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BASEM Annual Congress 2008 8–10 October 2008, Brighton, UK

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PRIZE WINNER OF THE DJO (AIRCAST) CLINICAL SCIENCE PRIZE 2008 AT THE BASEM ANNUAL CONGRESS 2008. THE EFFECT OF PELVIC SUPPORT BELTS ON MUSCLE RECRUITMENT PATTERNS IN CHRONIC BACK AND LEG PAIN PATIENTS: A CROSS-SECTIONAL STUDY

H. Al-Hashimi. Queen Mary University of London, London, UK

Study design This was a cross sectional study measuring onsets of six trunk and hip muscles in subjects with back and leg pain (BLP) compared to healthy controls with and without an application of a pelvic belt.

Objective To determine whether muscle activation was different when wearing a belt between control and BLP subjects during hip extension and flexion.

Background Muscle activation of the trunk and gluteal muscles stabilise the spine in preparation for movement. In back pain delayed onset of oblique internus and multifidus indicates a deficient motor control. While several hypotheses have been suggested regarding the biomechanics of pelvic belts. Little is known about their effect on the temporal pattern of muscle activation.

Methods Seven patients with BLP and 12 control subjects participated. Surface electromyography (sEMG) of six lumbopelvic muscles was recorded during hip flexion in standing and hip extension in the prone position. The onset of muscle activation was compared between groups and between the two belt conditions (without and with belt).

Results None of the muscles consistently activated before beginning of movement. Subjects with BLP showed delayed onset times of oblique internus on the symptomatic side, compared with control subjects. Onset sEMG of the transverses abdominus and multifidus was significantly earlier in BLP when wearing the belt (p<0.05). In the control group, no consistent differences were found between the muscle onsets with and without the belt (p>0.05). Isolated differences were noted in the other muscles.

Conclusion In subjects without back pain a belt has no effect; but in patients with BLP wearing a belt may alter muscle activation patterns. It may reverse to a degree the abnormal activation pattern.

Clinical relevance Assuming that delayed onset of transverse abdominus and multifidus leads to inefficient ability of muscles to stabilise the lumbar spine, wearing the belt contributes to stabilization during the tasks assessed. Knowledge of these differences in muscle activation patterns in patients with BLP when wearing the belt broadens the understanding of clinicians treating low back pain.

PRIZE WINNER OF THE DJO (AIRCAST) BASIC SCIENCE PRIZE 2008 AT THE BASEM ANNUAL CONGRESS 2008. THE MECHANISM FOR EFFICACY OF ECCENTRIC LOADING IN ACHILLES TENDON INJURY: AN IN VIVO STUDY IN HUMANS

J. D. Rees, G. Lichtwark, R. Wolman, A. Wilson. Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK

Aim Degenerative disorders of tendons present an enormous clinical challenge. Eccentric, but not concentric, exercises have been shown to be highly effective in managing tendinopathy of the Achilles tendon. The mechanism for the efficacy of these exercises is unknown although it has been speculated that forces generated during eccentric loading are of a greater magnitude. Our objective was to determine the mechanism for the beneficial effect of eccentric exercise in Achilles tendinopathy.

Methods Seven healthy volunteers performed eccentric and concentric loading exercises for the Achilles tendon. Achilles tendon (AT) force and length changes were determined using a combination of motion analysis, force plate data and real time ultrasound.

Results During eccentric and concentric exercises there was minimal (non-significant) intra-subject variability in both peak AT force and length. There was a linear inter-subject relationship between peak AT force and patient mass for both eccentric and concentric exercise (R2 0.59 and 0.49 respectively). High frequency oscillations in tendon force occurred in all subjects during eccentric exercises but were rare in concentric exercises and were highly significant (p<0.0001). Typical force characteristics of two subjects during concentric and eccentric centric loading of the Achilles tendon showing sinusoidal variation in eccentric exercise only.

Conclusion Magnitude of force generated in eccentric loading cannot explain the therapeutic benefit of these exercises. High frequency oscillations in tendon force are observed during eccentric but not concentric exercise. These oscillations provide a mechanism to explain the therapeutic benefit of eccentric loading in Achilles tendinopathy and parallels recent evidence from bone remodelling where the frequency of the loading cycles is of more significance than the absolute magnitude of the force.1

LOW BONE DENSITY ON DUAL ENERGY X RAY ABSORPTION SCANS IN NOVICE JOCKEYS

1L. C. Free, 2M. Turner, 1N. G. Shenker. 1Addenbrooke’s, Cambridge University Hospitals, Cambridge CB2 2QQ, UK, 2British Horseracing Authority, 151 Shaftesbury Avenue, London WC2H 8AL, UK

Aim Osteoporosis is a disease of bone in which bone mineral density (BMD) is decreased leading to a reduced fracture threshold. Osteoporotic fractures are classically associated with older patients, but may also affect younger people. A high incidence of fractures in French riders has prompted a review of the characteristics of British apprentice jockeys. In a population of novice jockeys, is their bone density as measured by dual energy x ray absorption (DEXA) scans low?

