Preparticipation screening and new player medicals – a few points to ponder

June 29, 2011 by

It’s currently pre-season in the UK for our Football Leagues, and many Football Club doctors like myself are being kept busy with new player signing medicals and pre-participation evaluations (PPE).

Despite the widespread use of pre-participation evaluation testing, there is still little consensus on the exact nature, composition, and effectiveness of the PPE as a screening procedure for the primary and secondary prevention of medical conditions, and as part of an overall injury prevention strategy. Similarly, there is much variation in the way that new player medicals are conducted, depending amongst other things on the Country, the Sport, and the availability of local resources.

During the PPEs in which I have been involved, in a number of different settings and in the context of a number of different sports and with a number of different teams, I have always wondered if I have been performing the most appropriate examinations and ordering the correct investigations at the right time to make a difference to the health of the sports participant.

Here are just three of many different points to ponder with regard to PPEs and player screening medicals :

1) Special tests in physical examination – which, when, who and why?

Many PPE and medical screening proformas include a battery of physical examination tests which must be completed and ticked off as either ‘normal’ or showing some abnormality which may or may not have particular relevance. One has to consider which tests are appropriate for different individuals in different sports, and the reliability and validity of these tests. It is easy to forget the difference in pre-test probabilities when comparing asymptomatic athletes with those with specific symptoms, and sometimes a puzzle to know what to do if some of the tests do turn out to be positive. Who conducts the examination obviously has an effect on reliability, validity and reproducibility. Importantly, we need to ask ourselves why we are doing the tests – is it to detect problems and potential issues, to document ‘baseline’ observations against future observations, or both?

2) Cost-effectiveness

There is a wide variation of resources available to different teams and individual athletes, and it is sometimes hard to know if a screening programme or new player medical is a cost-effective intervention. What’s even harder is to work out is which tests and investigations are the ones that are likely to give the most ‘bang for your buck.’ One example is the routine MRI scanning employed by some Football Clubs as a screening tool to detect joint problems. These are done at considerable cost, and may detect lesions whose natural history may be difficult to interpret when put into context of the whole clinical picture.

For those Clubs that are less well off, can the cost of video-analysis and functional movement testing be justified as cost-effective? What about ‘routine’ blood tests for haemoglobin and iron etc?

3) Risk-benefit ratio

Using the MRI screening issue as an example, if an asymptomatic lesion is discovered which may have a poorly understood natural course, in sharing that information with the individual how much physical and possibly psychological harm can be caused? Will scans lead to unnecessary and possibly harmful interventions? Will the results affect the player’s career in terms of ongoing transfers? Will player concern about lesions detected on scans lead to poor performance?

There are still perhaps many more questions to be answered in relation to PPE and new player medicals than we currently have the evidence-based answers for.

Check out this 2004 thematic issue of CJSM for a wider look at some of the issues involved in PPE. The other resource well worth a read is the 4th Edition of ‘Preparticipation Physical Evaluation’ published by the American Academy of Pediatrics and co-authored by the AAFP, AAP, ACSM, AMSSM, AOSSM and AOASM.

CJSM would like to know about your experience with PPEs and new player medicals – what dilemmas you have come across with these, and what goes on in your PPEs and new player medicals?

(photograph by Charlie Goldberg, UCSD School of Medicine)

Filed under General Interest, Preparticipation Evaluation and Screening Tagged with

World Cup time in Germany for the International Women’s Football Teams

June 26, 2011 by

It’s an exciting time in Germany right now as the Women’s Football World Cup kicked off today with the hosts off to a winning start against Canada, and with France beating Nigeria.

Since 1991, the tournament has been held every 4 years, this being only the second time that the tournament has been staged in Europe since it was last hosted by Sweden in 1995. Germany will be looking to win the Cup for the third time running, and as hosts are the current favourites and the team to beat according to most commentators. There are 16 teams competing for the title, with the final taking place on the 17th of July in Frankfurt.

