Gordon O. Matheson

Stress fractures in athletes: A study of 320 cases

We analyzed cases of 320 athletes with bone scan- positive stress fractures (M = 145, F = 175) seen over 3.5 years and assessed the results of conservative management. The most common bone injured was the tibia (49.1 %), followed by the tarsals (25.3%), metatar sals (8.8%), femur (7.2%), fibula (6.6%), pelvis (1.6%), sesamoids (0.9%), and spine (0.6%). Stress fractures were bilateral in 16.6% of cases. A significant age difference among the sites was found, with femoral and tarsal stress fractures occurring in the oldest, and fibular and tibial stress fractures in the youngest. Run ning was the most common sport at the time of injury but there was no significant difference in weekly running mileage and affected sites. A history of trauma was significantly more common in the tarsal bones. The average time to diagnosis was 13.4 weeks (range, 1 to 78) and the average time to recovery was 12.8 weeks (range, 2 to 96). Tarsal stress fractures took the longest time to diagnose and recover. Varus alignment was found frequently, but there was no significant difference among the fracture sites, and varus alignment did not affect time to diagnosis or recovery. Radiographs were taken in 43.4% of cases at the time of presentation but were abnormal in only 9.8%. A group of bone scan- positive stress fractures of the tibia, fibula, and meta tarsals (N = 206) was compared to a group of clinically diagnosed stress fractures of the same bone groups (N = 180), and no significant differences were found. Patterns of stress fractures in athletes are different from those found in military recruits. Using bone scan for diagnosis indicates that tarsal stress fractures are much more common than previously realized. Time to diagnosis and recovery is site-dependent. Technetium99 bone scan is the single most useful diagnostic aid. Conservative treatment of stress fractures in athletes is satisfactory in the majority of cases.

Risk Factors for Stress Fractures

Preventing stress fractures requires knowledge of the risk factors that predispose to this injury. The aetiology of stress fractures is multifactorial, but methodological limitations and expediency often lead to research study designs that evaluate individual risk factors. Intrinsic risk factors include mechanical factors such as bone density, skeletal alignment and body size and composition, physiological factors such as bone turnover rate, flexibility, and muscular strength and endurance, as well as hormonal and nutritional factors. Extrinsic risk factors include mechanical factors such as surface, footwear and external loading as well as physical training parameters. Psychological traits may also play a role in increasing stress fracture risk. Equally important to these types of analyses of individual risk factors is the integration of information to produce a composite picture of risk.The purpose of this paper is to critically appraise the existing literature by evaluating study design and quality, in order to provide a current synopsis of the known scientific information related to stress fracture risk factors. The literature is not fully complete with well conducted studies on this topic, but a great deal of information has accumulated over the past 20 years. Although stress fractures result from repeated loading, the exact contribution of training factors (volume, intensity, surface) has not been clearly established. From what we do know, menstrual disturbances, caloric restriction, lower bone density, muscle weakness and leg length differences are risk factors for stress fracture.Other time-honoured risk factors such as lower extremity alignment have not been shown to be causative even though anecdotal evidence indicates they are likely to play an important role in stress fracture pathogenesis.

Achilles tendonitis: are corticosteroid injections useful or harmful?

ObjectiveThe use of local corticosteroid injections for the treatment of Achilles tendonitis is controversial. Some authors advocate their use based on efficacy in accelerating the healing process of Achilles tendonitis; others feel the associated side effects should preclude their use altogether. The purpose of this study was to comprehensively review and critically appraise the available literature in order to examine the evidence concerning this clinical dilemma. Data sourcesMEDLINE was searched using MeSH and textwords for English- and French-language articles related to Achilles tendonitis and corticosteroids published since 1966. Additional references were reviewed from the bibliographies of the retrieved articles. The total number of articles reviewed was 145. Study selectionAll clinical study designs were included as well as related animal studies using experimental and quasi-experimental designs. Data extraction and synthesisIn reviewing the literature, particular attention was paid to the relative strengths of the different study designs. From these data, the factors associated with effectiveness and safety of injected corticosteroids were examined. Main resultsThe only rigorous studies (one randomized controlled trial, one cohort study) showed no benefit of corticosteroids over placebo. In animal studies, corticosteroid injections decrease adhesion formation, temporarily weaken the tendon if given intratendinously, but have no effect on tendon strength if injected into the paratenon. The overall incidence of side effects with locally injected corticosteroids is ∼1%. Most side effects are temporary, but skin atrophy and depigmentation can be permanent. Although there are many case reports of Achilles tendon rupture following local corticosteroid injection, there are no published rigorous studies that evaluate the risk of rupture with or without corticosteroid injection. ConclusionsThere are insufficient published data to determine the comparative risks and benefits of corticosteroid injections in Achilles tendonitis. The decreased tendon strength with intratendinous injections in animal studies suggests that rupture may be a potential complication for several weeks following injection.

