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Emerging trends in hamstring injuries in the Australian Football League
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2013 ASICS Conference / Journal of Science and Medicine in Sport 16S (2013) e59–e83
January 2008 and June 2010 were reviewed to identify players who underwent shoulder surgery on their dominant (serving) shoulder. Surgical details including date, procedures performed, and complications were recorded. The primary outcomes were ability and time to return to professional play, and ability to return to previous level of function, as determined by their highest singles ranking pre-injury and post operatively over a 2.5-year period. Results/discussion: During the study period eight WTA players underwent dominant arm shoulder surgery. All procedures were arthroscopic, most (88%) of players had more than one procedure performed during surgery. The mean age of players at surgery was 25 (range 18–31), and mean follow up was 39 months (range 24–54). A high rate of return to play was noted with seven players (88%) returning to professional play with a mean time of 7.0 months after surgery. However a prolonged and often incomplete recovery time to previous functional level was noted following surgery, with only 2 out of 8 players achieving their previous singles ranking by 18 months post operatively At nearly 2.5 years only four players (50%) returned to their pre-injury singles ranking, with their peak singles ranking being attained at a mean of 2.4 years post. To our knowledge, this represents the first study to assess the outcomes of shoulder surgery in professional tennis players, or in professional female overhead athletes. Previous studies have focused on return to play of elite baseballers or older recreational tennis athletes. We believe our methodology of assessing ranking is a more sensitive tool to assess level of recovery. This information is useful when counselling patients, coaching staff on expectations regarding return to play and likely attainment of pre-surgical level of function. http://dx.doi.org/10.1016/j.jsams.2013.10.151 13 Is intradiscal methylene blue injection an effective treatment alternative for discogenic low back pain? B. Mitchell ∗ , A. Barnard Metro Pain Clinic, Australia Background: Discogenic low back pain (LBP) is caused by internal disc disruption, expansion of sensory nerve endings along annular tears, and inflammatory reactions in the degenerated nucleus pulposus by a number of cytokines and nitric oxide. Methylene Blue (MB), an inhibitor of nitric oxide synthase has been controversially suggested as an effective treatment for chronic intractable discogenic pain. Peng and colleagues (Peng et al., Pain, 2010) reported in a randomised controlled study, the active group receiving intradiscal MB injections resulted in a 52.5-point reduction in mean numeric pain rating score and 91.6% in satisfaction rate at 24 months after procedure, a result that surpasses most other non-surgical LBP treatments. However a more recent, smaller cohort study has shown that the efficacy of intradiscal MB injection is maintained in only 20% of patients after 12 months (Kim et al., Ann Rehabil Med, 2012). Here we report on the outcome of our first 7 consecutive patients receiving MB to treat discogenic LBP. Method: Seven patients diagnosed with at least one symptomatic lumbar disc as confirmed using ISIS (International Spine Intervention Society) standardised provocative discography, received 1 ml of 1% Methylene Blue (10 mg) into the center of the nucleus pulposus under fluoroscopic guidance. Pain levels and analgesic use was recorded and patients followed up 6–9 months post procedure. Results: All seven patients reported nil pain relief following intradiscal MB treatment. Similarly no reduction to analgesic use
was observed either. Within the following 6–9 months, 4 patients had undergone either a posterior or anterior lumbar interbody fusion, whilst another 2 had undergone a nucleoplasty procedure for their discogenic LBP. The remaining patient (currently 6 weeks post MB injection) is considering their next treatment option. Discussion: All seven of our consecutive patients receiving intradiscal MB failed to respond to the injections and either proceeded to or considering alternative interventional and/or surgical procedures. Both published studies and our seven patients used similar patient selection criteria and low dose (0.5% or 1%) MB. Further studies about whether repeated MB injections work for chronic discogenic pain might be necessary, however, larger doses of MB or multiple injection regimes must proceed with caution due to experimental evidence of neurological impairment with large dose MB. Conclusion: These poor 6–9 month results combined with the 12 month outcome data reported by Kim and colleagues seriously questions whether MB injection is in actual fact an effective treatment method for discogenic low back pain. http://dx.doi.org/10.1016/j.jsams.2013.10.152 14 Emerging trends in hamstring injuries in the Australian Football League T. Pizzari 1,3,∗ , R. Taylor 2 , P. Coburn 3 1
