nonexistent in the literature. Thus, we propose to set up optimal control problems as follows. For the underlying dynamics, we use a phenomenological model of the time course of maximum voluntary isometric contraction force. Then, we provide mathematical formulations of key performance indicators for loading schemes identified in sport science and use those as objective functionals or constraints. We then solve those optimal control problems using previously obtained parameter estimates for the elbow flexors. We discuss our choice of training goals, analyze the structure of the computed solutions, and give evidence of their real-life feasibility. The proposed optimization methodology is independent from the underlying model and can be transferred to more elaborate physiological models once suitable ones become available.

Cyclically producing the same average muscle-tendon force with a smaller duty increases metabolic rate

Ground contact duration and stride frequency each affect muscle metabolism and help scientists link walking and running biomechanics to metabolic energy expenditure. While these parameters are often used independently, the product of ground contact duration and stride frequency (i.e. duty factor) may affect muscle contractile mechanics. Here, we sought to separate the metabolic influence of the duration of active force production, cycle frequency and duty factor. Human participants produced cyclic contractions using their soleus (which has a relatively homogeneous fibre type composition) at prescribed cycle-average ankle moments on a fixed dynamometer. Participants produced these ankle moments over short, medium and long durations while maintaining a constant cycle frequency. Overall, decreased duty factor did not affect cycle-average fascicle force (p ≥ 0.252) but did increase net metabolic power (p ≤ 0.022). Mechanistically, smaller duty factors increased maximum muscle-tendon force (p < 0.001), further stretching in-series tendons and shifting soleus fascicles to shorter lengths and faster velocities, thereby increasing soleus total active muscle volume (p < 0.001). Participant soleus total active muscle volume well-explained net metabolic power (r = 0.845; p < 0.001). Therefore, cyclically producing the same cycle-average muscle-tendon force using a decreased duty factor increases metabolic energy expenditure by eliciting less economical muscle contractile mechanics.

Exhaustion of Skeletal Muscle Fibers Within Seconds: Incorporating Phosphate Kinetics Into a Hill-Type Model

Initiated by neural impulses and subsequent calcium release, skeletal muscle fibers contract (actively generate force) as a result of repetitive power strokes of acto-myosin cross-bridges. The energy required for performing these cross-bridge cycles is provided by the hydrolysis of adenosine triphosphate (ATP). The reaction products, adenosine diphosphate (ADP) and inorganic phosphate (P i ), are then used-among other reactants, such as creatine phosphate-to refuel the ATP energy storage. However, similar to yeasts that perish at the hands of their own waste, the hydrolysis reaction products diminish the chemical potential of ATP and thus inhibit the muscle's force generation as their concentration rises. We suggest to use the term "exhaustion" for force reduction (fatigue) that is caused by combined P i and ADP accumulation along with a possible reduction in ATP concentration. On the basis of bio-chemical kinetics, we present a model of muscle fiber exhaustion based on hydrolytic ATP-ADP-P i dynamics, which are assumed to be length- and calcium activity-dependent. Written in terms of differential-algebraic equations, the new sub-model allows to enhance existing Hill-type excitation-contraction models in a straightforward way. Measured time courses of force decay during isometric contractions of rabbit M. gastrocnemius and M. plantaris were employed for model verification, with the finding that our suggested model enhancement proved eminently promising. We discuss implications of our model approach for enhancing muscle models in general, as well as a few aspects regarding the significance of phosphate kinetics as one contributor to muscle fatigue.

Strength and Electromyographic Responses of Upper and Lower Limbs During Maximal Intermittent Contractions in Males and Females

Carr, JC and Ye, X. Strength and electromyographic responses of upper and lower limbs during maximal intermittent contractions in males and females. J Strength Cond Res XX(X): 000-000, 2020-This study examined the strength and electromyographic (EMG) responses of upper vs. lower limb muscles during intermittent maximal contractions in both sexes. Twenty subjects (n = 7 women) performed a fatiguing protocol (6, 30-second intermittent maximal isometric contractions with a 50% duty cycle) with either the elbow flexors or the knee extensors on separate visits. Bipolar surface EMG signals were detected from the biceps brachii and vastus lateralis muscles (n = 5 women retained). Women maintained more of their maximal force than men (Δforce: men vs. women = -55.0 ± 12.8% vs. -43.3 ± 9.9%, p = 0.042). Although force loss was similar between the elbow flexors and knee extensors, the EMG responses showed greater reductions for the biceps brachii than those for the vastus lateralis (Δamplitude: biceps brachii vs. vastus lateralis: -32.0 ± 22.3% vs. -18.9 ± 28.9%; Δmedian frequency: biceps brachii vs. vastus lateralis: -31.1 ± 14.5% vs. -10.3 ± 17.0%). During a series of maximal intermittent isometric contractions with 30 seconds of recovery between work bouts, women are more fatigue resistant than men. In addition, the greater electrophysiological fatigue exhibited by the biceps brachii than that by the vastus lateralis suggests that high-intensity contractions involving elbow flexion will have a greater rate of fatigue progression than those involving knee extension.

