Return to sport and beyond following intramuscular tendon hamstring injury: A case report of an English Premier League football player

BackgroundHamstring strain injuries are the most common type of injury in elite football and are associated with a high risk of reinjury, particularly those involving the intramuscular tendon (IMT). Limited information is available regarding the rehabilitation and return to sport (RTS) processes following such injuries. This case study describes the clinical presentation of an elite football player following IMT hamstring injury, their on- and off-pitch rehabilitation alongside performance monitoring throughout RTS and beyond.Case scenarioAn elite football player suffered a grade 2c hamstring injury during an English Premier League (EPL) match. The player underwent early post-injury management, alongside progressive off-pitch physical preparation. The ‘control-chaos continuum’ was used as a framework for on-pitch rehabilitation to prepare the player for a return to full team training and competition. Objective and subjective markers of the player's response to progressive on- and off-pitch loading were monitored throughout RTS and beyond.OutcomesThe player returned to on-pitch rehabilitation after 11 days, to full team training having achieved weekly pre-injury chronic running load outputs after 35 days and played in the EPL 40 days post-injury. The player did not suffer reinjury for the rest of the EPL season.ConclusionAn understanding the unique structural and mechanical properties of the IMT, alongside expected RTS timeframes are important to inform rehabilitation and decision-making processes post-injury. Performance and frequent load-response monitoring throughout RTS and beyond, in conjunction with practitioner experience and effective communication are critical in facilitating effective RTS and reduce risk of reinjury following IMT injury.     

Syndesmosis and deltoid ligament injuries in the athlete

Purpose

Injury to the syndesmosis and deltoid ligament is less common than lateral ligament trauma but can lead to significant time away from sport and prolonged rehabilitation. This literature review will discuss both syndesmotic and deltoid ligament injuries without fracture in the professional athlete.

Methods

A narrative review was performed using PUBMED, OVID, MEDLINE and EMBASE using the key words syndesmosis, injury, deltoid, ankle ligaments, and athlete. Articles related to the topic were included and reviewed.

Results

The incidence of syndesmotic injury ranges from 1 to 18 % of ankle sprains. This may be underreported and is an often missed injury as clinical examination is generally not specific. Both MRI and ultrasonography have high sensitivities and specificities in diagnosing injury. Arthroscopy may confirm the diagnosis, and associated intra-articular pathology can be treated at the same time as surgical stabilization. Significant deltoid ligament injury in isolation is rare, there is usually associated trauma. Major disruption of both deep and superficial parts can lead to ankle dysfunction. Repair of the ligament following ankle fracture is not necessary, but there is little literature to guide the management of deltoid ruptures in isolation or in association with syndesmotic and lateral ligament injuries in the professional athlete.

Conclusion

Management of syndesmotic injury is determined by the grade and associated injury around the ankle. Grade I injuries are treated non-surgically in a boot with a period of non-weight bearing. Treatment of Grade II and III injuries is controversial with little literature to guide management. Athletes may return to training and play sooner if the syndesmosis is surgically stabilized. For deltoid ligament injury, grade I and II sprains should be treated non-operatively. Unstable grade III injuries with associated injury to the lateral ligaments or the syndesmosis may benefit from operative repair.

Level of evidence

IV.     

Rehabilitation of Watson-Jones proximal tibial avulsion injury in elite academy level football: A report of two separate cases in one season

ObjectivesWatson-Jones proximal tibial avulsion injuries occur more frequently in athletic and muscular adolescent males. However, they are rare and therefore infrequently described in the medical literature. Two of these injuries occurred in a Category 1 football academy in the same season within a six-month period. We have described the cases with the hope of better informing other clinicians should they encounter this injury.MethodsThis case report describes the injury mechanism, surgical management and rehabilitation for the two cases [Players A and B]. Outcomes measures including player speed, agility and power were compared with scores from players of the same age group at the time of injury in the Premier League academies. Risk factors are also discussed.ResultsBoth players were managed surgically, initially. Player B had the surgical fixation removed during rehabilitation. Player A still has the fixation in situ. Post-surgery, player A returned to full play at thirty-two weeks and thirty-eight weeks for player B. No critical incidents occurred during rehabilitation.ConclusionWatson-Jones avulsion fractures, although rare, can be managed successfully. Athletes can achieve a successful return to play at their previous level.     

