William J Ribbans

Variants within the MMP3 gene are associated with Achilles tendinopathy: possible interaction with the COL5A1 gene

Objectives: Sequence variation within the COL5A1 and TNC genes are known to associate with Achilles tendinopathy. The primary aim of this case-control genetic association study was to investigate whether variants within the matrix metalloproteinase 3 (MMP3) gene also contributed to both Achilles tendinopathy and Achilles tendon rupture in a Caucasian population. A secondary aim was to establish whether variants within the MMP3 gene interacted with the COL5A1 rs12722 variant to raise risk of these pathologies. Methods: 114 subjects with symptoms of Achilles tendon pathology and 98 healthy controls were genotyped for MMP3 variants rs679620, rs591058 and rs650108. Results: As single markers, significant associations were found between the GG genotype of rs679620 (OR = 2.5, 95% CI 1.2 to 4.90, p = 0.010), the CC genotype of rs591058 (OR = 2.3, 95% CI 1.1 to 4.50, p = 0.023) and the AA genotype of rs650108 (OR = 4.9, 95% CI 1.0 to 24.1, p = 0.043) and risk of Achilles tendinopathy. The ATG haplotype (rs679620, rs591058, and rs650108) was under-represented in the tendinopathy group when compared to the control group (41% vs 53%, p = 0.038). Finally, the G allele of rs679620 and the T allele of COL5A1 rs12722 significantly interacted to raise risk of AT (p = 0.006). No associations were found between any of the MMP3 markers and Achilles tendon rupture. Conclusion: Variants within the MMP3 gene are associated with Achilles tendinopathy. Furthermore, the MMP3 gene variant rs679620 and the COL5A1 marker rs12722 interact to modify the risk of tendinopathy. These data further support a genetic contribution to a common sports related injury.

Matrix metalloproteinase genes on chromosome 11q22 and the risk of anterior cruciate ligament (ACL) rupture.

As matrix metalloproteinases (MMPs) are critical to ligament homeostasis and integrity, the aim of this study was to investigate whether four functional polymorphisms within four MMP genes, which cluster on chromosome 11q22 associate with risk of ACL ruptures. Three hundred and forty‐five [129 with ACL ruptures (ACL group) and 216 asymptomatic controls (CON group)] unrelated Caucasians were recruited for this case‐control study. Fifty‐four participants reported non‐contact mechanisms of ACL rupture (NON subgroup). All participants were genotyped for the MMP10 C/T rs486055, MMP1 1G/2G rs1799750, MMP3 G/A rs679620 and MMP12 A/G rs2276109 variants. After adjusting for sex, age and weight, the AG and GG genotypes of the MMP12 rs2276109 variant were significantly (P=0.030) under‐represented among the NON subgroup (14%), when compared with the CON group (26%). No other variants were significantly different between groups. Adjusted for the same confounders, the two four‐variant haplotypes T‐1G‐A‐A (CON 14%, ACL 9%, P=0.033) and C‐2G‐G‐G (CON 14%, NON 5%, P=0.021) were significantly different between the CON and the ACL groups, and the CON group and the NON subgroup, respectively. This is the first report that indicates an association between the chromosomal region 11q22 and the risk of ACL rupture.

Classification Systems for Hallux Rigidus: A Review of the Literature

Background Hallux rigidus (HR) is one of the most common causes of forefoot pain. A number of classification systems have been developed to evaluate HR. These systems are based on either radiological parameters alone or a combination of radiological and clinical features. The purpose of this paper is to critically evaluate HR classification systems by undertaking a detailed review using English language medical and paramedical databases. Materials and Methods The authors identified 18 formal HR classification systems described in the literature, some of which are variations on a theme. Results No clear consensus on the construction of HR classification systems appears to exist. Different criteria and methods are used which make comparison difficult. Furthermore, it appears that, no serious consideration has been given to their reliability and validity. Criteria used to justify inclusion of these parameters have been based mainly on clinical experience rather than formal research. Conclusion For such a common condition, there is a need for a properly constructed, prospective study to develop a suitable classification system. It should include scientifically validated parameters to help stratify different stages of the disease and aid clinical and scientific communication.

Bacterial recolonization during foot surgery: a prospective randomized study of toe preparation techniques.

