Local anesthetic use in sport for early return to play – should we be offering these jabs?

January 13, 2012 2 Comments

The use of local anesthetics in sports injury management is a bit of dark art – often practised, but not so often talked about. Certainly, there is a paucity of medical literature on the subject, with perhaps more articles in the lay press.

Statistics on the use of local anesthetics in different sports are not widely available, but it is likely that they are most widely used in the contact sports including the football codes (American football, soccer, and rugby league and union).

When they are used, the aim is usually to eliminate or diminish pain caused by an injury which may be acute or chronic, or another condition such as an ingrowing toenail, significantly enough in order for a player to return to play.

Some questions remain about their use, however –

– Are they safe for players in the short and long term?

– Are we currently using them in an ethically-sound manner?

The World Anti-doping Agency currently places no restrictions on the use of local anesthetics in sport, although there is a debate about whether the elimination of pain constitutes a performance enhancing intervention. Most governing bodies leave the decision as to whether use local anesthetics to the team physician and patient. The NCAA, for example, mentions that ‘use is medically justified only when permitting the athlete to continue the competition without potential risk to his or her health.’ (see section 31.2.3.4.1 of NCAA drug policies).

The assessment of potential risk to health from using local anesthetics in order to assist a player to return to play is a difficult one. To a large extent, the risk depends upon the nature of the injury. Most of us would, I suspect, be reluctant to administer a local anesthetic to a player with an acute grade 1 medial collateral ligament injury of the knee in order for them to attempt to play, but may be less concerned about blocking a toe with an undisplaced phalangeal fracture.

Orchard and colleagues reviewed a case series of 268 injuries over a 6 year period in which local anesthetic was administered to allow an early return to play. In this series, around 10% of players competing did so with the assistance of a local anesthetic. The most common injuries for which local anesthetics were administered were rib injuries, iliac crest hematomas, acromioclavicular joint injuries, and finger and thumb injuries. A total of 6 ‘major’ complications were noted, including two cases of distal clavicle osteolysis (questionable as to whether this was a true complication), a partial tendoachilles rupture, an adductor longus tendinopathy (again, causality is questionable), prepatellar infected bursitis and a scapholunate ligament tear, with 11 ‘minor’ complications.

Orchard and colleagues went on to publish a retrospective survey of 100 players over ten seasons who had been injected with local anesthetic on 1023 occasions for 307 injuries. There was an average of 5 years’ follow-up. They found that 98% of players stated they would have had the procedure in the same circumstances again, although nearly a third felt that there were side effects associated with the use of the local anesthetic. 22% of players thought that the anesthetic had delayed their recovery and 6% thought that their injury was worsened due to playing on with a local anesthetic block.

The authors concluded that ‘the most commonly injected injuries – acromioclavicular joint sprains, finger and rib injuries, and iliac crest contusions appear to be quite safe (in the context of professional sport) to inject at long-term follow up.’

They conceded that ‘a few injuries may have been made substantially worse by playing after an injection,’ and also mentioned that there was ‘still insufficient evidence to completely determine the safety of local anesthetic injections in the majority of potential circumstances,’ calling for further studies to assess long-term safety.

There is good evidence that local anesthetic injections are both chondrotoxic and myotoxic when administered during both in vitro and in vivo studies. Given that the long-term safety of local anesthetic injections is unknown, can we safely recommend and administer these to our patients in order to allow them an early return to play?

Perhaps even more important are the ethical and safeguarding issues surrounding the use of local anesthetics in sports injury. What happens if a player chooses not to have an injection following  an injury when it is common practice amongst the team for other players to have this intervention in order that they may be able to play with a similar injury? Will they be discriminated against by the team manager or other players, or be subject to coercion?

Should there be an independent assessment of the appropriateness of using these injections prior to administration?

Do we need a review and a consensus opinion from WADA or individual governing bodies ?

CJSM would like to hear your thoughts

Leave a Comment

Leave a Comment

Filed under Drugs and Doping in Sport, Elite sport, Ethics and probity in SEM, General Interest, Safeguarding in Sport Tagged with , ,

Guest blog – Starting out in SEM, by Dr Tamim Khanbhai

January 6, 2012 1 Comment

 I am relatively new to Sports & Exercise medicine (SEM), having made the big change from a stable career in General Practice / Family Medicine to the more uncertain life as a SEM physician. People often ask how I went into a speciality that many other medics don’t even know exist.

