Genetics and sports

Instruments to assess patients with rotator cuff pathology: a systematic review of measurement properties

PURPOSE

The aims of this study were to obtain an overview of the methodological quality of studies on the measurement properties of rotator cuff questionnaires and to describe how well various aspects of the design and statistical analyses of studies on measurement properties are performed.

METHODS

A systematic review of published studies on the measurement properties of rotator cuff questionnaires was performed. Two investigators independently rated the quality of the studies using the Consensus-based Standards for the selection of health Measurement Instruments checklist. This checklist was developed in an international Delphi consensus study.

RESULTS

Sixteen studies were included, in which two measurement instruments were evaluated, namely the Western Ontario Rotator Cuff Index and the Rotator Cuff Quality-of-Life Measure. The methodological quality of the included studies was adequate on some properties (construct validity, reliability, responsiveness, internal consistency, and translation) but need to be improved on other aspects. The most important methodological aspects that need to be developed are as follows: measurement error, content validity, structural validity, cross-cultural validity, criterion validity, and interpretability.

CONCLUSION

Considering the importance of adequate measurement properties, it is concluded that, in the field of rotator cuff pathology, there is room for improvement in the methodological quality of studies measurement properties.

LEVEL OF EVIDENCE

II.

A systematic review of single-bundle versus double-bundle anterior cruciate ligament reconstruction

INTRODUCTION

Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction is becoming increasingly common. However, no definitive data on the superiority of DB reconstruction have been shown when compared with single-bundle (SB) ACL reconstruction.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of keywords such as 'ACL', 'reconstruction', 'DB' and 'SB'. Only articles published in peer-reviewed journals were included in this systematic review.

AREAS OF AGREEMENT

Several new techniques are available for ACL reconstruction. DB ACL reconstruction could provide better outcome for patients in terms of closer restoration of normal knee biomechanics and improving the rotatory laxity of the knee.

AREAS OF CONTROVERSY

Data are lacking to allow definitive conclusions on the use of DB reconstruction techniques for routine management of patients with ACL tear.

GROWING POINTS

Given the limitations of the current studies, it is not possible to recommend systematic use of DB ACL reconstruction. Even though biomechanical results are encouraging, subjective patient evaluation is similar for SB and DB reconstruction.

AREAS TIMELY FOR DEVELOPING RESEARCH

Studies of higher levels of evidence, for instances large adequately powered randomized trials, should be conducted to bring new insight in this field. With the current evidence available, a simple SB ACL reconstruction is a suitable technique, and it should be not abandoned until stronger scientific evidence in favour of DB ACL reconstruction will be produced.

Physiopathology of intratendinous calcific deposition

In calcific tendinopathy (CT), calcium deposits in the substance of the tendon, with chronic activity-related pain, tenderness, localized edema and various degrees of decreased range of motion. CT is particularly common in the rotator cuff, and supraspinatus, Achilles and patellar tendons. The presence of calcific deposits may worsen the clinical manifestations of tendinopathy with an increase in rupture rate, slower recovery times and a higher frequency of post-operative complications. The aetiopathogenesis of CT is still controversial, but seems to be the result of an active cell-mediated process and a localized attempt of the tendon to compensate the original decreased stiffness. Tendon healing includes many sequential processes, and disturbances at different stages of healing may lead to different combinations of histopathological changes, diverting the normal healing processes to an abnormal pathway. In this review, we discuss the theories of pathogenesis behind CT. Better understanding of the pathogenesis is essential for development of effective treatment modalities and for improvement of clinical outcomes.

Osteoporotic vertebral fractures: current concepts of conservative care

INTRODUCTION

Osteoporotic vertebral compression fractures (VCFs) are a growing public health problem with important socio-economic effects in western countries. In the USA, 10 million people over 50 suffer from osteoporosis. In these patients, 1.5 million annual fractures have been registered, and 50% of these are vertebral compression.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the keywords 'osteoporosis', 'vertebral compression fractures', 'brace', 'bracing', 'orthosis', 'conservative management' and 'rehabilitation' over the years 1966-2011. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context of conservative management of osteoporotic vertebral fractures.

AREAS OF AGREEMENT

Conservative management for patients with osteoporotic vertebral fractures includes bed rest, pain medication, physiotherapy and bracing.

AREAS OF CONTROVERSY

A conservative management for patients with osteoporotic VCFs s has not been standardized. The utility of vertebral augmentation techniques has been questioned by recent randomized controlled trials.