Fifty patients undergoing foot or ankle surgery were randomized into two groups for the purposes of toe preparation. Twenty-four patients underwent a standard preparation which included placing antiseptic between the toes while 26 were additionally cleaned by sliding a gauze swab soaked in topical antiseptic back and forth several times. Povidone iodine followed by chlorhexidine in alcohol was used in both groups. All toes were covered by a sterile glove during surgery unless the toes themselves were to be operated upon. Bacteria were cultured from the toe clefts in 4% of all patients immediately following preoperative disinfection. Significantly fewer patients whose toes had been additionally scrubbed (group 1) showed bacterial recolonization at the end of surgery compared with those undergoing a standard prep (group 2) (7.7% vs 20.8%). We conclude that additional scrubbing of toe clefts prior to surgery reduces the incidence of recolonization of bacteria during the surgical procedure.

The management of posterior ankle impingement syndrome in sport: A review

A literature review has been undertaken to assess the efficacy of management of Posterior Ankle Impingement Syndrome with an emphasis on sport. The evidence is confined to Level IV and V studies. There is a lack of prospective studies on the natural history of this condition and the outcomes of conservative treatment. Dance dominates the literature accounting for 62% of reported sports. Forty-seven papers have reported on the surgical outcomes of 905 procedures involving both open and artho-endoscopic techniques. 81% of patients required excision of osseous pathology and 42% soft-tissue problems resolving. There is a lack of standardisation of outcome reporting particularly in the open surgery group. However, the complication rates are relatively low: 3.9% for open medial, 12.7% for open lateral and 4.8% for arthro-endocopic surgery. Return to sport appears quicker for all activities in the arthro-endoscopic group but comparison of long term outcomes is more difficult with no evidence supporting superior long term results of one technique over another. Soccer players appear to return more quickly to activity than dancers.

Hallux rigidus: A cross-sectional study to evaluate clinical parameters

BACKGROUND Hallux rigidus (HR) is a common condition with history and physical examination used to help evaluate pathology, grade clinical changes and to inform treatment. METHOD A cross-sectional study was undertaken to evaluate the demographics of and clinical parameters encountered in HR. In 110 subjects (180 feet) aged 18-70 years (mean 52 years) a standardized history and physical examination was undertaken. Clinical parameters associated with HR were evaluated. The Foot Health Status Questionnaire (FHSQ) was used to measure health-related quality-of-life dimensions. RESULTS Seventy (64%) subjects had bilateral HR and 73 (66%) were female. Mean HR onset was 44 (14-68 years) years and median HR duration 6 years (1-33 years). A history of 1st MTPJ trauma presented in 22% of subjects; 74% of whom had unilateral HR. Eighty-four (47%) feet had pes planus based on a positive Foot Posture Index. A correlation between pes planus and 1st MTPJ pain was found (r=0.84, p=0.05). In 74% of feet, hallux abductus interphalangeus angle (HAI degrees ) was greater than normal (< or =10 degrees ). A correlation between HAI and reduced 1st MTPJ ROM was found (r=0.92, p=0.05). Second toe length was the same as the hallux in 111 feet (62%). A correlation between valgus hallucal rotation and 1st MTP joint pain in HR was found (r=.78, p=.05). A positive relationship was found between 2nd toe length and 1st MTPJ pain (p=0.001<0.05). A correlation between hallucal interphalangeal joint (IPJ) hyperextension and 1st MTPJ pain was found (r=0.78, p=0.01). A positive relationship was found between lesser MTPJ pain and supination at propulsion (p<0.001). There was no evidence of Achilles tendon contracture. The FHSQ results concur with clinical findings. CONCLUSIONS HR was associated with female gender, bilateral involvement, older age groups, increased HAI degrees, 2nd toe length similar to hallux, hallucal IPJ hyperextension, lesser MTP joint pain, flat foot and certain gait alterations. HR was not associated with Achilles tendon tightness or footwear. The content validity of clinical parameters of HR needs to be established by formal research prior to their inclusion in a classification of HR.

Tibialis Posterior Tendon and Deltoid and Spring Ligament Injuries in the Elite Athlete

The tibialis posterior tendon and the spring and deltoid ligament complexes combine to provide dynamic and passive stabilization on the medial side of the ankle and hindfoot. Some of the injuries will involve acute injury to previous healthy structures, but many will develop insidiously. The clinician must be aware of new treatment strategies and the level of accompanying scientific evidence regarding injuries sustained by athletes in these areas, while acknowledging that more traditional management applied to nonathletic patients is still likely to be appropriate in the setting of treatment for elite athletes.

