A sport-medicine-education collaborative intervention framework for patellar tendinopathy: theoretical foundation and implementation pathway

Abstract

Objective

To develop an interdisciplinary collaborative framework for implementing Sport-Medicine-Education for managing patellar tendinopathy (PT; note that PT is used throughout this manuscript to refer exclusively to patellar tendinopathy, not physical therapy or physical therapist) and to establish its content validity through expert consensus using the Consolidated Framework for Implementation Research (CFIR), the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, and Education-Unload-Reload-Prevention.

Methods

A multi-phase framework development process was utilized. Phase 1 included systematic literature synthesis with PRISMA guidance, identifying 170 records from PubMed (October 20, 2024), 155 articles to full-text review, and 73 studies eventually included, expert co-creation meetings (n = 15 experts), Delphi consensus generation (3 rounds, 92% agreement), and external validation, including feasibility consultation at three clinical sites. CFIR was utilized to determine implementation facilitators and barriers within five domains. Feasibility of the framework utilized RE-AIM dimensions with 16 specific measures.

Results

The integrative model includes three main dimensions: Sport Science (load management, biomechanical assessment, performance optimization), Medicine (clinical diagnosis, physical rehabilitation, pain management), and Health Education (patient education, self-management skills, behavioral support). Through the integration of literature synthesis, expert workshops, and Delphi consensus, 23 facilitators and 15 barriers to implementation were identified across the CFIR domains. The five-phase implementation pathway (Pre-implementation→Planning→Active Implementation→Sustainability→Scale-up) was rated for feasibility at 4.2 out of 5.0 on a 5-point Likert scale by the 15-member expert panel during the Delphi process. Based on Delphi consensus, the expert panel established the following RE-AIM target thresholds for future validation: reach of ≥ 70% of eligible patients, effectiveness of at least a 13-point improvement on the Victorian Institute of Sport Assessment-Patella (VISA-P), adoption across ≥ 3 institutions with complete MDT representation, ≥ 85% implementation fidelity, and ≥ 70% maintenance at 12 months.

Conclusion

This study proposes a theory-driven collaborative framework for patellar tendinopathy management that integrates formalized implementation strategies with specified evaluation criteria. The model serves as a conceptual blueprint and implementation manual for the transition from fragmented to integrated multidisciplinary care, with the potential to enhance clinical outcomes and reduce recurrence rates. However, its real-world effectiveness requires empirical validation through prospective implementation studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-026-01628-6.

Introduction

Patellar tendinopathy (PT) is an overuse injury affecting 14.2–45% of elite jumping athletes, with the highest prevalence among basketball players at 31.9% [1]. The condition is characterized by load-related anterior knee pain that substantially impairs athletic performance and quality of life [2]. Although effective evidence-based interventions exist, with HSR training achieving 76% symptom improvement rates in controlled trial settings [3], real-world outcomes remain poor: only 46% of athletes return to their pre-injury performance level, and recurrence rates exceed 27% across prospective studies [3]. This persistent gap between research efficacy and clinical effectiveness suggests that implementation failures, rather than knowledge gaps, are the primary cause of poor outcomes in PT management [4].

Three theoretical models for facilitation offer spaces for meeting PT management issues. The Consolidated Framework for Implementation Research (CFIR) presents 39 constructs in five domains to precisely define implementation determinants [5]. RE-AIM uses a pragmatic evaluation approach with five dimensions, diverting attention away from efficacy toward pragmatic effectiveness in real-world settings [5]. The Education-Unload-Reload-Prevention (EdUReP) model organizes patient education along the rehabilitation spectrum to correct the educational deficits found in 67% of PT patients [6]. While each model has intrinsic value, their integration when practiced together within musculoskeletal rehabilitation environments is yet to be investigated.

Significant discrepancies exist between disciplinary advancement and integrative clinical application. Sport science, medicine, and education operate largely in isolation; coordinated multidisciplinary care is documented in only 23% of PT cases across surveyed clinical settings [7]. Among these, structured health education is a frequently underrepresented component, with patient education delivered inconsistently or omitted entirely in many treatment plans. This gap is critical, as organized interprofessional practice that incorporates systematic patient education has been shown to improve outcomes by 31% beyond standard care [8]. However, no operational system exists to allow systematic implementation of cooperative PT care. Fragmentation persists, with most multidisciplinary settings engaging in “parallel play,” where multiple disciplines work alongside each other but without integrated goals [9], undermining therapy effectiveness.

This study aims to develop a collaborative framework for patellar tendinopathy management through the integration of Sport Science, Medicine, and Health Education by: (1) synthesizing CFIR, RE-AIM, and EdUReP theoretical models into a unified operational structure; (2) establishing evidence-based implementation strategies; and (3) defining detailed evaluation standards for future validation [10–12].

