Anterolateral Ligament Reconstruction Does Not Delay Functional Recovery, Rehabilitation, and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Matched-Pair Analysis From the SANTI (Scientific ACL Network International) Study Group.

PURPOSE: To determine whether the addition of an anterolateral ligament reconstruction (ALLR) resulted in delayed functional recovery (based on the Knee Santy Athletic Return to Sport [K-STARTS] score) at 6 months after anterior cruciate ligament reconstruction (ACLR). METHODS: A retrospective analysis of prospectively collected data from consecutive patients who underwent an ACLR between September 2017 and December 2020 was conducted. Patients who received an isolated hamstring autograft (isolated ACLR group) were propensity matched in a 1:1 ratio to patients who received a hamstring autograft ACLR combined with an ALLR (ACLR-ALLR group). Outcome measures included the Tegner Activity Scale and the K-STARTS test-a validated composite return-to-sports test (including the Anterior Cruciate Ligament-Return to Sport After Injury scale, Qualitative Assessment of Single-Leg Landing tool, limb symmetry index, and ability to change direction using the Modified Illinois Change of Direction Test). RESULTS: The study included 111 matched pairs. At 6 months postoperatively, there were no significant differences between groups in the overall K-STARTS score (65.4 for isolated ACLR vs 61.2 for ACLR-ALLR, P = .087) or the Tegner Activity Scale score (3.7 for isolated ACLR vs 3.8 for ACLR-ALLR, P = .45). In addition, an evaluation of the subscales of the K-STARTS score revealed no disadvantage across the domains of neuromuscular control, limb symmetry index, agility, or psychological readiness to return to sport when an ALLR was performed. CONCLUSIONS: The addition of ALLR at the time of ACLR does not delay functional recovery. Specifically, at 6 months postoperatively, there was no disadvantage in patients undergoing ALLR-ACLR, when compared with those undergoing isolated ACLR, with respect to neuromuscular control, limb symmetry indices (hop tests), agility, or psychological readiness to return to sport. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

First case of chronic post-traumatic anterior pituitary dysfunction in a professional rugby player: A case report.

BACKGROUND: Post-traumatic hypopituitarism has been reported as a complication in a number of contact sports. Although rugby is a sport with a high risk and high incidence of concussion, no such cases have been reported to date. CASE PRESENTATION: A 35-year-old professional rugby player presented with fatigue and reduced libido complaints after nearly 300 professional games during his 15-year career. At the end of the season, biological monitoring was performed and revealed low total testosterone level associated with a low luteinizing hormone, suggestive of central hypogonadism. Brain magnetic resonance imaging (MRI) revealed the presence of a 10-mm sequel lesion in the right medial temporal lobe and two additional punctiform lesions, all suggestive of post-traumatic brain injury lesions. Testosterone replacement therapy was initiated and the player perceived an overall decrease in fatigue and complete restoration of his libido after only a couple of weeks of treatment. During follow-up, thyrotropic deficiency was diagnosed 2 years after initial diagnosis treated by l-Thyroxin. CONCLUSIONS: In conclusion, this case report highlights a new post-traumatic brain injury complication in a professional rugby player, namely chronic post-traumatic anterior pituitary dysfunction. STUDY DESIGN: Case report; level of evidence 4.

Smoking and Vaping in Amateur Rugby Players, Coaches and Referees: Findings from a Regional Survey Might Help to Define Prevention Targets.

A high prevalence of cigarette smoking has been documented in France, and new patterns of tobacco and nicotine consumption are emerging, especially in some sports. In the amateur rugby population, data are scarce on harmful consumption and on the awareness of the risk of smoking. We analyzed the consumption of tobacco and other nicotine products in French amateur players, coaches and referees. Amateur players (>12 years old), coaches and referees participating in the Burgundy amateur championship were invited to answer an electronic, anonymous questionnaire during the 2017-2018 sport season. Among the 683 subjects (gender ratio M/F = 0.9), 176 (25.8%) were current smokers, including 32.4% of the referees and 28.2% of the coaches. The prevalence of smokers was higher in females (37.5%) than in males (24.6%). Most (86.4%) smoked within 2 h before/after a rugby session. Only 28 subjects (4.1%) usually vaped; 21 of them (75%) vaped within 2 h before/after a rugby session. Other tobacco or nicotine products were infrequent. The awareness about the risks of smoking before/after sport was incomplete, including in coaches and referees. The prevalence of cigarette smoking is alarming across the whole spectrum of rugby amateur actors. Education programs are urgently needed to reduce tobacco consumption in this at-risk population.

