Opening the Chamber of secrets: our response to "the end of the beginning".
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Exercise↗
Biomedical subjects
M E Batt
Publications and source records attributed to M E Batt.
Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review.
A literature search was performed to determine whether non-steroidal anti-inflammatory drugs (NSAIDs) adversely affect the healing of stress fractures. Evidence exists from laboratory studies and animal subjects that NSAIDs can affect fracture healing. This link has not been proved or disproved in human subjects, particularly for stress fractures. In view of the high usage of NSAIDs in treating musculoskeletal disorders, research is required to investigate whether the healing of stress fractures is affected by these drugs.
Anti-Inflammatory Agents, Non-Steroidal↗
Magnetic resonance imaging of the lumbar spine in asymptomatic professional fast bowlers in cricket.
Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.
Adult↗
The value of combining single photon emission computerised tomography and computerised tomography in the investigation of spondylolysis.
The aim of this study was to assess the diagnostic value of combining single photon emission computerised tomography (SPECT) with reverse gantry computerised tomography (rg-CT) in the investigation of spondylolysis. Patient characteristics and imaging results in 118 patients, aged 8-44 years, with low back pain (LBP) were analysed. SPECT showed increased scintigraphic uptake in 80 patients, and spondylolysis was identified on rg-CT in 53. The Cohen Kappa ratio of 0.362 (95% CI: 0.198-0.526) suggests only fair agreement for the result of increased scintigraphic activity with the finding of spondylolysis on rg-CT. We conclude that these investigations give mutually exclusive information, which leads to four diagnostic categories. When there was increased scintigraphic activity on SPECT, 58.8% (95% CI: 48.0-69.5%) of patients had spondylolysis on rg-CT. With rest from provoking activities, these lesions may heal. We interpret the findings of increased scintigraphic activity, but no spondylolysis demonstrated on rg-CT as indicating a bone stress response. These also require rest from provoking activity to prevent a stress fracture developing. In this study, 84.2% (95% CI: 72.67-95.8%) of those patients without increased activity on SPECT had no spondylolysis identified on rg-CT. These patients may need further investigations such as magnetic resonance imaging (MRI) to diagnose pathology, which typically does not involve the posterior elements--but rest from sport may not be so important. There were five patients in our study, without increased scintigraphic activity, but in whom bilateral chronic-appearing (wide separation, smooth sclerotic bone margins) spondylolyses were identified at L5. These all were anticipated from previous plain radiographs or MRI. This group will almost certainly not heal, and if the spondylolyses are the cause of pain these vertebrae will need stabilisation by surgery if physiotherapy fails.
Adolescent↗
Is risk of fast bowling injury in cricketers greatest in those who bowl most? A cohort of young English fast bowlers.
OBJECTIVES: To determine whether young fast bowlers are exceeding directives limiting bowling and how incidence of fast bowling injury varies with amount of bowling. METHODS: A prospective cohort study of injuries sustained by 70 fast bowlers (mean (SD) age 15.3 (2.4) years) was undertaken. Bowlers were recruited from the Centres of Excellence of three "First Class" counties in England in January 1998. Details of injuries were collected by telephone questionnaire every six weeks for six months from each bowler. The number of balls bowled in matches and practices by each bowler was recorded. The cohort was divided into groups according to the number of balls bowled in the study period, and bowling injury incidences were calculated for each group. MAIN OUTCOME MEASURES: All injuries caused by bowling and interfering with bowling. RESULTS: Telephone follow up was achieved when planned on 97.9% of occasions. There were 23 bowling injuries reported in the study period that met the inclusion criteria. The overall incidence of bowling injury in the study period was 32.8 per 100 fast bowlers. The incidence of bowling injury for the 15 bowlers who bowled less than 1000 balls in the study period was 20.0 per 100 fast bowlers. The incidence for the 32 who bowled 1000-2000 balls was 37.5 per 100 fast bowlers. The incidence for the 14 who bowled 2000-3000 balls was 35.7 per 100. The incidence for the nine who bowled more than 3000 balls was 33.3 per 100. CONCLUSIONS: The expected increased incidence of bowling injury in young fast bowlers who bowl most was not observed, although more than 12% exceeded the recommended limit.
