Merry Christmas Everybody

Happy Christmas Docs

Thanks to all who have contributed to the discussion. This year has been an interesting one, it’s been the year of amongst other things the dreaded groin pain the Achilles heel and PMETB!

For those who want to view the archives for 2008

http://lists.sportsinjurymanager.co.uk/mailman/private/ukadis/2008/subject.html

I hope the discussions continue and perhaps we will bring something new to the blog in 2009 all ideas welcome.

Best wishes to all for 2009. Enjoy the break for those who get one, have a drink or two, eat plenty of pies and then of course take plenty of moderate intensity exercise in January.

JB

Wrightington Sports Shoulder Conference 2009

Wrightinton Sports Shoulder Conference

Dates: 18-20 June 2009

Venue: Wrightington Conference Centre, Wrightington Hospital

International Guest Faculty:
Guiseppe Porcellini - Italy
Joe DeBeer - South Africa
Dan Guttmann - USA
Ehud Rath - Israel
Anne Cools - Belguim
Paolo Paladini - Italy
UK Faculty: Stuart Cosgrove, David Jones, Jo Gibson, Nick Granthan, Jonathan Harris, Mike Loosemore, Lennard Funk, Ian Trail, John Haines, Robert Conlon, Sarah Russell.

The latest advances in the management of sports injuries of the shoulder.
The conference welcomes all clinicians and therapists with an interest or experience of managing shoulder disorders in athletes.
The international faculty includes experts from the fields of orthopaedic surgery, physiotherapy, sports medicine and radiology. All are experienced in treating athletes.
The course comprises a mixture of lectures , case discussions , workshops and live surgery . Emphasis is on the particular issues of athletic shoulder injuries, including pathology recognition, diagnosis, non-operative and operative interventions. We will concentrate on innovative methods of return to play as soon as possible, drawing on current evidence and the faculties experience.
In order to ensure plenty of opportunity for participation and discussion, we will restrict delegate numbers. Therefore, early application is recommended in order to avoid disappointment.

• Download the Course Programme here (pdf)
• For more information and to apply click here

ARSENAL FOOTBALL CLUB MEDICAL OFFICER - Job Advertisement

ARSENAL FOOTBALL CLUB MEDICAL OFFICER

Reporting to the Manager, the Club Doctor will be responsible for the treatment, care and rehabilitation of all first team squad players of Arsenal Football Club.

Main Duties & Responsibilities

To attend the Training Centre 2 to 3 days per week and attend all First team fixtures – Home and Away.

Injury management duties to include:

Assisting in primary assessment
Arranging investigations, as appropriate
Arranging secondary care input, as appropriate
To be available at all times by phone for opinion
To liaise with medical teams from other countries and National Associations, as appropriate

Person Specification

The person applying for this position must have achieved and be able to demonstrate the following:

· At least five years working in elite sports environment

· Experience of primary care/accident and emergency

· Computer literate

· Able to work within a close medical team

Although not essential - MFSEM/FFSEM would be preferred.

All applications with full CV should be sent to:

Ken Friar Managing Director Arsenal Football Club
Highbury House
75 Drayton Park
London N5 1BU

No later than Friday 5th December 2008

Arsenal Football Club actively promotes equal opportunities in
employment and welcomes all applications

High-Resolution Ultrasound in the Diagnosis of Upper Limb Disorders: A Tertiary Referral Centre Experience.

Annals of Plastic Surgery. 61(3):259-264, September 2008.

Allen, Gina M. BM, DCH, MRCP, MRCGP, FRCP, MFSEM *; Drakonaki, Eleni E. MD +; Tan, Melissa Ley H. MBChB ++; Dhillon, Manpreet MBChB, MRCS, FRCR ++; Rajaratnam, Vaikunthan MBBS, AM, MBA(USA), FRCS, FICS(USA) ++[S]

Abstract:
The purpose of this study is to determine the reliability of high-resolution ultrasound (HRUS) in the diagnosis of upper limb disorders compared with the initial clinical opinion. We prospectively studied 178 patients referred for HRUS examination (47.2% hand, 34.8% wrist, and 18% elbow examinations) by recording the clinical opinion, the specific ultrasound diagnosis, and the final diagnosis, as established by surgery (79.9%) or follow-up (20.1%). HRUS examination was highly reliable in diagnosing cystic lesions, synovial disease, ligament injury and foreign bodies (100%), and slightly less reliable for solid lesions (82.1%) and nerve, bone, and tendon disorders (97%, 91.7%, 86.5%, respectively). HRUS examination resulted in significantly more correct diagnoses (92.1%) than the clinical opinion (70.8%) (McNemar test, P = 0.001). The agreement between the HRUS diagnosis and the clinical opinion was slight (Kappa test, k = 0.16). HRUS examination is more reliable than clinical examination in diagnosing upper limb disorders.

Regenerative Injection of Elite Athletes with Career-Altering Chronic Groin Pain

Am J Phys Med Rehabil. 2008 Aug 6.
A Consecutive Case Series.
Topol GA, Reeves KD.

From the Physical Medicine and Rehabilitation Service, Jaime Slullitel Rosario Orthopedic and Trauma Institute, Argentina (GAT); Servicio de Medicina Física y Rehabilitación del Hospital Provincial de Rosario, Argentina (GAT); Team Physiatrist, Rosario Rugby Union, Argentina (GAT); Meadowbrook Rehabilitation Hospital, Gardner, Kansas (KDR); and Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas, Kansas (KDR).

Topol GA, Reeves KD: Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series. Am J Phys Med Rehabil 2008. OBJECTIVE:: To obtain multisport and long-term outcome data from use of regenerative injection therapy on career-threatened athletes. DESIGN:: Consecutive enrollment of elite performance-limited athletes with chronic groin/abdominal pain who failed a conservative treatment trial. The treatment consisted of monthly injection of 12.5 dextrose in 0.5% lidocaine in abdominal and adductor attachments on the pubis. Injection of the nociceptive source was confirmed by repetition of resistive testing 5 min after injection. RESULTS:: Seventy-five athletes were enrolled. Seventy-two athletes (39 rugby, 29 soccer, and 4 other) completed the minimum two treatment protocol. Their data revealed a mean groin pain duration of 11 (3-60) mos. Average number of treatments received was 3 (1-6). Individual paired t tests for VAS of pain with sport (VAS Pain) and Nirschl pain phase scale measured at 0 and an average of 26 (6-73) mos indicated VAS Pain improvement of 82% (P < 10), and Nirschl pain phase scale improvement of 78% (P < 10). Six athletes did not improve following regenerative injection therapy treatment and the remaining 66 returned to unrestricted sport. Return to unrestricted sport occurred in an average of 3 (1-5) mos. CONCLUSIONS:: Athletes returned to full elite-level performance in a timely and sustainable manner after regenerative injection therapy using dextrose.

