Guest Blog by BJSM Associate Editor – Dr John Orchard

Jake Ballard- ACL injury in 4th quarter, photo: deadspin.com

Being an injury geek, the most interesting part of  last week’s Super Bowl was hearing that two New York Giants players had suffered ACL injuries on the FieldTurf surface. I have previously made the comment that the football codes are to Australians what languages are to the Swiss. Sadly most Australians, including myself, are monolingual, only being proficient in the English language (and for many Australians even this is open to argument). The Swiss, by comparison, are masters of many languages, including English and their four native ones, but many of them only follow one type of football. As an Australian, I can hold a conversation about most of the football codes and American Football is perhaps my fifth or sixth football “language”¹.

I have long had a strong interest in the relationship between ACL injuries and the playing surface². I think the published research from the various football codes can be combined to get a true understanding of ACL shoe-surface risk factors. Interestingly, ACL injuries are relatively uncommon in the EPL³ compared both to other football codes and soccer played in other countries. I believe that this is the case because the vast majority of EPL matches are played on ryegrass.

Ryegrass is to ACL tears what the Mediterranean diet is to heart disease⁴. The football (soccer) teams playing in Australia’s A-League get more ACL injuries than EPL teams, even though the schedule has less than half as many games. On a population basis, the rate of ACL injuries in the UK⁵ is about a quarter of the rate in Australia⁶. Obviously there are many confounders, but I am certain that climatic factors are at least partially responsible for the large discrepancy.

Ryegrass has less 'grip' than most other turfgrasses as it has no thatch/lateral growth. More pics and comment at the 'further reading' link (below) or in the 4th edition of www.clinicalsportsmedicine.com

I studied ACL injuries in the NFL about a decade ago¹. This study compared rates of ACL injuries on natural grass compared to artificial turf, at that stage primarily Astroturf. The rates on Astroturf were not significantly higher than natural grass – however the circumstances under which the ACL injuries occurred varied substantially according temperature with respect to artificial turf¹.

In domed stadiums, the ACL injury rate was constant (and fairly high) throughout the season. In artificial turf stadiums there that were in the open air, with variable temperatures, the ACL injury rate was very high early in the season (hot weather) and much lower later in the season (outside air was cold).

These data tell me that artificial turf may be quite safe, possibly even desirable, in very cold weather, but in warm/hot weather it may be associated with an increased risk of ACL injuries. The majority of NFL stadiums that use artificial turf have switched to newer products in recent years — FieldTurf is the number one brand. FieldTurf performance is better than the older generation artificial surfaces with respect to player satisfaction, probably because the surface is softer and ‘feels’ more like natural grass.

However, the shoe-surface traction may be at least as high with FieldTurf as with older artificial surfaces. Player satisfaction is actually quite high when shoe-surface traction is high, but this may be associated with higher ACL injury risk². Although I haven’t seen any data with respect to FieldTurf and temperature, the null hypothesis is that shoe- surface traction is higher on all artificial surfaces in hotter weather and lower in colder weather⁷.

MARCH 2010 STUDY – WHERE ARE THESE DATA?

A study which I have only seen in abstract form, presented at a conference in March 2010, showed that FieldTurf was associated with an 88% greater relative risk of ACL injury compared to natural grass surfaces in the NFL over a seven year period (which was highly significant)⁸. I have been eagerly awaiting the full paper, as I would expect it to perhaps show that the FieldTurf stadiums which were in the open air in cooler climates didn’t have a problem, but those in domed stadiums or in warmer climates were of higher ACL risk. If such results were observed, it doesn’t mean that FieldTurf or artificial surfaces shouldn’t be used for football. It would just mean they should be reserved mainly for the situation where common sense suggests they should be used – in cold climates where natural grass doesn’t grow well in winter. My question is, where are the data? The BMJ recently emphasized the importance of airing the results of clinical trials.

The Sydney University women’s first grade football team played their home matches last year on an artificial (not FieldTurf) surface, one of the few in Sydney. They apparently had zero ACL injuries in their away games (all on natural grass) and three ACL injuries on their artificial (home) surface. This is not statistically significant but when you sift through the surface literature you have to wonder why you would take the risk of playing on artificial turf in a warm climate like Sydney where natural grass grows beautifully and is cheap to maintain? The main papers that report that new generation artificial turf has acceptable injury rates were either conducted in cold climates⁹ or sponsored by industry¹⁰. It is frustrating that there has been a long delay in seeing a paper which I believe will more accurately reflect the risks involved, but when the Hershman study appears as a full paper, I think it will be a landmark one and worth the wait ⁸.