Active recovery has a positive and acute effect on recovery from fatigue induced by repeated maximal voluntary contractions of the plantar flexors

This study investigated the acute effect of active recovery (AR) following fatigue induced by 80 three-second maximal voluntary isometric plantar flexion contractions (MVICs) in 12 young men. AR consisted of a total of 180 voluntary isometric ramp contractions of the plantar flexors (0.75-s contraction/relaxation) targeting 10% of MVIC torque. MVIC torque, voluntary activation and root mean square values of electromyographic signals for the triceps surae normalized by each peak-to-peak amplitude of compound motor action potential were determined before, and immediately, 10, 20 and 30 min after the fatiguing task. Evoked torques were similarly assessed except for immediately after it. The AR and passive recovery were randomly performed on two days by each participant between 5 min and 10 min after the fatiguing task. For all the parameters other than MVIC torque, there was no significant difference between the conditions at any time point. MVIC torque decreased significantly immediately after the fatiguing task regardless of condition (P < 0.05), and the corresponding decrease in MVIC torque recovered 30 min after the fatiguing task only in AR (P < 0.05). These results suggest an acute positive effect of AR on recovery of neuromuscular function and/or contractile properties after fatigue.

Effect of knee joint angle on the neuromuscular activation of the quadriceps femoris during repetitive fatiguing contractions

We assessed the effect of knee joint angle on the EMG amplitude and frequency of the four individual muscles in the quadriceps femoris during repetitive fatiguing maximum voluntary contractions (MVCs). Fifteen healthy men and women performed two fatiguing tasks consisting of 40 MVCs in flexion (80°) and extension (140˚) (full extension = 180˚). Neuromuscular activation of the vastus intermedius (VI), vastus lateralis (VL), vastus medialis (VM), and rectus femoris (RF) was recorded using surface electrodes, and median frequency (MF) and root mean square (RMS) of electromyographic (EMG) signals (normalized by pre-test MVCs) were calculated. MVCs significantly decreased from the 10th to the 40th repetition in both flexion and extension. The MFs of VI and VM in flexion and that of RF flexion and extension were significantly decreased after the 10th repetition. There were no significant changes in normalized EMG amplitude in any muscles specific to knee angle. Stepwise regression analysis suggested that predictive synergistic action may occur in RF/VM and RF/VI in flexion and in RF/VM in extension. This suggest that EMG MF of RF/VM is independent, but that of RF/VI and RF/VL is dependent upon knee joint angle, which may, in part, explain joint angle-specific muscle fatigue.

Vestibular-Evoked Responses Indicate a Functional Role for Intrinsic Foot Muscles During Standing Balance

Maintaining standing balance involves multisensory processing and integration to produce dynamic motor responses. Electrical vestibular stimulation (EVS) delivered over the mastoid processes can be used to explore the vestibular control of balance. The purpose of this study was to determine whether intrinsic foot muscles exhibit vestibular-evoked balance responses and to characterize the traits associated with these responses. Electromyography (EMG) of the abductor hallucis (AH), abductor digiti minimi (ADM) and medial gastrocnemius (MG) and anterior-posterior (AP) forces were sampled while quietly standing participants were subjected to a random continuous EVS signal (peak-to-peak amplitude = ±3 mA). The relationship between EVS input and motor output was characterized in both the frequency (coherence) and time (cumulant density) domains. When head orientation was rotated in yaw from left to right, the biphasic cumulant density function was inverted for all muscle (EVS-EMG) and whole-body (EVS-AP forces) balance responses. When vision was occluded, the EVS-EMG and EVS-AP forces coherence function amplitude increased at low frequencies (<2 Hz) and was accompanied by a heightened medium-latency peak amplitude for all muscles as well as the whole-body balance response (AP forces) compared to when static visual cues were present. The enhanced coherence amplitudes at lower frequencies may highlight a mechanism for the increase in postural sway from vision to occluded vision. The current findings indicate that the vestibular control of standing balance can be represented by the intrinsic foot muscles and implicate a postural role for these muscles in modulating quiet standing.

EFEITO AGUDO DO LASER DE BAIXA POTÊNCIA NA FADIGA DO BÍCEPS BRAQUIAL DE ATLETAS DE VOLEIBOL

RESUMO Introdução: A laserterapia de baixa potência tem entre seus propósitos auxiliar a recuperação de tecidos biológicos, atenuando os efeitos da fadiga muscular e contribuindo com a melhora do desempenho em atletas. Aspectos metodológicos ainda limitam as conclusões do efeito agudo da laserterapia sobre o desempenho muscular. Objetivo: Verificar o efeito agudo do laser terapêutico de baixa potência na fadiga induzida do bíceps braquial de atletas de voleibol. Métodos: Este foi um estudo randomizado e duplo-cego, aprovado pelo Comitê de Ética da UNESP de Marília. Participaram do estudo 19 atletas de voleibol de ambos os sexos. Realizou-se coleta de dados eletromiográficos do músculo bíceps braquial no exercício isométrico de flexão de cotovelo antes e após a aplicação do laser terapêutico. Um haltere com 75% do pico de força, obtido por uma célula de carga, foi utilizado para o protocolo de fadiga. Em seguida, os voluntários foram submetidos à aplicação do laser (ativo ou placebo) em seis pontos do músculo bíceps braquial. Os dados eletromiográficos foram analisados no domínio da frequência, utilizando-se o software Myosystem®. Verificou-se a distribuição de normalidade dos dados pelo teste de Shapiro-Wilk, e utilizou-se Anova (split plot) de medidas repetidas a fim de testar a interação entre tempo e grupo. Resultados: Para nenhuma das variáveis analisadas foi observada interação significativa entre grupo e tempo, indicando que o grupo irradiado não apresentou vantagens com relação ao grupo placebo. Conclusão: Após o protocolo de fadiga proposto, uma única aplicação de laser de baixa potência não foi suficiente para produzir efeitos positivos no desempenho de força e no sinal eletromiográfico do músculo bíceps braquial de atletas de voleibol.