Laparoscopic inguinal ligament tenotomy and mesh reinforcement of the anterior abdominal wall: a new approach for the management of chronic groin pain

Surg Laparosc Endosc Percutan Tech. 2008 Aug;18(4):363-8.

Lloyd DM, Sutton CD, Altafa A, Fareed K, Bloxham L, Spencer L, Garcea G.

Department of Laparoscopic and Upper Gastrointestinal Surgery, The Leicester Royal Infirmary, Leicester.

BACKGROUND: Chronic groin pain has an incidence of up to 6.2% and is common in people undertaking regular sports activity. A variety of surgical options exist for unresolving pain, which consist, for the most part, of a repair of the posterior abdominal wall, with or without mesh placement. We describe a new technique, which combines laparoscopic inguinal ligament tenotomy in conjunction with a mesh repair. METHODS: A retrospective analysis of the notes of 48 patients was undertaken in conjunction with a mailed questionnaire. Success of surgery was judged on return to preinjury sporting activity, severity of pain scores, frequency of pain scores, and functional limitation scores. RESULTS: There were no major complications associated with the procedure. Severity of pain, frequency of pain, and functional limitation scores were all significantly improved after surgery (P=0.0012, <0.0001, and <0.0001, respectively). Ninety-two percent of patients polled returned to normal sports activity after their surgery (n=24). The median return to strenuous sports activity was 28 days (range of 14 to 40 d). CONCLUSIONS: The success rates of laparoscopic tenotomy and mesh repair are comparable with the published literature and a lower median time interval before returning to preinjury sporting activity.

Achilles Tendon Doppler Flow May Be Associated With Mechanical Load Among Active Athletes.

Am J Sports Med. 2008 Jul 1.

Malliaras P, Richards PJ, Garau G, Maffulli N.
Brunel University.
BACKGROUND: Tendon Doppler flow may be associated with tendon pain in symptomatic patients, but the relationship between Doppler flow and pain among athletes who are still competing is unclear. HYPOTHESIS: Among active athletes, Doppler flow may partly reflect tendon adaptation to increased mechanical load and/or asymptomatic tendinopathy. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The Achilles tendons of 61 badminton players (24 elite, 37 recreational) were examined with gray-scale and color Doppler ultrasound. Achilles tendon pain and activity level (badminton training, badminton playing, badminton years) were measured. RESULTS: Doppler flow was not associated with current Achilles tendon pain but was associated with an increased anteroposterior tendon diameter (an indicator of tendinopathy) (P = .02). Athletes who had been playing badminton for longer were more likely to have Doppler flow (P < .01), and there was a trend toward an association between a greater number of badminton playing hours per week and Doppler flow (P = .07). CONCLUSION: Achilles tendon Doppler flow appears to be a sign of asymptomatic tendinopathy rather than pain among active athletes. The association between weekly badminton hours and badminton years and Doppler flow suggests that Doppler flow may be a response to mechanical load in this cohort.

Magnetic resonance imaging appearance of the shoulder after subacromial injection with corticosteroids can mimic a rotator cuff tear.

Arthroscopy. 2008 Jul;24(7):846-9. Epub 2007 Apr 24
Borick JM, Kurzweil PR.
Southern California Center for Sports Medicine, Long Beach, California, USA. jayborick@hotmail.com
Subacromial injections have been used to treat rotator cuff problems. Previous studies have noted the difficulty in performing accurate injections into this area. In addition, one must also question the effects that misplaced corticosteroids could have on the surrounding tissues. In this case, a 51-year-old woman presented with several weeks of left shoulder pain and was diagnosed with rotator cuff tendonitis. After a subacromial injection with betamethasone and lidocaine, the patient noted 3 weeks of near complete pain relief, followed by a return of her symptoms. A magnetic resonance imaging scan obtained 7 weeks after the injection showed a full-thickness tear of the supraspinatus tendon. Five weeks later, the patient underwent arthroscopic evaluation of the shoulder and subacromial decompression. The rotator cuff tendons were noted to be intact and normal in appearance. The patient eventually had full resolution of her symptoms. Six months postoperatively, she underwent a new scan that showed a normal supraspinatus tendon. Apparently, the subacromial injection penetrated the anterior half of the supraspinatus tendon, causing a transient effect and signal change. One should use caution in the interpretation of magnetic resonance imaging scans of the shoulder soon after the injection of corticosteroids.

High Resolution Ultrasound by Sonosite - Low Price

	High resolution colour imaging at a B/W price. For a limited period you can have the SonoSite® TITAN® hand-carried ultrasound imaging system – for the price you were thinking you could only get black and white. For clearer results - the TITAN high resolution colour system from SonoSite. That means dependability - drop tested from 1 metre. User friendly. Fully supported. And as part of the package, we’ll introduce you to the system, and all its capabililties, on a one day training course. Because SonoSite’s sole focus is hand-carried ultrasound, all systems are designed to perform high-quality examinations wherever and whenever needed,whether hospital or clinic, ski slope or stadium, trackside or by the pool.
	SonoSite TITAN Weighing 3.5 kg. True go anywhere portability AC or battery powered L38 transducer 38-mm broadband linear array – imaging to 9 cm in depth
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	If you’re not ready to purchase outright consider one of our leasing plans from as little as £6 (incl. VAT) per day (based on a 5 year plan with no deposit required.)
© 2008 SonoSite, Inc. All rights reserved. MKT01609 06-08 SonoSite Ltd Registered in England and Wales No 04104159 Registered Office: Carmelite, 50 Victoria Embankment, Blackfriars, London EC4Y 0DX SonoSite Ltd is registered and operates under UK data legislation. All rights reserved. Details are subject to change without notice.