For further reading on ACL injury prevention follow this link to Dr. Orchard’s Article on page 17 of Sport Health.

POST SCRIPT FEBRUARY 22nd – ACL rupture at Widnes Vikings in Super League – ‘pitch not to blame”

References

1. Orchard J, Powell J. Risk of knee and ankle sprains under various weather conditions in American football. Medicine & Science in Sports & Exercise 2003;35(7):1118-23.

2. Orchard J. Is there a relationship between ground and climatic conditions and injuries in football? Sports Med 2002;32(7):419-32.

3. Walden M, Hagglund M, Ekstrand J. Regional differences in injury incidence in European professional football. Scand J Med Sci Sports 2011:in press.

4. Orchard J, Chivers I, Aldous D, Bennell K, Seward H. Ryegrass is associated with fewer non-contact anterior cruciate ligament injuries than bermudagrass. Br J Sports Med 2005;39:704-09.

5. Jameson SS, Dowen D, James P, Serrano-Pedraza I, Reed MR, Deehan D. Complications following anterior cruciate ligament reconstruction in the English NHS. Knee 2011.

6. Janssen K, Orchard J, Driscoll T, van Mechelen W. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia 2003-04 to 2007-08: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2011:doi: 10.1111/j.600-0838.2010.01253.x.

7. Torg JS, Stilwell G, Rogers K. The effect of ambient temperature on the shoe-surface interface release coefficient. Am J Sports Med 1996;24(1):79-82.

8. Hershman E, Powell J, Bergfeld J, Johnson R, Spindler K, Wojtys E, et al. American Professional Football Games Played on FieldTurf have Higher Lower Extremity Injury Rates. American Academy of Orthopedic Surgeons Annual Meeting. San Francisco, 2010.

9. Ekstrand J, Timpka T, Hägglund M. Risk of injury in elite football played on artificial turf versus natural grass: a prospective two-cohort study. Br J Sports Med 2006;40:975 – 80.

10. Meyers M, Barnhill B. Incidence, causes and severity of high school football injuries on FieldTurf versus natural grass. Am J Sports Med 2004;32(7):1626-38.

***************************************************************

John Orchard BA, MD, PhD, FACSP, FACSM, FFSEM (UK), is a Sports Physician, and an Adjunct Associate Professor at the University of Sydney, School of Public Health.

UKsem was the first conference to have a ‘Moneyball’ panel session; attendees voted with their feet that this should happen again. What’s ‘Moneyball’? The unabridged term refers to Michael Lewis’ book of that name. It’s about a baseball team who performed much better than they should have by recruiting cheap players who didn’t have the ‘look’ of top draft picks but whose statistics were impeachable. The implication is that an astute statistician may help to recruit this type of player whereas a ‘sport expert’ might be fooled by intangibles – the style, the charisma, pedigree – but in the end things that don’t predict success as well as the carefully analyzed data. The concept was in the news in Australia just today.

In the sports medicine setting, Dr John Orchard raised raised the concept in 2009. He’d read the book (didn’t wait for the Brad Pitt movie) and figured that team physios and team sports physicians could augment team performance. This appreciation, literally valuing of the sports medicine / fitness team would lead to great salaries for those individuals. At the conference Moneyball session, Liverpool Football Club’s Peter Brukner estimated that many soccer/football clubs in the English Premier League have annual player salaries over 100 million GBP but pay less than 0.5% of that for ‘maintenance’ – the sports medicine team. Seems crazy and I suspect that in Formula 1 the investment in the ‘asset’ would be much higher.

Security sit - ready for action - at Liverpool vs. Chelsea, November 20, 2011

Also in the UKsem session was power lawyer Mary O’Rourke, QC, who is clearly a pre-eminent sports lawyer in the UK. She emphasized the risk that sports physicians are at when taking care of players who might be earning over 100,000 GPB per week. Is your personal liability insurance in place for the 40 million GPB or so you might be sued for?  I didn’t realize that as Dick Steadman operates in Colorado, the legislation in that stats caps any medicolegal claim at $10 million. In the UK, there is no cap. Food for thought for both players, and physicians. Lots of players have value greater than $10 million.