La Trobe University, Australia Alphington Sports Medicine, Australia 3 Mill Park Physiotherapy Centre, Australia 2
Introduction: Hamstring muscle strain injuries continue to be the most common injury and cause of missed games in the Australian Football League (AFL). Despite the research that has been conducted into this injury, the injury rates have remained relatively steady over the past 20 years in the AFL. The identification of risk factors and the implementation of prevention strategies could be being counteracted by continual changes in the game demands and the emergence of new risk factors. The aim of the current study was to collect data surrounding every hamstring injury during the 2011 AFL season. Methods: Data were collected on player factors, injury details, extrinsic factors, and recovery information associated with the injured player and the hamstring injury. Results: Ninety-one hamstring muscle strain injuries from 75 players were reported during the 2011 season. Sixteen injuries were recurrent strains (21%) and of these, three players had two recurrences. Players aged <20 years were 1.7 times more likely to sustain an injury than those aged >24 years. The biceps femoris muscle was injured in 85% of cases, most commonly at the distal musculotendinous junction. The majority of strains occurred during high speed running or when combining running with lumbar flexion. There was no relationship between mechanism of injury and resultant location of injury within the muscle, however players who sustained an acceleration injury were significantly more likely to take longer to return to play (>25 days). Where there was no clear injury incident, players were 8 times more likely to return to play within 3 weeks. Hamstring injuries most commonly occurred during games, in the later rounds of the season, in the third quarter of a game and during or the week following playing on a significantly harder ground. Workload data revealed a greater game percentage three weeks prior to injury. Discussion: In a previous study conducted in the 2002 season, players over 24 years old were four times more likely to sustain a hamstring injury than those under 20 years. The reverse was
2013 ASICS Conference / Journal of Science and Medicine in Sport 16S (2013) e59–e83
true in 2011 and might reflect the changing nature of the game. Considering that injuries occurred later in games, later in the season, following and during playing on harder grounds, and following an increased game load it could implicate cumulative loading and fatigue as associated factors in hamstring injury.
e65
16 Operative vs non-operative treatment of acute Achilles tendon rupture: The debate continues. . . Y. Kaplan
http://dx.doi.org/10.1016/j.jsams.2013.10.153 15 Can diagnostic ultrasound measure quadriceps size and vastus medialis to vastus lateralis ratio in patellofemoral pain syndrome? L. Giles 1,∗ , K. Webster 1 , J. McClelland 1 , J. Cook 2 1 2
La Trobe University, Australia Monash University, Australia
Introduction: Discrepencies in size between vastus medialis (VM) and the rest of the quadriceps musculature (vastus intermedius (VI), vastus lateralis (VL), and rectus femoris (RF)) are thought to be present in a population with patellofemoral pain syndrome (PFPS). Thickness measures with diagnostic ultrasound could provide a cheap, time efficient method of measuring individual quadriceps muscle size for research and clinical purposes. This study aimed to determine the validity of ultrasound in measuring individual quadriceps muscle thickness by comparing results to magnetic resonance imaging (MRI) measures of muscle thickness and cross sectional area (CSA). Methods: Three female and two male participants with unilateral PFPS underwent bilateral ultrasound and MRI scanning of the quadriceps. Points were marked on the skin bilaterally over the mid-belly of VM, VL, VI, RF, and VMO. Comparisons were drawn for each muscle between ultrasound muscle thickness (USMT), and MRI muscle thickness (MRIMT) and CSA at these points. Pearson’s correlation coefficient (r) and intraclass correlation