GROWING POINTS

Randomized controlled trials are being performed worldwide on vertebral augmentation techniques.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although spinal orthoses are commonly used for the management of patients with osteoporotic vertebral fractures, in the literature there is only one randomized controlled trial on bracing for this condition. While the best conservative management for subjects with osteoporotic VCFs s is not defined and standardized, no conclusions on the superiority of vertebral augmentation techniques over conservative management can be drawn.

Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon

BACKGROUND

Chronic tears of the Achilles tendon with a tendon gap exceeding 6 cm are a surgical challenge. The purpose of this study is to report the long-term results of reconstruction of such chronic Achilles tendon ruptures with use of a free autologous gracilis tendon graft.

METHODS

Twenty-one patients underwent reconstruction of a chronic rupture of the Achilles tendon. Fifteen patients were available for clinical and functional assessment on the basis of anthropometric measurements, isometric strength testing, and the Achilles Tendon Total Rupture Score after a mean duration of follow-up of 10.9 years (range, eight to twelve years).

RESULTS

All fifteen patients were able to walk on the tiptoes, and no patient used a heel lift or walked with a visible limp. At an average of 10.9 years of follow-up, the maximum calf circumference of the operatively treated leg remained substantially decreased and the operatively treated limb was significantly weaker than the contralateral, normal limb. Two patients had developed tendinopathy of the contralateral Achilles tendon, one had developed tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon eight years after the index tear.

CONCLUSIONS

The long-term results of treatment of chronic tears of the Achilles tendon with free gracilis tendon grafting showed that patients retained good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.

The FIFA 11+ program is effective in preventing injuries in elite male basketball players: a cluster randomized controlled trial

BACKGROUND

Recently, structured training programs for sports injury prevention ("The 11" and "The 11+") have been validated in soccer. The FIFA 11+ program has not been evaluated in basketball.

HYPOTHESIS

The FIFA 11+ program is effective in reducing the rates of injury in male basketball players.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

The authors randomized 11 teams of the same club. Seven teams were allocated to the intervention group (80 players; mean [SD] age 13.5 [2.3] years), and 4 teams were allocated to the control group (41 players; mean [SD] age 15.2 [4.6] years). The authors conducted an injury surveillance program during a 9-month season. The primary outcome was any injury to the athletes. The secondary outcome was any injury to the lower extremity (foot, ankle, lower leg, knee, thigh, groin, and hip). They included an analysis of the type of exposure (match or training), injury location in the body, and type of injury (acute or overuse).

RESULTS

During the 9-month season, 23 (19%) of the 121 players included in the study sustained a total of 31 injuries (14 in the intervention group and 17 in the control group). In the intervention group, injury rates per 1000 athlete-exposures were lower than those in the control group, with statistical significance, for overall injuries (0.95 vs 2.16; P = .0004), training injuries (0.14 vs 0.76; P = .007), lower extremity injuries (0.68 vs 1.4; P = .022), acute injuries (0.61 vs 1.91; P < .0001), and severe injuries (0 vs 0.51; P = .004). The intervention group also had statistically significant lower injury rates for trunk (0.07 vs 0.51; P = .013), leg (0 vs 0.38; P = .007), and hip and groin (0 vs 0.25; P = .023) compared with the control group. There was no statistically significant difference in match injuries, knee injuries, ankle injuries, and overuse injuries between 2 groups. The most frequent acute injury diagnoses were ligament sprains (0.41 and 0.38 in the intervention and control groups, respectively; P < .006) and contractures (0.76 and 0.07 in the control and intervention groups, respectively; P < .003).

CONCLUSION

The FIFA 11+ warm-up program is effective in reducing the rates of injuries in elite male basketball players.

Biological resurfacing for early osteoarthritis of the shoulder

Young patients with degenerative shoulder disease are a therapeutic challenge. To try to delay a shoulder arthroplasty, biological interpositional arthroplasty has been proposed to provide a biologically active bearing surface that could eventually results in the formation of fibrocartilage, fibrous tissue, or hyaline cartilage. Anterior capsule, autogenous fascia lata, Achilles tendon allograft, lateral meniscus allograft, human dermis, and porcine small intestine submucosa have been used as interposition material, either alone or in combination with a hemiarthroplasty or humeral resurfacing procedure. Some investigators have reported favorable long-term results, although others have found this procedure unreliable. Several variables are unknown at present, such as the best biological resurfacing device, healing potential, possible antigenic responses, optimal fixation technique or position, aftercare restrictions. Further prospective studies with long follow-up are necessary to provide data that will help to define the role of biological glenoid resurfacing in young patients with glenohumeral arthritis.

