Collegiate rugby union injury patterns in New England: a prospective cohort study.

OBJECTIVE: To establish injury profile of collegiate rugby union in the USA. DESIGN/ SETTING: 31 men's and 38 women's collegiate rugby union teams prospectively recorded injuries during games and practice during the 2005-06 season. Three teams withdrew before data collection. An injury was defined as one: (1) occurring in an organised intercollegiate game or practice; and (2) requiring medical attention during or after the game or practice, or (3) resulting in any restriction of the athletes' participation for >or=1 day(s) beyond the day of injury, or in a dental injury. MAIN OUTCOME MEASURES: In total, 847 injuries (447 in men; 400 in women) during 48,026 practice (24,280 in men; 23,746 in women) and 25,808 game (13,943 in men; 11,865 in women) exposures were recorded. RESULTS: During games, injury rates of 22.5 (95% CI 20.2 to 25.0) and 22.7 (20.2 to 25.5) per 1000 game athletic exposures or 16.9 (15.1 to 18.9) and 17.1 (15.1 to 19.1) per 1000 player game hours were recorded for men and women, respectively. Over half of all match injuries were of major severity (>7 days' absence) (men 56%; women 51%) and the tackle was the game event most often associated with injury (men 48%; women 53%). CONCLUSIONS: Collegiate game injury rates for rugby were lower than rates recorded previously in men's professional club and international rugby and lower than reported by the National Collegiate Athletic Association Injury Surveillance System for American football, but similar to rates reported for men's and women's soccer in 2005-06.

Injuries in martial arts: a comparison of five styles.

OBJECTIVE: To compare five martial arts with respect to injury outcomes. METHODS: A one year retrospective cohort was studied using an injury survey. Data on 263 martial arts participants (Shotokan karate, n = 114; aikido, n = 47; tae kwon do, n = 49; kung fu, n = 39; tai chi, n = 14) were analysed. Predictor variables included age, sex, training frequency (3 h/week), experience (<3 years v >or=3 years), and martial art style. Outcome measures were injuries requiring time off from training, major injuries (>or=7 days off), multiple injuries (>or=3), body region, and type of injury. Logistic regression was used to determine odds ratios (OR) and confidence intervals (CI). Fisher's exact test was used for comparisons between styles, with a Bonferroni correction for multiple comparisons. RESULTS: The rate of injuries, expressed as percentage of participants sustaining an injury that required time off training a year, varied according to style: 59% tae kwon do, 51% aikido, 38% kung fu, 30% karate, and 14% tai chi. There was a threefold increased risk of injury and multiple injury in tae kwon do than karate (p<0.001). Subjects >or=18 years of age were at greater risk of injury than younger ones (p<0.05; OR 3.95; CI 1.48 to 9.52). Martial artists with at least three years experience were twice as likely to sustain injury than less experienced students (p<0.005; OR 2.46; CI 1.51 to 4.02). Training >3 h/week was also a significant predictor of injury (p<0.05; OR 1.85; CI 1.13 to 3.05). Compared with karate, the risks of head/neck injury, upper extremity injury, and soft tissue injury were all higher in aikido (p<0.005), and the risks of head/neck, groin, and upper and lower extremity injuries were higher in tae kwon do (p<0.001). No sex differences were found for any of the outcomes studied. CONCLUSIONS: There is a higher rate of injury in tae kwon do than Shotokan karate. Different martial arts have significantly different types and distribution of injuries. Martial arts appear to be safe for young athletes, particularly those at beginner or intermediate levels.

Early scintographic diagnosis of bone stress and fractures in athletic adolescents.

A study of radionuclide bone scintigraphy in adolescents was conducted to evaluate the pattern of stress-related abnormalities and their correlation with both symptoms and roentgenography. In 26 episodes of stress-related abnormal scintigraphy, 12 (46%) had a multifocal pattern of abnormalities. Forty foci were identified by scintigraphy, with 11 (28%) exhibiting abnormal roentgenograms. These multiple abnormalities were frequently unsuspected clinically, and studies limited to symptomatic areas would have failed to detect them. It is recommended that patients with stress-related symptoms be screened utilizing radionuclide bone scintigraphy to facilitate the early detection of abnormalities in bone prior to the development of cortical disruption, thereby preventing increased morbidity and possible disabling sequelae.

Back pain in young athletes. Significant differences from adults in causes and patterns.