Having had the privilege of working with the England Women’s under 23’s team for a few years prior to taking on my current role with Leyton Orient FC, I am taking a particular interest in the England Women’s team and hoping that they will go at least one step further than the quarter final stages which is the furthest they have gone so far in the tournament last time out in China in 2007 and in Sweden in 1995. Another fan is my 12-year old niece Anna, who plays for a local team in Sheffield. They had a great season and managed to win their local Cup tournament this year making this uncle particularly proud!

I have nothing but the greatest of respect for top-level Women Footballers who are incredibly dedicated athletes, often competing in a world far removed from that of their male International counterparts and receiving only a fraction of the financial rewards of the men. They commonly work in other occupations or are to be found studying for qualifications in their spare time, all the while pursuing their careers as top-level International athletes. Their level of dedication and training matches that of the men for the most part, and I have found them an absolute pleasure to work with and have been humbled by their dedication to their Sport.

I had the pleasure of watching the England Women’s measured performance during their 2-1 win against the USA earlier this year in preparation for their World Cup bid. The game was held at our very own Brisbane Road stadium, my team Leyton Orient’s home ground, and I had the fortune to sit back, relax, and watch the game as crowd doctor on that occasion. England got off to a great start with 2 early goals and managed to keep in front until the end, despite a goal from the visitors and a USA-dominated second half.

Women’s Football is not without its particular problems when it comes to injuries, with most of us being aware of a well-documented significantly increased risk of ACL injuries in women when compared to their male counterparts. Hartmut and colleagues’s 1 year prospective study of the Women’s Bundesliga published last year in CJSM followed up 254 players from all 12 Women’s Premier League teams in Germany and reported an injury rate of 3.3 per 1000 hours (games 18.5 per 1000 hours ; practice 1.4 per 1000 hours). Most of these (31%) were ankle injuries, with 22.1% knee, 12.9% thigh, and 7.1% head injuries, with a seasonal peak towards the start of the season and with injury rates doubling in the last half an hour of play. The authors noted that most of the severe injuries were non-contact injuries, and speculated that these may well be prevented by ‘certain coordinative training methods’ (Hartmut G et al, 2010). 

This FIFA health and fitness guide for players and coaches, written by Katharina Grimm and Donald Kirkendall and based on original articles published as a supplement on Women’s Football in the British Journal of Sports Medicine in 2007  ,explains some injury prevention strategies for women footballers, and includes the ‘PEP’ programme (Prevent injury and Enhance Performance) with specific exercises focussed on the prevention of the more common injuries including ACL injuries, ankle and head injuries. It also provides additional useful information about nutrition, bone health and some more general topics in a format friendly to coaches and players. Well worth a read.

(picture by WOGERCAN10)

Filed under Female Athletes, General Interest, Patient Education Tagged with

Anyone for Tennis? Wimbledon Championships in full swing

June 23, 2011 by 1 Comment

And so to the gloriously British Grand Slam Premier Tennis event that is Wimbledon which is currently in full swing. Well – full swing insomuch as the British weather is currently allowing, but at least with the Centre Court’s retractable roof, installed in time for the 2009 Championships, we are guaranteed to get through at least some of the scheduled games every day. As I write in London not more than a few miles away from the courts, the rain is currently pouring down – a not so welcome tradition of the Championships, together with the more desirable traditions such as strawberries and cream, ‘Henman Hill,’ and the inevitable tireless British banter about why we haven’t managed to produce a Men’s Champion since the legendary Fred Perry way back in 1936 when he won for a third time.

A total of 128 players take part over the fortnight in the single tournaments, with 64 pairs in single-sex doubles and 48 couples in the mixed doubles. However, there are always a few high-profile players who don’t make it to the Championships because of injury. A quick look at the injury statistics reveals some of the big names you won’t be seeing this year including number 2 seed and current US and Australian Open Champion Kim Clijsters, Juan Carlos Ferrero, Sam Querry and Benjamin Becker. The good news is that current Ladies Champion, Serena Williams, is back to defend her crown after all of her well documented medical problems following a foot laceration on glass sustained in a restaurant.

