Operative treatment in non-emergency sports injuries: a sports medicine clinic experience

PURPOSE

To elucidate referrals from sports medicine clinic (SMC) to orthopedics, consensus rates among physicians and surgeons on surgical need in these patients, and reasoning of the patients who refused to have surgery despite the recommendations by both groups in non-emergency sports injury patients.

METHODS

We conducted a retrospective cohort analysis by using the administrative and referral records of a sports medicine clinic for the 15 months between October 2017 and January 2019. Gender, age, diagnosis, and type of sport were compared between two groups (patients referred to orthopedics vs patients treated in SMC). Agreement between orthopedics and SMC on surgical need in those patients who were referred to orthopedics was evaluated. We additionally screened the hospital archive for surgery reports of patients recommended surgery, and, if a patient did not have a surgery record, we investigated the reasons by telephone interview and categorized these reasons.

RESULTS

Surgical evaluation needed for 4.7% (n = 155) of the patients. Patients referred to orthopedics were younger (median: 22.0 years), mostly male (n = 119, 76.8%), and involved in contact sports (n = 108, 69.7%) (p < 0.001 for all) compared to patients treated conservatively. Majority of the consultations were made owing to certain diagnoses such as cruciate/collateral ligament sprain (n = 70, 45.2%), meniscal tear (n = 21, 13.5%), and cartilage injuries (n = 15, 9.7%). Most of the patients diagnosed with Achilles tendon rupture (n = 2, 100%) and patellar instability (n = 13, 81.3%) were referred to surgery. Orthopedics agreed with the sports medicine physicians' opinions in most cases (n = 110, 71.0%). Thirty-four patients (30.9%) recommended surgery by the surgeon postponed/refused the treatment for various reasons or had surgery in another hospital.

CONCLUSION

Most non-emergency sports injuries can be treated conservatively. Young and male patients participating in contact sports are more likely to need surgical treatment. Non-surgeon musculoskeletal health-care providers may consider referring patients to orthopedics considering the data demonstrated in this study. Nevertheless, patient's motivation to undergo an operation should be considered before referring to orthopedics.

Role of echocardiography on early diagnosis of atrial remodelling and fibrosis in elite athletes

There is emerging data indicating that long-standing vigorous exercise may be associated with atrial structural remodelling. This remodelling process is may be the cause of the increasing frequency of atrial arrythmias in athletes. Early diagnosis of atrial remodelling by atrial imaging could have a role in management of atrial arrythmias in elite athletes. In this study we aimed to diagnose early phases of atrial remodelling in elite athletes. Two groups of athletes including professional weight lifters (n = 33), professional marathoners (n = 32) and sedentary participants (n = 30) were enrolled. We also studied patients who received cardiotoxic chemotherapy (n = 10) for comparison. Serum TGF-beta level as a marker of fibrosis was measured. Both left atrial (LA) 3D volume and strain values were analysed. There was a positive correlation between serum TGF-beta levels and LA volumes and negative correlation between TGF-beta levels and strain values. TGF-beta levels were higher among chemotherapy and weight lifter groups, compared to control and marathoner groups [mean 0.57 ± 0.3 and 0.55 ± 0.2 vs. 0.45 ± 0.2 and 0.47 ± 0.2, respectively, p = 0.005]. LA volumes were higher among chemotherapy and weight lifter groups [median 33 (26-38) and 31 (23-36) respectively, p = 0.005], and strain values were lower in these two groups [mean 20.3 ± 2.5 and 24.6 ± 4.5, respectively, p < 0.005] compared to control and marathoner groups. Total exercise volume was higher in weight lifter group compared to marathoners [13,780 (2496-36,400) vs. 4732 (780-44928), respectively, p = 0.001]. There wasn't any difference between any group regarding left ventricular systolic and diastolic functions. Vigorous exercise causes atrial remodelling and fibrosis in elite athletes. Strength exercise carries higher risk for atrial fibrosis than endurance exercise. Burden of exercise is correlated with the severity of cardiac fibrosis. Echocardiographic evaluation of the left atrium and TGF-beta levels may help to detect subclinical cardiac remodelling and fibrosis.

Self-reported bio-psycho-social factors partially distinguish patellar tendinopathy from other knee problems and explain patellar tendinopathy severity in jumping athletes: A case-control study

OBJECTIVE

To determine what combinations of self-reported factors distinguish patellar tendinopathy (PT) from other knee problems, and explain PT severity variance.

DESIGN

Case-control study.

SETTING

Social media, private practice and National Health Service.

PARTICIPANTS

An international sample of jumping athletes diagnosed with either PT (n = 132; 30.7 ± 8.9 years; 80 males; VISA-P = 61.6 ± 16.0) or another musculoskeletal knee condition (n = 89; 31.8 ± 9.9 years; 47 males; VISA-P = 62.9 ± 21.2) by a clinician in the last 6 months.

