Friday, 27 April 2007

Topical glyceryl trinitrate for chronic Achilles tendinopathy.

Hunte G,
Lloyd-Smith R.
University of British Columbia, Vancouver, British Columbia, Canada.
OBJECTIVE: To determine whether continuous application of topical glyceryl trinitrate decreases pain and symptoms in chronic noninsertional Achilles tendinopathy. DESIGN: Randomized double-blind placebo-controlled study of 6-months' duration. SETTING: Community and referral study at an Australian University Hospital. PARTICIPANTS: Recruitment was through newspaper advertisements and private consulting rooms. Eligibility criteria were age >18 years, a history of insidious onset of Achilles tendon pain, a tender nodule localized to the region of the calcaneal insertion, and an ultrasound examination that excluded a tendon tear. Exclusion criteria were Achilles tendinopathy of <3 months' duration, a previous operation on, or dislocation of, the affected ankle or leg, distal neurologic signs, a local corticosteroid injection in the previous 3 months, and current pregnancy. The 65 participants (84 affected tendons; 62% men) had a median age of 49 years (range, 24-79 years), with a median duration of symptoms of 16 months (range, 4-147 months). INTERVENTION: Participants were assigned an active transdermal patch (1/4 of a Nitro-Dur 5 [Schering-Plough] glyceryl trinitrate patch), which delivered 1.25 mg of glyceryl trinitrate over 24 hours, or a placebo patch. Patients were required to cut the patches into quarters and apply 1/d to the site of maximal tenderness for the 24-week duration of the study. All patients were also given 500-mg paracetamol tablets for use with headaches, and instructed in a rehabilitation program that comprised rest from aggravating activities, the use of heel-raise wedges, prolonged daily stretching of the gastrocnemius and soleus musculature, and an eccentric calf muscle-strengthening program. MAIN OUTCOME MEASURES: At the baseline, 2, 6, 12, and 24-week examinations the patient completed a symptom assessment sheet to rate the severity of Achilles pain with activity, at rest, and at night (0 = no pain, 4 = very severe pain). The single assessor used the same scale to measure local tenderness; an 11-point scale for the patient to report pain after the single-leg 10-hop test; and also measured the ankle plantar flexor mean peak force and ankle plantar flexor work. Follow-up was 89% complete. MAIN RESULTS: The groups did not differ in pain with activity, night pain, or local tenderness until the 12-week assessment when participants in the glyceryl trinitrate group reported less pain on each measure (mean scores, 0.9 vs. 1.6 [P = 0.02]; 0.2 vs. 0.7 [P = 0.04]; and 0.9 vs. 1.6 [P = 0.02], respectively). The difference was maintained at 24 weeks for pain with activity (mean scores, 0.4 vs. 1.0 [P = 0.03]). At 24 weeks the glyceryl trinitrate group reported less pain on the 10-hop test than the placebo group (mean scores, 0.5 vs. 1.6 [P = 0.005]). Although the intervention group showed a greater increase in plantar flexor mean total work at 24 weeks than the placebo group, the baseline scores were significantly different. The groups did not differ in pain at rest or in ankle plantar flexor peak force. Combining all the measures showed an estimated 14% (95% CI, 9%-19%) excess of asymptomatic tendons in the intervention group at 6 months. Reported main side effects were headaches (glyceryl trinitrate group, 53%; placebo group, 45%) and rashes (glyceryl trinitrate group, 16%%; placebo group, 12%). CONCLUSION: A topical glyceryl trinitrate patch was more effective than placebo for reducing pain from chronic noninsertional Achilles tendonitis in the first 12 and 24 weeks of use.