Methods All apprentice jockeys at the British Racing School were offered bone densitometry. A questionnaire of basic data was completed & informed consent obtained. BMD was determined by DEXA measured at the hip and lumbar spine. Body fat percentage was determined by total body scan.

Results Of the 53 novice jockeys, 10 (18.87%) were female, the mean (SD) age was 19.16 (2.39) years, height 165.7 (7.68) cm, weight 54.8 (6.37) kg, body fat 13.36 (4.84) % and BMI 19.94 (1.66). The mean lumbar T-score (SD) was −1.48 (1.2) and lumbar Z-score was −1.11 (1.1). The mean femoral T-score was −0.92 (0.96) & femoral Z-score was −0.67 (0.88). 33 (62.3%) jockeys had lumbar T-scores <−1, and of those, 21 (39.6% of total) also had femoral T-scores <−1, defining them as osteopenic.

Conclusions The weight restrictions imposed on jockeys by the horse-racing industry impact on their lifestyle and nutritional status, potentially compromising both short- and long-term health and performance, similar to the problems observed in other weight-category and aesthetic sports. Despite nutritional education and random drug testing, concerns remain about methods and results of “making weight”. Further investigation and education is required.

PERSISTENT SYMPTOMS FOLLOWING NON OPERATIVE MANAGEMENT IN LOW-GRADE MEDIAL COLLATERAL LIGAMENT INJURY OF THE KNEE—THE ROLE OF THE DEEP MEDIAL COLLATERAL LIGAMENT?

L. Jones, Q. Bismil, F. Alyas, D. Connell, J. Bell. Wimbledon Knee Clinic, Parkside Hospital, Wimbledon, London, UK

Aims Incomplete injuries (grade I or II) to the medial collateral ligament (MCL) of the knee are common and usually self-limiting. Some patients complain of chronic medial knee pain following grade I or II MCL injury. This study highlights the importance of anatomical investigation of these patients and evaluates a successful treatment technique.

Methods We reviewed a consecutive case series of 34 patients (mean age 37 years, range 11–54; 11 patients were female; mean follow up 20.4 months, range 38–11). They presented with chronic pain following a grade I/II MCL injury and associated tenderness and thickening of the deep MCL. The knee was assessed by MRI using three plane fast spin echo proton density sequences and sagittal and coronal proton density fat suppressed sequences. In all patients there was radiological evidence of injury to both the superficial and the deep MCL, with thickening, scarring and tearing on coronal sections. Patients were treated with an ultrasound guided injection of local anaesthetic and steroid into the deep MCL and clinically reassessed. The patients were assessed for recurrence of symptoms with a postal questionnaire.

Results On clinical reassessment five minutes after injection all patients reported resolution of their medial knee pain. At mean follow-up 20.4 months (range 11–38 months) all patients were back to pre-injury level of work. 96% had returned to sporting activity. 81% reported no change in the level of sporting function.

Conclusions In patients with persistent medial knee pain following grade I/II MCL sprain, pain arising from the deep MCL should be considered. Symptoms and signs are difficult to differentiate from a medial meniscus tear. In patients with clinical features of a deep MCL injury, MRI will confirm diagnosis, exclude coexistent pathology and localise the lesion within the deep MCL. A single corticosteroid injection provides excellent clinical outcome 20 months post injection.

AN OBSERVATIONAL PILOT STUDY: PEDOMETER-DETERMINED PHYSICAL ACTIVITY LEVELS AND BODY COMPOSITION IN ENGLISH SCHOOL CHILDREN

M. Magro, T. Margham, Z. Hudson. Centre for Sport and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mann Ward, The Mile End Hospital, Bancroft Road, London E1 4DG, UK

The aims of the study were 1) to identify if a relationship exists between physical activity levels (steps-per-day) and BMI, waist circumference (WC) and percentage body fat. 2) Examine if a difference between weekend and weekday physical activity levels exists and 3) to see if activity levels are affected by ethnicity, gender and socioeconomic status.

91 children (46 girls and 45 boys, aged 11–12 years) from an East London school wore a sealed pedometer for 7 consecutive days (minimum 2 weekdays and 2 weekends) to determine activity levels. The ethnic composition was 56% British Bangladeshi and 44% Non-Bangladeshi. BMI was classified according to the International Obesity Task Force classification1 and WC was compared to British percentiles.2 Percentage body fat was measured using bioelectrical impedance analysis.

Mean steps counts were 8797 (girls) and 9989 (boys) on weekdays, and 11 097 (girls) and 13 108 (boys) on weekends. 18.4% children were classified as obese using BMI, whilst using WC 44.7% were obese. Percentage body fat demonstrated that 57.9% had excess body fat. ANOVA was carried out to determine if physical activity levels were significantly different between the markers of body composition, gender, ethnicity and socioeconomic status.

To our knowledge, this is the first study to compare these markers of body composition to pedometer-determined activity levels in Britain. It is also the first study to look specifically at British Bangladeshi children. The results are extremely interesting, as the school is situated within one of the 5 London Olympic boroughs for 2012, yet nearly 45% of children can be classified as obese and mean levels of physical activity are below the recommended 16 000 steps/day for boys and 13 000 for girls.3

Our results provide evidence that levels of childhood obesity are high in East London and that child are not meeting the recommended levels of physical activity.

