- Email: [email protected]
Hip and groin MRI and US findings in elite asymptomatic Australian football players
S98
Thursday 1 November Papers / Journal of Science and Medicine in Sport 15 (2013) S34–S126
ing was explored in a purposive sample of consenting experienced physiotherapists using semi-structured interviews until data saturation. Interviews were analysed using the framework method to reveal emerging themes, with this data then being used to illustrate the systematic review data. Results: Initial searching yielded a total of 3497 studies. Forty seven of these met the inclusion criteria. In total, 11 separate treatment modalities were identified, with strong evidence supporting eccentric exercises and extra-corporeal shockwave therapy (ESWT) and moderate evidence for low-level laser therapy, and concentric exercises. Limited evidence was found for foot orthoses and therapeutic ultrasound. Taping and soft-tissue mobilisation studies were only identified by case studies/series rather than randomised controlled trials. There was conflicting evidence for topical glyceryl trinitrate. Framework analysis of semi-structured interviews revealed common themes which highlighted that physiotherapists were frequently utilising eccentric exercises, based on their strong evidence base. Manual therapy was also frequently applied, and foot orthoses prescription was often considered. Barriers to translating the research into practice included heterogeneous outcome measures employed in different studies, over-stringency of traditional evidence synthesis approaches and lack of access to primary research reports. Discussion: The graded evidence combined with qualitatively analysed clinical reasoning produced a novel guide for clinicians conservatively managing mid-portion Achilles tendinopathy. Additionally, these findings allow experienced clinicians to review the evidence base and reflect on their clinical reasoning. Key areas for future research include evaluating the efficacy of foot orthoses, manual therapy, aetiological factors, how to manage different stages of presentation such as reactive or degenerative tendinopathy and eccentric exercise protocol adaptation. http://dx.doi.org/10.1016/j.jsams.2012.11.236 234
for hamstring muscle pairs e.g. biceps femoris short head (BFSH): biceps femoris long head (BFLH) ratio as well as for a medial vs lateral muscle group comparison e.g. BFSH + BFLH: semitendinosus (ST) + semimembranosus (SM) ratio. Results: Manual segmentation of axial MR images was shown to have high reliability for determining hamstring muscle volumes with CV’s ranging from 1.1% for SM to 2.7% for BFSH. Baseline normative muscle ratio data for the various muscle pair comparisons are presented as median (interquartile range 25%–75%) values with preferred kicking leg defining dominance. The following ratios were found; BFSH:BFLHdominant 0.53(0.46–0.62), BFSH:BFLHnon-dominant 0.50(0.47–0.58); ST:SMdominant 0.98(0.91–1.03), ST:SMnon-dominant 0.95(0.86–1.02). The normative muscle ratios for the medial vs lateral muscle group comparison were BFLH + BFSH:ST + SMdominant 0.68(0.64–0.70), BFLH + BFSH:ST + SMnon-dominant 0.65(0.62–0.71). In a first series of analyses, SSM was able to accurately classify players with injured vs non-injured BFLH. Conclusion: The current hamstring muscle morphometric data in uninjured players provides valuable “normative” data for future prospective studies into hamstring strains. The large differences in the volume ratios between the BFLH and BFSH maybe of potential importance in (re)injury of the hamstrings as may the smaller overall lateral vs medial muscle group volume (∼30%) given the predominance of lateral hamstring strains. Information provided by SSM on shape parameters in relation to muscle injury may provide information of further clinical interest. http://dx.doi.org/10.1016/j.jsams.2012.11.237 235 Hip and groin MRI and US findings in elite asymptomatic Australian football players G. Lammers 1,∗ , D. Connell 1 , P. Baquie 2 , T. Page 3 , M. Opar 4 1
Imaging @ Olympic Park, Victoria Hawthorn Football Club 3 Collingwood Football Club 4 La Trobe University 2
Muscle morphometry of the individual hamstring muscles in semi-elite AFL Players: Preliminary findings from a longitudinal study T. Brancato 1,∗ , C. Engstrom 1 , J. Fripp 2,1 1 2
The University of Queensland Commonwealth Scientific and Industrial Research Organisation
Introduction: Hamstring strains in the Australian Football League (AFL) have a high incidence (15%) and recurrence rate (34%) with lateral hamstring injuries most common (83%). Retrospective studies have found significant muscle volume asymmetries ≤23 months post hamstring injury; however examination of the association between hamstring strains and muscle asymmetry has not been investigated prospectively. This study presents baseline data from a longitudinal study focusing on individual hamstring morphometry in uninjured and injured semi-elite AFL players. Methods: Bilateral, contiguous 5 mm axial magnetic resonance (MR) images of the hamstring muscles were acquired from 26 male semi-elite AFL players (23 ± 4 years, 6 ± 4 years playing history at semi-elite level; uninjured [N = 16], self-reported previous hamstring injury [N = 10]). Manual segmentation procedures for the MR images were extensive with reliability analyses conducted using Coefficients of Variation (CV) and Dice Coefficients. Slice sampling and statistical shape modelling (SSM) approaches were also explored as a means of increasing the clinical applicability and efficiency of morphometric analyses. In the uninjured players, “normative” unilateral and bilateral volume ratios were calculated
