Exercise Professional Education

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04/28/2026

Altered energy dissipation patterns and increased ground reaction force in patients with chronic ankle instability after fatiguing exercises

"Abstract
The purpose of this study was to investigate whether the interaction between chronic ankle instability (CAI) and fatigue alters energy absorption strategies and ground reaction force (GRF) during landing. This cross-sectional study was conducted in a laboratory setting and included 20 patients with CAI, 20 copers, and 20 healthy controls. All participants performed single-leg drop landing before and after the fatigue protocol. The fatigue protocol consisted of repeated cycles of multidirectional running, hopping, and jumping tasks. Heart rate (HR) and rated perceived exertion (RPE) were monitored after each cycle, and the protocol was repeated until participants reached ≥ 85% of maximal heart rate and RPE ≥ 17. Lower-extremity angles and power, relative joint contribution to shock absorption, and GRF were measured from initial foot contact to 200 ms after landing. The interaction effect of group and fatigue was analyzed using functional ANOVA and two-way repeated measures ANOVA. Interaction effects showed that after fatiguing exercises, patients with CAI exhibited (1) less sagittal hip excursion, (2) more eccentric power patterns in the hip and knee joints, (3) a greater contribution of the hip and knee to total lower-extremity energy dissipation, and (4) greater vertical GRF during the initial phase of landing compared to copers and/or controls. Under fatigue, patients with CAI demonstrated altered proximal kinetic strategies with greater GRF. Despite these adaptations, patients with CAI exhibited higher GRF after fatigue. This highlights the need for interventions aimed at optimizing neuromuscular control to more efficiently distribute impact forces across the lower-extremity."

Hyung Gyu Jeon, Tae Kyu Kang, Hyunsoo Kim, Kyeongtak Song, Sae Yong Lee, Altered energy dissipation patterns and increased ground reaction force in patients with chronic ankle instability after fatiguing exercises, Journal of Biomechanics, 2026,
113289, ISSN 0021-9290, https://doi.org/10.1016/j.jbiomech.2026.113289.

04/21/2026

The pathogenesis of tendinopathy: balancing the response to loading

"Abstract
Tendons are designed to withstand considerable loads. Mechanical loading of tendon tissue results in upregulation of collagen expression and increased synthesis of collagen protein, the extent of which is probably regulated by the strain experienced by the resident fibroblasts (tenocytes). This increase in collagen formation peaks around 24 h after exercise and remains elevated for about 3 days. The degradation of collagen proteins also rises after exercise, but seems to peak earlier than the synthesis. Despite the ability of tendons to adapt to loading, repetitive use often results in injuries, such as tendinopathy, which is characterized by pain during activity, localized tenderness upon palpation, swelling and impaired performance. Tendon histological changes include reduced numbers and rounding of fibroblasts, increased content of proteoglycans, glycosaminoglycans and water, hypervascularization and disorganized collagen fibrils. At the molecular level, the levels of messenger RNA for type I and III collagens, proteoglycans, angiogenic factors, stress and regenerative proteins and proteolytic enzymes are increased. Tendon microrupture and material fatigue have been suggested as possible injury mechanisms, thus implying that one or more 'weak links' are present in the structure. Understanding how tendon tissue adapts to mechanical loading will help to unravel the pathogenesis of tendinopathy."

Key Points
• Tendons are metabolically active and respond readily to both loading and unloading
• Mechanical loading results both in protein synthesis and degradation of collagen
• Without sufficient rest (24 h) after exercise, net loss of collagen might occur that leaves the tendon vulnerable to injury
• Tendinopathy is associated with neovascularization, but newly formed blood vessels (and nerves) disappear during healing
• The pathogenesis of tendinopathy can be accelerated by overloading

Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 2010 May;6(5):262-8. doi: 10.1038/nrrheum.2010.43. Epub 2010 Mar 23. PMID: 20308995.

09 April 2010
In the version of this article initially published online, the tendon in Figure 1 was indicated as being 0.5–1.0mm2 instead of 0.5–1.0cm2. In addition, the measurements relating to the collagen fascicle, fibril and molecule in Figure 1 should all refer to the diameter of these entities. These errors have been corrected in all versions of the article.

04/15/2026

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04/14/2026

Intra-articular remodeling of hamstring tendon grafts after anterior cruciate ligament reconstruction

Abstract

Purpose
A summary is provided on the existing knowledge about the specific healing phases of the intra-articular hamstring tendon graft used for ACL reconstruction. Differences between human and animal in vivo studies are explained, and implications for the postoperative time period are laid out.