Shoulder functional status in rugby union players with and without history of shoulder problems.

OBJECTIVES: To assess the effects of (1) rugby union practice, (2) history of injury managed nonoperatively, and (3) history of injury managed operatively on shoulder functional status in male rugby union players. DESIGN: Cross sectional study. SETTING: Clinical. PARTICIPANTS: 86 male athletes were assigned into four groups: multisport athletes, rugby union players without shoulder problems, with history of shoulder injury managed nonoperatively and with history of shoulder injury managed operatively. MAIN OUTCOME MEASURES: SI-RSI questionnaire, maximal isometric glenohumeral internal and external rotator strength, unilateral seated shot put test, upper quarter Y balance test. RESULTS: Healthy players presented higher internal (p = 0.03) and external (p = 0.04) rotator strength than multisport athletes. History of shoulder injury managed nonoperatively did not impair physical abilities but limited player's psychological readiness (p < 0.001). After 4.5-months, shoulder stabilization surgery impaired maximal muscle strength and upper quarter body stability and mobility (p < 0.001 for all). CONCLUSIONS: The shoulder functional status in rugby union player presented increased glenohumeral rotator strength when compared to non-collision sport athletes. In rugby union players, psychological concerns remained in the long-term after a shoulder injury managed nonoperatively, and psychological and physical readiness seemed not be reached at 4.5 months postoperatively to respond to rugby union practice demand.

Cardiovascular prevention and at-risk behaviours in a large population of amateur rugby players.

BACKGROUND AND AIM: We aimed to investigate cardiovascular risk factors and health behaviours prospectively in a large population of French amateur rugby players. METHODS: An anonymous questionnaire was displayed to rugby players aged over 12 years enrolled in the 2014-2015 French amateur rugby championship from the Burgundy region (n = 5140). Questions addressed awareness on: (a) cardiovascular prevention; (b) tobacco, alcohol and highly caffeinated beverages consumption; and (c) adherence to prevention guidelines (ECG checks, training in basic life support, avoidance of sports practice during fever/infectious episodes). RESULTS: Among the 640 participants who completed the questionnaires, most were male (90%) and were aged under 35 years (80%). Almost half had basic life support training (42%), but only a minority attended an ECG check-up before licensing (37%), and only a few were aware of the cardiovascular prevention information campaign (17%), similarly across the age groups. Surprisingly, playing rugby with fever was commonly reported (44%) and was even more frequent in young women (55%). A high number of respondents were current smokers (35%), of whom most reported consumption less than 2 hours before/after a rugby session. Alcohol drinkers were frequent (69%), of whom most (79%) drank alcohol less than 2 hours before/after a match. Highly caffeinated beverages consumption (34%) was high, particularly in younger players (39%). Half highly caffeinated beverages consumption was in the setting of a rugby session, even greater in women and mainly motivated by performance enhancement (34%). CONCLUSION: Our findings from a representative regional cohort may help to identify targets for cardiovascular prevention through the development of educational programmes aiming to improve the knowledge and behaviour of amateur rugby players.

Combined Anterior Cruciate and Anterolateral Ligament Reconstruction in the Professional Athlete: Clinical Outcomes From the Scientific Anterior Cruciate Ligament Network International Study Group in a Series of 70 Patients With a Minimum Follow-Up of 2 Years.

