J. Karlsson

Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload.

The primary purpose of this study was to evaluate whether a preseason strength training programme for the hamstring muscle group – emphasising eccentric overloading – could affect the occurrence and severity of hamstring injuries during the subsequent competition season in elite male soccer players. Thirty players from two of the best premier‐league division teams in Sweden were divided into two groups; one group received additional specific hamstring training, whereas the other did not. The extra training was performed 1–2 times a week for 10 weeks by using a special device aiming at specific eccentric overloading of the hamstrings. Isokinetic hamstring strength and maximal running speed were measured in both groups before and after the training period and all hamstring injuries were registered during the total observational period of 10 months. The results showed that the occurrence of hamstring strain injuries was clearly lower in the training group (3/15) than in the control group (10/15). In addition, there were significant increases in strength and speed in the training group. However, there were no obvious coupling between performance parameters and injury occurrence. These results indicate that addition of specific preseason strength training for the hamstrings – including eccentric overloading – would be beneficial for elite soccer players, both from an injury prevention and from performance enhancement point of view.

Terminology for Achilles tendon related disorders

The terminology of Achilles tendon pathology has become inconsistent and confusing throughout the years. For proper research, assessment and treatment, a uniform and clear terminology is necessary. A new terminology is proposed; the definitions hereof encompass the anatomic location, symptoms, clinical findings and histopathology. It comprises the following definitions: Mid-portion Achilles tendinopathy: a clinical syndrome characterized by a combination of pain, swelling and impaired performance. It includes, but is not limited to, the histopathological diagnosis of tendinosis. Achilles paratendinopathy: an acute or chronic inflammation and/or degeneration of the thin membrane around the Achilles tendon. There are clear distinctions between acute paratendinopathy and chronic paratendinopathy, both in symptoms as in histopathology. Insertional Achilles tendinopathy: located at the insertion of the Achilles tendon onto the calcaneus, bone spurs and calcifications in the tendon proper at the insertion site may exist. Retrocalcaneal bursitis: an inflammation of the bursa in the recess between the anterior inferior side of the Achilles tendon and the posterosuperior aspect of the calcaneus (retrocalcaneal recess). Superficial calcaneal bursitis: inflammation of the bursa located between a calcaneal prominence or the Achilles tendon and the skin. Finally, it is suggested that previous terms as Haglund’s disease; Haglund’s syndrome; Haglund’s deformity; pump bump (calcaneus altus; high prow heels; knobbly heels; cucumber heel), are no longer used.

Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle: CLINICAL AND RADIOLOGICAL FINDINGS AFTER FOLLOW-UP FOR 15 TO 30 YEARS

In this retrospective study, we assessed the outcome in 99 patients who underwent reconstruction of the lateral ligaments of the ankle for chronic anterolateral instability with a minimum follow-up of 15 years. Two techniques were compared: 54 patients had an anatomical reconstruction (AR group) and 45 had an Evans tenodesis (ET group). They were followed up for 19.9+/-3.6 years and 21.8+/-4.6 years, respectively. During follow-up, seven patients in the AR group and 17 in the ET group required a further operation (p = 0.004). At follow-up, significantly more patients (n = 15) in the ET group had limited dorsiflexion than in the AR group (n = 6, p = 0.007) and 18 in the ET group had a positive anterior drawer test compared with seven in the AR group (p = 0002). In the ET group 27 had tenderness on palpation of the ankle compared with 15 in the AR group (p = 0.001). Stress radiographs showed ligamentous laxity significantly more often in the ET group (n = 30) than in the AR group (n = 13, p < 0.001). The mean values for talar tilt and anterior talar translation were significantly higher in the ET group than in the AR group (p < 0.001, p = 0.007, respectively). There were degenerative changes on standard radiographs in 32 patients in the AR group and 35 in the ET group (p = 0.05). Four patients in the ET group had developed severe osteoarthritis compared with none in the AR group (p = 0.025). Assessment of functional stability revealed a mean Karlsson score of 83.7+/-10.4 points in the AR group and 67.0+/-15.8 points in the ET group (p < 0.001). According to the Good rating system, 43 patients in the AR group had good or excellent results compared with 15 in the ET group (p < 0.001). Compared with anatomical reconstruction, the Evans tenodesis does not prevent laxity in a large number of patients. Long-standing ligamentous laxity leads to degenerative change in the ankle, resulting in chronic pain, limited dorsiflexion and further operations. The functional result deteriorates more rapidly after the Evans tenodesis than after anatomical reconstruction.

Anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a 2- to 10-year follow-up, multicenter study.

