Extracorporeal Shockwave Therapy in the Management of Sports Medicine Injuries.

ABSTRACT: Treatment of musculoskeletal conditions in athletes with extracorporeal shockwave therapy (ESWT) is gaining popularity as greater evidence supports its use. ESWT protocols (describing energy flux density, number of impulses, type of shockwave (focused or radial), number/frequency/duration of treatment session, area of application, and postprocedural therapy protocols) can be adjusted in the clinical setting. Protocols vary across studies, and optimal protocols for most indications are yet to be determined. ESWT can safely be used to treat various musculoskeletal conditions in athletes, including rotator cuff tendinopathy, lateral elbow epicondlyopathy, greater trochanteric pain syndrome, hamstring tendinopathy, patellar tendinopathy, Achilles tendinopathy, other tendinopathies, plantar fasciopathy, bone stress injuries, and medial tibial stress syndrome. ESWT can be used to treat in-season athletes, as it often requires no/minimal time away from sport and may result in rapid benefits. ESWT should be used in conjunction with physical therapy to facilitate longer-term gains in function and to optimize healing.

Abduction in Proximal Hamstring Tendon Avulsion Injury Mechanism: A Report on 3 Athletes.

Proximal hamstring tendon avulsions are typically sustained during forced hip hyperflexion combined with knee extension. We present 3 cases of athletes with a proximal hamstring tendon avulsion caused by an alternative injury mechanism that also involves a considerable hip abduction component (flexion-abduction injury mechanism). All cases had at least one concurrent injury of the medial thigh muscles, either on the ipsilateral or contralateral side. The 2 elite athletes with this injury mechanism returned to sport at preinjury level relatively quickly. A history of the flexion-abduction mechanism should raise suspicion of a hamstring tendon avulsion with concomitant injury of the medial thigh muscles. The magnetic resonance imaging (MRI) protocol should include both legs, and any concurrent injury may need to be addressed as well. In future studies, it would be interesting to investigate whether injury mechanism holds prognostic value in proximal hamstring tendon avulsions.

Clinical Outcomes Following Primary Anterior Cruciate Ligament Reconstruction with Hamstring Autograft versus Planned Hybrid Graft.

Few studies have compared outcomes between autografts versus hybrid grafts (combination of autograft and allograft) for anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare revision rate and patient-reported outcomes following primary ACLR with a hamstring autograft versus a preoperatively planned hybrid autograft-allograft. At a minimum 2-year follow-up, patients who had undergone primary ACLR with a double-stranded semitendinosus and gracilis hamstring autograft (A) or a planned hybrid (H) graft (single-strand semitendinosus with nonirradiated peroneus longus or tibialis posterior allograft) were contacted to fill out a survey containing the Knee Injury and Osteoarthritis Outcome Score (KOOS), Subjective International Knee Documentation Committee (IKDC) score, Single Assessment Numeric Evaluation (SANE), 12-Item Short-Form Health Survey (SF-12), and visual analog scale (VAS) for activity level prior to injury and at follow-up. From this collection of patients, a matched-pair comparison was made between groups, with patients matched by gender, age at the time of surgery, and follow-up time. Revision rate at follow-up was 8.4 and 2.4% in the A and H groups, respectively (p = 0.073). A total of 148 surveys were completed (83 A, 65 H), from which 36 matched pairs were formed. Within the matched pairs, average age at surgery did not differ significantly between groups (A: 35.7 years, H: 36.0 years, p = 0.23). Time to follow-up was 4.3 and 3.7 years in the A and H groups, respectively. Patients with a hybrid graft had significantly higher KOOS Quality of Life subscores (A 69.6, H 79.2, p = 0.028), subjective IKDC scores (A 72.6, H 79.7, p = 0.031), and SANE scores (A 83.2, H 91.4, p = 0.015) at follow-up. Otherwise, no significant differences were found in patient-reported outcome scores between groups. A preoperatively planned hybrid graft, with use of a fresh-frozen, nonirradiated allograft, should be considered as a viable alternative for primary ACLR in older patients.

Paediatric physeal sparing posterior cruciate ligament (PCL) reconstruction with parental donation allograft: Rationale and operative approach.

BACKGROUND: Paediatric PCL injuries are rare but constitute a significant management challenge. We describe a novel approach to the surgical management of an 11-year-old boy who presented with persisting symptomatic instability following 18months of failed conservative therapy. METHODS: PCL reconstruction was performed using a physeal sparing, all-inside technique under fluoroscopic control. This avoids the potential for iatrogenic growth injury. A parentally donated hamstrings allograft was used to ensure adequate graft size, and reinforced using a non-elastic two millimetre braided suture. Graft reinforcement safeguards against stretching during the early healing phase, but must be removed thereafter to avoid creating a physeal tether. RESULTS: At three months, clinical examination under anaesthesia showed equivalent PCL laxity in the operated knee compared to the normal contralateral knee. The graft reinforcement tape was incised as planned with no change in laxity assessment. Arthroscopic evaluation demonstrated a quiet joint with a well healed graft and no synovitis. Postoperative long leg radiographs showed no growth deformity against preoperative status. CONCLUSION: In paediatric patients with persisting symptomatic instability despite appropriate conservative management, surgical reconstruction of the PCL should be considered. Standard treatment has higher complication rates and poorer graft survival than in an adult cohort. Specific problems include iatrogenic growth plate injury causing growth arrest or angular deformity, inadequate graft size if using hamstrings autograft, and the additional technical challenge of small patient size. Early results from extra-physeal, all-inside PCL reconstruction using a parentally donated allograft are promising and may provide an alternative solution to traditional surgical management.