Robert G. McCormack

The effect of knee flexion and quadriceps contraction on the axial view of the patella.

Axial views of the patella are standard in the investigation of anterior knee symptoms, and many investigators use congruence angles and patellar tilt in determining the diagnosis and appropriate treatment. A variety of different methods are used to obtain axial radiographs of the patella, but they are static representations of a dynamic phenomenon. The effect of quadriceps contraction on these indices has not been well defined. The purpose of this study was to compare the 30 degree axial view of the patella with the 45 degree axial view of the patella and to study the effect of quadriceps contraction on the 30 degree axial radiograph of the patella. Forty knees with normal patellofemoral joints and 20 knees with patellar subluxation were radiographed using 30 degree axial views of the patella with the quadriceps relaxed and contracted and with 45 degree axial views with the quadriceps relaxed. There was no significant difference in the sulcus or congruence angles between the 30 and 45 degree axial view in either the control or the patellar subluxation group. Contraction of the quadriceps did not cause a significant or consistent alteration in the congruence angles in either group. With quadriceps contraction, 55% of patients will centralize the patella, whereas 40% will actually increase lateral tracking or subluxation. In conclusion, the 30 degree axial view of the patella is equivalent to the 45 degree axial view in the assessment of patellar subluxation. Quadriceps contraction does not alter the congruence angles obtained in these axial views in a significant or consistent manner.(ABSTRACT TRUNCATED AT 250 WORDS)

CanadianAcademyofSportandExerciseMedicinePosition Statement: Neuromuscular Training Programs Can Decrease Anterior Cruciate Ligament Injuries in Youth Soccer Players

Cathy J. Campbell, BPE, MSc, MD, Dip Sport Med,* James D. Carson, MD, Dip Sport Med,* Elena D. Diaconescu, MD,† Rick Celebrini, PT, PhD,‡ Marc R. Rizzardo, Dip Sports Physio, BScPT, MPE, BPE,‡ Veronique Godbout, MD, Dip Sport Med, MA, MedEd, BSc,§ Jennifer A. Fletcher, MD, Dip Sport Med,¶ Robert McCormack, MD,k Ross Outerbridge, MD, Dip Sport Med,** Taryn Taylor, MSc, MD, Dip Sport Med,†† Naama Constantini, MD, DFM, Dip Sport Med,‡‡ and Manon Cote, MD, Dip Sport Med, BScPT§§

Thoraco-lumbar flexion-distraction injury in a competitive gymnast: a case report.

CASE REPORT A seventeen-year-old female gymnast developed progressive thoraco-lumbar back pain over a five-month period. There was no radiation of the pain and no neurological symptoms. The patient reported that five months prior to the initial assessment she completed a landing during training during which her lumbar spine was forced into forward flexion. With this landing she sustained an un-displaced fracture of her right calcaneous. The patient was able to return to training after several months, though she reported gradually increasing thoraco-lumbar back pain and was eventually unable to resume training due to back pain. Physical exam revealed normal spinal alignment with a full range of spine motion. Pain was reproduced with spine extension at the thoraco-lumbar junction. With forward flexion, a palpable locally painful inter-spinous gap was evident at the T12-L1 level. The neurological examination was normal. Plain lateral radiographs of the lumbar spine were normal. Dynamic flexion and extension lateral radiographs revealed inter-spinous widening and segmental kyphosis at the T12-L1 inter-space on flexion, while extension resulted in 3mm of retrolisthesis between T12 and L1 indicative of abnormal segmental motion. A CT scan, with three-dimensional reconstructions, revealed a 50% subluxation of the T12-L1 facets bilaterally. (Figs. 1A–C). A bone scan showed increased uptake at the T12-L1 level on the right side. An MRI showed disruption of the annulus of the T12-L1 disc with posterior displacement of the nucleus. There was protrusion of the T12-L1 disc into the spinal canal with effacement of the CSF at the T12-L1 level. There was a mild focal kyphosis at the T12-L1 level. (Figs. 1D–F). The diagnosis was that of a flexion distraction injury with persistent subluxation of the T12-L1 facets, and disc disruption. Given the degree of subluxation, the associated ligamentous injury, and disruption of the disc, and the patient’s expectations, we recommended surgical stabilization. Due to the MRI evidence of disc disruption and the anticipated high loading of the spine, an anterior and posterior arthrodesis was the preferred option. A posterior T12-L1 trans-foraminal inter-body fusion utilizing Motech titanium cages and posterior Moss-Miami (DePuy-Spine Raynham, MA), instrumentation and a right iliac crest bone graft was performed. Following a four-day hospital stay, the patient wore a Jewitt thoraco-lumbar orthosis for six weeks. Physical rehabilitation was carried out under the guidance of a physiotherapist. Activities were restricted until two months following surgery. Rehabilitation involved a gradual re-introduction of the patient’s training program over a period of six to eight weeks following which the patient was able to resume her full intense training regime. Six months following surgery, the patient was able to compete at an international level and did so successfully. Follow-up radiographs at one year post-operatively revealed satisfactory fusion at the T12-L1 inter-space (Fig. 2). Clinical follow-up at 44 months following surgery confirmed an excellent result with continued participation in competitive gymnastics.

