Mark E. Batt

Chondrocyte and mesenchymal stem cell-based therapies for cartilage repair in osteoarthritis and related orthopaedic conditions

Osteoarthritis (OA) represents a final and common pathway for all major traumatic insults to synovial joints. OA is the most common form of degenerative joint disease and a major cause of pain and disability. Despite the global increase in the incidence of OA, there are no effective pharmacotherapies capable of restoring the original structure and function of damaged articular cartilage. Consequently cell-based and biological therapies for osteoarthritis (OA) and related orthopaedic disorders have become thriving areas of research and development. Autologous chondrocyte implantation (ACI) has been used for treatment of osteoarticular lesions for over two decades. Although chondrocyte-based therapy has the capacity to slow down the progression of OA and delay partial or total joint replacement surgery, currently used procedures are associated with the risk of serious adverse events. Complications of ACI include hypertrophy, disturbed fusion, delamination, and graft failure. Therefore there is significant interest in improving the success rate of ACI by improving surgical techniques and preserving the phenotype of the primary chondrocytes used in the procedure. Future tissue-engineering approaches for cartilage repair will also benefit from advances in chondrocyte-based repair strategies. This review article focuses on the structure and function of articular cartilage and the pathogenesis of OA in the context of the rising global burden of musculoskeletal disease. We explore the challenges associated with cartilage repair and regeneration using cell-based therapies that use chondrocytes and mesenchymal stem cells (MSCs). This paper also explores common misconceptions associated with cell-based therapy and highlights a few areas for future investigation.

Plantar fasciitis: a prospective randomized clinical trial of the tension night splint.

OBJECTIVE The objective of this study was to evaluate the efficacy of a tension night splint (TNS) as part of a treatment regimen for the management of plantar fasciitis. DESIGN The design was a randomized clinical trial. SETTING The setting was a university-based primary care sports medicine clinic in California. PATIENTS Forty patients with plantar fasciitis entered the study (age range, 20-74 years; average age, 45.7 years). Excluded from the study were patients with other concomitant ankle or foot pathology. Thirty-two patients (21 women, 11 men) completed the study with 33 treated feet. INTERVENTION The patients were randomized to one of two treatment groups. The control group (n = 17) received standard treatment of antiinflammatory medication (Ibuprofen), a Viscoheel sofspot heel cushion (Bauerfeind USA, Kennesaw, GA, U.S.A.) and a stretching program for the gastrocnemius and soleus muscles. The tension night split group (n = 16) received the same standard treatment protocol and additionally an office manufactured custom fitted posterior splint to be used at night. Those patients in the control group not responding to treatment after 8-12 weeks were crossed over to the tension night splint group. Patients were reviewed every 4 weeks for symptom assessment and compliance. MAIN OUTCOME MEASURES The main outcome measures were subjective assessment of pain (Visual analogue scale), plantar fascial tenderness, and ankle range of motion. Patients were discharged from either arm of the trial when they had resumed normal activities with minimal or no discomfort. This end point was recorded as weeks to cure. MAIN RESULTS There was no significant difference in the demographics of the two groups (p > 0.05). In the control group, 6 of 17 were cured after an average interval of 8.8 weeks. The remaining 11 of 17 control group patients were crossed over to receive a TNS in addition to control modalities. Following cross over 8 of 11 of this group were cured after an average of 13 weeks. Three of the 11 failed to significantly respond. Of the 15 patients (16 feet) originally randomly assigned to the TNS group 16 of 16 were cured with an average treatment time of 12.5 weeks. The TNS treatment protocol was a significantly more efficacious treatment regime (p < 0.05). Thus, of 33 cases of plantar fasciitis treated in this study three failed treatment. CONCLUSION When used in combination with a visco-elastic heel pad, stretching program and nonsteroidal anti-inflammatory drugs, the TNS is an effective treatment of plantar fasciitis.

Consensus statement on epidemiological studies of medical conditions in tennis, April 2009

Background: The reported incidence, severity and nature of injuries sustained in tennis vary considerably between studies. While some of these variations can be explained by differences in sample populations and conditions, the main reasons are related to differences in definitions and methodologies employed in the studies. Objective: This statement aims to review existing consensus statements for injury surveillance in other sports in order to establish definitions, methods and reporting procedures that are applicable to the specific requirements of tennis. Design: The International Tennis Federation facilitated a meeting of 11 experts from seven countries representing a range of tennis stakeholders. Using a mixed methods consensus approach, key issues related to definitions, methodology and implementation were discussed and voted on by the group during a structured 1-day meeting. Following this meeting, two members of the group collaborated to produce a draft statement, based on the group discussions and voting outcomes. Three revisions were prepared and circulated for comment before the final consensus statement was produced. Results: A definition of medical conditions (injuries and illnesses) that should be recorded in tennis epidemiological studies and criteria for recording the severity and nature of these conditions are proposed. Suggestions are made for recording players’ baseline information together with recommendations on how medical conditions sustained during match play and training should be reported. Conclusions: The definitions and methodology proposed for recording injuries and illnesses sustained during tennis activities will lead to more consistent and comparable data being collected. The surveillance procedures presented here may also be applicable to other racket sports.

Biomechanical analysis of the effect of orthotic shoe inserts: a review of the literature.

AbstractPhysical 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.