Methods
A systematic review of the existing literature was performed on the topic of tendon remodelling of hamstring grafts in ACL reconstruction using Medline database. Publications between 1982 and 2012 were included. Special focus was directed on in vivo human and animal studies analysing intra-articular free tendon graft remodelling.

Results
Animal and human in vitro and vivo researches have demonstrated three characteristic stages of graft healing after ACL reconstruction: an early graft healing phase with central graft necrosis and hypocellularity and no detectable revascularization of the graft tissue, followed by a phase of proliferation, the time of most intensive remodelling and revascularization and finally, a ligamentization phase with characteristic restructuring of the graft towards the properties of the intact ACL. However, a full restoration of either the biological or biomechanical properties of the intact ACL is not achieved.

Conclusion
Significant knowledge on human cruciate ligament remodelling has been added in the understanding of the processes during the course of graft healing. Most importantly, the remodelling process in humans is prolonged compared to animal studies. While today's rehabilitation protocols are often extrapolated from findings of animal in vivo healing studies, current findings of human in vivo healing studies might require new post-operative regimens following hamstring ACL reconstruction.

Janssen RP, Scheffler SU. Intra-articular remodelling of hamstring tendon grafts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2014 Sep;22(9):2102-8. doi: 10.1007/s00167-013-2634-5. Epub 2013 Aug 27. PMID: 23982759; PMCID: PMC4142140.

04/07/2026

Wearing a knee brace or ankle brace... so what... right?

"Abstract
This paper extends an initial investigation and
application of gait asymmetry using wireless gyroscope,
normalized Symmetry Index (SInorm), and normalized crosscorrelation (Ccnorm). In this study, one side of the participant’s lower exteremity movement is restricted using knee brace or ankle brace. Wireless gyroscopes are then attached to
participant’s left thigh, left shank, right thigh and right shank.
Measurement data are collected for duration of one minute while
participant is walking on a treadmill. The experimental results
are satisfactory. Significant asymmetric gait was observed when
the participant walks with knee brace or ankle brace on one side
of the limbs. The knee brace produced greater asymmetry than
ankle brace. These were apparent in both SInorm and Ccnorm."

"VIII. CONCLUSION
Gait asymmetry is one of the crucial parameters in gait
analysis. It defines the coordination of the left limb and right
limb in providing support and propulsion during walking. Gait
of healthy individual is fairly symmetrical with acceptable
deviations. This study supports the application of SInorm and
Ccnorm in identifying gait asymmetry in normal gait and
abnormal gait generated by restricting knee or ankle
movement. SInorm was found to behave differently when the
participants walked with knee brace or ankle brace. Significant
difference in Ccnorm was also observed with p < 0.01."

D. Gouwanda, "Further validation of Normalized Symmetry Index and normalized cross-correlation in identifying gait asymmetry on restricted knee and ankle movement," 2012 IEEE-EMBS Conference on Biomedical Engineering and Sciences, Langkawi, Malaysia, 2012, pp. 423-427, doi: 10.1109/IECBES.2012.6498167.

03/31/2026

Catastrophizing contributes to the association between posttraumatic stress symptoms and pain outcomes in individuals with chronic low back pain: Differential effects as a function of s*x

"Abstract
Posttraumatic stress symptoms (PTSS) are prevalent among individuals with chronic low back pain (CLBP) and are associated with worse pain-related outcomes. Pain catastrophizing is a cognitive factor associated with both trauma symptoms and pain, though it remains unclear whether these associations differ by s*x, particularly given evidence that males and females may differ in trauma-related cognitive and emotional responses to pain. This study examined the extent to which pain catastrophizing contributes to the association between PTSS and pain outcomes in patients with CLBP, and whether these associations vary by s*x. Participants were 742 adults with opioid-treated CLBP enrolled in a multisite randomized trial. Self-report measures assessed presence of PTSS (i.e., positive screen), pain catastrophizing, severity, and interference, and CLBP-related disability. Moderated mediation analyses were conducted using PROCESS Macro, controlling for psychological well-being, age, opioid dose, and study site. Results indicated that a positive PTSS screen was associated with higher catastrophizing, which in turn was associated with worse pain outcomes (severity, interference, and disability). S*x moderated the association between PTSS and catastrophizing, with a stronger relationship in males than females. Consequently, the indirect associations of PTSS with all pain outcomes via catastrophizing were significantly stronger among males. Findings support catastrophizing as a cognitive factor influencing the association between PTSS and pain-related outcomes in CLBP, and this association appears more salient in males. These findings highlight the importance of screening for PTSS and pain-related cognitive processes. Trauma-responsive interventions, informed by s*x-related differences in coping and socialization, may enhance precision care in CLBP."