THE PROFILE OF INJURIES OVER A MATCH PERIOD IN ENGLISH PREMIERSHIP RUGBY

1R. C. Pring, 1J. H. M. Brooks, 2S. P. T. Kemp. 1University College London in conjunction with the Rugby Football Union, London, UK, 2Rugby Football Union, Rugby House, Rugby Road, Twickenham, Middlesex TW1 1DZ, UK

The aim of this research was to profile injuries over a match period in English professional rugby union.

Injury data were collected prospectively over two seasons on 546 English premiership players. Match time was divided into four successive twenty-minute quarters. Injury incidence was calculated over successive quarters by playing position, mechanism, body part injured and pathology. Loss of time from training and match play was used as the definition of injury.1

The incidence of injury was significantly greater in the latter quarter of each half, both for forwards and backs. The outside back positions demonstrated an increased incidence of injury over successive quarters. All other grouped playing positions showed a drop in injury incidence after half time although this was not statistically significant. Non-contact injuries showed a progressive increase in incidence over successive quarters unlike contact injuries. Contact injuries showed a significant increase in incidence in the latter quarter of each half and a drop in incidence after half time. Head and neck injuries showed no variation in incidence over each quarter unlike upper limb, trunk and lower limb injuries which had an increased incidence in the latter quarter of each half. Joint (non bone) and ligament, and muscle and tendon injuries showed an increase incidence in the latter quarter of each half. This was not the case for fractures and bone stress injuries, lacerations and skin conditions and central and peripheral nerve lesions.

The overall incidence of injury increased in the latter quarter of each half. Fatigue is likely to play a role in injuries that follow this incidence pattern.1 2 However, this pattern is not always evident when analysing by certain mechanisms of injury, body part injured or pathology type. Video analysis of match play may provide more information regards causal factors.

KNEE FUNCTION AFTER MEDIAL PATELLO-FEMORAL LIGAMENT RECONSTRUCTION

M. Rashid, K. Dogiparthi, L. van Niekerk. Friarage Hospital, South Tees Hospitals NHS Trust, Northallerton, North Yorkshire, UK

Aims Chronic patello-femoral joint instability leads to recurrent subluxation and dislocation affecting knee function and preventing participation at sport. Traumatic dislocation of the patella results in rupture of the medial patello-femoral ligament (MPFL) in the majority of cases with a high incidence of chronic instability after a second dislocation. MPFL reconstruction can prevent recurrent dislocation and improve knee function. We report in our experience in MPFL reconstruction using hamstring tendons and its effect on the knee function in patients with chronic patello-femoral joint instability.

Methods In this prospective cohort study 62 patients with chronic patello-femoral instability were treated with MPFL reconstruction through a minimally invasive and arthroscopically assisted approach. In this procedure the semitendonsis with or without the gracilis tendons are routed from the pes anserinus to the most distal portion of the medial intramuscular septum before being secured to the superomedial border of the patella. All patients were evaluated pre-operatively and then post-operatively for a mean of 25 months (range 12–48 months). Knee function was assessed with the use of the International Knee Documentation Committee (IKDC), Tegner, Kujala and Lysholm scores.

Results There were 37 male and 25 female patients with average age of 26.9 years (range 20–59). There were 2.7 mean pre-operative patellar dislocations (range 2–7). Twelve patients had associated knee ligament injuries, six had associated meniscal injuries and 10 patients had femoral trochlear dysplasia. IKDC score improved from 44.1 to 75, Lysholm score improved from 55.4 to 76 and Kujala score improved from 57.4 to 84 and Tegner activity score improved from 2 to 6. There were overall 87% good to excellent results. No recurrent dislocations or wound related complications.

Conclusion Medial patello-femoral reconstruction can provides excellent results in the treatment of patello-femoral joint instability with poor knee function.

THE EFFECTS OF AN AEROBIC DANCE INTERVENTION PROGRAMME ON PHYSIOLOGICAL FACTORS IN ADOLESCENT GIRLS

K. Stewart, A. Mooney J, A. MacLean, W. S. Hillis. University of Glasgow, Department of Sports Medicine, Glasgow, UK

Aim Participation in physical activity has been shown to decrease throughout adolescence1 and by age 13–15, only 41% of girls do at least 60 minutes of physical activity on each day of the week compared to 68% of boys.2 This study examined the effect of a 10-week aerobic dance intervention programme on body fat and aerobic fitness of adolescent girls.

Methodology Twenty-eight female subjects age (mean ±SD) 14.8 (±0.48) years, height 158.6 cm (±6.39), weight 55.2 kg(±8.53) were recruited from one Secondary School in Glasgow to participate in this study. A girls-only physical education (PE) class (with girls who typically have very low interest and adherence to PE) was randomly divided into an intervention group and an inactive control group. The dance group undertook a 10-week aerobic dance programme, while the inactive control group continued with their usual PE class. A second age-matched class of girls who had enrolled in Standard Grade PE were recruited as an active control group. Physiological assessment including height, weight, skinfold thickness and aerobic fitness was carried out on all subjects. In addition POLAR heart rate monitors were used to record the intensity of each session.

