Efficacy of the FIFA cooling break heat policy during an intermittent treadmill football simulation in hot conditions in trained males.

OBJECTIVE: To evaluate the efficacy of the Fédération Internationale de Football Association (FIFA) cooling break policy against alternative cooling configurations in attenuating thermal strain during simulated football in the heat. METHODS: 12 males (age: 27±6 years, V̇O2peak: 61±7 mL/kg/min) completed five 90 min intermittent treadmill football match simulations in 40°C and 41% relative humidity (32°C wet-bulb globe temperature) with different cooling configurations: regular match without cooling breaks (REG), 3 min breaks without cooling (BRKno-cool), 3 min breaks with cooling (BRKcool: current FIFA policy; chilled fluid ingestion and ice towel across neck and shoulders), 5 min extended half-time without cooling breaks (ExtHTonly) and 3 min cooling breaks with 5 min ExtHT (ExtHTcool). Rectal temperature (Tre), heart rate, whole-body sweat rate (WBSR) and rating of perceived exertion (RPE) were recorded. Data are presented as mean (95% CIs). RESULTS: Final Tre was lower in BRKno-cool (0.20°C (0.01, 0.39), p=0.038), BRKcool (0.39°C (0.21, 0.57), p<0.001) and ExtHTcool (0.40°C (0.22, 0.58), p<0.001) than REG (39.1°C (38.8, 39.3)). Mean Tre was lower in ExtHTcool (38.2°C (38.0, 38.4)) than BRKcool (38.3°C (38.1, 38.5), p=0.018), BRKno-cool and ExtHTonly (38.4°C (38.2, 38.6), p<0.001) and REG (38.5°C (38.3, 38.7), p<0.001). Mean heart rate was lower during BRKcool (6 beats/min (4, 7), p<0.001) and ExtHTcool (7 beats/min (6, 8), p<0.001) compared with REG. WBSR was comparable across trials (p≥0.07) and RPE was attenuated during BRKcool (0.4 (0.1, 0.7), p=0.004) and ExtHTcool (0.5 (0.2, 0.7), p=0.002), compared with REG. CONCLUSION: BRKcool and ExtHTcool attenuated thermal, cardiovascular and perceptual strain during a simulated football match in the heat. Additional strategies may be required in field settings or under harsher conditions.

A concept mapping approach to identifying the barriers to implementing an evidence-based sports injury prevention programme.

BACKGROUND AND AIM: Understanding the barriers to programme use is important to facilitate implementation of injury prevention programmes in real-word settings. This study investigated the barriers to coaches of adolescent female soccer teams, in Victoria, Australia, implementing the evidence-based FIFA 11+ injury prevention programme. METHODS: Concept mapping with data collected from 19 soccer coaches and administrators. RESULTS: Brainstorming generated 65 statements as barriers to 11+ implementation. After the statements were synthesised and edited, participants sorted 59 statements into groups (mean, 6.2 groups; range, 3-10 groups). Multidimensional scaling and hierarchical cluster analysis identified a six-cluster solution: Lack of 11+ knowledge among coaches (15 statements), Lack of player enjoyment and engagement (14), Lack of link to football-related goals (11), Lack of facilities and resources (8), Lack of leadership (6) and Lack of time at training (5). Statements in the 'Lack of 11+ knowledge among coaches' cluster received the highest mean importance (3.67 out of 5) and feasibility for the Football Federation to address (3.20) rating. Statements in the 'Lack of facilities and resources' cluster received the lowest mean importance rating (2.23), while statements in the 'Lack of time at training' cluster received the lowest mean feasibility rating (2.19). CONCLUSIONS: A multistrategy, ecological approach to implementing the 11+-with specific attention paid to improving coach knowledge about the 11+ and how to implement it, linking the 11+ to the primary goal of soccer training, and organisational leadership-is required to improve the uptake of the 11+ among the targeted coaches.

Location of the sural nerve during posterolateral approach to the ankle.