There was also an introduction to the idea of clincians using agents to help them get better deals in this new world. Clinicians valued more = larger contracts = need for help with negotiation and for digging out the good gigs. Makes sense.

A great idea for future conferences in the UK and beyond. I can see it traveling very well at AMSSM in Atlanta 2012, the VSG (Netherlands), Australia, Switzerland, South Africa, and among the ECOSEP member countries.

For a detailed movie review and background to Moneyball click here please.

And on the subject of Liverpool Football Club, it seems like Brad Pitt is a fan!

I learned that about 12% of high fit 80+ year olds die annually. Seems a bit unfair. But 27% of low fit 60-69 year olds die annually! No typo. High fit 80-yr olds are HALF AS LIKELY TO DIE as low fit 60-yr olds. Are we talking about 80-yr old Olympians? Nope. High fit is top 40%. Low fit = bottom 20%. Not too hard.

Prof Steve Blair (giving the audience both barrels of evidence, below) provided the data and reminded us that 150 minutes of moderately vigorous activity weekly (walking to and from the fridge) will leave the low fitness group in the dust. Alternatively, 70 minutes of vigorous walking to the fridge will do it. Not a big ask. As he said, the folks who are ‘too busy’ to do this generally have 3-4 hours a day to watch TV. And I guess there’ll be a few who have 10-20 years in the grave to think about it. Sounds non-PC but is actually just a fact.

Prof Dan Lieberman, ‘the Barefoot Professor’ wore black slipper type shoes to remind us not to polarize the debate into ‘barefoot’ vs ‘shod’ running. He highlighted the evolutionary advantage that humans have to run down game in the heat. 9-15 km daily, daily, daily back in the day. He really argued for the benfits of forefoot strike to prevent injuries. He’s doing an interview with the BMJ team tomorrow and there’ll be a session on running shoes/orthoses/etc. with Benno Nigg too. In the meantime see orthotics and patellofemoral pain in the BMJ.

The FIFA research team (F-MARC) including Philippe Tscholl, Mario Bizzini and Jiri Dvorak (photo above) shared the facts that 2010 World Cup football players used medication including NSAIDs and cortisone at a remarkable rate – comparable to that of osteoarthritic octogenarians in a care facility.  A concern. Doctors must do better. No lessons learned from previous World Cups in Germany and France. In a nutshell – FIFA 11+ prevents lower limb injuries and is being rolled out around the world. Football for Health — health messages with players as ambassadors and school children as the target is proving effective and electric. Great uptake – a lesson in implementation which is the theme of January’s BJSM issue (2012). No hyperlink there just yet. BJSM Blog gives you today’s news but not tomorrow’s!

We are hours away from freshening up the podcast page with a suite of interviews. Just need to get the switch at BMA house. We’ll tweet you when it’s ready (@BJSM_BMJ).

And if you add a question for any conference speaker below we’ll try to get it answered. No promises though! Or via Twitter.

PS: Thanks to our terrific team from BMJ for being at UKsem 2011. I am sure you have earned a spot for 2012!

Looking for a world class conference bringing together sport and exercise medicine, conditioning and science with nutrition, rehabilitation and high performance coaching?. This conference will provide new knowledge for those working with elite sport and recreational athletes as well as those presenting to all clinicians for exercise prescription. See the UKsem home page including the concise video (and Andy Franklin-Miller’s very modish shirt)…Will you be there?

The UKsem site is the best place to find the conference program. Names I am looking forward to hearing from include Roald Bahr (sports injury prevention-always great value), Dan Lieberman (the ‘barefoot doctor’), Damien Comolli (the secret to Liverpool’s success), Vern Gambetta (the art and science of coaching).Vern has over 4000 followers as @coachGambetta on Twitter so you know he’s doing something right.

‘Sleepers’ for many will be Carl Askling on hamstring rehabilitation and Richard Frobell on conservative management of ACLs. The former has terrific programs for both prevention and treatment. He discovered the difference between ‘type I’ (sprinters/football players) and ‘type II’ (stretching/dancer’s) hamstring strains and their very different prognoses. Great teaching videos for both rehab and determining return to play.

Dr Frobell headed up the New England Journal of Medicine RCT which randomized ACL patients to rehab or surgery. Not every conference presenter can open up with that claim…’Thanks for coming and if you doze off during my talk you can read all about in the NEJM….’. Good one. 10 years of hard work to become the overnight sensation. BJSM comments on that paper are here in a WarmUp and here in a podcast with Dr Frobell and his research team. Do your homework and then ask him the stumper at UKsem. Or buy him beer for the great effort!

