Gustaaf Reurink

Platelet-rich plasma injections in acute muscle injury

In this randomized trial involving athletes with acute hamstring muscle injuries, injection of platelet-rich plasma did not result in shortening of the time until patients could resume their sports activity or in a reduction in reinjury rates, as compared with placebo.

2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern

Deciding when to return to sport after injury is complex and multifactorial—an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups—each group focused on 1 section of the consensus statement. Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athletes return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.

Therapeutic interventions for acute hamstring injuries: a systematic review

Background Despite the high rate of hamstring injuries, there is no consensus on their management, with a large number of different interventions being used. Recently several new injection therapies have been introduced. Objective To systematically review the literature on the effectiveness of therapeutic interventions for acute hamstring injuries. Data sources The databases of PubMed, EMBASE, Web of Science, Cochrane Library, CINAHL and SPORTDiscus were searched in May 2011. Study eligibility criteria Prospective studies comparing the effect of an intervention with another intervention or a control group without intervention in subjects with acute hamstring injuries were included. Data analysis Two authors independently screened the search results and assessed risk of bias. Quality assessment of the included studies was performed using the Physiotherapy Evidence Database score. A best evidence synthesis was used to identify the level of evidence. Main results Six studies were included in this systematic review. There is limited evidence for a positive effect of stretching, agility and trunk stability exercises, intramuscular actovegin injections or slump stretching in the management of acute hamstring injuries. Limited evidence was found that there is no effect of non-steroidal anti-inflammatory drugs or manipulation of the sacroiliac joint. Conclusions There is a lack of high quality studies on the treatment of acute hamstring injuries. Only limited evidence was found to support the use of stretching, agility and trunk stability exercises, intramuscular actovegin injections or slump stretching. Further research is needed using an appropriate control group, randomisation and blinding.

Magnetic Resonance Imaging in Acute Hamstring Injury: Can We Provide a Return to Play Prognosis?

BackgroundSports physicians are increasingly requested to perform magnetic resonance imaging (MRI) of acute hamstring muscle injuries and to provide a prognosis of the time to return to play (RTP) on the basis of their findings.ObjectivesTo systematically review the literature on the prognostic value of MRI findings for time to RTP in acute hamstring muscle injuries.Data SourcesThe databases of PubMed, EMBASE, CINAHL, Web of Science and Cochrane Library were searched in June 2013.Study Eligibility CriteriaStudies evaluating MRI as a prognostic tool for determining time to RTP in athletes with acute hamstring injuries were eligible for inclusion.Data AnalysisTwo authors independently screened the search results and assessed risk of bias using criteria for quality appraisal of prognosis studies. A best-evidence synthesis was used to identify the level of evidence.ResultsOf the 12 studies included, one had a low risk of bias and 11 a high risk of bias. There is moderate evidence that injuries without hyperintensity on fluid-sensitive sequences are associated with a shorter time to RTP and that injuries involving the proximal free tendon are associated with a longer time to RTP. Limited evidence was found for an association of central tendon disruption, injury not affecting the musculotendinous junction and a total rupture with a longer time to RTP. The other MRI findings studied showed either no association or there was conflicting evidence.ConclusionThere is currently no strong evidence for any MRI finding that gives a prognosis on the time to RTP after an acute hamstring injury, owing to considerable risks of bias in the studies on this topic.

Predicting return to play after hamstring injuries

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 associated with TTRTP. For clinical practice, prognosis of the TTRTP in these injuries should better be based on clinical parameters.

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

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 patients could be included in the final analysis because data after RTP were not available in 16 cases. There were 17 re-injuries (27%). None of the baseline MRI findings were univariately associated with re-injury. A higher number of previous hamstring injuries (adjusted OR (AOR) 1.33; 95% CI 1.11 to 1.61), more degrees of active knee extension deficit after RTP (AOR 1.13; 95% CI 1.03 to 1.25), isometric knee flexion force deficit at 15° after RTP (AOR 1.04; 95% CI 1.01 to 1.07) and presence of localised discomfort on hamstring palpation after RTP (AOR 3.95; 95% CI 1.38 to 11.37) were significant independent predictors of re-injury. Athletes with localised discomfort on hamstring palpation just after RTP were consequently almost four times more likely to sustain a re-injury. Conclusions The number of previous hamstring injuries, active knee extension deficit, isometric knee flexion force deficit at 15° and presence of localised discomfort on palpation just after RTP are associated with a higher hamstring re-injury rate. None of the baseline MRI parameters was a predictor of hamstring re-injury. Trial registration number ClinicalTrial.gov number NCT01812564.

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.