Introduction: Hip and groin pain is a common injury at the elite level of Australian football with musculoskeletal imaging playing an important role in diagnosis. Radiology findings in athletes without pain are important as they increase diagnostic accuracy and improve the ability to interpret findings with clinical relevance. Several MRI studies exist that report on findings in asymptomatic athletes. However, recent advances in the understanding of enthesopathy and the potential contribution of the hip joint in the development of groin pain warrants further MRI investigation in asymptomatic athletes. When considering pathologies associated with groin pain ultrasound (US) may be a more relevant diagnostic tool for some structures including the adductor tendons, inguinal ligament and conjoint tendon. Ultrasound studies are less frequent in groin pain research with the exception of hernia studies. The purpose of this study was to examine US and MRI findings in asymptomatic Australian football players and to compare findings with the development of hip and groin symptoms in the following season. Methods: Sixty-three Australian football players from two AFL clubs completed US and MRI imaging during the 2011 preseason. At the time of imaging all players were free of groin pain symptoms. All images were independently reviewed by two radiologists with 19 and 15 years of clinical experience. Throughout the season, players were tracked for onset of symptoms by club medical staff and compared against pre-season imaging findings.
Thursday 1 November Papers / Journal of Science and Medicine in Sport 15 (2013) S34–S126
Results: Enthesopathy was reported in 29% (18/63) of players analysed and in 29% (18/63) of players a pubic symphysis defect was reported. Cam lesions were present in 29% (18/63) of players and hip joint capsule thickening was observed in 11% (7/63) of players. Correlations between reported findings and injury episodes during the season will also be presented. Discussion: When interpreting imaging in athletes with hip and groin pain the findings of enthesopathy, pubic symphysis defects and cam lesions in uninjured athletes should be considered. Ultrasound appears to be a useful tool in visualising hip joint capsule thickening that may develop prior to a cam lesion. The US findings in this study suggest that US may be a viable alternative for assessing the hip and groin compared to MRI and CT that has been preferred historically. Including imaging as a component of preseason screening may be useful in identifying athletes at risk of hip and groin injury. http://dx.doi.org/10.1016/j.jsams.2012.11.238 236 Medio-lateral knee position during knee flexion tests is predictive of hip kinematics during running S. LeRossignol 1,∗ , E. Ageberg 2 , M. Smith 1 , M. Creaby 1 1 2
Australian Catholic University Lund University
Introduction: Knee injuries, including Iliotibial band syndrome (ITBS) and patellofemoral pain syndromes (PFPS), are prevalent in distance runners. Current literature links altered hip and knee kinematics during running with these injuries. Quantitative measurement of hip and knee kinematics is difficult within the clinical setting. Thus clinically feasible tests that are predictive of hip and knee kinematics during running may be beneficial. Mediolateral knee position during a clinical test involving knee flexion (minisquat) is predictive of peak internal hip rotation during the test, but its relationship with hip and knee kinematics during running is not known. The purpose of this study was to determine if five clinical tests of knee control are predictive of hip and knee kinematics during running. Methods: Twenty runners with no musculoskeletal injuries, who ran at least 10 km per week, volunteered for this study (31.5 ± 8.9 years, 178.5 ± 4.8 cm, 75.5 ± 9.4 kg). Participants performed five clinical tests of knee control, which were recorded with a high definition camera in the frontal plane. The tests were: single leg mini squat (SLMS), single leg squat on step (SLS), forward lunge (Lunge), single leg hop for distance (SLH) and triple hop for distance (TRH). A clinician assessed and scored each performance on a 4 point scale according to their mediolateral knee position (over, medial or lateral relative to the foot). Three-dimensional running kinematics were obtained during treadmill running at 4 m/s. The hip and knee kinematics calculated were: peak internal hip rotation (HIR), peak hip adduction (HAD) and peak knee abduction (KAB) during the stance phase of running. Pearson correlations between the knee position scores of each clinical test and hip and knee kinematics were performed. A forward stepwise regression was used to determine which clinical test was the strongest predictor of each kinematic variable. An alpha level of 0.05 was set. Results: Larger HIR during running was correlated with a more medial knee position during the SLH, lunge and TRH. The knee position score of the SLH was the strongest predictor of HIR. Knee position score of the clinical tests were not correlated to either HAD or KAB during running.