10th Scientific Meeting Sport + Exercise Medicine QMUL - 12th September Skeel Lecture theatre

Friday 12 September 2008

The Centre for Sport and Exercise Medicine (CSEM) at Queen Mary, University of London (QMUL)

Venue - Skeel Lecture Theatre

Contact barryghill@hotmail.com Mob: 07968 586 855

TENTH SCIENTIFIC MEETING IN SPORTS & EXERCISE MEDICINE & REUNION

MORNING SESSION

0930 Registration and Commercial Exhibition

1000 Welcome & Introduction – Mr J B King

CHAIR: Dr T Crisp

1010 P1 Metatarsal fractures in Professional Football. Dr G Steinbergs

1020 P2 Establishing practical guidelines for exercise in Type I Diabetics

1030 P3 An experimental design to assess relationship in ability to perform a timed, eyes closed, single leg stance test, with 7 without quarter squat. Ms L Barnes

1040 P4 The effect of cryotherapy on dynamic unilateral balance in healthy adults. Ms S Cru

1050 P5 A cohort study to investigate hydration status of professional rugby union players. Ms M Sturley.

1100 P6 A pilot observational study of vertical pressure distribution and blister formation on the hand of sitting volleyball players. Dr JM Zhang

1110 P7 A comparative study of Achilles tendon stiffness. Dr S Ahmad

1120 Refreshments and Commercial Exhibition

CHAIR: Dr R Carbon

1150 P8 Comparison of 2 verbal cues used to initiate an isolated transversus abdominis muscle contraction in normal subjects. Mr N Lynne

1200 P9 The effect of exercise on self-esteem and physical self-perception in obese children of Tower Hamlets. Ms C McCall

1210 P10 Test-Retest reliability of repeated single leg squat until volitional quadriceps fatigue. Ms A Ogles

1220 P11 Retrospective audit of patients who have undergone Cheilectomy & Akin’s osteotomy to reduce Hallux Valgus deformity. Dr H Oshiba

1230 P12 Correlation between changes in neovascularisation and clinical severity in patients with resistant Achilles Tendinopathy. Dr J Humphrey

1240 KEYNOTE SPEECH: OBESITY – A SPORTS PHYSICIAN’S PROBLEM. Dr Z Iqbal

1300 Buffet Lunch and Commercial Exhibition

AFTERNOON SESSION

CHAIR: Dr I Beasley

1400 P14 Evaluation of physical balance ability of patients with CFS/ME. Mr N Dyer

1410 P15 Effect of specific weight bearing ankle stretch on functional outcome following an acute lateral ankle sprain. Mr P Howarth

1420 P16 Return to play after musculoskeletal injury in the English Rugby Premiership League & National League One. Dr J Noakes

1430 P17 Injury type and rate in Junior Elite Hockey players in England. Ms L O’Flynn

1440 P18 High volume distension arthrography with steroid and steroid alone, in the treatment of adult idiopathic adhesive capsulitis of the shoulder. Dr R Findlay

1450 P19 Ultrasound detection of injuries in the paediatric severe ankle sprain. Dr A Pillai

1500 P20 Pedometer determined physical activity levels in secondary school children in Tower hamlets. Dr T Margham

1510 P21 Improving the ability of medical; students to communicate complex ideas in writing. Dr C Chung

1520 Refreshments and Commercial Exhibition

CHAIR: Dr J D Perry

1550 P22 Application of surface EMG to assess muscle recruitment patterns in novice & experienced rowers. Ms C Sharpe

1610 P23 TBA

1630 KEY NOTE SPEECH – MOUNTAIN MEDICINE – Dr R Casserley

1700 John King Prize (SPONSORED BY DJO) presentation & CLOSE

PUB CRAWL CONFERENCE & REUNION MEAL IN THE OCTAGON, QUEEN MARY

Job Advert - GPwSI Sports & Exercise

GPwSI Sports & Exercise

£400 per day (plus accommodation & travel)

Based in the North East

Hays Healthcare has an excellent locum opportunity for a GPwSI in Sports & Exercise medicine.

Our client requires a GPwSI to work Tuesday – Thursday (0830-1630) and Friday AM at a military site in the North East of England from 14^th of July for 1 month in the first instance, with the opportunity to extend up to 12 months.

You will be working as part of a multi-disciplinary team consisting of a Physio and a Remedial Instructor and will provide clinical assessment and diagnosis to patients' requirements and make timely decisions regarding future management.

To be considered you must have full GMC registration, be on the GP Register and be included on a PCT Medical Performers list. Ideally you will also possess the Msc or Diploma in Sports & Exercise medicine or at the very least have a keen interest in this field.

This an excellent opportunity for an either an experienced sports & exercise doctor to practice in their chosen speciality or for a doctor hoping to develop their skills & experience in this exciting field.

Accommodation and travel costs will be covered.

For more information about this or any other vacancy with Hays Healthcare, call Owen on 0113 2615878 or email owen.beilby@hays.com.

LTA Sports Medicine Congress London 21+22 June 2008

The LTA are delighted to announce the 2008 LTA Sports Science
and Sports Medicine Conference to be held on 21st and 22nd of
June, 2008 just prior to the start of
The Championships, Wimbledon.

The program includes presentations and workshops from the
world’s leading experts in Sports Science, Sports Medicine,
Tennis and High Performance Sport, some highlights include:

Day 1 - Saturday 21st June

Dr Donald Chu – the world’s leading expert on athletic
training and plyometrics will provide the opening
keynote presentation.

Dr Mark Kovacs from the United States Tennis Association
will present on some of the latest tennis training techniques.

Graeme Maw will conclude the first day who will draw on
extensive experience as a Sports Scientist and Performance
Director to highlight the benefits of sports
science to everyday training and coaching practices.

Day 2 – Sunday 22nd June

Leading rehabilitation experts Todd Ellenbecker,
Director of Sports Medicine,
ATP Tour and Prof. Ann Cools, Dept. of Rehabilitation,

University Hospital, Ghent, Belgium will feature in
a session focusing on advanced rehabilitation techniques.

Dr Ulrike Mushaweck will present on the latest surgical
techniques for hernia repair as part of session dedicated
to innovative treatments in sports medicine.

