Grading scale of radiographic findings in the pubic bone and symphysis in athletes.

PURPOSE: Radiographic abnormalities in the pubic bone and symphysis are often seen in athletes with groin pain. The aim was to create a grading scale of such radiologic changes. MATERIAL AND METHODS: Plain radiography of the pelvic ring including the pubic bone and the symphysis was performed in 20 male athletes, age 19-35, with long-standing uni- or bilateral groin pain. We used two control groups: Control group 1: 20 healthy age-matched men who had undergone radiologic examination of the pelvis due to trauma. Control group 2: 120 adults (66 men and 54 women) in 9 age groups between 15 and 90 years of age. These examinations were also evaluated for interobserver variance. RESULTS AND CONCLUSION: The grading scale was based on the type and the amount of the different changes, which were classified as follows: No bone changes (grade 0), slight bone changes (grade 1), intermediate changes (grade 2), and advanced changes (grade 3). The grading scale is easy to interpret and an otherwise troublesome communication between the radiologist and the physician was avoided. There was a high interobserver agreement with a high kappa value (0.8707). Male athletes with long-standing groin pain had abnormal bone changes in the symphysis significantly more frequently and more severely (p>0.001) than their age-matched references. In asymptomatic individuals such abnormalities increased in frequency with age both in men and women.

Herniographic findings in athletes with unclear groin pain.

BACKGROUND: Groin pain in athletes is a common symptom and may, among many other entities, be caused by skeletal changes in the symphysis and the pubic bone or hernia. MATERIAL AND METHODS: Herniographies in 51 athletes -- mainly soccer players -- with unclear groin pain were reviewed. The prevalence of various hernias and skeletal changes at the symphysis and os pubis was registered. A questionnaire was also sent to the patients 3-20 years after the herniography. RESULTS: A hernia was found in 13 patients. Four patients had an indirect inguinal hernia. Eight patients had a direct inguinal hernia and 1 had an obturator hernia. The prevalence of direct inguinal hernia was higher than expected in young men. This may be explained by strain at physical exercise. Bone changes at the pubic symphysis were found in 32 patients, 21 of whom had advanced changes. CONCLUSION: A hernia can be found with herniography in one-fourth of athletes with long-standing unclear groin pain. Therefore herniography should be included in the diagnostic procedure. Lesions of the symphysis may be the result of strain of tendons, ligaments and fascias. This may predispose for an inguinal hernia as well.

Abnormally decreased regional bone density in athletes with medial tibial stress syndrome.

Medial tibial stress syndrome, a common condition of uncertain origin found in athletes, is characterized by pain in the distal posteromedial aspect of the tibia during exercise, with or without increased scintigraphic uptake in the affected region. To determine whether medial tibial stress syndrome with increased scintigraphic uptake is associated with a change in tibial bone mineral density confined to the site of the increased uptake, we measured bone mineral density (in grams per square centimeter) in 18 adult male athletes with long-standing medial tibial stress syndrome and compared the measurements with those of 16 age- and sex-matched control subjects and with those of 18 athletes without medial tibial stress syndrome who had a comparable training regimen. Tibial bone mineral density in the region corresponding to the pain was 15%+/-9% lower in the patients than in control subjects and 23%+/-8% lower than in the athletic control subjects (both significant differences). Bone mineral densities in most other regions of the body were higher than in the control subjects but lower than in the athletic controls at the corresponding sites. In summary, medial tibial stress syndrome is associated with low regional bone mineral density.

Immediate external compression in the management of an acute muscle injury.