PURPOSE: To evaluate clinical outcomes in professional athletes after combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction at a minimum follow-up of 2 years. METHODS: A retrospective analysis of prospectively collected data from the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group database was performed. All professional athletes who underwent primary combined ACL and ALL reconstruction between January 2011 and March 2016 were included. Patient assessment included physical examination, pre- and postoperative subjective and objective International Knee Documentation Committee (IKDC), Tegner activity scale, and Lysholm scores. RESULTS: Seventy-two professional athletes underwent primary ACL and ALL reconstruction; 70 (97%) were available, with a mean follow-up of 3.9 years (range, 2-7). The preoperative side-to-side anteroposterior laxity difference was 7.1 ± 1.4 mm, and this decreased significantly after surgery to 0.4 ± 0.9 mm (P < .0001). Pivot-shift grade evolved from 16 grade I (22.8%) and 54 grade II or III (77.2%) preoperatively, to 66 absent pivot shift (94.3%) and 4 grade I (5.7; P < .001). By 1-year postoperatively, 60 athletes (85.7%) returned to professional sport, with a mean time interval of 7.9 months (range, 5-12). Preoperatively, the mean subjective IKDC was 56.1 ± 12.3, the Lysholm score was 48.4 ± 12.5, and the Tegner score was 9.3 ± 1. At final follow-up, the mean subjective IKDC was 90.5 ± 7.6 (P < .0001), the Lysholm score was 94.4 ± 7.5 (P < .0001), and the Tegner score was 8.8 ± 1.5 (P < .004). The objective IKDC evolved from 39 grade C (55.7%) and 31 grade D (44.3%) preoperatively to 65 grade A (92.9%) and 5 grade B (7.1%) (P < .0001). Eleven Patients (15,7%) underwent a subsequent ipsilateral reoperation including 4 (5.7%) revision ACL reconstructions. The risk of graft rupture was significantly higher in female patients (13.6% vs 2.1% in male patients; P = .048). CONCLUSIONS: Combined ACL and ALL reconstruction is associated with excellent outcomes in professional athletes with respect to graft rupture rates, return to sport, knee stability, and reoperation rates after injury. LEVEL OF EVIDENCE: Level IV, case series.

Workload, Fatigue, and Muscle Damage in an Under-20 Rugby Union Team Over an Intensified International Tournament.

PURPOSE: To examine the effects of an intensified tournament on workload, perceptual and neuromuscular fatigue, and muscle-damage responses in an international under-20 rugby union team. METHODS: Players were subdivided into a high-exposure group (HEG, n = 13) and a low-exposure group (LEG, n = 11) according to match-play exposure time. Measures monitored over the 19-d period included training session (n = 10) and match (n = 5) workload determined via global positioning systems and session rating of perceived exertion. Well-being scores, countermovement jump height performance, and blood creatine kinase concentrations were collected at various time points. RESULTS: Analysis of workload cumulated across the tournament entirety for training and match play combined showed that high-speed running distance was similar between groups, while a very likely larger session rating of perceived exertion load was reported in HEG vs LEG. In HEG, high-speed activity fluctuated across the 5 successive matches, albeit with no clear trend for a progressive decrease. No clear tendency for a progressive decrease in well-being scores prior to or following matches was observed in either group. In HEG, trivial to possibly small reductions in postmatch countermovement jump performance were observed, while unclear to most likely moderate increases in prematch blood creatine kinase concentrations occurred until prior to match 4. CONCLUSIONS: The magnitude of match-to-match changes in external workload, perceptual and neuromuscular fatigue, and muscle damage was generally unclear or small. These results suggest that irrespective of exposure time to match play players generally maintained performance and readiness to play across the intensified tournament. These findings support the need for holistic systematic player-monitoring programs.

Fluctuations in running and skill-related performance in elite rugby union match-play.

This study investigated end-game and transient changes in running activities and whether these were concomitantly associated with reductions in skill-related performance in senior international rugby union match-play. Altogether, 18 official matches were analysed (322 individual observations) using computerised video-based tracking and event coding (Amisco Pro®, SUP, Nice, France). In forwards and backs, trivial to small reductions (% difference: -2.1, ±1.3 to -10.0, ±4.0%) in total distance and that covered at high speeds (>18.0 km h-1) occurred in the second- versus the first-half while there were trivial differences in skill-related performance measures (-2.3, ±4.5 to 7.5, ±14.0%). In both positions, small to moderate declines (-42, ±10 to -21, ±7%) occurred in high-speed running in the final 10-min and 5-min periods versus mean values for all other 10-min and 5-min periods throughout the game while only small changes (-18, ±51 to 13, ±41%) in skill-related performance were observed. Trivial changes in running and skill-related performance (-11, ±74 to 7, ±39%) were observed in the 5-min period immediately following the most intense 5-minute periods of play compared to mean performance over the other 5-min periods. These findings suggest that international rugby union players were generally able to maintain skill-related performance over the course of match-play even when declines in running performance occurred.