Methods

Study design and strategy

This study was not registered as a clinical trial, as it constitutes theoretical framework development research rather than a clinical intervention trial. This study employed a mixed-methods framework development process grounded in implementation science principles [13]. The design merged theoretical, empirical evidence review, and expert consensus building with the aim of ensuring scientific rigor as well as clinical relevance. A pragmatic paradigm was employed in recognition of the complexity of real-world healthcare settings and the need for implementation strategies to be both structured and adaptive [14]. Framework development was iterative, emphasizing stakeholder feedback, revision, and external feasibility consultation to maximize applicability across diverse clinical settings. This approach aligns with emerging best practices in implementation science that advocate for co-design and context-specific tailoring while maintaining core fidelity to evidence-based frameworks.

Framework development process

Development of the framework was a rigorous combinatorial four-step process, as indicated in Fig. 1.

Fig. 1.

Framework development process. Note: Four-phase systematic development process including literature synthesis, expert co-creation workshops, Delphi consensus, and external validation. Abbreviations: CFIR, Consolidated Framework for Implementation Research; RE-AIM, Reach, Effectiveness, Adoption, Implementation, Maintenance; EdUReP, Education-Unload-Reload-Prevention; PT, patellar tendinopathy

Phase 1 included an elaborate synthesis of literature in the form of PRISMA guideline adoption to yield 170 records, which were retrieved from PubMed (October 20, 2024), out of which 155 articles were analyzed at full-text level to finally select 73 studies, through the final synthesis in the forms of collaborative care, implementation science, and rehabilitation management [15].

Phase 2 involved co-creation workshops with 15 multidisciplinary professionals (5 sports scientists, 5 physicians/physiotherapists, 5 health educators) using the nominal group technique to create the initial framework components [16].

Phase 3 consisted of the execution of the three-round modified Delphi approach, using a structured questionnaire specifically developed for this study (see Supplementary File: Delphi Questionnaire). The questionnaire was designed to achieve consensus on the framework structure, implementation plan, and evaluation parameters. The Delphi questionnaire underwent pilot testing with three experts prior to full deployment to ensure clarity and comprehensiveness of all items, ultimately achieving 92% consensus for the final elements.

Phase 4 involved external review by 10 independent experts and a feasibility consultation at three clinical sites (one university sports medicine clinic, one hospital rehabilitation center, one community physiotherapy practice). Clinicians at these sites reviewed the framework materials and provided structured feedback on perceived practicability, resource requirements, and implementation timeline. Feedback indicated general agreement that the 12–18-month timeline was realistic, though two sites recommended extending the planning phase to allow for staff training. This phase served as a preliminary acceptability assessment rather than a formal pilot implementation with patient enrollment. This iterative process ensured that the framework achieved an appropriate balance between theoretical fidelity and practical workability.

Literature search strategy

A systematic search was conducted on 20 October 2024 within PubMed by two reviewers (WL and FJ) to identify studies relevant to patellar tendinopathy management, collaborative care interventions, and implementation frameworks. The adopted search approach utilized the three-concept-block strategy with Boolean operators for cross-linking: (1) patellar tendinopathy keywords, (2) collaborative/multidisciplinary care keywords, and (3) implementation science keywords. The entire search strategy is listed in Supplementary Table S1.

Eligibility criteria

The study was eligible if it: (1) dealt with the diagnosis, treatment, or management of patellar tendinopathy; (2) involved collaborative/multidisciplinary practices, implementation models, or patient education programs; (3) was written in the English language; and (4) had human participants. The specific PICOS (Population, Intervention, Comparison, Outcomes, Study design) criteria are given in Supplementary Table S2.

Studies were excluded if they were: (1) case reports, editorials, letters, or opinion pieces; (2) conference abstracts without available full text; (3) animal or in vitro studies; or (4) focused exclusively on other tendinopathies (e.g., Achilles, rotator cuff) without relevance to patellar tendinopathy. Grey literature and conference proceedings were not systematically searched; this decision is acknowledged as a limitation (see Discussion).

Study selection process

The literature search yielded 170 records in PubMed (October 20, 2024). Titles and abstracts were screened independently by two reviewers based on pre-established eligibility criteria, with considerable inter-rater agreement (Cohen’s κ = 0.82). At title and abstract screening, 15 articles were excluded: 10 for addressing non-patellar tendinopathies, 2 for having inappropriate study designs (animal studies), 1 for not having collaborative/implementation content, and 2 for low relevance to the research aims. This left 155 articles to be reviewed at full text.

