Clinical findings just after return to play predict hamstring re-injury, but baseline MRI findings do not

__Abstract__ Background Acute hamstring re-injuries are common and hard to predict. The aim of this study was to investigate the association between clinical and imaging findings and the occurrence of hamstring re-injuries. Methods We obtained baseline data (clinical and MRI findings) of athletes who sustained an acute hamstring injury within 5 days of initial injury. We also collected data of standardised clinical tests within 7 days after return to play (RTP). The number of re-injuries was recorded within 12 months. We analysed the association between the possible predictive variables and re-injuries with a multivariate Cox proportional-hazards regression model. Results Eighty patients were included at baseline and 64 p

Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study

Background: Despite being one of the most common sports injuries, there are no criteria-based rehabilitation programs published for acute adductor injuries. Purpose: To evaluate return-to-sport (RTS) outcomes and reinjuries after criteria-based rehabilitation for athletes with acute adductor injuries. Study Design: Cohort study; Level of evidence, 2. Methods: Male adult athletes with an acute adductor injury underwent a supervised, standardized criteria-based exercise rehabilitation program. Magnetic resonance imaging (MRI) was used to grade the injury extent from 0 (negative finding) to 3 (complete tear/avulsion). There were 3 milestones used to evaluate the RTS continuum: (1) clinically pain-free, (2) completion of controlled sports training, and (3) return to full team training. Subsequent injuries were registered within the first year. Results: We included 81 athletes with an acute adductor injury (MRI grade 0: n = 14; grade 1: n = 20; grade 2: n = 30; grade 3: n = 17). Of these, 61 (75%) athletes achieved RTS milestone 1, 50 (62%) achieved RTS milestone 2, and 75 (93%) achieved RTS milestone 3. There were no statistical differences in the RTS duration between MRI grade 0, 1, and 2 at any RTS milestone; thus, these were grouped together as grade 0-2. The median time (interquartile range [IQR]) for athletes with grade 0-2 injuries to become clinically pain-free was 13 days (IQR, 11-21 days), to complete controlled sports train

One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy

OBJECTIVE: The study examined whether the addition of a night splint to eccentric exercises is beneficial for functional outcome in chronic mid-portion Achilles tendinopathy. DESIGN: One-year follow-up of a randomised controlled single blinded clinical trial. SETTING: Sports medicine department in a general hospital. PATIENTS: 58 patients (70 tendons) were included. INTERVENTIONS: All patients completed a 12-week heavy load eccentric training programme. One group received a night splint in addition to eccentric exercises. Main outcome measurements: Outcome scores were: Victorian Institute of Sport Assessment - Achilles (VISA-A) score, subjective patient satisfaction and neovascularisation score measured with Power Doppler Ultrasonography. RESULTS: For both groups the VISA-A score increased significantly (from 50 to 76 (P < 0.01) in the eccentric group and from 49 to 78 (P < 0.01) in the night splint group). No significant differences in VISA-A score were found between the groups from baseline to one year (P = 0.32). Presence of neovessels at baseline did not predict change in VISA-A score after one year in the whole group (P = 0.71). CONCLUSION: Eccentric exercises with or without a night splint improved functional outcome at one-year follow-up. At follow-up there

Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach

OBJECTIVE: To asses if three-dimensional imaging of the Achilles tendon by Ultrasonographic Tissue Characterisation (UTC) can differentiate between symptomatic and asymptomatic tendons. DESIGN: Case-control study. SETTING: Sports medical department of The Hague medical centre. PATIENTS: Twenty-six tendons from patients with chronic midportion Achilles tendinopathy were included. The "matched" control group consisted of 26 asymptomatic tendons. INTERVENTIONS: Symptomatic and asymptomatic tendons were scanned using the UTC-procedure. One researcher performed the ultrasonographic data-collection. These blinded data were randomised and outcome measures were determined by two independent observers. Main outcome measurements: The raw ultrasonographic images were analysed with a custom-designed algorithm that quantifies the three-dimensional stability of echopatterns, qua intensity and distribution over contiguous transverse images. This three-dimensional stability was related to tendon structure in previous studies. UTC categorizes four different echo-types that represent: I) highly stable; II) medium stable; III) highly variable and IV) constantly low intensity and variable distribution. The percentages of echo-types were calculated and the maximum tendon-thickness was measured. Finally, the inter-observer reliability of UTC was determined. RESULTS: Symptomatic tendons showed less pixels in echo-types I and II than asymptomatic tendons (51.5% versus 76.6%, p<0.001), thus less three-dimensional stability of the echopattern. The mean maximum tendon thickness was 9.2 mm in the symptomatic group and 6.8 mm in the asymptomatic group (p<0.001). The Intra-class Correlation Coefficient (ICC) for the inter-observer reliability of determining the echo-types I+II was 0.95. The ICC for tendon thickness was 0.84. CONCLUSION: UTC can quantitatively evaluate tendon structure and thereby discriminate symptomatic and asymptomatic tendons. As such UTC might be useful to monitor treatment protocols

Incidence of midportion Achilles tendinopathy in the general population

Background Achilles tendon disorders, like Achilles tendinopathy, are very common among athletes. In the general population, however, knowledge about the incidence of Achilles tendinopathy is lacking. Desi

The value of MRI STIR signal intensity on return to play prognosis and reinjury risk estimation in athletes with acute hamstring injuries