Adolescent↗
Comparing spondylolysis in cricketers and soccer players.
OBJECTIVE: To determine whether the location of spondylolysis in the lumbar spine of athletes differs with biomechanical factors. METHODS: Single photon emission computerised tomography and reverse gantry computerised tomography were used to investigate 42 cricketers and 28 soccer players with activity related low back pain. Sites of increased scintigraphic uptake in the posterior elements of the lumbar spine and complete or incomplete fracture in the pars interarticularis were compared for these two sports. RESULTS: Thirty seven (90.4%) cricketers and 23 (82.1%) soccer players studied had sites of increased uptake. In cricketers, these sites were on the left of the neural arch of 49 lumbar vertebrae and on the right of 33 vertebrae. In soccer players there was a significantly different proportion, with 17 sites on the left and 28 on the right (difference of 22.0%; 95% confidence interval (CI) 0.04 to 0.38). Lower lumbar levels showed increased scintigraphic uptake more frequently than did higher levels, although the trend was reversed at L3 and L4 in soccer. Forty spondylolyses were identified in the lumbar vertebrae of the cricketers and 35 spondylolyses in the soccer players. These comprised 26 complete and 14 incomplete fractures in the cricketers, and 25 complete and 10 incomplete fractures in the soccer players. Similar numbers of incomplete fractures were found either side of the neural arch in soccer players, but there were more incomplete fractures in the left pars (14) than in the right (2) in cricketers. The proportion of incomplete fractures either side of the neural arch was significantly different between cricket players and soccer players (difference of 37.5%; 95% CI 0.02 to 0.65). Most complete fractures were at L5 (66.7%) and more were found at L3 (15.7%) than L4 (6.9%). However, incomplete fractures were more evenly spread though the lower three lumbar levels with 41.7% at L5, 37.5% at L4, and 20.8% at L3. CONCLUSIONS: Fast bowling in cricket is associated with pars interarticularis bone stress response and with development of incomplete stress fractures that occur more frequently on the left than the right. Playing soccer is associated with a more symmetrical distribution of bone stress response, including stress fracturing. Within cricketers, unilateral spondylolyses tend to arise on the contralateral side to the bowling arm.
Adolescent↗
Revalidation in sport and exercise medicine.
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Clinical Competence↗
Results of inguinal canal repair in athletes with sports hernia.
AIMS: To evaluate the role of surgical exploration and repair of the inguinal canal in athletes suspected of having a sports hernia. METHODS: Thirty-five (34 males, 1 female) athletes with a suspected sports hernia underwent surgical exploration and inguinal hernia repair. After six months, all athletes were sent questionnaires to assess any improvement in analogue pain scores, return to sport, recurrence of symptoms and the overall result of surgery. RESULTS: Operative findings revealed a tear in the external oblique aponeurosis with or without a significant posterior bulge (n=20), a lone significant posterior bulge (n=10), a tear in the conjoint tendon with dilated superficial ring (n=3), small direct hernial sac (n=1) and lipoma of the spermatic cord (n=1). Surgery consisted of repair of external oblique tear (when present) and prolene darn or lichtenstein mesh repair of the posterior inguinal canal. Twenty-seven patients replied to the questionnaire giving a response rate of 78%; of these, 25 patients (93%: 95% CI 83-100) had returned to normal athletic activities at pre-injury level. There was a marked improvement in level of pain (median pain level=8 pre-operative vs 2 post-operative, p<0.001). Eleven patients (41%) rated the results as excellent, eleven (41%) as good and five (18%) as fair and none worse. Six patients complained of occasional discomfort related to the scar. Three patients complained of recurrence of their symptoms after 4 to 5 months following strenuous exercise. CONCLUSION: Sports hernia presents with a spectrum of surgical findings. Athletes with sports hernia should be considered for routine hernia repair, as the majority of the patients benefit from surgery. It is important to offer a structured rehabilitation programme to maximise the benefits of surgery.
Adult↗
Delayed union stress fractures of the anterior tibia: conservative management.