Stress fractures in athletes.

A stress fracture is a partial or complete bone fracture that results from repeated application of stress lower than the stress required to fracture the bone in a single loading. Otherwise healthy athletes, especially runners, sustain stress injuries or fractures. Prevention or early intervention is the preferable treatment. However, it is difficult to predict injury because runners vary with regard to biomechanical predisposition, training methods, and other factors such as diet, muscle strength, and flexibility. Stress fractures account for 0.7% to 20% of all sports medicine clinic injuries. Track-and-field athletes have the highest incidence of stress fractures compared with other athletes. Stress fractures of the tibia, metatarsals, and fibula are the most frequently reported sites. The sites of stress fractures vary from sport to sport (eg, among track athletes, stress fractures of the navicular, tibia, and metatarsal are common; in distance runners, it is the tibia and fibula; in dancers, the metatarsals). In the military, the calcaneus and metatarsals were the most commonly cited injuries, especially in new recruits, owing to the sudden increase in running and marching without adequate preparation. However, newer studies from the military show the incidence and distribution of stress fractures to be similar to those found in sports clinics. Fractures of the upper extremities are relatively rare, although most studies have focused only on lower-extremity injuries. The ulna is the upper-extremity bone injured most frequently. Imaging plays a key role in the diagnosis and management of stress injuries. Plain radiography is useful when positive, but generally has low sensitivity. Radionuclide bone scanning is highly sensitive, but lacks specificity and the ability to directly visualize fracture lines. In this article, we focus on magnetic resonance imaging, which provides highly sensitive and specific evaluation for bone marrow edema, periosteal reaction as well as detection of subtle fracture lines.

Return-to-play in sport: a decision-based model.

Objective: Return-to-play (RTP) decisions are fundamental to the practice of sports medicine but vary greatly for the same medical condition and circumstance. Although there are published articles that identify individual components that go into these decisions, there exists neither quantitative criteria nor a model for the sequence or weighting of these components within the medical decision-making process. Our objective was to develop a decision-based model for clinical use by sports medicine practitioners. Data Sources: English literature related to RTP decision making. Main Results: We developed a 3-step decision-based RTP model for an injury or illness that is specific to the individual practitioner making the RTP decision: health status, participation risk, and decision modification. In Step 1, the Health Status of the athlete is assessed through the evaluation of Medical Factors related to how much healing has occurred. In Step 2, the clinician evaluates the Participation Risk associated with participation, which is informed by not only the current health status but also by the Sport Risk Modifiers (eg, ability to protect the injury with padding, athlete position). Different individuals are expected to have different thresholds for “acceptable level of risk,” and these thresholds will change based on context. In Step 3, Decision Modifiers are considered and the decision to RTP or not is made. Conclusions: Our model helps clarify the processes that clinicians use consciously and subconsciously when making RTP decisions. Providing such a structure should decrease controversy, assist physicians, and identify important gaps in practice areas where research evidence is lacking.

IOC consensus paper on the use of platelet-rich plasma in sports medicine

PRP and its variant forms were originally used in clinical practice as an adjunct to surgery to assist in the healing of various tissues. PRP has also been used in prosthetic surgery to promote tissue healing and implant integration, and to control blood loss. 4 5 Furthermore, the application of activated PRP has an effect on pain and pain medication use following open subacromial decompression surgery. 5

2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhoea and osteoporosis. This consensus statement represents a set of recommendations developed following the 1st (San Francisco, California, USA) and 2nd (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team and implementation of treatment contracts. This consensus paper has been endorsed by the Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians and other healthcare professionals, the American College of Sports Medicine and the American Medical Society for Sports Medicine.