Latissimus dorsi tendon transfer for massive irreparable rotator cuff tears: a systematic review

Tendon transfers have been proposed as a possible solution to restore pain-free functions, strength, and range of motion in patients with massive and irreparable cuff tears. The aim of this review is to establish the outcomes of (1) latissimus dorsi tendon transfer (LDT-T) surgery performed as a single procedure or in combination with other muscle-tendon transfer procedures, replacement, or both; (2) LDT-T in primary and revision surgery for massive irreparable rotator cuff tears; (3) the LDT-T procedure in relation to subscapularis and teres minor integrity; (4) the LDT-T procedure in relation to the reattachment position on the humeral head of the transferred tendon; (5) the LDT-T procedure performed as a single or a double incision; (6) arthroscopic, open, or combined approach: and (7) the LDT-T procedure in patients with preoperative osteoarthritis and a nonosteoarthritic condition with the evaluation of osteoarthritis progression. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies of levels of evidence I-IV were included. The LDT-T surgical procedure, outcomes, and complications were evaluated. Twenty-two studies describing 493 shoulders in 487 patients were included in our study. There were no prospective randomized, controlled studies. LDT-T is a promising strategy for the management of massive and irreparable rotator cuff tears, even though no agreement was found on several aspects and options of LDT-T. Randomized prospective control studies are still awaited on this subject.

Bilateral tibial hallux sesamoid agenesis and fibular hallux sesamoid hypoplasia in a patient with bilateral hallux valgus

We report the clinical features, radiographic findings, management, and results of a patient with bilateral hallux valgus and associated bilateral tibial hallux sesamoid agenesis and fibular hallux sesamoid hypoplasia. Our patient was managed operatively with good clinical results. Combined tibial sesamoid agenesis and fibular sesamoid hypoplasia do not seem to negatively influence the management of hallux valgus.

On the Evolution of Sport

Sports have received little attention from evolutionary biologists. I argue that sport began as a way for men to develop the skills needed in primitive hunting and warfare, then developed to act primarily as a lek where athletes display and male spectators evaluate the qualities of potential allies and rivals. This hypothesis predicts that (1) the most popular modern male sports require the skills needed for success in male-male physical competition and primitive hunting and warfare; (2) champion male athletes obtain high status and thereby reproductive opportunities in ways that parallel those gained by successful primitive hunters and warriors; (3) men pay closer attention than do women to male sports so they can evaluate potential allies and rivals; and (4) male sports became culturally more important when opportunities to evaluate potential allies and rivals declined as both the survival importance of hunting and the proportion of men who experience combat decreased. The characteristics of primitive and modern sports are more consistent with these predictions than those generated by intersexual sexual selection theories of sport.

Animal models for translational research on shoulder pathologies: from bench to bedside

Several animal models have been used for in vivo and in vitro shoulder research. In vitro models, consisting of cadaveric specimens, are useful in providing basic understanding of the functioning of the shoulder and for biomechanical experiments. In vivo models provide the means to model living phenomena, such as tendon healing process, tendinopathy, instability, and adaptive responses to surgery. However, intrinsic differences among different species make translation to human shoulder pathologies difficult. Most of the animals used in experimental settings are quadrupeds, using the forelimbs for weight-bearing during locomotion, with no or minimal overhead activity. The various animal models already used to study shoulder pathologies are presented in this article. However, there is a lack of validation for these animal models, which provides challenge to the further research in this field.

Clinical tests for the diagnosis of rotator cuff disease

Several tests have been described to examine the shoulder. However, there is a lack of consensus on clinical assessment of patients with shoulder pain and suspected rotator cuff pathology. This review reports the diagnostic accuracy of clinical tests for rotator cuff pathology. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 21 clinical tests for rotator cuff pathology are reported from the available literature. Twenty studies investigated supraspinatus pathology, 12 infraspinatus pathology, and 9 subscapularis pathology. Most tests for rotator cuff pathology are inaccurate, and the recent literature shows that there is insufficient evidence to recommend 1 clinical test over another for diagnosis of rotator cuff pathology. Poor diagnostic accuracy of clinical tests for rotator cuff pathology may be related to the close relationships of structures in the shoulder, to a lack of understanding of anatomical basis of the tests, or to their lack of reproducibility.

