Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Steffan Griffin (@lifestylemedic)

The RFU’s Rugby Medicine Meeting, suitably held at the location of next year’s Rugby World Cup final, a chance for all those working within the game to catch-up and listen to expert opinion on a variety of topics and their relevance to current practice – from tendinopathy to occlusion training.

In case you missed it, here a few information highlights:

Session 1: Tendinopathy

Dr Jonathan Rees: Current models of tendinopathy

• Take tendinopathy research with pinch of salt if there are small sample sizes and recruitment bias (which is common due to the relapsing-remitting nature of the condition (= most will improve naturally after a relapse anyway!))
• There are many theories surrounding the cause of tendinopathy:
  • Professor Jill Cook’s model with load as the centre of the model
  • Sai-Chuen Fu’s theory that clinical presentation is preceded by a failed healing/repair response
  • Dr Rees’ model that there is an element of inflammation present showing an active process at work in the process
• Treatment protocols using eccentric exercises have effect via force fluctuation within the tendon and not simply the magnitude of force
• Denervation techniques such as high-volume injections treat the pain but not the tendon
• PRP/stem cell treatments lack a strong evidence base despite their popularity

Professor Hakan Alfredson: Surgical decision making in respect to rehabilitation

• Ultrasound and Doppler are considered gold-standard diagnostic tools, they are dynamic and can assess neovascularity
• If a tendon is thickened with more hypo-echoism than usual, consider a partial tendon rupture as a differential diagnosis
• Best current surgical management of tendinopathy in elite athletes focuses on structures around the tendons such as fat pads, where neovascular structures seem to originate. This means minimal disturbance to the tendon, allowing early and aggressive rehabilitation and good results in this cohort

Dr Dylan Morrisey: Rehabilitation of Achilles and Patellar Tendinopathy

• Is there an inflammatory element to the healing process? Research needed in this area
• Mobile phone technology to help educate and show patients how to correctly perform their prescribed exercises is a new and novel tool
• Despite many new advances, loading is still the core management principle. However, the degree is dependent on multiple intrinsic and extrinsic factors from age to demand
• Current evidence shows a role for shockwave therapy as an adjunct with a positive effect on pain scores and function

Session 2: Rugby World Cup 2015 & Concussion Update

• RWC 2015 is a unique challenge for medical staff as they have to prepare the squad for a (hopeful!) 7-game tournament with short turnaround between matches
• Need to prepare players for 100-minute matches as a huge emphasis on scoring points in the last quarter – see the All Blacks!
• Preparation for the tournament includes identifying surgical cases for next January and implementing a clear recovery protocol
• The medical board ensures training of all incoming medical teams in immediate care, thus creating an international legacy benefiting the sport whilst also distributing the equipment to clubs after the tournament for a more local legacy
• The RFU are currently designing an e-resource to all Premiership/Championship coaches and players, which will be mandatory and will educate them about concussion
• There will also be a video repeat of any suspected concussion incident available to the medical teams, which will be mandatory viewing before being able to return the player to the field (This will be trialled in the Premiership next year)
• PSCA now renamed ‘head injury assessment’ and updated to include element of the SAC test and tandem-gait test
• Practice review of the last 2 years show that more players are being removed, although this is still less than the number returning to play

Session 3: Masterclasses

Masterclass 1: Current concepts in surgical decision making when treating the professional rugby player. Mr Andrew Wallace

• The tackle is the most common injury event
• There are some general rules regarding mechanism of injury and pathology
  • Try-scoring associated with labral injury
  • Tackling associated with labral/rotator cuff pathology
  • Direct impact associated with labral/AC-joint and clavicular fractures
• In elite rugby players, over 30% of operations reveal multiple pathologies
• Bony defects are a good prognostic marker for recurrence of injury
• Distal biceps and pectoralis major injuries are on the rise

Masterclass 2: Current concepts in athletic groin pain. Dr Andy-Franklin Miller

• Groin pain is the third main cause of time-out and is strongly associated with impaired performance
• There is a general difficulty in diagnosing pathology due to different terminologies and understanding of pathology
• Knowing anatomy is important: the pelvis should be seen as a ‘polo-mint’, it’s integrity unable to be compromised at one-point alone
• The pubic symphysis can take linear load but not rotational forces, and so there is a role to discover the biomechanics of movements affecting the pelvis so that we are able to target cause of pain and dysfunction
• In sport, the pelvis has to absorb a significant force, and so poor pelvic control and poor turning techniques increases susceptibility to injury
• Rehabilitation should not be seen as a means to treat pain, but as an opportunity to develop and improve controlled sport-specific movement and thus potentially enhance performance

It was a fantastic day spent listening to some leading figures in the field as they discussed some of topical issues in the sport, and to hear about the enormously exciting medical and logistical challenge that the Rugby World Cup presents. Many thanks to Dr Simon Kemp for allowing me to attend the meeting and write a blog of it’s fantastic content.

Steffan Griffin is a third year medical student at the University of Birmingham currently intercalating at Cardiff Metropolitan University in Sports Science. As an ambassador for Move.Eat.Treat and the president of the Birmingham University Sport and Exercise Medicine Society (BUSEMS), he is passionate about the role of exercise as a proactive healthcare tool. He is involved with the Undergraduate Sports & Exercise Medicine Society (USEMS) committee as the Conference Officer. He combines a passion for all things SEM related with an avid interest in sport, and tries to live as active a life as possible.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.