Alexander Matthews1, David Pyne1,2, Philo Saunders2, Kieran Fallon1,2, Peter Fricker1,21Medical School, Australian National University, Canberra, ACT, Australia; 2Australian Institute of Sport, Canberra, ACT, AustraliaPurpose: To develop and evaluate a questionnaire that quantifies the self-reported frequency, duration and severity of illness symptoms in highly-trained athletes. We examined whether runners had more symptoms than recreationally-active individuals, and whether runners more prone to illness were undertaking more strenuous training programs.Methods: A daily illness questionnaire was administered for three months during the summer to quantify the type, frequency, duration, and severity of illness symptoms as well as the functional impact on the ability to undertake exercise performance. A total of 35 participants (12 highly-trained runners living in a community setting and 23 recreationally-active medical students) completed the questionnaire.Results: Runners had a similar frequency of illness (2.1 ± 1.2 vs. 1.8 ± 2.3 episodes, mean ± SD, P = 0.58), but substantially longer duration (5.5 ± 9.9 vs 2.8 ± 3.1 days, P < 0.01) and illness load (7.7 ± 16.2 vs 4.5 ± 4.8 units, P = 0.001) than age- and sex-matched recreationally-active individuals respectively. Runners more prone to illness symptoms had marginally higher training loads.Conclusions: The athlete illness questionnaire is useful for quantifying the pattern of self-reported symptoms of illness in field settings. Highly-trained runners experience longer episodes of illness with a greater impact on daily activity than recreationally-active individuals.Keywords: athlete, self-reported illness, questionnaire, exercise performance

Nicola Maffulli1, Umile Giuseppe Longo2, Mattia Loppini2, Filippo Spiezia2, Vincenzo Denaro21Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, England; 2Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, ItalyAbstract: Tendon injuries can be acute or chronic, and caused by intrinsic or extrinsic factors, either alone or in combination. Tendinopathies are a common cause of disability in occupational medicine and account for a substantial proportion of overuse injuries in sports. Tendinopathy is essentially a failed healing response, with haphazard proliferation of tenocytes, abnormalities in tenocytes, with disruption of collagen fibres and subsequent increase in noncollagenous matrix. The scientific evidence base for managing tendinopathies is limited. What may appear clinically as an “acute tendinopathy” is actually a well advanced failure of a chronic healing response in which there is neither histologic nor biochemical evidence of inflammation. In this review we report the new options for the management of tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, injections (intratendinous injections of corticosteroids, aprotinin, polidocanol platelet-rich plasma, autologous blood injection, high-volume injections) and surgery. Open surgery aims to excise fibrotic adhesions, remove areas of failed healing and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New surgical techniques aim to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. These procedures are intrinsically different from the classical ones in present use, because they do not attempt to address directly the pathologic lesion, but act only to denervate them. They include endoscopy, electrocoagulation, and minimally invasive stripping. Further randomized controlled trials are necessary to clarify better the best therapeutic options for the management of tendinopathy.Keywords: tendon, tendinopathy, management, injections, surgery, sports

Nicola Maffulli1, Umile Giuseppe Longo2, Stefano Campi2, Vincenzo Denaro21Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, England; 2Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Via Alvaro del Portillo, Rome, ItalyAbstract: The menisci are two semilunar-shaped fibrocartilagenous structures, which are interposed between the femoral condyles and tibial plateaux. They have an important role in knee function. Long-term follow-up studies showed that virtually all meniscectomized knees develop arthritic changes with time. The meniscus has functions in load bearing, load transmission, shock absorption, joint stability, joint lubrication, and joint congruity. Because of these functions, meniscal tissue should be preserved whenever possible. A well-trained surgeon can safely rely on clinical examination for diagnosing meniscal injuries. History and clinical examination are at least as accurate as magnetic resonance imaging in the skilled orthopedic surgeon’s hand. When meniscal repair is not possible, partial resection of the meniscus is indicated. Meniscal repair has evolved from open to arthroscopic techniques, which include the inside-out and outside-in suture repairs and the all-inside techniques. Meniscal transplantation is generally accepted as a management alternative option for selected symptomatic patients with previous complete or near-complete meniscectomy.Keywords: meniscus, arthroscopy, meniscectomy, meniscal repair, sports

