Groin problems keep two prominent 100 meter sprinters out of the World Championships

August 25, 2011 by

The Jamaican 100 meter sprinter and former twice world record holder at that distance, Asafa Powell, is the latest big name to pull out of a forthcoming event with a groin problem. Powell apparently originally developed symptoms following a race in Budapest in July this year, and later pulled out of the London Grand Prix hoping that things would settle in time for him to be able to compete at the World Championships in Daegu, South Korea later this month. However, he was forced to pull out of the 100 meter heats, although may make himself available for the 4 x 100m relay on the 4th of September.

Powell is the second high profile athlete who is unable to compete at the World Championships at the 100m distance, with Tyson Gay having previously undergone arthroscopic surgery on his hip earlier this year. Gay was reported to have been suffering from hip impingement, according to his surgeon Dr Marc Phillipon.

Groin pain is surely one of the most frustrating conditions suffered by those who participate in sport, and presents one of the trickiest diagnostic challenges for Sports Physicians, especially in its chronic presentation. Acute hip and groin pain often occurs in those sports that require quick changes in direction and kicking such as soccer, and chronic groin pain similarly tends to occur in those who participate in sports in which explosive sprints are combined with twisting and kicking. The diagnostic challenge of chronic groin pain presents due to a combination of factors, including complex regional anatomy, the heterogeneity of sites where pain occurs and tenderness can be elicited, and often the co-existence of a number of different pathologies including some of the more obscure, less well-recognised conditions such as obturator nerve entrapment, described here in CJSM by Bradshaw and McCrory.

In a paper published in BJSM in 2007, Per Hölmich identified 3 primary patterns of longstanding groin pain amongst 207 consecutive athletes involved in a number of different sports using a standardised clinical examination programme, categorising patterns related to adductor-related dysfunction, iliopsoas-related dysfunction, and rectus abdominis-related dysfunction together with combinations of these patterns. This concept of clinical entities was later extended in the 3rd Edition of Clinical Sports Medicine by Brukner and Khan to include pubic bone stress-related dysfunction, but how useful this concept is in Clinical Practice continues to be a subject for debate.

Falvey and colleagues, in a paper in the British Journal of Sports Medicine, more recently attempted to make sense of the so-called ‘groin triangle,’ suggesting a ‘novel educational model based on patho-anatomical concepts’ in order to assist in the diagnosis of chronic groin pain in athletes.

Even more recently, Bizzini described the groin area as the ‘Bermuda triangle’ of sports medicine, and I think that it is fair to say that most clinicans will continue to find themselves lost from time-to-time when assessing their patients with groin pain.

Any tips from our blog readers on the assessment of chronic groin pain? CJSM would love to hear your practice pearls.

(picture by Chell Hill, 2010)

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Brave fighter Scott LeDoux succumbs to Lou Gehrig’s disease

August 19, 2011 by

I was saddened to hear of the death of the ‘Fighting Frenchman,’ Alan Scott LeDoux last week. LeDoux died of Amyotrophic Lateral Sclerosis (ALS), also widely known as Lou Gehrig’s disease, which was originally diagnosed in 2008. He had a distinguished and colourful career having fought many famous heavyweight fighters including George Foreman, Larry Holmes, Leon Spinks, Ken Norton, and Gerry Coetzee. He also fought Muhammad Ali in a five round exhibition match, and his final bout was against Britain’s Frank Bruno in 1983 which ended in a technical knock-out. LeDoux ended his career with a record of 33-13-4, with 22 knockouts.

Arguably his best boxing achievements were his draws with Leon Spinks just two months prior to Spinks’ defeat of Ali for the World Heavyweight Championship, and with Ken Norton. During his controversial fight with Norton, he had his opponent on the canvass twice in the tenth round. Following his boxing career, LeDoux entered the world of politics and was a commissioner in Anoka County, Minnesota, until he stepped down from his role due to his declining physical health.