Yamin JB, Wilson JM, Meints SM, Jamison RN, Aglio LS, Zgierska AE, Barrett B, Garland EL, Burzinski CA, Goldstein E, Edwards RR. Catastrophizing contributes to the association between posttraumatic stress symptoms and pain outcomes in individuals with chronic low back pain: Differential effects as a function of s*x. J Pain. 2026 Feb 25;42:106250. doi: 10.1016/j.jpain.2026.106250. Epub ahead of print. PMID: 41759690.

03/24/2026

Five-year follow-up of patients with knee osteoarthritis not eligible for total knee replacement: results from a randomised trial

"ABSTRACT

Objectives
The main objective was to investigate 5-year outcomes in patients with knee osteoarthritis, randomised to one of two non-surgical treatments.

Setting
Two outpatient clinics.

Participants
At baseline, 100 patients with radiographic and symptomatic knee osteoarthritis not found eligible for knee replacement (KR) were included. Main exclusion criteria were average score above 75 of the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales pain, symptoms, function of daily living and quality of life; KOOS4 and average knee pain the previous week greater than 60 mm on a 100 mm visual analogue scale.

Interventions
Patients were randomised to supervised
non-surgical treatment consisting of patient education, supervised exercise, weight loss, insoles, and pain medication (the MEDIC treatment) or written advice. The 12-week MEDIC treatment included patient education, neuromuscular exercise, insoles and a dietary weight loss programme and/or pain medication if needed and written advice consisted of two leaflets.

Primary and secondary outcome measures
Primary outcome was 5-year mean change for KOOS4. Secondary outcomes included KOOS subscales, self-reported health, usage of pain medication and self-reported physical activity.

Results
Thirty-nine (78%) and 36 (72%) from the MEDIC and written advice groups responded at 5 years. There were no between-group differences in KOOS4 (difference5.3 (95% CI −1.5 to 12.1) or any secondary outcomes. However, the 95% CI included the minimal clinically important difference for the main outcome. Seventy-six percent of the MEDIC group and 66% of the written advice group experienced clinically important improvements in KOOS4. Fifteen patients (30%) from the MEDIC group and 17 (34%) from the written advice group received KR in the index knee. Undergoing KR did not result in a statistically significant greater improvement in KOOS4 (difference 6.1 (95% CI −1.1 to 13.4).

Conclusions
No statistically significant differences between supervised non-surgical treatment and written advice were demonstrated at 5 years. Most patients experienced clinically important improvements, irrespective of initial treatment strategy or KR."

Larsen JB, Roos EM,Laursen M, et al. Five-yearfollow-upof patientswith knee osteoarthritisnot eligible for total kneereplacement: results from arandomised trial. BMJ Open2022;12:e060169. doi:10.1136/bmjopen-2021-060169

03/17/2026

Physical activity behavior predicts endogenous pain modulation in older adults

"Abstract
Older adults compared with younger adults are characterized by greater endogenous pain facilitation and a reduced capacity to endogenously inhibit pain, potentially placing them at a greater risk for chronic pain. Previous research suggests that higher levels of self-reported physical activity are associated with more effective pain inhibition and less pain facilitation on quantitative sensory tests in healthy adults. However, no studies have directly tested the relationship between physical activity behavior and pain modulatory function in older adults. This study examined whether objective measures of physical activity behavior cross-sectionally predicted pain inhibitory function on the conditioned pain modulation (CPM) test and pain facilitation on the temporal summation (TS) test in healthy older adults. Fifty-one older adults wore an accelerometer on the hip for 7 days and completed the CPM and TS tests. Measures of sedentary time, light physical activity (LPA), and moderate to vigorous physical activity (MVPA) were obtained from the accelerometer. Hierarchical linear regressions were conducted to determine the relationship of TS and CPM with levels of physical activity, while controlling for demographic, psychological, and test variables. The results indicated that sedentary time and LPA significantly predicted pain inhibitory function on the CPM test, with less sedentary time and greater LPA per day associated with greater pain inhibitory capacity. Additionally, MVPA predicted pain facilitation on the TS test, with greater MVPA associated with less TS of pain. These results suggest that different types of physical activity behavior may differentially impact pain inhibitory and facilitatory processes in older adults."

Naugle KM, Ohlman T, Naugle KE, Riley ZA, Keith NR. Physical activity behavior predicts endogenous pain modulation in older adults. Pain. 2017 Mar;158(3):383-390. doi: 10.1097/j.pain.0000000000000769. PMID: 28187102.

It was an excellent weekend in Columbus with our colleagues Evan Broadhead and Logan DeSellems, with Charlie Rowe and Wi...
03/15/2026

It was an excellent weekend in Columbus with our colleagues Evan Broadhead and Logan DeSellems, with Charlie Rowe and Will Fox supporting MSS Advanced Course 1 - Executing and Interpreting the QMAMC complete! A critical competency for successful practice.