John Orchard1, Trefor James2, Alex Kountouris2, Marc Portus21School of Public Health, University of Sydney, Sydney, Australia; 2Cricket Australia, Melbourne, AustraliaAbstract: This study analyzes injuries occurring prospectively in Australian men’s cricket at the state and national levels over 11 seasons (concluding in season 2008–09). In the last four of these seasons, there was more cricket played, with most of the growth being a new form of the game – Twenty20 cricket. Since the introduction of a regular Twenty20 program, injury incidence rates in each form of cricket have been fairly steady. Because of the short match duration, Twenty20 cricket exhibits a high match injury incidence, expressed as injuries per 10,000 hours of play. Expressed as injuries per days of play, Twenty20 cricket injury rates compare more favorably to other forms of cricket. Domestic level Twenty20 cricket resulted in 145 injuries per 1000 days of play (compared to 219 injuries per 1000 days of domestic one day cricket, and 112 injuries per 1000 days of play in first class domestic cricket). It is therefore recommended that match injury incidence measures be expressed in units of injuries per 1000 days of play. Given the high numbers of injuries which are of gradual onset, seasonal injury incidence rates (which typically range from 15–20 injuries per team per defined ‘season’) are probably a superior incidence measure. Thigh and hamstring strains have become clearly the most common injury in the past two years (greater than four injuries per team per season), perhaps associated with the increased amount of Twenty20 cricket. Injury prevalence rates have risen in conjunction with an increase in the density of the cricket calendar. Annual injury prevalence rates (average proportion of players missing through injury) have exceeded 10% in the last three years, with the injury prevalence rates for fast bowlers exceeding 18%. As the amount of scheduled cricket is unlikely to be reduced in future years, teams may need to develop a squad rotation for fast bowlers, similar to pitching staff in baseball, to reduce the injury rates for fast bowlers. Consideration should be given to rule changes which may reduce the impact of injury. In particular, allowing the 12th man to play as a full substitute in first class cricket (and therefore take some of the bowling workload in the second innings) would probably reduce bowling injury prevalence in cricket.Keywords: injury profile, cricket, sport, Twenty 20

Christopher J BeedieDepartment of Sports Science, Tourism and Leisure, Canterbury Christ Church, University, Canterbury, UKAbstract: The ergogenic effects of caffeine on performance are well documented. These effects are more evident in endurance and short-duration, sustained-effort events than in interactive or stop-go sports. Experimentally-induced placebo effects of caffeine on sports performance have also been observed in a number of recent studies. In the present paper it is argued that, given the nature of the sports in which caffeine effects are observed, the well documented hypoalgesic effects of caffeine, and the fact that pain is highly placebo-responsive, a reduction in perceived pain might be the common factor in both the biologic and placebo ergogenic effects of caffeine on sports performance. This idea is supported by evidence from medicine that suggests placebo effects are often associated with mechanisms similar or identical to those of the substance the subject believes they have ingested. Research findings from both biomedicine and sports medicine that attest to the interaction of biologic and psychologic factors in caffeine and pain responses are briefly reviewed. In conclusion, it is recommended that researchers investigate the pain hypothesis. Furthermore, researchers should consider psychosocial factors that might modulate the pain response as variables of interest in future caffeine and performance research.Keywords: caffeine hypoalgesia, nocebo effects, research methods

Jon E BlockJon E Block, PhD., Incorporated, San Francisco, CA, USAAbstract: Cold and compression are routinely applied immediately after acute injury or ­following surgery to alleviate pain, reduce swelling and speed functional recovery. The objective of this literature review is to describe the published clinical findings regarding combined cold and compression therapy in the management of musculoskeletal injuries and after orthopedic operative procedures. Of 33 potential articles triaged, the findings of 21 randomized controlled trials were assessed and summarized. The findings reported by these 21 studies were largely subjective pain outcomes and, to a lesser degree, swelling and range of motion, and were inconsistent and divergent, making it difficult to recommend the most appropriate, effective clinical application of cold and compression. Further, 18 of the 21 reported studies evaluated cold and static compression, where the extent and duration of the compression was not uniform within or across studies. Operative procedures may offer a more controlled environment for rigorous investigations. However, such studies must be powered sufficiently to account for variations in surgical procedure that could affect outcomes. More uniform operative procedures, such as total knee arthroplasty, represent a well circumscribed intervention for studying the clinical utility of cold compression therapy because the operative technique is standardized, surgical tissue damage is extensive, intraoperative blood loss is high, and post-operative edema and pain are severe. Findings from randomized controlled trials of knee arthroplasty generally showed cold compression therapy provides better outcomes such as pain relief than alternative interventions. While the effects of cold and static compression are clearly better than no treatment, they do not appear to be directly additive.Keywords: cryotherapy, injury

