Editorial This edition of the South African Journal of Sports Medicine has as its theme injuries to the hip and pelvic region in sport. Although injuries to the hip and pelvis in sport are uncommon compared to other joints of the lower limb such as the knee and the foot and ankle, they nevertheless represent a specific challenge to the medical staff having to diagnose and treat these Injuries. Often, these injuries are particularly frustrating to the sportsperson as they consult health professional after health professional in search of a diagnosis and treatment. Two review articles have therefore been devoted to discuss a clinical approach to overuse injuries of the hip and pelvis in sport. In the first of these articles, an attempt has been made to provide the reader with an overview of the injuries as they occur in the hip and pelvis and in the second article specific bony overuse injuries of the hip are discussed. Overuse injuries of the hip and pelvis can be classified according to the anatomical area that is injured. A large part of the overview article focuses on injuries of the sacro-iliac joint and the symphesis pubis. These two joints have been selected because it is difficult to make a final diagnosis of injuries that occur in these joints. Special groups of patients who develop overuse injuries of the growth plate, namely adolescent athletes, also feature prominently in the review. In the second review, Dr Derman discusses bony overuse injuries of the hip and pelvis, according to the type of bone that is injured. This article is par­ ticularly useful in identifying bony overuse injuries that may require surgical intervention. Also, the value of using the correct imaging techniques to diag­ nose these injuries is highlighted. In summary, these two articles have attempted to provide the reader with an approach to the diagnosis and management of conditions that are frustrating to diagnose, often difficult to treat. It is hoped that this will contribute to the improved care of the athlete with an injury to the hip or pelvic region. Dr M P Schwellnus, MBBCh, MSc(Med), MD, FACSM Co-editor: South African Journal of Medicine SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) SEVENTH SOUTH AFRICAN SPORTS MEDICINE ASSOCIATION CONGRESS 24-26 M A R C H 1997 SU N C IT Y P E A K PERFORMANCE ENHANCEMENT AND KNOWLEDGE South African Sports Medicine Association Dear Delegates The Theme for our 1997 Congress is “ PEAK” Performance Enhancement And Knowledge. This is appropriate during this time of growth and development of SASMA. We are for once taken seriously by all and sundry especially our National Sporting Codes. It is imperative that this Congress is of the highest standard and extrem ely well attended by all involved in Sports Medicine. Running alongside the three day sports medicine program m e will be an orthopaedic traum atology programme. In addition there will be a one day General practitioner sym posium emphasizing gen­ eral practice and exercise related areas. The largest ever exhibition is planned as well as extensive social sporting events. Please book early. Dr Shorty Moolla President An outstanding congress that covers all areas of sports medicine You’ll be able to attend any o f m ore than 150 presenta­ tions covering a wide range o f disciplines - everything from cardiology to exercise physiology - physiotherapy to first aid, orthopaedics to neurology - and much more. FAX- BACK Enquiry Form To: Val McKenzie Fax: (011) 402-0164 Post: P.O. Box 53101, Troyeville, 2139 Tel: (011) 402-3240/53/57 (To reach us before 30 November 1996) 1. I am interested in p re se n tin g a free paper. Please send m e an abstract fo rm . 2. I w o u ld lik e to s u g g e s t.................................... ..........................................as a p o te n tia l speaker, C o n ta c t Tel: ........................F a x : ............................ 3. I w o u ld lik e m ore in fo rm a tio n a b o u t e x h ib itin g at the congress. 4. Please ensure that I re ce ive m ore in fo rm a ­ tio n on this e x c itin g SA SM A congress. 5. Please ensure that I rece ive m ore in fo rm a ­ tio n on the o rth o p a e d ic congress. 6. Please ensure th at I rece ive m ore in fo rm a ­ tio n on the 1 d a y GP sym p o siu m . Miss N a m e :............... S u rn a m e :.......... M r ......... M rs .. P o s itio n ................................ C o m p a n y /U n iv e rs ity etc. Postal address..................... Dr.. Prof Tel . Fax PHONE: +27 11 402-3240/53/57 MAIL TO : X PO Box 53101 Troyeville, 2139 FAX TO: +27 11 402-0164 2 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) TIIE SOTTII AFRICAN JOURNAL OF SPORTS MEDICINE VOLUME 3 NUMBER 3 SEPTEMBER 1996 Editors P rofT D Noakes CONTENTS Dr MP Schwellnus Editorial Board Editorial 1 Dr M E Moolla D r P de Jager Dr J S k ow n o Contents 3 Dr P Schwartz P rof R Stretch Dr C de Ridder P rof B C Andrews Dr E W Derman Mr R H Farman Overuse injuries of the hip and pelvis in sport E W Derman MP Schwellnus 4 P rof R II Mars Dr C A Noble International Advisory Board Stress fractures and bone stress injuries of the hip and pelvis MP Schwellnus 14 Lyle J Micheli Associate Clinical Professor o f O rthopaedic Surgery Boston, USA Chester R K yle Research Director, Sports Equipment Research A ssociates California, USA Prof H C Wildnr Ilollmann President des Deutsehcn Sportarztcbundcs Kohi, West Germany Rights, obligations and utility in sports medicine research S Olivier Sports related head injuries: A Neuropsychological perspective SJ Anderson 19 23 Howard J Green Professor, Department o f Kinesiology Ontario, Canada Product News 28 George A Brooks Professor, Department o f California, USA Neil F Gordon Director, Exercisc Physiology Texas, USA Edmund R Burke Associate Professor, Biology Department, University o f Colorado Colorado, USA Graham N Smilh P h ysiologist Glasgow, S cotla n d The Editor The South African Journal o f Sports Medicine PO Box 115, Newlands 7725 PRODUCTION Andrew Thomas PUBLISHING Glenbarr Publishers cc Private Bag X 14 Paiidands 2 1 9 6 Tel: (O i l) 4 4 2 -9 7 5 9 Fax: (O i l) 8 8 0 -7 8 9 8 AD VERTISIN G Andrew Thomas REPRODUCTION Output Reproduction PRINTING Hortors Reparil-Gel Relieves muscular pain The views expressed in individual articles arc the per sonal views o f the Authors and are not necessarily shared by the editors, the Advertisers or the Publishers. No articles may be reproduced without the written consent o f the Publishers. SPORTS MEDICINE SEPTEMBER 1996 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Overuse injuries of the hip and pelvis in sport Clinical diagnosis and management of common overuse injuries: A review Dr M P Selnvellnus (MBBCh, MSc (Med), MD, FACSM) Dr E W Derman (MBChB, BSc (MedXHons), PhD, FACSM) INTRODUCTION This article is devoted to overuse injuries o f the hip and pelvis in sport. Overuse injuries in this anatomical area can b e very difficult to diagnose and therefore manage. In particular, conditions in the sacroiliac joint and the symphysis pubis can b e frustrating as athletes often end up with chronic pain that prevents them from com pet­ ing. M edical professionals treating these conditions are equally frustrated in trying to pinpoint the exact nature o f the aetiology and pathology o f these conditions. In our practice, we refer to patients with chronic groin or but­ tock pain that have consulted a variety o f m edical prac­ titioners as presenting with the “ difficult groin syn­ drom e” and the “ difficult buttock syndrom e” respec­ tively. A s a result, we have, over years, developed an approach to deal with the “ difficult groin syndrom e” and the “ difficult buttock syndrom e” . T h e aim o f this review article is to focus on the clini­ cal assessment o f th e athlete presenting with pain in the hip and pelvis, and to discuss som e o f the m ore com m on overuse injuries that can occur in this region. T he major portion o f th e discussion is devoted to conditions that are unique to sports participation rather than conditions that also occur in the non-athletic population. Bony overuse injuries o f the hip and pelvis are covered in a separate article in this issue. OVERUSE INJURIES OF THE HIP AND PELVIS IN SPORT Overuse injuries o f the hip and pelvis in sports are m ore com m on than acute traumatic injuries.' In com parison to the knee, lower leg and foot, overuse injuries o f the hip and pelvis are relatively uncommon in athletes. In several large surveys, injuries to th e hip and pelvis accounted for only between 2.6 and 5% o f all reported injuries.2 Because these injuries are not frequent, they have not b een well studied. However, these injuries are often difficult to diagnose and can b e frustrating to treat. T he frequency and type o f overuse injuries o f th e hip Address for correspondence: Dr M P Scliwellnus Senior Lecturer Department o f Physiology University of Cape Town Medical School Sports Science Institute of South Africa Boundary Road Newlands 77 2 5 South Africa and pelvis have been reported in one large survey.' In this study on 204 athletes (114 males, 90 fem ales) pre­ senting with hip and pelvis injuries, bony injuries accounted for 35.5% and soft-tissue injuries for 64.5% o f all injuries. T he frequency o f occurrence o f specific bony and soft-tissue injuries was noted to b e different in males and fem ales and is indicated in Table 1 (bony injuries) and Table 2 (soft-tissue injuries). Table 1: B ony overuse injuries o f the hip and pelvis in athletes (prevalence as % o f total h ip and pelvis injuries) Injury M ales Fem ales Sacroiliitis 6.4 15.6 Pelvic stress fracture 9.0 7.0 Osteitis pubis 7.1 7.9 Osteoarthritis o f hip 4.2 3.1 Apophysitis (iliac crest) 3.2 3.0 Apophysitis (ant sup iliac spine) 2.0 1.0 Sacral injury 0.8 1.0 From Lloyd-SmiLh e t al 1985 Table 2: S oft tissue overuse injuries o f the liip and pelvis in athletes (prevalence as % o f total hip and pelvis injuries) Injury- M ales G luteus m edius tendonitis 13.5 Trochanteric