Results Baseline results confirmed that the intervention group had a significantly higher percentage body fat (p = 0.011) and lower aerobic fitness (p = 0.018) than the Standard Grade group. Following the dance programme, the dance group showed a significant decrease in percentage body fat (p = 0.004) compared to the usual PE group and although not statistically significant, an increasing trend was seen in aerobic fitness. No differences were seen in Standard grade group (p>0.05).

Conclusion Aerobic dance is a useful tool in trying to improve activity levels and reduce body fat in adolescent girls. A longitudinal intervention study with a larger cohort would help to investigate the potential benefit further.

EXERCISE AND HAEMOSTASIS IN PATIENTS WITH CYANOTIC CONGENITAL HEART DISEASE

D. White, K. Stewart, W. S. Hillis. University of Glasgow, Department of Sports Medicine, Glasgow, UK

Aim This study investigated the haemostatic response to acute and maximal exercise in patients with Eisenmenger physiology. These patients have unique haemostatic abnormalities in the resting state, and are at risk of both thrombosis and a bleeding diathesis.

Methodology Nine patients with Eisenmenger physiology and 6 healthy control subjects had symptom-limited treadmill cardiopulmonary exercise testing, using a modified Bruce protocol with subjects being encouraged to exercise to maximum capacity. Heart rate response, blood pressure, peak oxygen consumption (VO2 max) and ventilatory efficiency (Ve/Vco2) were measured. Blood samples were taken from each subject: Pre-exercise, peak-exercise, and after 30 minutes recovery. Haematocrit, platelet count, prothrombin time (PT), activated partial thromboplastin time (APTT), and plasma fibrinogen were analysed. Platelet activation was assessed using a flow-cytometric technique with 2 separate monoclonal antibodies: CD62 (P-selectin) and anti-fibrinogen with ADP and epinephrine used as agonists.

Results There were significant differences between the exercise times by Eisenmenger patients (496±222 seconds) and controls (1064±181 seconds) (p = 0.000) with peak oxygen consumption significantly decreased (16±2 vs 41±16 ml/kg/min) (p = 0.005) and ventilatory response to exercise significantly increased in the patient group (52±10 vs 41±16) (p = 0.000). Of these variables, only platelet count showed a significant change with exercise and recovery in either group. Expressed as positive events per 5000 platelets, CD62 platelet activation at rest was higher in patients group than in controls (32.47±15.27 vs 18.63±5.25), whereas anti-Fibrinogen platelet activation at rest was higher in the control group (196.41±87.84 vs 253.45±37.22). This observation remained at peak exercise and after recovery. Platelet activation (CD62 or anti-Fibrinogen) was not significantly altered by exercise in the Eisenmenger group (p>0.05). Agonist stimulation with either ADP or Epinephrine did not alter this response.

Conclusion Maximal exercise in cyanotic congenital heart disease patients does not significantly affect their haemostatic balance thus supporting these patients safely participating in appropriate physical activity.

A COMPARISON OF BONE MINERAL DENSITY IN ELITE, INTERNATIONAL KENYAN AND BRITISH CAUCASIAN MALE LONG DISTANCE RUNNERS

1D. Brooke, 2C. Pedlar, 1N. Tiller, 1M. Perry, 3L. Dimitriou, 1D. Morrissey, 2N. Pollock. 1The Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, The Royal London Hospital (Mile End), Bancroft Road, London E1 4DG, UK, 2UK Athletics and English Institute of Sport, St Mary’s University College, Teddington, London, UK, 3Middlesex University, Archway Campus, Highgate Hill, London, UK

This study compared the bone mineral density (BMD) of international, world-class Kenyan and British long distance runners.

Participants (n = 4 Kenyan) (Average age: 21.0 years ±0.71, Average VO2 max: 74.7 ml/kg/min ±3.28) and (n = 7 British Caucasian) (Average age: 24.4 years ±4.50 and VO2 max: 74.2 ml/kg/min ±3.81) were scanned by dual x ray absorptiometry (DXA) at L2–4, femoral neck and radius.

The total BMD z-score in the Kenyan athletes was −1.4 g.cm−2 relative to 0.4 g.cm−2 in the Caucasian athletes (p = 0.01). The L2–4 was also significantly less in the Kenyan athletes with an osteoporotic score of −2.4 g.cm−2 relative to 0.01 g.cm−2 (p = 0.01). The femoral neck scores were also significantly reduced (−1.2 vs 0.51 g.cm−2).