Experiences of professional rugby union players returning to competition following anterior cruciate ligament reconstruction

ObjectivesThe purpose of this study was to gain a greater understanding of the emotions and coping strategies utilized when returning to competition following anterior cruciate ligament (ACL) reconstruction.DesignA qualitative approach, consisting of five semi-structured interviews and a pre-designed diary, was conducted concurrent with each ’player’s return to competition, allowing each to record emotional responses experienced and identify coping strategies employed.ParticipantsFive professional male rugby union players, who had suffered an ACL injury that required surgical reconstruction, participated in the study. Each had spent between six to twelve months in rehabilitation.ResultsContent analysis was conducted on both pre- and post- return data, identifying 12 higher order themes. Confidence building; anticipation; anxiety; physical preparation; psychological preparation; and social support were prevalent pre-return to competition. Post-return higher order themes consisted of confidence building; positive performance emotions; performance anxieties; problem focused coping; social support; and dealing with fears.ConclusionsFor the players in this study, gaining confidence in the injured knee joint appears to be influential, with increases in confidence provided by completing clinical and sport specific tests, and by performance accomplishments. Successful return can be enhanced further by the use of a specific goal setting program aimed at reintroducing the player to competition.     

Deltoid Ligament and Tibiofibular Syndesmosis Injury in Chronic Lateral Ankle Instability: Magnetic Resonance Imaging Evaluation at 3T and Comparison with Arthroscopy

Objective

To evaluate the prevalence of deltoid ligament and distal tibiofibular syndesmosis injury on 3T magnetic resonance imaging (MRI) in patients with chronic lateral ankle instability (CLAI).

Materials and Methods

Fifty patients (mean age, 35 years) who had undergone preoperative 3T MRI and surgical treatment for CLAI were enrolled. The prevalence of deltoid ligament and syndesmosis injury were assessed. The complexity of lateral collateral ligament complex (LCLC) injury was correlated with prevalence of deltoid or syndesmosis injuries. The diagnostic accuracy of ankle ligament imaging at 3T MRI was analyzed using arthroscopy as a reference standard.

Results

On MRI, deltoid ligament injury was identified in 18 (36%) patients as follows: superficial ligament alone, 9 (50%); deep ligament alone 2 (11%); and both ligaments 7 (39%). Syndesmosis abnormality was found in 21 (42%) patients as follows: anterior inferior tibiofibular ligament (AITFL) alone, 19 (90%); and AITFL and interosseous ligament, 2 (10%). There was no correlation between LCLC injury complexity and the prevalence of an accompanying deltoid or syndesmosis injury on both MRI and arthroscopic findings. MRI sensitivity and specificity for detection of deltoid ligament injury were 84% and 93.5%, and those for detection of syndesmosis injury were 91% and 100%, respectively.

Conclusion

Deltoid ligament or syndesmosis injuries were common in patients undergoing surgery for CLAI, regardless of the LCLC injury complexity. 3T MRI is helpful for the detection of all types of ankle ligament injury. Therefore, careful interpretation of pre-operative MRI is essential.     

A qualitative investigation into the individual injury burden of amateur rugby players

ObjectiveTo examine the individual experiences of injury burden in amateur Rugby players across the onset of injury, rehabilitation, and return to play.DesignQualitative.SettingIrish amateur Rugby clubs.ParticipantsThree male and two female Rugby players who sustained a severe injury that resulted in a time loss of at least 28 days.Main outcome measuresSemi-structured interviews were used to explore the injury burden experienced during the three phases of injury.ResultsHierarchical content analysis revealed 36 codes representing individual injury burden, which were clustered into seven themes across personal (emotional reaction; impact on performance or involvement; lack of knowledge; severity of injury and incapacitation) and situational (exposure to others playing; negative experiences with treatment or rehabilitation; societal burden) dimensions.ConclusionsThe findings indicate that individual injury experiences can affect a player’s recovery and rehabilitation outcome, potentially extending the injury process and affecting player availability for the team. As such, injury management should focus on alleviating any injury-related burden experienced by players, as well as burden placed on the team, to maximise rehabilitation outcomes.     

A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture

This report describes the development and current use of decision-making criteria for returning patients to high-level physical activity with nonoperative management of anterior cruciate ligament ruptures, and presents the results of treatment for patients who met our criteria as candidates for nonoperative rehabilitation and attempted to return to high-level physical activity with nonoperative management. The screening examination consists of four one-legged hop tests, the incidence of knee giving-way, a self-report functional survey, and a self-report global knee function rating. We screened 93 consecutive patients with acute unilateral anterior cruciate ligament rupture, classifying them as either candidates (n = 39, 42%) or noncandidates (n = 54, 58%) for nonoperative management. Of the 39 rehabilitation candidates 28 chose nonoperative management and returned to preinjury activity levels, 22 of whom (79%) returned to preinjury activity levels without further episodes of instability or a reduction in functional status. No patient sustained additional articular or meniscal damage as a result of rehabilitation or return to activity. The decision-making scheme described in this study shows promise in determining who can safely postpone surgical reconstruction and temporarily return to physically demanding activities. Continued study to refine and further validate the decision-making scheme is recommended. Received: 9 March 1999/Accepted: 25 October 1999     