Scoring systems for the functional assessment of patients with rotator cuff pathology

Ideally, an outcome instrument measures phenomena that are directly relevant to the patient and provides a comprehensive assessment of the impact of a condition on the patient's daily life. During the past decades, several rating scales have been developed to assess the functional status of patients with shoulder pain. Several scoring systems are currently available for the evaluation of patients with rotator cuff pathology. Each of them evaluates shoulder function using specific variables. The main features of these scoring systems are presented in this review. Although many scoring systems are commonly used to evaluate shoulder function, we are still far from a single outcome evaluation system, which is reliable, valid, and sensitive to clinically relevant changes, takes into account both patient's and physician's perspective, and is short and practical to use.

Histopathology of rotator cuff tears

The pathogenesis of rotator cuff tears is multifactorial. Tendon abnormalities of the rotator cuff include alteration of collagen fiber structure, tenocytes, cellularity, and vascularity. Ruptured tendons show marked collagen degeneration and disordered arrangement of collagen fibers. Fibroblast population decreases as the size of the tear in the rotator cuff increases. The larger fibroblast population seen in the smaller tears is also actively proliferating and is part of an active reparative process. Inflammatory cell infiltrate correlates inversely to rotator cuff tear size in the torn supraspinatus tendon samples, with larger tears showing a marked reduction in all cell types. As tear size increase, there is also a progressive decrease in the number of blood vessels. Whether rotator cuff tear heals spontaneously is an important pathologic and clinical question. Histologic changes indicative of repair and inflammation lead to consider biological options in addition to biomechanical treatment of the rotator cuff tears.

Biological factors in the pathogenesis of rotator cuff tears

Rotator cuff tears are common, and lead to shoulder pain and functional impairment. Despite their frequency and related disability, etiology and pathogenesis are still debated. Multiple factors contribute to tears of the rotator cuff. Extrinsic factors are anatomic variables, such as acromial morphologic characteristics, os acromiale, and acromial spurs that compress the rotator cuff by bony impingement or direct pressure from the surrounding soft tissue. Intrinsic factors arise from the tendon itself, because of tensile overload, aging, microvascular supply, traumatisms, or degeneration. Little information is available from a cellular and molecular point of view. We reviewed the biological factors involved in the pathogenesis of rotator cuff tears. Understanding the mechanism of rotator cuff pathology would facilitate the rationale for therapeutic interventions, by guiding the design, selection, and implementation of treatment strategies such as biologic modulation and preventive measures.

Role of growth factors in rotator cuff healing

The histologic lesion underlying overuse rotator cuff tendinopathy is a failed healing response, with haphazard proliferation of tenocytes, disruption of tendon cells and collagen fibers, and increased noncollagenous extracellular matrix. Recent attention has focused on the biological pathways by which tendons heal, leading to the identification of several growth factors (GFs) involved in this process. No studies have been published on the time course of the various GFs during rotator cuff healing process in vivo, in humans. We review what is known about these GFs and their role in rotator cuff healing.

Biological strategies to enhance healing of the avascular area of the meniscus

Meniscal injuries in the vascularized peripheral part of the meniscus have a better healing potential than tears in the central avascular zone because meniscal healing principally depends on its vascular supply. Several biological strategies have been proposed to enhance healing of the avascular area of the meniscus: abrasion therapy, fibrin clot, organ culture, cell therapy, and applications of growth factors. However, data are too heterogeneous to achieve definitive conclusions on the use of these techniques for routine management of meniscal lesions. Although most preclinical and clinical studies are very promising, they are still at an experimental stage. More prospective randomised controlled trials are needed to compare the different techniques for clinical results, applicability, and cost-effectiveness.

Scaffolds in tendon tissue engineering

Tissue engineering techniques using novel scaffold materials offer potential alternatives for managing tendon disorders. Tissue engineering strategies to improve tendon repair healing include the use of scaffolds, growth factors, cell seeding, or a combination of these approaches. Scaffolds have been the most common strategy investigated to date. Available scaffolds for tendon repair include both biological scaffolds, obtained from mammalian tissues, and synthetic scaffolds, manufactured from chemical compounds. Preliminary studies support the idea that scaffolds can provide an alternative for tendon augmentation with an enormous therapeutic potential. However, available data are lacking to allow definitive conclusion on the use of scaffolds for tendon augmentation. We review the current basic science and clinical understanding in the field of scaffolds and tissue engineering for tendon repair.