Dr David Connell, Radiologist, Royal National Orthopaedic
Hospital will present the latest findings from imaging
research on spinal injuries.

This conference will be of interest to a wide range athlete
support staff – strength and conditioning professionals,
coaches, doctors and physiotherapists involved in non-elite
and elite sport.

Registration and Cost

The conference will be held at the Millennium Gloucester
Hotel, Harrington GardensLondon SW7 4LH.


Day 1, Saturday 21st June is £105
(plus optional £20 for dinner event)*

Day 2, Sunday 22nd June is £125

* This will be held at the National Tennis Centre on
Saturday 21st June 2008 7.00pm - 10.30pm


To register please contact Isobel Newling on 020 8487 7183
or email: Isobel.newling@LTA.org.uk
or fax the form below to 0208 487 7308.

The Full registration form and conference
program can be found at the following LINK

CLICK HERE

A review of plantar heel pain of neural origin: differential diagnosis and management.

Ali M. Alshami^{, a,} , Tina Souvlis^a and Michel W. Coppieters^a

^aDivision of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Qld. 4072, Australia

Received 18 January 2006;

revised 28 December 2006;

accepted 15 January 2007.

Available online 30 March 2007.

Abstract

Plantar heel pain is a symptom commonly encountered by clinicians. Several conditions such as plantar fasciitis, calcaneal fracture, rupture of the plantar fascia and atrophy of the heel fat pad may lead to plantar heel pain. Injury to the tibial nerve and its branches in the tarsal tunnel and in the foot is also a common cause. Entrapment of these nerves may play a role in both the early phases of plantar heel pain and recalcitrant cases. Although the contribution of nerve entrapment to plantar heel pain has been well documented in the literature, its pathophysiology, diagnosis and management are still controversial. Therefore, the purpose of this article was to critically review the available literature on plantar heel pain of neural origin. Possible sites of nerve entrapment, effectiveness of diagnostic clinical tests and electrodiagnostic tests, differential diagnoses for plantar heel pain, and conservative and surgical treatment will be discussed.

Job Opportunity Sports Medicine - club Dr Totenham Hotspur FC

Job Advertisement Totenham Hotspur FC

A vacancy has arisen at Totenham Hotspur Football Club for the
position of club Doctor on a fixed term part time basis.

We are looking to appoint a Club Doctor to be based in London on
a fixed term, part-time basis.  The Doctor will report directly
to the Head of Medical Services, be involved in routine medical
care,ensure Doping Control Regulations are met and maintaining
legally robust player medical records.

Key responsibilities include:

The Doctor is required to attend daily clinics, all home and away
First Team games, as well as any tours involving the First Team,
providing the full duties of a medical officer, in accordance with
the Football Association requirements for a team sports physician.

The Doctor will maintain the health and fitness of squad members
through the provision of Sports Medicine support working with the
Head of Medical Services and other members of the
multidisciplinary team.

The position will also monitor and advise on the rehabilitation of
squad players during and between duties, through liaison with
players, coaches, Club medical teams, GPs, specialists and
guardians and also assist in the provision of assessment of
fitness to playof squad members whilst on international squad duty.

Other responsibilities include providing Primary Care management
and appropriate referral to Secondary Care of all injuries and
illnesses affecting squad members while on duty.  In some cases
this may involve a domiciliary visit.

The successful applicant must:

be of good standing on the GMC GP Register, or the GMC Specialist
Register, hold a PMETB GP CCT or equivalent (please note the
latteris preferred),hold a Postgraduate Diploma or MSc in Sport
and Exercise Medicine, be a Member or Fellow of the Faculty of
Sport and Exercise Medicine, have at least two or more years
experience as a team doctor at an elite level of sport, preferably
football,be able to show evidence of ongoing CPD, in accordance
with the FA Rules,and annual medical appraisal in the major
specialty of their work portfolio,have passed a pitch-side
immediate trauma care course in the last year (FA Resuscitation
+ Emergency Aid Certification or equivalent),hold appropriate
medical indemnity insurance including Sport and Exercise
Medicine,possess excellent communication as well as personal
organisational skills.

All applicants should contact the Club for an application pack:

ann.vetere@tottenhamhotspur.com

Closing Date:  Wednesday 18 June 2008 at 5.00pm

Short-listed candidates will be notified no later than 20 June
2008 and Interviews will be held on Wednesday 2 July 2008
at Spurs Lodge,Chigwell. The successful candidate would be
expected to be available from 1 August 2008.

Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study.

Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD.

Department of Radiology, St. Paul's Hospital, Vancouver, BC V6Z 1Y6, Canada. maxwellnj@upmc.edu

OBJECTIVE: Chronic tendinosis of the Achilles tendon is a common overuse injury that is difficult to manage. We report on a new injection treatment for this condition. SUBJECTS AND METHODS: Thirty-six consecutive patients (25 men, 11 women; mean age, 52.6 years) with symptoms for more than 3 months (mean, 28.6 months) underwent sonography-guided intratendinous injection of 25% hyperosmolar dextrose every 6 weeks until symptoms resolved or no improvement was shown. At baseline and before each injection, clinical assessment was performed using a visual analogue scale (VAS) for pain at rest (VAS1), pain during normal daily activity (VAS2), and pain during or after sporting or other physical activity (VAS3). Sonographic parameters including tendon thickness, echogenicity, and neovascularity were also recorded. Posttreatment clinical follow-up was performed via telephone interview. RESULTS: Thirty-three tendons in 32 patients were successfully treated. The mean number of treatment sessions was 4.0 (range, 2-11). There was a mean percentage reduction for VAS1 of 88.2% (p < 0.0001), for VAS2 of 84.0% (p < 0.0001), and for VAS3 of 78.1% (p < 0.0001). The mean tendon thickness decreased from 11.7 to 11.1 mm (p < 0.007). The number of tendons with anechoic clefts or foci was reduced by 78%. Echogenicity improved in six tendons (18%) but was unchanged in 27 tendons (82%). Neovascularity was unchanged in 11 tendons (33%) but decreased in 18 tendons (55%); no neovascularity was present before or after treatment in the four remaining tendons. Follow-up telephone interviews of the 30 available patients a mean of 12 months after treatment revealed that 20 patients were still asymptomatic, nine patients had only mild symptoms, and one patient had moderate symptoms. CONCLUSION: Intratendinous injections of hyperosmolar dextrose yielded a good clinical response--that is, a significant reduction in pain at rest and during tendon-loading activities--in patients with chronic tendinosis of the Achilles tendon.

