Pay attention to the evidence: in the longer term, intraarticular corticosteroid injections offer only harm for knee osteoarthritis.

With respect to the long-term effects of intra-articular corticosteroid injections (IACIs) in knee osteoarthritis (OA), we are at the stage where it seems like the jury has returned a verdict but the judge hasn't yet accepted it. Supporters of IACIs for knee OA, when reading about potential and actual harms and complete lack of any benefit in the medium- or long- term, are now clutching at straws that we shouldn't even expect to observe any benefit in the longer term. Sadly, the same arguments that orthopaedic surgeons use to justify continuing with knee arthroscopy when there are only documented long-term harms and no documented long-term benefits, are being used by rheumatologists to justify continuing with IACIs for knee OA. The only actual reason to keep recommending both IACIs and knee arthroscopy (which sadly society guidelines still do) is the "status quo", with the self-affirming argument that the quality of the RCTs published to date is not (yet) high enough to justify a change in expert opinion. There is a very strong argument against preserving the status quo for knee OA: outcomes everywhere keep getting worse. Knee replacements seem to be on a steady growth curve upwards in all countries and knee OA prevalence itself is also increasing. Something is badly wrong with the status quo for knee OA: if we were getting good results with medical treatment then fewer people would be needing knee replacements, not more. A very easy place to start questioning the status quo is to read a systematic review showing worse results than all comparators for IACIs followed by an editorial saying "let's not give up on IACIs for knee OA just yet". But as mentioned you could just as easily start with an orthopaedic journal editorial saying "let's not give up on knee arthroscopy just yet" after a systematic review showing no benefit for this procedure either.

Management of lumbar bone stress injury in cricket fast bowlers and other athletes.

Background: Recent guidelines (including a special series in The Lancet) have emphasised a minimal role for imaging when assessing low back pain in adults, as the majority of patients will have non-specific findings on imaging that do not correlate well with pain. Objective: To assess whether the diagnosis of lumbar bone stress injuries in young athletes should be considered an exception to the recommendation to avoid imaging for low back pain in adults. Method: Narrative review. Results: Early lumbar bone stress injury diagnosis has been available via traditional MRI sequences (and its precursor Single Photon Emission Computed Tomography (SPECT)) for 25-30 years. MRI assessments using bone window sequences (such as Volumetric Interpolated Breath-hold Examination (VIBE)) have allowed a better understanding of the diagnosis and prognosis of lumbar bone stress injury in young athletes. MRI with bone sequences has allowed non-radiating scans to serially follow the healing of unilateral stress fractures. In the majority of cases, non-chronic unilateral fractures can heal; however, this takes three-six months rather than the six-ten weeks that would be the typical unloading period if using symptoms (only) as a guide. The use of MRI to provide evidence of bony healing (as opposed to fibrous union, which creates the pars defect that predisposes to further bone stress lesions) can lead to better long-term outcomes in athletes. There is evidence to flag this as a structural lesion which is both painful and, more importantly, can heal/resolve if managed correctly. Therefore it represents an important 'specific' diagnostic subset within adult low back pain. Conclusion: Structural (rather than functional) management of bone stress injuries in high-demand athletes, such as cricket pace bowlers, is in contrast to the recommendation of functional management for general back pain in adults. Structural management is justified when there are demonstrable superior outcomes of having better structure. Although this has not yet been shown in randomised trials of elite athletes, apparent lengthier Test cricket careers of pace bowlers who do not have pars defects suggest better athletic outcomes if bony healing is achieved. For lower demand young adults, or athletes with established bilateral pars defects, functional management may be more pragmatic.

World netball cardiac screening guidelines.