Abstract The clinical outcome of anatomical reconstruction or tenodesis in the treatment of chronic anterolateral ankle instability was assessed in a retrospective multicenter study. The anatomical reconstruction group (group A) consisted of 106 patients (mean age at operation 24 ± 8.4 years) and the tenodesis group (group B) of 110 patients (mean age at operation 26 ± 11.4 years). Patients were evaluated at a mean follow-up of 5.5 ± 2.8 years in group A and 5.2 ± 2.9 years in group B. The review protocol included patient characteristics, physical examination, two ankle scoring scales to evaluate the functional results, and standard anteroposterior and lateral radiographs to evaluate degenerative changes. Mechanical stability was evaluated using standardized stress radiographs. A larger number of reoperations was performed in group B (P = 0.008). At physical examination, more patients in group B had a smaller range of ankle motion than those in group A (P = 0.009). ¶A larger proportion of patients in group B had medially located osteophytes, as seen on standard radiographs (P = 0.04). On stress radiographic examination, the mean talar tilt (P = 0.001) and mean anterior talar translation (P < 0.001) were seen to be significantly greater in group B than in group A. There were no differences in mean Karlsson score between the groups, but more patients in group A had an excellent result on the Good score (P = 0.011). Unlike anatomical reconstructions, tenodeses do not restore the normal anatomy of the lateral ankle ligaments. This results in restricted range of ankle motion, reduced long-term stability, an increased risk of medially located degenerative changes, a larger number of reoperations, and less satisfactory overall results.

Is a knee brace advantageous after anterior cruciate ligament surgery? A prospective, randomised study with a two-year follow-up.

The aim of this study was to evaluate the use of a knee brace after arthroscopic anterior cruciate ligament reconstruction using central third patellar tendon autografts. Fifty patients were randomly allocated to two groups. The patients in Group A wore a brace for three weeks post‐operatively, while the patients in Group B were rehabilitated without the use of a brace. Pre‐operatively, the groups were comparable in terms of age, sex, activity level, knee laxity and muscle strength. The follow‐up examination was performed by one independent observer. All the patients were followed up for a minimum of two years. At the follow‐up, there were no significant differences between the study groups in terms of the Tegner activity level, Lysholm score, IKDC evaluation system, one‐leg‐hop quotient, KT‐1000 measurements and isokinetic torque. Using the visual analogue scale, the patients in Group A evaluated their pain during the first two post‐operative weeks as 1.0 (0–7), compared with 2.3 (0–9) in Group B (P=0.04). Furthermore, the patients in Group A had a tendency towards fewer problems with swelling, haemathrosis and wound leakage during the early post‐operative period (P=0.08). We conclude that the patients who were rehabilitated with the use of a brace had less pain and a tendency towards fewer complications during the early post‐operative period than the patients who were rehabilitated without the use of a brace. However, there were no differences in terms of function or knee laxity at the two‐year follow‐up.

Prevention of anterior cruciate ligament injuries in sports—Part I: Systematic review of risk factors in male athletes

AbstractPurpose The purpose of this study was to report a comprehensive literature review on the risk factors for anterior cruciate ligament (ACL) injuries in male athletes.Methods All abstracts were read and articles of potential interest were reviewed in detail to determine on inclusion status for systematic review. Information regarding risk factors for ACL injuries in male athletes was extracted from all included studies in systematic fashion and classified as environmental, anatomical, hormonal, neuromuscular, or biomechanical. Data extraction involved general characteristics of the included studies (type of study, characteristics of the sample, type of sport), methodological aspects (for quality assessment), and the principal results for each type of risk factor.ResultsThe principal findings of this systematic review related to the risk factors for ACL injury in male athletes are: (1) most of the evidence is related to environmental and anatomical risk factors; (2) dry weather conditions may increase the risk of non-contact ACL injuries in male athletes; (3) artificial turf may increase the risk of non-contact ACL injuries in male athletes; (4) higher posterior tibial slope of the lateral tibial plateau may increase the risk of non-contact ACL injuries in male athletes.ConclusionAnterior cruciate ligament injury in male athletes likely has a multi-factorial aetiology. There is a lack of evidence regarding neuromuscular and biomechanical risk factors for ACL injury in male athletes. Future research in male populations is warranted to provide adequate prevention strategies aimed to decrease the risk of this serious injury in these populations.Level of evidenceSystematic review on level I–IV studies, Level IV.

Patellofemoral pain syndrome: pain, coping strategies and degree of well-being.

The purpose of this study was to evaluate how patients with patellofemoral pain syndrome (PFPS) experience their pain, what coping strategies they use for the pain, and their degree of well‐being. Fifty patients, 15–52 years old, with PFPS were evaluated with multidimensional pain inventory (MPI), coping strategies questionnaire (CSQ) and Spielberger state trait anxiety inventory (STAI). Reliability of the evaluation methods was established for 12 patients.

