Michael B. Ryan

A retrospective case-control analysis of 2002 running injuries

Objective: To provide an extensive and up to date database for specific running related injuries, across the sexes, as seen at a primary care sports medicine facility, and to assess the relative risk for individual injuries based on investigation of selected risk factors. Methods: Patient data were recorded by doctors at the Allan McGavin Sports Medicine Centre over a two year period. They included assessment of anthropometric, training, and biomechanical information. A model was constructed (with odds ratios and their 95% confidence intervals) of possible contributing factors using a dependent variable of runners with a specific injury and comparing them with a control group of runners who experienced a different injury. Variables included in the model were: height, weight, body mass index, age, activity history, weekly activity, history of injury, and calibre of runner. Results: Most of the study group were women (54%). Some injuries occurred with a significantly higher frequency in one sex. Being less than 34 years old was reported as a risk factor across the sexes for patellofemoral pain syndrome, and in men for iliotibial band friction syndrome, patellar tendinopathy, and tibial stress syndrome. Being active for less than 8.5 years was positively associated with injury in both sexes for tibial stress syndrome; and women with a body mass index less than 21 kg/m2 were at a significantly higher risk for tibial stress fractures and spinal injuries. Patellofemoral pain syndrome was the most common injury, followed by iliotibial band friction syndrome, plantar fasciitis, meniscal injuries of the knee, and tibial stress syndrome. Conclusions: Although various risk factors were shown to be positively associated with a risk for, or protection from, specific injuries, future research should include a non-injured control group and a more precise measure of weekly running distance and running experience to validate these results.

A prospective study of running injuries: the Vancouver Sun Run “In Training” clinics

Objectives: Seventeen running training clinics were investigated to determine the number of injuries that occur in a running programme designed to minimise the injury rate for athletes training for a 10 km race. The relative contributions of factors associated with injury were also reported. Methods: A total of 844 primarily recreational runners were surveyed in three trials on the 4th, 8th, and 12th week of the 13 week programme of the “In Training” running clinics. Participants were classified as injured if they experienced at least a grade 1 injury—that is, pain only after running. Logistic regression modelling and odds ratio calculation were performed for each sex using the following predictor variables: age, body mass index (BMI), previous aerobic activity, running frequency, predominant running surface, arch height, running shoe age, and concurrent cross training. Results: Age played an important part in injury in women: being over 50 years old was a risk factor for overall injury, and being less than 31 years was protective against new injury. Running only one day a week showed a non-significant trend for injury risk in men and was a significant risk factor in women and overall injury. A BMI of > 26 kg/m2 was reported as protective for men. Running shoe age also significantly contributed to the injury model. Half of the participants who reported an injury had had a previous injury; 42% of these reported that they were not completely rehabilitated on starting the 13 week training programme. An injury rate of 29.5% was recorded across all training clinics surveyed. The knee was the most commonly injured site. Conclusions: Although age, BMI, running frequency (days a week), and running shoe age were associated with injury, these results do not take into account an adequate measure of exposure time to injury, running experience, or previous injury and should thus be viewed accordingly. In addition, the reason for the discrepancy in injury rate between these 17 clinics requires further study.

A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma

Objective: To appraise existing evidence for prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injection therapies for lateral epicondylosis (LE). Design: Systematic review. Data sources: Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine. Search strategy: names and descriptors of the therapies and LE. Study Selection: All human studies assessing the four therapies for LE. Main results: Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. In follow-up periods ranging from 9 to 108 weeks, studies reported sustained, statistically significant (p<0.05) improvement in visual analogue scale primary outcome pain score measures and disease-specific questionnaires; relative effect sizes ranged from 51% to 94%; Cohen’s d ranged from 0.68 to 6.68. Secondary outcomes also improved, including biomechanical elbow function assessment (polidocanol and prolotherapy), presence of abnormalities and increased vascularity on ultrasound (autologous whole blood and polidocanol). Subjects reported satisfaction with therapies on single-item assessments. All studies were limited by small sample size. Conclusions: There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.