Thursday, 5 April 2007

The Effect of Pes Cavus on Foot Pain and Plantar Pressure

Joshua Burnsa, Jack Crosbiea, Adrienne Hunta, Robert Ouvrierb
Received 19 October 2004; accepted 10 March 2005 published online 9 May 2005.
Background. Clinical management of patients with painful pes cavus is challenging because the mechanism of foot pain is poorly understood. The purpose of this study was to explore the influence of various pes cavus aetiologies on foot pain and plantar pressure characteristics, and to identify the relationship between foot pain and plantar pressure.
Methods. Seventy subjects were recruited for this study. They included 30 subjects with pes cavus of unknown aetiology (idiopathic), 10 subjects with pes cavus of neurological aetiology (neurogenic) and 30 subjects with a normal foot type. The presence and location of foot pain was recorded and barefoot plantar pressures were measured using the EMED-SF platform for the whole foot, rearfoot, midfoot and forefoot regions.
Findings. Subjects with pes cavus of either idiopathic or neurogenic aetiology reported a higher proportion of foot pain (60%) compared to subjects with a normal foot type (23%) (P=0.009). Pressure–time integrals under the whole foot, rearfoot and forefoot regions in pes cavus, of both idiopathic and neurogenic origin, were higher than in the normal foot type (P<0.01). Pressure–time integrals in subjects reporting foot pain were higher than for pain free subjects (P<0.001). There was a significant correlation between pressure–time integral and foot pain (r=0.49, P<0.001).
Interpretation. Foot pain is a common finding among individuals with pes cavus. Regardless of aetiology, pes cavus is characterized by abnormally high pressure–time integrals which are significantly related to foot pain. An understanding of the relationship between pes cavus pressure patterns and foot pain will improve the clinical management of these patients.

Thursday, 8 March 2007

Effects of Low-Intensity Pulsed Ultrasound on Tendon–Bone Healing in an Intra-articular Sheep Knee Model

Effects of Low-Intensity Pulsed Ultrasound on Tendon–Bone Healing in an Intra-articular Sheep Knee Model
William R. Walsh, Ph.D.a, Paul Stephens, M.D.a, Frank Vizesi, M.S.a, Warwick Bruce, M.D.a, James Huckle, Ph.D.b, Yan Yu, Ph.D.a
Purpose: This study reports the mechanical and histologic properties of intra-articular tendon–bone healing with the application of low-intensity pulsed ultrasound (LIPUS) in an ovine knee model.

Methods: A single digital extensor tendon autograft from the right hoof was used as the graft in 89 adult sheep. Femoral fixation was achieved with an EndoButton (Smith & Nephew Endoscopy, Andover, MA) and tibial fixation by tying over a bony post. LIPUS treatment was performed daily for 20 minutes over the femoral and tibial tunnels until sacrifice in all groups, apart from the 26-week group, which was treated only for the first 12 weeks. Histology was performed at 3, 6, 12, and 26 weeks. Mechanical testing was performed at 6, 12, and 26 weeks.

Results: The LIPUS-treated group showed increased cellular activity at the tendon–bone interface and general improvement in tendon–bone integration and vascularity. Stiffness and peak load were greater compared with the control group at 26 weeks after surgery (P < .05).

Conclusions: The application of LIPUS appears to improve healing at the tendon–bone interface for soft tissue grafts fixed with a suspensory fixation technique. Histology supports a benefit based on increased integration between tendon and bone and a biologically more active interface, which would account for the improved mechanical properties. Clinical Relevance: The indications of LIPUS may be expanded to include tendon–bone healing, for example, in anterior cruciate ligament reconstruction.

Wednesday, 7 March 2007

H-reflex latency and nerve root tension sign correlation in fluoroscopically guided, contrast-confirmed, translaminar lumbar epidural steroid-bupivaca

Michael F. Stretanski DO
a Surgical Neurology of North Central Ohio, Mansfield, OH, USA
Arch Phys Med Rehabil 2004;85:1479-82.


To examine the correlation between physical examination parameters, commonly referred to as “nerve root tension signs,” and H-reflex latency measurements both pre- and postepidural steroid-bupivacaine (Marcaine) injection, and to propose mechanisms of pain alleviation.


Prospective observational, with H-reflex latency measurement and physical examination at baseline and at 10 minutes postinjection.


Physical medicine and rehabilitation practice, outpatient surgical center, and community setting.


Ten consecutively recruited patients (6 women, 4 men; age range, 40–71y) with clinical radiculopathy and compatible magnetic resonance imaging findings, who were unaware of the outcome measures.


Patients received a fluoroscopically guided, contrast-confirmed, paramedian translaminar lumbar epidural injection of 120mg of methylprednisolone acetate (80mg/mL) and 2.0mL of .25% preservative-free Marcaine.

Main outcome measures

Seated slump testing (SST), straight-leg raising (SLR), and H-reflex latency were measured bilaterally both pre- and postinjection. Differences were measured by using the paired t test in an A-B design.