My story, which is no doubt different from many others in SEM started with me qualifying as a GP in 2009. Whilst being a GP registrar I realised I was weak in musculoskeletal medicine and always felt this was poorly taught in medical school, and so I was toying with the idea of doing a postgraduate qualification in musculoskeletal (MSK) problems.  A friend had done an SEM MSc, and having always enjoyed watching a variety of sports and playing a few (recreationally), it felt like a good way to go.

I also happened to have a GP group that met once weekly in the Leyton Orient FC (LO) football ground. This may sound strange but there is a ‘health centre’ within the stadium and we used a meeting room that overlooked the stadium. This group ran for about a year and there is no doubt, that starting a distance learning SEM MSc combined with watching over LO FC football ground on a weekly basis really filled me with excitement. From that moment on my ambition was to complete the MSc and work with LO in some capacity, perhaps even as their club doctor one day.

The SEM MSc took two years to complete but it was distance learning and although my knowledge was improving, getting experience in SEM medicine is not straightforward. It’s not like doing a dermatology diploma where you can simply call the local hospital and sit in with dermatologists. There are extremely few SEM clinics in the NHS or community setting in London, where I am based.

However I approached multiple SEM consultants in the NHS and predominately in the private sector, and physiotherapists. Thankfully ‘we’ seem to be quite a decent bunch and most were more than happy for me to gain experience in their clinics. For me it was a real insight into the medicine involved in SEM and it soon became apparent that the knowledge base required is huge and covers many disciplines. My aim at this point was still to complete the MSc but also be a team doctor. For me it became apparent that getting into clinics or meeting teachers on an MSc course was relatively straight forward but getting involved in a team was a much more closed circle. How to get in?? I was keen to be involved in football, as it is a sport that I played and enjoyed from as early as I can remember. Well snooker is another love, but not sure about the amount of SEM required here! Perhaps some health promotion!

Getting into club football involved attending Football Association conferences and by chance I managed to meet the doctor at Leyton Orient. Of course meeting and getting involved are two different things but by now I had made some ‘contacts’. A friend put in a good word for me and luckily LO needed a reserves team doctor. I met with the club doctor and pretty soon the role was mine.

This was really great experience, in a friendly club, and my first insight into the role and responsibilities of a club doctor and the medical setup within a professional club. Fortunately I stayed there for almost 18 months after which I managed to get the club doctor role at Barnet FC in July 2011 and where I have been working since. I also gained more experience by offering my services for ‘free’ working as a pitch side doctor for BUCS (British Universities & Colleges Sport) which was by chance organised by the England Women’s football doctor and has lead me to get a role as the team doctor for England women’s U-15’s starting in February 2012.

Over the last year whilst this was all going on, I thought more deeply about a full time career in SEM and decided to pursue this full time. It is an area that is exciting, challenging and diverse. I took the big step of leaving my successful and stable career in general practice and although nervous have been back in hospital over the last 5 months having started in August 2011. Fellow SEM registrars are supportive and although there are doubts about future jobs within the NHS, this is definitely the area of speciality that I want to pursue full time. The last few months have been great and cemented my decision to move from GP.

The role of a SEM physician is clearly challenging, especially when you have to describe your role to fellow physicians and surgeons who have never heard of your speciality and convince them of the need for SEM, let alone convincing government to provide more jobs within the NHS setting.

So why did I make this risky decision to change career? Well, because I believe SEM has a major part to play in the future of health/exercise promotion, tackling obesity, injury prevention and management  to name but a few areas. Additionally as SEM physicians in a relatively young speciality, I think it is in our hands to promote this speciality playing a major part in shaping the future of SEM to make it the success it should be.

Dr Khanbhai is a current specialty trainee (registrar) in Sport and Exercise Medicine based in London, UK

Leave a Comment

Leave a Comment

Filed under General Interest

Time for a break? Competition over the Christmas and New Year period

December 30, 2011

And so we have reached the Christmas and New Year break, with good-will on offer to one and all. For many of us, this is a time to get away from work – to spend quality time with our family and friends, and to take a breather from the every-day grind of the nine-’til-five. Perhaps some of us will be indulging a little more than usual by way of food, drink and merry-making.

This is, however, not the case for many of those involved in Sport including the athletes themselves and their numerous support staff. In fact, this is often one of the busiest times of the year for those involved in Professional sport, and the fixture calendar can be particularly crowded as the National sporting bodies and Leagues cram in the fixtures, perhaps in order to secure large crowds of seasonal fans and lucrative television rights.

