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

CONFERENCE REPORT

By Dr. David Samra & Dr. Liam West (@Liam_West)

The IOC World Conference on Prevention of Injury and Illness in Sport (Doha, 4-7 May, 2015) addressed injury prevention, screening, surveillance and evidence-based management for common injuries and illnesses among athletes.

The format of the conference demonstrated a wide spectrum of clinical reasoning styles among candidates. It centered on case-based discussion invoking clinical reasoning and decision-making. In small groups, delegates were given 10 minutes to discuss how they would manage two clinical case examples. Presenters outlined the most up to date evidence on the topic and then re-visited the cases with delegates, encouraged to raise discussion points for the expert panel on management.

Below we share some educational pearls from the conference sessions.

Concussion

• Identification and diagnosis of concussion require high index of suspicion and removal from play, independent of the pressures of the competitive and entertainment aspects of sport.
• Dr Winne Meeuwisse (Canada) illustrated the importance of effective education of coaches, parents and players outside of the pressures of competition. Candidates were instructed on how to administer the SCAT 3, performing it on themselves. This was very interesting in identifying common misconceptions and perhaps a few hangovers in the room.
• Dr Michael Makdissi presented the use of concussion modifying factors to identify those at risk of prolonged or difficult concussion. He recommended these patients receive multi-modal management in treatment of post-concussive symptoms.(1)

Hamstring Injuries: Minimising the risk of re-injuries

• Carl Askling’s hamstring lengthening strength protocol received a lot of attention. It involves 3 specific exercises (“Extender”, “Diver”, “Glider”). Askling described a preliminary test of hamstring “insecurity” (Askling H Test) to assist in guiding the need for extended rehabilitation prior to return to high-speed running (to prevent re-injury risk during rehabilitation).(2,3)
• He reiterated that the Nordic hamstring exercise is of great value in prevention of hamstring injury, particularly in athletes with previous history of strain.(4)

Groin Pain

• Professor Per Holmich, Denmark, presented the evidence for conservative treatment (exercise-based) and adductor tenotomy for athletic groin injuries. (5–7). He emphasized:
  • the need for clear assessment for accurate diagnosis using the consensus on classification of groin pain causes (adductors, psoas, inguinal, hip joint and other). (8)
  • Morphological changes of FAI do not influence the success of an exercise program for adductor-related groin pain.(9)
  • The overlap of pathologies on MRI, and poor correlation with clinical features, reinforces the problems with using imaging for guidance of management.(10)

Injury Surveillance and Periodic Health Evaluations (PHEs)

• This session emphasized a paradigm shift toward the goal of risk assessment and management rather than “injury prevention”. Presenters stressed:
  • the use of audit process and periodic health evaluations.
  • Collection of multiple sources of information in PHEs may assist in identifying individuals’ risks that may be reversible.
  • The best evidence to date suggests that the predictive value of PHEs has probably been overestimated.
  • Therefore it may be more worthwhile to apply proven intervention programs to a whole team, in order of priority.
• In regards to optimizing injury prevention strategies, Prof Roald Bahr addressed the potential opportunities from post-season analysis. Post-season analysis has the advantages of increased injury disclosure and allowance of increased intervention and rehabilitation time.

Prevention and Treatment of Heat Illness

• Dr Juan-Manuel Alonso defined heat illnesses and outlined the upcoming consensus guidelines (11) that aims to minimize heat risk to athletes.
• Acclimatisation is critical to prevent heat illness.

Achilles Tendinopathy

• Dr Johannes Tol outlined the correlation between increased quality of evidence and reduced effect size for injectable therapies. He summated that there is no strong evidence to support any injection for Achilles tendinopathy.
• Discussion about surgery of the plantaris tendon as a novel experimental therapy.(12)
• Discussion of the existence of an optimal Achilles tendon loading program. Just because there is the most evidence in eccentric loading programs, doesn’t mean this is the optimal program; Likely needs to be individualized based on symptoms, location, sport specificity and response.
• Case study- strong variability in clinical approaches with some clinicians unafraid to use cortisone to treat “reactive” Achilles tendinopathy, and others cautious due to concerns of longer-term catabolic effects.
• Some evidence for shock wave but only in calcific tendinosis, particularly Achilles (13). Stronger evidence of no effect for patella tendinosis or other non-calcific tendinosis.
• Tendonopathy relies on load for improvement – mechanotransduction is the mainstay of treatment.(14)

Pharmacology and Injectable Therapies for Acute Sports Injuries

• NSAIDs- general view that they should be avoided. Further evidence presented about the lack of benefit and potential detrimental effect of NSAIDs in acute injury and bone injury. But it has possible prevention benefits for DOMs or myositis ossificans.
• Dr John Orchard presented data from professional rugby league players to suggest that some pain-killing injections may be less safe than others. With 5-year follow-up, lower satisfaction and higher complications came from wrist, ankle, sternum and some rib injections.
• Cortisone injections- no role in acute injuries. The balance of pro-inflammatory and anti-inflammatory macrophages changes at around day 4 and this influences the progenitor myocytes for muscle repair.
• Dr Adam Weir concluded that there is no benefit shown for PRP in “acute musculoskeletal injuries”.(15,16) This generated debate and discussion, as a number of clinicians did not agree that there is no role for PRP in acute injuries. Dr Weir pointed out the issues with the persistence of debate in platelet rich therapies, as there are many possible indications, preparations and administration regimes. There are always more permutations to re-ignite debate. Exactly which preparation of PRP into which acute musculoskeletal injury?

Return to Sport Decisions

• Dr Willem Millweusse elucidated the steps occurring in clinical decision making in return to play. This model identifies and accepts the influences of non-medical factors in the process.
• Prof Roald Bahr took the delegates through the varying decision-based models (17,18) for return to play in sport – you can listen to his views on a BJSM Podcast here.