Reliability and Validity of Diagnosing Acetabular Labral Lesions with Magnetic Resonance Arthrography

BACKGROUND Arthroscopic surgery of the hip is being increasingly used to diagnose and treat various abnormalities, including acetabular labral tears. Magnetic resonance arthrography has been suggested as the imaging test of choice for the evaluation of the acetabular labrum. There is substantial variability in the previously reported accuracy of magnetic resonance arthrography for diagnosing labral lesions. Interobserver reliability has not been established previously. The purpose of this study was to establish the interobserver reliability and the validity of magnetic resonance arthrography for detecting lesions of the acetabular labrum in a retrospective case series. METHODS Two radiologists independently assessed the acetabular labrum on magnetic resonance arthrograms of ninety-five hips in ninety-three patients who underwent hip arthroscopy for a suspected acetabular labral lesion. Magnetic resonance arthrography findings were compared with the gold standard, which was defined as the assessment of the labrum during the hip arthroscopy. RESULTS At arthroscopy, ninety-one labral lesions were identified in the ninety-five hips. The interobserver reliability of detecting labral lesions with magnetic resonance arthrography was fair (kappa=0.268). Magnetic resonance arthrography, as interpreted by observers A and B, showed a sensitivity of 86% and 86%, specificity of 75% and 50%, negative predictive value of 19% and 13%, and positive predictive value of 99% and 98%, respectively. CONCLUSIONS Because of its limited reliability and the high prevalence of labral lesions, magnetic resonance arthrography provides a limited complementary benefit in the detection of labral lesions in patients with a high clinical suspicion of labral pathology. When there is a high clinical suspicion of a labral lesion, magnetic resonance arthrography has a poor negative predictive value and cannot be used to rule out a labral lesion. Physicians should critically consider whether the findings on a magnetic resonance arthrogram will alter the treatment strategy for an individual patient with a clinical suspicion of labral pathology.

Outcome After Surgical Repair of Proximal Hamstring Avulsions A Systematic Review

Background: At the present time, no systematic review, including a quality assessment, has been published about the outcome after proximal hamstring avulsion repair. Purpose: To determine the outcome after surgical repair of proximal hamstring avulsions, to compare the outcome after acute (≤4 weeks) and delayed repairs (>4 weeks), and to compare the outcome after different surgical techniques. Study Design: Systematic review and best-evidence synthesis. Methods: PubMed, CINAHL, SPORTdiscus, Cochrane library, EMBASE, and Web of Science were searched (up to December 2013) for eligible studies. Two authors screened the search results separately, while quality assessment was performed by 2 authors independently using the Physiotherapy Evidence Database (PEDro) scale. A best-evidence synthesis was subsequently used. Results: Thirteen studies (387 participants) were included in this review. There were no studies with control groups of nonoperatively treated proximal hamstring avulsions. All studies had a low methodological quality. After surgical repair of proximal hamstring avulsion, 76% to 100% returned to sports, 55% to 100% returned to preinjury activity level, and 88% to 100% were satisfied with surgery. Mean hamstring strength varied between reporting studies (78%-101%), and hamstring endurance and flexibility were fully restored compared with the unaffected side. Symptoms of residual pain were reported by 8% to 61%, and reported risk of major complications was low (3% rerupture rate). No to minimal difference in outcome was found between acute and delayed repair in terms of return to sports, patient satisfaction, hamstring strength, and pain. Achilles allograft reconstruction and primary repair with suture anchors led to comparable results. Conclusion: The quality of studies included is low. Surgical repair of proximal hamstring avulsions appears to result in a subjective highly satisfying outcome. However, decreased strength, residual pain, and decreased activity level were reported by a relevant number of patients. Minimal to no differences in outcome of acute and delayed repairs were found. Limited evidence suggests that an Achilles allograft reconstruction yields results comparable with primary repair in delayed cases where primary repair is not possible. High-level studies are required to confirm these findings.

Rationale, secondary outcome scores and 1-year follow-up of a randomised trial of platelet-rich plasma injections in acute hamstring muscle injury: the Dutch Hamstring Injection Therapy study

Background Platelet-rich plasma (PRP) injections are an experimental treatment for acute muscle injuries. We examined whether PRP injections would accelerate return to play after hamstring injury. The methods and the primary outcome measure were published in the New England Journal of Medicine (NEJM) as ‘Platelet-rich plasma injections in acute muscle injury’ (2014). This article shares information not available in the NEJM letter or online supplement, especially the rationale behind the study and the secondary outcome measures including 1 year re-injury data. Methods We performed a multicentre, randomised, double-blind, placebo-controlled trial in 80 competitive and recreational athletes with acute hamstring muscle injuries. Details can be found in the NEJM (http://www.nejm.org/doi/full/10.1056/NEJMc1402340). The primary outcome measure was the time needed to return to play during 6 months of follow-up. Not previously reported secondary outcome scores included re-injury at 1 year, alteration in clinical and MRI parameters, subjective patient satisfaction and the hamstring outcome score. Results In the earlier NEJM publication, we reported that PRP did not accelerate return to play; nor did we find a difference in the 2-month re-injury rate. We report no significant between-group difference in the 1-year re-injury rate (HR=0.89; 95% CI, 0.38 to 2.13; p=0.80) or any other secondary outcome measure. Conclusions At 1-year postinjection, we found no benefit of intramuscular PRP compared with placebo injections in patients with acute hamstring injuries in the time to return to play, re-injury rate and alterations of subjective, clinical or MRI measures.