Hydrodilatation in the management of shoulder capsulitis.

Bell S, Coghlan J, Richardson M.

Australas Radiol. 2003 Sep;47(3):247-51.

Department of Surgery, Monash Medical Centre, Melbourne, Victoria, Australia. snbell@sprint.net.au

The aim of this study was to research the benefit of hydraulic arthrographic capsular distension (hydrodilatation) in the management of adhesive capsulitis of the shoulder. One hundred and nine shoulders with primary adhesive capsulitis were treated with hydrodilatation. Prior to the procedure, 93 shoulders were painful. Two months following the procedure, 31 continued to have some pain. In the 109 shoulders, the measured range of passive glenohumeral movement improved by approximately 30 degrees in all directions. The procedure was of similar benefit if carried out early or late in the disease process. The absolute improvement in movement range was similar in severe and mild cases. The severe cases in the long term, although improved, still had more restriction in movement and tended to have more pain than the other cases. There was considerable improvement in all the non-diabetic patients. The patients with diabetes responded less well in the long term to hydrodilatation and had an increased requirement for arthroscopic surgery. Effective treatment of adhesive capsulitis can be achieved in the majority of cases with an immediate hydrodilatation of the shoulder. Technically, it is important to achieve maximum distension, preferably with capsular rupture, and to utilize cortisone in the fluid injected.

Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections.

J Bone Joint Surg Am. 2007 Oct;89(10):2173-8.

Schilders E, Bismil Q, Robinson P, O'Connor PJ, Gibbon WW, Talbot JC.

Department of Orthopaedics, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, England. e.schilders@btopenworld.com.

BACKGROUND: Adductor dysfunction is a condition that can cause groin pain in competitive athletes, but the source of the pain has not been established and no specific interventions have been evaluated. We previously defined a magnetic resonance imaging protocol to visualize adductor enthesopathy. The aim of this study was to elucidate, in the context of adductor-related groin pain in the competitive athlete, the role of the adductor enthesis (origin), the relevance of adductor enthesopathy diagnosed with magnetic resonance imaging, and the efficacy of entheseal pubic cleft injections of local anesthetic and steroids. METHODS: We reviewed the findings in a consecutive series of twenty-four competitive athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. Magnetic resonance imaging was performed to assess the adductor longus origin for the presence or absence of enthesopathy. Seven patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and seventeen patients (Group 2) had enthesopathy confirmed on magnetic resonance imaging. All patients were treated with a single pubic cleft injection of local anesthetic and steroid into the adductor enthesis. At one year after this treatment, the patients were assessed for recurrence of symptoms. RESULTS: On clinical reassessment five minutes after the injection, all twenty-four athletes reported resolution of the groin pain. At one year, none of the seven patients in Group 1 had experienced a recurrence. Sixteen of the seventeen patients in Group 2 had a recurrence of the symptoms (p <>

Arthroscopic surgery of the hip: current concepts and recent advances.

J Bone Joint Surg Br. 2006 Dec;88(12):1557-66.

Khanduja V, Villar RN.

The Wellington Hospital, St John's Wood, London, UK. vikaskhanduja@aol.com

This review describes the development of arthroscopy of the hip over the past 15 years with reference to patient assessment and selection, the technique, the conditions for which it is likely to prove useful, the contraindications and complications related to the procedure and, finally, to discuss possible developments in the future.

Groin pain in the soccer athlete: fact, fiction, and treatment

Clin Sports Med. 1998 Oct;17(4):787-93, vii.

Gilmore J.

Groin and Hernia Clinic, London, England, United Kingdom.Groin pain in the soccer athlete is a common problem accounting for 5% of soccer injuries. Groin distribution has proved to be the most common cause of groin pain. Other causes are direct trauma, ostetis pubis, muscle injuries, fractures, bursitis, hip problems, and hernia and referred pain. Soccer players with groin pain present a complex management problem that is discussed.

Long-standing groin pain in sportspeople falls into three primary patterns, a "clinical entity" approach: a prospective study of 207 patients.

Br J Sports Med. 2007 Apr;41(4):247-52; discussion 252. Epub 2007 Jan 29.

Hölmich P.

Department of Orthopaedic Surgery, Amager University Hospital, Copenhagen DK-2300 S, Denmark.

per.holmich@ah.hosp.dk

BACKGROUND: Groin pain remains a major challenge in sports medicine. AIM: To examine 207 consecutive athletes (196 men, 11 women) with groin pain using a standardised and reliable clinical examination programme that focused on signs that suggest pathology in (1) the adductors, (2) the ilopsoas and (3) the rectus abdominis. PATIENTS AND METHODS: Most patients were football players (66%) and runners (18%). In this cohort, the clinical pattern consistent with adductor-related dysfunction, was the primary clinical entity in 58% of the patients and in 69% of the football players. Iliopsoas-related dysfunction was the primary clinical entity in 36% of the patients. Rectus abdominis-related dysfunction was found in 20 (10%) patients but it was associated with adductor-related pain in 18 of these patients. Multiple clinical entities were found in 69 (33%) patients; of these, 16 patients had three clinical entities.
CONCLUSIONS: These descriptive data extend previous findings that physical examination for groin pain can be reliable. While underscoring the prevalence of adductor-related physical examination abnormality in football players, the data highlight the prevalence of examination findings localising to the iliopsoas among this cohort. Also, the fact that combinations of clinical entities were present has important implications for treatment. The finding of multiple abnormal clinical entities also raises the possibility that earlier presentation may be prudent; it is tempting to speculate that one clinical entity likely precedes other developing entities. These data argue for the need for a trial where clinical entities are correlated with systematic investigation including MRI and ultrasonography.

Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI.

AJR Am J Roentgenol. 2007 Mar;188(3):W291-6.

Cunningham PM, Brennan D, O'Connell M, MacMahon P, O'Neill P, Eustace S.

Department of Radiology, Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland.