S99
Discussion: Assessment of knee position during the SLH, lunge and TRH could be used in situations where measurement of running kinematics is not available to infer HIR during running. The SLH should be used primarily for assessment of knee position because it is the best predictor of HIR during running. http://dx.doi.org/10.1016/j.jsams.2012.11.239 237 Effect of foot orthoses on ankle kinematics and kinetics in male runners with Achilles tendinopathy S. Sussmilch-Leitch 1,∗ , K. Crossley 2 , T. Wrigley 3 , M. Creaby 4 1
Department of Physiotherapy, The University of Melbourne School of Health and Rehabilitation Sciences, University of Queensland 3 Centre for Health, Exercise and Sports Medicine, The University of Melbourne 4 Centre of Physical Activity Across the Lifespan, School of Exercise Science, Australian Catholic University 2
Introduction: Achilles tendinopathy (AT) is a common injury among male runners, affecting the longevity of sporting careers and participation in exercise. Abnormal rearfoot biomechanics are thought to be risk factors for AT, but their role is not well established. There is evidence to suggest that people with AT have altered eversion kinematics at the rearfoot, which may result in disproportionate loading across the medial and lateral aspects of the Achilles tendon. Altered ankle dorsiflexion mechanics have also been discussed as a cause of AT, where the tendon may be placed under a greater load in the sagittal plane. The purpose of this study was to evaluate the immediate eversion and dorsiflexion kinematic and kinetic effects of foot orthoses in runners with AT. Methods: Thirteen adult males (age 42 yr ± 10, weight 78 kg ± 12, height 178 cm ± 6) with midportion AT symptoms, running > 20 kilometres per week, were recruited. Confirmation of AT pathology was performed using diagnostic ultrasound. Three dimensional kinematic and kinetic data were collected using a Vicon motion analysis system and AMTI force plates during the stance phase of shod running gait for two conditions: i) with prefabricated semi-rigid foot orthoses, and ii) no orthoses. Each participant completed at least five overground running trials per condition at a controlled running speed. Data processing was completed in Workstation and BodyBuilder software to determine: peak rearfoot eversion angle, rearfoot eversion excursion, peak ankle dorsiflexion angle, peak plantarflexion moment and plantarflexion impulse. Statistical analyses were performed using a paired samples t-test with SPSS software (version 19). An alpha level of 0.05 was set. Results: The ankle eversion excursion was significantly reduced with use of foot orthoses (11.9 deg ± 4.3) compared to footwearonly (13.4 deg ± 4.3; p = 0.03). No differences between conditions were observed for the other variables (p > 0.05). Discussion: Our data demonstrate that the immediate use of foot orthoses reduces rearfoot eversion motion in male runners with midportion AT during the stance phase of running. This change results in kinematic parameters similar to those in asymptomatic runners, which may have a beneficial treatment response. Other elements of frontal and sagittal plane mechanics were not altered. Further studies are required to evaluate the long term biomechanical effects of foot orthoses in people with AT and its role in improving pain and function outcomes across both genders. http://dx.doi.org/10.1016/j.jsams.2012.11.240
Thursday 1 November Papers / Journal of Science and Medicine in Sport 15 (2013) S34–S126
ing was explored in a purposive sample of consenting experienced physiotherapists using semi-structured interviews until data saturation. Interviews were analysed using the framework method to reveal emerging themes, with this data then being used to illustrate the systematic review data. Results: Initial searching yielded a total of 3497 studies. Forty seven of these met the inclusion criteria. In total, 11 separate treatment modalities were identified, with strong evidence supporting eccentric exercises and extra-corporeal shockwave therapy (ESWT) and moderate evidence for low-level laser therapy, and concentric exercises. Limited evidence was found for foot orthoses and therapeutic ultrasound. Taping and soft-tissue mobilisation studies were only identified by case studies/series rather than randomised controlled trials. There was conflicting evidence for topical glyceryl trinitrate. Framework analysis of semi-structured interviews revealed common themes which highlighted that physiotherapists were frequently utilising eccentric exercises, based on their strong evidence base. Manual therapy was also frequently applied, and foot orthoses prescription was often