coefficient (ICC) using a random effects model (absolute agreement) were used to compare USMT and MRIMT, and compare the thickness ratio for MRI and US of VM:VL and VMO:VL. Spearman’s correlation coefficient (rho) was used to compare USMT with MRI CSA. Results: Ultrasound thickness measures were significantly correlated to MRIMT for VMO (r = 0.86, ICC = 0.63), VM (r = 0.86, ICC = 0.43), VL (r = 0.94, ICC = 0.81), and RF (r = 0.86, ICC = 0.71), no significant correlation was found for VI (r = 0.37, ICC = 0.24). The ratio of thickness between muscles for MRI and ultrasound were significantly correlated for VM:VL (r = 0.86, ICC = 0.82) and VMO:VL (r = 0.92, ICC = 0.921). Ultrasound thickness measures were significant correlated to MRI CSA measures for VM (rho = 0.73), VL (rho = 0.83), and RF (rho = 0.88), and no significant correlation was found for VMO (rho = 0.20) and VI (rho = 0.310). Conclusion: Significant correlations were found for VM, VL and RF between USMT and MRI measures of muscle thickness and CSA, indicating these measures can be used to measure muscle size. The VMO USMT measure was significantly correlated to MRIMT but not to MRI CSA, and the VI USMT measure was not significantly correlated to either MRIMT or MRI CSA. Caution is advised in interpretation of these results as the small sample size in this study highlights the risk of type II error. Significant correlations were found between MRI and Ultrasound muscle thickness ratios for VM:VL and VMO:VL, indicating these measures may be useful for investigating if a difference is present in the size of VM and VL in PFPS. http://dx.doi.org/10.1016/j.jsams.2013.10.154
Physical Therapy and Sports Medicine Institute, Lerner Sports Center, Hebrew University, Jerusalem, Israel Background: Despite the fact that acute Achilles tendon ruptures (AATR) are common sports injuries, there is a lack of consensus on the best management. The primary aim of medical professionals should be to return these patients to full functional pain-free activity in the shortest time possible, without increasing their susceptibility to re-rupture. Herein lies the controversy in the literature. The question remains whether surgery is always indicated for these cases, or can early, gradual rehabilitation achieve the same or even better short and long-term results. The aims of the research were to identify and summarize the up-to-date evidence-based practice concerning the optimal effectiveness of different interventions in the treatment of AATR. Methods: A search was conducted using multiple databases, including the Cochrane Musculoskeletal Injuries Group’s specialized register the Medline, PubMed, Embase and Cinahl search registers (to March 2013). All prospective, level 1 and 2, randomized and quasi-randomized were reviewed including their conclusions and recommendations. Search headings included “non-operative vs operative treatment”, acute Achilles tendon ruptures”, “randomized control trials”. Results: Twelve studies, involving 1074 patients were included. Most of the studies had poor methodology and inadequate reporting of outcomes. Most trials showed good to excellent long-term results in the non-operated group, with no significantly higher rerupture rate compared to the operative cases. These all used early functional post-op rehabilitation. Patients fitted post-operatively with a functional brace rather than a cast tended to have shorter in-patient stay, fewer days off work, a quicker return to sporting activity, better range of ankle motion and strength. Conclusions: Contrary to previously reported studies, there is strong evidence that AATR may be successfully rehabilitated in a non-operative manner without increasing their susceptibility to rerupture. This needs to be further studied with larger sample sizes and further high-quality research protocols. What is more apparent is that early functional rehabilitation in an active brace post-surgery is more advantageous than the current protocol of immobilization. This is irrespective of whether surgery has occurred or not. http://dx.doi.org/10.1016/j.jsams.2013.10.155 17 Factors influencing the implementation of self-report measures for athlete monitoring A. Neumaier ∗ , L. Main, P. Gastin Deakin University, Australia Introduction: Self-report measures are a relatively simple and theoretically effective means of athlete monitoring above traditional physiological and performance measures. The objectives of self-report measures include early detection and ultimately prevention of undesired outcomes such as overtraining and injury. However achieving such objectives is dependent on how the measure is implemented. This study sought to investigate how athlete