03/14/2026

Cool video

03/10/2026

Incidental Rotator Cuff Abnormalities on Magnetic Resonance Imaging

"Abstract

Importance:
Shoulder pain is a common musculoskeletal complaint often attributed to rotator cuff (RC) abnormalities. Diagnostic imaging is frequently used, but the association between RC abnormalities and shoulder symptoms remains uncertain.

Objective:
To determine the prevalence of RC abnormalities in a general population sample and their association with shoulder symptoms.

Design, setting, and participants:
Population-based cross-sectional study in a nationally representative random sample of adults aged 41 to 76 years who underwent standardized clinical assessment and bilateral 3-Tesla magnetic resonance imaging (MRI) of the shoulders conducted from February 2023 to April 2024 in Finland. Eligibility criteria included ability to undergo MRI and absence of previous shoulder replacement surgery.

Exposures:
Structured interviews, standardized questionnaires, clinical shoulder tests, and shoulder MRI.

Main outcomes and measures:
RC tendon status was classified on MRI as normal, tendinopathic, partial-thickness tear (PTT), or full-thickness tear (FTT). Shoulder symptoms were defined as pain or dysfunction in the preceding week. The prevalence of RC abnormalities was compared across age groups and between symptomatic and asymptomatic shoulders, adjusting for demographic factors, concurrent MRI findings, and clinical examination."

Results:
Among 602 participants (median age, 58 [range, 41-76] years; 52% female), RC abnormalities on MRI were found in 595 (98.7%; 95% CI, 97.5%-99.5%): 25% tendinopathy, 62% PTT, and 11% FTT. The prevalence and severity of abnormalities increased with age but did not differ between s*xes. RC abnormalities were present in 96% of asymptomatic shoulders (1039 of 1076) and 98% of symptomatic shoulders (126 of 128). Only FTTs were more prevalent in symptomatic shoulders (14.6%) than in asymptomatic shoulders (6.5%), but this difference diminished after adjustment (absolute difference, 0.8%; 95% CI, -3.4% to 6.0%).

Conclusions and relevance:
In this population-based study, RC abnormalities were nearly universal after age 40 years and showed poor concordance with shoulder symptoms. These findings suggest that RC abnormalities often represent normal age-related changes rather than disease and call into question the clinical value of routine imaging for atraumatic shoulder pain."

Ibounig T, Järvinen TLN, Raatikainen S, Härkänen T, Sillanpää N, Bensch F, Haapamäki V, Toivonen P, Björkenheim R, Ryösä A, Kanto K, Lepola V, Joukainen A, Paavola M, Koskinen S, Rämö L, Buchbinder R, Taimela S. Incidental Rotator Cuff Abnormalities on Magnetic Resonance Imaging. JAMA Intern Med. 2026 Feb 16:e257903. doi: 10.1001/jamainternmed.2025.7903. Epub ahead of print. PMID: 41697693; PMCID: PMC12910452.

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Why I started Exercise Professional Education

When looking at the landscape of ​​​the exercise industry Greg realized that something was missing. The continuing education offered was a hodge-podge of information promoting the latest technique to "release" this or "functionalize" that. It appeared like a tumultuous sea of competing philosophies and disconnected notions of how exercise should be done. There wasn't a complete system of practice that addressed the entire continuum. From how to handle the first contact with a potential client, to collecting relevant information about where to even begin an exercise process (let alone deciding if you should), to integrating the marketing and communication to the medical community, and ethically and rationally building a long-term professional relationship with a client coaching them across their lifespan in regards to exercise and wellness programming.

The course work offered by Exercise Professional Education and the Muscle System Specialist program is just that.

The philosophical basis for the course content is unique and does not follow the mainstream views of working with the body like what we refer to as the "fabric paradigm". (This paradigm sees the body as a material akin to "play dough" or "silly puddy" that needs to kneaded, stretched, and smashed in order to make it work and feel better). Nor does the course content proselytize the body-view of "functionalism" and all its pseudo-religious denominations. (This paradigm posits that exercise should always mimic or reflect the natural way the body moves - whatever that means - and activities of daily living, and that in order to be effective an exercise must involve the whole body simultaneously during an exercise, decrying "isolation" and "those stupid machines like the seated knee extension and the seated shoulder press".

The material is suited for personal trainers, strength and conditioning coaches, physical therapists, occupational therapists, performance enhancement specialists, and exercise physiologists. Any exercise professional that wants to think in a new complex systems and informatics way, and use an expanded view of exercise to improve client health and wellness, will benefit from this material.