After full-text screening, 82 studies were excluded due to: inadequate collaborative/implementation framework in full text (n = 13), and no apparent collaborative care or implementation details (n = 69), leaving 73 studies to be included in the final synthesis for framework development. Studies excluded and reasons for exclusion are included in Supplementary Table S3 and Table S5. The entire selection process according to PRISMA guidelines is presented in Figure S1 (PRISMA flowchart).

Quality assessment

Methodological quality of included studies was evaluated using the corresponding tools for study design: the Cochrane Risk of Bias 2.0 tool for randomized trials, Newcastle-Ottawa Scale for cohort and case-control studies, the Modified Delphi Appraisal Tool for studies that were consensus studies, and the JBI Critical Appraisal Checklist for qualitative studies. Quality appraisal was carried out independently by two reviewers, with disagreement resolved by discussion or referral to a third reviewer. Included studies were those with quality appraisals that were moderate to very high. The results of the quality appraisals are included in Supplementary Table S4.

Data extraction and synthesis

A standardized data extraction form was developed to capture study characteristics, participant details, intervention components, collaborative care elements, theoretical models, outcome measures, key findings, and framework implications. The complete list of extraction categories is provided in Supplementary Table S6.

Two reviewers independently undertook data extraction, and disagreements were resolved through consensus discussion.

Due to considerable heterogeneity in study design, interventions, and outcomes, instead of meta-analysis, a narrative synthesis was undertaken. Outcomes were theme-coded using the following: (a) CFIR’s five domains (Innovation Characteristics, Outer Setting, Inner Setting, Individual Characteristics, Process) to determine implementation determinants; (b) RE-AIM framework’s five dimensions (Reach, Effectiveness, Adoption, Implementation, Maintenance) to organize assessment measures; and (c) emergent themes regarding collaborative care models, patient education strategies, and load management strategies. This systematic organization of evidence enabled directly the construction of our three-dimensional collaborative structure model (Sport-Medicine-Education), the five-phase implementation procedure, and the overall RE-AIM evaluation framework.

CFIR application methods

CFIR application involved systematic charting of the determinants of implementation for the five domains, as depicted in Table 1 [17]. For Innovation Characteristics, we assessed framework complexity, relative advantage, and adaptability to local contexts. Outer Setting analysis consisted of patient demands, peer influence, and external policies that form adoption. Inner Setting assessment included organizational culture, implementation climate, and resources. Characteristics of Individuals assessed the knowledge of stakeholders, self-efficacy, and organizational commitment. Process domain assessed planning quality, engagement strategy, and strategy for executing the plan. The domains were assessed using structured interviews and surveys among major stakeholders, with selective highlighting of specific facilitators and barriers. The comprehensive CFIR application allowed for the formulation of targeted strategies for resolving the implementation challenges that were salient.

Table 1.

CFIR five domains application

CFIR Domain	Key Elements Assessed	Identified Facilitators	Identified Barriers	Implementation Strategies
Innovation Characteristics	Relative advantage, Complexity, Adaptability, Evidence strength	Strong evidence base (n = 4); Clear clinical benefits (n = 1)	Perceived complexity (n = 2)	Simplify protocols; Provide quick reference guides
Outer Setting	Patient needs, Peer pressure, External policies	High patient demand (n = 3); Professional body support (n = 1)	Insurance limitations (n = 2)	Advocate for policy changes; Develop billing codes
Inner Setting	Culture, Climate, Resources, Leadership	Leadership commitment (n = 4); Learning climate (n = 2)	Time constraints (n = 4); Resource limitations (n = 3)	Phased implementation; Efficiency optimization
Characteristics of Individuals	Knowledge, Self-efficacy, Identification	Professional motivation (n = 3); Champion presence (n = 1)	Knowledge gaps (n = 2)	Targeted training; Mentorship programs
Process	Planning, Engaging, Executing, Reflecting	Structured planning tools (n = 2); Regular feedback loops (n = 2)	Competing priorities (n = 2)	Protected implementation time; PDSA cycles

Data analysis methods

Data analysis utilized deductive and inductive methods. Descriptive statistics and weighted scoring for priority were applied to analyze quantitative survey data. Thematic analysis by framework method was applied in analyzing qualitative interview and workshop data with 88% inter-rater agreement between two independent coders [18]. CFIR constructs acted as the original coding structure with emergent themes added through constant comparison. Synthesis of quantitative and qualitative results followed convergent mixed-methods design, allowing for rich understanding of determinants of implementation and effectiveness of strategy.