MAIN OUTCOME MEASURES

We considered clinical diagnosis (case = having PT vs control = having other knee problems) as the dependent variable. Severity and sporting impact were defined by VISA-P and availability, respectively.

RESULTS

A model comprising seven factors distinguished PT from other knee problems; training duration (OR = 1.10), sport type (OR = 2.31), injured side (OR = 2.28), pain onset (OR = 1.97), morning pain (OR = 1.89), condition acceptability (OR = 0.39) and swelling (OR = 0.37). Sports-specific function (OR = 1.02) and player level (OR = 4.11) explained sporting availability. 44% of PT severity variance was explained by quality of life (β = 0.32), sports-specific function (β = 0.38) and age (β = -0.17).

CONCLUSION

Sports-specific, biomedical and psychological factors partially distinguish PT from other knee problems. Availability is mainly explained by sports-specific factors, while psychosocial factors impact on severity. Adding sports-specific and bio-psycho-social factors into assessments could help better identification and management of jumping athletes with PT.

Adolescent male soccer players have higher growth rates and risk of injury is associated with biological maturity

BACKGROUND

The objective of this study was to ascertain disparities in growth and maturation between male adolescents engaged in soccer and their non-athletic counterparts, as well as to examine the injury features specific to young soccer players.

METHODS

A total of 206 soccer players between the ages of 11-16 years, and 208 non-athletic peers were enrolled. Height, weight, body mass index (BMI), annual growth rate, and skeletal age evaluated using a left handwrist x-ray were determined. Biological and sexual maturation were evaluated using skinfold thickness, body composition, and Tanner stages. The game positions, initial age for playing soccer, the number of games per/ week, the number of sports injuries, date of injury, duration for return to activity, the site, nature, mechanism, and rate of injury were recorded for soccer players. Using an injury card, the characteristics of soccer player injuries were recorded.

RESULTS

The mean age of the participants was 13.6 ± 1.5 years. There was no difference in the growth rates between the groups at the ages of 11.0, 12.0, and 15.0 but at the ages of 13.0 and 14.0 years growth rates were higher in the soccer group. The soccer players were taller than the controls. For all Tanner stages, soccer players had a lower BMI and total body fat percentage, as well as a faster growth rate. Injuries occurred at a rate of 39.3% per year among soccer players. The most common being toe injuries, and playing soccer increased the risk of multiple injuries. Additionally, injuries occurred more frequently in soccer players who were taller, heavier, with higher total body fat and/or higher growth rate, and most commonly occurred during Tanner stage 4. Futhermore, Tanner stage 4 had a higher incidence of two or more injuries than the other stages.

CONCLUSIONS

Adolescent male soccer players have higher growth rates than their non-athletic peers, and their biological maturity status is associated with an increased risk of injury.

Ramadan Observance Exacerbated the Negative Effects of COVID-19 Lockdown on Sleep and Training Behaviors: A International Survey on 1,681 Muslim Athletes

Objective

Disrupted sleep and training behaviors in athletes have been reported during the COVID-19 pandemic. We aimed at investigating the combined effects of Ramadan observance and COVID-19 related lockdown in Muslim athletes.

Methods

From an international sample of athletes (n = 3,911), 1,681 Muslim athletes (from 44 countries; 25.1 ± 8.7 years, 38% females, 41% elite, 51% team sport athletes) answered a retrospective, cross-sectional questionnaire relating to their behavioral habits pre- and during- COVID-19 lockdown, including: (i) Pittsburgh sleep quality index (PSQI); (ii) insomnia severity index (ISI); (iii) bespoke questions about training, napping, and eating behaviors, and (iv) questions related to training and sleep behaviors during-lockdown and Ramadan compared to lockdown outside of Ramadan. The survey was disseminated predominately through social media, opening 8 July and closing 30 September 2020.

Results

The lockdown reduced sleep quality and increased insomnia severity (both p < 0.001). Compared to non-Muslim (n = 2,230), Muslim athletes reported higher PSQI and ISI scores during-lockdown (both p < 0.001), but not pre-lockdown (p > 0.05). Muslim athletes reported longer (p < 0.001; d = 0.29) and later (p < 0.001; d = 0.14) daytime naps, and an increase in late-night meals (p < 0.001; d = 0.49) during- compared to pre-lockdown, associated with lower sleep quality (all p < 0.001). Both sleep quality (χ² = 222.6; p < 0.001) and training volume (χ² = 342.4; p < 0.001) were lower during-lockdown and Ramadan compared to lockdown outside of Ramadan in the Muslims athletes.