2013 ASICS Conference / Journal of Science and Medicine in Sport 16S (2013) e59–e83
January 2008 and June 2010 were reviewed to identify players who underwent shoulder surgery on their dominant (serving) shoulder. Surgical details including date, procedures performed, and complications were recorded. The primary outcomes were ability and time to return to professional play, and ability to return to previous level of function, as determined by their highest singles ranking pre-injury and post operatively over a 2.5-year period. Results/discussion: During the study period eight WTA players underwent dominant arm shoulder surgery. All procedures were arthroscopic, most (88%) of players had more than one procedure performed during surgery. The mean age of players at surgery was 25 (range 18–31), and mean follow up was 39 months (range 24–54). A high rate of return to play was noted with seven players (88%) returning to professional play with a mean time of 7.0 months after surgery. However a prolonged and often incomplete recovery time to previous functional level was noted following surgery, with only 2 out of 8 players achieving their previous singles ranking by 18 months post operatively At nearly 2.5 years only four players (50%) returned to their pre-injury singles ranking, with their peak singles ranking being attained at a mean of 2.4 years post. To our knowledge, this represents the first study to assess the outcomes of shoulder surgery in professional tennis players, or in professional female overhead athletes. Previous studies have focused on return to play of elite baseballers or older recreational tennis athletes. We believe our methodology of assessing ranking is a more sensitive tool to assess level of recovery. This information is useful when counselling patients, coaching staff on expectations regarding return to play and likely attainment of pre-surgical level of function. http://dx.doi.org/10.1016/j.jsams.2013.10.151 13 Is intradiscal methylene blue injection an effective treatment alternative for discogenic low back pain? B. Mitchell ∗ , A. Barnard Metro Pain Clinic, Australia Background: Discogenic low back pain (LBP) is caused by internal disc disruption, expansion of sensory nerve endings along annular tears, and inflammatory reactions in the degenerated nucleus pulposus by a number of cytokines and nitric oxide. Methylene Blue (MB), an inhibitor of nitric oxide synthase has been controversially suggested as an effective treatment for chronic intractable discogenic pain. Peng and colleagues (Peng et al., Pain, 2010) reported in a randomised controlled study, the active group receiving intradiscal MB injections resulted in a 52.5-point reduction in mean numeric pain rating score and 91.6% in satisfaction rate at 24 months after procedure, a result that surpasses most other non-surgical LBP treatments. However a more recent, smaller cohort study has shown that the efficacy of intradiscal MB injection is maintained in only 20% of patients after 12 months (Kim et al., Ann Rehabil Med, 2012). Here we report on the outcome of our first 7 consecutive patients receiving MB to treat discogenic LBP. Method: Seven patients diagnosed with at least one symptomatic lumbar disc as confirmed using ISIS (International Spine Intervention Society) standardised provocative discography, received 1 ml of 1% Methylene Blue (10 mg) into the center of the nucleus pulposus under fluoroscopic guidance. Pain levels and analgesic use was recorded and patients followed up 6–9 months post procedure. Results: All seven patients reported nil pain relief following intradiscal MB treatment. Similarly no reduction to analgesic use
was observed either. Within the following 6–9 months, 4 patients had undergone either a posterior or anterior lumbar interbody fusion, whilst another 2 had undergone a nucleoplasty procedure for their discogenic LBP. The remaining patient (currently 6 weeks post MB injection) is considering their next treatment option. Discussion: All seven of our consecutive patients receiving intradiscal MB failed to respond to the injections and either proceeded to or considering alternative interventional and/or surgical procedures. Both published studies and our seven patients used similar patient selection criteria and low dose (0.5% or 1%) MB. Further studies about whether repeated MB injections work for chronic discogenic pain might be necessary, however, larger doses of MB or multiple injection regimes must proceed with caution due to experimental evidence of neurological impairment with large dose MB. Conclusion: These poor 6–9 month results combined with the 12 month outcome data reported by Kim and colleagues seriously questions whether MB injection is in actual fact an effective treatment method for discogenic low back pain. http://dx.doi.org/10.1016/j.jsams.2013.10.152 14 Emerging trends in hamstring injuries in the Australian Football League T. Pizzari 1,3,∗ , R. Taylor 2 , P. Coburn 3 1