Tissue engineered strategies for skeletal muscle injury

Skeletal muscle injuries are common in athletes, occurring with direct and indirect mechanisms and marked residual effects, such as severe long-term pain and physical disability. Current therapy consists of conservative management including RICE protocol (rest, ice, compression and elevation), nonsteroidal anti-inflammatory drugs, and intramuscular corticosteroids. However, current management of muscle injuries often does not provide optimal restoration to preinjury status. New biological therapies, such as injection of platelet-rich plasma and stem-cell-based therapy, are appealing. Although some studies support PRP application in muscle-injury management, reasons for concern persist, and further research is required for a standardized and safe use of PRP in clinical practice. The role of stem cells needs to be confirmed, as studies are still limited and inconsistent. Further research is needed to identify mechanisms involved in muscle regeneration and in survival, proliferation, and differentiation of stem cells.

Tissue engineering for rotator cuff repair: an evidence-based systematic review

The purpose of this systematic review was to address the treatment of rotator cuff tears by applying tissue engineering approaches to improve tendon healing, specifically platelet rich plasma (PRP) augmentation, stem cells, and scaffolds. Our systematic search was performed using the combination of the following terms: “rotator cuff”, “shoulder”, “PRP”, “platelet rich plasma”, “stemcells”, “scaffold”, “growth factors”, and “tissue engineering”. No level I or II studies were found on the use of scaffolds and stem cells for rotator cuff repair. Three studies compared rotator cuff repair with or without PRP augmentation. All authors performed arthroscopic rotator cuff repair with different techniques of suture anchor fixation and different PRP augmentation. The three studies found no difference in clinical rating scales and functional outcomes between PRP and control groups. Only one study showed clinical statistically significant difference between the two groups at the 3-month follow up. Any statistically significant difference in the rates of tendon rerupture between the control group and the PRP group was found using the magnetic resonance imaging. The current literature on tissue engineering application for rotator cuff repair is scanty. Comparative studies included in this review suggest that PRP augmented repair of a rotator cuff does not yield improved functional and clinical outcome compared with non-augmented repair at a medium and long-term followup.

Growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration

Intervertebral disc (IVD) degeneration is frequent, appearing from the second decade of life and progressing with age. Conservative management often fails, and patients with IVD degeneration may need surgical intervention. Several treatment strategies have been proposed, although only surgical discectomy and arthrodesis have been proved to be predictably effective. Biological strategies aim to prevent and manage IVD degeneration, improving the function and anabolic and reparative capabilities of the nucleus pulposus and annulus fibrosus cells and inhibiting matrix degradation. At present, clinical applications are still in their infancy. Further studies are required to clarify the role of growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration.

Advances in meniscal tissue engineering

Meniscal tears are the most common knee injuries and have a poor ability of healing. In the last few decades, several techniques have been increasingly used to optimize meniscal healing. Current research efforts of tissue engineering try to combine cell-based therapy, growth factors, gene therapy, and reabsorbable scaffolds to promote healing of meniscal defects. Preliminary studies did not allow to draw definitive conclusions on the use of these techniques for routine management of meniscal lesions. We performed a review of the available literature on current techniques of tissue engineering for the management of meniscal tears.

Video analysis of the mechanisms of shoulder dislocation in four elite rugby players

BACKGROUND

Shoulder injuries are common in rugby, with the most severe match injury being shoulder dislocation and instability. A limitation of epidemiological studies is that the injury information is based on player interviews after the injury or reports from the medical staff. The objective of this study is to describe the specific injury mechanisms for shoulder dislocation using video recordings in a consecutive series of 4 elite male rugby players who sustained an episode of shoulder dislocation during an official match.

METHODS

Videotapes were reviewed to identify the mechanism of the injury. The incidents, including the play leading up to each incident, were analysed. A shoulder dislocation mechanism score was developed to describe the injury mechanism and the events leading up to the injury.

RESULTS

For all the athletes, player-to-player contact was responsible for the shoulder dislocation. Three of the four injuries resulted from trauma with the elbow in an extended position forcing the shoulder to exceed the limits of the normal range of motion, causing anterior shoulder dislocation. One injury resulted from trauma with the elbow in a flexed position and the direction of the injuring force along the longitudinal axis of the humerus causing posterior shoulder dislocation.