Analysis of Running and Technical Performance in Substitute Players in International Male Rugby Union Competition.

PURPOSE: To investigate the patterns and performance of substitutions in 18 international 15-a-side men's rugby union matches. METHODS: A semiautomatic computerized time-motion system compiled 750 performance observations for 375 players (422 forwards, 328 backs). Running and technical-performance measures included total distance run, high-intensity running (>18.0 km/h), number of individual ball possessions and passes, percentage of passes completed, and number of attempted and percentage of successful tackles. RESULTS: A total of 184 substitutions (85.2%) were attributed to tactical and 32 (14.8%) to injury purposes respectively. The mean period for non-injury-purpose substitutions in backs (17.7%) occurred between 70 and 75 min, while forward substitutions peaked equally between 50-55 and 60-65 min (16.4%). Substitutes generally demonstrated improved running performance compared with both starter players who completed games and players whom they replaced (small differences, ES -0.2 to 0.5) in both forwards and backs over their entire time played. There was also a trend for better running performance in forward and back substitutes over their first 10 min of play compared with the final 10 min for replaced players (small to moderate differences, ES 0.3-0.6). Finally, running performance in both forward and back substitutes was generally lower (ES -0.1 to 0.3, unclear or small differences) over their entire 2nd-half time played compared with their first 10 min of play. The impact of substitutes on technical performance was generally considered unclear. CONCLUSIONS: This information provides practitioners with practical data relating to the physical and technical contributions of substitutions that subsequently could enable optimization of their impact on match play.

Platelet-rich plasma as a treatment for chronic patellar tendinopathy: comparison of a single versus two consecutive injections.

BACKGROUND: platelet-rich-plasma is increasingly used in chronic patellar tendinopathy. Ideal number of PRP injections needed is not yet established. This study compares the clinical outcomes of a single versus two consecutive PRP injections. METHOD: between December 2009 and January 2012, 40 athletes with proximal patellar tendinopathy were treated by PRP injection. Patients received single (20 patients) or two PRP injections 2 weeks apart (20 patients). All patients underwent prospective clinical evaluation, including Victorian Institute of Sport Assessment-Patella (VISA-P) score, visual analog scale (VAS) for pain, and Tegner scale before PRP and after a minimum of 2 year follow-up. RESULTS: 9 patients failed PRP treatment and needed surgery. 1 patient was lost to follow-up. For the remaining patients, the VISA-P, VAS, and Tegner scores all significantly improved from 35.2 to 78.5 (p = 0.0001), 6.6 to 2.4 (p = 0.0001), and 4.8 to 6.9 (p = 0.0003). Patients who received two injections had better scores than those who received single injection with VAS of 1.07 versus 3.7 (p = 0.0005), Tegner score of 8.1 versus 5.9 (p = 0.0003) and VISA-P of 93.2 versus 65.7 (p = 0.0001). CONCLUSIONS: two consecutive PRP injections in chronic patellar tendinopathy showed better improvement in outcomes when compared to single injection. LEVEL OF EVIDENCE: randomized prospective consecutive series, Level 2.

The epidemiology of 1345 shoulder dislocations and subluxations in French Rugby Union players: a five-season prospective study from 2008 to 2013.