In a prospective, non-randomized study 40 athletes with contusion or distension injuries to the thigh or the calf muscle were followed with tests of range of motion (ROM) of knee or ankle joint, test of serum creatine kinase (CK) and ultrasonography of the injury until completely recovered. An experimental group of 19 injuries where subjects received treatment with application of a maximum compression bandage within 5 min (mean = 2 min) of the injury was compared to a control group of 21 injuries where subjects were treated with rest and elevation only, and in some cases non-maximum compression after 10-30 min. No significant differences were noted with respect to time to complete subjective recovery, ultrasonic size of the injury or time to normal findings on ultrasound between treatment and control groups. Strain injuries, although showing a tendency to be smaller in size, took a longer time to complete recovery than contusion injuries (mean +/- SD = 26 +/- 22 days and 19 +/- 9 days, respectively, P = 0.02). Diagnostic CK values and reductions in ROM were not correlated to the severity of the trauma, while ROM showed weak correlation to the sonographically measured size of the hematoma (r = 0.42: P < 0.01). Injuries displaying a circumscript anechoic, low-echogenic or mixed lesion at the diagnostic ultrasound investigation normalized more slowly (P = 0.001) and took longer to complete recovery (P = 0.001) than injuries with diffuse hyperechogenic lesions. We conclude that in this study the application of a maximum compression bandage within 5 min of a muscle trauma did not significantly reduce the size of the hematoma nor significantly shorten the time to complete subjective recovery compared with no immediate treatment. The diagnostic ultrasound investigation was valuable in predicting the severity of the trauma.

Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases.

OBJECTIVE: To compare information gained by ultrasonography and magnetic resonance imaging (MRI) in chronic achilles tendinopathy with regard to the nature and severity of the lesion. DESIGN: Imaging of both achilles tendons with ultrasonography and MRI was performed prior to unilateral surgery. Operative findings and histological biopsies together served as a reference. PATIENTS: Twenty-seven patients (22 men, 5 women; mean age 44 years; 21 athletes) suffering from chronic achilles tendinopathy participated in the study. Eighteen patients had unilateral and 9 had bilateral symptoms. RESULTS AND CONCLUSIONS: Surgical findings included 4 partial ruptures, 21 degenerative lesions and 2 macroscopically normal cases. Microscopy revealed tendinosis (degeneration) in all tendon biopsies, including cases with a partial rupture, but only slight changes in the paratendinous tissues (paratenon). Ultrasonography was positive in 21 of 26 and MRI in 26 of 27 cases. Severe intratendinous abnormalities and a sagittal tendon diameter > 10 mm suggested a partial rupture. In tendons with a false negative result histopathological changes were mild and a tendency towards a better clinical outcome was noted in the sonographic cases. Assessment of the paratenon was unreliable with both methods. Ultrasonography and MRI give similar information and may have their greatest potential as prognostic instruments.

Increasing incidence of Achilles tendon rupture.

During the period 1987-91, 153 cases of total Achilles tendon rupture were diagnosed in the city of Malmo (population 230,000). Almost two thirds were caused by sporting activities, notably badminton. Ruptures caused by nonsports injuries were found in older subjects. Compared to the age-specific incidence in 1950-73, a marked increase in both sports and nonsports injuries was found and patients in the latter group were older than in the former period. Patients with Achilles tendon ruptures can be classified into two subgroups with partly different etiologies: young or middle-aged athletes and older non-athletic persons. The increase in the former group is mostly explained by increased participation in recreational sports; the cause of increase in the latter group is unknown.

Anterior cruciate ligament reconstruction with the patellar tendon--augmentation or not? A 2-year follow-up of 82 patients.

The aim of this bi-centre study was to assess the possible effects of the addition of the Kennedy ligament augmentation device (LAD) in the reconstruction of the anterior cruciate ligament (ACL). The method of reconstruction used was a modification of the Brückner and Broström procedures, using the medial third of the patellar tendon tunnelled through the proximal tibia into the lateral femoral condyle and fastened with pull-out sutures. Eighty-two patients with chronic ACL insufficiency and severe symptoms of instability in spite of physiotherapy were randomly selected for reconstruction with or without a LAD. The LAD-augmented knees had the synthetic augmentation stitched to and embedded into the autogenous tissue and the composite graft was pulled through a femoral tunnel and stapled proximally. The patients were followed up regularly and the 2-year results are presented here. The outcome in both groups was good. The augmented-knee group had a larger extension deficit 1 month post-operatively compared to the non-augmented knee group but a smaller extension deficit at the 2-year follow-up. There was no difference in the median of the Lysholm knee function score but there were more patients in the non-augmented group with a lower Lysholm knee function score at the 2-year follow-up.

Sports-related groin pain: evaluation with MR imaging.