Conclusion

Muslim athletes reported lower sleep quality and higher insomnia severity during- compared to pre-lockdown, and this was exacerbated by Ramadan observance. Therefore, further attention to Muslim athletes is warranted when a circadian disrupter (e.g., lockdown) occurs during Ramadan.

Lockdown Duration and Training Intensity Affect Sleep Behavior in an International Sample of 1,454 Elite Athletes

Objective: To investigate the effect of 1) lockdown duration and 2) training intensity on sleep quality and insomnia symptoms in elite athletes.

Methods: 1,454 elite athletes (24.1 ± 6.7 years; 42% female; 41% individual sports) from 40 countries answered a retrospective, cross-sectional, web-based questionnaire relating to their behavioral habits pre- and during- COVID-19 lockdown, including: 1) Pittsburgh sleep quality index (PSQI); 2) Insomnia severity index (ISI); bespoke questions about 3) napping; and 4) training behaviors. The association between dependent (PSQI and ISI) and independent variables (sleep, napping and training behaviors) was determined with multiple regression and is reported as semi-partial correlation coefficient squared (in percentage).

Results: 15% of the sample spent < 1 month, 27% spent 1–2 months and 58% spent > 2 months in lockdown. 29% self-reported maintaining the same training intensity during-lockdown whilst 71% reduced training intensity. PSQI (4.1 ± 2.4 to 5.8 ± 3.1; mean difference (MD): 1.7; 95% confidence interval of the difference (95% CI): 1.6–1.9) and ISI (5.1 ± 4.7 to 7.7 ± 6.4; MD: 2.6; 95% CI: 2.3–2.9) scores were higher during-compared to pre-lockdown, associated (all p < 0.001) with longer sleep onset latency (PSQI: 28%; ISI: 23%), later bedtime (PSQI: 13%; ISI: 14%) and later preferred time of day to train (PSQI: 9%; ISI: 5%) during-lockdown. Those who reduced training intensity during-lockdown showed higher PSQI (p < 0.001; MD: 1.25; 95% CI: 0.87–1.63) and ISI (p < 0.001; MD: 2.5; 95% CI: 1.72–3.27) scores compared to those who maintained training intensity. Although PSQI score was not affected by the lockdown duration, ISI score was higher in athletes who spent > 2 months confined compared to those who spent < 1 month (p < 0.001; MD: 1.28; 95% CI: 0.26–2.3).

Conclusion: Reducing training intensity during the COVID-19-induced lockdown was associated with lower sleep quality and higher insomnia severity in elite athletes. Lockdown duration had further disrupting effects on elite athletes’ sleep behavior. These findings could be of relevance in future lockdown or lockdown-like situations (e.g., prolonged illness, injury, and quarantine after international travel).

The effects of home confinement on physical activity level and mental status in professional football players during COVID-19 outbreak

OBJECTIVES

The coronavirus outbreak caused significant changes in football around the world, such as the suspension of leagues and home isolation of players, etc. The main purpose of the present study was to assess the psychological impacts of lockdown and similar restrictions on professional football players during the coronavirus pandemic.

MATERIALS AND METHODS

The players from 36 professional football teams (n = 977) among Turkish Super League and First League teams were invited to complete a questionnaire including the Center for Epidemiologic Studies Depression Scale (CES-D), Impact of Event Scale-Revised Scores (IES-R) and short form of International Physical Activity Questionnaire (IPAQ).

RESULTS

The online survey was completed by 237 players (24.3%). The mean number of self-quarantine day of participants was 26.9 ± 6.2 days. The median CES-D Scale and IES-R scores were 6.0 (min:0, max:42) and 23.0 (min:0, max:59), respectively. IPAQ scores of the players showed that four-fifths of the players still maintain high physical activity levels. There were negative, very weak and significant correlations between CES-D score and being married (r = -0.146, p = 0.024), as well as between CES-D score and IPAQ-Walking (r = -0.189, p = 0.004). A significant positive very weak correlation was observed between CES-D score and self-quarantine days (r = 0.148, p = 0.024). IPAQ-Walking was an independent predictor of CES-D.

CONCLUSION

These findings support that maintaining regular physical activity and routinely exercising in a safe home environment is one of the most important strategies to ensure healthy mental state.

COVID-19 Lockdowns: A Worldwide Survey of Circadian Rhythms and Sleep Quality in 3911 Athletes from 49 Countries, with Data-Driven Recommendations

Objective

In a convenience sample of athletes, we conducted a survey of COVID-19-mediated lockdown (termed ‘lockdown’ from this point forward) effects on: (i) circadian rhythms; (ii) sleep; (iii) eating; and (iv) training behaviors.