Results

Collaborative framework core architecture

Literature synthesis results

Systematic review uncovered 73 high-quality studies that informed framework development. The most frequently investigated from among these were: load management strategies (n = 12), multidisciplinary team interventions (n = 3), clinical assessment protocols (n = 3), patient education strategies (n = 18), and implementation facilitators/barriers (n = 15). Across the 73 included studies, three overarching findings emerged from the thematic synthesis. First, the literature consistently demonstrated fragmentation between sport science and clinical medicine perspectives: 68.5% of studies (n = 50) focused on single-discipline interventions, with no study reporting a fully integrated approach combining load management with clinical rehabilitation and patient education. Second, implementation gaps were pervasive, with 79.5% of studies (n = 58) lacking systematic evaluation of how interventions were adopted and sustained in clinical practice. Third, patient education showed high variability in content and delivery, with 50.7% of studies (n = 37) reporting inconsistent or unstandardized educational approaches. These findings directly informed the three-dimensional structure of the collaborative framework and underscored the need for implementation science integration. Three recurring themes to promote integrated collaborative strategies were determined through analysis: (1) sport science and clinical medicine views being fragmented, with no evidence for integrated load management methods within clinical rehabilitation programs; (2) lack of interprofessional collaboration models as the majority of studies were single-discipline interventions; and (3) lack of formal implementation models that were consistent with PT management, wherein studies done failed to conduct systematic evaluation of adoption and sustainability. These results explicitly guided the three-dimensional structure (Sport Science-Medicine-Education) of our collaborative framework and emphasized the imperative of implementation science integration. Thematic synthesis of primary outcomes from all included studies is reported in Supplementary Table S7.

Four decades of PT research development as charted in Fig. 2 demonstrate paradigmatic accumulations over time from early tendinitis ideas to today’s multidisciplinary period, placing our historical perspective upon an integrated framework approach. The three theoretical frameworks within our model provide complementary strengths (see Supplementary Table S8 for detailed comparison): CFIR offers implementation guidance, RE-AIM provides pragmatic evaluation, and EdUReP organizes patient-centered rehabilitation content.

Fig. 2.

Evolution of patellar tendinopathy research (1980–2024). Note: Narrative timeline illustrating six key paradigm shifts in PT research based on the authors’ interpretation of landmark publications, not a formal bibliometric analysis. Key references are cited for each era

The collaborative Sport-Medicine-Education model consists of four interrelated layers that are designed to support systematized management of PT as presented in Fig. 3 [19–21]. The theoretical foundation layer integrates CFIR for implementation and RE-AIM for evaluation of outcomes. The core collaboration layer consists of three interrelated dimensions: Sport Science with load quantification and performance optimization, Medicine with tissue healing and symptom management, and Health Education with patient empowerment and facilitating behavioral change. The collaboration mechanism layer enables inter-professional interaction through four components: role matrices that identify precise roles, formal communication protocols that guarantee information flow, evidence-based decision algorithms, and mechanisms for conflict resolution. The patient pathway layer applies EdUReP principles to four phases of rehabilitation: acute care, progressive loading, return to sport, and secondary prevention.

Fig. 3.

Sport-medicine-education collaborative framework. Note: Multi-layered framework structure showing integration of CFIR/RE-AIM theories, three core dimensions, collaboration mechanisms, and EdUReP model

Through triangulation of evidence from the systematic literature review (Phase 1), expert co-creation workshops (Phase 2), and Delphi consensus rounds (Phase 3), a total of 23 facilitators were identified across CFIR domains: Innovation Characteristics (n = 5), i.e., high relative advantage and sound evidence base; Outer Setting (n = 4), i.e., patient demand for coordinated care; Inner Setting (n = 6), i.e., leadership and resource availability; Characteristics of Individuals (n = 4), i.e., professional motivation; and Process (n = 4), i.e., identification of a champion. 15 barriers, on the other hand, were found, mainly in Inner Setting (n = 7) because of limited time and other priorities. The number of facilitators and barriers per domain reflects the frequency with which these factors were endorsed across all three data sources, rather than findings from any single phase.

Three dimensions detailed description

The framework’s three dimensions encompass distinct yet complementary components essential for comprehensive PT management as shown in Table 2 [22–24].

Table 2.

Framework three dimensions detailed description

Dimension	Core Components	Key Professionals	Primary Interventions	Interface with Other Dimensions
Sport Science	Load management (acute: chronic workload ratio 0.8–1.3) Training modification Biomechanical assessment Performance optimization	Sports scientists Strength & conditioning coaches Biomechanists Performance analysts	Workload monitoring systems Movement screening Sport-specific progressions Return-to-performance protocols	Shares load data with Medicine Receives pain thresholds from Medicine Collaborates with Education on athlete understanding
Medicine	Clinical diagnosis (ultrasound >4 mm thickness) Physical therapy Pain management Tissue healing monitoring	Sports physicians Physiotherapists Radiologists Pain specialists	Eccentric exercise (3 × 15 reps, 2×daily) Isometric loading (5 × 45s at 70% MVC) Manual therapy Imaging surveillance	Provides medical clearance to Sport Science Receives loading history from Sport Science Refers to Education for self-management
Health Education	Patient education (85% knowledge retention) Self-management skills Behavioral change support Psychological support	Health educators Sports psychologists Behavioral therapists Nurse educators	Multimedia education resources Motivational interviewing Cognitive-behavioral strategies Peer support groups	Reinforces medical advice Supports training adherence Facilitates communication between dimensions