Our purpose was to assess the role of MRI in evaluating the musculoskeletal system in athletes with chronic pain laterally in the groin of unknown etiology. Magnetic resonance imaging (MRI) of the pubic ring was performed in 11 young athletes (soccer players) with long-standing groin pain. MR findings were compared with plain films and isotope examination (bone scan Tc 99M). Abnormal MRI findings included a broadened and irregular symphysis with a characteristic pattern of low signal intensity on T1W and high signal intensity on T2W images localized in the superior pubic ramus at a distance from the symphysis. Positive findings were also observed on plain films and on nuclear medicine studies. However, the imaging findings in the superior public ramus of the symphysis was located considerably more laterally on MRI. MRI is a valuable method for evaluating discrete and ambiguous pelvic pain in athletes, particularly for identifying concomitant changes in the superior ramus, which may give rise to long-standing pain localized laterally in the groin.

Fifth metatarsal fractures. Biomechanics, classification, and treatment.

Fractures of the fifth metatarsal are treated conceptually based on anatomic location and character of the fracture site. Intra-articular disruptions require reconstruction, if possible. Malalignment of acute fractures requires either closed reduction or open reduction if the malalignment represents a load-bearing dysfunction to the forefoot. Segmental defects require bone grafting and stabilization with plate and screws. Jones fracture is most effectively managed with medullary lag screw delivery in the active or athletic patient. Casting can be considered for high-risk patients. Late bone grafting for sclerotic nonunion is necessary with inlaid grafts harvested from the calcaneus or tibia. Tuberosity fractures require open reduction only when articular involvement is a problem or when distraction is apparent. Otherwise, they can be expected to heal rapidly without long-term problems.

Blood flow in chronic Achilles tendinopathy.

Thirty five patients, most of them athletes, with chronic Achilles tendinopathy were enrolled in a study of tendon blood flow using laser Doppler flowmetry at rest and during physical provocation by passive stretch and contraction of the triceps. The patients were compared with a group of 40 healthy volunteers assessed according to a similar protocol in a previous study. In both groups values were significantly lower at the distal insertion, but otherwise the values were evenly distributed throughout the tendon. Blood flow in the symptomatic tendons was significantly elevated as compared with the controls. Both groups demonstrated a similar vascular response to physical loading, a progressive decline in blood flow as tension increased. Contrary to popular belief chronic Achilles tendinopathy is associated with an increased blood flow of uncertain origin. A local deficiency in tendon blood supply does not initiate the lesion nor does it explain why the condition persists.

Blood flow in the human Achilles tendon assessed by laser Doppler flowmetry.

This study evaluated microvascular perfusion in the human Achilles tendon by laser Doppler flowmetry (LDF) at rest, during vascular occlusion, and during passive stretch and isometric contraction of the triceps surae. In 40 healthy volunteers, an intratendinous needle probe was introduced 5 mm above the distal insertion, at the midportion, and at the musculotendinous junction of both legs. Values were obtained at rest and during temporary vascular occlusion. Twenty-eight of the subjects also were assessed during physical provocation by passive stretch and isometric contraction of the triceps surae. Blood flow was significantly lower near the calcaneal insertion but otherwise was distributed evenly in the tendon. The output signal showed a pulsatile variation synchronous with heart activity, and temporary vascular occlusion always caused a pronounced reduction in LDF values. Passive stretch and isometric contraction induced a progressive decline in LDF values as tension increased. Hyperemia often appeared after contraction. Tendon blood flow was higher in women and decreased with increasing age.

No effect of piroxicam on achilles tendinopathy. A randomized study of 70 patients.

70 consecutive adult, nonrheumatic patients with a painful achilles tendinopathy were randomized to treatment with either a nonsteroid antiinflammatory drug (piroxicam) or placebo. Both groups received adjunct treatment with a period of rest combined with stretching and strengthening exercises. 52/70 cases were engaged in various sports, notably running. All subjects were evaluated on days 3, 7, 14, and 28 with respect to pain, tenderness, swelling, ankle joint movement and muscle strength. Results were judged from residual symptoms and an overall assessment of the efficacy. No differences were seen between the groups at any time during the study. The overall result was identical with a rate of success slightly better than 50 percent which corresponds to the placebo response reported in other studies.

Ultrasound examination of soft tissue injury of the lower limb in athletes.