Sonographically Guided Intratendinous Injection of Hyperosmolar Dextrose to Treat Chronic Tendinosis of the Achilles Tendon: A Pilot Study

OBJECTIVE Chronic tendinosis of the Achilles tendon is a common overuse injury that is difficult to manage. We report on a new injection treatment for this condition. SUBJECTS AND METHODS Thirty-six consecutive patients (25 men, 11 women; mean age, 52.6 years) with symptoms for more than 3 months (mean, 28.6 months) underwent sonography-guided intratendinous injection of 25% hyperosmolar dextrose every 6 weeks until symptoms resolved or no improvement was shown. At baseline and before each injection, clinical assessment was performed using a visual analogue scale (VAS) for pain at rest (VAS1), pain during normal daily activity (VAS2), and pain during or after sporting or other physical activity (VAS3). Sonographic parameters including tendon thickness, echogenicity, and neovascularity were also recorded. Posttreatment clinical follow-up was performed via telephone interview. RESULTS Thirty-three tendons in 32 patients were successfully treated. The mean number of treatment sessions was 4.0 (range, 2-11). There was a mean percentage reduction for VAS1 of 88.2% (p < 0.0001), for VAS2 of 84.0% (p < 0.0001), and for VAS3 of 78.1% (p < 0.0001). The mean tendon thickness decreased from 11.7 to 11.1 mm (p < 0.007). The number of tendons with anechoic clefts or foci was reduced by 78%. Echogenicity improved in six tendons (18%) but was unchanged in 27 tendons (82%). Neovascularity was unchanged in 11 tendons (33%) but decreased in 18 tendons (55%); no neovascularity was present before or after treatment in the four remaining tendons. Follow-up telephone interviews of the 30 available patients a mean of 12 months after treatment revealed that 20 patients were still asymptomatic, nine patients had only mild symptoms, and one patient had moderate symptoms. CONCLUSION Intratendinous injections of hyperosmolar dextrose yielded a good clinical response--that is, a significant reduction in pain at rest and during tendon-loading activities--in patients with chronic tendinosis of the Achilles tendon.

Sonographically Guided Intratendinous Injections of Hyperosmolar Dextrose/Lidocaine: A Pilot Study for the Treatment of Chronic Plantar Fasciitis

Objective: To report on the effectiveness of sonographically guided injections of hyperosmolar dextrose at reducing the pain associated with chronic plantar fasciitis. Design: Case series. Setting: Ultrasound division of St Paul’s Hospital. Patients: 20 referrals (3 men, 17 women; age 51 (SD 13) years) from local sports medicine primary care practitioners who had failed previous conservative treatments. Interventions: A 27-gauge needle administered a 25% dextrose/lidocaine solution under sonographic guidance at 6 week intervals returning for a median of three consultations. Main outcome measures: Visual analogue scale (VAS) items for pain levels at rest (VAS1), activities of daily living (VAS2), and during or after physical activity (VAS3) were recorded at baseline and at the final treatment consultation (post-test). A telephone interview conducted an average of 11.8 months after the post-test consultation provided a measure of long-term follow-up. Results: 16 patients reported a good to excellent outcome, while the symptoms in 4 patients were unchanged. There was a significant decrease (p<0.001) in all mean VAS items from pre-test to post-test: VAS1 (36.8 (SD 25.6) to 10.3 (10.9)), VAS2 (74.7 (20.8) to 25.0 (27.7)) and VAS3 (91.6 (9.2) to 38.7 (35.1)) and there were no apparent changes after the follow-up interview. Conclusions: Sonographically guided dextrose injections showed a good clinical response in patients with chronic plantar fasciitis insofar as pain was reduced during rest and activity. Further studies including a control group are needed to validate these outcomes.