BACKGROUND: An understanding of the epidemiology of shoulder dislocation/subluxation in rugby union players could help develop targeted prevention programmes and treatment. We performed a multiyear epidemiological survey of shoulder dislocation/subluxation in a large cohort of rugby players. METHODS: A descriptive epidemiological study was performed prospectively for five playing seasons (2008-2013) in all players licensed in the French Rugby Union. Rugby players were categorised into five groups by age. The player and the team physician reported the injury to the club insurance company if it occurred during training or a match. The goals of the study were to define the rate, type and causes of shoulder dislocation/subluxation. RESULTS: 88,044 injuries were reported, including 1345 (1.5%) episodes of dislocation/subluxation in 1317 men and 28 women, mean age 22.5±5.9 years. About 10/10,000 men and 5/10,000 women reported an episode of shoulder dislocation/subluxation per season, including 83/10,000 senior professionals, 17/10,000 senior amateurs, 21/10,000 juniors, 12/10,000 cadets and <1/10,000 rugby school players. Shoulder dislocation/subluxation was significantly more frequent in senior and junior players (p<0.001). Injuries mainly occurred during a match (66%) in the middle of the season (44%). The most frequent playing position was forwards (56%) and the main mechanism was tackling (69%). When reported, the history of recurrence was found in 66% of injured players, fractures in 22% and acromioclavicular injury in 6.7%. Nerve injury was associated with shoulder dislocation in 6% of cases. CONCLUSIONS: Senior professionals and junior male forward rugby players with a history of shoulder dislocation/subluxation should receive special attention from sports medicine professionals and orthopaedic surgeons.

A new approach to quantifying physical demand in rugby union.

The objective of the study was to describe an original approach to assessing individual workload during international rugby union competitions. The difference between positional groups and between the two halves was explored. Sixty-seven files from 30 French international rugby union players were assessed on a computerised player-tracking system (Amisco Pro(®), Sport Universal Process, Nice, France) during five international games. Each player's action was split up into exercise and recovery periods according to his individual velocity threshold. Exercise-to-recovery (E:R) period ratios and acceleration were calculated. Results indicated that about 65% of exercise periods lasted less than 4 s; half of the E:Rs were less than 1:4, and about one-third ranged between 1 and 1:4 and about 40% of exercise periods were classified as medium intensity. Most acceleration values were less than 3 m·s(-2) and started from standing or walking activity. Back row players showed the highest mean acceleration values over the game (P < 0.05). No significant decrease in physical performance was seen between the first and second halves of the games except for back rows, who showed a significant decrease in mean acceleration (P < 0.05). The analysis of results emphasised the specific activity of back rows and tended to suggest that the players' combinations of action and recovery times were optimal for preventing large decrease in the physical performance.

Surgical treatment of anterior instability in rugby union players: clinical and radiographic results of the Latarjet-Patte procedure with minimum 5-year follow-up.

BACKGROUND: Anterior instability in rugby players is characterized by the common finding of a bony lesion, which has been identified as a potential cause of recurrence after soft-tissue reconstruction. The Latarjet-Patte procedure is effective in the treatment of recurrent anterior instability in collision sports such as rugby union. METHODS: We retrospectively assessed 34 rugby players (37 shoulders) stabilized with the Latarjet-Patte procedure. The mean follow-up was 12 years. All patients underwent clinical and radiographic assessment preoperatively and at final follow-up. Functional evaluation was performed with the Walch-Duplay and Rowe scores. A visual analog scale score for the evaluation of pain and the subjective shoulder value were recorded. In addition, all patients completed a questionnaire regarding the return to playing rugby. RESULTS: No recurrence of either dislocation or subluxation occurred. Persistent apprehension on clinical examination was present in 5 patients (14%). A bony lesion of the glenoid was present in 73% and a Hill-Sachs lesion in 68%. Sixty-five percent of the patients returned to playing rugby; only 1 patient did not return to playing rugby because of his shoulder. The mean Walch-Duplay and Rowe scores were 86 and 93 points, respectively. The mean subjective shoulder value was 90%. Radiographic healing of the bone block was observed in 89% of cases. At final follow-up, 11 patients (30%) had minor arthritic changes, with no cases of moderate or severe arthritis. CONCLUSION: The Latarjet-Patte procedure provides a reliable method for stabilizing the shoulder, resulting in a return to playing rugby in a high number of cases without increasing the risk of long-term arthritic degradation.

How they won Rugby World Cup through height, mass and collective experience.