Common hip injuries in sport

SummaryAs a major weight-bearing joint, normal hip function is fundamental to successful sporting participation. Not only is it important in running-, jumping- and kicking-based activities, it also contributes to the generation and transference of forces in upper limb-dominated activities. Injuries to the hip do not account for a large proportion of the sports physician’s workload, but may result in significant morbidity. The wide variety of acute, subacute and chronic injuries, affecting both the joint and surrounding soft tissues, can prove a diagnostic dilemma. The predisposition and the types of injuries around the hip vary with the age of the athlete. The young child rarely sustains a significant injury but one should be aware of orthopaedic conditions common in this age group that may manifest themselves through exercise. The immature skeleton of the adolescent is relatively injury prone and the demands of sport often exceed the capacity of the growing musculoskeletal system. In adults and older athletes, a further spectrum of injury exists, along with the effects of aging tissues and the concerns of degenerative joint disease. Rational treatment is based on a clear diagnosis developed through sound knowledge and a thorough history and examination. For the sports physician, treatments are typically early physical therapy and structured, progressive rehabilitation programmes which are individualised to the needs of the athlete. The spectrum of hip injuries is reviewed with current recommended diagnoses and management.

Musculoskeletal problems of the chest wall in athletes.

AbstractChest pain in the athlete has a wide differential diagnosis. Pain may originate from structures within the thorax, such as the heart, lungs or oesophagus. However, musculoskeletal causes of chest pain must be considered. The aim of this review is to help the clinician to diagnose chest wall pain in athletes by identifying the possible causes, as reported in the literature. Musculoskeletal problems of the chest wall can occur in the ribs, sternum, articulations or myofascial structures. The cause is usually evident in the case of direct trauma. Additionally, athletes’ bodies may be subjected to sudden large indirect forces or overuse, and stress fractures of the ribs caused by sporting activity have been extensively reported. These have been associated with golf, rowing and baseball pitching in particular. Stress fractures of the sternum reported in wrestlers cause pain and tenderness of the sternum, as expected. Diagnosis is by bone scan and limitation of activity usually allows healing to occur. The slipping rib syndrome causes intermittent costal margin pain related to posture or movement, and may be diagnosed by the ’hooking manoeuvre’, which reproduces pain and sometimes a click. If reassurance and postural advice fail, good results are possible with resection of the mobile rib. The painful xiphoid syndrome is a rare condition that causes pain and tenderness of the xiphoid and is self-limiting. Costochondritis is a self-limiting condition of unknown aetiology that typically presents with pain around the second to fifth costochondral joints. It can be differentiated from Tietze’s syndrome in which there is swelling and pain of the articulation. Both conditions eventually settle spontaneously although a corticosteroid injection may be useful in particularly troublesome cases. The intercostal muscles may be injured causing tenderness between the ribs. Other conditions that should be considered include epidemic myalgia, precordial catch syndrome and referred pain from the thoracic spine.

Osteitis pubis in collegiate football players.

Osteitis pubis in athletes is an inflammatory condition of the pubic symphysis and surrounding muscular insertions. It is of uncertain etiology, however, and is seen particularly in those sports requiring sprinting and sudden changes of direction. There is a paucity of literature of this condition occurring in players of American football. This report presents two such cases and details proposed etiology and a specific management protocol.

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.

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.

Golfing injuries : an overview

SummaryGolf is becoming an increasingly available and popular sport. It is played by people of all ages and abilities, which accounts for a wide spectrum of injury. Few reports of injuries exist, but increasing media attention of the golfing injuries of professional players has raised the profile of these medical conditions.Numerically, the vast majority of problems occur from soft tissue musculoskeletal injuries rising principally from overuse. The injury pattern seen is influenced by the age, ability and amount of play. Anatomically, most injuries are localised to the back, wrist, elbow and shoulder. In addition to causing new injuries the game may cause recrudescence of old injuries and exacerbate pre-existing degenerative disease. A different injury pattern is seen among elite players compared with recreational players, and this relates to skill and amount of practice. Appropriate conditioning and attention to technique may help to reduce the incidence of injury.There are no injuries exclusive to golf, however fracture of the hamate bone is an uncommon injury seen in sports involving the use of a club or bat. The high number of childhood golf-related head injuries is disturbing. Most of these arise from blows to the head from a golf club and highlight the need for early tuition in the safety aspects of the game.Golf is becoming an increasingly available and popular sport. It is played by people of all ages and abilities, which accounts for a wide spectrum of injury. Few reports of injuries exist, but increasing media attention of the golfing injuries of professional players has raised the profile of these medical conditions. Numerically, the vast majority of problems occur from soft tissue musculoskeletal injuries rising principally from overuse. The injury pattern seen is influenced by the age, ability and amount of play. Anatomically, most injuries are localised to the back, wrist, elbow and shoulder. In addition to causing new injuries the game may cause recrudescence of old injuries and exacerbate pre-existing degenerative disease. A different injury pattern is seen among elite players compared with recreational players, and this relates to skill and amount of practice. Appropriate conditioning and attention to technique may help to reduce the incidence of injury. There are no injuries exclusive to golf, however fracture of the hamate bone is an uncommon injury seen in sports involving the use of a club or bat. The high number of childhood golf-related head injuries is disturbing. Most of these arise from blows to the head from a golf club and highlight the need for early tuition in the safety aspects of the game.