I’ll stop there as I want you to use your coffee break to go to the UKsem site, not to read this. And by ‘sleepers’ – I meant – ‘under the radar’ — not lectures to sleep in. I would reserve sleeping for Friday morning 9:35 – 10:05. Something about how Mad Men, the Marlboro Man and Freakonomics have the answer to ‘smokadiabesity‘? Weird!

The UKsem site is great but if you insist on only following BJSM pages you can see Andy Franklin-Miller’s WarmUp about the conference here and listen to two interviews with the mellifluous BBC-trained sports physician and fashionista.

July podcast – his conference highlights

October podcast – lower limb biomechanics plus a sneaky conference plug in the last 3 minutes of this 24 minute file.

Nice shirt….

“Prevention is better than a cure, no matter what disease we look at…football is an ideal platform to promote a healthy lifestyle and prevent disease.”       – Professor Jiri Dvorak, FIFA’s Chief Medical Officer

This month’s BJSM Editor’s Choice (free online) highlights an innovative approach to health and exercise promotion in Africa. Authors Colin Fuller, Astrid Junge, Cadrivel Dorasami, Jeff DeCelles, and Jiri Dvorak investigated how FIFA’s 11 for Health programme (watch promo video) impacted 10 to 15 year old children’s health knowledge in Mauritius and Zimbabwe. They conclude that the collaborative implementation model was successful and that post-programme analyses showed significant increases in most of the participants’ health knowledge.

Photo courtesy of: StephenandMelanie, Flickr Creative Commons

As an outcome of these successful pilot projects and the 2011 nationwide implementation of the programme in Mauritius, over the last 2 months Dr Junge and Dr Fuller worked with Dr. Dvorak on a four-week programme expansion initiative. This involved ‘training the trainers’ in Nairobi (Kenya), and Windhoek (Namibia), and making presentations to Football Associations in Botswana and Malawi. (Read more about the nationwide implementation initiative here).

Dr. Dvorak also presented the results of successful nationwide implementation of the programme to the 61st FIFA Congress on June 1st, 2011 in Zurich. This congress received global media attention. Following the presentation, officials from many countries around the world approached FIFA’s medical team (F-MARC) to express their desire to partner in this initiative.

This project team exemplifies commitment to combining scientific rigour with social responsibility to create an exercise-based tool for health promotion. The potential for scaling up this programme means is has tremendous public health significance. BJSM will highlight ‘success stories’ from around the world as part of the journal’s promotion of ‘implementation’ as a key issue for sports medicine in the 2010s.

Would you like to share successful implementation stories?

Leave a comment below, or send an email: karim.khan@ubc.ca

The Oslo Sports Trauma Research Centre, located at the Norwegian School of Sports Sciences has a diverse team of experts from the fields of exercise medicine, ortheopedics, epidemiology, biostatistics, and physiotherapy. Its led by professors Lars Engebretsen and Roald Bahr who are both renowned for their experience with national team and Olympic sports medicine. Cutting-edge researchers and advocates for evidence-based practice.

Want to know more about:

• Injury patterns in World Cup freestyle skiing
• Risk of injury in female youth football players
• Outcomes of the first meeting of the 4 IOC Research Centres in Capetown

Check out their website NOW!  It’s a great online resource.

Also see:

Bahr’s warm up discussion on ACL injuries in BJSM

and

Engebresten’s insights on platelet-rich plasma and The importance of sports medicine for the Vancouver Olympic Games — also in past issues BJSM.

As most of you will know from the news barrage, the UK High Court has overturned an earlier decision of the Health Professions Council to have sports physiotherapist Stephen Brennan struck off.(1)

Background: Brennan admitted his part in the ‘Bloodgate’ scam. He provided fake blood capsules to the player (Tom Williams) in order to deceive match officials into accepting a replacement, thereby allowing a specialist kicker to take the field.  Brennan also ‘took an active role in the drafting of false witness statements’ in an effort to sustain the deception.(1) The HPC decided he displayed a degree of premeditation in his actions because he purchased and carried blood capsules in his bag for the purpose of removing players from the field. Brennan had used the capsules a number of times previously. However it appears that he administered these for ‘player welfare reasons’ indicating that he felt deception was required to achieve health aims.