Ann E RahmannDivision of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Queensland, AustraliaAbstract: Expert opinion considers the referral of people with osteoarthritis (OA) for physiotherapy to be a core component of managing the functional disability and pain of the disease. Clinical guidelines for the physiotherapy management of people with OA focus on three main areas: exercise, pain relief, and specific manual therapy techniques. Land-based group and individual physiotherapy exercise programs, as well as manual therapy, have demonstrated a distinct benefit in favor of physiotherapy intervention. Similarly, both general and specific aquatic physiotherapy exercise programs have shown positive outcomes for people with OA. This review will focus primarily on therapeutic exercise to improve strength and fitness and reduce pain in people with hip or knee OA. An overview of the principles of hydrodynamics relevant to aquatic exercise is also included to facilitate an understanding of effective aquatic exercise programs. The issue of compliance with exercise programs will also be discussed. Clinicians will, therefore, gain an understanding of the benefits of land-based and aquatic exercise for people with OA.Keywords: exercise, physical therapy, aquatic therapy, hip and knee osteoarthritis, strength, pain, aerobic exercise

Marie-Ludivine Chateau-Degat1, Gérard Papouin2, Philippe Saint-Val3, Antonio Lopez21Axe sante des populations et environmentale, CHUQ, Laval University, Quebec, Canada; 2Service de Cardiologie, Centre Hospitalier Territorial du Taone, 3Fédération Tahitienne de Karaté, Papeete, French PolynesiaBackground: Aging is associated with a decrease in physical skills, sometimes accompanied by a change in quality of life (QOL). Long-term martial arts practice has been proposed as an avenue to counter these deleterious effects. The general purpose of this pilot study was to identify the effects of an adapted karate training program on QOL, depression, and motor skills in 50-year-old men.Methods and design: Fifteen 50-year-old men were enrolled in a one-year prospective experiment. Participants practiced adapted karate training for 90 minutes three times a week. Testing sessions, involving completion of the MOS 36-item Short Form Health Survey (SF36) and Beck Depression Inventory, as well as motor and effort evaluation, were done at baseline, and six and 12 months.Results: Compared with baseline, participants had better Beck Depression Inventory scores after one year of karate training (P < 0.01) and better perception of their physical health (P < 0.01), but not on the mental dimension (P < 0.49). They also improved their reaction time scores for the nondominant hand and sway parameters in the eyes-closed position (P < 0.01).Conclusion: Regular long-term karate practice had favorable effects on mood, perception of physical health confirmed by better postural control, and improved performance on objective physical testing. Adapted karate training would be an interesting option for maintaining physical activity in aging.Keywords: karate, balance, training, sport, aging