Knee joint angle and vasti muscle electromyograms during fatiguing contractions

We compared vasti muscle electromyograms for two knee joint angles during fatiguing tetanic contractions. Tetanic contraction of the knee extensors was evoked for 70 s by electrical stimulation of the femoral nerve at knee joint angles of 60° (extended, with 0° indicating full extension) and 110° (flexed) in eight healthy men. Surface electromyography was recorded from the vastus intermedius (VI), vastus lateralis (VL) and vastus medialis (VM) muscles. Knee extension force and M-wave amplitudes and durations were calculated every 7 s, which were normalized by the initial value. Normalized knee extension force was decreased at the flexed knee joint angle compared with that of the extended knee joint angle (P<0·05). Decreased normalized M-wave amplitude and increased normalized M-wave duration of the VI were greater at the flexed knee joint angle than the extended knee joint angle (P<0·05), whereas those for the VL and VM were similar (P>0·05). These results suggest that peripheral fatigue profiles of the VI might be greater at the flexed than the extended knee joint angles, but that of VL and VM might be similar in the tested range of knee joint angles (i.e. 60°-110°) during continuous tetanic contraction induced by electrical stimulation. Therefore, greater reduction of knee extension force at the flexed knee joint angle than the extended knee joint angle may reflect fatigue development of the VI more than other quadriceps femoris components.

Central and peripheral fatigability in boys and men during maximal contraction

PURPOSE

The purpose of this study was to examine central and peripheral factors of fatigability that could explain the differences in fatigability between adults and prepubertal boys after maximal sustained isometric contraction.

METHODS

A total of 11 untrained adult men and 10 prepubescent boys volunteered to participate in this study. The level of voluntary activation was assessed before and after fatigue by means of the twitch interpolation technique as well as peak twitch torque, maximum rate of torque development and maximum M-wave (Mmax) area of the soleus and medial gastrocnemius. The fatigue-inducing protocol consisted of a sustained maximal voluntary contraction (MVC) of the ankle's plantar flexor at 100% of MVC until the task could no longer be sustained at 50% of MVC.

RESULTS

During the fatigue-inducing protocol, boys were fatigued less, showing longer endurance limit and delayed torque and agonist EMG decrease. After fatigue, the level of activation decreased to a similar extent in both groups, and boys were less affected regarding their peak twitch torque and rate of torque development, whereas no differentiation between the groups was observed regarding the decrease in Mmax area of the examined muscles.

CONCLUSIONS

The results obtained provide evidence that the greater fatigability resistance in prepubertal children during sustained maximal contractions is mainly explained by peripheral rather than central factors.

Gastrocnemius and soleus are selectively activated when adding knee extensor activity to plantar flexion

The gastrocnemius is a biarticular muscle that acts not only as a plantar flexor, but also as a knee flexor, meaning that it is an antagonist during knee extension. In contrast, the soleus is a monoarticular plantar flexor. Based on this anatomical difference, these muscles' activities should be selectively activated during simultaneous plantar flexion and knee extension, which occur during many activities of daily living. This study examined the selective activation of gastrocnemius and soleus activities when voluntary isometric activation of knee extensors was added to voluntary isometric plantar flexion. Ten male volunteers performed isometric plantar flexion at 10%, 20%, and 30% of maximum effort. During each plantar flexion task, isometric knee extension was added at 0%, 50%, and 100% of maximum effort. When knee extension was added, the average rectified value of the electromyographic activity of the medial gastrocnemius was significantly depressed (P=.002), whereas that of the soleus was significantly increased (P<.001) regardless of the plantar flexion level. These results suggest that plantar flexion with concurrent knee extensor activity leads to selective activation of the soleus and depression of the synergistic activity of the gastrocnemius.

What is the ideal dose and power output of low-level laser therapy (810 nm) on muscle performance and post-exercise recovery? Study protocol for a double-blind, randomized, placebo-controlled trial

Background

Recent studies involving phototherapy applied prior to exercise have demonstrated positive results regarding the attenuation of muscle fatigue and the expression of biochemical markers associated with recovery. However, a number of factors remain unknown, such as the ideal dose and application parameters, mechanisms of action and long-term effects on muscle recovery. The aims of the proposed project are to evaluate the long-term effects of low-level laser therapy on post-exercise musculoskeletal recovery and identify the best dose andapplication power/irradiation time.