This is the first study into BMD of elite Kenyan long distance athletes. There is one previous case report of an osteoporotic fracture in a Kenyan athlete.1 It has been reported that long distance runners have increased BMD in their legs due to the forces transmitted during the repetitive movements of running.2 Some research has shown individual relative reductions in lumbar spine BMD probably due to the transmission of relatively less load.3 There is a recognised association between a negative energy balance in female athletes and low BMD as a part of the female athlete triad but this has not been fully investigated in male athletes. Potential predisposing factors for the low BMD scores in the Kenyan group are discussed including micro-nutrient deficiency, a negative energy balance and genetic predisposition. This study is the first to identify low BMD in a group of elite Kenyan male athletes. It raises important scientific and clinical questions including the aetiology and genetics of low BMD in athletes and the role of screening in elite athletes.

ULTRASONOGRAPHICALLY DETECTED CHANGES IN ACHILLES TENDONS AND SELF REPORTED SYMPTOMS IN ELITE GYMNASTS COMPARED WITH CONTROLS—AN OBSERVATIONAL STUDY

C. Emerson, R. Jalan, D. Morrissey. Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, London E1 4DG, UK

The aims of the study were to measure Achilles tendon (AT) thickness, abnormality frequency and symptom history in a group of elite gymnasts with comparison to age-matched controls.

This was a controlled observation study involving 20 male and 20 female elite gymnasts of mean (SD) age 15.5 years (2.2), and 24 male and 16 female controls of mean age 15.2 (2.1). Reliability studies were performed between a qualified radiologist and the primary author. AT thickness and abnormality presence were measured for both tendons using ultrasound. Height and weight were measured. Information about previous AT or heel symptoms, age, weekly training hours and leg dominance were gathered using a supervised questionnaire.

Reliability studies showed good agreement of tendon thickness (level of agreement  =  +/−0.14 mm) and abnormality detection. There was no difference in age between the gymnasts and controls (p = 0.59), but controls were significantly heavier (p<0.001), taller (p<0.001) and less active (p<0.001). Gymnasts had significantly thicker tendons at the mid-tendon (p<0.003). Among gymnasts there were 28/80 tendons with previous AT symptoms, compared with 0/80 of the controls respectively. In addition, ultrasound scanning showed 27/80 gymnast tendons to have structural abnormalities, compared with 4/80 controls. There was no statistical relationship between a history of AT symptoms and ultrasound-detected abnormalities.

The AT of elite gymnasts may have training related adaptation, and display more abnormalities than less active controls.

ARTHROSCOPIC FULL THICKNESS ROTATOR CUFF REPAIR IN ELITE RUGBY PLAYERS

A. Tambe, L. Funk. Wrightington, Wigan & Leigh NHS Trust, Lancashire, UK

Aims To review the results of arthroscopic rotator cuff repair in elite contact athletes.

Methods Eleven professional rugby players were treated by arthroscopic rotator cuff repair between over a two year period. Data were collected from the operative records and patients recalled for outcome scoring and ultrasound scans.

Results There were 7 Rugby league and 4 rugby union players, including 6 internationals. The mean age was 25.7 years. All had a traumatic episode during matchplay. The main presenting complaints were pain and weakness. None were able to return to rugby after injury. The mean time to surgery was 5 weeks. Cuff tears were small in three, moderate in five, large in two and massive in one patient. The mean width of the cuff tear was 1.8 cm. Associated injuries included two Bankart lesions, one posterior Labral tear and two 360 degree Labral tears. The biceps was involved in three cases. Two were debrided and a tenodesis performed in one. Repair was with suture anchors and a supervised accelerated rehabilitation programme undertaken. The mean final follow-up was 18 months (3–28). Constant scores improved from 44 preoperatively to 101. The mean score at three months was 95. Oxford shoulder score improved from 34 to 9, with a three month score of 18. The mean time of return to full match play was 4.8 months. There were no complications and postoperative scans in nine confirmed the repairs to be healed.

Conclusions Rotator cuff injury in the contact athlete can be addressed successfully by arthroscopic technique. Arthroscopic cuff repair gives good, reproducible results with rapid return to play.

ACHILLES TENDON DOPPLER FLOW MAY BE ASSOCIATED WITH MECHANICAL LOADING AMONG ACTIVE ATHLETES

1P. Malliaras, 2P. J. Richards, 3G. Gaura, 4N. Maffulli. 1School of Health Science and Social Care, Brunel University, Uxbridge, Middlesex UB8 3PH, UK, 2X-ray Department, University Hospital of North Staffordshire NHS Trust, North, Staffs Royal Infirmary, Princes Road, Hartshill, Stoke on Trent, Staffordshire ST4, 7LN, UK, 3Department of Trauma and Orthopaedic Surgery, University of Cagliari, Cagliari, Italy, 4Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Thornburrow Drive, Hartshill, Stoke on Trent, Staffordshire ST4 7QB, UK

Background Tendon Doppler flow may be associated with tendon pain in symptomatic patients, but the relationship between Doppler flow and pain among athletes who are still competing is unclear.

Hypothesis Among active athletes, Doppler flow may partly reflect tendon adaptation to increased mechanical load and/or asymptomatic tendinopathy.

Study design Case-control study.

Methods The Achilles tendons of 61 badminton players (24 elite, 37 recreational) were examined with gray-scale and Doppler ultrasound. Achilles tendon pain and activity level (badminton training, badminton playing, badminton years) were measured.

