Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population.

BACKGROUND: Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%. High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT). METHODS: RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited. INCLUSION CRITERIA: male, 18-55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment. DISCUSSION: Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment. TRIAL REGISTRATION: EudraCT: 2015-003587-36 3 Dec 2015.

Tennis injury data from The Championships, Wimbledon, from 2003 to 2012.

OBJECTIVE: The primary aims of this retrospective study were to describe the burden of injury presenting to the medical team and the changes in injury profile over 10 years (2003-2012) at The Championships, Wimbledon. Secondary aims included description of gender difference in rates, distribution and pathology of injuries. DESIGN: Retrospective observational cohort of player injury presentations over 10 years (2003-2012) at The Championships, Wimbledon. RESULTS: The overall rate of presentation of injury for all players over the 10-year period was 20.7 per 1000 sets played. Injury rates were lower for male players (17.7 injuries per 1000 sets played) than female players (23.4 injuries per 1000 sets played). There was variability in the numbers of injuries reported by men and women players over the 10-year period. CONCLUSIONS: The rates of presentation of injury at this Grand Slam tennis tournament varied between male and female players, and between years. More robust systems of data collection are required in professional tennis to enable more sophisticated injury data analysis between sexes, years and different playing surfaces.

Use of ultrasound to identify chronic Achilles tendinosis in an active asymptomatic population.

OBJECTIVES: The aim of the study was to identify the prevalence of degenerative change in the Achilles tendons of currently asymptomatic individuals and correlate it with their degree of physical activity. METHODS: We recruited 126 healthy subjects, mean age 33.1, range 20 - 50 (78 males and 48 females). Their levels of physical activity were assessed by a questionnaire and scored using the Allied Dunbar Fitness Survey criteria, modified to exclude non-weight bearing activity. One investigator, who was blinded to the activity levels, ultrasound scanned all 252 tendons. Tendons were examined for evidence of hypoechoic regions, localised fusiform thickening, and the cross-sectional diameter of each was measured. RESULTS: Overall 59% (149) of tendons had ultrasound evidence of hypoechoic regions. In 50 tendons (in 31 patients) there was a history of previous Achilles pain and 84% of these had hypoechoic regions. Thirty three percent of subjects in the lowest quartile of activity had evidence of hypoechoic regions compared to 72.6% in the most active quartile (Pearson Chi2 p < 0.01). Only 5.6% of all Achilles tendons had ultrasound evidence of localised fusiform thickening, with none in the inactive group compared to 6.4% in the very active group (Pearson Chi2 p = 0.03). CONCLUSIONS: Degenerative changes, identified by ultrasound, are common in the Achilles tendon and are often asymptomatic. There is a direct relationship between these changes and levels of current and lifetime activity. The natural history of asymptomatic chronic Achilles tendinosis and their relationship to future pain or tendon pathology is unknown.

A survey of injuries sustained in the game of touch.

Three hundred and forty-five Touch football players were retrospectively surveyed to determine the nature and incidence of injuries sustained over a one year period. The definition of injury was that it prevented playing or training for at least one week. A total of 177 injuries were sustained by 117 players who participated in a total of 1043 hours of playing and training each week. The injury rate was 4.85/1000 hours of playing or training which was less than in other football codes. This rate was significantly more (p < 0.05) among males and no relationship was evident based on representative or training status. 71% of injuries were to the lower limb. 23% of all injuries involved the ankle. Less than 3% of injuries affected the head or neck. 54% of injuries were considered mild in that they only prevented playing or training for less than two weeks. Only 17% of injuries were stated to have been caused by contact with another player. This study found that the injury rate in Touch was much less than in other football codes.

ICEROSS--a consensus view: a questionnaire survey of the use of ICEROSS in the United Kingdom.

The management of the individual with a trans-tibial amputation has been strongly influence by the increasing use of the ICEROSS socket system over recent years. Despite this growth in clinical experience, there has been very little research into its place in current prosthetic practice, and prescribing activity is largely determined by personal experience. In order to formulate the current consensus view on the use of ICEROSS, questionnaire were sent to 42 doctors and 43 senior prosthetists around the UK. The influence of 38 different factors on prescribing activity was assessed using a grading system (ranging from "primary indication" to "absolute contraindication"). An 85% response rate was achieved and no significant differences in response between the two professional groups were identified. Those factors considered by most to be positive indications for using ICEROSS were "pistoning", "shear-sensitive skin/split-skin grafts", "patient unsuccessful with supracondylar (s/c) or cuff suspension" and "insufficient suspension due to change in type or level of activity". Those considered by most to be absolute contra-indications were "ulceration/unhealed scars", "poor patient hygiene" and "poor commitment to prosthetic rehabilitation". This consensus of opinion is in keeping with the results of the few published adults of ICEROSS usage. There was a lack of consensus, however, about the use of ICEROSS in some situations, including skin complications. Whilst some consensus does exist about the use of ICEROSS, the results of this survey indicate significant variations in clinical practice with serve to illustrate the urgent need for data from prospective clinical trials.