Does platelet-rich plasma ameliorate chronic achilles tendinopathy?

Objective: To compare the effectiveness of an injection of platelet-rich plasma (PRP) with a placebo injection on pain and function in patients with chronic midportion Achilles tendinopathy, in conjunction with an eccentric exercise program. Design: Double-blind, block-randomized, placebo-controlled, single-center trial. Sample size was calculated with 80% power to show a minimum clinically important difference on the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire at P # 0.05. Setting: Sports medicine out-patient clinic at The Hague Medical Center, the Netherlands, between August 2008 and January 2009, with follow-up until July 2009. Participants: Participants were recruited through advertisements on Web sites and radio that were aimed at health professionals and the general public. Inclusion criteria were a clinical diagnosis of chronic midportion Achilles tendinopathy made at the sports medicine clinic, based on a painful and thickened tendon during activity and on palpation, located 2 to 7 cm proximal to the insertion on the calcaneus; age, 18 to 70 years; and symptoms present for

Simultaneous rupture of the anterior cruciate ligament and patellar tendon.

2 months. Exclusion criteria were clinical suspicion of other musculoskeletal injuries or inflammatory disorders, or use of medications that might cause tendinopathy; previous treatment with a heavy-load eccentric exercise program or inability to undertake one; and previous injection with PRP. The 52 participants (mean age, 50 y; median duration of symptoms, 31 wk; 85% previously or currently active in sports; 52% women) were stratified by high or low ankle-activity levels, and randomized in blocks of 12. Intervention: Fifty-four milliliters of venous blood was collected from each participant and mixed with 6 mL of citrate. After the blood was centrifuged, the PRP was mixed with a sodium bicarbonate buffer. Identical syringes of 4 mL of PRP and 4 mL of isotonic saline solution were prepared. An unblinded physician masked the appropriate injection with a covering sheath, and, using Color-Doppler guidance, injected the PRP or placebo into the degenerative area of the tendon through 3 punctures and several small depots. For the first week after the injection activity was restricted; a week of stretching exercises was then followed by a 12-week daily eccentric exercise program that comprised 180 repetitions of ‘‘heel drops’’ on a step. All other treatments were to be avoided during the 24-week follow-up, except for acetaminophen. After 4 weeks, sports could be resumed at a level that caused no more than mild pain and no morning stiffness. Main outcome measures: The primary outcome measure was the VISA-A scale (scores 0–100, no activity and maximum pain to maximum activity and no pain) measured at baseline and at 6, 12, and 24 weeks. Secondary measures were patient satisfaction and return to sport. No participant was lost to follow up. Main results: After adjustment for baseline VISA-A scores and duration of symptoms, improvement on the VISA-A scale did not differ between the treatment groups (difference in VISA-A scores at 6, 12, and 24 wk: 2.5 points [95% CI, –6.9 to 11.9]; –1.6 [95% CI, –11.9 to 8.7]; and –0.9 [95% CI, –12.4 to 10.6]). After 24 weeks the groups did not differ in patient satisfaction or in the proportion who returned to sports (PRP, 78% vs placebo, 67%; adjusted difference, 1.4%; 95% CI, –17.0% to 19.8%). Overall, 60% of patients reported excellent or good satisfaction with the treatments. There was similar adherence to the exercise regimen (PRP, 70.9% and control, 74.6%). No microbial growth was found in the collected PRP samples and no complications were reported after treatment. Conclusion: A PRP injection did not improve pain or functional outcomes for patients with chronic Achilles tendinopathy who were all treated with a concurrent eccentric exercise regimen.