Results Doppler flow was not associated with self reported Achilles tendon pain, but was associated with an increased anteroposterior tendon diameter (an indicator of tendinopathy) (p = 0.02). Athletes who had been playing badminton for longer were more likely to have Doppler flow (p<.01), and there was a trend towards an association between a greater number of badminton playing hours per week and Doppler flow (p = 0.07).

Conclusion Achilles tendon Doppler flow appears to be a sign of asymptomatic tendinopathy rather than pain among active athletes. The association between weekly badminton hours and badminton years and Doppler flow suggests that Doppler flow may be a response to mechanical load in this cohort.

Clinical relevance Achilles tendon Doppler flow among active athletes may not be associated with pain and is not an indication for treatment.

HIP JOINT RANGE OF MOVEMENT IN PROFESSIONAL YOUTH AND SENIOR TEAM FOOTBALLERS: A CASE-CONTROL STUDY

1C. Manning, 2Z. Hudson. 1Physiotherapy Department, Springfield Hospital, Chelmsford CM1 7GU, UK, 2Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 4DG, UK

Objective To determine if there is evidence of abnormal movement in the hip joint of youth and senior team professional footballers, and whether leg dominance affects this, and then compare with age-matched controls.

Methods Passive hip joint range of movement (ROM)—internal rotation (IR), external rotation (ER), flexion, abduction, extension—together with the Faber’s test and the hip quadrant were assessed in 20 youth team and 20 senior team professional footballers and 40 age-matched control subjects.

Results Youth and senior team footballers had significantly less IR and Faber’s movement than their respective controls (p<0.001). Senior team footballers were also significantly less flexible into IR (p<0.05) and Faber’s than the youth team (p<0.001). Both senior and youth team footballers demonstrated significantly increased abduction compared to youth and senior controls (both p<0.001). A much higher proportion of senior footballers had a positive hip quadrant (45% of all hips) compared to all other groups. No significant difference in hip ROM was found between dominant and non-dominant legs.

Conclusion A specific pattern of hip ROM was found in professional footballers (both youth and senior team) which appeared to be different from controls. These changes suggest a capsular pattern is present specific to playing football, and may demonstrate the early stages of hip degeneration to which it has been shown ex-professional players are prone to. Hip joint ROM exercises may be necessary in these players to restore normal hip ROM and prolong or prevent the onset of hip osteoarthritis (OA).

AN OBSERVATIONAL STUDY TO DETERMINE THE RELATIONSHIP BETWEEN HIP ROTATION RANGE OF MOTION MEASURES AND LOW BACK PAIN IN AMATEUR GOLFERS

E. Murray, D. Morrissey. The Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, The Royal London Hospital (Mile End), London E1 4DG, UK

Aim This cross-sectional observational study investigated the relationship between a series of hip rotation range measures and presence of low back pain in amateur golfers. Medial rotation deficits in lead hip rotation correlated with a history of LBP in elite level golfers.1 The primary hypothesis was that lead hip internal rotation range would differ between subjects with and without a history of low back pain.

Methods Participants were recruited from a single golf club. Measurements of hip lateral and medial rotation, during both active and passive movement were made in all subjects using an inclinometer. A screening questionnaire was employed to identify those subjects with a history of low back pain (n = 12) and those without (n = 18). Measures of hip rotation were compared between groups.

Results There was significantly less medial rotation of the lead hip in the group with low back pain (p<0.05) than the no low back pain group. Further there was a significant difference between the lead and non lead hip in the low back pain group (p<0.001). No statistically significant differences were found for these measures between the non lead hips, nor for measures of lateral rotation.

Conclusion In a small cohort of amateur golfers medial rotation range of motion deficits in the lead hip were observed in subjects with a history of low back pain. The relevance and natural history of this observation need to be established by further study.

RECREATIONAL TRAMPOLINE INJURIES; IS IT SAFER TO BE A COUCH POTATO?

A. Newton. Emergency Department, Grange Road Uphill, Weston-Super-Mare, Somerset, UK

This report presents a case series of patients seen in a District General Hospital Emergency Department with trampoline injuries.

Aim The aim of the study was to achieve a better understanding of the type of injury sustained by children using trampolines and if possible to try to identify mechanistic patterns of injury causation.

Methods Case data were collected for 70 sequential cases presenting in a period of just under nine months to a District General Emergency Department (data collected during the year 2007).

Results During the study period a range of ages of children presented with injuries sustained on recreational trampolines (the youngest child being 18 months of age and the oldest 15 years of age). The peak age group for presentation with trampoline injuries was between the age of 6 and 9 years of age. The most common mechanisms by which injury had occurred was a fall from an unfenced trampoline and falls involving another child who was using the trampoline at the same time.

Conclusions We conclude that specific advice should be given regarding children using recreational trampolines. In particular recreational trampolines are unsuitable for children younger than 5 years of age, trampolines should always be fitted with safety fences and trampolines should only be used by one child at a time.