considered. Barriers to translating the research into practice included heterogeneous outcome measures employed in different studies, over-stringency of traditional evidence synthesis approaches and lack of access to primary research reports. Discussion: The graded evidence combined with qualitatively analysed clinical reasoning produced a novel guide for clinicians conservatively managing mid-portion Achilles tendinopathy. Additionally, these findings allow experienced clinicians to review the evidence base and reflect on their clinical reasoning. Key areas for future research include evaluating the efficacy of foot orthoses, manual therapy, aetiological factors, how to manage different stages of presentation such as reactive or degenerative tendinopathy and eccentric exercise protocol adaptation. http://dx.doi.org/10.1016/j.jsams.2012.11.236 234
for hamstring muscle pairs e.g. biceps femoris short head (BFSH): biceps femoris long head (BFLH) ratio as well as for a medial vs lateral muscle group comparison e.g. BFSH + BFLH: semitendinosus (ST) + semimembranosus (SM) ratio. Results: Manual segmentation of axial MR images was shown to have high reliability for determining hamstring muscle volumes with CV’s ranging from 1.1% for SM to 2.7% for BFSH. Baseline normative muscle ratio data for the various muscle pair comparisons are presented as median (interquartile range 25%–75%) values with preferred kicking leg defining dominance. The following ratios were found; BFSH:BFLHdominant 0.53(0.46–0.62), BFSH:BFLHnon-dominant 0.50(0.47–0.58); ST:SMdominant 0.98(0.91–1.03), ST:SMnon-dominant 0.95(0.86–1.02). The normative muscle ratios for the medial vs lateral muscle group comparison were BFLH + BFSH:ST + SMdominant 0.68(0.64–0.70), BFLH + BFSH:ST + SMnon-dominant 0.65(0.62–0.71). In a first series of analyses, SSM was able to accurately classify players with injured vs non-injured BFLH. Conclusion: The current hamstring muscle morphometric data in uninjured players provides valuable “normative” data for future prospective studies into hamstring strains. The large differences in the volume ratios between the BFLH and BFSH maybe of potential importance in (re)injury of the hamstrings as may the smaller overall lateral vs medial muscle group volume (∼30%) given the predominance of lateral hamstring strains. Information provided by SSM on shape parameters in relation to muscle injury may provide information of further clinical interest. http://dx.doi.org/10.1016/j.jsams.2012.11.237 235 Hip and groin MRI and US findings in elite asymptomatic Australian football players G. Lammers 1,∗ , D. Connell 1 , P. Baquie 2 , T. Page 3 , M. Opar 4 1
Imaging @ Olympic Park, Victoria Hawthorn Football Club 3 Collingwood Football Club 4 La Trobe University 2
Muscle morphometry of the individual hamstring muscles in semi-elite AFL Players: Preliminary findings from a longitudinal study T. Brancato 1,∗ , C. Engstrom 1 , J. Fripp 2,1 1 2
The University of Queensland Commonwealth Scientific and Industrial Research Organisation
Introduction: Hamstring strains in the Australian Football League (AFL) have a high incidence (15%) and recurrence rate (34%) with lateral hamstring injuries most common (83%). Retrospective studies have found significant muscle volume asymmetries ≤23 months post hamstring injury; however examination of the association between hamstring strains and muscle asymmetry has not been investigated prospectively. This study presents baseline data from a longitudinal study focusing on individual hamstring morphometry in uninjured and injured semi-elite AFL players. Methods: Bilateral, contiguous 5 mm axial magnetic resonance (MR) images of the hamstring muscles were acquired from 26 male semi-elite AFL players (23 ± 4 years, 6 ± 4 years playing history at semi-elite level; uninjured [N = 16], self-reported previous hamstring injury [N = 10]). Manual segmentation procedures for the MR images were extensive with reliability analyses conducted using Coefficients of Variation (CV) and Dice Coefficients. Slice sampling and statistical shape modelling (SSM) approaches were also explored as a means of increasing the clinical applicability and efficiency of morphometric analyses. In the uninjured players, “normative” unilateral and bilateral volume ratios were calculated