We performed ultrasonography on 32 athletes complaining of intense pain in a swollen and tender thigh or calf after a contusion or stretching trauma. The ultrasonogram was used to visualize the presence and size of a suspected hematoma. The findings included the following: 7 patients with a circumscribed, anechoic lesion compatible with a liquefied hematoma; 10 patients with a circumscribed lesion of mixed echogenicity compatible with areas of liquefied hematoma, coagulated blood, and edema; and 15 patients with a diffuse change in echogenicity of the whole muscle. The circumscribed liquefied, and mixed hematoma were more common after contusion trauma, while the diffuse type was more common after injury caused by stretching. Ultrasonography is useful in localizing the hematoma and in characterizing the different types. Differentiation is important in diagnosis and choice of treatment.

Longstanding groin pain in athletes. A multidisciplinary approach.

In 21 male athletes (age 20 to 40 years) with longstanding unexplained groin pain, a multidisciplinary investigation was performed in order to reveal the underlying cause. These examinations included general surgery for detection of inguinal hernia and neuralgia, orthopaedic surgery for detection of adductor tenoperiostitis and symphysitis, urology for detection of prostatitis, radiology for performing herniography and plain film of the pelvic bones, nuclear medicine for isotope studies of the pubic bone and symphysis. In 19 patients there was a positive diagnosis for 2 or more of the diseases (10 patients had 2 diseases, 6 patients had 3 diseases, 3 patients had 4 diseases). Two patients had only signs of symphysitis. Our results show the complexity of longstanding groin pain in athletes. It also explains why therapy for one specific disease entity may fail. We conclude that this clinical setting demands the recruitment of a team with experience of different aspects of groin pain.

The effect of external pressure on intramuscular blood flow at rest and after running.

Local blood flow in the thigh was measured with 133Xe clearance technique in eight male distance runners after compression with a foam rubber compress and a standard elastic bandage. Two degrees of compression were tested, and an initial experiment with rested subjects was followed by a similar experiment immediately after running. Maximum compression exerted a cutaneous pressure of 85 (+/- 8) mm Hg and caused an immediate cessation of intra-muscular blood flow in the compressed area. Moderate compression gave a cutaneous pressure of 40 (+/- 5) mm Hg and resulted in a reduction of blood flow by approximately 50%. During compression, there were no significant differences in the blood flow of rested subjects compared to subjects immediately after running. In acute soft tissue injuries, a maximum compression bandage should effectively reduce or eliminate the formation of an intra-muscular hematoma, and an additive effect on blood flow of ice should not be expected.

Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study.

Two hundred consecutively seen patients who had an injury to either the anterior cruciate ligament or the medial collateral ligament, or both, were randomly allocated to treatment by either conservative or a surgical regimen. Injuries to the medial collateral ligament could not be demonstrated to benefit from surgical treatment in any respect--with or without surgery the results were excellent. With injuries to the anterior cruciate ligament, recovery was more rapid without surgery but otherwise the results differed between the groups in only one respect: the pivot-shift test was more often positive after conservative treatment. The results were good in both treatment groups even though most of the patients who had an injury of the anterior cruciate ligament were somewhat less pleased with the outcome after a period of time.

Hinged cast after knee ligament surgery.

One hundred thirteen patients scheduled for repair of knee ligament injuries were randomized to postoperative immobilization in either a hinged or a long leg cast. The time of disability (i.e., sick leave) was significantly shorter (6 weeks) with a hinged cast, but only in ACL cases. All types of injuries regained their range of motion more rapidly after use of a hinged cast. There was no evidence that the motion permitted in a hinged cast hampers the result as regards to stability.

Traumatic hemarthrosis in stable knees.

A thorough arthroscopic examination was performed in 90 consecutive patients with sprained knee injuries with hemarthrosis, but without signs of instability or fracture. The source of bleeding was found in all but five joints. Thirty-nine injuries were tears of the cruciate ligament, only three of which were complete tears. Fourteen injuries were (osteo)chondral fractures and six were meniscal lesions. The remainder bled from the synovium or meniscal attachments. The arthroscopic examination resulted in an altered course of treatment in few, if any, of these patients.

Anterior tibial compartment pressure during race walking.

In 14 race walkers the intramuscular pressure in the anterior tibial muscle was measured with a wick catheter. At rest the pressure was 10 to 15 mmHg and increased by a factor of 10 during full speed walking. Those walkers who experienced pain in the anterior tibial muscle also had a higher than average pressure. Fasciotomy decreased the intramuscular pressure and relieved the pain.