The effect of three different levels of footwear stability on pain outcomes in women runners: a randomised control trial

Background The present study examines the injury status in women runners who are randomised to receive a neutral, stability or motion control running shoe. Methods 81 female runners were categorised into three different foot posture types (39 neutral, 30 pronated, 12 highly pronated) and randomly assigned a neutral, stability or motion control running shoe. Runners underwent baseline testing to record training history, as well as leg alignment, before commencing a 13-week half marathon training programme. Outcome measures included number of missed training days due to pain and three visual analogue scale (VAS) items for pain during rest, activities of daily living and with running. Results 194 missed training days were reported by 32% of the running population with the stability shoe reporting the fewest missed days (51) and the motion control shoe (79) the most. There was a significant main effect (p<0.001) for footwear condition in both the neutral and pronated foot types: the motion control shoe reporting greater levels of pain in all three VAS items. In neutral feet, the neutral shoe reported greater values of pain while running than the stability shoe; in pronated feet, the stability shoe reported greater values of pain while running than the neutral shoe. No significant effects were reported for the highly pronated foot, although this was limited by an inadequate sample size. Conclusion The findings of this study suggest that our current approach of prescribing in-shoe pronation control systems on the basis of foot type is overly simplistic and potentially injurious.

879 SONOGRAPHICALLY GUIDED INJECTIONS OF DEXTROSE TO TREAT TENDINOSIS AT THE INSERTION AND MID‐PORTION OF THE ACHILLES TENDON

in 1999: the Raffaeli-Righetti Technique. We investigated benefits and limitations of this technique. Methods: 592 patients were submitted to epiduroscopy from 2001 to 2007, the resaflex was used for 128 of these from 2004 to 2007. We used a fogarty balloon, and a new instrument that allowed the lysis of fibrosis without damaging dura and ganglion root, using a radio-frequency device named “R-Resablator”. Results: The Fogarty balloon allowed reducing of 50% the volume of the fluids used in the periduroscopy. The second innovation was the lysis of channel obstructions (fat and/or fibrotic tissues) with the R-Resablator, allowing reaching the site of pain origin and improving the efficiency of the periduroscopy of 30%. Only few complications were observed with this method. Moreover it was possible to study normal and pathological morphologies of the dura with direct imaging. Discussion: Only in a few cases we identified anatomicalpathological image that modified the diagnosis. For this reason, epiduroscopy is not an important diagnostic tool, but offers greater therapeutic benefit than traditional epiduroscopy, and it is more easily performed and repeatable.

Footwear usage and injury patterns in fitness class participants: a prospective pilot study

The differences in location of the helical axis between barefoot and shod conditions indicated a large influence of footwear on the torsion axis of the foot. In the vertical direction the helical axis was lower with shoes while barefoot it lied close to the midfoot area. This indicated that the bare foot rotated about an axis that is dictated by the foot; while wearing shoes the foot was forced into a movement dictated by the shoe. The vertical location of the helical axis for the shod condition was similar to the location of the torsion element that lied in the midfoot area of the shoes. In the medio-lateral direction the axis for the shod condition was more lateral than for barefoot. This again indicated an influence of the shoe on the rotation axis. However, this location did not agree with the location of the torsion element in the shoe. The effect of the shoe on the orientation of the helical axis was smaller than its effect on the location. More subjects would be needed to determine if there were significant differences between the conditions.

545 STRUCTURAL CHANGES, NOT NEOVASCULARISATION, ACCOUNTS FOR THE VARIATION IN PAIN WITH CHRONIC INFRAPATELLAR TENDINOPATHY

Results: The main outcome measures were: handicaps, severe headaches, neck pain, and neck disability. The relative risk for a 1-year disability increased by 3.5 with initial intense neck pain and headaches, by 4.6 times with reduced CROM, and by 4 times with multiple non-painful complaints. Conclusion: Non-recovered patients had early onset cognitive complaints worsening after 1 year. Results confirm that reduced active neck mobility, immediate intense neck pain and headaches and the presence of multiple non-painful-complaints are important prognostic factors for one-year handicap after acute whiplash.