All SST of the affected (injected) side improved from pre- to postinjection, with 3 patients reporting discordant hamstring pain and 7 reporting no pain. SLR ability increased by an average of 29°±12°, corresponding to an average relative increase of 54% on the affected side. A statistically significant difference was found (Student t test, P=.02) between pre and post H-reflex latency on the affected side but not when comparing changes between affected and unaffected sides (Student t test, P=0.6).


Significant improvements in SST and SLR result from low volume epidural injection of Marcaine, with questionable prolongation of the H-reflex to the gastrocnemius-soleus complex on the affected side.

A critical Appraisal of this paper can be found by clicking here, this was undertaken as part of the London Deanery SEM Spr training 21.3.07

Neurophysiologic Influences on Hamstring Flexibility: A Pilot Study.

Clinical Journal of Sport Medicine. 11(4):241-246, October 2001.
Krabak, Brian J. MD *+; Laskowski, Edward R. MD ++; Smith, Jay MD ++; Stuart, Michael J. MD [S]; Wong, Gilbert Y. MD [P]

Objective: To examine the potential contribution of neurologic influences on hamstring length during passive range of motion.

Design: Prospective study.

Settings: Academic sports medicine center.

Patients: 15 subjects undergoing arthroscopic surgery for unilateral knee injuries without previous injury to the contralateral knee.

Interventions: Subjects received: 1) spinal anesthesia with bupivacaine, 2) epidural anesthesia with lidocaine, 3) general anesthesia, or 4) femoral nerve block of injured leg only.

Main Outcome Measures: Noninjured leg popliteal angle preoperatively, intraoperatively under anesthesia, and postoperatively after recovery from anesthesia.

Results: The overall mean popliteal angle was 132.5 +/- 3.1[degrees] preoperatively, 134.31 +/- 11.6[degrees] intraoperatively, and 130.7 +/- 10.2[degrees] postoperatively. Overall, the intraoperative angle was significantly greater than the postoperative angle (p = 0.02). The mean change in popliteal angle was 8.1 +/- 2.2[degrees] (Group 1), -0.4 +/- 1.9[degrees] (Group 2), 0.9 +/- 1.4[degrees] (Group 3), and -2.4 +/- 3.8[degrees] (Group 4). There was no significant change in pre- to postoperative popliteal angle in relation to postoperative pain. Females had a greater mean popliteal angle (139.84[degrees]) compared with males (128.84[degrees]) (p = 0.04).

Clinical Relevance: Understanding the neuromuscular influences on muscle flexibility will assist in the development of new rehabilitative and injury preventative techniques.

Conclusion: The present pilot study implicates neural contributions to muscle flexibility. Further studies are needed to delineate the relative contributions of neural and muscular components and to facilitate new techniques in the rehabilitation and prevention of injury.

An unusual cause for chronic pain in the proximal hamstring (buttock) area

Vijay Vad, MD, Assistant Professor in Rehabilitation Medicine, Cornell University Medical College, Hospital for Special Surgery, New York, New York

Hamstring injuries are common in tennis. However, there is a sub-group of tennis players who maybe have a different aetiology of chronic hamstring pain at the muscle-tendon junction. A summary of 12 cases is presented below. All 12 were collegiate tennis players aged 20-22, who presented for a second opinion following extensive rehabilitation (minimum 4 months) for a presumed chronic hamstring strain.

The case histories showed the following characteristics for all of the players. They noted the onset of pain while lunging for a stroke, with the onset of hamstring pain on the ipsilateral side of their dominant arm. None had any low back or buttock pain. The pain at the muscle-tendon junction of the hamstring worsened with continued lunging as well as with bending and prolonged sitting.

Physical examination showed only mild to moderate pain reproduction with deep palpation, as well as with resisted hamstring manual muscle testing. The patients had L5 myotome weakness.

MRI of the lumbar spine was ordered to rule out the lumbar spine as the aetiology of the chronic hamstring pain. MRI showed an L4-L5 disc bulge without any nerve root compression.

The results of nerve conduction studies were normal, but the needle examination revealed spontaneous activity at the L5 myotome of the symptomatic limb.

At this point, the players had a series of L5 selective nerve root epidural injections (Ref. 1) performed under fluoroscopy (average of 1.4 injections, range of 1-3). This was combined with daily use at night of a back cryobrace combined with a 5-stage lumbar stabilisation programme using aqua-therapy (Ref. 2). At an average of eight weeks after the first injection, all players returned to pre-injury level of tennis competition.