La Trobe University, Australia Alphington Sports Medicine, Australia 3 Mill Park Physiotherapy Centre, Australia 2
Introduction: Hamstring muscle strain injuries continue to be the most common injury and cause of missed games in the Australian Football League (AFL). Despite the research that has been conducted into this injury, the injury rates have remained relatively steady over the past 20 years in the AFL. The identification of risk factors and the implementation of prevention strategies could be being counteracted by continual changes in the game demands and the emergence of new risk factors. The aim of the current study was to collect data surrounding every hamstring injury during the 2011 AFL season. Methods: Data were collected on player factors, injury details, extrinsic factors, and recovery information associated with the injured player and the hamstring injury. Results: Ninety-one hamstring muscle strain injuries from 75 players were reported during the 2011 season. Sixteen injuries were recurrent strains (21%) and of these, three players had two recurrences. Players aged <20 years were 1.7 times more likely to sustain an injury than those aged >24 years. The biceps femoris muscle was injured in 85% of cases, most commonly at the distal musculotendinous junction. The majority of strains occurred during high speed running or when combining running with lumbar flexion. There was no relationship between mechanism of injury and resultant location of injury within the muscle, however players who sustained an acceleration injury were significantly more likely to take longer to return to play (>25 days). Where there was no clear injury incident, players were 8 times more likely to return to play within 3 weeks. Hamstring injuries most commonly occurred during games, in the later rounds of the season, in the third quarter of a game and during or the week following playing on a significantly harder ground. Workload data revealed a greater game percentage three weeks prior to injury. Discussion: In a previous study conducted in the 2002 season, players over 24 years old were four times more likely to sustain a hamstring injury than those under 20 years. The reverse was
2013 ASICS Conference / Journal of Science and Medicine in Sport 16S (2013) e59–e83
true in 2011 and might reflect the changing nature of the game. Considering that injuries occurred later in games, later in the season, following and during playing on harder grounds, and following an increased game load it could implicate cumulative loading and fatigue as associated factors in hamstring injury.
e65
16 Operative vs non-operative treatment of acute Achilles tendon rupture: The debate continues. . . Y. Kaplan
http://dx.doi.org/10.1016/j.jsams.2013.10.153 15 Can diagnostic ultrasound measure quadriceps size and vastus medialis to vastus lateralis ratio in patellofemoral pain syndrome? L. Giles 1,∗ , K. Webster 1 , J. McClelland 1 , J. Cook 2 1 2
La Trobe University, Australia Monash University, Australia
Introduction: Discrepencies in size between vastus medialis (VM) and the rest of the quadriceps musculature (vastus intermedius (VI), vastus lateralis (VL), and rectus femoris (RF)) are thought to be present in a population with patellofemoral pain syndrome (PFPS). Thickness measures with diagnostic ultrasound could provide a cheap, time efficient method of measuring individual quadriceps muscle size for research and clinical purposes. This study aimed to determine the validity of ultrasound in measuring individual quadriceps muscle thickness by comparing results to magnetic resonance imaging (MRI) measures of muscle thickness and cross sectional area (CSA). Methods: Three female and two male participants with unilateral PFPS underwent bilateral ultrasound and MRI scanning of the quadriceps. Points were marked on the skin bilaterally over the mid-belly of VM, VL, VI, RF, and VMO. Comparisons were drawn for each muscle between ultrasound muscle thickness (USMT), and MRI muscle thickness (MRIMT) and CSA at these points. Pearson’s correlation coefficient (r) and intraclass correlation coefficient (ICC) using a random effects model (absolute agreement) were used to