Imaging in sport and exercise medicine: "a sports physician's outlook and needs".

Sport and exercise medicine (SEM) is an exciting new medical specialty that thrives on interdisciplinary practice. The SEM physician will usually be found managing a wider, multidisciplinary team of specialists, orchestrating their various inputs to ensure that the most effective management plan is delivered to the patient. One key member of this team is the radiologist, with whom the SEM physician usually has a very close working relationship. Areas of SEM practice that commonly involve significant input from radiologists include the use of appropriate imaging to confirm an accurate diagnosis and to inform management planning (such as decisions on return to play in the elite athlete), various screening and pre-participation assessments and also technical assistance with certain procedures. This article discusses the relationship between the SEM physician and the radiologist across each of these areas, illustrating the important contribution made by imaging services to the specialty of SEM.

The prevalence and associations of fatigue in systemic lupus erythematosus.

OBJECTIVE: This study assessed the prevalence and associations of fatigue in systemic lupus erythematosus (SLE). METHODS: Questionnaires were used to measure self-reported fatigue, disease activity, sleep quality, quality of life, anxiety and depression in 120 out-patients with SLE. RESULTS: Abnormal fatigue was reported by 97 (81%) patients, and 71 (60%) patients reported poor sleep quality. Fatigue correlated negatively with all measures of functioning. Fatigue scores were up to 33% higher in patients with active disease [Systemic Lupus Activity Measure (SLAM >/=3)] than in patients with inactive disease (SLAM >3) (P: < 0.05). There were significant correlations between fatigue and disease activity, sleep quality, anxiety and depression. CONCLUSION: Fatigue is a common complaint of patients with SLE and is associated with diminished ability to function. Apart from treating the primary disease, it may also be worthwhile to treat mood disorders and insomnia in order to reduce fatigue and improve quality of life.

The effects of 10 weeks military training on heel ultrasound and bone turnover.

To measure the physiological changes in bone in response to strenuous exercise we performed a prospective study of male army recruits over 10 weeks of basic training. Measurements performed at the start and completion of training consisted of ultrasound (US) measurements of the heel: velocity of sound (VOS in m/seconds) and broadband ultrasound attenuation (BUA in dB/MHz) and bone turnover markers; osteocalcin (OC), bone-specific alkaline phosphatase (BALP), and tartrate-resistant acid phosphatase (TRAP). Forty subjects were recruited for the study and 26 completed training. Over the 10-week study period there was a significant 1.7% fall in mean VOS [mean paired difference (mpd) 27.2 m/second, SEM 9.5 (95% CI 7.5-46.8) P = 0.009] and a nonsignificant 3.4% increase in BUA (P = 0.159). There were significant falls in markers of bone formation OC [11.6%, mpd 0. 11 microg/liter (95% CI 0.07-0.14) P < 0.001] and BALP [13.3%, mpd 3. 49 U/liter (CI 0.80-6.18) P = 0.013] and a nonsignificant 9.5% fall in TRAP a marker of bone resorption. The 10 recruits subsequently injured had a significantly lower VOS on entry [mean difference 24.2 m/seconds (95% CI 4.6-43.7) P = 0.017] and nonsignificantly raised BUA and baseline levels of all bone markers. The ultrasound changes may be accounted for by increase in trabecular separation and a fall in trabecular connectivity due to microfracture. The decrease in bone markers implies a fall in bone turnover.

Fatigue in systemic lupus erythematosus: a randomized controlled trial of exercise.

OBJECTIVE: To test the efficacy of a graded aerobic exercise programme in treating fatigue in systemic lupus erythematosus. METHODS: Ninety-three patients with systemic lupus erythematosus without active disease in any major organ were randomized, using a minimization protocol, to 12 weeks of graded exercise therapy, relaxation therapy or no intervention. RESULTS: Analysis by intention to treat showed that 16 of the 33 (49%) patients in the exercise group rated themselves as 'much' or 'very much' better compared with eight out of 29 (28%) in the relaxation group and five out of 32 (16%) in the control group (chi2=8.3, df=2, P=0.02). Fatigue improved significantly on one out of three measures after exercise therapy and there was a trend for fatigue to improve on all measures after exercise. CONCLUSION: These findings support the use of appropriately prescribed graded aerobic exercise in the management of patients with fatigue and systemic lupus erythematosus.