OBJECTIVE: The objectives of our study were, first, to use MRI to determine the prevalence of osteitis pubis and of adductor dysfunction at the symphysis pubis in soccer players presenting with pubalgia and, second, to determine whether the two entities are mechanically related and whether one of the entities precedes or predisposes the development of the other. MATERIALS AND METHODS: One hundred consecutive soccer players with debilitating groin pain were referred for MRI. One hundred asymptomatic age- and sex-matched elite athletes were included as control subjects. The "secondary cleft" sign was used to indicate an adductor microtear at the symphyseal enthesis. Osteitis pubis was recorded if paraarticular bone edema was identified along the symphyseal margins but was remote from the adductor attachment. Images were reviewed independently by two radiologists who were blinded to the side of symptoms. Statistical analysis was performed using the chi-square test. RESULTS: Of 100 patients, groin pain was directly attributed to inflammation at the symphysis pubis or its muscular attachments in 97 (isolated adductor microtears, n = 47; isolated osteitis pubis, n = 9; both, n = 41). An "accessory cleft," reflecting an adductor enthetic microtear, was identified in 88 of these patients (p <>

CONCLUSION: In soccer players with pubalgia, adductor dysfunction is a more frequent MRI finding than osteitis pubis. The findings of this study suggest that both entities are mechanically related and that osteitis pubis and adductor dysfunction frequently coexist but, because adductor dysfunction is commonly identified in the absence of osteitis, that adductor dysfunction most likely precedes the development of osteitis pubis in soccer players. The presence of edema on fat-suppressed images of the symphysis is a strong predictor of abnormality at this site in soccer players when compared with age- and sex-matched control subjects.

Clinical presentation of femoroacetabular impingement.

Knee Surg Sports Traumatol Arthrosc. 2007 Aug;15(8):1041-7. Epub 2007 May 12.

Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK.

Steadman Hawkins Research Foundation, Attn: Clinical Research, 181 W. Meadow Dr. Ste 1000, Vail, CO 81657, USA.

The purpose of this study was to identify subjective complaints and objective findings in patients treated for femoroacetabular impingement (FAI). Three hundred and one arthroscopic hip surgeries were performed to treat FAI. The most frequent presenting complaint was pain, with 85% of patients reporting moderate or marked pain. The most common location of pain was the groin (81%). The average modified Harris Hip score was 58.5 (range 14-100). The average sports hip outcome score was 44.0 (range 0-100). The anterior impingement test was positive in 99% of the patients. Range of motion was reduced in the injured hip. Patients who had degenerative changes in the hip had a greater reduction in range of motion. The most common symptom reported in patients with FAI was groin pain. Patient showed decreased ability to perform activities of daily living and sports. Significant decreases in hip motion were observed in operative hips compared to non-operative hips.

Sports hernias

Adv Surg. 2007;41:177-87.

Diesen DL, Pappas TN.Department of Surgery, Duke University, DUMC 3479, Durham, NC 27710, USA.

diese001@mc.duke.edu

Sportsman's hernia is an increasingly recognized cause of chronic groin pain in athletes. Although the definition is controversial, it is a condition of chronic inguinal/pubic exertional pain caused by rectus abdominal wall weakness or injury without a palpable hernia, usually affecting high-performance male athletes. Diagnosis is made after careful history and physical examination. Some radiographic studies such as ultrasound or MRI may be helpful in evaluating these patients and ruling out other pathology, although no radiographic study can rule out sportsman's hernias. Because sports hernias are not true hernias but an injury in the rectus insertion, unilateral or bilateral rectus reattachment is the most appropriate surgical treatment. This reattachment may be done in combination with adductor release in the setting of adductor pain or weakness on physical examination. Other surgical repairs (eg, Lichtenstein, Shouldice, Kugel, laparoscopic) do not stabilize the pelvis and tend not to be as successful. In the motivated patient, after surgical repair and physical rehabilitation, 95% are free of pain and able to return to competitive sports.

Sutureless tension-free hernia repair with human fibrin glue (tissucol) in soccer players with chronic inguinal pain: initial experience.

Int J Sports Med. 2007 Oct;28(10):873-6. Epub 2007 May 11.

Department of General Surgery, Second University of Naples, School of Medicine, Naples, Italy.

silvestro.canonico@unina2.it

Chronic groin pain is a common symptom experienced by soccer players, resulting in many athletes undergoing prolonged periods of conservative treatment. In a high proportion of these cases, however, the cause of groin pain is due to impalpable hernias, thus nullifying the usefulness of a conservative approach. Of the current surgical procedures for inguinal hernia repair, the Lichtenstein technique is widely used. The present study aims to evaluate the efficacy of mesh fixation with human fibrin glue (Tissucol) in open, tension-free inguinal repair, in the treatment of soccer players with groin hernia. A sutureless Lichtenstein technique was employed in 16 consecutive soccer players with primary groin hernia. Inguinal nerves were prepared and preserved. Human fibrin glue was used for mesh fixation, in place of conventional sutures. Results were rated as excellent in all cases, with no reported intra- or postoperative complications. All patients were discharged 4 - 5 h after the operation, and all returned to full pre-injury level sporting-activity, on average, 31 days (range 24 - 42 days) post surgery. This study confirms the efficacy of sutureless tension-free hernia repair with human fibrin glue for the treatment of soccer players suffering from chronic groin pain due to impalpable groin hernia.

Hip joint pain referral patterns: a descriptive study.

Pain Med. 2008 Jan;9(1):22-5.

Lesher JM, Dreyfuss P, Hager N, Kaplan M, Furman M.

Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.

Objective. To determine hip joint pain referral patterns. Design. Retrospective analysis. Setting. Multicenter. Patients. Fifty-one consecutive patients meeting clinical criteria of a symptomatic hip joint. Interventions. Fluoroscopically guided intra-articular hip joint injection. Outcome Measures. Anatomic pain map before hip injection and visual analog scale both before and after hip injection. Results. The hip joint was shown to cause pain in traditionally accepted referral areas to the groin and thigh in 55% and 57% of patients, respectfully. However, pain referral was also seen in the buttock and lower extremity distal to the knee in 71% and 22%, respectively. Foot and knee pain were seen in only 6% and 2% of patients, respectively, while lower lumbar spine referral did not occur. Fourteen pain referral patterns were observed. Conclusions. Buttock pain is the most common pain referral area from a symptomatic hip joint. Traditionally accepted groin and thigh referral areas were less common. Hip joint pain can occasionally refer distally to the foot. Lower lumbar spine referral did not occur.