Quantifying cardiac risk

• The athlete’s heart has 3 main differing component’s: 1) Electrical – bradycardia, repolarization abnormalities, voltage criteria for chamber enlargement; 2) Functional – enhanced diastolic filling, augmentation of stroke volume; 3) Structural – increased chamber wall thickness & cavity size
• A QTc > 500ms is highly suggestive of LQTS but below this threshold in the absence of symptoms or familial disease is unklikely to represent LQTS in elite athlete
• Bethesda criteria due to be revised and release expected late 2015 #KeepYourEyesPeeled
• Try the online ECG module here or listen to the latest Sports Cardiology Podcast here from BJSM

The Difficult Ankle

• Patients with chronic lateral ankle instability combined with retromalleolar pain should be suspected as having a concomitant peroneus brevis tendon injury
• There is no such thing as a simple ankle sprain – the forces an athlete sustains during a “rolled ankle” are substantial!
• Listen to the BJSM Podcast on the difficult ankle here

Respiratory Illness

• Drs Martin Schwellnus provided insights into the management of illness in athletes. Although more relevant for international travel, highlights were:
  • Importance of identifying allergies as they increase risk of infection
  • Intense exercise and travel can decrease immunity
  • Prevention strategies require athlete education
  • Bronchial hyper-responsiveness is worse after intense efforts due to a transiently protective effect of catecholamines.
  • Although the “neck check” is a long-held triage tool to identify systemically unwell athletes, it is putative. Dr Schwellnus and colleagues tested the utility of the neck check among South African marathon runners and found it had a useful predictive value for those who were unable to perform and complete the race (i.e unwell with symptoms below the neck).

General Comments

There was an emphasis on providing clinicians with a framework and tools with which to appraise current injury prevention and management, in order to improve practice.

The social program was fantastic and included desert dune 4×4 driving, spectacular hospitality and a visit to the Aspetar Sports Medicine institute, and Aspire Institute of Sport.

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

Dr. David Samra is a Specialist Registrar in Sports & Exercise Medicine based in Sydney, Australia.

Dr. Liam West is a junior doctor from the UK that has recently relocated to Melbourne to locum and gain further SEM experience.

References:

1. Makdissi M, Cantu RC, Johnston KM, McCrory P, Meeuwisse WH. The difficult concussion patient: what is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms? Br J Sports Med. 2013 Apr 1;47(5):308–13.
2. Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2013 Oct 1;47(15):953–9.
3. Askling CM, Tengvar M, Tarassova O, Thorstensson A. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2014 Apr 1;48(7):532–9.
4. Horst N van der, Smits D-W, Petersen J, Goedhart EA, Backx FJG. The Preventive Effect of the Nordic Hamstring Exercise on Hamstring Injuries in Amateur Soccer Players A Randomized Controlled Trial. Am J Sports Med. 2015 Mar 20;0363546515574057.
5. Weir A, Jansen J a. CG, van de Port IGL, Van de Sande HBA, Tol JL, Backx FJG. Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial. Man Ther. 2011 Apr;16(2):148–54.
6. Schilders E, Dimitrakopoulou A, Cooke M, Bismil Q, Cooke C. Effectiveness of a selective partial adductor release for chronic adductor-related groin pain in professional athletes. Am J Sports Med. 2013 Mar;41(3):603–7.
7. Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999 Feb 6;353(9151):439–43.
8. Weir A, Hölmich P, Schache AG, Delahunt E, de Vos R-J. Terminology and definitions on groin pain in athletes: building agreement using a short Delphi method. Br J Sports Med. 2015 Apr 23;
9. Hölmich P, Thorborg K, Nyvold P, Klit J, Nielsen MB, Troelsen A. Does bony hip morphology affect the outcome of treatment for patients with adductor-related groin pain? Outcome 10 years after baseline assessment. Br J Sports Med. 2014 Aug;48(16):1240–4.
10. Branci S, Thorborg K, Bech BH, Boesen M, Nielsen MB, Hölmich P. MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. Br J Sports Med. 2015 May;49(10):681–91.
11. Racinais, S, Alonso JM, Coutts AJ, Flouris AD, Girard O, González-Alonso J, Hausswirth C, Jay O, Lee JKW, Mitchell N, Nassis GP, Nybo L, Pluim BM, Roelands B, Sawka MN, Wingo JE & Périard JD. Consensus recommendations on training and competing in the heat. Scand J Med Sci Sports 2015:25(Suppl. 1):6-19

12. Van Sterkenburg MN, Kerkhoffs GMMJ, Kleipool RP, Niek van Dijk C. The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study. J Anat. 2011 Mar;218(3):336–41.
13. Gerdesmeyer L, Wagenpfeil S, Haake M, et al. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: A randomized controlled trial. JAMA. 2003 Nov 19;290(19):2573–80.
14. Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med. 2009 Apr;43(4):247–52.
15. Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JAN, Bierma-Zeinstra SMA, et al. Platelet-Rich Plasma Injections in Acute Muscle Injury. N Engl J Med. 2014 Jun 26;370(26):2546–7.
16. Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JAN, Bierma-Zeinstra SMA, et al. Rationale, secondary outcome scores and 1-year follow-up of a randomised trial of platelet-rich plasma injections in acute hamstring muscle injury: the Dutch Hamstring Injection Therapy study. Br J Sports Med. 2015 May 4;
17. Creighton DW, Shrier I, Shultz R, et al. Return-to-play in sport: a decision-based model. Clin J Sport Med 2010;20:379–85.

18. Herring SA, Kibler WB, Putukian M. The team physician and the return-to-play decision: a consensus statement-2012 update. Med Sci Sports Exerc 2012;44:2446–8.