2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad.

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: 1) low energy availability with or without disordered eating, 2) menstrual dysfunction, and 3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.

Preparticipation evaluation : an evidence-based review

Objective:To review available evidence establishing the validity of the preparticipation evaluation (PPE) as a method for screening health risk prior to participation in exercise and sport. Specific emphasis was placed on reviewing original research evaluating methods to screen participants for risk of sudden cardiovascular death. Literature on the current state of the PPE as a screening tool for athletic participation was examined. Data Sources:Electronic databases were searched for articles relating to mass screening for sports participation and sudden cardiac death in athletes published up to January 2004. Databases searched included Medline (OVID Web, 1966–2004), PubMed (1966–2004), Sport Discuss (1975–2004), Current Contents, CISTI Source (1993–2004), Cochrane Database of Systematic Reviews, and EBM Reviews. Additional references from the bibliographies of retrieved articles were also reviewed. Selection Criteria:All study designs were retrieved, but only those studying athletes and/or student-athletes under age 36 years were reviewed. Of the original research retrieved, the majority of the articles sought to establish incidence or prevalence of cardiovascular causes of sudden death in athletes or the validity of various screening tools. Original research articles seeking to establish the current use of the PPE in all its various forms were also reviewed. All of the articles selected for review consisted of type II, population-based data. Data Extraction and Synthesis:The initial literature search identified 639 papers. Of these, 310 articles that met the selection criteria were reviewed, and 25 articles were identified as original research directly relating to the PPE. All of these contained type II evidence—population-based clinical studies. The majority of the literature on the PPE consists of type III evidence—case-based opinion papers and position papers from respected authors and sports medicine societies and reports of expert committees. This literature was also reviewed, but only original research relevant to the PPE is reported in this article. The majority of these studies examined cardiovascular diseases and screening procedures. Results:The 5 studies that assessed the format or effectiveness of the PPE concluded that it was inadequate. The format of the PPE is not standardized and does not consistently address the American Heart Association recommendations for cardiovascular screening history and physical exams. A variety of health care professionals, some without proper training, administer the PPE. The 12 original studies that looked at specific cardiovascular screening techniques were divided on the effectiveness of history, physical examination, electrocardiogram, and echocardiography for detecting cardiovascular risks for sudden death in athletes. Conclusions:A PPE is required by most sport organizations in America, but research as to its effectiveness is very limited. PPEs have been mandatory in Italy for many years, and we can draw on some the data recorded over this time. Otherwise, very few studies in America or elsewhere have been performed on the PPE process. The research available indicates that the PPE is not implemented adequately or uniformly. An opportunity exists to create a standardized, validated PPE that meets medical standards for quality and provides sensitive, specific screening of potential participants in sport and exercise.

The prevention of sport injury: an analysis of 12,000 published manuscripts.

Objective:To identify the nature and extent of research in sport injury prevention with respect to 3 main categories: (1) training, (2) equipment, and (3) rules and regulations. Data Sources:We searched PubMed, CINAHL, Web of Science, Embase, and SPORTDiscus to retrieve all sports injury prevention publications. Articles were categorized according to the translating research into injury prevention practice model. Results:We retrieved 11 859 articles published since 1938. Fifty-six percent (n = 6641) of publications were nonresearch (review articles and editorials). Publications documenting incidence (n = 1354) and etiology (n = 2558) were the most common original research articles (33% of total). Articles reporting preventive measures (n = 708) and efficacy (n = 460) were less common (10% of the total), and those investigating implementation (n = 162) and effectiveness (n = 32) were rare (1% of total). Six hundred seventy-seven studies focused on equipment and devices to protect against injury, whereas 551 investigated various forms of physical training related to injury prevention. Surprisingly, publications studying changes in rules and regulations aimed at increasing safety and reducing injuries were rare (<1%; n = 63) with a peak of only 20 articles over the most recent 5-year period and an average of 10 articles over the preceding 5-year blocks of time. Conclusions:Only 492 of 11 859 publications actually assessed the effectiveness of sports injury prevention interventions or their implementation. Research in the area of regulatory change is underrepresented and might represent one of the greatest opportunities to prevent injury.