Chemical radiculitis

`Chronic hamstring strain’ is actually a chemical radiculitis from an L4-L5 disc bulge. The chemical irritation of the nerve root from the disc nucleus pulposus can manifest itself only at the muscle-tendon junction at times without any back or buttock pain. Increased pain with prolonged sitting can also lead to a suspicion of a disc causing nerve root irritation.

The transforaminal epidural injections under fluoroscopy, which are a much more precise form of the old epidural technique, have the advantage of precisely delivering the medication at the nerve-disc interphase where the pathology lies, while minimising nerve root injury or dural puncture incidence. These more exotic epidurals produced a 75% success rate in a retrospective study (Ref. 1) and 84% success rate in a prospective study at our institution, with long-lasting relief of pain when combined with a precise rehabilitation program.

The goal of rehabilitation is to gradually restore the delicate balance between flexibility, strength and endurance. The rehabilitation programme is carried out in four phases. In the early stages of phase1, aqua-therapy is used in combination with isometric strengthening and stretching. Phase 2 emphasises non-weight bearing, concentric strengthening. Phase 3 emphasises functional weight-bearing eccentric strengthening. The last phase, Phase 4, focuses on sports-specific training.

Ref. 1. Vad, V. et al. Fluoroscopic transforaminal lumbar epidural steroids: An Outcome Study. Arch. of Phys. Med. Rehabil. 79: 1362-1366, 1998

Ref. 2. Vad, V. et al. Segmental instability: rehabilitation considerations. Seminars in Spine Surgery 8: 1-8, 1996.

Thursday, 1 March 2007

The Effects of Resisted Sprint Training on Acceleration Performance and Kinematics in Soccer, Rugby Union, and Australian Football Players

Christopher D. Spinks

Strength and Conditioning Department, New South Wales Institute of Sport, Sydney, New South Wales, Australia

Aron J. Murphy and Robert G. Lockie

Human Performance Laboratory, University of Technology, Sydney, New South Wales, Australia

Warwick L. Spinks

Human Performance Laboratory, Institute of Sport and Exercise Science, James Cook University, Townsville, Queensland, Australia


Spinks, C.D., A.J. Murphy, W.L. Spinks, and R.G. Lockie. The effects of resisted sprint training on acceleration performance and kinematics in soccer, rugby union, and Australian football players. J. Strength Cond. Res. 21(1):77–85. 2007.— Acceleration is a significant feature of game-deciding situations in the various codes of football. However little is known about the acceleration characteristics of football players, the effects of acceleration training, or the effectiveness of different training modalities. This study examined the effects of resisted sprint (RS) training (weighted sled towing) on acceleration performance (0–15 m), leg power (countermovement jump [CMJ], 5-bound test [5BT], and 50-cm drop jump [50DJ]), gait (foot contact time, stride length, stride frequency, step length, and flight time), and joint (shoulder, elbow, hip, and knee) kinematics in men (N = 30) currently playing soccer, rugby union, or Australian football. Gait and kinematic measurements were derived from the first and second strides of an acceleration effort. Participants were randomly assigned to 1 of 3 treatment conditions: (a) 8-week sprint training of two 1-h sessions·wk−1 plus RS training (RS group, n = 10), (b) 8-week nonresisted sprint training program of two 1-h sessions·wk−1 (NRS group, n = 10), or (c) control (n = 10). The results indicated that an 8-week RS training program (a) significantly improves acceleration and leg power (CMJ and 5BT) performance but is no more effective than an 8-week NRS training program, (b) significantly improves reactive strength (50DJ), and (c) has minimal impact on gait and upper- and lower-body kinematics during acceleration performance compared to an 8-week NRS training program. These findings suggest that RS training will not adversely affect acceleration kinematics and gait. Although apparently no more effective than NRS training, this training modality provides an overload stimulus to acceleration mechanics and recruitment of the hip and knee extensors, resulting in greater application of horizontal power.