Design and methods

A double-blind, randomized, placebo-controlled clinical trial with be conducted. After fulfilling the eligibility criteria, 28 high-performance athletes will be allocated to four groups of seven volunteers each. In phase 1, the laser power will be 200 mW and different doses will be tested: Group A (2 J), Group B (6 J), Group C (10 J) and Group D (0 J). In phase 2, the best dose obtained in phase 1 will be used with the same distribution of the volunteers, but with different powers: Group A (100 mW), Group B (200 mW), Group C (400 mW) and Group D (0 mW). The isokinetic test will be performed based on maximum voluntary contraction prior to the application of the laser and after the eccentric contraction protocol, which will also be performed using the isokinetic dynamometer. The following variables related to physical performance will be analyzed: peak torque/maximum voluntary contraction, delayed onset muscle soreness (algometer), biochemical markers of muscle damage, inflammation and oxidative stress.

Discussion

Our intention, is to determine optimal laser therapy application parameters capable of slowing down the physiological muscle fatigue process, reducing injuries or micro-injuries in skeletal muscle stemming from physical exertion and accelerating post-exercise muscle recovery. We believe that, unlike drug therapy, LLLT has a biphasic dose–response pattern.

Trial registration

The protocol for this study is registered with the Protocol Registry System, ClinicalTrials.gov identifier NCT01844271.

Influence of knee flexion angle and age on triceps surae muscle fatigue during heel raises

The triceps surae (TS) muscle-tendon unit is 1 of the most commonly injured in elite and recreational athletes, with a high prevalence in middle-aged adults. The performance of maximal numbers of unilateral heel raises is used to assess, train, and rehabilitate TS endurance and conventionally prescribed in 0° knee flexion (KF) for the gastrocnemius and 45° for the soleus (SOL). However, the extent of muscle selectivity conferred through the change in the knee angle is lacking for heel raises performed to volitional fatigue. This study investigated the influence of knee angle on TS muscle fatigue during heel raises and determined whether fatigue differed between middle-aged and younger-aged adults. Forty-eight healthy individuals aged 18-25 and 35-45 years performed maximal numbers of unilateral heel raises in 0° and 45° KF. Median frequencies and linear regression slopes were calculated from the SOL, gastrocnemius medialis (GM), and gastrocnemius lateralis (GL) surface electromyographic signals. Stepwise mixed-effect regressions were used for analysis. The subjects completed an average of 45 and 48 heel raises in 0° and 45° KF, respectively. The results indicated that the 3 muscles fatigued during testing as all median frequencies decreased, and regression slopes were negative. Consistent with muscle physiology and fiber typing, fatigue was greater in the GM and GL than in the SOL (p < 0.001). However, knee angle did not influence TS muscle fatigue parameters (p = 0.814), with similar SOL, GM, and GL fatigue in 0° and 45° KF. These findings are in contrast with the traditionally described clinical use of heel raises in select knee angles for the gastrocnemius and the SOL. Furthermore, no difference in TS fatigue between the 2 age groups was able to be determined, despite the reported higher prevalence of injury in middle-aged individuals.

Fatiguing exercise intensity influences the relationship between parameters reflecting neuromuscular function and postural control variables

The purpose of this study was to investigate the influence of fatiguing exercise intensity on the nature and extent of fatigue-induced changes in neuromuscular function and postural stability in quiet standing. We also explored the contribution of selected neuromuscular mechanisms involved in force production to postural stability impairment observed following fatigue using an approach based on multivariate regressions. Eighteen young subjects performed 30-s postural trials on one leg with their eyes closed. Postural trials were performed before and after fatiguing exercises of different intensities: 25, 50 and 75% of maximal isometric plantarflexor torque. Fatiguing exercises consisted of sustaining a plantarflexor isometric contraction at the target intensity until task failure. Maximal isometric plantarflexor torque, electromyographic activity of plantarflexor and dorsiflexor muscles, activation level (twitch interpolation technique) and twitch contractile properties of plantarflexors were used to characterize neuromuscular function. The 25% exercise was associated with greater central fatigue whereas the 50 and 75% exercises involved mostly peripheral fatigue. However, all fatiguing exercises induced similar alterations in postural stability, which was unexpected considering previous literature. Stepwise multiple regression analyses showed that fatigue-related changes in selected parameters related to neuromuscular function could explain more than half (0.51≤R²≤0.82) of the changes in postural variables for the 25% exercise. On the other hand, regression models were less predictive (0.17≤R²≤0.73) for the 50 and 75% exercises. This study suggests that fatiguing exercise intensity does not influence the extent of postural stability impairment, but does influence the type of fatigue induced and the neuromuscular function predictors explaining changes in postural variables.

3D fascicle orientations in triceps surae

The aim of this study was to determine the three-dimensional (3D) muscle fascicle architecture in human triceps surae muscles at different contraction levels and muscle lengths. Six male subjects were tested for three contraction levels (0, 30, and 60% of maximal voluntary contraction) and four ankle angles (−15, 0, 15, and 30° of plantar flexion), and the muscles were imaged with B-mode ultrasound coupled to 3D position sensors. 3D fascicle orientations were represented in terms of pennation angle relative to the major axis of the muscle and azimuthal angle (a new architectural parameter introduced in this study representing the radial angle around the major axis). 3D orientations of the fascicles, and the sheets along which they lie, were regionalized in all the three muscles (medial and lateral gastrocnemius and the soleus) and changed significantly with contraction level and ankle angle. Changes in the azimuthal angle were of similar magnitude to the changes in pennation angle. The 3D information was used for an error analysis to determine the errors in predictions of pennation that would occur in purely two-dimensional studies. A comparison was made for assessing pennation in the same plane for different contraction levels, or for adjusting the scanning plane orientation for different contractions: there was no significant difference between the two simulated scanning conditions for the gastrocnemii; however, a significant difference of 4.5° was obtained for the soleus. Correct probe orientation is thus more critical during estimations of pennation for the soleus than the gastrocnemii due to its more complex fascicle arrangement.