Methods

In total, 3911 athletes [mean age: 25.1 (range 18–61) years, 1764 female (45%), 2427 team-sport (63%) and 1442 elite (37%) athletes] from 49 countries completed a multilingual cross-sectional survey including the Pittsburgh Sleep Quality Index and Insomnia Severity Index questionnaires, alongside bespoke questions about napping, training, and nutrition behaviors.

Results

Pittsburgh Sleep Quality Index (4.3 ± 2.4 to 5.8 ± 3.1) and Insomnia Severity Index (4.8 ± 4.7 to 7.2 ± 6.4) scores increased from pre- to during lockdown (p < 0.001). Pittsburgh Sleep Quality Index was predominantly influenced by sleep-onset latency (p < 0.001; + 29.8%), sleep efficiency (p < 0.001; − 21.1%), and total sleep time (p < 0.001; − 20.1%), whilst Insomnia Severity Index was affected by sleep-onset latency (p < 0.001; + 21.4%), bedtime (p < 0.001; + 9.4%), and eating after midnight (p < 0.001; + 9.1%). During lockdown, athletes reported fewer training sessions per week (− 29.1%; d = 0.99). Athletes went to bed (+ 75 min; 5.4%; d = 1.14) and woke up (+ 150 min; 34.5%; d = 1.71) later during lockdown with an increased total sleep time (+ 48 min; 10.6%; d = 0.83). Lockdown-mediated circadian disruption had more deleterious effects on the sleep quality of individual-sport athletes compared with team-sport athletes (p < 0.001; d = 0.41), elite compared with non-elite athletes (p = 0.028; d = 0.44) and older compared with younger (p = 0.008; d = 0.46) athletes.

Conclusions

These lockdown-induced behavioral changes reduced sleep quality and increased insomnia in athletes. Data-driven and evidence-based recommendations to counter these include, but are not limited to: (i) early outdoor training; (ii) regular meal scheduling (whilst avoiding meals prior to bedtime and caffeine in the evening) with appropriate composition; (iii) regular bedtimes and wake-up times; and (iv) avoidance of long and/or late naps.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40279-021-01601-y.

Pain during walking and ascending stairs before hyaluronic acid injection was common in patients with knee osteoarthritis: a qualitative study

Background/aim

Knee osteoarthritis (OA) is a common pathology characterized by degeneration of the articular cartilage. The aim of the research was to ask patients how they decided to make the injection, what treatments they received, their complaints prior to and after the injection and how they feel at the moment, and whether they are currently exercising or not. Thus, to demonstrate the patients’ outcomes with their own expression.

Materials and methods

A total of 92 knee OA patients completed semistructured interviews, which included six open-ended questions.

Results

A total of 92 patients (66 female, 26 male) aged between 36 and 95 years (mean 65.511.14) were included. Before the injection, the majority of the OA patients had pain complaints when walking (72.8%) and stair climbing (70.7%). One to four years after intraarticular injection, 45.2% of patients felt a decrease in their complaints. The majority of patients did not consider diet and exercise as a treatment option. In addition, almost all patients declared that they decided on hyaluronic acid injection treatment with the physician’s recommendation.

Conclusion

Pain during walking and stair climbing before hyaluronic acid injection was common in knee OA patients. Overall the patients felt a decrease in the symptoms after injection. Patients did not consider diet and exercise as a treatment option despite the recommendation by a physician.

Evaluation of stoppage time due to field injuries in professional football games: do players really need medical help so often?

This study aimed to identify the incidence of stoppage time due to field injuries in professional football (soccer) games and to evaluate if the players involved really need medical care and whether team physicians deal with fake injuries. A total of 893 injury time-outs occurred leading to 956 treatments during 266 matches included in the study. The mean stoppage time was 88.7 ± 34.4 seconds. Less than one fifth of the injuries (17.4%) resulted in an impossibility to complete the game. The overall time-loss injury incidence which led players to miss the next game was 9.1/1000 match-hours (n = 80, 8.4% of all injuries). The players on teams in the lead at the time of the incident had significantly higher injury time-out incidence than players on teams who were losing (p < 0.05). Increasing the knowledge of team physicians, coaches, referees, and rule-makers about the medical needs of players during the game will help to identify the behaviour pattern of players.

Do Plantar Pressure and Loading Patterns Vary with Joint Hypermobility in Young Females?

BACKGROUND

Joint hypermobility is a connective tissue disorder that increases joint range of motion. Plantar pressure and foot loading patterns may change with joint hypermobility. We aimed to analyze static plantar pressure in young females with and without joint hypermobility.

METHODS

Joint laxity in 27 young females was assessed cross sectionally using the Beighton and Horan Joint Mobility Index. Participants were divided into the hypermobility (score, 4-9) and no hypermobility (score, 0-3) groups according to their scores. Static plantar pressure and forces were recorded using a pedobarographic mat system.