Saturday, 24 February 2007

A Multidisciplinary Approach to the Evaluation, Reconstruction and Rehabilitation of the Multi-Ligament Injured Athlete

Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA.
Knee dislocations with multi-ligamentous involvement are potentially limb-threatening injuries that require extensive surgical and rehabilitative intervention. These knee injuries, such as combined anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament and/or lateral collateral ligament injuries, are devastating injuries with results that vary from total disability to nearly full recovery of function. Recent surgical advances, including the use of allograft tissues, have increased the efficacy of these procedures while posing new challenges. By combining scientifically based surgical and rehabilitative approaches, improved outcomes in these difficult cases are being reported in the orthopaedic literature.This review details the epidemiology and biomechanics of these serious knee ligament injuries. In addition, state-of-the-art surgical and rehabilitative techniques will be outlined. Clinical and diagnostic imaging evaluation of these knee injuries is reviewed in order to plan and execute the surgical and rehabilitative practices. We review the basic science, surgical and rehabilitative theories and practices associated with bringing patients with these serious knee injury injuries to full recovery, and detail the development of strategies for developing protocols to address these complicated cases.

Friday, 2 February 2007

Hamstring Injury Site predicts return to sport

Hamstring muscle strain is one of the most common injuries in sports. Still, knowledge is limited about the progression of clinical and magnetic resonance imaging characteristics and their association with recovery time in athletes.

Eighteen elite sprinters with acute first-time hamstring injuries were examined, clinically and with MRI. All injuries occurred in the long head of the biceps femoris muscle. The results showed that injury to the proximal tendon, and closeness to the ischial tuberosity, were associated with longer time to return to pre-injury level.

CONCLUSION: Careful palpation during the first 3 weeks after injury and magnetic resonance imaging investigation performed during the first 6 weeks after injury provide valuable information that can be used to predict the time to return to pre-injury level of performance in elite sprinting.

Wednesday, 31 January 2007

Influence of a custom foot orthotic intervention on lower extremity dynamics in healthy runners.

Clin Biomech (Bristol, Avon). 2006 Jul;21(6):623-30. Epub 2006 Apr 5

Department of Exercise Science, University of Massachusetts-Amherst, 111 Totman Building, 30 Eastman Lane, Amherst, MA 01003-9258, USA.

OBJECTIVE: To investigate the influence of a custom foot orthotic intervention on the lower extremity dynamics in healthy runners. DESIGN: Three-dimensional kinematics and kinetics were collected on 15 female runners (>15 miles per week) while each performed the over-ground running trials in either a shoe only or a shoe+custom foot orthotic condition. Kinematic and kinetic variables were analyzed using Paired Sample t-tests. BACKGROUND: Custom foot orthotics are frequently prescribed treatment modality for the management of overuse running injuries. Although it is generally accepted that a custom foot orthotic intervention produces positive clinical outcomes, it remains unclear what influence this therapeutic modality has on the dynamics of the lower extremity. METHODS: Each subject performed five acceptable over-ground running trials (3.6 m s(-1) +/-5%) with and without the custom foot orthotic intervention in a running shoe. Selected maximum ankle and knee joint angles and moments were measured during the stance phase. RESULTS: While wearing the custom foot orthotic, subjects exhibited significantly decreased maximum values in rearfoot eversion angle, rearfoot eversion velocity and internal ankle inversion moment. CONCLUSIONS: In this sample of healthy female runners, the custom foot orthotic intervention led to significant decreases in maximum values for ankle dynamics in the frontal plane and in the sagittal plane of the knee joint. Relevance It remains unclear how a custom foot orthotic intervention influences lower extremity dynamics to produce positive clinical outcomes. Furthering our understanding of the dynamic influence will not only inform improved prescription and manufacturing practices but may provide insight into the mechanisms that cause overuse injuries.

Tuesday, 30 January 2007

The Role of Core Stability in Athletic Function

The Role of Core Stability in Athletic Function.

Current Opinion

Sports Medicine. 36(3):189-198, 2006.
Kibler, W Ben 1; Press, Joel 2; Sciascia, Aaron 1

The importance of function of the central core of the body for stabilisation and force generation in all sports activities is being increasingly recognised. 'Core stability' is seen as being pivotal for efficient biomechanical function to maximise force generation and minimise joint loads in all types of activities ranging from running to throwing. However, there is less clarity about what exactly constitutes 'the core', either anatomically or physiologically, and physical evaluation of core function is also variable.