Sudden cardiac adverse events remain an area of concern in sport. The precise risk for netball athletes is unknown but the annual incidence of sudden cardiac death in sports is reported at 0.5-2 cases in 100 000 young competitive athletes between the ages of 12-35 years. Cardiac screening in the sport and exercise medicine context aims at identifying pathologies associated with catastrophic events when combined with physical activity. There is an ongoing debate relating to the standardisation of the pre-participatory medical assessment (PPMA). World Netball (WN) commissioned a cardiac screening policy (13 March 2022). The minimum PPMA recommended by World Netball is a history, physical examination, and a resting 12-lead electrocardiogram (ECG). ECGs should be interpreted in accordance with athlete-specific ECG interpretation criteria. Expansion of sports cardiology experience and infrastructure, in combination with universal emergency response planning for sudden cardiac arrest, is intended to safeguard athlete health and player welfare in WN.

The prevalence of Achilles and patellar tendon injuries in Australian football players beyond a time-loss definition.

Little is known about the prevalence and associated of morbidity of tendon problems. With only severe cases of tendon problems missing games, players that have their training and performance impacted are not captured by traditional injury surveillance. The aim of this study was to report the prevalence of Achilles and patellar tendon problems in elite male Australian football players using the Oslo Sports Trauma Research Centre (OSTRC) overuse questionnaire, compared to a time-loss definition. Male athletes from 12 professional Australian football teams were invited to complete a monthly questionnaire over a 9-month period in the 2016 pre- and competitive season. The OSTRC overuse injury questionnaire was used to measure the prevalence and severity of Achilles and patellar tendon symptoms and was compared to traditional match-loss statistics. A total of 441 participants were included. Of all participants, 21.5% (95% CI: 17.9-25.6) and 25.2% (95% CI 21.3-29.4) reported Achilles or patellar tendon problems during the season, respectively. Based on the traditional match-loss definition, a combined 4.1% of participants missed games due to either Achilles or patellar tendon injury. A greater average monthly prevalence was observed during the pre-season compared to the competitive season. Achilles and patellar tendon problems are prevalent in elite male Australian football players. These injuries are not adequately captured using a traditional match-loss definition. Prevention of these injuries may be best targeted during the off- and pre-season due to higher prevalence of symptoms during the pre-season compared to during the competitive season.

Surgical Management of Ureteral Strictures Arising From Radiotherapy for Prostate Cancer.

Ureteral strictures arising from radiotherapy for the treatment of prostate cancer are rare. We describe four cases of these ureteral strictures emphasizing pre-operative factors that may have contributed to development of the strictures, their ultimate surgical management, and the patients' short-term outcomes.

The global burden of occupationally related low back pain: estimates from the Global Burden of Disease 2010 study.

OBJECTIVES: The study was part of the Global Burden of Disease 2010 study and aimed to quantify the burden arising from low back pain (LBP) due to occupational exposure to ergonomic risk factors. METHODS: Exposure prevalence was based on occupation distribution; estimates of relative risk came from a meta-analysis of relevant published literature. The work-related burden was estimated as disability-adjusted life years (DALYs). Estimates were made for each of 21 world regions and 187 countries, separately for 1990 and 2010 using consistent methods. RESULTS: Worldwide, LBP arising from ergonomic exposures at work was estimated to cause 21.7 million DALYs in 2010. The overall population attributable fraction was 26%, varying considerably with age, sex and region. 62% of LBP DALYs were in males-the largest numbers were in persons aged 35-55 years. The highest relative risk (3.7) was in the agricultural sector. The largest number of DALYs occurred in East Asia and South Asia, but on a per capita basis the biggest burden was in Oceania. There was a 22% increase in overall LBP DALYs arising from occupational exposures between 1990 and 2010 due to population growth; rates dropped by 14% over the same period. CONCLUSIONS: LBP arising from ergonomic exposures at work is an important cause of disability. There is a need for improved information on exposure distributions and relative risks, particularly in developing countries.

Regional differences in injury incidence in European professional football.