Some sports participants enjoy a break at this time of year, whilst others are perhaps not so fortunate. For example, in the German Football Bundersliga, teams enjoy a four-week period during which the players can take a breather. It is true to say that some teams decide to fly overseas to train and compete in non-league tournaments during this period in order to maintain their in-season fitness, and some players also fly off to take part in National tournaments on other continents, but some teams certainly allow their players time off to spend with their friends and families citing the importance of rest and recouperation for both physical and psychological recovery.

There have been almost annual calls for a winter break for teams in the English Football League for the last few decades, with some managers and players stating that the demands of the football season, together with matches played during the summer period in competitions such as the World Cup and the European Championships, effectively mean that some players have very little time in which to recover and that this leads to adverse physical and psychological consequences for those players together with negative effects on the performance of National teams playing in the summer period and club sides.

Requests for winter breaks in football in the UK have been increasing over the last few seasons, and regional officials and organisations have tended to put the blame for the players’ busy schedules firmly at the door of FIFA and UEFA.

The latest calls for time off during the Christmas and New Year period here in the UK come from former England Manager Sven Goran-Eriksson, the new Sunderland Manager, Martin O’Neill, League One Football Manager Gus Poyet at Brighton, and Wolverhampton Wanderers midfielder Stephen Hunt. However, others are not in agreement with this strategy including Arsenal’s German defender Per Mertesacker who seems to prefer playing in the UK whilst his German footballing colleagues are enjoying some time off back in Germany at this time.

Arguments for the Christmas and New Year break include the following:

  • Allow for physical recovery
  • Allow for ‘psychological recovery’ and protect against adverse psychological effects of stress during the season / travel etc
  • Injury prevention (possibly linked to adverse weather conditions and hard grounds)
  • Improve overall performance over the season

There is a paucity of evidence on which to make these arguments, however.

Looking in greater detail at just one of these arguments, injury prevention, the evidence to support this has been somewhat conflicting. Although I could find nothing in the literature on the effect of a winter break on injury incidence, one might wish to extrapolate from research looking at the incidence of injuries occurring at different times of the season.

In a study published in the British Journal of Sports Medicine in 1998 on the effect of seasonal change in rugby league on the incidence of injury, an increased incidence of injury in summer was demonstrated, and in another prospective study published in the American Journal of Sport Medicine of injury incidence amongst players of one rugby league club over a nine season period, injury risk was found to have greatly increased as a result of changing the playing calendar from the winter months to the spring and summer period.

A study published in 2007 in the British Journal of Sports Medicine on the association of ground hardness with injuries in rugby union showed a seasonal change in ground hardness and an early season bias of injuries.

Orchard discussed the relationship between ground and climactic conditions and injuries in different codes of football, including soccer, rugby league rugby union, American football, Australian football and Gaelic football in 2002, and found an early-season bias for injuries to the lower limb. He concluded that variations in playing characteristics were likely to account for the patterns seen.

I could find nothing in the literature specifically relating to research on the proposed positive effects of a winter break on psychological factors such as mood profiles etc

Should we be offering our players and teams a mid-winter break, and if so, on the basis of which argument(s)?

CJSM would like to hear your thoughts.

In the meantime, all of us at CJSM would like to wish our blog readers a very happy Christmas and New Year, and we devote this blog post to all those who are working with teams over the Christmas and New Year period.

Leave a Comment

Leave a Comment

Filed under General Interest, Injury Prevention, Psychology in Sport

Injury risks of artificial turf in soccer

December 16, 2011 7 Comments

Ever since Astroturf was first installed at the Houston Astrodome back in the 1960’s, there has been much controversy about the use of artifical grass playing surfaces used in a number of different sports. The main issues relate both to ‘playability’ and the way that the surface properties affect playing dynamics, and to the risk of injuries occuring on artificial surfaces.

Despite this controversy, artificial surfaces have been used in a wide range of different sports and in some famous venues. In American Football, for example, the New England Patriots and the New England Revolution share an artificial playing surface at the Gillette stadium, whilst most field hockey games these days are played on an artificial surface.

In the UK, I vividly remember the early artificial surfaces used in football back in the 1980’s, when many teams dreaded the trip to Queens Park Rangers, Luton Town, Oldham Athletic and Preston North End on account of their ‘plastic pitches.’ At the time, most of the pitches were derided by football fans due a combination of their poor playability and recurrent carpet-burn injuries sustained by the players and they lost favour quickly.