Current injury monitoring and player education practices in Irish amateur rugby union

ObjectivesTo ascertain current injury surveillance and player education practices in Irish amateur rugby union.DesignCross-sectional survey.SettingAmateur rugby clubs in Ireland.ParticipantsMedical professionals and rugby coaches of the top 58 amateur rugby clubs in Ireland.Main outcome measuresThe survey investigated the current injury and training load monitoring practices in operation in Irish amateur rugby. It also explored whether player education sessions regarding injury prevention and concussion recognition and management were conducted in these clubs.ResultsForty-four clubs completed the survey, giving an overall response rate of 76%. Ninety-one percent of the responding clubs monitored injuries. Sixty-four percent of these clubs operated return to play protocols for all injuries, while 36% operated return to play protocols for concussion only. Injury prevention education was conducted by 71% of these clubs and 82% educated players on concussion recognition and management.ConclusionsImplementing effective injury monitoring strategies in both amateur and professional sport settings may aid in minimizing injury risk. In Ireland, 91% of the responding clubs monitored injuries and 71% educated players on injury prevention. By implementing one centralized injury surveillance system for Irish amateur rugby, injury trends can be effectively monitored and used to guide prevention strategies.     

Rehabilitation duration and time of starting sport-related activities associated with return to the previous level of sports after anterior cruciate ligament reconstruction

ObjectivesTo determine predictors for return to previous level of sports after anterior cruciate ligament reconstruction (ACLR).DesignCross-sectional;SettingAthletic teams.ParticipantsNinety-one athletes who had ACLR with hamstring-tendon autograft within 1–5 years participated in this study. Athletes indicated their sport participation levels, injury profile, rehabilitation duration, and time to start sport-related activities (running, cutting-pivoting) after ACLR. Athletes answered whether they returned to the same previous level of frequency, duration, and intensity of sports.Main outcome measuresAthletes’ characteristics, injury and surgical factors, duration of post-operative rehabilitation program, and time to start sport-related activities after ACLR were evaluated by univariate logistic regression to determine predictors for return to previous level of sports.ResultsNine athletes (10%) returned to their self-described previous level of sports. Predictors for returning to previous level of sports were rehabilitation duration >4 months (OR:6.78; p = .011), time to start running ≤4 months (OR:8.62; p = .047) and cutting-pivoting <6 months after surgery (OR:5.02; p = .030).ConclusionLonger post-operative rehabilitation duration and time to start sport-related activities after ACLR predicted return to previous level of sports. Spending adequate time in post-operative rehabilitation program and time-based resumption of sports-related activities after ACLR might be key factors for returning to previous sports level.     

Bilateral medial patellofemoral ligament reconstruction in high-level athletes

This report presents two cases of high-level athletes with bilateral patellar dislocations who were able to return to their preinjury level of activity after bilateral medial patellofemoral ligament (MPFL) reconstruction, without any major complications. Patient 1 was a 19-year-old male volleyball player for a top-level college volleyball team, and patient 2 was a 24-year-old woman who was a member of a national-level adult softball team. MPFL reconstruction could be an effective treatment for bilateral patellar dislocation in high-level athletes. Level of evidence V.     

Anatomic bundle reconstruction of the deltoid ligament

BackgroundThe aim of this study was to evaluate the outcome of an anatomic bundle reconstruction of the deltoid ligament in patients with stage IV adult flatfoot deformity.Materials and MethodsEleven patients (50.8 ± 8.1 years, 4 females) were treated with such a procedure combined with osseous realignment as needed.ResultsAt 43 months the tibiotalar angle improved from 26.3 degrees (Range 18 – 35) to 11.0 degrees (Range 5 – 18). The AOFAS score improved from 37.4 points (Range 30 – 50) to 85.1 points (Range 82 – 90). No severe complications occurred in this group.ConclusionAnatomic bundle reconstruction of the deltoid ligament is an effective method in the correction of the tibitalar tilt in servere adult pes planus deformity.Level-of-EvidenceLevel IV - Case series     

Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation

Knee ligament injuries often result in a premature end to a career in sports. The treatment after rupture of the anterior cruciate ligament (ACL) may be operative or conservative. In both cases, the goal is to reach the best functional level for the patient without risking new injuries or degenerative changes in the knee. Return to high level of athletic activity has been an indicator of treatment success. Rehabilitation is an important part of the treatment. Knowledge of healing processes and biomechanics in the knee joint after injury and reconstruction, together with physiological aspects on training effects is important for the construction of rehabilitation programmes. Current rehabilitation programmes use immediate training of range of motion. Weight bearing is encouraged within the first week after an ACL reconstruction. Commonly, the patients are allowed to return to light sporting activities such as running at 2-3 months after surgery and to contact sports, including cutting and jumping, after 6 months. In many cases, the decisions are empirically based and the rehabilitation programmes are adjusted to the time selected for returning to sports. In this article, some criteria that should be fulfilled in order to allow the patient to return to sports are presented. Surgery together with completed rehabilitation and sport-specific exercises should result in functional stability of the knee joint. In addition, adequate muscle strength and performance should be used as a critical criterion. Other factors, such as associated injuries and social and psychological hindrances may also influence the return to sports and must be taken into consideration, both during the rehabilitation and at the evaluation of the treatment.     