OBJECTIVES: To determine whether there are significant differences in the causes of back pain in young athletes compared with the general adult population and to review the diagnosis and assessment of young athletic adolescent patients who present with this complaint. DESIGN: Retrospective randomized case comparison study with two cohorts segregated by age and type of activity. SETTING: The adolescent sports medicine clinic of a children's hospital compared with the acute low back pain clinic of an orthopedic hospital. PATIENTS: One hundred adolescent athletes (aged 12 to 18 years; mean age, 15.8 years) with a chief complaint of low back pain were compared with 100 adults (aged 21 to 77 years; mean age, 31.9 years) with acute low back pain. INTERVENTIONS: None. MAIN OUTCOME MEASURES/RESULTS: Sixty-two percent of the adolescents had derangements of their posterior elements associated with the onset of back pain. Forty-seven percent of the 100 adolescents were ultimately shown to have a spondylolysis stress fracture of the pars interarticularis. By contrast, 5% of adult subjects were found to have spondylolysis associated with low back pain. Similarly, discogenic back pain was the final diagnosis in 48 of the 100 subjects in the adult group, while 11 of the 100 in the adolescent group had back pain attributable to disc abnormalities. Muscle-tendon strain accounted for back pain in 27% of the adults, while only 6% of the adolescents were diagnosed as having muscle-tendon strain. These differences were significant. Spinal stenosis and osteoarthritis as causes of back pain were encountered in 10% of the adults, while these conditions were not encountered in the children. CONCLUSIONS: There is a significant differences in the major causes of low back pain in young athletes compared with causes of low back pain in the general adult population. Physicians diagnosing back pain in young athletes must have a specific understanding of these differences to avoid incorrect diagnosis and harmful delays in proper treatment.

Upper extremity injuries in the paediatric athlete.

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.

Common painful sports injuries: assessment and treatment.

The increasing participation in organized sports has been paralleled by an increasing number of sports injuries. An exact diagnosis of the injury and an understanding of the mechanisms of injury are essential for proper management, relief of pain, and restoration of function. The two mechanisms of injury are single-impact macrotrauma and repetitive microtrauma. Overuse injuries, which result from repetitive microtrauma, are caused by the interaction of a number of risk factors. Determining the etiological factors present in a given injury is essential for proper management and prevention of overuse injuries. The roles of non-narcotic analgesics, muscle relaxants, and nonsteroidal anti-inflammatory drugs (NSAIDs) in aiding recovery and restoration of function in sports injuries have been extensively studied. NSAIDs, in particular, have been demonstrated in clinical and laboratory studies to speed recovery from overuse sports injury. Their place in acute sports injuries due to single-impact macrotrauma, however, is more controversial.

Foot and ankle problems in the young athlete.

In the U.S., greater than half of boys and one quarter of girls in the 8- to 16-yr-old age range are engaged in some type of competitive, scholastic, organized sport during the school year. Children and adolescents are becoming more involved in sports at earlier ages and with higher levels of intensity. Foot and ankle problems, in particular, are the second most common musculoskeletal problem facing primary care physicians in children under 10 yr of age next to acute injury. This report focuses on foot and ankle problems, trauma, and overuse in the young athletic population. Guidelines are given for both conservative and surgical management. Specific problems addressed include pes planus, tarsal coalition, adolescent bunion, os trigonum, accessory navicular, physeal fractures, sprains, peroneal tendon subluxation, metatarsal fractures, sesamoid fractures, turf toe, stress fractures, tendonitis, osteochondritis dissecans, ankle impingement, bursitis, Haglund's deformity, sesamoiditis, plantar fasciitis, apophysitis, osteochondroses, cuboid syndrome, and reflex sympathetic dystrophy. An extensive review of the literature is performed and presented in combination with the extensive experience of a well-established sports medicine clinic at the Boston Children's Hospital.

Tenosynovitis of the flexor hallucis longus in a long-distance runner.

Chronic inflammation of the flexor hallucis longus (FHL) tendon can result in stenosing tenosynovitis. This condition has been well documented in ballet dancers. It usually presents as posteromedial ankle pain, worsened by plantarflexion activities. Although conservative therapy benefits most patients, some recalcitrant cases may require surgical intervention. This is the first case report that describes the occurrence of this condition in a runner with an anomalous flexor hallucis longus muscle.