INTRODUCTION: A conservative method of treating four delayed union stress fractures of the anterior mid-tibia is described, with an illustrative case history. METHODS: Once diagnosed each of the patients was treated in a pneumatic lower leg brace with modified rest. The mean (range) age of the patients was 28 (24-32) years and all were involved in professional or amateur sports. The mean (range) duration of symptoms before diagnosis and definitive treatment of the four fractures was 9 (3-14) months. RESULTS: Use of this technique avoided the need for surgery in this group of patients and allowed return to unrestricted activity an average of 12 months from presentation. CONCLUSION: The treatment is cost effective and avoids the often uncertain results and morbidity associated with surgery for these difficult stress fractures.
Adult↗
Surface effects on ground reaction forces and lower extremity kinematics in running.
INTRODUCTION: Although running surface stiffness has been associated with overuse injuries, all evidence to support this suggestion has been circumstantial. In the present study, the biomechanical response of heel-toe runners to changes in running surface has been investigated. METHODS: Six heel-toe runners performed shod running trials over three surfaces: a conventional asphalt surface, a new rubber-modified asphalt surface, and an acrylic sports surface. The surfaces were categorised according to impact absorbing ability using standard impact test procedures (BS 7044). RESULTS: The rubber-modified asphalt was found to exhibit the greatest amount of mechanical impact absorption, and the conventional asphalt the least. The comparison of peak impact force values across surfaces for the group of subjects demonstrated no significant differences in magnitude of force. However, a significant reduction in loading rate of peak impact force was detected for the rubber-modified surface compared with conventional asphalt (P < 0.1). Although analysis of group data revealed no significant differences in kinematic variables when running on the different surfaces, a varied response to surface manipulation among runners was demonstrated, with marked differences in initial joint angles, peak joint angles, and peak joint angular velocities being observed. DISCUSSION: For some subjects, the maintenance of similar peak impact forces for different running surfaces was explained by observed kinematic adjustments. For example, when running on the surface providing the least impact absorption, an increased initial knee flexion was observed for some subjects, suggesting an increased lower extremity compliance. However, for some subjects, sagittal plane kinematic data were not sufficient for the explanation of peak impact force results. It appears that the mechanism of adaptation varies among runners, highlighting the requirement of individual subject analyses.
Biomechanical Phenomena↗
Five facts and five concepts for rehabilitation of mechanical low back pain.
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Humans↗
Biomechanical analysis of the effect of orthotic shoe inserts: a review of the literature.
Physical activity is increasingly recognised as an important component of primary disease prevention. Overuse injuries are common sequelae of exercise and sporting activities in general, and of running in particular, frequently resulting in cessation of activity. It has been proposed that there is a link between foot shape, foot function and the occurrence of injury. As a means of treatment and prevention of further injury, orthoses and shoe inserts are widely prescribed in the belief that they can alter the pattern of lower extremity joints' alignment and movement. Although this is an assumption widely made in the treatment of many joint conditions, the manner through which this treatment could be effective is not clear. This article aims to examine the literature to gain an improved understanding of the present state of knowledge regarding the effect of foot shape and orthotic use on foot kinematic and plantar pressure characteristics. The effects of foot type on the occurrence of lower limb injury during sporting activities and different aspects of biomechanics are reviewed, and the effects of applying orthoses on injury treatment and prevention and on various aspects of biomechanics of the lower limb joints are discussed. Further research is required, firstly to establish the casual effect of foot type and function on the risk of lower extremity overuse injury, and secondly to document the specific effect of orthotic therapy on injury treatment and prevention. Specifically, more prospective studies are necessary to investigate the long term effect of orthotic intervention.
Biomechanical Phenomena↗
Artificial playing surfaces research: a review of medical, engineering and biomechanical aspects.
In this paper, current knowledge of artificial playing surfaces is reviewed. Research status in the fields of sports medicine, engineering and biomechanics is described. A multidisciplinary approach to the study of artificial sports surface properties is recommended. The development of modelling techniques to characterise fundamental material properties is described as the most appropriate method for the unique specification of material properties such as stiffness and damping characteristics. It is suggested that the systematic manipulation of fundamental surface material properties in biomechanics research will allow the identification of subject responses to clearly defined surface variation. It is suggested that subjects should be grouped according to characteristic behaviour on specific sports surfaces. It is speculated that future biomechanics research will identify subject criterion related to differing group responses. The literature evidence of interactions between sports shoes and sports surfaces leads to the suggestion that sports shoe and sports surface companies should work together in the development of ideal shoe - surface combinations for particular groups of subjects.