Sport Science component includes four key elements: (1) Acute: chronic workload ratio-managed load administration 0.8–1.3, (2) Training adaptation within sport-specific progressions, (3) Biomechanical assessment to determine movement impairments accountable for excessive tendon loading, (4) Maximization of performance by rehabilitation and athletic development congruence. The predominant professionals to involve here are strength coaches, sports scientists, and biomechanists who communicate to maximize loading patterns.

The Medicine dimension entails: (1) Clinical diagnosis with ultrasound imaging revealing >4 mm tendon thickening and neovascularization, (2) Physical therapy treatment with eccentric exercise (3 × 15 repetitions, 2 sessions daily) and isometric loading (5 × 45 s at 70% MVC), (3) Pain management techniques with load modification with adjunct therapies, (4) Tissue healing monitoring by serial imaging and biomarker assessment. These are done by medical professionals like sports physicians and physiotherapists.

Health Education module consists of: (1) Education of the patient using multimedia materials with 85% recall of the information, (2) Development of self-management skills using load monitoring and symptom understanding, (3) Change in behavior using motivational interviewing skill facilitation, (4) Psychological support for fear-avoidance beliefs in 58% of chronic diseases. The modules are taught by health educators and psychologists, and patient adherence and participation are promoted.

Five-phase implementation pathway

The implementation pathway comprises five sequential phases over 12–18 months as shown in Fig. 4. Each phase is supported by specific CFIR-ERIC-aligned strategies with defined responsible parties, expected outputs, and success criteria (see Supplementary Table S9 for the complete implementation strategy checklist) [25, 26].

Fig. 4.

Five-phase implementation pathway. Note: Implementation timeline spanning 12–18 months from pre-implementation through scale-up, with key milestones and deliverables. Abbreviations: CFIR, Consolidated Framework for Implementation Research; ORIC, Organizational Readiness for Implementing Change; MDT, multidisciplinary team; RE-AIM, Reach, Effectiveness, Adoption, Implementation, Maintenance; VISA-P, Victorian Institute of Sport Assessment-Patella; VAS, Visual Analog Scale; PDSA, Plan-Do-Study-Act; REDCap, Research Electronic Data Capture

Pre-implementation (Months 1–2) involves organizational readiness assessment for implementing the Organizational Readiness for Implementing Change (ORIC) tool with a minimum score of 4.0/5.0. The important activities are stakeholder mapping to determine champions by discipline, resource audit providing investment quantification (medium-sized clinic, $50,000–75,000), and team building developing multidisciplinary leadership committee.

Planning Phase (Months 3–4) involves context-specific implementation planning, establishment of communication protocols with weekly MDT meetings and shared electronic records, educational toolkit development such as patient leaflets and clinician guides, and team training with competency levels of 90%.

Active Implementation (Months 5–10) initiates MDT care delivery with bi-weekly case conferences, introduces team-based treatment protocols with decision trees, collects process and outcome data by means of REDCap database, and does monthly plan-do-study-act (PDSA) cycles for ongoing improvement.

Sustainability Phase (Months 11–14) is prioritizing fidelity monitoring of > 80% on key components, barrier mitigation through problem-solving directed towards clear problems, optimization of resources to cost-neutrality, and policy integration of embedding framework within organizational processes.

Scale-up Period (Months 15–18) prioritizes dissemination of results by conference presentations and peer-reviewed publications, train-the-trainer program development that reaches 50 + clinicians, institutionalization of quality assurance systems monitored quarterly, and building implementation networks to provide sustained support.

RE-AIM evaluation system

It should be noted that the following target thresholds were established through the three-round Delphi consensus process and represent aspirational benchmarks for future empirical validation, rather than observed outcomes from this study. The comprehensive evaluation system employs 16 metrics across RE-AIM dimensions as shown in Fig. 5 and detailed in Table 3 [26].

Fig. 5.

RE-AIM evaluation framework with pt-specific metrics. Note: Radar chart and detailed metrics table showing five evaluation dimensions with 16 specific indicators and target thresholds

Table 3.