The objective of this study was to investigate regional differences in injury incidence in men's professional football in Europe. A nine-season prospective cohort study was carried out between 2001-2002 and 2009-2010 involving 1357 players in 25 teams from nine countries. Teams were categorized into different regions according to the Köppen-Geiger climate classification system. Teams from the northern parts of Europe (n = 20) had higher incidences of injury overall [rate ratio 1.12, 95% confidence interval (CI) 1.06 to 1.20], training injury (rate ratio 1.16, 95% CI 1.05 to 1.27), and severe injury (rate ratio 1.29, 95% CI 1.10 to 1.52), all statistically significant, compared to teams from more southern parts (n = 5). In contrast, the anterior cruciate ligament injury incidence was lower in the northern European teams with a statistically significant difference (rate ratio 0.43, 95% CI 0.25 to 0.77), especially for noncontact anterior cruciate ligament injury (rate ratio 0.19, 95% CI 0.09 to 0.39). In conclusion, this study suggests that there are regional differences in injury incidence of European professional football. However, further studies are needed to identify the underlying causes.

High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003-2004 to 2007-2008: time for an anterior cruciate ligament register by Scandinavian model?

The aim of this paper was to provide a descriptive epidemiology of anterior cruciate ligament (ACL) reconstructions in Australia. Data on all ACL reconstructions were collected from July 1, 2003 till June 30, 2008. Main outcome measures were the incidence of ACL reconstructions for Australia, per age group, sex and sport, including estimates of direct costs. There were 50 187 ACL reconstructions over the 5-year period studied. The population-based incidence of ACL reconstructions per 100 000 person-years was 52.0 [95% confidence intervals (CI): 51.6; 52.5], higher than previously published incidences from other western countries (Scandinavia 32-38). The population incidence rose rapidly through adolescence and early adulthood and then gradually declined. Males had a higher population incidence than females. Skiing had the highest incidence of ACL reconstructions per 100 000 person-years, followed by Australian rules football, rugby, netball and soccer. The total estimated hospital costs associated with ACL reconstruction surgery were over A$75 million (€45 million) per year. Further research is necessary to examine the causes for the higher population incidence of ACL reconstructions in Australia compared with other countries. The establishment of a national register of ACL injuries, similar to those developed in Scandinavia should be considered.

The association between hip and groin injuries in the elite junior football years and injuries sustained during elite senior competition.

OBJECTIVE: To establish the relationship between the history of hip and groin injuries in elite junior football players prior to elite club recruitment and the incidence of hip and groin injuries during their elite career. DESIGN: Retrospective cohort study. SETTING: Analysis of existing data. PARTICIPANTS: 500 Australian Football League (AFL) players drafted from 1999 to 2006 with complete draft medical assessment data. ASSESSMENT OF RISK FACTORS: Previous history of hip/groin injury, anthropometric and demographic information. MAIN OUTCOME MEASUREMENT: The number of hip/groin injuries resulting in > or =1 missed AFL game. RESULTS: Data for 500 players were available for analysis. 86 (17%) players reported a hip/groin injury in their junior football years. 159 (32%) players sustained a hip/groin injury in the AFL. Players who reported a previous hip or groin injury at the draft medical assessment demonstrated a rate of hip/groin injury in the AFL >6 times higher (IRR 6.24, 95% CI 4.43 to 8.77) than players without a pre-AFL hip or groin injury history. CONCLUSIONS: This study demonstrated that a hip or groin injury sustained during junior football years is a significant predictor of missed game time at the elite level due to hip/groin injury. The elite junior football period should be targeted for research to investigate and identify modifiable risk factors for the development of hip/groin injuries.

Decreased incidence of knee posterior cruciate ligament injury in Australian Football League after ruck rule change.