Inguinal hernia vs. arthritis of the hip in sporting adolescents--case report and review of the literature.

Eur J Med Res. 2007 Jul 26;12(7):314-9.

Holzheimer RG, Gresser U.

Department of Surgery and Rheumatology, Praxisklinik Sauerlach, Sauerlach, Germany. gresser.holzheimer@web.de

Chronic pain in the hip, groin or thigh can be caused by a wide spectrum of diseases posing extended diagnostic problems. We describe the case of a 10-years old child with chronic pain in the groin with gait restriction for more than six months without successful classification and treatment. The girl suffered from heavy pain in the groin after a sporting contest which forced her to walk with walking sticks and to avoid climbing stairs. Within six months she was examined by pediatric, orthopedic, pediatric surgery, pediatric orthopedic, radiology, pediatric rheumatology specialists. Working diagnoses were transient synovitis (coxitis fugax), arthritis, streptococcal arthritis, Morbus Perthes, rheumatic fever, rheumatoid arthritis. She was treated with antibiotics and ibuprofen in high dosage. Repeated laboratory tests and imaging studies (ultrasound, x-rays, magnetic resonance imaging) of the hip and pelvis did not support any of these diagnoses. Six months after beginning of the complaints the girl was presented by her mother to our institution. The physical examination showed a sharp localized pain in the groin, just in the region of the inguinal ligament with otherwise free hip movement. There was no visible inguinal hernia. The family history for hernia was positive. After infiltration of the ilioinguinal nerve the girl had a complete long-lasting disappearance of pain and gait disturbance. This led to the diagnosis of inguinal hernia with nerve entrapment. After hernia repair and neurolysis/neurectomy there was a continuous state of disappearance of pain and gait disturbances.

CONCLUSION: To avoid such a diagnostic dilemma one should always discuss all possible causes. Non-visible inguinal hernia may be more common in females than previously thought. Nerve entrapment as a cause of groin pain has been well described. The relationship of the start of complaints with sporting activity, a positive family history for inguinal hernia, a lack of signs of inflammation and bone involvement in the laboratory and imaging studies together with a localized pain in the groin, almost immediate long-lasting disappearance of pain after infiltration of the ilioinguinal nerve allowing free motion leads to the diagnosis of inguinal hernia with nerve entrapment. Hernia repair and neurolysis are the adequate treatment avoiding unnecessary radiation.

Air Bubble Saline Arthrosonography in Imaging Rotator Cuff Tears

Air Bubble Saline Arthrosonography in Imaging Rotator Cuff Tears

By David Martin, MBBS, BMed Sc(Hons), FRACS, FAOrthA; Parminder J. S. Jeer, MBBS, FRCS, FRCS(Tr&Orth); Yegappan Kalairajah, MA, MPhil, MBBChir, FRCS; Mark Falworth, MBBS, FRCS(Eng), FRCS (Tr&Orth); Steven Zadow, MBBS(Hons), FRANZCR; Neil Simmons, MBBS, FRACR
ORTHOPEDICS 2008; 31:140

February 2008

Air bubble saline arthrosonography decreases user dependency and increases accuracy in the identification and characterization of rotator cuff tears.

The accurate identification and characterization of rotator cuff tears is important when planning surgical intervention and determining the prognosis in patients with rotator cuff pathology.^1,2 Imaging modalities used to investigate a suspected rotator cuff tear include plain radiography, magnetic resonance imaging (MRI), and ultrasonography scanning, all of which can be combined with arthrography.

Magnetic resonance imaging and ultrasonography scanning have been reported to be highly accurate in detecting rotator cuff tears.^3-10 Reports comparing ultrasonography scanning and MRI findings with arthrography and surgical findings suggest similar specificity but lower sensitivity of ultrasonography scanning in the detection of full and partial thickness tears.^11,12 These studies demonstrated the possibility of limited accuracy of ultrasonography scanning diagnosis when lower frequency transducers were used, along with high operator dependency.^11,12 However, compared with MRI, ultrasonography scanning is more readily available, more economical, and less time-consuming. Despite these advantages, ultrasonography scanning has not been widely accepted in the orthopedic community, particularly as an office tool in the investigation of rotator cuff pathology.^13,14

This article describes a new method of combining ultrasonography scanning with an air bubble and saline arthrogram to improve the ease of identification and characterization of rotator cuff tears.

Technique

Air bubble arthrosonogram improves the investigator’s ability to recognize and characterize rotator cuff tears. The technique involves shaking 15 mL of saline with 3 to 5 mL of air in a 20-mL syringe to generate numerous air bubbles. The ultrasonography scanning probe is positioned posteriorly over the infraspinatus tendon with the patient facing the monitor. The mixture is then injected into the glenohumeral joint using a 22-gauge, 50-mm–long needle, which is inserted beneath the probe using a standard posterior approach to the shoulder. After retracting the needle, the patient is encouraged to exercise the shoulder for 30 seconds to aid the distribution of the air bubbles and saline. If pain is a limiting factor when performing shoulder movements, the saline can be substituted with a local anesthetic. Standard ultrasonography scanning of the shoulder is then performed.

Improved visualization of the rotator cuff tear is possible due to the air bubble–tissue interface. In rotator cuff tears, the bubbles are seen escaping from the glenohumeral joint. The bubbles that adhere to the tear edge help to characterize the nature and extent of the tear. Partial tears are more easily identified, as the defect is more clearly visualized.

Figure 1: Left shoulder sta Standard ultrasonography scan along the long axis of the supraspinatus tendon. It is not clear from this image as to whether the previous cuff repair is intact. The bursa, humeral head, and trough from previous repair are seen (A). Left shoulder air bubble saline arthrogram demonstrating no significant differences compared with standard ultrasonography. With no fluid or bubbles in the bursa, the integrity of the previous supraspinatus tendon repair is confirmed. The humeral head and trough from previous repair are seen (B). Postgadolinium T1 fat saturated magnetic resonance image of the left shoulder demonstrating a thin and irregular supraspinatus tendon in the presence of a previous repair. No contrast has entered the bursa confirming an intact cuff repair, although there are irregularities on the articular surface of the supraspinatus. The metal artifact, humeral head, and corocoid process are seen (C). Abbreviations: A=metal artifact, B=bursa, CP=corocoid process, HH=humeral head, SS=supraspinatus tendon, and T=trough.