BACKGROUND: There is no consensus regarding the most appropriate surgical approach for the treatment of posterior malleolar fractures. The posterolateral approach facilitates more accurate reduction, but the sural nerve is potentially at risk during the approach. The location of this nerve in relation to this approach has not been clearly described in the literature. MATERIALS AND METHODS: We performed cadaveric dissection of 12 legs using the posterolateral approach, a 10-cm incision midway between the tendo-achilles and the lateral malleolus, commencing at the tip of the lateral malleolus and extending proximally. The horizontal distances of the sural nerve and the short saphenous vein to the incision were measured at the proximal and distal ends and at the mid-point of the incision (positive towards the Achilles and negative towards the lateral malleolus). RESULTS: In ten of the 12 cases, the sural nerve and short saphenous vein crossed the incision at an average of 56.7 mm and 61.0 mm along the incision, respectively. The median distances from the proximal end of the wound were -9.9 mm and -12.7 mm, 0.9 mm and -1.7 mm from the midpoint, and 6.3 mm and 7.7 mm from the distal end of the incision, respectively. CONCLUSION: The sural nerve and saphenous vein are at risk of iatrogenic injury over the whole length of the incision for the posterolateral approach for posterior malleolar fractures. CLINICAL RELEVANCE: When performing a posterolateral approach to the ankle, particular care should be taken at the midpoint of the incision.

Distal tendinosis of the tibialis anterior tendon.

BACKGROUND: Disorders of the tibialis anterior (TA) tendon have infrequently been reported but spontaneous rupture of this tendon is well recognized. The clinical presentation of tendinosis without rupture of the distal TA has not previously been reported and is the basis of this paper. MATERIALS AND METHODS: A study of 29 patients diagnosed with distal TA tendinosis was undertaken. Data collected included, patient demographics, weight, height, pain profile and examination findings. All patients underwent MRI of the symptomatic foot. Operative findings of those patients undergoing surgery for this condition were collected. RESULTS: Twenty-nine patients (32 feet) were included in the study group. Their mean age was 62 years and 27 patients were female. Twenty-one patients were overweight. The usual presenting symptom was burning medial midfoot pain that was often reported to be worst at night. Swelling over the TA tendon was frequently observed. On MRI the TA was thickened in all patients. Longitudinal split tears were observed in 19 feet. Chondral thinning and/or osteophyte formation at the first tarsometatarsal or medial naviculocuneiform joints was observed in 11 feet. Eleven feet underwent surgery. Universally the TA tendon was macroscopically thickened and had lost its normal fibrillary appearance. Longitudinal split tears were observed in eight tendons. Pathology was typical of a degenerative tendinosis. CONCLUSION: Distal TA tendinosis is a condition that seems to predominantly affect overweight elderly women. It often presents with nocturnal burning medial midfoot pain.

Chronic exertional compartment syndrome in the medial compartment of the foot.

BACKGROUND: Chronic exertional compartment syndrome of the foot has been previously described. There has been debate over the exact number and location of compartments. The involvement of the medial compartment has been consistently described in case reports; however, there is little in the orthopaedic literature on the exact anatomy for the fasciotomy and the resultant long term outcomes. MATERIALS AND METHODS: We present the results of five patients (seven feet) who were surgically treated by medial compartment decompression, releasing both superficial and deep fascial layers. There were three females and two males, average age of 23 (17 to 34) years. Decompression was bilateral in one, sequential in one, and unilateral in three. Three patients also had surgical treatment of chronic compartment syndrome elsewhere in their lower limbs. RESULTS: Preoperative post exertional compartment pressure measurements were 67.8 (32 to 114) mm at 1 minute and 50.2 (28 to 97) mm at 5 minutes. At an average of 21 (9 to 57) month followup, all but one patient had significant relief of their symptoms. CONCLUSION: Chronic exertional compartment syndrome may affect multiple compartments in the lower limb of a single patient. When affecting the medial compartment of the foot, release of the superficial and deep fascia is a reliable treatment. It is safe to perform bilaterally and in association with other lower limb decompressions as required.

Medial malleolar stress fracture secondary to chronic ankle impingement.