Evaluation of the reproducibility of the KT‐1000 arthrometer

The aim of the study was to examine whether the KT‐1000 arthrometer was reliable when it came to distinguishing between a group of patients with a chronic anterior cruciate ligament (ACL) rupture and a group of patients without an ACL rupture, and to examine the reproducibility of the examination between two experienced examiners. The aim was also to examine whether the KT‐1000 measurements were dependent on whether the patients were awake or under anaesthesia. The study comprised 40 patients: Group A consisted of 20 patients who had a chronic unilateral ACL rupture and Group B consisted of 20 patients who were scheduled for arthroscopy due to knee problems other than an ACL rupture. The KT‐1000 examination was performed before surgery by two experienced physiotherapists (PT I and PT II). PT II subsequently performed a retest of the patients under anaesthesia. The mean anterior side‐to‐side laxity difference between PT I and PT II was 0.2 mm in Group A and 1.8 mm in Group B (n.s., P=0.03). The anterior side‐to‐side measurements of knee laxity revealed significant differences between Group A and Group B, independent of who the measurements were made by when the patients were awake (PT I P=0.011, PT II P=0.001). However, no significant difference (P=0.063) was found when the patients were under anaesthesia. The interclass correlation coefficient (ICC) between PT I and PT II in Group A was 0.55 (P=0.005) for the anterior side‐to‐side laxity, while it was 0.60 (P=0.002) in Group B. There were no significant differences within Group A or Group B between the measurements made when people were awake compared with those under anaesthesia. The conclusions of the study were that the KT‐1000 arthrometer was able to distinguish a group of patients with an ACL rupture from a group without one. The reproducibility of the KT‐1000 measurements of anterior knee laxity between two experienced examiners was considered as fair. Furthermore, the measurements were not dependent on whether the patients were awake or under anaesthesia.

Prevention of non-contact anterior cruciate ligament injuries in sports. Part II: systematic review of the effectiveness of prevention programmes in male athletes.

PurposeTo synthesize the results of systematic literature review focused on the effectiveness of anterior cruciate ligament (ACL) injury prevention programmes in male athletes.MethodsAll abstracts and articles of potential interest identified through the systematic literature search were reviewed in detail to determine on inclusion status. Information regarding prevention programmes to reduce ACL injuries or to modify risk factors for ACL injuries in male athletes was systematically extracted and included intervention and study design, characteristics of participants, sport and level of competition, characteristics of prevention programmes, results, and conclusions. All studies were evaluated for methodological quality to assess the risk of bias.ResultsThe principal findings of this systematic review are as follows: (1) most of the studies applied prevention programmes that utilized risk factors as outcomes of interest as opposed to ACL injury incidence (5 and 2 studies, respectively); (2) the effectiveness of prevention programmes to reduce ACL injuries in male athletes is equivocal (1 in favour, 1 against) and only refers to soccer players; (3) the effectiveness of prevention programmes to modify risk factors for ACL injuries in male athletes is controversial (2 in favour, 3 against) and outcome data are limited to cutting manoeuvres.ConclusionData regarding the effectiveness of prevention programmes to reduce ACL injuries or to modify risk factors for ACL injuries in male athletes are scarce and not conclusive. Future research to better determine the most effective approaches to optimize the effectiveness of prevention programmes targeted to reduce ACL injuries in male athletes is warranted.Level of evidenceSystematic review on level I–II evidence studies, Level II.

Predictors of Clinical Outcome After Acute Achilles Tendon Ruptures

Background: In patients with an acute Achilles tendon rupture, it has not been possible to determine the superiority of a single specific treatment modality over other treatments with respect to symptoms and function. When several pertinent treatment protocols are available for an injury, it is of interest to understand how other variables, such as age, sex, or physical activity level, affect outcome to better individualize the treatment. Purpose: To investigate predictors of both symptomatic and functional outcomes after an acute Achilles tendon rupture. Study Design: Cohort study (Prognosis); Level of evidence, 2. Methods: Ninety-three patients (79 men and 14 women; mean age, 40 years) were evaluated prospectively at 3, 6, and 12 months. The main outcome measures in this study were the Achilles tendon Total Rupture Score (ATRS) for symptoms and maximum heel-rise height for function. The independent variables evaluated as possible predictors of outcome included treatment, sex, age, body mass index (BMI), physical activity level, symptoms, and quality of life. Results: Treatment, age, BMI, physical activity level, heel-rise height at 6 months, and the ATRS at 3 months were eligible for further analysis. Only male sex was included for the prediction models. The 4 different multiple linear regression models (predicting the ATRS at 6 and 12 months and heel-rise height at 6 and 12 months) were significant (P < .001-.002), and the R2 values for the models were 0.222 to 0.409. Surgical or nonsurgical treatment is a moderate predictor of symptoms and a weak predictor of heel-rise height after an acute Achilles tendon rupture. At the 6-month follow-up, surgical treatment was associated with a larger heel-rise height, but the opposite was seen at 12 months. Surgical treatment resulted in a lower degree of symptoms. Increasing age was a strong predictor of reduced heel-rise height, and an increase in age of 10 years reduced the expected heel-rise height by approximately 8%. A higher BMI was also a strong predictor of a greater degree of symptoms, and a 5-unit higher BMI predicted a reduction of approximately 10 points in the ATRS. Conclusion: The present study identified important possible predictors of outcome. Despite having a wide range of clinically relevant variables, the models had a limited ability to predict the final individual outcome. In general, the models appear to be better at predicting function than symptoms.