OBJECTIVE: To assess whether a rule change introduced in the Australian Football League (AFL) before the start of the 2005 season, to limit the run-up of ruckmen at the centre bounce, has been successful in reducing the incidence of knee posterior cruciate ligament (PCL) injuries. DESIGN: Cohort study with historical control. SETTING: The AFL competition from 1992 to 2008 inclusive. ASSESSMENT OF RISK FACTORS: The presence of a rule change (four seasons) compared with the previous 13 seasons (divided into two eras of seven and six seasons). MAIN OUTCOME MEASURE: Occurrence of knee PCL injury during a regular season or finals match, both from all causes and specifically from centre bounce ruck collision mechanisms. RESULTS: From 1992 to 1998 there were 11.0 PCL injuries per 10,000 player-hours, with 0.8 ruck injuries per 10,000 centre bounces. From 1999 to 2004, the rates increased to 12.9 per 10,000 player-hours and 5.6 ruck injuries per 10,000 centre bounces (p<0.01). The rates reduced to 5.9 PCL injuries per 10,000 player-hours and 0.9 ruck injuries per 10,000 centre bounces in the period 2005-2008 following the rule change (p<0.01). There was a lower relative risk in 2005-2008 than in 1999-2004 of incurring a centre bounce ruck PCL injury (0.16 (95% CI 0.04 to 0.69)) or of sustaining any PCL injury (0.45 (95% CI 0.28 to 0.75)). CONCLUSION: A rule change in the AFL to limit the run-up of ruckmen at the centre bounce has successfully reduced the rate of PCL injuries with this mechanism, with the total incidence of PCL injuries also falling.

Non-steroidal anti-inflammatory drugs in sports medicine: guidelines for practical but sensible use.

INTRODUCTION: Non-steroidal anti-inflammatory drugs (NSAID) are commonly used in sports medicine. NSAID have known anti-inflammatory, analgesic, antipyretic and antithrombotic effects, although their in-vivo effects in treating musculoskeletal injuries in humans remain largely unknown. NSAID analgesic action is not significantly greater than paracetamol for musculoskeletal injury but they have a higher risk profile, with side-effects including asthma exacerbation, gastrointestinal and renal side-effects, hypertension and other cardiovascular diseases. DISCUSSION: The authors recommend an approach to NSAID use in sports medicine whereby simple analgesia is preferentially used when analgesia is the primary desired outcome. However, based both on the current pathophysiological understanding of most injury presentations and the frequency that inflammation may actually be a component of the injury complex, it is premature to suppose that NSAID are not useful to the physician managing sports injuries. The prescribing of NSAID should be cautious and both situation and pathology specific. Both dose and duration minimisation should be prioritized and combined with simple principles of protection, rest, ice, compression, elevation (PRICE), which should allow NSAID-sparing. NSAID use should always be coupled with appropriate physical rehabilitation. CONCLUSION: NSAID are probably most useful for treating nerve and soft-tissue impingements, inflammatory arthropathies and tenosynovitis. They are not generally indicated for isolated chronic tendinopathy, or for fractures. The use of NSAID in treating muscle injury is controversial. Conditions in which NSAID use requires more careful assessment include ligament injury, joint injury, osteoarthritis, haematoma and postoperatively.

ZAP-70 by flow cytometry: a comparison of different antibodies, anticoagulants, and methods of analysis.

BACKGROUND: The clinical course of chronic lymphocytic leukaemia (CLL) is variable. ZAP-70 expression is believed to provide prognostic information. The flow cytometric detection of ZAP-70 is difficult because it is an intracellular antigen with weak expression in CLL. Consensus has not been reached as to the best method for measurement. METHODS: We analyzed 72 CLL patient samples for ZAP-70 expression and IgVH mutational status. Sensitivity and specificity of ZAP-70 expression against IgVH mutational status were assessed for two clones (2F3.2 and 1E7.2) and for four methods of analysis: percentage positivity (PP), comparing test to isotype control, ratio of geometric means of test and isotype control, and percentage and ratiometric methods comparing test and T/NK cell populations. The effects of anticoagulant, collection times, and time to analysis were also evaluated. RESULTS: Sensitivity and specificity were 85 and 88%, respectively, for Upstate PP; 70 and 88% for Caltag PP; 89 and 91% for Upstate ratio; 89 and 88% for Caltag ratio. Intraobserver variability was smaller when ZAP-70 expression was assessed using a ratiometric approach rather than the percentage method. By 48 h, we observed an average decrease of 13% in the Caltag ratio in the heparin preserved samples compared to an increase of 3% in those collected in EDTA. Within the first 24-h period, a greater percent variability was observed in those samples collected into EDTA compared with heparin. CONCLUSION: Our data support a rapid method for ZAP-70 measurement using commercially available fixation/permeabilization reagents, a conjugated antibody, and a ratiometric method of analysis that minimizes subjective interpretation of the results. This is a method of ZAP-70 assessment that could be included in a routine diagnostic CLL panel; however, the choice of anticoagulant and time of analysis after collection are critical factors in accurate assessment of ZAP-70 expression.

Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial.

BACKGROUND: Achilles tendinopathy is a common condition, which can become chronic and interfere with athletic performance. The proteinase inhibitor aprotinin (as injection) has been found to improve recovery in patellar tendinopathy (evidence level 1b) and Achilles tendinopathy. Internationally this therapy is being used based on this limited knowledge base. AIM: To evaluate whether aprotinin injections decrease time to recovery in Achilles tendinopathy. METHOD: A prospective, randomised, double blind, placebo controlled trial was performed comparing saline (0.9%) plus local anaesthetic injections and eccentric exercises with aprotinin (30,000 kIU) plus local anaesthetic injection and eccentric exercise. Three injections were given, each a week apart. In total, 26 patients, with 33 affected tendons, were enrolled for this study. RESULTS: At no follow up point (2, 4, 12, or 52 weeks) was there any statistically significant difference between the treatment group and placebo. This included VISA-A scores and secondary outcome measures. However, a trend for improvement over placebo was noted. CONCLUSION: In this study on Achilles tendinopathy, aprotinin was not shown to offer any statistically significant benefit over placebo. Larger multicentre trials are needed to evaluate the efficacy of aprotinin in Achilles tendinopathy.

Predictors of hamstring injury at the elite level of Australian football.

BACKGROUND: Hamstring injuries are the most common injury sustained by elite Australian football players and result in substantial costs because of missed training time, unavailability for matches and lost player payments. Evidence to support proposed risk factors for hamstring injury is generally lacking, limiting the development of appropriate prevention strategies. AIM: To identify intrinsic risk factors for hamstring injury at the elite level of Australian football. METHODS: A prospective cohort of 222 players underwent baseline measurement in the form of a self-report questionnaire and a musculo-skeletal screen during the pre-season period of the 2002 Australian football season. Injury surveillance and exposure data were collected for the full season. Logistic regression analyses were used to identify independent predictors of hamstring injury in this group of players. RESULTS: Thirty-one players sustained a hamstring injury. A past history (previous 12 months) of hamstring injury and increasing age were found to be independent predictors of hamstring injury. CONCLUSIONS: Older players and those with a previous history of hamstring injury are target groups for further research and implementation of injury prevention strategies. Restricted ankle dorsiflexion range of movement warrants consideration in the development of prevention programs for hamstring injury.

Classifying sports medicine diagnoses: a comparison of the International classification of diseases 10-Australian modification (ICD-10-AM) and the Orchard sports injury classification system (OSICS-8).

BACKGROUND: The International classification of diseases 10-Australian modification (ICD-10-AM) and the Orchard sports injury classification system (OSICS-8) are two classifications currently being used in sports injury research. OBJECTIVES: To compare these two systems to determine which was the more reliable and easier to apply in the classification of injury diagnoses of patients who presented to sports physicians in private sports medicine practice. METHODS: Ten sports physicians/sports physician registrars each coded one of 10 different lists of 30 sports medicine diagnoses according to both ICD-10-AM and OSICS-8 in random order. The coders noted the time taken to apply each classification system, and allocated an ease of fit score for individual diagnoses into the systems. The 300 diagnoses were each coded twice more by "expert" coders from each system, and these results compared with those of the 10 volunteers. RESULTS: Overall, there was a higher level of agreement between the different coders for OSICS-8 than for ICD-10-AM. On average, it was 23.5 minutes quicker to complete the task with OSICS-8 than with ICD-10-AM. Furthermore, there was also higher concordance between the three coders with OSICS-8. Subjective analysis of the codes assigned indicated reasons for disagreement and showed that, in some instances, even the "expert" coders had difficulties in assigning the most appropriate codes. CONCLUSIONS: Based on the results of this study, OSICS-8 appears to be the preferred system for use by inexperienced coders in sports medicine research. The agreement between coders was, however, lower than expected. It is recommended that changes be made to both OSICS-8 and ICD-10-AM to improve their reliability for use in sports medicine research.