Effects of cyclic static stretch on fatigue recovery of triceps surae in female basketball players

Static stretch is a safe and feasible method which usually is used before exercise to avoid muscle injury and to improve muscle performance. The purpose of this study was to determine the effects of cyclic static stretch (CSS) on fatigue recovery of triceps surae (TS) in female basketball players. Nine athlete volunteers between 20 and 30 years participated in this study containing two sessions. After warm-up a pressure cuff was fastened above the knee joint and its pressure was increased to 140 mmHg. The subjects were asked to perform one maximum voluntary contraction (MVC) followed by a fatigue test including maximum isometric fatiguing contraction of TS. These steps were similar in both sessions. Then, a two-minute rest was included in the first session while 4 static stretches were performed to TS in the second session. After interventions, one MVC was done and the pressure cuff was released. During these steps, peak torque (PT) and electromyography (EMG) were recorded. The amount of lower leg pain was determined by the visual analogue scale (VAS). The value of PT increased significantly after CSS but its increase was not significant after rest. It seems that the effects of rest and CSS on the EMG parameters, PT and pain are similar.

Comparison of neuromuscular adjustments associated with sustained isometric contractions of four different muscle groups

The extent and characteristics of muscle fatigue of different muscle groups when subjected to a similar fatiguing task may differ. Thirteen healthy young men performed sustained contractions at 50% maximal voluntary contraction (MVC) force until task failure, with four different muscle groups, over two sessions. Per session, one upper limb and one lower limb muscle group were tested (knee extensors and thumb adductor, or plantar and elbow flexors). Changes in voluntary activation level and contractile properties were derived from doublet responses evoked during and after MVCs before and after exercise. Time to task failure differed ( P < 0.05) between muscle groups (220 ± 64 s for plantar flexors, 114 ± 27 s for thumb adductor, 77 ± 25 s for knee extensors, and 72 ± 14 s for elbow flexors). MVC force loss immediately after voluntary task failure was similar (−30 ± 11% for plantar flexors, −37 ± 13% for thumb adductor, −34 ± 15% for knee extensors, and −40 ± 12% for elbow flexors, P > 0.05). Voluntary activation was decreased for plantar flexors only (from 95 ± 5% to 82 ± 9%, P < 0.05). Potentiated evoked doublet amplitude was more depressed for upper limb muscles (−59.3 ± 14.7% for elbow flexors and −60.1 ± 24.1% for thumb adductor, P < 0.05) than for knee extensors (−28 ± 15%, P < 0.05); no reduction was found in plantar flexors (−7 ± 12%, P > 0.05). In conclusion, despite different times to task failure when sustaining an isometric contraction at 50% MVC force for as long as possible, diverse muscle groups present similar loss of MVC force after task failure. Thus the extent of muscle fatigue is not affected by time to task failure, whereas this latter determines the etiology of fatigue.

On the ascent: the soleus operating length is conserved to the ascending limb of the force-length curve across gait mechanics in humans

The region over which skeletal muscles operate on their force-length (F-L) relationship is fundamental to the mechanics, control and economy of movement. Yet surprisingly little experimental data exist on normalized length operating ranges of muscle during human gait, or how they are modulated when mechanical demands (such as force output) change. Here we explored the soleus muscle (SOL) operating lengths experimentally in a group of healthy young adults by combining subject-specific F-L relationships with in vivo muscle imaging during gait. We tested whether modulation of operating lengths occurred between walking and running, two gaits that require different levels of force production and different muscle-tendon mechanics, and examined the relationship between optimal fascicle lengths (L(0)) and normalized operating lengths during these gaits. We found that the mean active muscle lengths reside predominantly on the ascending limbs of the F-L relationship in both gaits (walk, 0.70-0.94 L(0); run, 0.65-0.99 L(0)). Furthermore, the mean normalized muscle length at the time of the peak activation of the muscle was the same between the two gaits (0.88 L(0)). The active operating lengths were conserved, despite a fundamentally different fascicle strain pattern between walking (stretch-shorten cycle) and running (near continuous shortening). Taken together, these findings indicate that the SOL operating length is highly conserved, despite gait-dependent differences in muscle-tendon dynamics, and appear to be preferentially selected for stable force production compared with optimal force output (although length-dependent force capacity is high when maximal forces are expected to occur). Individuals with shorter L(0) undergo smaller absolute muscle excursions (P<0.05) so that the normalized length changes during walking and running remain independent of L(0). The correlation between L(0) and absolute length change was not explained on the basis of muscle moment arms or joint excursion, suggesting that regulation of muscle strain may occur via tendon stretch.