Speaking of tennis, the BMJ recently published a review article by Orchard and Kountouris on the management of tennis elbow, perhaps better termed lateral elbow pain. Included in the online article is some useful video footage showing eccentric wrist extensor exercises, together with a discussion of the anatomy, pathophysiology and treatment options including some of the recently introduced therapies such as platelet-rich plasma. Interestingly, however, there is little mention of the efficacy of topical NSAIDS in the short term management as highlighted in the useful Clinical Knowledge Summary of the condition on the NHS Evidence website here. Given that these are widely available as over-the-counter preparations, I have always found them a cheap and useful ‘starter for ten’ in combination with ice, activity modification, paracetamol and eccentric exercises.

It seems that the effectiveness of surgery for the condition is still in some doubt according to the recently-updated Cochrane review on surgery for persistent lateral elbow pain. Their review included 5 trials of 191 participants with symptoms of at least 5 months’ duration and failed conservative treatment, and concluded that it was difficult to draw conclusions from the results of the trials due to issues of heterogeneity of interventions, small sample sizes and poor reporting of outcomes. Perhaps it is a blessing that much of the misery of the condition seems to resolve regardless of intervention between 6-12 months following the onset of symptoms.

Some useful CJSM articles on the topic of lateral elbow pain can be found below. Enjoy the tennis!

Hart, Lawrence MB. Short- and Long-Term Improvement in Lateral Epicondylitis. November 2007 – Volume 17 – Issue 6 – pp 513-514

Chung, B, Wiley, J, Preston MPE, Rose, M S. Long-Term Effectiveness of Extracorporeal Shockwave Therapy in the Treatment of Previously Untreated Lateral Epicondylitis. September 2005 – Volume 15 – Issue 5 – pp 305-312

Lebrun, C. Shock-Wave Treatment for Chronic Lateral Epicondylitis in Recreational Tennis Players. May 2005 – Volume 15 – Issue 3 – pp 198-199

Newcomer, Karen L. MD; Laskowski, Edward R. MD; Idank, David M. DO; McLean, Timothy J. RPT; Egan, Kathleen S. PhM. Corticosteroid Injection in Early Treatment of Lateral Epicondylitis. October 2001 – Volume 11 – Issue 4 – pp 214-222

Burnham, Robert,  Gregg, Randy, Healy, Pam,  Steadward, Robert. The Effectiveness of Topical Diclofenac for Lateral Epicondylitis. April 1998 – Volume 8 – Issue 2 – pp 78 – 81

Waskowitz, Robert S. M.D.; Hawkins, Richard J. M.D. 1996. Local Corticosteroid Injection Versus Cyriax-Type Physiotherapy for Tennis Elbow. October 1996 – Volume 6 – Issue 4 – ppg 276

Filed under General Interest, Tendinopathies Tagged with

When Anatomy meets Technology – Learning and Educating with Anatomy Apps

June 21, 2011 by 12 Comments

With over 108 million iPhone sales since 2007 and rising, together with 60 million iPod touch sales and 25 million iPads, there is a now a huge global userbase for applications (Apps) on these devices with over 425,000 Apps in total available in the App store.  Android-capable mobile phones are also growing in popularity, and these have their own applications for use on these devices.

An App store search using ‘anatomy’ reveals 372 iPhone and iPod touch compatible anatomy Apps, together with 170 dedicated iPad anatomy Apps. Some of these show images of anatomy, some are ‘flash cards’ and some have integrated quizzes.

Anatomy apps can be useful for both learning anatomy and for using as an educational tool in  a patient consultation. Given the portability of the iPhone, iPod touch and iPad, it is easy to use these Apps in the clinic, at the training ground, or whilst on tour with teams, and most of the Apps do not require internet access to function once they have been downloaded.

Some of the better Apps have the ability to add notes and annotations to diagrams, and to view structures from multiple angles with magnification. Whilst the detail is sometimes limited, there is often more than enough to be able to use an App to help to explain the relevant structures to patients in order to improve their understanding of their injuries, and indeed to learn some of the anatomy that a Sports Physician might need. However, the extensive detail is often lacking, so there is room for improvement.