Assessing implementation,limited efficacy,and acceptability of the BEAST tool: A rehabilitation and return-to-sport decision tool for nonprofessional athletes with anterior cruciate ligament reconstruction

ObjectivesTo assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool – a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes.DesignProspective cohort.Participants43 nonprofessional pivoting sport athletes with ACLR.Main outcomeClinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes’ beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability).ResultsThe BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1–1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely).ConclusionThe BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.     

Current perspectives and clinical practice of physiotherapists on assessment,rehabilitation, and return to sport criteria after anterior cruciate ligament injury and reconstruction. An online survey of 538 physiotherapists

ObjectivesTo evaluate the perspectives and clinical practice of physiotherapists regarding rehabilitation after anterior cruciate ligament reconstruction (ACLR).DesignOnline survey.SettingSurvey platform.ParticipantsGreek physiotherapists.Outcome measuresThe survey consisted of 7 sections: participant demographics, importance of ACLR rehabilitation, clinical measurements, practice, criteria to progress rehabilitation, return to running and return to sport.ResultsSignificant variability in measures and criteria used for clinical decision-making were found including: limb symmetry in strength and function, knee range of motion and effusion, progression, and return to sport criteria. The majority of the practitioners (28.3%) extrapolate knee strength from hop capacity. Return to running ranged from 3 to 5 months post-operatively reflecting that this was tied to physical capacities, not time from surgery. 70.0% of the Greek physiotherapists would allow return to sport ≤9 months after ACLR. Agreement was found in using: physical measures, function, and dynamic stability in ACLR rehabilitation, but the mode and interpretation varied substantially. Less than 29.0% of the physiotherapists reported using patient-reported outcome measures in their decision-making.ConclusionCurrent ACLR rehabilitation practices in Greece are largely not aligned with the contemporary scientific evidence and guidelines.     

Calf injuries in professional football: Treat the patient or the scan? – A case study

ObjectiveTo describe a case of a professional football player with significant imaging findings despite a rather innocuous clinical presentation with gradual onset of calf pain and who was able to continue training and playing with minor medical intervention. To discuss some of the limitations of existing muscle injury grading systems and their potential to cover the full range of injury presentations for calf injuries.DesignCase report.SettingA professional football player was assessed by physical examination, clinical testing and imaging (MRI) after a gradual onset of a calf injury. After returning to training and competition, a follow-up of his symptoms was performed with regular ultrasound imaging assessments.ParticipantA professional football player (35 years, 1.90 m, 88 kg) male, African, striker, playing in the Professional Arabian Gulf League.ConclusionThe discordance between the clinical presentation and the imaging findings resulted in a challenging situation regarding the decision of whether to allow the player to train and compete. In addition, existing muscle injury grading systems do not seem to cover the full range of injuries seen in clinical practice.     

Skin Care for Active People

Abstract

Background: Pectoralis major injuries are an infrequent shoulder injury that can result in pain, weakness, and deformity. These injuries may occur during the course of an athletic competition, including football. The purpose of this study was to determine the incidence of pectoralis major ruptures in professional football players and time lost from the sport following injury. We hypothesized that ruptures most frequently occur during bench-press strength training. Methods: The National Football League Injury Surveillance System was reviewed for all pectoralis major injuries in all players from 2000 to 2010. Details regarding injury setting, player demographics, method of treatment, and time lost were recorded. Results: A total of 10 injuries—complete ruptures—were identified during this period. Five of the 10 were sustained in defensive players, generally while tackling. Nine occurred during game situations, and 1 occurred during practice. Specific data pertinent to the practice injury was not available. No rupture occurred during weight lifting. Eight ruptures were treated operatively, and 2 cases did not report the method of definitive treatment. The average days lost was 111 days (range, 42–189). The incidence was 0.004 pectoralis major ruptures during the 11-year study period. Conclusions: Pectoralis major injuries are uncommon while playing football. In the National Football League, these injuries primarily occur not during practice or while bench pressing but rather during games. When pectoralis major ruptures do occur, they are successfully treated operatively. Surgery may allow for return to full sports participation. Level of Evidence: IV, case series.