Henning Boecker1, Ahmed Othman1, Sarah Mueckter1, Lukas Scheef1, Max Pensel1, Marcel Daamen1, Jakob Jankowski1, HH Schild2, TR Tölle3, M Schreckenberger41FE Klinische Funktionelle Neurobildgebung, Radiologische Universitätsklinik, Friedrich-Wilhelms–Universität Bonn, Germany; 2Radiologische Universitätsklinik, Friedrich-Wilhelms-Universität Bonn, Germany; 3TUM Neurologische Klinik und Poliklinik im Neuro-Kopf-Zentrum, Klinikum rechts der Isar der Technischen Universität München, München, Germany; 4Klinik und Poliklinik für Nuklearmedizin am Mainzer Universitätsklinikum, Johannes Gutenberg-Universität, Mainz, GermanyAbstract: This perspective attempts to outline the emerging role of positron emission tomography (PET) ligand activation studies in human exercise research. By focusing on the endorphinergic system and its acclaimed role for exercise-induced antinociception and mood enhancement, we like to emphasize the unique potential of ligand PET applied to human athletes for uncovering the neurochemistry of exercise-induced psychophysiological phenomena. Compared with conventional approaches, in particular quantification of plasma beta-endorphin levels under exercise challenges, which are reviewed in this article, studying opioidergic effects directly in the central nervous system (CNS) with PET and relating opioidergic binding changes to neuropsychological assessments, provides a more refined and promising experimental strategy. Although a vast literature dating back to the 1980s of the last century has been able to reproducibly demonstrate peripheral increases of beta-endorphin levels after various exercise challenges, so far, these studies have failed to establish robust links between peripheral beta-endorphin levels and centrally mediated behavioral effects, ie, modulation of mood and/or pain perception. As the quantitative relation between endorphins in the peripheral blood and the CNS remains unknown, the question arises, to what extent conventional blood-based methods can inform researchers about central neurotransmitter effects. As previous studies using receptor blocking approaches have also revealed equivocal results regarding exercise effects on pain and mood processing, it is expected that PET and other functional neuroimaging applications in athletes may in future help uncover some of the hitherto unknown links between neurotransmission and psychophysiological effects related to physical exercise.Keywords: positron emission tomography, beta-endorphins, opioids

Leon Neve1, John Orchard2, Nathan Gibbs3, Willem van Mechelen4, Evert Verhagen4, Ken Sesel5, Ian Burgess6, Brett Hines61VU University, Amsterdam, The Netherlands; 2School of Public Health, University of Sydney, Sydney, NSW, Australia; 3South Sydney Sports Medicine, Sydney, NSW, Australia; 4EMGO, VU University, Amsterdam, The Netherlands; 5Sydney X-ray Centre, Sydney, NSW, Australia; 6Mater Imaging, Sydney, NSW, AustraliaBackground: Fluoroscopically guided lumbar cortisone injections have been proven useful in cases of lower-limb pain caused by lumbar disc prolapse (with evidence levels ll-1/ll-2). These injections are also sometimes used clinically in sports medicine for patients with non-specific exercise-related lower-limb pain, where no prolapse or other obvious cause of nerve-impingement is diagnosed via magnetic resonance imaging (MRI) or computed tomography (CT), even though this treatment scenario has not been adequately studied for this last diagnosis.Objectives: To explore whether fluoroscopically guided transforaminal lumbar cortisone injections may be a valid treatment method for non-specific exercise-related lower-limb pain.Study design: Retrospective case series.Methods: Patients were selected from databases at two sports clinics and divided into two groups: Group D, with back-related lower-limb pain and disc prolapse proven on CT or MR; and Group N, with non-specific exercise-related lower-limb pain. Patients were sent a questionnaire regarding: symptoms, improvement, effect of injections, satisfaction, side effects and other used treatments. Outcomes were compared between Group D and N.Results: 153 patients were eligible for the study (Group D: 93/Group N: 60). Eventually 110 patients responded (Group D: 67/Group N: 43). Twelve percent of Group D and 14% of Group N indicated that the injections had fully cured their symptoms. Altogether, 27% of Group D and 24% of Group N were certain the injections had improved their symptoms in the long term. A larger proportion however, indicated that the injection had certainly improved their symptoms in the short term, but noted that the effects were non-lasting (Group D: 28%/Group N: 30%). Two patients were certain the injections had actually worsened their symptoms. No significant differences in characteristics and outcomes between Group D and Group N were noted.Conclusions: Outcomes of this study suggest fluoroscopically guided lumbar cortisone injections may have similar outcomes in patients with non-specific exercise-related lower-limb pain compared to patients with disc prolapse proven on MRI or CT causing back-related lower-limb pain. This might suggest a potential role for these injections in the treatment of non-specific exercise-related lower-limb pain. It should be noted that this is a low level of evidence study (level 3) and further study is warranted.Keywords: back-related lower-limb pain, fluoroscopically guided cortisone injections

