A return-to-sport algorithm for acute hamstring injuries

Phys Ther Sport. 2011 Feb;12(1):2-14. Epub 2010 Aug 21.

Mendiguchia J, Brughelli M.

Head of Rehabilitation Department at Athletic Club de Bilbao, Garaioltza 147 CP:48196, Lezama (Bizkaia), Spain. jurdan24@hotmail.com

Abstract

Acute hamstring injuries are the most prevalent muscle injuries reported in sport. Despite a thorough and concentrated effort to prevent and rehabilitate hamstring injuries, injury occurrence and re-injury rates have not improved over the past 28 years. This failure is most likely due to the following: 1) an over-reliance on treating the symptoms of injury, such as subjective measures of "pain", with drugs and interventions; 2) the risk factors investigated for hamstring injuries have not been related to the actual movements that cause hamstring injuries i.e. not functional; and, 3) a multi-factorial approach to assessment and treatment has not been utilized. The purpose of this clinical commentary is to introduce a model for progression through a return-to-sport rehabilitation following an acute hamstring injury. This model is developed from objective and quantifiable tests (i.e. clinical and functional tests) that are structured into a step-by-step algorithm. In addition, each step in the algorithm includes a treatment protocol. These protocols are meant to help the athlete to improve through each phase safely so that they can achieve the desired goals and progress through the algorithm and back to their chosen sport. We hope that this algorithm can serve as a foundation for future evidence based research and aid in the development of new objective and quantifiable testing methods.

Skin-Derived Tenocyte-like Cells for the Treatment of Patellar Tendinopathy

1. Andrew W. Clarke, FRANZCR*†,
2. Faisal Alyas, FRCR†,
3. Tim Morris‡,
4. Claire J. Robertson, MSc, PGCE, MCSP§,
5. Jonathan Bell, FRCS(Orth)‖ and
6. David A. Connell, FRANZCR†

+ Author Affiliations

1. ^†Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom
2. ^‡MRC Clinical Trials Unit, London, United Kingdom
3. ^§University of London, London, United Kingdom
4. ^‖Kingston Hospital NHS Trust, Surrey, United Kingdom
5. Investigation performed at Royal National Orthopaedic Hospital, Stanmore, United Kingdom

1. *Andrew W. Clarke, Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, London HA7 4LP United Kingdom (e-mail: david.connell@googlemail.com).

Abstract

Background: Recent research of lateral elbow tendinopathy has led to the use of laboratory-amplified tenocyte-like cells.

Hypothesis: Ultrasound-guided injection of autologous skin-derived tendon-like cells are effective compared with other injectable therapies for the treatment of refractory patellar tendinosis.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: From 60 patellar tendons in 46 patients with refractory patellar tendinopathy, a 4-mm skin biopsy was sampled to grow tenocyte-like collagen-producing cells. Patients were allocated into 2 groups: (1) injection with laboratory-prepared, amplified collagen-producing cells derived from dermal fibroblasts and suspended in autologous plasma from centrifuged autologous whole blood or (2) injection with autologous plasma alone. Injections were made into the sites of hypoechogenicity, intrasubstance tears, and fibrillar discontinuity within the patellar tendon. The Victorian Institute of Sport Assessment (VISA) score was used to assess pain, severity, and functional disability. Ultrasound was performed to assess structural and blood flow changes, evaluating 4 criteria: tendon thickness, hypoechogenicity, intrasubstance tears, and neovascularity.

Results: In the cell group, mean VISA scores improved from 44 ± 15 before treatment to 75 ± 17 at 6 months; in the plasma group, from 50 ± 18 to 70 ± 14. Estimated average difference between groups was 8.1, a significantly higher score in the cell group. Patients treated with collagen-producing cells also had significantly faster improvement and a highly significant effect of treatment, with the difference between groups estimated as 2.5 per unit increase in . One patient treated with cell therapy had a late rupture and progressed to surgery; histopathology showed normal tendon structure.