Detailed RE-AIM evaluation indicators

RE-AIM Dimension	Evaluation Indicators	Data Source	Target Threshold	Assessment Time
REACH (Participation & Representativeness)	1. Patient participation rate (eligible patients who enrolled) 2.Representativeness across subgroups (age, sex, sport type) 3. Diversity of recruitment channels (clinic, community, referral)	Recruitment records, demographic data	≥ 70% (ref: Augustsson 2024)	Baseline – 6 months
EFFECTIVENESS (Clinical Outcomes)	4. VISA-P score improvement (MCID = 13 points) 5. VAS pain score reduction (0–10 scale) 6. Functional recovery rate (return to sport ≥ 80% pre-injury level) 7. Patient satisfaction score (1–5 Likert scale)	Clinical assessments (baseline, 3 m, 6 m)	VISA-P: ≥13↑; VAS: ≥2↓; Function: ≥80%; Satisfaction: ≥4/5	Baseline, 3 m, 6 m
ADOPTION (Uptake by Settings & Professionals)	8. Number of participating institutions (target ≥ 3) 9. Completeness of MDT (all 3 dimensions represented) 10. Clinician participation willingness (survey)	Institutional records, staff surveys	≥ 3 institutions; 100% MDT; ≥60% willingness	Phase 1–2 (Month 0–6)
IMPLEMENTATION (Fidelity & Cost)	11.Implementation fidelity score (adherence to protocols) 12. MDT meeting attendance rate (target ≥ 90%) 13. Toolkit utilization rate 14.Implementation cost per patient	Fidelity checklists, financial records	Fidelity: ≥80%; Attendance: ≥90%; Cost: TBD	Weekly (Phase 3)
MAINTENANCE (Sustainability)	15. Framework usage at 12 months post-implementation (≥ 70%) 16. Staff turnover rate (< 20%) & institutionalization level	12-month follow-up	Usage: ≥70%; Turnover: <20%	12 months post-implementation

Comprehensive evaluation framework with 16 specific indicators across five RE-AIM dimensions, including measurement tools, target thresholds, and assessment timelines for implementation evaluation. Implementation cost per patient (Indicator 14): A fixed target threshold was not specified at this stage due to variability across healthcare systems. For future validation studies, we recommend calculating this as total MDT personnel hours multiplied by local hourly rates, plus direct material costs (educational toolkits, assessment forms), divided by the number of patients treated. This per-patient cost can then be compared against standard care costs to determine cost-effectiveness

The Delphi panel set a Reach target of ≥ 70% participation of eligible patients, representative age (18–35 years) and competition levels recruiting, and use of several recruiting channels such as clinic referrals and collaboration with sporting organizations.

Effectiveness outcomes are primary outcomes of ≥ 13 points improvement in VISA-P score (minimum clinically important difference) and Visual Analog Scale (VAS) reduction of ≥ 2 points. Secondary outcomes are 80% return-to-sport rate at preinjury level, patient satisfaction scores of ≥ 4.0/5.0, and treatment compliance of > 85%.

Adoption measures are ≥ 3 different organizations’ participation (athletic department, sports medicine clinic, community physiotherapy), 90% of cases being represented fully by MDT (physician, sport scientist, physiotherapist, educator), and clinician willingness-to-continue rates of > 60%.

Implementation measures focus on fidelity scores of > 80% on formal checklists, > 90% attendance at MDT meetings, use of educational toolkit in > 75% of consultations, and favourable cost-benefit ratios (savings by reduced recurrence covering the costs of implementation).

Maintenance approaches incorporate 12-month framework application > 70%, incorporation in ≥ 2 structured organizational processes, ≤ 20% turnover among trained personnel, and continued outcome optimization at 6 and 12-month follow-up.

The theoretical model in Fig. 6 integrates the multi-layered structure of framework design, illustrating stepwise translation from theoretical building blocks (CFIR, RE-AIM, EdUReP) to operational framework design and implementation into clinical practice and to multi-level outcomes. The four-layered structure illustrates how implementation science principles are translated into actionable practicable clinical practices, with iterative refinement facilitated by continuous feedback cycles. The layered structure of the model is designed to balance theoretical rigor with practical usability, resolving the historic research-practice gap in PT management.

Fig. 6.

Integrated theoretical model: from theory to practice. Note: Four-layer transformation model showing progression from theoretical foundations through framework design to clinical outcomes with feedback loops. Abbreviations: CFIR, Consolidated Framework for Implementation Research; RE-AIM, Reach, Effectiveness, Adoption, Implementation, Maintenance; EdUReP, Education-Unload-Reload-Prevention; ERIC, Expert Recommendations for Implementing Change; HSR, heavy slow resistance; VISA-P, Victorian Institute of Sport Assessment-Patella; VAS, Visual Analog Scale; MDT, multidisciplinary team

Discussion

Summary of key findings

There are a number of novel contributions of this project to PT management and implementation science. Among them, one is a syncretization of CFIR, RE-AIM, and EdUReP frameworks, a novel integration of theories on the implementation process and clinical content that fills one of the gaps that recent systematic reviews have observed where, in musculoskeletal interventions, only 12% make use of implementation frameworks [27, 28]. Identification of 23 facilitators and 15 barriers within CFIR domains attains a degree of detail in delineating PT management implementation challenges heretofore unseen in research limited to single-domain analysis [29].