Electromyographic analysis of grand-plié in ballet and modern dancers.

PURPOSE: The purpose of this report is to describe lower extremity muscle activity in grand-plié, as determined by EMG analysis; to compare and contrast muscle function in grand-plié and demi-plié to support the hypothesis that grand-plié is not simply a deeper demi-plié, but rather a fundamentally different movement in terms of muscle use; and to present further evidence in support of the hypothesis that ballet dancers use muscles differently than modern dancers in dance movement. METHODS: Surface electromyography was used to analyze lower extremity muscle activity during grand-plié in first position with lower extremities turned out in five ballet and seven modern female professional dancers. RESULTS: Electromyographic (EMG) activity of tibialis anterior included continuous activity from heel-off during the lowering phase, through midcycle, and ending at heel-on during the rising phase in all grand-pliés; the majority of tibialis anterior EMG tracings in ballet dancers had additional activity at the end of the rising phase. All EMG tracings for vastus lateralis and medialis included a peak of activity during the lowering phase, a decrease (valley) at midcycle, followed by another peak during the rising phase; increased activity at the end of the rising phase was observed in most grand-plié in ballet, and not modern, dancers. Adductor EMG activity was also observed in all tracings with a peak during the lowering phase from heel-off to midcycle, a valley at midcycle, followed by a peak of activity in early rising phase; the midcycle valley was of lower, and the rising phase peak of higher, activity in ballet compared with modern dancers. Variation of EMG patterns was observed for lateral and medial gastrocnemius, gluteus maximus, and hamstrings. CONCLUSIONS: The data support the concept that lower extremity muscle activity in dance movement is comprised of three major types: (a) unique, characteristic activity required for the execution of the movement; (b) varied activity which is characteristic of dancers of different dance idioms; and (c) varied activity which may depend on factors such as balance, personal habit, and individual training background. Furthermore, EMG activity of vastus lateralis and medialis at the midcycle valley in grand-plié was significantly less in ballet dancers than in modern dancers despite similar degree of knee flexion, suggesting that ballet dancers may have lower patellofemoral joint reaction force at midcycle than modern dancers.

Electromyographic analysis of standing posture and demi-plié in ballet and modern dancers.

Surface electromyography was used to analyze lower extremity muscle activity during standing posture and demi-plié in first position with lower extremities turned out, in five ballet and seven modern female professional dancers. In standing posture, increased electromyographic (EMG) activity above baseline was detected most frequently at the medial gastrocnemius (54% standing repetitions) and tibialis anterior (29%) electrodes (all dancers); in ballet dancers, increased EMG activity during standing was significantly less frequent at the medial gastrocnemius, but more frequent at the tibialis anterior, than in modern dancers. In demi-plié, the tibialis anterior had a discrete peak of EMG activity at midcycle in all dancers (97% demi-pliés). All dancers also had midcycle EMG activity in both vastus lateralis and medialis (100% demi-pliés). At the end of rising phase of demi-plié, ballet dancers had greater EMG activity than at midcycle in vastus lateralis (100% demi-pliés) and medialis (92%); in modern dancers, end-rising phase voltage was lower than at midcycle for vastus lateralis (71% demi-pliés) and medialis (83%). Genu recurvatum > or = 10 degrees was observed at the beginning and end of demi-plié in all ballet dancers, but not in modern dancers. There was marked variation of EMG activity during demi-plié in the lateral gastrocnemius, medial gastrocnemius, gluteus maximus, hamstrings, and adductors. The results support the hypothesis that ballet and modern dancers have different patterns of muscle use in standing posture and demi-plié, which in part may be a result of differences in genu recurvatum and turnout between the two groups.

Anterior exposure of the cervicothoracic spine using a combined cervical and thoracic approach.

Anterior stabilization of severe structural deformities of the spine, especially kyphoscoliosis, at the cervicothoracic level is a difficult surgical procedure. A new combined procedure including anterolateral cervical and posterior transpleural transthoracic approaches to the cervicothoracic spine provided adequate-exposure from the third cervical to the ninth thoracic vertebra and at the same time gave access to the great vessels in the event that control of these became necessary. The procedure has been employed in six patients with severe cervicothoracic kyphoscoliosis. Despite the magnitude of the combined cervical and transthoracic exposure, the patients withstood the procedure well and there were no complications. The fusion was successful in all six patients. The kyphotic deformities were corrected by an average of 26 degrees and the scoliotic curves, by an average of 17 degrees.

Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot.

We reviewed the cases of four female ballet dancers with a stress fracture of a type that has not been reported previously. This fracture occurs in the proximal portion of the second metatarsal and involves the volar and medial aspects of Lisfranc's joint. A differential diagnosis of pain in the middle part of the foot in a dancer should include a consideration of this entity, which can be very difficult to diagnose on initial assessment. Oblique radiographs, tomograms, and a bone scan may be necessary to confirm the diagnosis. With early recognition and diagnosis, in three of the four patients the fracture healed with immobilization and modified training. One patient required surgical resection because of persistent non-union of the necrotic fracture fragment.

Release of the flexor hallucis longus tendon in ballet dancers.

Thirteen female ballet dancers had an operative release of the flexor hallucis longus tendon because of isolated stenosing tenosynovitis, and the results were reviewed after a mean duration of follow-up of six years and six months (range, two to ten years). All of the patients danced at the advanced or professional level, and all had failed to respond to non-operative management. The mean age of the patients at the time of the operation was twenty years (range, thirteen to twenty-six years). Symptoms, which included pain and tenderness over the medial aspect of the subtalar joint, had been present for a mean of six months (range, two to twelve months) preoperatively and were exacerbated by jumping and by attempts to perform en pointe work. Crepitus was present in six patients, and triggering was present in three. No patient had evidence of a symptomatic os trigonum. Postoperatively, all patients participated in a formal physical-therapy program for a mean of nine weeks (range, four to thirteen weeks). All patients returned to dancing, within a mean of five months (range, two to nine months), and eleven reached a level of full participation in dancing without restriction. At the time of the most recent follow-up, all patients noted improvement compared with the pre-operative condition. Eight patients were professional ballet dancers, four were students at advanced ballet schools, and one had stopped performing ballet for reasons unrelated to the tenosynovitis of the flexor hallucis longus. In addition, two of the students had decided not to pursue careers in dancing because of persistent, but greatly diminished, symptoms. No complications were noted in this series. We concluded that an operative release of the flexor hallucis longus is effective for the treatment of isolated stenosing tenosynovitis in female ballet dancers who place high demands on the foot and ankle and for whom non-operative treatment has failed.

Bankart repair for anterior instability of the shoulder. Long-term outcome.

Anterior instability of the shoulder is a commonly encountered entity in orthopaedic practice. The Bankart procedure is considered by many surgeons to be the treatment of choice for this condition. Despite its widespread popularity, there have been no studies on the long-term outcome of the Bankart procedure as far as we know. Sixty shoulders (fifty-six patients) that had been followed for a minimum of eight years after a Bankart procedure were evaluated for range of motion, stability, and strength according to the data form of the American Shoulder and Elbow Surgeons for examination of the shoulder. The results for the involved shoulder were compared with the findings for the contralateral, normal shoulder. All patients completed a questionnaire regarding the history of the instability of the shoulder, the level of participation in sports before and after the operation, the preoperative and postoperative level of pain, and whether the patient had ever sustained a dislocation that needed reduction by a physician. Information about the current ability of the patient to function at home, at work, and during sports also was requested. In addition, the patients were asked to rate the results of the operation and to indicate whether they would have the same procedure again for the same problem. At a mean of 11.9 years after the operation, the mean loss of external rotation was 12 degrees (range, 0 to 30 degrees) (p < 0.0001). There were no significant differences in forward elevation, abduction, or internal rotation between the involved shoulder and the contralateral, normal shoulder. One patient had crepitus on glenohumeral motion. Fifty-five of the fifty-six patients returned to the occupation that they had had preoperatively, without having to alter their activities. Twenty-eight patients had mild pain with strenuous activity, and one patient had pain at rest. Three patients had a dislocation of the involved shoulder because of a new traumatic event more than three years postoperatively. Fifty-two patients rated the result as good or excellent; three, as fair; and one, as poor. Fifty-four patients said that they would have a Bankart procedure performed again for the same problem. We present a new system for rating the shoulder that emphasizes function and is based specifically on the goals stated by the patients to be most important with regard to the shoulder. Using this system, we found that the Bankart procedure offers an excellent objective long-term outcome with a high degree of patient satisfaction.