Introduction: Hip and groin pain is a common injury at the elite level of Australian football with musculoskeletal imaging playing an important role in diagnosis. Radiology findings in athletes without pain are important as they increase diagnostic accuracy and improve the ability to interpret findings with clinical relevance. Several MRI studies exist that report on findings in asymptomatic athletes. However, recent advances in the understanding of enthesopathy and the potential contribution of the hip joint in the development of groin pain warrants further MRI investigation in asymptomatic athletes. When considering pathologies associated with groin pain ultrasound (US) may be a more relevant diagnostic tool for some structures including the adductor tendons, inguinal ligament and conjoint tendon. Ultrasound studies are less frequent in groin pain research with the exception of hernia studies. The purpose of this study was to examine US and MRI findings in asymptomatic Australian football players and to compare findings with the development of hip and groin symptoms in the following season. Methods: Sixty-three Australian football players from two AFL clubs completed US and MRI imaging during the 2011 preseason. At the time of imaging all players were free of groin pain symptoms. All images were independently reviewed by two radiologists with 19 and 15 years of clinical experience. Throughout the season, players were tracked for onset of symptoms by club medical staff and compared against pre-season imaging findings.
Thursday 1 November Papers / Journal of Science and Medicine in Sport 15 (2013) S34–S126
Results: Enthesopathy was reported in 29% (18/63) of players analysed and in 29% (18/63) of players a pubic symphysis defect was reported. Cam lesions were present in 29% (18/63) of players and hip joint capsule thickening was observed in 11% (7/63) of players. Correlations between reported findings and injury episodes during the season will also be presented. Discussion: When interpreting imaging in athletes with hip and groin pain the findings of enthesopathy, pubic symphysis defects and cam lesions in uninjured athletes should be considered. Ultrasound appears to be a useful tool in visualising hip joint capsule thickening that may develop prior to a cam lesion. The US findings in this study suggest that US may be a viable alternative for assessing the hip and groin compared to MRI and CT that has been preferred historically. Including imaging as a component of preseason screening may be useful in identifying athletes at risk of hip and groin injury. http://dx.doi.org/10.1016/j.jsams.2012.11.238 236 Medio-lateral knee position during knee flexion tests is predictive of hip kinematics during running S. LeRossignol 1,∗ , E. Ageberg 2 , M. Smith 1 , M. Creaby 1 1 2
Australian Catholic University Lund University
Introduction: Knee injuries, including Iliotibial band syndrome (ITBS) and patellofemoral pain syndromes (PFPS), are prevalent in distance runners. Current literature links altered hip and knee kinematics during running with these injuries. Quantitative measurement of hip and knee kinematics is difficult within the clinical setting. Thus clinically feasible tests that are predictive of hip and knee kinematics during running may be beneficial. Mediolateral knee position during a clinical test involving knee flexion (minisquat) is predictive of peak internal hip rotation during the test, but its relationship with hip and knee kinematics during running is not known. The purpose of this study was to determine if five clinical tests of knee control are predictive of hip and knee kinematics during running. Methods: Twenty runners with no musculoskeletal injuries, who ran at least 10 km per week, volunteered for this study (31.5 ± 8.9 years, 178.5 ± 4.8 cm, 75.5 ± 9.4 kg). Participants performed five clinical tests of knee control, which were recorded with a high definition camera in the frontal plane. The tests were: single leg mini squat (SLMS), single leg squat on step (SLS), forward lunge (Lunge), single leg hop for distance (SLH) and triple hop for distance (TRH). A clinician assessed and scored each performance on a 4 point scale according to their mediolateral knee position (over, medial or lateral relative to the foot). Three-dimensional running kinematics were obtained during treadmill running at 4 m/s. The hip and knee kinematics calculated were: peak internal hip rotation (HIR), peak hip adduction (HAD) and peak knee abduction (KAB) during the stance phase of running. Pearson correlations between the knee position scores of each clinical test and hip and knee kinematics were performed. A forward stepwise regression was used to determine which clinical test was the strongest predictor of each kinematic variable. An alpha level of 0.05 was set. Results: Larger HIR during running was correlated with a more medial knee position during the SLH, lunge and TRH. The knee position score of the SLH was the strongest predictor of HIR. Knee position score of the clinical tests were not correlated to either HAD or KAB during running.