Comparison with existing literature

Our three-dimensional framework construct lends substance to interprofessional collaboration beyond earlier multidisciplinary models. While earlier models of care are most typically defined by referral sequence between disciplines, our structure demands contemporaneous, integrated care by means of formal communication structures. This directly addresses the “parallel play” phenomenon, in which multiple disciplines work alongside each other but without integrated goals, that occurs in 78% of current multidisciplinary clinics [9]. Drawing on the collaboration mechanisms embedded in the framework (see Fig. 3), several structural ‘forcing functions’ are proposed to overcome this pattern, or “forcing functions,” to overcome this pattern: mandatory joint case-conference formats where all three dimensions present simultaneously, shared electronic health record templates requiring input from each discipline before treatment progression, and integrated outcome dashboards visible to all team members. These mechanisms are embedded within the collaboration layer of the framework (see Fig. 3) to ensure that interdisciplinary interaction is built into routine workflows rather than relying on ad hoc communication. The addition of behavior change theories via the Health Education component is a paradigm shift that acknowledges that tissue repair alone without psychological care and modification of movement patterns is a causative factor behind the 27% recurrence rate.

The five-step implementation plan with timelines provided, deliverables, and measures provide actionable guidance not found in previous theoretical models. Best practice from the Expert Recommendations for Implementing Change (ERIC) repository guides each step, those selected being paired with CFIR barriers that were found. The intended process is contrasted to ad-hoc implementation that has been the norm in 85% of sports medicine practice change.

Our results validate and contribute to the evidence base of collaborative care and PT management. The 31% estimate of improvement in outcomes is in agreement with interprofessional intervention impacts on chronic musculoskeletal disorders, justifying the transferability of collaborative principles into PT [30]. Our model, however, offers greater operational specificity compared to existing frameworks by combining PT-specific clinical content with structured implementation strategies.

The aforementioned time barrier and resource constraint barrier holds in referenced problems in systematic reviews of multidisciplinary care implementation [31]. Our framework, nevertheless, mitigates these barriers through phased implementation with graduated resource allocation and streamlined protocols. The 85% estimated rate of compliance is well over 60% that has been in popular citation for complex interventions, likely due to the incorporation of wide stakeholders in the designing process [32].

Comparison with other biopsychosocial models of sports medicine [33] reveals a qualitative difference. Biopsychosocial models, in accepting many factors, do not typically contain operational specificity as to how a large number of providers must be coordinated. This model addresses this gap through inclusion of definite role definitions, rules of communication, and decision algorithms to render actual integration rather than multidisciplinary coexistence possible.

The RE-AIM instruments created eclipse assessment comprehensiveness in current PT trials, with only 73% of studies simply reporting efficacy outcomes. The model surmounts the research-practice gap at the heart of poor real-world implementation despite strong research evidence due to the addition of reach, adoption, implementation, and maintenance variables.

Clinical and professional implications

The model is applied directly to practice. Systematic assessment protocols minimize diagnostic uncertainty, now accounting for 40% of PT delay diagnosis [34]. Structured MDT process arrangements coordinate resources; based on evidence from collaborative care models in comparable musculoskeletal conditions [30, 31], a reduction of approximately 25% in total treatment sessions may be anticipated through planned care that minimizes redundancy. This projection requires confirmation through prospective evaluation of the current framework.

For the athlete, structured management responds to the athlete’s core question of safe and timely return-to-sport. The model’s stepwise loading interventions, rooted in psychological counseling for fear-avoidance management, target the 54% of athletes who delay return as tissue is being rehabilitated [35]. Education components allow athletes to manage themselves, remain injury-free, and end recurrence cycling during high-risk time periods.

Role clarification reduces interprofessional conflict, evidence-based decision rules decrease clinical uncertainty, and formal communication protocols prevent information loss during care transitions. The adaptability of the model facilitates application across settings with flexibility in ensuring core components to ensure quality care.

Strengths and limitations

Beyond direct patient benefits, the framework has implications for professional development and role transformation. Regular MDT case conferences function as a continuous learning platform, enabling clinicians to remain updated on cross-disciplinary evidence and expand their competencies beyond traditional disciplinary boundaries. Furthermore, the Health Education dimension empowers clinicians to transition from a predominantly prescriptive role to a facilitative one, supporting patient autonomy in load management and self-monitoring. This shift has been associated with improved clinician job satisfaction and reduced professional burnout in comparable collaborative care models in chronic disease management.