BACKGROUND: Medial malleolar stress fractures are uncommon even in the sporting population. We believe that stress fractures of the medial malleolus may be the end stage of chronic anteromedial ankle impingement in elite running and jumping athletes. MATERIALS AND METHODS: We present five cases of elite athletes who presented to our institution with stress fractures of the medial malleolus over a 3-year period (2004 to 2007). In each case preoperative imaging revealed an anteromedial bony spur on the tibia. All fractures were internally fixed and at the same sitting had arthroscopic debridement of the bony spur. RESULTS: All fractures united without further intervention, average time to union was 10.2 (range, 6 to 16) weeks. At most recent review (average, 18 months; range, 8 to 37 months), all patients had resumed sporting activity to their previous level. No patient had suffered a recurrent fracture of the medial malleolus. CONCLUSION: We believe this region of impingement to be important in the development of the stress fracture and should be addressed at the time of fracture fixation.

Using multimedia to enhance the consent process for bunion correction surgery.

BACKGROUND: Obtaining informed consent from patients considering bunion surgery can be challenging. This study assessed the efficacy of a multimedia technology as an adjunct to the informed consent process. METHODS: A prospective, cohort study was conducted involving 55 patients (7 males, 48 females) who underwent a standardized verbal discussion regarding bunion correction surgery followed by completion of a knowledge questionnaire. A multimedia educational program was then administered and the knowledge questionnaire repeated. Additional supplementary questions were then given regarding satisfaction with the multimedia program. RESULTS: Patients answered 74% questions correctly before the multimedia module compared with 94% after it (P < 0.0001). Patients rated the ease of understanding and the amount of information provided by the module highly. Eighty-four percent of patients considered that the multimedia tool performed as well as the treating surgeon. CONCLUSION: Multimedia technology is useful in enhancing patient knowledge regarding bunion surgery for the purposes of obtaining informed consent.

Angiosarcoma in an area of lipodermatosclerosis.

We present an unusual case in a post phlebitic lower limb that had previously developed an area of lipodermatosclerosis. An area within this broke down as a result of an angiosarcoma rather than the more probable: formation of a venous ulcer.

Lateral meniscal cyst causing common peroneal palsy.

Lateral meniscal cysts are relatively common, but only in rare instances do they cause common peroneal nerve irritation. There are, we believe, no cases reported in which both the sensory and motor functions of the nerve have been compromised. We present a case of a lateral meniscal cyst that became palpable and led to symptoms of numbness and weakness in the distribution of the common peroneal nerve. The MRI findings were of an oblique tear of the lateral meniscus with an associated multiloculated meniscal cyst that coursed behind the biceps tendon before encroaching on the common peroneal nerve. Surgical resection confirmed the tract as located on the MRI and histology confirmed the mass to be a synovial cyst. Resection of the cyst and arthroscopic excision of the meniscal tear led to resolution of the symptoms in 3 months.

The surgical treatment of established congenital dislocation of the hip: results of surgery after planned delayed intervention following the appearance of the capital femoral ossific nucleus.

It has been proposed that the presence of the capital femoral ossific nucleus confers protection against ischemic injury or avascular necrosis (AVN) at the time of reduction of a congenitally dislocated hip. The current literature is contradictory. A prospective study was undertaken of the clinical and radiologic outcomes following closed or open reduction. Fifty hips were included in the study. These cases had presented late or had failed conservative treatment. In 28 hips treatment was intentionally delayed until the appearance of the ossific nucleus (but not beyond 13 months) and in 22 the ossific nucleus was present at clinical presentation. Six hips reached the age of 13 months without an ossific nucleus appearing and progressed to treatment. The significant AVN rate (more than grade 1) was 7% for closed reduction and 14% for open. However, the amended rate if hips were excluded that had failed Pavlik harness treatment was 0.0% and 9%, respectively (4% overall). Further surgical procedures were necessary in 57% of hips undergoing closed reduction and 41% after open, which compares favorably with other series. The authors conclude that the presence of the ossific nucleus is an important factor in the prevention of AVN, particularly after late closed reduction. Intentional delay in the timing of surgery does not condemn a hip to open surgery, but there is a comparable rate of secondary procedures becoming necessary, particularly after closed reduction. A simultaneous pelvic procedure may be appropriate after late closed reduction. The delayed strategy to await the appearance of the ossific nucleus for previously untreated dislocation allows a simple treatment algorithm to be employed that produces good clinical and radiologic outcomes.