Conclusion: Ultrasound-guided injection of autologous skin-derived tendon-like cells can be safely used in the short term to treat patellar tendinopathy, with faster response of treatment and significantly greater improvement in pain and function than with plasma alone.

Predictors of Outcome After Nonoperative and Operative Treatment of Adhesive Capsulitis

1. Brian K. Rill, MD*,
2. Cassie M. Fleckenstein, MS†,
3. Martin S. Levy, PhD‡,
4. Vinutha Nagesh, MS‡ and
5. Samer S. Hasan, MD, PhD†§

+ Author Affiliations

1. ^*Henry Ford Hospital, Sterling Heights, Michigan
2. ^†Cincinnati SportsMedicine Research and Education Foundation, Cincinnati, Ohio
3. ^‡University of Cincinnati, Cincinnati, Ohio
4. Investigation performed at Cincinnati Sports Medicine Research and Education Foundation, Cincinnati, Ohio

1. §Samer S. Hasan, MD, PhD, Cincinnati SportsMedicine Research and Education Foundation, 10663 Montgomery Road, First Floor, Cincinnati, OH 45242 (e-mail: cfleckenstein@csmref.org).

Abstract

Background: Few studies regarding adhesive capsulitis have concurrently evaluated nonoperative and operative treatment.

Purpose: The objectives were to evaluate the efficacy of operative and nonoperative treatment of adhesive capsulitis and to determine predictors of clinical outcome.

Study Design: Cohort study; Level of evidence, 3.

Methods: At minimum 24 months’ follow-up, 85 patients underwent self-assessment using the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) score, including 24 patients treated operatively.

Results: Mean number of yes responses on the SST improved from 4.0 ± 2.7 at initial presentation to 9.9 ± 2.8 at final follow-up (P < .0001). Patients who received nonoperative treatment and patients who underwent surgery demonstrated similar improvements on the SST. For the entire cohort, forward elevation and external rotation at the side improved from 119° ± 20° to 152° ± 15° and from 29° ± 18° to 46° ± 11° (P < .0001), respectively, between initial presentation and discharge from treatment. Internal rotation to the back improved from the gluteal area to the thoracolumbar junction (P < .0001). Improvements in forward elevation and external rotation were greater for patients undergoing surgery. After nonoperative treatment, patients with diabetes had a lower final SST than patients without diabetes (P < .05). For the entire cohort, initial SST predicted final SST (P < .05), and a shorter duration of symptoms predicted a higher final ASES score (P < .05). Younger patients (P < .001) and those with a lower initial SST (P < .05) were more likely to undergo surgery.

Conclusions: A multimodal nonoperative treatment program is effective for most patients with adhesive capsulitis. Patients who do not improve, including those with diabetes, respond well to manipulation and arthroscopic release. Residual motion deficits at discharge from treatment do not appear to affect longer-term clinical outcome.

Shaping the Future of Musculoskeletal Services Wednesday 8 June 2011 - London

Shaping the Future of Musculoskeletal Services


A conference for primary care musculoskeletal practitioners

These are challenging times for those involved in the delivery of musculoskeletal care in the UK. But new challenges also present opportunities to improve the care we deliver to our patients.



Arthritis Research UK is keen to continue its support for clinicians working in musculoskeletal ‘special interest’ roles and musculoskeletal interface clinics and would like to invite you to shape the future of musculoskeletal services. We hope this one-day conference will serve as a forum to share ideas and best practice and also develop networks for peer support.



Key themes Commissioning and pathways, education, continuing professional development and appraisal.



Target audience GPwSIs, PwSIs, AHPs and specialist nurses working in musculoskeletal interface services.



Date Wednesday 8 June 2011



Venue Skinner’s Hall, Dowgate Hill, London



The full price will be £70 but we are offering a reduced rate of £50 for those who book before Monday 28th March. To reserve your place please complete an application form and return to Donna Lakin. A full programme and further details will be published in due course.