New stuff: Are disciplinary measures warranted? Yes, absolutely. Using deception for health aims is arguably defensible; deception for the purpose of cheating is not. Also, we should not forget that Brennan falsified documents to sustain the lie.

However, being struck off is a serious decision, and while the mechanism for doing so should always be retained, it should be reserved for certain situations  such as threats to public health and safety posed by incompetent or malicious practitioners. Brennan was clearly a highly regarded and very competent physiotherapist (he was appointed as physiotherapist to the England rugby team immediately prior to these events).(1) Brennan was neither malicious nor incompetent, and while the actions were wrong, they did not pose a threat to public health or safety.

The public expects health professionals to be trustworthy and Brennan has fallen short of this expectation. The act of falsifying documents demonstrates a lack of integrity and veracity. For this lapse and for the original deception; some action is warranted. But what is appropriate? To be struck off seems harsh, especially for a first offense. Mandatory training in ethics and professionalism seems more reasonable, but some suggest this may not be enough.(2) It seems highly unlikely that Brennan will reoffend.

However, simply disciplining the individuals involved fails to attend to the issues central to the ‘Bloodgate’ scandal and common to the practice of medicine in sport. Health professionals are required to act in the best interests of their patients but identifying these can be problematic in the sports setting. Sports health professionals commonly face pressure within their employment setting that does not relate specifically to patient health.(3) Employers and coaches may make demands on sports health professionals contrary to the primary role of caring for players.(4)

We would love to see your comment – add a comment below!

References

1.       Health Professions Council Committees Findings.  Stephen Brennan Physiotherapist. 13/9/2010.   www.hpc-uk.org accessed 30th September 2010

2.       Holm, S. & McNamee, M. Ethics and Sports Medicine. BMJ 2009;  339:b3898

3.       Meldan Devitt, B. & McCarthy, C. ‘I am in blood Stepp’d in so far…’: Ethical dilemmas and the sports team doctor. Br J Sports Med. 2010. 44: 175-178

4.       Furrow, B.  The problem of the sports doctor: serving two (or is it three or four?) masters. Saint Louis University Law Journal. 2005: 50 165-183

AFC Conference on Science & Football Medicine

Kuala Lumpur March 18-20, 2011

The past 3 Asian Science and Football conferences (Tokyo; Kuala Lumpur & Muscat) were a great success with approx. 450 participants from all over the world.

KL promises a great program of keynote address symposiums, free papers, poster presentations  and clinical workshops in Sports Medicine.  It’s a “Low cost High output” activity at an excellent destination “Malaysia Truely Asia” – value for money. Here is the website: www.the-afc.com and you can email s.medicine@the-afc.com.

Be part of a stellar sport and exercise medicine event promoting Football for Health. Abstract deadline is January 31, 2011. Terrific destination for colleagues and friends.

Best wishes

Dato’ Gurucharan Singh
Chairman, OC for AFC Conference on Science and Football Medicine / Scientific Committtee

The American Association of Neurology has published a concussion position statement but the question is ‘Where is the reference to the international consensus’?

No-one would question that neurologists know about concussion but many of them would be the first to admit they are not experts in sport. How should an athlete train when returning to sport? Should a basketball player stay in the half-court or can she go full-court? When can a rugby player get back to the scrum? Definitely NOT in the NEUROLOGY CURRICULUM!

At a time when the credibility of medicine is being challenged on many fronts, disparate messages and silo thinking need to be minimized. Concussion was capably discussed at an international forum using NIH guidelines — relevant stakeholders were at the table and a consensus statement was published in numerous journals including Neurosurgery and also the Journal of Clinical Neuroscience.

The Consensus meeting represented 10 years of successful collaboration. The table of contents for this vibrant, multinational, interdisciplinary discussion highlights original data, debate and an overview that brought various disciplines under one roof.

We respectfully suggest the AAN position stand would have had even more credibility, and usefulness for a broad audience, if it had cited the 2009 Consensus Statement. As Heath and Heath suggest in their terrific book ‘Made to Stick‘, we need to provide clear, consistent, simple messages.

For those wanting more, listen to BJSM’s podcasts posted immediately after the Zurich meeting.

Previous Asian Football Confederation sports medicine conferences were held in Malaysia, Oman and Japan.

The 2011 Conference on Science and Football Medicine is being held from March 18–20 in Kuala Lumpur and a terrific cadre of football experts are on the program.