RESULTS

Higher peak pressures (P = .01) and peak pressure gradients (P = .025) were observed in the nondominant foot in the hypermobility group. According to the comparison of dominant and nondominant feet in each group, the hypermobility group showed significantly higher peak pressures (P = .046), peak pressure gradients (P = .041), and total force values (P = .028) in the nondominant foot.

CONCLUSIONS

The plantar pressure and loading patterns vary in young females with joint hypermobility. Evaluation of plantar loading as an injury prevention tool in individuals with joint hypermobility syndrome can be suggested.

Effects of hyperlipidemia on patellar tendon stiffness: A shear wave elastography study

BACKGROUND

Recent studies presented that increased adiposity and hyperlipidemia may cause tendon pathology. The aim of this study was to evaluate the effect of hyperlipidemia on the patellar tendon stiffness by shear wave elastography.

METHODS

A total of 51 participants (19 female, 32 male) were included. Participants were divided into two groups, according to their low-density lipoprotein levels, as the study group (hyperlipidemia, n = 24) and the control group (non-hyperlipidemia, n = 27). The patellar tendon and rectus femoris muscle shear wave velocities were measured by shear wave elastography.

FINDINGS

Patellar tendon shear wave velocities was 5.02 (SD: 0.78) m/s in the control group and 5.98 (SD: 1.19) m/s in the hyperlipidemia group (ES = 0.95, P = .001). There was a positive moderate statistically significant correlation between patellar tendon shear wave velocity and low-density lipoprotein (r = 0.432, p < .002). In the multiple linear regression analysis, only low-density lipoprotein was found as a significant predictor of patellar tendon shear wave velocity (CI: 0.005-0.028, P = .007).

INTERPRETATION

We evaluated the effects of hyperlipidemia and body mass index on patellar tendon mechanical properties with shear wave elastography. We found that the blood low-density lipoprotein level had an impact on patellar tendon stiffness independently of body mass index. Accordingly, it is important to evaluate individuals' low-density lipoprotein levels when examining risk factors for tendon pathology.

Effects of Blood Flow Restriction Training on Muscle Strength and Architecture

Korkmaz, E, Dönmez, G, Uzuner, K, BabayevaŞerife Şeyma Torgutalp, N, and Özçakar, L. Effects of blood flow restriction training on muscle strength and architecture. J Strength Cond Res XX(X): 000-000, 2020-The aim of this study was to compare the effect of the traditional resistance (RES) training and low-intensity resistance training with blood flow restriction (BFR) protocols on quadriceps and hamstring muscle strength, and rectus femoris (RF) and vastus lateralis architecture, in youth team soccer players. Twenty-three young trained soccer team players were divided into 2 groups: the RES group that practiced traditional high-intensity resistance training (80% 1 repetition maximum [1RM], 4 sets, 12 rep.) (n = 12) and the BFR group that performed low-intensity resistance exercise with BFR (30% 1RM, 4 sets, 30-15-15-15 rep) (n = 11)-unilateral knee extension exercise-twice a week for 6 weeks. Muscle strength (isokinetic concentric peak torque of the quadriceps and hamstring muscles) and ultrasonographic parameters (muscle thickness, pennation angle, and fascicle length) were assessed. Bilateral knee flexor and extensor strength was increased in both groups compared with pre-exercise. The increase in dominant side extensor muscle strength (60°·s p = 0.02, ηp = 0.256, 180°·s p = 0.019, ηp = 0.271) and RF thickness (p = 0.002, ηp = 0.361) was statistically higher in the BFR group than in the RES group. These findings support that occlusion training can provide better benefits than traditional strength training to improve muscle hypertrophy. In addition, the novelty of our study is that BFR training may affect the muscle structure measured by ultrasonography.

Thirty Minutes of Running Exercise Decreases T2 Signal Intensity but Not Thickness of the Knee Joint Cartilage: A 3.0-T Magnetic Resonance Imaging Study

OBJECTIVE

Recent studies showed a potential of magnetic resonance imaging (MRI), which can be used as an additional tool for diagnosing cartilage degeneration in the early stage. We designed a cross-sectional study in order to evaluate knee joint cartilage adaptation to running, using 3.0-T MRI equipped with the 3-dimensional turbo spin echo (VISTA = Volume ISotropic Turbo spin echo Acquisition) software. By this thickness (mm) and signal intensity (mean pixel value) can be quantified, which could be closely related to the fluid content of the knee joint cartilage, before and after running.

METHODS

A total of 22 males, aged 18 to 35 years, dominant (right) and nondominant (left) knees were assessed before and after 30 minutes of running. Cartilage thickness and signal intensity of surfaces of the patella, medial and lateral femoral and tibial condyles were measured.