Rye grass is associated with fewer non-contact anterior cruciate ligament injuries than bermuda grass.

OBJECTIVE: To assess the contribution of ground variables including grass type to the rate of anterior cruciate ligament (ACL) injury in the Australian Football League (AFL), specifically which factors are primarily responsible for previously observed warm season and early season biases for ACL injuries. METHODS: Grass types used at the major AFL venues from 1992 to 2004 were established by consultation with ground managers, and ground hardness and other weather variables were measured prospectively. RESULTS: There were 115 ACL injuries occurring in matches during the survey time period, 88 with a non-contact mechanism. In multivariate analysis, use of bermuda (couch) grass as opposed to rye grass, higher grade of match, and earlier stage of the season were independent risk factors for non-contact ACL injury. Ground hardness readings did not show a significant association with ACL injury risk, whereas weather variables of high evaporation and low prior rainfall showed univariate association with injury risk but could not be entered into a logistic regression equation. DISCUSSION: Rye grass appears to offer protection against ACL injury compared with bermuda (couch) grass fields. The likely mechanism is reduced "trapping" of football boots by less thatch. Grass species as a single consideration cannot fully explain the ACL early season bias, but is probably responsible for the warm season bias seen in the AFL. Weather variables previously identified as predictors are probably markers for predominance of bermuda over rye grass in mixed fields.

Methods for injury surveillance in international cricket.

BACKGROUND: The varying methods of cricket injury surveillance projects have made direct comparison of published studies in this field impossible. METHODS: A consensus regarding definitions and methods to calculate injury rates in cricket was sought between researchers in this field. This was arrived at through a variety of face-to-face meetings, email communication and draft reviews between researchers from six of the major cricket-playing nations. RESULTS: It is recommended that a cricket injury is defined as any injury or other medical condition that either: (a) prevents a player from being fully available for selection for a major match or (b) during a major match, causes a player to be unable to bat, bowl or keep wicket when required by either the rules or the team's captain. Recommended definitions for injury incidence (for matches, training sessions and seasons) and injury prevalence are also provided. It is proposed that match injury incidence is calculated using a denominator based on a standard time estimated for player exposure in matches, for the purposes of simplicity. This will allow all injury surveillance systems, including those with limited resources, to make calculations according to a standard definition. CONCLUSION: The consensus statement presented provides a standard which, if followed, allows meaningful comparison of injury surveillance data from different countries and time periods, which will assist in the possible identification of risk factors for injury in cricket.

Methods for injury surveillance in international cricket.

BACKGROUND: The varying methods of cricket injury surveillance have made direct comparison of published studies in this field impossible. METHODS: A consensus regarding definitions and methods to calculate injury rates in cricket was sought between researchers in this field. This was arrived at through a variety of face to face meetings, email communication, and draft reviews between researchers from six of the major cricket playing nations. RESULTS: It is recommended that a cricket injury is defined as any injury or other medical condition that either (a) prevents a player from being fully available for selection for a major match or (b) during a major match, causes a player to be unable to bat, bowl, or keep wicket when required by either the rules or the team's captain. Recommended definitions for injury incidence (for matches, training sessions, and seasons) and injury prevalence are also provided. It is proposed that match injury incidence is calculated using a denominator based on a standard time estimated for player exposure in matches, for the purposes of simplicity. This will allow all injury surveillance systems, including those with limited resources, to make calculations according to a standard definition. CONCLUSION: The consensus statement presented provides a standard which, if followed, allows meaningful comparison of injury surveillance data from different countries and time periods, which will assist in the possible identification of risk factors for injury in cricket.

Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection?

This paper discusses the theory that subtle lumbosacral canal impingement of the L5 nerve root may be a relatively common occurrence in older footballers and may in fact be a common underlying basis for the age related predisposition towards hamstring and calf strains.