Jörn Kircher, Christoph Ziskoven, Thilo Patzer, Daniela Zaps, Bernd Bittersohl, Rüdiger KrauspeUniversity Hospital, Orthopaedic Department, Heinrich-Heine University Düsseldorf, Düsseldorf, GermanyAbstract: The complete rupture of the pectoralis major tendon is an uncommon injury but has become increasingly common among athletes in recent years. This may be due to a higher number of individuals taking part in high-impact sports and weightlifting as well as the use of anabolic substances, which can make muscles and tendons vulnerable to injury. In recent literature, there are only few recommendations to rely on conservative treatment alone, but there are a number of reports and case series recommending early surgical intervention. Comparing the results of the two treatment regimens, there is clear evidence for a superior outcome after surgical repair with better cosmesis, better functional results, regaining of muscle power, and return to sports compared with the conservative treatment. In summary, anatomic surgical repair is the treatment of choice for complete acute ruptures of the pectoralis major tendon or muscle in athletes.Keywords: pectoralis major, rupture, athlete, conservative treatment, surgical treatment, steroid, tendon, sports injury

James G Hopker1, Abigail J Foad2, Christopher J Beedie2, Damian A Coleman2, Geoffrey Leach11Centre for Sports Studies, University of Kent, Chatham, Kent, UK; 2Department of Sports Science, Tourism and Leisure, Canterbury Christ Church University, Canterbury, Kent, UKPurpose: This study examined the therapeutic effects of an inert placebo gel on experimentally induced muscle pain in a sports therapy setting. It aimed to investigate the degree to which conditioned analgesia, coupled with an expectation of intervention, was a factor in subsequent analgesia.Methods: Participants were sixteen male and eight female sports therapy students at a UK University. With institutional ethics board approval and following informed consent procedures, each was exposed to pain stimulus in the lower leg in five conditions, ie, conditioning, prebaseline, experimental (two placebo gel applications), and postbaseline. In conditioning trials, participants identified a level of pain stimulus equivalent to a perceived pain rating of 6/10. An inert placebo gel was then applied to the site with the explicit instruction that it was an analgesic. Participants were re-exposed to the pain stimulus, the level of which, without their knowledge, had been decreased, creating the impression of an analgesic effect resulting from the gel. In experimental conditions, the placebo gel was applied and the level of pain stimulus required to elicit a pain rating of 6/10 recorded.Results: Following application of the placebo gel, the level of pain stimulus required to elicit a pain rating of 6/10 increased by 8.2%. Application of the placebo gel significantly decreased participant’s perceptions of muscle pain (P = 0.001).Conclusion: Subjects’ experience and expectation of pain reduction may be major factors in the therapeutic process. These factors should be considered in the sports therapeutic environment.Keywords: conditioning, expectation, perception, positive belief, sports therapy

Mahmut Nedim Doral1,2, Murat Bozkurt3, Egemen Turhan4, Gürhan Dönmez2, Murat Demirel5, Defne Kaya2, Kivanç Atesok7, Özgür Ahmet Atay1, Nicola Maffulli61Department of Orthopedics and Traumatology, 2Department of Sports Medicine, Hacettepe University School of Medicine, Sihhiye, Ankara, Turkey; 3Department of Orthopedics and Traumatology, Ankara Etlik Ihtisas Training and Research Hospital, Ankara, Turkey; 4Department of Orthopedics and Traumatology, Zonguldak Karaelmas University School of Medicine, Zonguldak, Turkey; 5Department of Orthopedics and Traumatology, Ankara Bayindir Medical Center, Ankara, Turkey; 6Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; 7St. Michael's Hospital Division of Orthopaedics Musculoskeletal Research Lab, Toronto, Ontario, CanadaAbstract: Although the Achilles tendon (AT) is the strongest tendon in the human body, rupture of this tendon is one of the most common sports injuries in the athletic population. Despite numerous nonoperative and operative methods that have been described, there is no universal agreement about the optimal management strategy of acute total AT ruptures. The management of AT ruptures should aim to minimize the morbidity of the injury, optimize rapid return to full function, and prevent complications. Since endoscopy-assisted percutaneous AT repair allows direct visualization of the synovia and protects the paratenon that is important in biological healing of the AT, this technique becomes a reasonable treatment option in AT ruptures. Furthermore, Achilles tendoscopy technique may decrease the complications about the sural nerve. Also, early functional postoperative physiotherapy following surgery may improve the surgical outcomes.Keywords: Achilles tendon rupture, percutaneous repair, endoscopic control, growth factors