Efeitos agudos do treinamento concorrente sobre os níveis séricos de leptina e cortisol em adultos jovens sobrepesados

OBJETIVO: Este estudo teve como objetivo analisar os efeitos imediatos do treinamento concorrente sobre a leptina e os níveis de cortisol em adultos jovens com sobrepeso. MÉTODOS: Este estudo utilizou uma metodologia quase-experimental. Foram 20 indivíduos voluntários de ambos os sexos, divididos em um grupo sobrepesado treinamento (GST n = 10) e um grupo sobrepesado controle (n = 10). A coleta de sangue foi realizada com os indivíduos em repouso após jejum de 12 horas. Os níveis de leptina e cortisol foram analisados por radioimunoensaio e ensaio por quimioluminescência chimiluminescence antes e imediatamente após o treinamento. ANOVA two way foi utilizada para análise estatística com nível de significância de p < 0,05. RESULTADOS: Na análise da leptina sérica, observou-se diferença significativa intergrupos (GST x GSC) nos momentos pré-intervenção (p = 0,02) e pós-intervenção (p = 0,01). Na análise intragrupos, não foram observadas alterações significativas. E na análise do cortisol sérico intergrupos (GST x GSC), foi observada uma diferença significativa nos momentos pré-intervenção (p = 0,01) e pós-intervenção (p = 0,01), porém, na análise intragrupos, não houve alterações significativas. CONCLUSÃO: Uma única sessão de treinamento concorrente não é suficiente para promover alterações agudas nos níveis de leptina e cortisol dos jovens adultos sobrepesados voluntários deste estudo.

EVIDENCE OF TIME-DEPENDENT TENSILE RESPONSE IN INTACT HUMAN TENDON

The present study was performed to establish whether intact human tendons exhibit time-dependent tensile properties, as they do in the in vitro state. Measurements were taken in seven men and involved ultrasound-based recording of the gastrocnemius tendon elongation during three sets of five repeated isometric plantarflexion contractions elicited by tetanic electrical stimulation. The plantarflexion moment corresponding to the tendon elongation in the fifth contraction presented a pattern dependent on the voltage applied: it was approximately constant when applying 50% of maximal voltage, but it decreased curvilinearly as a function of contraction number when applying 70 and 100% of maximal voltage, reaching in the fifth contraction 84% of the plantarflexion moment corresponding to the elongation examined in the first contraction. These results suggest that, once a threshold tendon elongation is undergone, in vivo tendons may exhibit substantial viscoelasticity. The present findings have implications for muscle and joint function and need to be accounted for by musculoskeletal models.

Are the myoelectric manifestations of fatigue distributed regionally in the human medial gastrocnemius muscle?

Myoelectric fatigue typically manifests as variations in the amplitude and spectrum of surface electromyograms (EMGs). Interestingly, these variations seem to be represented locally in different muscles. In this study, we ask whether such a regional distribution of myoelectric fatigue extends to the medial gastrocnemius (MG) muscle. If the MG muscle is activated locally during fatiguing contractions, or if the most fatigable MG fibers are located at distinct muscle regions, then, the myoelectric manifestations of MG fatigue are expected to appear locally in a grid of surface electrodes. With a matrix of surface electrodes (7×15 single-differential EMGs) we show that myoelectric fatigue, indeed, manifests regionally in the MG muscle of 12 subjects, who exerted intermittent, fatiguing plantar flections at 50% of their maximal effort. Contrary to the root mean square amplitude, the median frequency of surface EMGs varied consistently across subjects throughout the plantar flections (P=0.002). On average, changes in EMG spectrum were represented at 78-93 (interquartile interval) out of the 105 channels in the matrix, though with different degrees across channels. For all participants, about 29% of the channels detected significantly greater reductions in median frequency when compared to all channels in the matrix (P<0.003). Strikingly, these channels were not sparsely distributed; they rather occupied localized skin regions across subjects. Physiologically, our results suggest that, during sub-maximal fatiguing tasks, myoelectric manifestations of MG fatigue are represented in spatially localized muscle regions. Technically, the possibility of studying myoelectric fatigue in the MG muscle appears to depend on the electrode location.

Cortical and segmental excitability during fatiguing contractions of the soleus muscle in humans

OBJECTIVE

The aim of this study was to examine the cortical and segmental excitability changes during fatigue of the soleus muscle.

METHODS

Ten healthy young subjects performed 45 plantar flexion maximal voluntary contractions (MVCs) (7-s on/3-s off) in 9 epochs of five contractions. Motor evoked potentials (MEPs) using transcranial magnetic stimulation and H-reflexes were assessed during the task.

RESULTS

The torque and the soleus EMG activity both showed the greatest decline during the 1st epoch, followed by a gradual, but significant decrease by the end of the task (∼70% pre-fatigue). The H-reflex sampled at rest after each epoch decreased to 66.6±18.3% pre-fatigue after the first epoch, and then showed no further change. The MEP on 10% pre-fatigue MVC after each epoch increased progressively (252.9±124.2% pre-fatigue). There was no change in the MEPs on the 3rd MVC in each epoch. The silent period on the MVC increased (109.0±9.2% pre-fatigue) early with no further changes during the task.