Objectives: Previous studies have shown low to moderate evidence for a variety of magnetic resonance imaging (MRI) features as prognostic factors in athletes with hamstring injuries. Short-tau inversion recovery (STIR) signal intensity has not yet been investigated for assessing the prognosis of acute muscle injuries. Our aim was to explore the relationship between MRI STIR signal intensity and time to return to play (RTP) and to investigate the association between MRI STIR and reinjury risk in athletes with acute hamstring injuri

MRI observations at return to play of clinically recovered hamstring injuries

Background: Previous studies have shown that MRI of fresh hamstring injuries have diagnostic and prognostic value. The clinical relevance of MRI at return to play (RTP) has not been clarified yet. The aim of this study is to describe MRI findings of clinically recovered hamstring injuries in amateur, elite and professional athletes that were cleared for RTP. Methods: We obtained MRI of 53 consecutive athletes with hamstring injuries within 5 days of injury and within 3 days of RTP. We assessed the following parameters: injured muscle, grading of injury, presence and extent of intramuscular signal abnormality. We recorded reinjuries within 2 months of RTP. Results: MRIs of the initial injury showed 27 (51%) grade 1 and 26 (49%) grade 2 injuries. Median time to RTP was 28 days (range 12-76). On MRI at RTP 47 athletes (89%) had intramuscular increased signal intensity on fluid-sensitive sequences with a mean longitudinal length of 77 mm (±53) and a median cross-sectional area of 8% (range 0-90%) of the total muscle area. In 22 athletes (42%) there was abnormal intramuscular low-signal intensity. We recorded five reinjuries. Conclusions: 89% of the clinically recovered hamstring injuries showed intramuscular increased signal intensity on fluid-sensitive sequences on MRI. Normalisation of this increased signal intensity seems not required for a successful RTP. Low-signal intensity suggestive of newly developed fibrous tissues is observed in one-third of the clinically recovered hamstring injuries on MRI at RTP, but its clinical relevance and possible association with increased reinjury risk has to be determined

Platelet-Rich plasma Injection Management for Ankle osteoarthritis study (PRIMA): protocol of a Dutch multicentre, stratified, block-randomised, double-blind, placebo-controlled trial

INTRODUCTION: Platelet-rich plasma (PRP) is a potentially efficacious treatment for ankle osteoarthritis (OA), but its use has not been examined in high-quality studies. Systematic reviews show that PRP injections significantly decrease pain and improve function in patients with knee OA. Ankle OA is more common than hip or knee OA in the young active population; with a prevalence of 3.4%.PRP injections in ankle OA are shown to be safe and improve quality of life over time, but no randomised controlled trial has been conducted. Our randomised controlled trial will evaluate the efficacy of PRP injections for symptom reduction and functional improvement, compared with placebo, in the treatment of ankle (talocrural) OA. METHODS AND ANALYSIS: We will conduct the Platelet-Rich plasma Injection Management for Ankle OA study: a multicentre, randomised, placebo-controlled trial. One hundred patients suffering from ankle OA will be randomised into two treatment groups: PRP injection or placebo (saline) injection. Both groups will receive two injections of PRP or placebo at an interval of 6 weeks. Primary outcome is the American Orthopaedic Foot and Ankle Society score at 26 weeks. Secondary outcomes determined at several follow-up moments up to 5 years, include Ankle Osteoarthritis Score, Foot and Ankle Outcome Score, pain

Myotoxicity of injections for acute muscle injuries: A systematic review

Background: Injection therapies are widely used for muscle injuries. As there is only limited evidence of their efficacy, physicians should be aware of the potential harmful effects of these injected preparations. Objectives: The purpose of this review was to systematically review the literature on the myotoxic effects of intramuscular injection preparations commonly used for acute muscle injuries. Data Sources: The databases of PubMed, Embase, Web of Science, Cochrane Library, CINAHL and SportDiscus were searched in March 2013. Study Eligibility Criteria: Studies reporting histological evaluation or creatine kinase activity after intramuscular injection with local anaesthetics, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), platelet-rich plasma (PRP), Traumeel® and Actovegin®, or combination preparations were eligible for inclusion. Data A

Predicting return to play after hamstring injuries

__Abstract__ Background Previous studies on the prognostic value of clinical and MRI parameters for the time to return to play (TTRTP) in acute hamstring injuries showed only limited to moderate evidence for the various investigated parameters. Some studies had multiple methodological limitations, including retrospective designs and the use of univariate analysis only. The aim of this study was to assess the prognostic value of clinical and MRI parameters for TTRTP using multivariate analysis. Methods 28 clinical and MRI parameters were prospectively investigated for an association with TTRTP in 80 non-professional athletes with MRI positive hamstring injuries undergoing a standardised rehabilitation programme. The association between possible prognostic parameters and TTRTP was assessed with a multivariate linear regression model. Parameters that had a p value <0.2 on univariate testing were included in this model. Results 74 athletes were available for analysis. A total of nine variables met the criteria for the multivariate analysis: intensity of sports, level of sports, self-predicted TTRTP by the athlete, length of discomfort on palpation, deficit in passive straight leg raise, pain score on isometric knee flexion, isometric knee flexion strength deficit and distance of the proximal pole of the MRI hyperintensity to the tuber ischiadicum. Of these, only self-predicted TTRTP by the athlete and a passive straight leg raise deficit remained significantly associated with TTRTP after stepwise logistic regression. Conclusions The clinical parameters self-predicted TTRTP and passive straight leg raise deficit are independently associated with the TTRTP. MRI parameters in grade 1 and 2 hamstring injuries, as described in the literature, are not