Cross-sectional study to evaluate radiological parameters in hallux rigidus

BACKGROUND Hallux rigidus (HR) is a common condition with X-rays used to evaluate its pathology, grade joint changes and to inform treatment. METHOD A cross-sectional study was undertaken to evaluate radiological foot parameters in HR. In 110 subjects (180 feet) aged 18-70 years (mean 52 years) standard weight-bearing X-rays were examined using dorsal plantar and lateral views. RESULTS Seventy (64%) subjects had bilateral HR and 73 (66%) were female. The mean onset of HR (denoted by first metatarsophalangeal (MTP) joint restriction/pain) was 44 (14-68 years) years and median HR duration was 6 years (1-33 years). Flat or chevron-shaped metatarsal heads presented in 131 (73%) feet and a history of first MTP joint trauma in 22% (74% of whom had unilateral HR). In 74% of feet hallux abductus interphalangeus angle (HAI degrees) was greater than normal (< or =10 degrees). Correlations between first MTP joint narrowing and sclerosis (r=0.76, p=0.01) and increased HAI degrees and first MTP joint narrowing (r=0.34, p=0.01) was found. The mean hallux equinus angle of 11 degrees was outside the normal range (16-18 degrees). Abnormal sesamoid morphology presented in 117 (65%) feet (30% irregular or hypertrophic). Proximal sesamoid displacement was greater than that seen in non-HR. Metatarsus primus elevatus was within normal range (< or =8 mm) in 160 (89%) feet. The first metatarsal was longer than the second metatarsal in 66 (37%) feet although the first metatarsal was longer than the third metatarsal in 131 (73%) feet and may be responsible for altered forefoot function in HR. CONCLUSIONS HR was associated with female gender, bilateral involvement, older age groups, flat or chevron-shaped metatarsal head, longer proximal phalanx, increased HAI degrees and a first metatarsal longer than the third metatarsal. For radiological parameters to be considered valid for inclusion in a classification of HR their content validity needs to be established by formal research.

Considerations for the interpretation of epidemiological studies of injuries in team sports: illustrative examples.

Injury surveillance is an important component of the ‘‘sequence of prevention’’ 1 for reducing sports injury incidence, and a number of studies evaluating injury surveillance methodology have aimed to ensure that reliable and comparable data are produced. Arguably, the most important methodological issue surrounding injury surveillance is the definition of injury. This determines the threshold at which an injury is deemed reportable for surveillance purposes and has been addressed by a number of authors. The injury definition debate focuses on whether to use a broad definition or whether to place restrictions on a definition that might limit recognition to, for example, an injury that limits game participation. It has been suggested that 70% to 92% of all injuries are excluded when the injury definition is restricted, but it has been pointed out that no study using a broad definition has demonstrated good reliability and thus a ‘‘match time loss only’’ injury definition should be adopted. There is an emerging body of evidence that highlights issues of a sociocultural and psychological nature that may affect the validity of injury surveillance findings in team sports. These issues may result in both underreporting and overreporting of injuries. In rugby union, for example, it has been suggested that concussions may be underreported to avoid International Rugby Board rules restricting participation after such injuries. These matters, and their impact on injury surveillance, have not been discussed or assessed in detail. We believe that their further discussion is essential for both the development and accurate interpretation of injury surveillance data. Such matters are of particular significance not only for researchers designing and interpreting surveillance studies but also for team sport clinicians who must transfer research findings into evidence-based practice. In addition, they may raise ethical dilemmas more common in a team sports environment.

Coding sports injury surveillance data: has version 10 of the Orchard Sports Injury Classification System improved the classification of sports medicine diagnoses?

Objectives: To compare versions 8 and 10 of the Orchard Sports Injury Classification System (OSICS) to determine whether the revised version of OSICS has improved its use in a sports medicine setting, and to assess the inter-rater reliability of OSICS-10. Methods: Injury surveillance data, gathered over a 2 year period in professional football, cricket and rugby union to produce 335 diagnoses, were coded with both OSICS-8 and OSICS-10. Code–diagnosis agreement was assessed for OSICS-8 in terms of whether a diagnosis was codeable or noncodeable, and for OSICS-10 by evaluating the highest available OSICS-10 tier of coding. Eight clinicians coded a list of 20 diagnoses, comprising a range of pathologies to all gross anatomical regions, which were compared to assess inter-rater reliability. Results: All diagnoses could be assigned an appropriate code with OSICS-10, compared with 87% of diagnoses that could be assigned an OSICS-8 code. Contusions comprised almost half of OSICS-8 noncodeable diagnoses. OSICS-10 tier 2 codes accounted for 20% of diagnoses coded with the updated system. Of these 20%, almost half contained a more detailed diagnosis that did not have an available OSICS-10 tier 3 or 4 code. Inter-rater reliability increased with decreasing diagnostic detail, with an overall level shown to be moderate (k = 0.56). Conclusions: OSICS-10 is a more encompassing system than OSICS-8 to use in classifying sports medicine diagnoses, and has a moderate level of inter-rater reliability. Further minor revision may be required to address lack of detail in some strain, effusion and contusion codes.