CONCLUSIONS

This study provides preliminary evidence that thorough video analysis can provide detailed information about the mechanisms of shoulder dislocation in elite rugby players. Knowledge of the common mechanisms of injuries in these athletes may potentially lead to improved sports technique to attempt to reduce the occurrence of shoulder dislocations. Further studies with a larger number of patients are required to better clarify the exact mechanism of shoulder dislocation in rugby players, and how these results may be applied in training and matches to prevent shoulder dislocation in elite rugby players.

Genetic polymorphisms influence runners' responses to the dietary ingestion of antioxidant supplementation based on pequi oil (Caryocar brasiliense Camb.): a before-after study

Genes have been implicated in the levels of oxidative stress, lipids, CVD risk, immune reactivity, and performance. Pequi oil (Caryocar brasiliense) has shown anti-inflammatory and hypotensive effects, besides reducing exercise-induced DNA, tissue damages, and anisocytosis. Given that diet can interact with the human genome to influence health and disease, and because genetic variability can influence response to diet, we aim to investigate the influence of 12 gene polymorphisms on inflammatory markers, postprandial lipids, arterial pressure, and plasma lipid peroxidation of runners (N = 125), before and after 14 days of 400 mg pequi-oil supplementation, after races under closely comparable conditions. Arterial pressure was checked before races; blood samples were taken immediately after racing to perform leukogram and plateletgram, Tbars assay, lipid, and CRP dosages and genotyping. CAT, GST-M1/T1, CRP-G1059C, and MTHFR-C677T polymorphisms influenced post-pequi-oil responses in leukogram; Hp and MTHFR-C677T, in plateletgram; Hp, ACE, GSTT1, and MTHFR-A1298C, in lipid profile; MTHFR-A1298C, in C-reactive protein (CRP) levels; and Hp and MnSOD, in Tbars assay. Differences between ACE genotypes in leukogram and total cholesterol disappeared after pequi, and the same occurred for Hp and MnSOD in Tbars assay and for MTHFR-A1298C with CRP levels. Because genetic inheritance is one of the factors that drive atherosclerosis-related lipid abnormalities, results can contribute to a greater understanding of the influence of genetic polymorphisms in situations that push up free radicals. Knowledge is also expanded on how antioxidant supplementation affects an individual's genes and how athletic genetic makeup can affect the way a person responds to antioxidant supplements.

Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures

A laboratory study was performed to evaluate the histopathological features of the macroscopically intact portion of the Achilles tendon in patients undergoing surgery for an acute rupture of the Achilles tendon. Tendon samples were harvested from 29 individuals (21 men, 8 women; mean age: 46 ± 12) who underwent repair of an Achilles tendon tear tear, and from 11 male patients who died of cardiovascular events (mean age: 61). Three pieces of tendon were harvested: at the rupture site, 4 cm proximal to the site of rupture, 1 cm proximal to the insertion of the Achilles tendon on the calcaneum. Slides were assessed using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. Intra-observer reliability of the subscore readings was calculated. The pathological features were significantly more pronounced in the samples taken from the site of rupture than in the samples taken proximally and distal to it (0.008 < P < 0.01). There were no significant differences in the mean pathologic sum-scores in the samples taken proximally and distal to the site of rupture. Unruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations, with the latter demonstrating histopathological evidence of failed healing response even in areas macroscopically normal.

Patellar tendinopathy in master track and field athletes: influence of impact profile, weight, height, age and gender

PURPOSE

Patellar tendinopathy causes significant morbidity in professional and recreational athletes. Despite the relevance of the problem, its causative factors remain poorly understood. The purpose of this cross-sectional study is to evaluate the influence of age, gender, weight, height and impact profile on developing patellar tendinopathy in master track and field athletes.

METHODS

During the European Veterans Athletics Championships in Poznań in July 2006, 174 athletes (103 men and 71 women; mean age: 53.8 (SD 11.4) years, range 35-82 years) were evaluated with the VISA-P questionnaire. A fully trained orthopaedic surgeon made a diagnosis of patellar tendinopathy according to clinical criteria.