'Core stability' is defined as the ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated athletic activities. Core muscle activity is best understood as the pre-programmed integration of local, single-joint muscles and multi-joint muscles to provide stability and produce motion. This results in proximal stability for distal mobility, a proximal to distal patterning of generation of force, and the creation of interactive moments that move and protect distal joints. Evaluation of the core should be dynamic, and include evaluation of the specific functions (trunk control over the planted leg) and directions of motions (three-planar activity). Rehabilitation should include the restoring of the core itself, but also include the core as the base for extremity function.

Monday, 29 January 2007

Intra-articular injection of a nutritive mixture solution protects articular cartilage from osteoarthritic progression..

This is an interesting article, not yet fully published. Looking into intra-articular injections of dextrose based solutions and their effect on the protection of articular cartilage. I suspect there will be significant interest in this area in the months and years to come, it is very relevant to professional athletes and the question is, will we be using something like this prophylactically to prevent or minimise OA in later life ?

Intra-articular injection of a nutritive mixture solution protects articular cartilage from osteoarthritic progression induced by anterior cruciate ligament transection in mature rabbits: a randomized controlled trial

Yoo-Sin Park , Si-Woong Lim , Il-Hoon Lee , Tae-Jin Lee , Jong-Sung Kim and Jin Soo Han

Abstract (provisional)

Osteoarthritis (OA) is a degenerative disease which disrupts collagenous matrix of articular cartilage, and is difficult to cure because articular cartilage is a nonvascular tissue. Treatment of OA has targeted macromolecular substitutes for cartilage components, such as hyaluronic acid or genetically engineered materials. However, the goal of this study is to examine whether intra-articular injection of the elementary nutrients restores the matrix of arthritic knee joints of mature animals. A nutritive mixture solution (NMS) was composed of elementary nutrients such as glucose or dextrose, amino acids and ascorbic acid. It was administered five times, at the 6th, 8th, 10th, 13th, and 16th weeks, into the unilateral anterior cruciate ligament transected (ACLT) knee joints of mature New Zealand White rabbits. It was compared to normal saline (NS)-injection effect. OA progression was histopathologically evaluated by hematoxylin & eosin (H&E) staining, by the Mankin grading method, and by scanning electron microscopy (SEM) at the 19th week. NMS-injection decreased progressive erosion of articular cartilage overall compared to NS-injection (p<0.01),>

Evaluation and Treatment of Acromioclavicular Joint Injuries

Augustus D. Mazzocca, MD, and James Bicos, MD

From the Department of Orthopaedics, University of Connecticut Health Center, Farmington, Connecticut, and JRSI Sports Medicine, Indianapolis, Indiana

Address correspondence to Robert A. Arciero, MD, Professor, Orthopaedics, University of Connecticut Health Center, 10 Talcott Notch, Farmington, CT 06034

Acromioclavicular joint injuries and, more specifically, separations are commonplace both in general practice and during athletic participation.

This article reviews the traditional classification as well as the clinical evaluation of patients with acute and chronic acromioclavicular joint separations. It also highlights many recent advances, principally in the anatomy and biomechanics of the acromioclavicular joint ligamentous complex. The concept of increases in superior translation as well as disturbances in horizontal translation with injuries to this joint and ligaments are discussed.

This information, coupled with the unpredictable long-term results with the Weaver-Dunn procedure and its modifications, have prompted many recent biomechanical studies evaluating potential improvements in the surgical management of acute and chronic injuries.

The authors present these recent works investigating cyclic loading and ultimate failure of traditional reconstructions, augmentations, use of free graft, and the more recent anatomic reconstruction of the conoid and trapezoid ligaments.

The clinical results (largely retrospective), including acromioclavicular joint repair, reconstruction and augmentation with the coracoclavicular ligament, supplemental sutures, and the use of free autogenous grafts, are summarized.

Finally, complications and the concept of the failed distal clavicle resection and reconstruction are addressed. The intent is to provide a current, in-depth treatise on all aspects of acromioclavicular joint complex injuries to include anatomy, biomechanics, benchmark studies on instability and reconstruction, clinical and radiographic evaluation, and to present the most recent clinical research on surgical outcomes.

Web 2.0 and the Concept of Open Sports Medicine

Open Sports Medicine is a web blog aimed at bringing together current and relevant articles from the Sports Medicine literature and from Surgeons, Physicians and Rehabilitation Specialists internationally.

You will see RSS links to the most common journals in SEM on the right of the screen and at the bottom pre prepared pub med searches of common injuries and links to latest research articles. These will all automatically update.

I am looking for some volunteers from the SEM community to become regular contributors to this blog.