LeDoux and his wife Carol became advocates for research into neurodegenerative diseases, particularly supporting research programmes at the University of Minnesota. The brave fighter can be seen alongside his wife Carol talking about his hardest ever fight, against ALS, and promoting the importance of research into neurodegenerative diseases in this emotive video. LeDoux is survived by his wife Carol, two sisters Denise and Judy, two children from his first marriage, Molly and Joshua, a stepdaughter, Kelly, and four grandchildren.

McCrory discusses the issue of Sports Concussion and the Risk of Chronic Neurological Impairment in this article published in CJSM earlier this year, in which mention is made of the possible association of ALS in association with head injury. McKee and colleagues, in their study published in the Journal of Neuropathology and Experimental Neurology,  recently claimed to be the first authors to have found pathological evidence indicating that repetitive brain trauma may be associated with motor neuron disease, finding abundant TDP-43-positive inclusions in the spinal cords of 3 athletes with chronic traumatic encephalopathies.

Most of our American and Canadian readers will be familiar with New York Yankees’ first baseman Lou Gehrig, whose career was cut tragically short by ALS. Over a 15-season span from 1925 to 1939, Gehrig played in 2,130 consecutive games – a record which stood for 56 years until being finally broken by Cal Ripken Jr in 1995.

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PRP – magic bullet, or damp squib?

August 17, 2011 by 2 Comments

I’m guessing that not many of you will have seen the Academy Award-nominated biographical movie ‘Dr Ehrlich’s Magic Bullet’ starring Edward G Robinson. It outlines part of the career of the famous German scientist  Dr Paul Ehrlich, who popularised the concept of the ‘magic bullet’ therapy for the treatment of specific diseases. The film focuses on arsphenamine, ‘compound 606,’ and Ehrlich’s cure for syphylis.

The concept of the ‘magic bullet’ is rather older however, dating back at least to the 1800’s and deriving from the histochemical staining of tissues. It was Ehrlich’s opinion that, if a chemical could be found that targeted a pathogen, then a toxin could be delivered along with that chemical and hence a ‘magic bullet’ would be created that would destroy the pathogen leading to the elimination of a disease state. The concept was later realised following the discovery of monoclonal antibodies for which Köhler, Milstein and Jerne shared a Nobel Prize in 1984.

So-called ‘targeted therapies’ do not necessarily destroy their target as such, but may act to cause some form of modification, for example to a cell membrane via second messenger cascades or within the cell nucleus itself, leading to alterations in cellular genetic expression which then lead to a sequence of events that ultimately results in healing or an improvement in clinical symptoms.

Platelet-rich plasma (PRP) has been perhaps the most widely investigated preparation of late. PRP contains a number of growth factors including PDGF, IL-8, and CTGF, which have a number of different effects on different cells. Many of these actions are poorly understood, despite much basic science research, yet this has not prevented the clinical application of PRP for tendinopathies which is perhaps not surprising given the search for effective therapies for tendinopathies and the drive for ‘cutting-edge’ therapies in Sports Medicine.

However, when one stops to consider the knowledge gaps we have concerning the pathophysiology of tendinopathies, and our lack of understanding of the complex interactions involved in cellular healing mechanisms, then perhaps one may not be surprised to see the heterogeneity of results from clinical trials using PRP in the treatment of these conditions. The three main theories for the genesis of tendinopathy, namely overuse, overload and thermal stress, are still open to debate and there is a very wide range of possible actions of PRP on tendinopathic tendons.

Well-conducted clinical trials such as this one by de Jong et al on PRP for achilles tendinopathy, and systematic reviews such as this one by de Vos and colleagues ,have failed to find a positive clinical effect when using PRP use for the treatment of tendinopathies.

In this month’s systematic review in CJSM on the use of PRP in Sports Medicine as a new treatment for tendon and ligament injuries, Taylor and colleagues concluded that, despite several possible theoretical advantages to the use of PRP, there are very few well-conducted prospective studies and clinical trials available with which to inform clinical practice.