The resulting images of this technique, performed on the left and right shoulders of a 45-year-old man with previous cuff repairs, are presented in Figures 1 and 2. Four years after the cuff repairs, the patient reported discomfort and weakness in both shoulders. Standard ultrasonography scanning was performed (Figures 1A, 2A). Due to the difficulty in a definitive diagnosis, an air bubble saline arthrogram was performed in each case (Figures 1B, 2B). Magnetic resonance imaging was performed to confirm the ultrasonography findings (Figures 1C, 2C, 2D). An Acuson sequoia ultrasound machine with a 15- to 8-MHz–wide linear array (Acuson, Mountain View, California) was used to create these images.

Discussion

A diagnostic test is judged by its accuracy, sensitivity, and specificity. This modified technique improves upon conventional ultrasonography scanning in fulfilling these criteria.

This technique has been helpful in the diagnosis of rotator cuff pathology while also being simple, safe, and without complications. It has the advantages of arthrography without the possible complications linked to contrast media.¹⁵ Furthermore, it is quicker, more economical, and more accessible than MRI and sensitive enough to aid in the diagnosis of rotator cuff pathology. The ability to characterize tear size, thickness, and edge morphology is also improved on. It is particularly useful as an adjunct to ultrasonography scanning if there is a thickened subacromial bursa, which can make the diagnosis of a rotator cuff tear more difficult. The echogenic shadowing produced around the cuff tear is also helpful if a clear ultrasound image is not produced due to prior surgery, or if the anatomy is too distorted to confidently diagnose using standard ultrasound techniques. Air bubble saline arthrosonography can be used in these cases rather than MRI, which is more expensive and may not be as readily accessible.

Figure 2: Right shoulder standard ultrasonography scan along the long axis of the supraspinatus tendon at its anterior aspect. It is difficult to define the difference between the tendon and bursa, and the integrity of the previous cuff repair is not conclusive. The humeral head, cartilage, and trough from previous repair are seen (A). Right shoulder air bubble saline arthrogram demonstrating distension of the bursa and a more defined edge to the torn supraspinatus tendon. This confirms a full thickness tear of the previous repair. The humeral head, cartilage, and trough from previous repair are seen (B). Postgadolinium T1 fat saturated magnetic resonance image of the right shoulder demonstrating a more posterior aspect of the supraspinatus tendon which is irregular on its articular surface. Contrast in the bursal space suggests a torn cuff repair. The humeral head is seen (C). Postgadolinium T1 fat saturated magnetic resonance image of the right shoulder demonstrating contrast in the bursal space, confirming a full thickness tear of the supraspinatus tendon. The long head biceps, humeral head, and corocoid process are seen (D). Abbreviations: B=bursa, C=cartilage, CP=corocoid process, FTT=full thickness tear, HH=humeral head, LHB=long head biceps, SS=supraspinatus tendon, and T=trough.

Previous concerns with ultrasonography scanning were based on its operator and equipment dependency. This dependence should be reduced by the greater ease of interpretation of the ultrasonography images using the air bubble saline arthrosonogram technique. Furthermore, this technique should allow orthopedic surgeons performing office-based ultrasonography scanning greater diagnostic accuracy, thereby aiding in the management of rotator cuff disease.

We acknowledge that validation of the technique with a prospective study correlating ultrasonography scanning appearance with operative findings at surgery and MRI are needed.

References

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Authors

Drs Martin, Jeer, Kalairajah, and Falworth are from SPORTSMED SA; and Drs Zadow and Simmons are from Jones and Partners, Adelaide, Australia.

Drs Martin, Jeer, Kalairajah, Falworth, Zadow, and Simmons have no relevant financial relationships to disclose.

Correspondence should be addressed to: Mark Falworth, MBBS, FRCS(Eng), FRCS (Tr&Orth), SPORTSMED SA, 32 Payneham Rd, Stepney Adelaide, SA 5069, Australia.

Surgical treatment of acute versus chronic complete proximal hamstring ruptures: results of a new allograft technique for chronic reconstructions.

Am J Sports Med. 2008 Jan;36(1):104-9. Epub 2007 Nov 30.

Folsom GJ, Larson CM.Minnesota Sports Medicine Orthopaedic Sports Medicine Fellowship Program, Twin Cities Orthopaedics, Eden Prairie, Minnesota 55344, USA.BACKGROUND: Acute surgical repair of proximal hamstring ruptures has been shown to result in a high return to preinjury activity level. HYPOTHESIS: Achilles allograft reconstruction of chronic complete proximal hamstring ruptures results in improved function and strength that approaches that of acute surgical repairs. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2002 and 2005, 26 patients underwent surgical treatment for complete proximal hamstring ruptures. Twenty-one were acute primary repairs. Five chronic ruptures were treated with Achilles allograft reconstruction with (n = 2) or without (n = 2) interference screw fixation or mobilization and primary repair (n = 1). Isokinetic strength testing was conducted postoperatively in 11 acute and 3 chronic cases, and a functional questionnaire was given at most recent follow-up.

RESULTS: Subjective results for all patients at a mean follow-up of 20 months revealed good leg control in 96%, no pain in 80%, and return to sporting activities in 76%. Ninety-six percent of patients said they would have the procedure done again. With the isokinetic testing available at most recent follow-up, there was no significant difference in the mean hamstring strength deficits for the acute versus chronic groups tested at 60 deg/s (8% vs 21%, P =.295) and 180 deg/s (12% vs 2%, P = .294). Overall, there were 3 major adverse events and 5 patients with superficial wound drainage treated with antibiotics. CONCLUSION: Surgical treatment of acute and chronic complete proximal hamstring ruptures can result in a high return to full activity. Reconstruction of chronic ruptures with Achilles allograft appears to restore function and strength comparable to acute repairs.