RESULTS

There was no effect of gender upon the presence of patellar tendinopathy (n.s.). No significant track and field specialty effect upon the frequency of patellar tendinopathy was found on the VISA-P questionnaire scores. There was no effect of track and field specialty on the VISA-P score. No evidence of a statistically significant association was found between age and VISA-P score (n.s.). There was no statistically significant difference in either prevalence of patellar tendinopathy or VISA-P score between high-impact and low-impact athletes (n.s.).

CONCLUSION

In master track and field athletes, impact profile, weight, height, age and gender did not exert any influence on developing patellar tendinopathy.

Platelet-rich plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial

BACKGROUND

After reinsertion on the humerus, the rotator cuff has limited ability to heal. Growth factor augmentation has been proposed to enhance healing in such procedure.

PURPOSE

This study was conducted to assess the efficacy and safety of growth factor augmentation during rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Eighty-eight patients with a rotator cuff tear were randomly assigned by a computer-generated sequence to receive arthroscopic rotator cuff repair without (n = 45) or with (n = 43) augmentation with autologous platelet-rich fibrin matrix (PRFM). The primary end point was the postoperative difference in the Constant score between the 2 groups. The secondary end point was the integrity of the repaired rotator cuff, as evaluated by magnetic resonance imaging. Analysis was on an intention-to-treat basis.

RESULTS

All the patients completed follow-up at 16 months. There was no statistically significant difference in total Constant score when comparing the results of arthroscopic repair of the 2 groups (95% confidence interval, -3.43 to 3.9) (P = .44). There was no statistically significant difference in magnetic resonance imaging tendon score when comparing arthroscopic repair with or without PRFM (P = .07).

CONCLUSION

Our study does not support the use of autologous PRFM for augmentation of a double-row repair of a small or medium rotator cuff tear to improve the healing of the rotator cuff. Our results are applicable to small and medium rotator cuff tears; it is possible that PRFM may be beneficial for large and massive rotator cuff tears. Also, given the heterogeneity of PRFM preparation products available on the market, it is possible that other preparations may be more effective.

Current treatment options for tendinopathy

IMPORTANCE OF THE FIELD

Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management.

AREAS COVERED IN THIS REVIEW

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy.

WHAT THE READER WILL GAIN

The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined.

TAKE-HOME MESSAGE

Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.

Tissue engineered biological augmentation for tendon healing: a systematic review

INTRODUCTION

Tendon injuries give rise to significant morbidity. In the last few decades, several techniques have been increasingly used to optimize tendon healing.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the commercial names of each scaffold and the keywords 'tendon', 'rotator cuff', 'supraspinatus tendon', 'Achilles tendon', 'growth factors', 'cytokines', 'gene therapy', 'tissue engineering', 'mesenchymal' and 'stem cells' over the years 1966-2009. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context to tissue-engineered biological augmentation for tendon healing.

AREAS OF AGREEMENT

Several new techniques are available for tissue-engineered biological augmentation for tendon healing, growth factors, gene therapy and mesenchimal stem cells.

AREAS OF CONTROVERSY

Data are lacking to allow definitive conclusions on the use of these techniques for routine management of tendon ailments.

GROWING POINTS

The emerging field of tissue engineering holds the promise to use new techniques for tendon augmentation and repair. Preliminary studies support the idea that these techniques can provide an alternative for tendon augmentation with great therapeutic potential.

AREAS TIMELY FOR DEVELOPING RESEARCH

The optimization strategies discussed in this article are currently at an early stage of development. Although these emerging technologies may develop into substantial clinical treatment options, their full impact needs to be critically evaluated in a scientific fashion.

Sport injuries: a review of outcomes

Injuries can counter the beneficial aspects related to sports activities if an athlete is unable to continue to participate because of residual effects of injury. We provide an updated synthesis of existing clinical evidence of long-term follow-up outcome of sports injuries. A systematic computerized literature search was conducted on following databases were accessed: PubMed, Medline, Cochrane, CINAHL and Embase databases. At a young age, injury to the physis can result in limb deformities and leg-length discrepancy. Weight-bearing joints including the hip, knee and ankle are at risk of developing osteoarthritis (OA) in former athletes, after injury or in the presence of malalignment, especially in association with high impact sport. Knee injury is a risk factor for OA. Ankle ligament injuries in athletes result in incomplete recovery (up to 40% at 6 months), and OA in the long term (latency period more than 25 years). Spine pathologies are associated more commonly with certain sports (e.g. wrestling, heavy-weight lifting, gymnastics, tennis, soccer). Evolution in arthroscopy allows more accurate assessment of hip, ankle, shoulder, elbow and wrist intra-articular post-traumatic pathologies, and possibly more successful management. Few well-conducted studies are available to establish the long-term follow-up of former athletes. To assess whether benefits from sports participation outweigh the risks, future research should involve questionnaires regarding the health-related quality of life in former athletes, to be compared with the general population.