THE 2006 EUROPEAN BMX CHAMPIONSHIPS

A. Newton. Emergency Department, Grange Road Uphill, Weston-Super-Mare, Somerset, UK

This report describes the medical provision at the site of the European BMX Championships held at Cheddar during the summer of 2006. An analysis of the clinical workload dealt with during the event was conducted. European BMX championships have been held on an annual basis since the late 1970s, with a progressive increase in popularity and number of participants occurring over that time.

Aim To better understand the need for medical cover at an event of this nature.

Method Over the 4 day event 219 patients were treated in the medical facility on-site; clinical data were captured on all presentations.

Results The number of presentations, both new and review cases, increased progressively throughout the event; reflecting the intensity of competitive races during the event (more practice sessions were included in the programme during the first couple of days). Children under the age of 16 accounted for a disproportionate degree of the workload, given the fact that only a third of all competitors were children. The vast majority of injured riders reported that their injury had resulted as a direct consequence of them losing control of their bicycle during an event (without actively colliding with another rider). The majority (88%) of cases were managed on site; however 26 patients (12%) were taken to hospital for x ray and further assessment/management. Of the patients taken to hospital 8 required admission.

Conclusion The number of injuries and the severity of some of the injuries dealt with during the event indicate the vital importance of providing appropriate medical cover on-site for a BMX competition of this nature. The severity of some of the cases dealt with also demonstrates the vital importance of the staff assigned to providing such medical cover being appropriately trained and equipped to respond to such clinical emergencies in the pre-hospital setting.

BILATERAL SIMULTANEOUS AVULSION FRACTURES OF THE ANTERIOR SUPERIOR ILIAC SPINE IN AN ADOLESCENT ATHLETE

M. A. Quigley, S. H. Boyce. Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries DG1 4GG, UK

The apophyses of the adolescent skeleton are areas of secondary ossification that are responsible for modulating the contour of bones and not the length. They are the sites of muscle origin or tendon insertion and are therefore subjected to traction type forces when muscles contract. These forces can cause an inflammatory apophysitis, particularly when they are chronic and repetitive. They can also result in avulsion type injuries when they are subjected to sudden explosive muscle action. These may involve avulsion of the anterior superior iliac spine (ASIS) at the pelvic origin of the sartorius muscle. ASIS avulsions arise in situations of over extension or forced extension of the hip (eg long jump take off), forced extension of hip with flexed knee (kick a ball with force) and during episodes of stressful and simultaneous hip flexion and knee extension (sprinting).

We report a case of simultaneous bilateral ASIS avulsion fractures in a 16 year old boy when participating in a 100 metre sprint. ASIS avulsions tend to be unilateral; this is the first documented case of simultaneous bilateral ASIS avulsions. There was a sudden onset of pain in both hip areas midway through the race. He was unable to weight bear or perform active hip movements. Examination revealed diffuse swelling and tenderness at both ASIS and a pelvic x ray confirmed bilateral avulsion fractures of the ASIS. The left-sided fragment was 3 cm long and displaced 2 cm caudally, with the right-sided fragment 4 cm long and displaced 2 cm. He was admitted to the orthopaedic ward and managed conservatively with analgesia and three weeks of bed rest with both hips held flexed at approximately 60 degrees. He was mobilised with crutches at three weeks and at six weeks was pain free with a complete range of hip movements. Following a course of physiotherapy rehabilitation he was able to return to full activity by eighteen weeks post injury.

Anterior superior iliac spine avulsion can be managed conservatively or by open reduction and internal fixation. Internal fixation (IF) is preferred if the fragment is displaced more than 2–3 cm, or if the athlete needs a speedier return to sports participation, particularly at a high level of performance. Conservative treatment involves bed rest, anti-inflammatories, graded mobilisation and weight-bearing under physiotherapy guidance. Complications of ASIS avulsion include bony exostosis formation, non-union of the fracture and meralgia paresthetica.

AWARENESS, INTEREST & EXPOSURE TO SPORT & EXERCISE MEDICINE IN MEDICAL SCHOOL

L. Rohman, W. Alwan, H. Rauf. St George’s University of London, London, UK

Objectives To assess the awareness, interest, need and exposure of medical students at a London Medical school to the new specialty Sports and Exercise Medicine (SEM).

Design A questionnaire distributed at teaching sessions to medical students, used against a control questionnaire on a well-known specialty, Paediatrics. Questions were a combination of multiple choice, single best answer and five point Likert scale questions.

Participants 330 medical students attending lectures at a large London Medical School and included all year groups on the 5 year MBBS course. 272 questionnaires were returned. 194 SEM were distributed and 151 returned while 136 Paediatrics were handed out and 121 returned.

Main Outcome Measures Responses to questions designed to assess awareness, interest, need and exposure of medical students to SEM.