The recent IOC consensus paper on the use of PRP in sports medicine published in BJSM also highlighted the limited amount of basic science research, the paucity of well-conducted clinical studies on PRP, and the heterogeneity of methodological issues between different studies making comparisons of clinical effects difficult to judge. The IOC group’s recommendation was that clinicans should proceed with caution in the clinical use of PRP.

The debate is on as to whether there is a true lack of efficacy of PRP in the treatment of tendinopathies, or whether we simply need more well-designed clinical research.

What do you think? Where do we need to focus our research efforts? Should we forget the idea of ‘targeted therapies’ such as PRP and ‘magic bullets’ for tendinopathies?

CJSM would like to hear your views.

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France, Le Tour, cycling injuries and cycle helmets

August 6, 2011 by 13 Comments

Welcome back following a short break in France, during which I spent a week in the Languedoc admiring the scenery and enjoying the French hospitality. Not everyone was as lucky as I was to be taking things easy, however, and Le Tour was in full swing during my time there, this being the 98th edition of the race since it was first held in 1903. The gruelling 21 stages run over 23 days covers a distance of 3430 km, and the race is a real test with a chequered and interesting history.

This year’s Tour was won by an Australian for the first time, Cadel Evans, who gained the lead on the penultimate day.

As usual, there were a number of casualties, mostly from crashes involving some high profile riders. These included Britain’s Bradley Wiggins who crashed out on stage 7 of Le Tour with a fractured clavicle during a pile-up which can be seen in this Guardian UK video footage . Others injured during the race included Andreas Klöden, Alexandre Vinokourov, Janez Brajcovic, Jurgen Van Den Broeck and Chris Horner who were all unable to continue the race due to their injuries.

Again this year, a large proportion of serious  injuries were caused by collisions with vehicles, including an incident with a car involved with TV coverage which resulted in injuries to Juan Antonia Flecha and Johnny Hoogerland and led to Christian Prudhomme, Tour organiser, to say ‘It’s a scandal.’ Hoogerland’s dramatic lacerations following his collision with barbed wire can be seen in this image. In addition, Nikki Sorensen was struck by a photographer on his motorbike.

For a useful review of injuries associated with cycling, see this 2001 article by Thompson and Rivara published in American Family Physician.

Those of us who are perhaps more used to keeping safe whilst cycling in the streets might be more interested in this article published earlier this year in Injury Prevention by Lusk and colleagues, based on regional data from Montreal, which highlights the differences in injury rates between cycling on cycle tracks compared with comparable reference streets. The study found that the relative risk of injury on cycle tracks was 0.72 (95% CI 0.60 to 0.85) compared with cycling in reference streets, suggesting that the risk of injury from cycling on tracks is less than cycling in the streets.

A key element of road cycle safety surely has to be legislation for the mandatory use of helmets which still hasn’t found it’s way here in the UK. This is perhaps regretful – especially following the introduction of the London Cycle Hire Scheme which merely advises riders to consider wearing a cycle helmet . The British Medical Association currently supports the introduction of legislation, but this is opposed by the Transport and Health Study Group. Whether or not the position on mandatory laws for cycle helmets in the UK will change in the future may well depend on reaction following  the recent publication of the ‘Health on the Move 2’ report .

Historically, Australia has taken the lead Internationally on compulsory cycle helmet laws which have been enforced there since 1990, with New Zealand following suit in 1994. Read more about issues related to cycle helmets in Australia and Internationally on this interesting Australian website.

A recent bmj.com poll on the compulsory wearing of helmets by adult cyclists resulted in 68% of respondents (n=1439) voting no to the idea of mandatory wearing of helmets. The BMJ blog led to a lively debate on the topic. Despite the controversy, I for one will continue to wear my cycle helmet whilst cycling on the roads.

Do you think that there should be world-wide mandatory legislation for cycle helmet wear for road cyclists? CJSM would like to hear your thoughts on this – feel free to post your comments on the blog.

Vote on our quick poll on the issue on our website front page here.

(Pictures from mIKL194FV and AFP) 

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