Achilles tendon ruptures in elite athletes

BACKGROUND

The management of Achilles tendon (AT) ruptures in elite athletes can be challenging. We performed a retrospective review of prospectively collected data study to evaluate the results of percutaneous repair of an acute AT rupture in elite athletes.

MATERIALS AND METHODS

Seventeen elite athletes with prodromal tendinous problems sustained an acute tear of the AT and underwent percutaneous surgical repair. We performed preoperative evaluations the day of surgery, and report the results of postoperative evaluation at a final followup at an average of 72 months from the procedure. Each patient was evaluated for limb dominance, trauma history, duration and type of preoperative symptoms, and postoperative AT Total Rupture Score (ATRS).

RESULTS

All patients were able to fully weightbear on the operated limb by the end of the 8th postoperative week. The average time to return to full sport participation was 4.8±0.9 months. Two of the 15 elite athletes on whom we have full data suffered from a superficial infection of the surgical wound.

CONCLUSION

Our study suggests that percutaneous repair of the AT is a good option for elite athletes, allowing a safe and prompt return to sport activities.

Candidate genes for physical performance in the horse

Intense selection for speed, endurance or pulling power in the domestic horse (Equus caballus) has resulted in a number of adaptive changes in the phenotype required for elite athletic performance. To date, studies in humans have revealed a large number of genes involved in elite athletic performance, but studies in horses are rare. The horse genome assembly and bioinformation tools for genome analyses have been used to compare human performance genes with their equine orthologues, both to retrieve pathways for these genes and to investigate their chromosomal distribution. In this review, 28 candidate genes for equine performance are presented that have polymorphisms associated with human elite athletic performance and may have impact on athletic performance in horses. A significant accumulation of candidate genes was found on horse chromosomes 4 and 12. Genes involved in pathways for focal adhesion, regulation of actin cytoskeleton, neuroactive ligand-receptor interaction, and calcium signalling were over-represented. Genome-wide association studies for athletic performance in horses may benefit from the strong conserved synteny of the chromosomal arrangement of genes in humans and horses.

Gene doping: the hype and the harm

"Gene doping" is the term used to describe the potential abuse of gene therapy as a performance-enhancing agent. Gene doping would apply the techniques used in gene therapy to provide altered expression of genes that would promote physical superiority. For example, insulin-like growth factor 1 (IGF-1) is a primary target for growth hormone; overexpression of IGF-1 can lead to increased muscle mass and power. Although gene doping is still largely theoretical, its implications for sports, health, ethics, and medical genetics are significant.

Inter-individual variability in adaptation of the leg muscles following a standardised endurance training programme in young women

There is considerable inter-individual variability in adaptations to endurance training. We hypothesised that those individuals with a low local leg-muscle peak aerobic capacity (VO2peak) relative to their whole-body maximal aerobic capacity (VO2max) would experience greater muscle training adaptations compared to those with a relatively high VO2peak. 53 untrained young women completed one-leg cycling to measure VO2peak and two-leg cycling to measure VO2max. The one-leg VO2peak was expressed as a ratio of the two-leg VO2max (Ratio(1:2)). Magnetic resonance imaging was used to indicate quadriceps muscle volume. Measurements were taken before and after completion of 6 weeks of supervised endurance training. There was large inter-individual variability in the pre-training Ratio(1:2) and large variability in the magnitude of training adaptations. The pre-training Ratio(1:2) was not related to training-induced changes in VO2max (P = 0.441) but was inversely correlated with changes in one-leg VO2peak and muscle volume (P < 0.05). No relationship was found between the training-induced changes in two-leg VO2max and one-leg VO2peak (r = 0.21; P = 0.129). It is concluded that the local leg-muscle aerobic capacity and Ratio(1:2) vary from person to person and this influences the extent of muscle adaptations following standardised endurance training. These results help to explain why muscle adaptations vary between people and suggest that setting the training stimulus at a fixed percentage of VO2max might not be a good way to standardise the training stimulus to the leg muscles of different people.