Results A total response rate of 82% was achieved—77.8% for the SEM questionnaire and 89.0% for the paediatrics questionnaire. Only 29% of pre-clinical students and 40% of clinical medical students were aware of SEM as a specialty, compared to 95% and 98% who were aware of Paediatrics as a specialty (p<0.0001). 69.3% said they were interested in SEM and 34.7% were considering SEM as a future career. 84.6% of students felt that there was a need for SEM to improve healthcare across all age groups. Only 25.5% agreed that they had received adequate exposure to SEM in medical school compared to 45.2% that believed they had adequate exposure to Paediatrics (p = 0.001). 67.3% of respondents believed that there should be an individual taught module on SEM.

Conclusions Medical students are interested in SEM and recognise the benefits of the newly formed specialty regardless of their poor awareness, which we hypothesise is due to the lack of exposure. There is a need for SEM to be formally included into the undergraduate medical curriculum.

ESTABLISHING A HAEMATOLOGICAL REFERENCE RANGE FOR UK ATHLETICS TRACK ATHLETES: A THREE-YEAR RETROSPECTIVE ANALYSIS OF SERIAL BLOOD MEASUREMENTS

1S. Sinha-Roy, B. Moore, 2C. Pedlar, 2M. Perry, 1D. Morrissey, 2N. Pollock. 1The Centre for Sports and Exercise Medicine Barts and The London School of Medicine and Dentistry, The Royal London Hospital (Mile End), Bancroft Road, London E1 4DG, UK, 2UK Athletics and English Institute of Sport, Hospital of St John & St Elizabeth, 60 Grove End Rd, St John’s Wood, London NW8 9NH, UK

The primary aim of this study was to produce a reference range of haematological and biochemical parameters for elite international standard track athletes. By individualising a reference range it was hoped that seasonal variations, inter-individual variability and incidences of abnormalities in performance related parameters would be easily observed.

A retrospective analysis of serial blood measurements for male (n = 11) and female (n = 16) elite international, UK Athletics (UKA) track athletes aged 18–30 years. Statistical tests were applied to calculate group differences between athletes and individual differences over the course of the athletic season.

The individualised reference ranges produced were narrower than the clinically accepted reference range and showed great variability between each athlete. Clinically significant low serum ferritin levels (⩽30 ng/mL) were noted in 40% of male and 75% of female athletes studied. Grouping athletes according to their chosen event (sprint, middle, and long distance) yielded statistically significant (p<0.05) variations in 20 of the 32 investigated parameters in males and 15 of the 32 parameters in females. Significant seasonal variation (p<0.001) also existed in several parameters including; haematocrit, mean corpuscular haemoglobin concentration, magnesium and serum ferritin for both male and female athletes.

Athletes competing in different track events have significant differences in numerous blood parameters, notably red blood cell count, haemoglobin, haematocrit and serum ferritin levels. Despite elite athletes’ physiology differing from normal healthy individuals, their blood results are compared against standardised values for the normal population.1 2 However by individualising reference ranges for athletes’ subtle variations in haematological and biochemical parameters can be observed. In addition the determination of this individual range may assist in the identification of individual abnormalities. The high rate of low serum ferritin levels detected in both male and female athletes highlights the importance of screening for iron deficiency in elite athletes.

CURRENT PRACTICE FOR RETURN TO PLAY FOLLOWING ARTICULAR KNEE INJURY IN ENGLISH PREMIERSHIP RUGBY 2006/2007. AN INTERVIEW LED QUESTIONNAIRE STUDY

S. A. Tindal, 2Z. Hudson. 1Leicester Tigers Rugby Football Club, Leicester, UK, 2Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK

Aim To evaluate the management and return to play (RTP) strategies currently used in English professional rugby union following articular knee injuries.

Method The head physiotherapist of all 12 premiership rugby union clubs was interviewed using a questionnaire generated following a review of the available evidence. Open and closed questions obtained a mixture of quantitative and qualitative information regarding four specific knee injuries (anterior cruciate ligament (ACL), medial collateral ligament (MCL), chondral defect and meniscal tears). The questions reviewed epidemiology, injury management, decision-making, and objective markers for progression through rehabilitation to RTP. The results were subsequently analysed to identify trends in injury management, rehabilitation and current practice to provide suggestions for possible best practice.

Results A total of 121 articular knee injuries were reported during the season, this represented ACL, MCL, chondral and meniscal injuries. Additionally, the recurrence rates reported were 12%, 7%, 18% and 7% for ACL, MCL, chondral and meniscal injuries, respectively. Methods of ensuring safe RTP varied for each condition and in each stage of rehabilitation. An example of variation included one club returning a meniscal repair at two weeks, yet a menisectomy at four weeks. Early to middle stages of rehabilitation had a general agreement of 92% for traditional outcome measures such as range of motion, visual analogue scales and single leg balance. The later stages of rehabilitation underutilised reliable functional tests1–3 with only three clubs (25%) using more than one form of reliable test.1–3 All 12 of the clubs believed that a RTP guideline would either “definitely” or “probably” benefit their clubs medical team and 58% of the clubs believed it would “definitely” help the recurrence rate of injuries.

Conclusions An objective RTP guideline for the four specific articular knee injuries mentioned would be beneficial to the 12 English premiership rugby clubs medical teams. Further investigation is warranted into safe RTP guidelines for specific knee pathology.

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