Extract taken from BMJ Article on Web 2.0

The more we use, share, and exchange information on the web in a continual loop of analysis and refinement, the more open and creative the platform becomes; hence, the more useful it is in our work. What seems clear is that Web 2.0 brings people together in a more dynamic, interactive space. This new generation of internet services and devices—often referred to as social software—can be leveraged to enrich our web experience, as information is continually requested, consumed, and reinterpreted. The new environment features a highly connected digital network of practitioners (medical or otherwise), where knowledge exchange is not limited or controlled by private interests. For me, the promise of open access in Web 2.0—freed of publishing barriers and multinational interests—is especially compelling.

Surgical Treatment of Tarsal Navicular Stress Fractures

Volume 14, Issue 4, Pages 248-251 (October 2006)
Lisa E. Choi, MD, Loretta B. Chou, MDCorresponding Author Informationemail address

The tarsal navicular is part of the medial column of the foot. It articulates with the talus as well as the cuneiforms. The navicular can be injured with repetitive loading, such as in an athlete, resulting in a stress fracture. Patients complain of pain over the medial midfoot, especially with axial load. Plain radiographs may be normal, and MRI, CT or bone scan may be necessary to confirm the diagnosis. Nonoperative management can be successful with cast immobilization. For competitive athletes with delayed union or nonunion, surgical repair may be indicated. This is accomplished with interfragmentary screws and autogenous cancellous bone graft. Cast immobilization is important to prevent motion at the fracture site during the postoperative healing period. Nonweightbearing restrictions are used for eight to twelve weeks, or until radiographic bony union is verified. Using a comprehensive rehabilitative program, full motion and strength can be expected with eventual return to full athletic activity.

Operative Treatment of Stress Fractures of the Metatarsals

Volume 14, Issue 4, Pages 239-247 (October 2006)
G. Andrew Murphy, MDCorresponding Author Informationemail address

A common presenting complaint in athletes and nonathletes alike, metatarsal stress fractures may be a source of persistent pain and loss of lower limb use, resulting in loss of recreational and vocational performance. Although most fractures respond to traditional conservative treatments, some may require more aggressive intervention on the part of the treating orthopaedic surgeon. The identification of these particular problem fractures and the search for associated conditions is important for the optimal outcome of these injuries. Attention to surgical technique is important; the options for adjunctive procedures are presented.

Pars Interarticularis Stress Lesions in the Lumbar Spine of Cricket Fast Bowlers

Medicine & Science in Sports & Exercise. 39(1):28-33, January 2007.

Purpose: This prospective magnetic resonance (MR) imaging study investigated the development of symptomatic pars lesions in the lumbar spine of adolescent cricket fast bowlers.

Methods: Annual MR examinations of the lumbar spine in male fast bowlers (N = 51) and swimmers (N = 20) without a prestudy history of symptomatic back injury were conducted to identify stress-induced pars injuries over 4 and 2 yr periods, respectively.

Results: Symptomatic L4 and L5 pars lesions developed in 11 of 51 and 1 of 51 of the bowlers, respectively. Preexisting L5 lesions were observed in both bowlers (10 of 51) and swimmers (4 of 20). No significant difference existed between the proportion of bowlers and swimmers with preexisting L5 lesions (P = 1.00, Fisher's exact test). In contrast, bowlers had a significantly greater proportion of L4 pars lesions compared with swimmers, with 22% of the bowlers developing L4 injuries during the study, whereas there were no L4 lesions in the swimmers (P = 0.027, Fisher's exact test). The symptomatic L4 lesions in the bowlers developed between 15 and 17 yr of age, and all were unilateral lesions lateralized to the nonbowling-arm side. The MR characteristics of the L4 pars lesions were consistent with a stress fracture through the cortical bone. Of the acquired L4 lesions in the bowlers, 4 of 11 and 7 of 11 developed in individuals with and without preexisting L5 defects, respectively. No significant association existed between the acquired L4 pars lesions and preexisting L5 defects in the bowlers (P = 0.216, Fisher's exact test).

Conclusion: Fast bowling was directly associated with the development of symptomatic pars lesions of the lumbar spine, particularly unilateral L4 stress lesions, in a significant proportion of the adolescent bowlers examined in this prospective MR study.