RESULTS

Cartilage thickness of the lateral condyle decreased at the dominant knee, while it increased at the medial tibial plateau. Signal intensity decreased at all locations, except the lateral patella in both knees. The most obvious decrease in signal intensity (10.6%) was at the medial tibial plateau from 949.8 to 849.0 of the dominant knee.

CONCLUSION

There was an increase in thickness measurements and decrease in signal intensity in medial tibial plateau of the dominant knee after 30 minutes of running. This outcome could be related to fluid outflow from the tissue. Greater reductions in the medial tibial plateau cartilage indicate greater load sharing by these areas of the joint during a 30-minute running.

Meloxicam and diclofenac do not change VEGF and PDGF-ABserum levels of platelet-rich plasma

BACKGROUND/AIM

Platelet-rich plasma (PRP) application has gained widespread interest for musculoskeletal injuries. Nonsteroidal antiinflammatory drugs are frequently used in sports medicine before and/or after PRP application. Our study seeks to determine whether serum levels of platelet-derived growth factor-AB (PDGF-AB) and vascular endothelial growth factor (VEGF) levels of PRP would be affected by nonsteroidal antiinflammatory drugs.

MATERIALS AND METHODS

Two different final concentrations of diclofenac (0.5 μg mL^-1 and 2.5 μg mL^-1), meloxicam (0.8 μg mL^-1 and 2.0 μg mL^-1), and acetylsalicylic acid (final concentration 450 μm) were obtained in separate tubes with PRPs prepared from 20 healthy male volunteers. Medicine-free PRP was the control group. Growth factors were measured using ELISA.

RESULTS

PDGF-AB and VEGF serum levels did not change with diclofenac, meloxicam, or acetylsalicylic acid addition. PDGF-AB and VEGF serum levels correlated with each other.

CONCLUSION

Diclofenac, meloxicam, and acetylsalicylic acid did not affect PDGF-AB and VEGF serum levels.

Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes

Objective

To describe a clinical treatment algorithm for posterior ankle impingement (PAI) syndrome in professional football players.

Material and methods

A case series of 26 elite professional football players diagnosed and treated for posterior ankle impingement syndrome were included for the study. All of the athletes received conservative treatment with physical therapy modalities initially. If the first line medical treatment and rehabilitation was ineffective to alleviate the symptoms, ultrasound-guided corticosteroid injection was proposed and thereafter the patients underwent posterior ankle arthroscopy if the complaints are still unresolved. The pain scores (AOFAS, VAS), and time to return to play were the main outcome measures.

Results

The complaints of 18 (69.2%) players were subsided with non-surgical treatment whereas three of acute cases and five of the chronic cases did not respond to medical treatment and arthroscopic surgery was performed for eight athletes. Eighteen players returned to training for a mean time of 36.3 days (24–42 days) after conservative treatment. The patients who underwent arthroscopic surgery returned to training for a mean time of 49.8 days (42–56 days) after the surgery. All athletes returned to their previous level of competition after treatment without any complications or recurrence in a mean follow-up 36.5 months (19–77 months).

Conclusion

Non-surgical treatment modalities were effective in 2/3 of posterior ankle impingement syndrome in elite football players. On the other hand, posterior ankle arthroscopy is safe and effective treatment option for posterior ankle impingement syndrome if the conservative treatment fails.

Level of evidence

Level IV, Therapeutic study

Effects of immobilization and whole-body vibration on rat serum Type I collagen turnover

Objective

The aim of this study was to investigate the effects of short-term, high-magnitude whole-body vibration (WBV) on serum type I collagen turnover in immobilized rats.

Materials and Methods

Thirty Wistar albino rats were randomly divided into the following 5 groups: immobilization (IS), immobilization + remobilization (IR), immobilization + WBV (IV), control (C), and WBV control (CV). Immobilization was achieved by casting from the crista iliaca anterior superior to the lower part of the foot for 2 weeks. The applied WBV protocol involved a frequency of 45 Hz and amplitude of 3 mm for 7 days starting a day after the end of the immobilization period. Serum type I collagen turnover markers were measured by using ELISA kits.

Results

Serum NH2-terminal propeptide of type I collagen (PINP) levels were significantly lower in the immobilization groups (p < 0.02) compared with the control groups. Although WBV improved PINP levels in the control groups, there were no differences in PINP levels among the immobilization groups. Similarly, serum COOH-terminal telopeptide of type I collagen (CTX) levels were higher in the WBV controls than their own controls (p < 0,05). Immobilization led to deterioration of tendon tissue, as observed by histopathological analysis with a transmission electron microscope.

Conclusion

Although 1 week of WBV had a positive effect on type I collagen turnover in controls, it is not an efficient method for repairing tissue damage in the early stage following immobilization.