Here are my ‘Top 5’ Anatomy Apps currently available in the App store :

1) Pocket Body – The Interactive Human Body (iPad / iPod Touch / iPhone) (App store link here)

This App by eMedia Interactive LTD has a 9-layer graphic of the human body, with 4 views (anterior, left lateral, posterior and right lateral), and the images magnify up nicely without significant pixellation. Muscles, bones, tendons, vessels and nerves are all shown. Pins are attached to most of the muscles, and a quick press reveals the origin, insertion, key relations, functions, and innervation and vascular supply. In addition, some clinical notes are shown although these are somewhat limited in scope and not always accurate. It is possible to add your own notes, and to edit these. Many of the pins attached to nerves are red, and indicate the structures but give no additional detail although you can add your own notes and indeed can add your own pins on the model.

There are 3 different quizzes available – a ‘locate pins’ quiz, an MCQ, and a flash card type quiz and these can be set to examine any particular region. In addition, there is the ability to take a screenshot of an image and to share the image by email, post on your Facebook page or link to Twitter, or save to your device. This is a great App for learning the basics of musculoskeletal anatomy, and for showing relevant structures to patients.

2) Muscle System Pro II (Nova Series) and Skeletal System Pro II (Nova Series) (iPad / iPod Touch / iPhone) (App store links here – muscle & skeletal)

These are 2 separate Apps by 3D4 Medical, and show some really quite beautiful images, with the ability to view from many different angles. The image pins link to information boxes. The information on muscles shows origin, insertion, action, innervation and vascular supply. There is also the ability to add your own notes. Individual structures can be shown such as different bones, with excellent quality images when fully magnified, and with much anatomical detail. There are quizzes, although these are somewhat easy for anyone except novices. The images are probably the best available on these devices and are particularly impressive on the iPad, and these can be shared by email or social networking applications.

3) Muscle Trigger Points (iPod Touch / iPhone / iPad) (App store link here)

This App by Real Bodywork acts as a reference for common muscle trigger points. There is information on over 70 muscles and 100 different trigger point patterns, with information on the action of the relevant muscles and on the referral pain patterns. There is a 3D model which rotates in 2 animations to anterior and posterior images showing the different muscles, and muscles can be viewed individually from a list, or by choosing ‘zones.’ Real Bodywork provide a number of other anatomy Apps in addition to the Muscle Trigger Point App, including a ‘Learn Muscles’ App, a muscle and bone anatomy 3D for iPad, and skeletal anatomy 3D quiz and reference.

4) Instant Anatomy Lectures, Flash Cards, A/V Lectures and MCQ Apps (iPad / iPod Touch / iPhone / Android) (App store link here)

Robert Whitaker has been offering a number of excellent resources from his Instant Anatomy series for a number of years now. These originally started with books, going on to CD ROMs, and now a series of Apps. There are podcasts of anatomy lectures, video podcasts, and flash card Apps. This series of Apps offers some quite wonderful learning material, especially for the novice, and a great way to learn anatomy. The diagrams are easy to understand, although are more suited to learning than to explaining structures and pathology to patients. Some of the Apps are free on the App store, offered as ‘tasters’ with limited information, so you can try them out for yourself. Highly recommended for medical students and those re-engaging with anatomy after a while.

5) Aspects of Anatomy (iPad / iPod Touch / iPhone) (App store link here)

This App was developed by my one of my former anatomy teachers at University College, London, Professor Peter Abrahams, who is now Professor of Anatomy at Warwick University. He is also one author of the excellent ‘Essentials of Clinical Anatomy’ text. It consists of a series of 38 short (3-8 minute) lectures on a number of plastinated specimens, together with some related clinical information on related topics such as Colles fracture. In addition, imaging modalities are included, together with ‘spot’ quizzes (don’t I remember those during my Anatomy finals!) and clinically relevant MCQs. This is a wonderful resource for medical students and those revisiting anatomy.

CJSM would be interested to hear about your favourite Anatomy Apps, and how you use them in your clinical practice.

Filed under Basic Sciences in SEM, General Interest, Patient Education Tagged with

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