CONCLUSIONS

These findings support that the motor cortex increases excitability during fatigue, but with a concomitant inhibition.

SIGNIFICANCE

These findings are in contrast to upper extremity muscles and may reflect a distinct response specific to postural, fatigue-resistant muscle.

Analysis of knee flexion angles during 2 clinical versions of the heel raise test to assess soleus and gastrocnemius function

STUDY DESIGN

Controlled laboratory study, using a repeated-measures, counterbalanced design.

OBJECTIVES

To provide estimates on the average knee angle maintained, absolute knee angle error, and total repetitions performed during 2 versions of the heel raise test.

BACKGROUND

The heel raise test is performed in knee extension (EHRT) to assess gastrocnemius and knee flexion (FHRT) for soleus. However, it has not yet been determined whether select knee angles are maintained or whether total repetitions differ between the clinical versions of the heel raise test.

METHODS

Seventeen healthy males and females performed maximal heel raise repetitions in 0° (EHRT) and 30° (FHRT) of desired knee flexion. The average angle maintained and absolute error at the knee during the 2 versions, and total heel raise repetitions, were measured using motion analysis. Participants' kinematic measures were fitted into a generalized estimation equation model to provide estimates on EHRT and FHRT performance applicable to the general population.

RESULTS

The model estimates that average angles of 2.2° and 30.7° will be maintained at the knee by the general population during the EHRT and the FHRT, with an absolute angle error of 3.4° and 2.5°, respectively. In both versions, 40 repetitions should be completed. However, the average angles maintained by participants ranged from -6.3° to 21.6° during the EHRT and from 22.0° to 43.0° during the FHRT, with the highest absolute errors in knee position being 25.9° and 33.5°, respectively.

CONCLUSION

On average, select knee angles will be maintained by the general population during the select heel raise test versions, but individualized performance is variable and total repetitions do not distinguish between versions. Clinicians should, therefore, interpret select heel raise test outcomes with caution when used to respectively assess and rehabilitate soleus and gastrocnemius function.

Isometric fatigue patterns in time and time-frequency domains of triceps surae muscle in different knee positions

The occurrence of fatigue in triceps surae (TS) muscles during sustained plantar flexion contraction is investigated by means of the RMS electromyogram (EMG) and the instantaneous median frequency (IMF) of the short time Fourier transform (STFT). Six male subjects realized a 40% maximal plantar flexion isometric voluntary contraction until fatigue in two knee positions. Electrodes were positioned on gastrocnemius medialis, gastrocnemius lateralis and soleus muscles. The torque (TO) and EMG signals were synchronized. The RMS and the median of the IMF values were obtained, respectively, for each 250 ms and 1s windows of signal. Each signal was segmented into 10 epochs, from which the mean values of IMF, RMS and TO were obtained and submitted to linear regressions to determine parameter trends. Friedman test with the Dunn's post hoc were used to test for differences among muscles activation for each knee position and among slopes of regression curves, as well as to observe changes in TS RMS values over time. The results indicate different activation strategies with the knee extended (KE) in contrast to knee flexed (KF). With the KE, the gastrocnemii showed typical fatigue behavior with significant (p<0.05) IMF reductions and RMS increases over time, while soleus showed concomitant RMS and IMF increases (p<0.05) suggesting an increased soleus contribution to the torque production. With KF, the gastrocnemii were under activated, increasing the role of soleus. Thus, time-frequency analysis represented an important tool for TS muscular fatigue evaluation, allowing differentiates the role of soleus muscle.

The effects of fatigue of the plantar flexors on peak torque and voluntary activation in untrained and resistance-trained men

The purpose of this study was to compare the effects of fatigue of the plantar flexors on peak torque and voluntary activation in untrained (UT) and resistance-trained (RT) men. Six men with no previous resistance training experience and 8 men with similar histories of chronic resistance training (9.8 ± 5.9 years, 3.8 ± 0.7 days/week) volunteered for this study. Subjects performed isometric maximal voluntary contractions (MVCs) before and immediately after unilateral dynamic isotonic contractions performed at 40% of MVC until volitional exhaustion. Voluntary activation of the plantar flexors was assessed using the interpolated twitch method (ITT) and central activation ratio (CAR). Surface electromyographic (EMG) amplitude of the soleus and medial gastrocnemius (MG) was measured during the MVC. There were significant reductions in MVC torque in both UT and RT groups after the fatiguing exercise (-10.7 ± 6.8%, p < 0.02; -9.1 ± 8.7%, p < 0.02, respectively), with no difference in the number of repetitions performed between groups. The UT and RT men experienced a significant decrease in ITT after the fatiguing exercise bout (-14.2 ± 11.8%, p = 0.03; -7.8 ± 9.3%, p = 0.045, respectively). The UT group experienced a significant decrease in CAR (99.5 ± 0.8% to 91.4 ± 6.4%, p = 0.025) with no change (p > 0.05) in the RT group. There was also a fatigue-induced decrease in normalized EMG amplitude for the soleus and MG muscles in both groups (p < 0.05). However, no differences were determined between groups for ITT, CAR, or EMG. Despite similar reductions in MVC torque postexercise, the UT men had a significant decrease in CAR and experienced nearly twice the decline in ITT than the RT men. These results indicate that the neural adaptations associated with chronic resistance training may lead to less susceptibility to central fatigue as measured by ITT and CAR.