Double layer repair of tibialis anterior muscle hernia in a soccer player: a case report and review of the literature

BACKGROUND

muscle herniations usually present in athletes especially in the lower legs; occurring through defects in the deep fascial layer of the muscles and typically seen following local blunt trauma or muscle hypertrophy after strenuous exercise. Management of muscle hernias varies from conservative therapy to surgical repair and usually needs multidisciplinary collaboration for differential diagnosis.

METHODS

herein tibialis anterior muscle hernia in 17-year-old male soccer player was presented. The diagnosis was confirmed with dynamic ultrasonographic views changing with the different movements of the ankle. Since the symptoms were not relieved with conservative methods, surgical repair of the defect was offered.

RESULTS

we preferred to repair fascial defect with double layer and Mesh graft that were placed over primary suture repair. No complications were reported such as wound or mesh infection postoperatively. The patient was clinically satisfied and returned his previous activity level after 3 months of surgery. After 2 years of follow-up the feature of the bulge was dissolved and player was satisfied with the operation.

CONCLUSION

knowledge of the lower extremity muscle herniation is essential for both proper management and/or surgical referral. The importance of protective devices in prevention, dynamic ultrasonography in diagnosis and double layer repair of the fascial defect with Mesh graft in treatment of muscle herniations were highlighted.

Surgical treatment of Achilles tendon ruptures: the comparison of open and percutaneous methods in a rabbit model

BACKGROUND

This study was intended to investigate the healing properties of open and percutaneous techniques in a rabbit model and compare histological, electron microscopical, and biomechanical findings of the healed tendon between the groups.

METHODS

Twenty-six rabbits were randomly assigned to two groups of thirteen rabbits each. Percutaneous tenotomy of the Achilles tendon (AT) was applied through a stab incision on the right side 1.5 cm above the calcaneal insertion in all animals. Using the same Bunnell suture, the first group was repaired with the open and the second group was repaired with the percutaneous method. ATs were harvested at the end of eight weeks for biomechanical and histological evaluation.

RESULTS

When the sections were evaluated for fibrillar density under electron microscopy, it was noted that fibrils were more abundant in the percutaneous repair group. The tendon scores in the percutaneous group were less than the open group indicating closer histological morphology to normal. The difference was not significant (p=0.065). The mean force to rupture the tendon was 143.7± 9.5 N in percutaneous group and 139.2±8.2 N in the open group. The difference was not significant (p=0.33).

CONCLUSION

Percutaneous techniques provide as good clinical results as the open techniques do. The healing tendon shows better findings in histological and electron microscopical level with percutaneous technique.

Bioremoval of Reactive Blue 220 by Gonium sp. biomass

Gonium sp. was tested for the bioremoval of Reactive Blue 220 (RB220) dye at different conditions such as pH values, initial dye concentrations and biomass concentrations to evaluate the possibility of using this microalga in treating wastewaters. According to the data obtained from the experiments, microalgae removed RB220 with the highest yield (54.2%) at pH 8, and could treat the applied dye with the highest removal percentage as 84.2% at the lowest dye concentration (26.2 mg/L RB220). Increasing Gonium sp. biomass concentration from 0.21 to 0.53 g/L stimulated RB220 removal rate from 87.7% to 96.8%. The present study clearly indicated that Gonium sp. biomass could be used as a bioremediation biosorbent in treating RB220 dye in the related wastewaters.

Proximal humeral physeal widening: little leaguer's shoulder or a variation of normal development?

Little leaguer's shoulder is a syndrome involving the proximal humeral epiphyseal plate and has been reported in adolescent athletes between 13-16 years of age. We present an adolescent case with radiological findings of little leaguer's shoulder syndrome in a non-athletic patient. The patient had applied significant rotational stress to the proximal humeral physis as a result of overuse due to physiotherapy, but the left asymptomatic side appeared more affected radiologically, which led to the idea that this may be a physiological change that occurs in adolescents. We thus evaluated the anteroposterior radiography of 10 healthy male adolescents of the same age with no skeletal or muscular complaints. We demonstrated a minimal widening of the lateral part of the proximal humeral epiphysis in two of these 10 patients. We believe little leaguer's shoulder should also be considered in adolescents with proximal humeral pain and a history of overuse. A larger study must be conducted to investigate whether these finding may be a variation of physiological development.

Achilles tendon rupture: physiotherapy and endoscopy-assisted surgical treatment of a common sports injury

Although the Achilles tendon (AT) is the strongest tendon in the human body, rupture of this tendon is one of the most common sports injuries in the athletic population. Despite numerous nonoperative and operative methods that have been described, there is no universal agreement about the optimal management strategy of acute total AT ruptures. The management of AT ruptures should aim to minimize the morbidity of the injury, optimize rapid return to full function, and prevent complications. Since endoscopy-assisted percutaneous AT repair allows direct visualization of the synovia and protects the paratenon that is important in biological healing of the AT, this technique becomes a reasonable treatment option in AT ruptures. Furthermore, Achilles tendoscopy technique may decrease the complications about the sural nerve. Also, early functional postoperative physiotherapy following surgery may improve the surgical outcomes.