Mouthguards in Sport Activities: History, Physical Properties and Injury Prevention Effectiveness

Review Article

Sports Medicine. 37(2):117-144, 2007.
Knapik, Joseph J 1; Marshall, Stephen W 2; Lee, Robyn B 1; Darakjy, Salima S 1; Jones, Sarah B 1; Mitchener, Timothy A 1; delaCruz, Georgia G 1; Jones, Bruce H 1

Three systematic reviews were conducted on: (i) the history of mouthguard use in sports; (ii) mouthguard material and construction; and (iii) the effectiveness of mouthguards in preventing orofacial injuries and concussions. Retrieval databases and bibliographies were explored to find studies using specific key words for each topic. The first recorded use of mouthguards was by boxers, and in the 1920s professional boxing became the first sport to require mouthguards. Advocacy by the American Dental Association led to the mandating of mouthguards for US high school football in the 1962 season. Currently, the US National Collegiate Athletic Association requires mouthguards for four sports (ice hockey, lacrosse, field hockey and football). However, the American Dental Association recommends the use of mouthguards in 29 sports/exercise activities.

Mouthguard properties measured in various studies included shock-absorbing capability, hardness, stiffness (indicative of protective capability), tensile strength, tear strength (indicative of durability) and water absorption. Materials used for mouthguards included: (i) polyvinylacetate-polyethylene or ethylene vinyl acetate (EVA) copolymer; (ii) polyvinylchloride; (iii) latex rubber; (iv) acrylic resin; and (v) polyurethane. Latex rubber was a popular material used in early mouthguards but it has lower shock absorbency, lower hardness and less tear and tensile strength than EVA or polyurethane. Among the more modern materials, none seems to stand out as superior to another since the characteristics of all the modern materials can be manipulated to provide a range of favourable characteristics. Impact studies have shown that compared with no mouthguard, mouthguards composed of many types of materials reduce the number of fractured teeth and head acceleration. In mouthguard design, consideration must be given to the nature of the collision (hard or soft objects) and characteristics of the mouth (e.g. brittle incisors, more rugged occusal surfaces of molars, soft gingiva). Laminates with different shock absorbing and stress distributing (stiffness) capability may be one way to accommodate these factors.

Studies comparing mouthguard users with nonusers have examined different sports, employed a variety of study designs and used widely-varying injury case definitions. Prior to the 1980s, most studies exhibited relatively low methodological quality. Despite these issues, meta-analyses indicated that the risk of an orofacial sports injury was 1.6-1.9 times higher when a mouthguard was not worn. However, the evidence that mouthguards protect against concussion was inconsistent, and no conclusion regarding the effectiveness of mouthguards in preventing concussion can be drawn at present. Mouthguards should continue to be used in sport activities where there is significant risk of orofacial injury.

ACLD - In the Skeletally Immature

Managing Anterior Cruciate Ligament Deficiency in the Skeletally Immature Individual: A Systematic Review of the Literature.

Thematic Issue

Clinical Journal of Sport Medicine. 16(6):457-464, November 2006.
Mohtadi, Nick MD *; Grant, John MD, PhD *+

Objective: To perform a systematic review of the literature to answer whether early ACL reconstruction for a skeletally immature individuals result in improved outcome compared with nonsurgical treatment or delaying the reconstruction until skeletal maturity in the pediatric athlete.

Data Sources: Articles were restricted to the English language, and 6 databases were searched (MEDLINE, CINAHL, EMBASE, ACP Journal Club, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews). The following keywords were used: anterior cruciate ligament, ACL, child, immature, pediatric, pediatric, and young.

Selection Criteria: All studies examining the ACL reconstruction in skeletally immature individuals, including citations describing complications. Excluded were articles looking at ACL repairs and ACL avulsion injuries. All types of study design, including review articles, were included. Comparative studies were reviewed in detail and analyzed qualitatively.

Data Extraction and Synthesis: A total of 615 articles were identified. Sixty-six articles met the inclusion and exclusion criteria. There were no articles with levels of evidence better than level III. The majority of the articles represented case series and reviews with expert opinion.

Results: There were 7 articles that provided comparisons between surgical and nonsurgical treatment in order to answer the question.

Conclusions: The study designs are inadequate to answer the question of whether early or delayed ACL reconstruction results in the best possible outcome in skeletally immature individuals. Future prospective studies are required to answer the question adequately. A proposed algorithm was described to deal with the question.


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