Regarding resource considerations, the framework is designed with scalability in mind. For community clinics with limited budgets, the EdUReP educational components can be implemented through low-cost strategies such as printed patient handouts, brief motivational interviewing integrated into routine consultations, and freely available online exercise video libraries. These approaches require minimal additional equipment and can be delivered by existing clinical staff with targeted training, reducing the need for dedicated health educators. The phased implementation pathway further allows organizations to adopt core components incrementally based on available resources.

Several limitations should be acknowledged. First, the framework was developed through synthesis of existing literature and expert consensus rather than prospective empirical validation; consequently, the proposed target thresholds and anticipated outcomes require confirmation through future implementation studies [36]. Second, the systematic literature search was limited to a single database (PubMed), and databases such as EMBASE, CINAHL, SPORTDiscus, and the Cochrane Library were not searched. While PubMed provides broad biomedical coverage, this single-database approach may have missed relevant studies, particularly from nursing, allied health, and sport science journals, and represents a methodological limitation of the evidence synthesis. Third, the resource requirements for full framework implementation (estimated $50,000–75,000 for a medium-sized clinic) may limit applicability in low-resource settings, potentially restricting adoption to well-resourced sports medicine environments. Fourth, coordinating multiple professionals across three dimensions demands significant organizational commitment and may prove challenging in settings where siloed practice is deeply entrenched [37]. Fifth, while feasibility consultations were conducted at three clinical sites, these involved expert review of framework materials rather than formal pilot implementation with patient enrollment; therefore, the practical challenges of real-world delivery remain to be empirically determined.

Future research directions

Future research should prioritize a Type 2 hybrid effectiveness-implementation trial design, which simultaneously evaluates clinical effectiveness and implementation outcomes, directly aligned with the dual focus of this framework. Such trials should compare framework implementation against standard care across multiple sites. Cost-effectiveness analyses within diverse healthcare systems would inform resource allocation decisions. Adaptation studies targeting broader populations (youth athletes, recreational athletes) and alternative delivery settings (telehealth, primary care) would enhance generalizability. The development of standardized implementation facilitation toolkits and training modules would support wider dissemination and reduce the burden on adopting organizations.

Conclusion

This study presents a Sport-Medicine-Education collaborative framework for patellar tendinopathy management that integrates CFIR implementation principles, RE-AIM evaluation dimensions, and EdUReP educational structure. Through systematic literature synthesis, expert co-creation, and Delphi consensus, the framework identified 23 facilitators and 15 barriers, established a five-phase implementation pathway, and defined 16 evaluation metrics, providing operational guidance for transitioning from fragmented to integrated multidisciplinary care. By addressing both clinical content and the implementation process, this framework offers a structured foundation for improving outcomes for individuals with patellar tendinopathy. Future research should prioritize prospective empirical validation, particularly through effectiveness-implementation hybrid designs led by multidisciplinary teams in sports medicine clinics, hospital rehabilitation centers, and community physiotherapy practices, to determine real-world impact across diverse clinical settings and populations.

Authors' contributions

Wei Liu: Conceptualization, Methodology, Investigation, Writing - original draft, Project administration. Fugao Jiang: Methodology, Data curation, Formal analysis, Investigation, Writing - original draft. Chunli Han: Data curation, Formal analysis, Investigation, Validation.Gongchang Yu: Investigation, Validation, Writing - review & editing. Bin Shi: Validation, Writing - review & editing. Jinhai Sun: Conceptualization, Supervision, Writing - review & editing, Project administration.

Funding

This work was supported by the Capacity Building and Continuing Education Center of the National Health Commission Special Project on Chronic Disease Management (Grant No. GWJJMB202510010124): Research on the Collaborative Chronic Disease Management Model of “Sports, Medicine and Education”; the National Natural Science Foundation of China General Project (Grant No. 8237461): Mechanical and molecular biological mechanisms of spinal regulation of intervertebral disc mechanical microenvironment to improve nucleus pulposus degeneration; and the National Social Science Foundation of China Major Project (Grant No. 20&ZD336): Research on Chinese wisdom and solutions for global sports governance from the perspective of a community with a shared future for mankind.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to privacy and ethical restrictions protecting patient confidentiality, but are available from the corresponding author on reasonable request and with appropriate ethical approval.

Declarations

Ethics approval and consent to participate

This study was reviewed and approved by the Institutional Review Board (IRB) of Qufu Normal University (approval number: QNUIRB-2024-SSE-073, approval date: September 15, 2024). The study adhered to the ethical principles outlined by the IRB of Qufu Normal University and followed all relevant regulations for research involving human participants. The research was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent after being fully informed of the study purpose, procedures, and potential risks.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.