The correction of spinal deformity in idiopathic torsional dystonias.

The torsional dystonias constitute a group of motion disorders of unknown etiology with variable onset, progression, and severity that frequently result in spinal curvature. Four patients with this uncommon disorder, with curves averaging 70 degrees (range, 55 to 95 degrees), underwent surgical correction for progressive spinal deformity. All of them had improvement in function postoperatively, but there was a high rate of postoperative complications.

Osteotomy of the fusion mass in scoliosis.

The value of an osteotomy of the fusion mass in attaining realignment of the spine when a lateral shift of the trunk over the pelvis has developed in the frontal plane was studied in fifty-five patients. All had had a previously fused but progressive spinal deformity. The indications for osteotomy were progression of the curve, imbalance of the trunk, pain, deteriorating cardiopulmonary function, or pseudarthrosis, or a combination of these conditions. Twenty-one patients had idiopathic scoliosis; fourteen, congenital scoliosis; ten, paralytic scoliosis; four, myelodysplastic scoliosis; and six had scoliosis secondary to miscellaneous conditions. A total of 154 osteotomies of the fusion mass, or 2.8 osteotomies per patient, were performed. Nine patients underwent an anterior spinal osteotomy or wedge resection as well. Most had a two-stage procedure which consisted of a posterior osteotomy, halo-femoral traction, and a posterior re-fusion with Harrington instrumentation two weeks later. At an average follow-up of thirty-two months, it was found that osteotomy of the fusion mass enabled the surgeon to realign the trunk over the pelvis and to correct pelvis obliquity, but correction of the angular deformity was only secondary. Although the rate of complications was high (51 per cent, including one postoperative death), osteotomy of the fusion mass and re-fusion may be indicated in a patient with a previously fused but progressively unbalanced, painful deformity of the spine.

Diastematomyelia and structural spinal deformities.

Sixty patients with diastematomyelia were seen over a thirty-year period and congenital scoliosis was found in 60 per cent. All of the patients had associated vertebral abnormalities and most (87 per cent) had a neural deficit. Myelography was helpful in the diagnosis, particularly prior to any procedure that might cause traction on the spinal cord. Laminectomy for removal of the spur was indicated when neural deficits were progressive or before corrective surgery on the spine, and in ten patients the operation alleviated neural sequelae. Observation of patients with diastematomyelia who have no neural deficit or a stable, non-progressing deficit is recommended.

Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients.

We report on the experience with our first seventy patients who had reflex sympathetic dystrophy and were less than eighteen years old (average age, 12.5 years). In our series, the patients were predominantly girls (male to female ratio, 11:59) and the lower extremity was involved most often (sixty-one of the seventy patients). The average time from the initial injury to the diagnosis was one year, which indicates that the syndrome remains under-recognized in patients in this age-group. Conservative treatment with physical therapy, transcutaneous electrical nerve stimulation, psychological therapies including cognitive-behavioral management and relaxation training, and tricyclic anti-depressants was effective in improving the average scores for pain and function for forty patients. Sympathetic blocks were helpful for twenty-eight of thirty-seven patients. Thirty-eight of the seventy patients in the series continued to have some degree of residual pain and dysfunction. Reflex sympathetic dystrophy in children differs in presentation and clinical course from the syndrome in adults. It is best treated in a multidisciplinary fashion.

Lumbar facet stress fracture in a ballet dancer.

A frequent cause of back pain in athletes and dancers is stress injury to the posterior vertebral elements. Stress fractures affect the pars interarticularis and, rarely, other vertebral regions. The authors present their experience with the diagnosis and treatment of a fourth lumbar inferior articular facet stress fracture in a ballerina in this brief report and discuss the literature concerning posterior element stress fractures.

Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace.

Sixty-seven persons with symptomatic spondylolysis or grade 1 spondylolisthesis were treated with the modified Boston brace. The average age was 16.0 years, and the average follow-up was 2.5 years. Following treatment, 52 persons (78%) had either an excellent or good result with no pain and returned to full activities. Nine (13%) continued to have mild symptoms, and six (9%) subsequently required fusion in situ. Twelve of the patients showed radiographic evidence of healing of their pars defect(s). This group and those with the best overall results tended to be men with spondylolysis and relatively acute onset of symptoms. Age, delay in treatment, spina bifida, and bone scan result did not correlate with the ultimate clinical result.