OBJECTIVES: To investigate the evolution of anthropometric characteristics in World Cup rugby players and identify elements associated with performance. DESIGN: Age, weight and height were collected for 2692 World Cup rugby players as well as rankings in each World Cup, and collective experience of winners, finalists, semifinalists and quarter finalists in comparison to the rest of the competitors. Anthropometric parameters were compared according to age and position (back and forwards). RESULTS: From 1987 to 2007, forwards and backs have become heavier by 6.63 and 6.68 kg and taller by 0.61 and 1.09 cm, respectively. The collective experience of the forwards' pack is a value increasing with the final ranking attained, as well as the weight of forwards and the height of backs. CONCLUSIONS: For all Rugby World Cups, the highest performing teams have the tallest backs and heaviest forwards with the highest percentage of collective experience.

Activity level recovery after arthroscopic PCL reconstruction: a series of 21 patients with a mean follow-up of 29 months.

Surgical treatment of PCL tears is often indicated after conservative management failure and it is known to be challenging with unpredictable outcomes. This study aims to describe and to evaluate the outcome of an arthroscopic PCL anterolateral bundle reconstruction using a quadriceps tendon autograft. Our hypothesis is that knee stability and function can be restored using this technique allowing patients to resume their pre-injury level of activity. Between 2005 and 2008, 21 consecutive patients underwent an isolated PCL reconstruction and were evaluated after a mean follow-up of 29 months (range 12-48). The mean time from injury to surgery was 28 months. All patients were assessed pre- and post-operatively using IKDC evaluation, Tegner and Lysholm scores. The differential laxity was measured radiologically using the Telos® stress device. Pre-operatively, no patients were classified A or B on the IKDC objective score. At last follow-up, 81% of patients were classified A or B. The average differential anteroposterior laxity was 11.2 mm (range 8-15) in the preoperative evaluation and 3.6 mm (range 0-7) at the final follow-up (p=0.01). The mean subjective IKDC score was 39.5 before surgery and 74.5 at the last follow-up (p<0.01). The Tegner and Lysholm scores were significantly improved (p<0.001). 81% of patients were able to resume the same pre-injury level of activity. Patients with high level activity before injury were found to have the best subjective outcomes. Satisfactory laxity control and clinical outcomes were obtained in this series allowing patients to resume their pre-injury activities and sports.

Arthroscopic identification of isolated tear of the posterolateral bundle of the anterior cruciate ligament.

PURPOSE: The goal of this study was to arthroscopically identify and assess the progressive changes in isolated ruptures of the posterolateral bundle of the anterior cruciate ligament (ACL) over time. METHODS: This prospective study investigated 174 patients for isolated posterolateral bundle tears during arthroscopic ACL reconstruction. The preoperative side-to-side anterior laxity was measured in all patients. The torn ACLs were inspected and analyzed arthroscopically to determine the tear pattern. RESULTS: Complete ACL tears were identified in 78.7% of patients and partial ACL tears in 21.3%. Isolated anteromedial bundle tears were identified in 22 patients and posterolateral bundle tears in 15 patients. Statistical analysis showed a significant difference in preoperative differential knee laxity between the group with complete ACL rupture and the group with partial ACL rupture. On arthroscopic evaluation, the posterolateral bundle had retracted distally toward the tibial surface over time. The amount of retraction was correlated to the time period from injury to reconstruction. CONCLUSIONS: In this study the exact diagnosis of an ACL partial tear was made at arthroscopy in all cases. Our observations confirm the evolution of the ruptured posterolateral bundle, which shows a retraction toward the tibia over time. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria based on consecutive patients with a universally applied gold standard.

Influence of maxillary mouthguards on physiological parameters.

INTRODUCTION: The purpose of this study was to test the influence of two types of maxillary mouthguards (a self-adapted and a custom-made model: SA and CM, respectively) on various physiological parameters generally associated with performance in team sports. METHODS: Nineteen trained male subjects participating in team sports were tested. Visual reaction time, explosive power, ventilation at rest, and ventilation and oxygen consumption during submaximal and maximal exercise were measured in three randomized conditions: normal, with SA mouthguards, or with CM mouthguards. RESULTS: Wearing SA or CM mouthguards did not significantly alter any of the measured parameters compared with the normal condition. CONCLUSIONS: Wearing a maxillary mouthguard does not affect the main physiological parameters generally associated with team sport performance. These results provide additional support to the policy of encouraging athletes to wear individually fitted maxillary mouthguards.