Robert-Jan de Vos

Doha agreement meeting on terminology and definitions in groin pain in athletes

Background Heterogeneous taxonomy of groin injuries in athletes adds confusion to this complicated area. Aim The ‘Doha agreement meeting on terminology and definitions in groin pain in athletes’ was convened to attempt to resolve this problem. Our aim was to agree on a standard terminology, along with accompanying definitions. Methods A one-day agreement meeting was held on 4 November 2014. Twenty-four international experts from 14 different countries participated. Systematic reviews were performed to give an up-to-date synthesis of the current evidence on major topics concerning groin pain in athletes. All members participated in a Delphi questionnaire prior to the meeting. Results Unanimous agreement was reached on the following terminology. The classification system has three major subheadings of groin pain in athletes: 1. Defined clinical entities for groin pain: Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain. 2. Hip-related groin pain. 3. Other causes of groin pain in athletes. The definitions are included in this paper. Conclusions The Doha agreement meeting on terminology and definitions in groin pain in athletes reached a consensus on a clinically based taxonomy using three major categories. These definitions and terminology are based on history and physical examination to categorise athletes, making it simple and suitable for both clinical practice and research.

The Value of Power Doppler Ultrasonography in Achilles Tendinopathy A Prospective Study

Background Neovascularization, detected with power Doppler ultrasonography (PDU), is thought by some to play a central role in pathogenesis of Achilles tendinopathy. Hypothesis Power Doppler ultrasonography neovascularization score is correlated with clinical severity at baseline and after conservative treatment. Study Design Cohort study (prognosis); Level of evidence, 2. Methods Seventy tendons from 58 patients with chronic midportion Achilles tendinopathy were included, and 63 symptomatic tendons were analyzed. All patients were prescribed a 12-week heavy-load eccentric training program and evaluated with PDU at baseline and 12 weeks. Patient satisfaction, Victorian Institute of Sports Assessment—Achilles (VISA-A) score, and mean visual analog scale (VAS) score were correlated with degree of neovascularization (5-grade scale). Results Of the 63 symptomatic tendons, baseline neovascularization scores were 23 grade 0 (37% no neovessels), 18 grade 1, 8 grade 2, 8 grade 3, and 6 grade 4 (63% neovascularization grades 1-4). At baseline, neovascularization was not significantly correlated with the mean VAS score (r = .19, P = .131) and VISA-A score (r = —.23, P = .074). At 12-week follow-up, the neovascularization score significantly correlated with the mean VAS score (r = .43, P < .001) and VISA-A score (r = —.46, P < .001). No significant differences were found in improvement of VISA-A score after treatment between patients with neovessels (grades 1-4) or without neovessels (grade 0) at baseline. Conclusion Sixty-three percent of the symptomatic tendons were found to have neovessels at baseline. There was no significant correlation between neovascularization score and clinical severity at baseline, but at follow-up, there was a significant correlation. Neovascularization at baseline did not predict clinical outcome after conservative treatment.

Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review

Background Chronic lateral epicondylar tendinopathy is frequent in athletes, and platelet-rich plasma (PRP) is being used increasingly in its treatment. Objective To systematically review the literature on the efficacy of PRP injections for chronic lateral epicondylar tendinopathy. Methods The databases of PubMed, EMBASE, CINAHL, Medline OvidSP, Scopus, Google Scholar, Web of Science and Cochrane Library were searched in October 2013. Inclusion criteria were a clinical diagnosis of chronic lateral epicondylar tendinopathy, a randomised controlled trial, an intervention with a PRP injection and the outcome measures described in terms of pain and/or function. One author screened the search results and two authors independently assessed the study quality using the Physiotherapy Evidence Database (PEDro) score. A study was considered to be of high quality if its PEDro score was ≥6. A best evidence synthesis was used to identify the level of evidence. Results 6 studies were included, of which four were considered to be of high quality. Three high-quality studies (75%) and two low-quality studies showed no significant benefit at the final follow-up measurement or predefined primary outcome score when compared with a control group. One high-quality study (25%) showed a beneficial effect of a PRP injection when compared with a corticosteroid injection (corticosteroid injections are harmful in tendinopathy). Based on the best evidence synthesis, there is strong evidence that PRP injections are not efficacious in chronic lateral epicondylar tendinopathy. Conclusions There is strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy.

Interobserver Reliability of Neovascularization Score Using Power Doppler Ultrasonography in Midportion Achilles Tendinopathy

Background Power Doppler ultrasonography is widely used to examine neovascularization in midportion Achilles tendinopathy. The reliability of the grading of the degree of neovascularization has not been examined previously. Hypothesis Power Doppler ultrasonography can be performed with a high interobserver reliability to determine the neovascularization score in patients with midportion Achilles tendinopathy. Study Design Case control study (diagnosis); Level of evidence, 4. Methods Thirty-three symptomatic and 17 asymptomatic Achilles tendons from 25 consecutive patients were included for ultrasound examination. Victorian Institute of Sport Assessment–Achilles score was used to assess the severity of the Achilles tendinopathy. Each tendon was scored twice by different radiologists using the modified Öhberg score for neovascularization. Results The intraclass correlation coefficient for interobserver reliability was 0.85. Neovascularization was observed in 70% (23/33) of the symptomatic tendons and in 29% (5/17) of the asymptomatic tendons. The Spearman correlation coefficient between the Victorian Institute of Sport Assessment–Achilles score and the degree of neovascularization was −0.16 (P =. 10). Conclusion An excellent interobserver reliability was found for determining the degree of neovascularization on power Doppler ultrasonography examination. Neovessels were present in a majority of symptomatic tendons. The severity of symptoms was not correlated with the neovascularization score. Clinical Relevance Power Doppler ultrasonography is widely used to evaluate tendinopathy without knowledge of the difference in observations between several testers. Interobserver reliability of the evaluation of the degree of neovascularization in chronic midportion Achilles tendinopathy is excellent.

Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes

Background Groin pain in athletes is frequent and many different treatment options have been proposed. The current level of evidence for the efficacy of these treatments is unknown. Objective Systematically review the literature on the efficacy of treatments for groin pain in athletes. Methods Nine medical databases were searched in May 2014. Inclusion criteria: treatment studies in athletes with groin pain; randomised controlled trials, controlled clinical trials or case series; n>10; outcome measures describing number of recovered athletes, patient satisfaction, pain scores or functional outcome scores. One author screened search results, and two authors independently assessed study quality. A best evidence synthesis was performed. Relationships between quality score and outcomes were evaluated. Review registration number CRD42014010262. Results 72 studies were included for quality analysis. Four studies were high quality. There is moderate evidence that, for adductor-related groin pain, active exercises compared with passive treatments improve success, multimodal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises and adductor tenotomy improves treatment success over time. There is moderate evidence that for athletes with sportsmans hernia, surgery results in better treatment success then conservative treatment. There was a moderate and inverse correlation between study quality and treatment success (p<0.001, r=−0.41), but not between study quality and publication year (p=0.09, r=0.20). Conclusions Only 6% of publications were high quality. Low-quality studies showed significantly higher treatment success and study quality has not improved since 1985. There is moderate evidence for the efficacy of conservative treatment (active exercises and multimodal treatments) and for surgery in patients with adductor-related groin pain. There is moderate evidence for efficacy of surgical treatment in sportsmans hernia.

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.

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.

Terminology and definitions on groin pain in athletes: building agreement using a short Delphi method

Background Groin pain in athletes occurs frequently and can be difficult to treat, which may partly be due to the lack of agreement on diagnostic terminology. Objective To perform a short Delphi survey on terminology agreement for groin pain in athletes by a group of experts. Methods A selected number of experts were invited to participate in a Delphi questionnaire. The study coordinator sent a questionnaire, which consisted of demographic questions and two ‘real-life’ case reports of athletes with groin pain. The experts were asked to complete the questionnaire and to provide the most likely diagnosis for each case. Questionnaire responses were analysed by an independent researcher. The Cohens κ statistic was used to evaluate the level of agreement between the diagnostic terms provided by the experts. Results Twenty-three experts participated (96% of those invited). For case 1, experts provided 9 different terms to describe the most likely diagnosis; for case 2, 11 different terms were provided to describe the most likely diagnosis. With respect to the terms provided for the most likely diagnosis, the Cohens κ was 0.06 and 0.002 for case 1 and 2, respectively. This heterogeneous taxonomy reflects only a slight agreement between the various diagnostic terms provided by the selected experts. Conclusions This short Delphi survey of two ‘typical, straightforward’ cases demonstrated major inconsistencies in the diagnostic terminology used by experts for groin pain in athletes. These results underscore the need for consensus on definitions and terminology on groin pain in athletes.

Clinical tests in shoulder examination: how to perform them

Background This article describes the best clinical tests of shoulder function and injury as identified in a recent systematic review published in the British Journal of Sports Medicine. Discussion A description of the different tests is given, with photographs of the exact test procedure.

The Tendon Structure Returns to Asymptomatic Values in Nonoperatively Treated Achilles Tendinopathy but Is Not Associated With Symptoms A Prospective Study

Background: Tendinopathy is characterized by alterations in the tendon structure, but there are conflicting results on the potential of tendon structure normalization and no large studies on the quantified, ultrasonographic tendon structure and its association with symptoms. Purpose: To determine whether the tendon structure returns to values of asymptomatic individuals after treatment with 2 substances injected within the tendon, to assess the association between the tendon structure and symptoms, and to assess the prognostic value of the baseline tendon structure on treatment response. Study Design: Cohort study; Level of evidence, 2. Methods: This study was part of a randomized trial on chronic midportion Achilles tendinopathy using eccentric exercises with either a platelet-rich plasma or saline injection. Symptoms were recorded using the Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire. The tendon structure was quantified with ultrasound tissue characterization (UTC); echo types I + II (as a percentage of total tendon types I-IV) are structure related. Follow-up was at 6, 12, 24, and 52 weeks. A control group of asymptomatic subjects (similar age) was selected to compare the tendon structure. Patient symptomswere correlated with the tendon structure using a linear model. Results: Fifty-four patients were included in the symptomatic group. The mean (±SD) echo types I + II in the symptomatic group increased significantly from 74.6% ± 10.8% at baseline to 85.6% ± 6.0% at 24-week follow-up. The result for echo types I + II at 24 weeks was not significantly different (P = .198) from that of the asymptomatic control group (87.5% ± 6.0%). In 54 repeated measurements at 5 time points, the adjusted percentage of echo types I + II was not associated with the VISA-A score (main effect: β = .12; 95% CI, −0.12 to 0.35; P = .338). The adjusted baseline echo types I + II were not associated with a change in the VISA-A score from baseline to 52 weeks (β = −.15; 95% CI, −0.67 to 0.36; P = .555). Conclusion: In symptomatic, tendinopathic Achilles tendons, the ultrasonographic tendon structure improved during nonoperative treatment and normalized after 24 weeks to values of matched asymptomatic controls. There was no association between the tendon structure and symptoms. The percentage of echo types I + II before treatment was not associated with change in symptoms over time. This study demonstrates that restoration of the tendon structure is not required for an improvement of symptoms.