Athletic Injuries↗
A prospective controlled study of diagnostic imaging for acute shin splints.
OBJECTIVE: The purpose of this prospective, observational study was to examine the relationship of clinical examination, plain radiograph (XR), triple-phase bone scan (TPBS), and magnetic resonance imaging (MRI) in the investigation of patients presenting with acute shin splints. METHODS: 23 subjects with exercise induced lower leg pain and diffuse tibial tenderness of less than 3 months' duration were recruited. Subjects were excluded if there was clinical evidence of compartment syndrome, muscle hernia, or stress fracture. Each subject underwent XR, TPBS, and MRI within 2 wk of physical examination. Four asymptomatic controls underwent TPBS and MRI. Clinical findings, XR, TPBS, and MRI findings were independently recorded using a consistent template and subsequently analyzed. A single consensus lesion was chosen that provided the greatest overlap and highest grade to allow comparison of clinical and imaging findings. Sensitivity and specificity were calculated from data relating to clinical findings and diagnostic imaging. RESULTS: Eighteen subjects had bilateral symptoms and five unilateral with a mean duration of symptom of 5.4 wk (+/- 3.5). Of 41 symptomatic lower legs, there were TPBS abnormalities in 36 and MRI findings in 34. Analysis of clinical findings to TPBS and MRI demonstrated a sensitivity and specificity of 84%, 33% and 79%, 33%, respectively. Assuming TPBS as the "gold-standard," MRI findings demonstrated a sensitivity of 95% and specificity of 67%. There was poor agreement between the grading of TPBS and MRI (k = 0.3). In the 5/46 asymptomatic limbs, 3/5 demonstrated uptake on bone scan and 4/5 signal change with MRI. Imaging abnormalities were similarly seen in the four control patients. CONCLUSIONS: MRI may be used rather than TPBS and radiographs for evaluating acute tibial pain in athletes where avoidance of radiation exposure is desirable. Similar sensitivity and specificity may be expected from both investigations; however, in the light of abnormal TPBS and MRI findings in control and asymptomatic limbs, we recommend further studies be performed to define the extent of nonpathological TPBS and MRI changes.
Acute Disease↗
Effects of seasonal change in rugby league on the incidence of injury.
OBJECTIVES: To assess the effects that the recent seasonal change in rugby league from winter to summer has had on the incidence of injury. METHODS: All injuries that occurred during games and training were recorded throughout four consecutive seasons (three winter, one summer) for the first team squad of a British professional rugby league club. Data included nature of injury, days lost as the result of injury, player position, month, and season. RESULTS: An increasing incidence of injury over the four seasons was observed, with the summer seasons having an incidence almost double that of the first winter season recorded (696.8 per 1000 hours and 363.55 per 1000 hours respectively). The severity of injury was shown to decline over the four seasons. Most injuries were incurred in matches (74.9%) rather than during training (25.1%). CONCLUSIONS: The findings show an increasing incidence of injury in summer rugby but with decreased severity. It is not known if this is the result of playing back to back rugby seasons or is a consequence of a change in playing season and ground conditions.
Adult↗
The coming of age of sports medicine.
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Accreditation↗
Traumatic occlusion of the external iliac artery in a racing cyclist: a cause of ill defined leg pain.
Stenosis of the external iliac artery in healthy athletes, although uncommon, has been reported in competition cyclists. A case of a racing cyclist whose chronic vague leg symptoms were incorrectly attributed to L4/5 nerve root irritation is reported. This highlights the importance of clinical vascular testing when assessing ill defined leg pain. The role of trauma as a causative factor in this condition has not been previously documented.
Adult↗
Stress fracture of the proximal humeral epiphysis in an elite junior badminton player.
An elite junior badminton player presented with a chronic painful dominant shoulder after an intense training course. An acute stress fracture to the proximal humeral epiphysis was found. Two-plane radiography will identify abnormalities of the growth plate but comparative films of the unaffected side may also be required to differentiate subtle changes. Rest with subsequent rehabilitation is the appropriate management of these injuries although ideally they should be subjected to primary prevention.
Adolescent↗