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ICON 2019—International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients
  1. Bill Vicenzino1,
  2. Robert-Jan de Vos2,
  3. Hakan Alfredson3,
  4. Roald Bahr4,5,
  5. Jill L Cook6,
  6. Brooke K Coombes7,
  7. Siu Ngor Fu8,
  8. Karin Gravare Silbernagel9,
  9. Alison Grimaldi1,10,
  10. Jeremy S Lewis11,12,13,
  11. Nicola Maffulli14,15,16,
  12. SP Magnusson17,18,
  13. Peter Malliaras19,
  14. Sean Mc Auliffe5,
  15. Edwin H G Oei20,
  16. Craig Purdam6,
  17. Jonathan D Rees21,22,
  18. Ebonie Kendra Rio6,
  19. Alex Scott23,
  20. Cathy Speed24,
  21. Inge van den Akker-Scheek25,
  22. Adam Weir2,26,27,
  23. Jennifer Moriatis Wolf28,
  24. Johannes Zwerver29
  1. 1 School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, Queensland, Australia
  2. 2 Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
  3. 3 Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umeå, Sweden
  4. 4 Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
  5. 5 Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  6. 6 La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia
  7. 7 Allied Health Sciences, Physiotherapy, Griffith University, Nathan, Queensland, Australia
  8. 8 Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
  9. 9 Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
  10. 10 Physiotec, Tarragindi, Queensland, Australia
  11. 11 School of Health and Midwifery, University of Hertfordshire, Hertfordshire, UK
  12. 12 Therapy Department, Central London Community Healthcare NHS Trust, London, UK
  13. 13 Department of Physical Therapy & Rehabilitation Science, College of Health Science, Qatar University, Doha, Qatar
  14. 14 Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Baronissi, Italy
  15. 15 Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospitial, London, United Kingdom
  16. 16 School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Keele University, Stoke on Trent, England
  17. 17 Department of Physical Therapy, Bispebjerg Hospital, Kobenhavn, Denmark
  18. 18 Department of Sports Medicine, Bispebjerg Hospital, Kobenhavn, Denmark
  19. 19 Department of Physiotherapy, Monash University, Clayton, Victoria, Australia
  20. 20 Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, Netherlands
  21. 21 Fortius Clinic, London, UK
  22. 22 Centre for Sports & Exercise Medicine, Queen Mary University of London, London, UK
  23. 23 Department of Physical Therapy, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
  24. 24 Sports Medicine and Human Performance, Cardiff Metropolitan University, Cardiff, UK
  25. 25 University Medical Center, Department of Orthopaedics, University of Groningen, Groningen, Netherlands
  26. 26 Aspetar Sports Groin Pain Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  27. 27 Sport Medicine and Exercise Clinic Haarlem (SBK), Haarlem, Netherlands
  28. 28 Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois, USA
  29. 29 Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
  1. Correspondence to Professor Bill Vicenzino, School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, Queensland, Australia; b.vicenzino{at}


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

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

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

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

  • Consensus
  • Tendinopathy
  • Measurement
  • Treatment
  • Evidence based

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  • Twitter @Bill_Vicenzino, @rj_devos, @@kgSilbernagel, @@alisongrimaldi, @JeremyLewisPT, @@DrPeteMalliaras, @Seaniemc89, @drjrees, @tendonpain, @@akkerscheeki, @@Hans Zwerver

  • Contributors BV: concept, project lead, methods, data collection and analysis, writing. Other committee members R-JdV, JZ, AW, EKR, AS, SMcA: project oversight, methods, data collection, writing. Larger group: Delphi process, writing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval was gained for the study from the University of Queensland, Australia Ethics Committee (Approval #2018001439).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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