I was therefore somewhat surprised to read on the BBC sport website that there are moves afoot for a return to the use of artificial turf in the Football League, headed by Wycombe Wanderers and Accrington Stanley. My interest was all the more galvanised by the fact that Wycombe play in the same league as the team that I look after, Leyton Orient. From the Clubs’ point of view, the argument for installing an artificial playing surface centres on economics, with artificial pitches being much easier to maintain than grass. In addition, it is easy to host other events at stadia with an artificial surface such as pop concerts and other social events. There are independent advocates both for the use of artificial surfaces in soccer, and against their use.

As a team physician, my immediate thoughts turned to the risks of injury when playing on artificial playing surfaces. There is no doubt that there has been an evolution of the quality of playing surfaces over the years. Astroturf, developed back in the 1960’s, was known for it’s somewhat abrasive properties, and the risk of ‘carpet burn’ injuries was all-too-apparent to anyone who dared to perform a slide tackle or similar manouvre on the surface. These were not the only injuries of concern on early artificial surfaces, and there were plenty of papers in the literature that reported an increased risk of other injuries on artificial playing surfaces (see Ekstrand & Nigg, 1989 ; Girard et al, 2007 ; & Steele & Milburn, 1988).

However, the modern third and fourth generation pitches are very different in construction and often promoted as possessing the same properties and injury-risk profiles as grass. For example, Dragoo and Braun reported that the overall injury rate on the new surfaces is comparable to that seen on natural pitches.

Therefore, it was with interest that I read a new review article by Williams and colleagues published in Sports Medicine in November 2011 of football injuries on third and fourth generation artificial turfs compared with natural turf.

The authors performed a literature search using Cochrane Collaboration review methodology to evaluate injury characteristics and risk factors for injury on artificial turfs compared with natural grass turf over a range of ‘football’ codes including Rugby Union, Soccer and American Football. The outcome measure used to assess each included study was the incidence rate ratio for injuries on natural and artificial turf, calculated using natural turf as the reference.

The authors found an increased incidence of ankle injury playing on artificial turf in 8 cohorts, although injury risk for knee injuries was inconsistent. There seemed to be a trend towards less muscle injuries playing on artificial turf compared with natural turf. There was, however, no data on head injuries and concussion.They concluded that their included studies showed a trivial difference in injury rates between third and fourth generation artificial turf when compared with natural turf. Limitations of the study were accepted, including the need for longitudinal prospective cohort studies including an adequate number of teams, and controlling for confounding factors such as weather and gender etc, and I think that there were indeed a number of important limitations of the study such that it is perhaps difficult to draw conclusions based on the evidence we have.

For me, the jury’s still out on the issue of injury risk with the newer artificial playing surfaces, but the traditionalist in me still thinks that soccer was meant to be played on a natural surface. Even if the risk of injury is, in time, proved to be no greater on an artificial surface, having watched soccer played on 3rd generation pitches and having played on them myself, I can say that from my point of view it never really looks or feels the same.

What do our readers think?

Should we entertain an expansion of artificial playing surfaces? If so, should that be just within specific sports? How do you think that we should assess injury risk on these surfaces and do you think that the effects seen would be different in different sports?

CJSM would like to hear your thoughts.

References :

Ekstrand J, Nigg BM. 1989. Surface-related injuries in soccer. Sport Med 8(1):56-62

Girard O et al. 2007. Effects of playing surface on plantar pressures and potential injuries in tennis. Br. J. Sp. Med. 41(11):733-8

Steele JR & Milburn PD. 1988. Effect of different synthetic sport surfaces on ground reaction forces at landing in netball. J. Sport. Biomech. 4(2):130-45

Dragoo JL & Braun HJ. 2010. The effect of playing surface on injury rate :a review of the current literature. Sport Med. 40(11):981-990

Williams S, Hume PA & Kara S. 2011. A Review of Football Injuries on Third and Fourth Generation Artificial Turfs Compared with Natural Turf. Sports Med. 41(11):903-923

(Images of (1) modern artifical turf diagrammatic, (2) side view of artificial turf, and (3) Aspmyra, Norway taken from Wikimedia)

 

Filed under Evidence-based Medicine in SEM, General Interest, Injury Prevention Tagged with

← Older posts

Newer posts →