Functional anatomy of the Achilles tendon

The Achilles tendon is the strongest and thickest tendon in the human body. It is also the commonest tendon to rupture. It begins near the middle of the calf and is the conjoint tendon of the gastrocnemius and soleus muscles. The relative contribution of the two muscles to the tendon varies. Spiralisation of the fibres of the tendon produces an area of concentrated stress and confers a mechanical advantage. The calcaneal insertion is specialised and designed to aid the dissipation of stress from the tendon to the calcaneum. The insertion is crescent shaped and has significant medial and lateral projections. The blood supply of the tendon is from the musculotendinous junction, vessels in surrounding connective tissue and the osteotendinous junction. The vascular territories can be classified simply in three, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. This leaves a relatively hypovascular area in the mid-portion of the tendon where most problems occur. The Achilles tendon derives its innervation from the sural nerve with a smaller supply from the tibial nerve. Tenocytes produce type I collagen and form 90% of the cellular component of the normal tendon. Evidence suggests ruptured or pathological tendon produce more type III collagen, which may affect the tensile strength of the tendon. Direct measurements of forces reveal loading in the Achilles tendon as high as 9 KN during running, which is up to 12.5 times body weight.

Paget-Schroetter syndrome forerunning the diagnoses of thoracic outlet syndrome and thrombophilia

Reported here is a 22-year-old professional wrestler who was diagnosed to have Paget-Schroetter syndrome after Greco-Roman wrestling. On substantial neuromuscular examination and laboratory testing, he was found to have also thoracic outlet syndrome and heterozygous mutations for factor V Leiden and methyltetrahydrofolate reductase genes. To the best knowledge of the authors, the concomitance of these pathologies is discussed for the first time in the literature.

Bioaccumulation of copper(II) and nickel(II) by the non-adapted and adapted growing Candida sp

The effect of copper(II) and nickel(II) ions on the growth and bioaccumulation properties of non-adapted and adapted growing cells of a non-pathogenic Candida sp. has been tested under laboratory conditions as a function of initial pH and initial metal ion concentration. Optimum pH value for maximum metal ion accumulation was determined as 4.0 for both the metal ions. Although the copper(II) adapted Candida sp. was capable of removing of copper(II) with the maximum specific uptake capacity of 36.9 mg g-1 at 783.6 mg dm-3 initial copper(II) concentration, non-adapted Candida was only capable of bioaccumulating copper(II) with 23.1 mg g-1 maximum uptake capacity from aqueous solution at 578.7 mg dm-3 initial copper(II) concentration. The non-adapted and nickel(II) adapted Candida cells also showed the highest nickel(II) uptake capacities (46.8 and 30.8 mg g-1, respectively) at 321.5 and 300.6 mg dm-3 initial nickel(II) concentrations, respectively. For both the non-adapted and nickel(II) adapted Candida sp., the growth of cells was totally inhibited by 500 mg dm-3 of nickel(II) ions. The results also indicated that copper(II) adapted Candida sp. has been found to be more efficient to accumulate larger amounts of copper(II) than that of nickel(II) bioaccumulated by nickel(II) adapted Candida at higher initial metal ion concentrations without loosing its biological activity.

Comparison of copper(II) biosorptive properties of live and treated Candida sp

Biosorption of copper(II) ions from aqueous solutions was studied to compare the binding capacities of untreated (live) or treated (dried, autoclaved, perchloric acid (HClO4)-washed, ethanol-treated, formaldehyde-treated) Candida sp. Due to the ion exchange nature of metal biosorption, copper(II) uptake was strongly affected by the solution pH and optimum adsorption pH value was determined as 5.0 for all the live and treated Candida sp. At the optimal conditions, metal ion uptake increased with increasing initial copper(II) concentration up to 300 mg l-1 for all the biomass types. It is found that all the treatment methods used to kill the yeast (except for formaldehyde treatment) increased the copper(II) biosorption capacity of Candida cells. The results also indicated that copper(II) biosorption by live, autoclaved and formaldehyde-treated yeasts was consisted of an initial, rapid surface binding of copper(II) followed by a second, slower intracellular uptake of copper(II), but copper(II) uptake by the other treated yeasts took place only via surface binding. Both the Freundlich and Langmuir adsorption models were suitable for describing the short-term biosorption of copper(II) by all the untreated and treated Candida.