compare USMT and MRIMT, and compare the thickness ratio for MRI and US of VM:VL and VMO:VL. Spearman’s correlation coefficient (rho) was used to compare USMT with MRI CSA. Results: Ultrasound thickness measures were significantly correlated to MRIMT for VMO (r = 0.86, ICC = 0.63), VM (r = 0.86, ICC = 0.43), VL (r = 0.94, ICC = 0.81), and RF (r = 0.86, ICC = 0.71), no significant correlation was found for VI (r = 0.37, ICC = 0.24). The ratio of thickness between muscles for MRI and ultrasound were significantly correlated for VM:VL (r = 0.86, ICC = 0.82) and VMO:VL (r = 0.92, ICC = 0.921). Ultrasound thickness measures were significant correlated to MRI CSA measures for VM (rho = 0.73), VL (rho = 0.83), and RF (rho = 0.88), and no significant correlation was found for VMO (rho = 0.20) and VI (rho = 0.310). Conclusion: Significant correlations were found for VM, VL and RF between USMT and MRI measures of muscle thickness and CSA, indicating these measures can be used to measure muscle size. The VMO USMT measure was significantly correlated to MRIMT but not to MRI CSA, and the VI USMT measure was not significantly correlated to either MRIMT or MRI CSA. Caution is advised in interpretation of these results as the small sample size in this study highlights the risk of type II error. Significant correlations were found between MRI and Ultrasound muscle thickness ratios for VM:VL and VMO:VL, indicating these measures may be useful for investigating if a difference is present in the size of VM and VL in PFPS. http://dx.doi.org/10.1016/j.jsams.2013.10.154
Physical Therapy and Sports Medicine Institute, Lerner Sports Center, Hebrew University, Jerusalem, Israel Background: Despite the fact that acute Achilles tendon ruptures (AATR) are common sports injuries, there is a lack of consensus on the best management. The primary aim of medical professionals should be to return these patients to full functional pain-free activity in the shortest time possible, without increasing their susceptibility to re-rupture. Herein lies the controversy in the literature. The question remains whether surgery is always indicated for these cases, or can early, gradual rehabilitation achieve the same or even better short and long-term results. The aims of the research were to identify and summarize the up-to-date evidence-based practice concerning the optimal effectiveness of different interventions in the treatment of AATR. Methods: A search was conducted using multiple databases, including the Cochrane Musculoskeletal Injuries Group’s specialized register the Medline, PubMed, Embase and Cinahl search registers (to March 2013). All prospective, level 1 and 2, randomized and quasi-randomized were reviewed including their conclusions and recommendations. Search headings included “non-operative vs operative treatment”, acute Achilles tendon ruptures”, “randomized control trials”. Results: Twelve studies, involving 1074 patients were included. Most of the studies had poor methodology and inadequate reporting of outcomes. Most trials showed good to excellent long-term results in the non-operated group, with no significantly higher rerupture rate compared to the operative cases. These all used early functional post-op rehabilitation. Patients fitted post-operatively with a functional brace rather than a cast tended to have shorter in-patient stay, fewer days off work, a quicker return to sporting activity, better range of ankle motion and strength. Conclusions: Contrary to previously reported studies, there is strong evidence that AATR may be successfully rehabilitated in a non-operative manner without increasing their susceptibility to rerupture. This needs to be further studied with larger sample sizes and further high-quality research protocols. What is more apparent is that early functional rehabilitation in an active brace post-surgery is more advantageous than the current protocol of immobilization. This is irrespective of whether surgery has occurred or not. http://dx.doi.org/10.1016/j.jsams.2013.10.155 17 Factors influencing the implementation of self-report measures for athlete monitoring A. Neumaier ∗ , L. Main, P. Gastin Deakin University, Australia Introduction: Self-report measures are a relatively simple and theoretically effective means of athlete monitoring above traditional physiological and performance measures. The objectives of self-report measures include early detection and ultimately prevention of undesired outcomes such as overtraining and injury. However achieving such objectives is dependent on how the measure is implemented. This study sought to investigate how athlete