Neuromuscular fatigue induced by alternating isometric contractions of the ankle plantar and dorsiflexors

Ankle muscle activity is important in regulating postural control as well as more complex movement tasks. Fatigue of these muscles clearly influences postural stability; however, the mechanisms responsible for this change have not been well characterized. In this study the fatigue produced in the plantar (PF) and dorsiflexors (DF) during intermittent, isometric contractions was examined and the recovery process was monitored for ten minutes post-fatigue. Fifteen healthy participants alternated between isometric PF and DF contractions until the torque was reduced to >50% of the pre-fatigue maximal voluntary contraction level in both directions. Peripheral fatigue was identified by measuring the change in the twitch torque and M-wave amplitude pre and post-fatigue. Central fatigue was determined by comparing the level of voluntary activation in the PF and DF between pre and post-fatigue. The fatigue protocol decreased the torque production in PF and DF to similar levels; however, the characteristics and recovery of the fatigue were different for the two muscle groups. This study demonstrates that although the torque produced by two antagonist muscles can be reduced to the same level, the mechanisms responsible for this change may not be similar and therefore may not impact motor tasks in the same way.

Power output and electromyographic activity during and after a moderate load muscular endurance session

The purpose of this study was to examine (a) the mechanical power and the electromyographic (EMG) activity during a moderate load muscular endurance session and (b) the maximal mechanical power output and EMG activity using a light load and a heavy load afterward. Sixteen men (age: 20.7 +/- 1.1 years) performed 4 sets of 20 repetitions with an initial load of 50% of 1 repetition maximum (1RM), and 2 minutes of rest, in the squat exercise. Furthermore, the subjects performed 4 repetitions with loads of 40 and 80% of 1RM before, immediately after, and 30 minutes after the end of the session. Average power and EMG activity from vastus medialis (VM), vastus lateralis (VL), and rectus femoris (RF) were recorded during the concentric phase of the lift. Average power did not change during the first 2 sets, while it decreased (p < 0.05) during the third and the fourth set. Average quadriceps (AQ), VM, VL, and RF activity increased (p < 0.05) until the 11th repetition, approximately, during each set while it increased gradually from set to set. Maximal power and AQ, VM, and VL activity with the loads of 40 and 80% of 1RM were decreased (p < 0.05) after the session. Blood lactate reached 10.2 +/- 2.5 and 13.1 +/- 4.1 mmolxL after the second and the fourth set, respectively. It appears that during a muscular endurance session with submaximal power output, mechanical performance may gradually decrease, probably due to metabolic fatigue, while muscle electrical activity may increase. Following this type of a session, maximal power output and muscle activation with a light and especially with a heavy load are reduced.

A biomechanical assessment of isometric handgrip force and fatigue at different anatomical positions

The present work examined the handgrip force at different anatomical positions for both hands. Anthropometrics, handgrip force, and fatigue were obtained from a representative sample of 20 males randomly selected from the German Jordanian University students. The hand dynamometer first was calibrated with respect to the volunteer's maximal grip strength, and he was then asked to squeeze maximally until the grip force decreased to 50% of its maximal due to fatigue; this test was performed for both hands at different anatomical positions with 2 min of rest for recovery of muscle function. The results showed differences in the handgrip force between subjects of the same anatomical positions and for the different anatomical positions, differences in the time for 50% of the force maximal for both right hand and left hand, higher time required to achieve 50% of maximal handgrip force for the nondominant hand, and maximal handgrip force was obtained when arm adduction with 90 degrees forward at the elbow joint. Recommendations for future work are to measure fatigue time at different percentages, 25%, 50%, 60%, and 75% of maximal force and to investigate the factors affecting handgrip force over a larger sample.

Scientific bases and clinical utilisation of the calf-raise test

BACKGROUND

Athletes commonly sustain injuries to the triceps surae muscle-tendon unit. The calf-raise test (CRT) is frequently employed in sports medicine for the detection and monitoring of such injuries. However, despite being widely-used, a recent systematic review found no universal consensus relating to the test's purpose, parameters, and standard protocols.

OBJECTIVES

The purpose of this paper is to provide a clinical perspective on the anatomo-physiological bases underpinning the CRT and to discuss the utilisation of the test in relation to the structure and function of the triceps surae muscle-tendon unit.

DESIGN

Structured narrative review.

METHODS

Nine electronic databases were searched using keywords and MESH headings related to the CRT and the triceps surae muscle-tendon unit anatomy and physiology. A hand-search of reference lists and relevant journals and textbooks complemented the electronic search.

SUMMARY

There is evidence supporting the clinical use of the CRT to assess soleus and gastrocnemius, their shared aponeurosis, the Achilles tendon, and the combined triceps surae muscle-tendon unit. However, employing the same clinical test to assess all these structures and their associated functions remains challenging.

CONCLUSIONS

Further refinement of the CRT for the triceps surae muscle-tendon unit is needed. This is vital to support best practice utilisation, standardisation, and interpretation of the CRT in sports medicine.