S99
Discussion: Assessment of knee position during the SLH, lunge and TRH could be used in situations where measurement of running kinematics is not available to infer HIR during running. The SLH should be used primarily for assessment of knee position because it is the best predictor of HIR during running. http://dx.doi.org/10.1016/j.jsams.2012.11.239 237 Effect of foot orthoses on ankle kinematics and kinetics in male runners with Achilles tendinopathy S. Sussmilch-Leitch 1,∗ , K. Crossley 2 , T. Wrigley 3 , M. Creaby 4 1
Department of Physiotherapy, The University of Melbourne School of Health and Rehabilitation Sciences, University of Queensland 3 Centre for Health, Exercise and Sports Medicine, The University of Melbourne 4 Centre of Physical Activity Across the Lifespan, School of Exercise Science, Australian Catholic University 2
Introduction: Achilles tendinopathy (AT) is a common injury among male runners, affecting the longevity of sporting careers and participation in exercise. Abnormal rearfoot biomechanics are thought to be risk factors for AT, but their role is not well established. There is evidence to suggest that people with AT have altered eversion kinematics at the rearfoot, which may result in disproportionate loading across the medial and lateral aspects of the Achilles tendon. Altered ankle dorsiflexion mechanics have also been discussed as a cause of AT, where the tendon may be placed under a greater load in the sagittal plane. The purpose of this study was to evaluate the immediate eversion and dorsiflexion kinematic and kinetic effects of foot orthoses in runners with AT. Methods: Thirteen adult males (age 42 yr ± 10, weight 78 kg ± 12, height 178 cm ± 6) with midportion AT symptoms, running > 20 kilometres per week, were recruited. Confirmation of AT pathology was performed using diagnostic ultrasound. Three dimensional kinematic and kinetic data were collected using a Vicon motion analysis system and AMTI force plates during the stance phase of shod running gait for two conditions: i) with prefabricated semi-rigid foot orthoses, and ii) no orthoses. Each participant completed at least five overground running trials per condition at a controlled running speed. Data processing was completed in Workstation and BodyBuilder software to determine: peak rearfoot eversion angle, rearfoot eversion excursion, peak ankle dorsiflexion angle, peak plantarflexion moment and plantarflexion impulse. Statistical analyses were performed using a paired samples t-test with SPSS software (version 19). An alpha level of 0.05 was set. Results: The ankle eversion excursion was significantly reduced with use of foot orthoses (11.9 deg ± 4.3) compared to footwearonly (13.4 deg ± 4.3; p = 0.03). No differences between conditions were observed for the other variables (p > 0.05). Discussion: Our data demonstrate that the immediate use of foot orthoses reduces rearfoot eversion motion in male runners with midportion AT during the stance phase of running. This change results in kinematic parameters similar to those in asymptomatic runners, which may have a beneficial treatment response. Other elements of frontal and sagittal plane mechanics were not altered. Further studies are required to evaluate the long term biomechanical effects of foot orthoses in people with AT and its role in improving pain and function outcomes across both genders. http://dx.doi.org/10.1016/j.jsams.2012.11.240