bursitis 15.1 Hamstring strain 9.5 Iliopsoas strain 7.9 A ddu ctor strain 9.5 Piriform is strain/ syndrom e 4.0 From Lloyd-Sm itli el. al 1985 Overall the m ost com m on bony injury was sacroiliitis (10.3%), followed by pelvic and femoral neck stress frac­ tures (8.1%), osteitis pubis (6.3%), osteoarthritis o f the hip (5.4% ), apoph ysitis o f th e iliac crest (3.1% ), apophysitis o f the anterior superior iliac spine (1.4%) and sacral bone stress in ju r y (0.9%). The m ost com mon soft tissue overuse injury was strain o f the gluteus m edius m uscle (18%). This was followed by trochanteric bursitis (16.7%), hamstring strain (9.5%), iliopsoas Fem ales 24.0 18.8 9 .4 '5.2 2.1 2.1 4 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) strain (6.8%), adductor strain (6.3%), and piriformis strain/syndrom e (3.1%). Overuse injuries o f the hip and pelvis can also be clas­ sified according to the anatomical structures involved. A convenient classification is to divide overuse injuries o f the hip and pelvis into those that affect join ts (sacroili­ ac, pubic symphysis, hip, lumbar spine), bones (lumbar vertebrae, sacrum, pelvic ring, femur), soft tissues (muscles, tendons, ligaments, bursae, nerves, blood ves­ sels), and growth plates (Table 3). Pathology in pelvic organs such as bowel, bladder, reproductive organs can give rise to referred pain, and must also b e considered (Table 3). T he aetiology, clinical diagnosis and manage­ ment o f m ore com m on overuse injuries o f the hip and pelvis will now b e discussed. OVERUSE INJURIES OF THE JOINTS SACROILIAC JOIN T DYSFUNCTION Introduction The sacroiliac joint is the m ost com m on site o f bony overuse injury in the hip and pelvis region o f the ath­ lete.1 It appears to b e more com m on in fem ales than males. It is not clear whether this is related to gender differences in the functional or structural anatomy o f the pelvis. Aetiology and m echanism o f injury T he precise aetiology and m echanism o f injury in this condition has not been well established. However, the postulated m echanism o f injury is an increase in the shear force across the sacroiliac joint during running. T he shear forces can b e increased under the following conditions: - weakness o f the abductor muscles - muscle strength imbalances between the two hip joints3 - running on uneven surfaces - leg length discrepancies (found in 44% o f patients with this condition)1 - associated non-athletic conditions such as ankylosing spondylitis - varum alignment o f the lower limb (it is not clear from the study by Lloyd-Smith precisely what type o f varum alignment is a particular risk factor) The precise m echanism o f how shear forces produce movem ent and how this causes pain is not well under­ stood. It has been shown that patients with sacroiliac joint dysfunction have antagonistic movement o f the two innominate bones ie. when the one innominate bone tilts anteriorly th e other one will tilt posteriorly.3 T he m ove­ m ent o f the sacrum is not documented. Pathology The pathology o f sacroiliac join t dysfunction is pre­ sumed to b e inflammation in the joint. This has howev­ er not been well documented. Clinical diagnosis T he main symptom o f sacroiliac join t dysfunction is pain in the lower back or buttock area. The pain is usually vague and is often described as stiffness. It is often more severe in the early morning or after a period o f inactivi­ ty. Other characteristics o f the pain are: - gradual onset o f pain - precipitated by exercise but aggravated by a period o f rest after exercise - episodes o f exacerbation and remission - radiation to the back o f the thigh, hip joint or groin - associated with pain in other sites (gluteus medius, trochanteric bursa)1 - may b e associated with arthralgia in other areas o f the body On examination there is tenderness over the sacroiliac joints. T his may b e difficult in the very muscular or over­ weight patient. Four tests have been described to assess th e sacroiliac joint.'’ Sacroiliac joint dysfunction can b e diagn osed i f the m ajority o f th ese tests are positive. Table 3: Overuse in juries of the hip and pelvis: Classification by anatomical area 1. Overuse Injuries o f the joints a. Sacroiliac joint - Sacroiliac joint dysfunction b. Pubic symphysis - Traumatic osteitis pubis c. Hip joint - Degenerative osteoarthritis o f the hip d. Lumbosacral joint - Degenerative joint disease 2. Overuse injuries o f the bony structures a. Lumbar vertebrae - Pars interarticulares bone stress - Degenerative spondylosis b. Sacrum - Sacral bone stress c. Pelvic ring (ilium, ischium, pubic bones) - Bone stress injuries d. Femur - Bone stress injuries 3. Overuse injuries o f tile soft tissue a. Snapping hip syndrome - Snapping hip syndrome (anterior) - Snapping hip syndrome (lateral) b. Muscles - Chronic muscle injuries c. Nerves - Entrapment neuropathies d. Bursa - Chronic bursitis e. Tendons - Chronic tendinopathy f. Other soft tissue injuries - Conjoint tendon injuries g. Blood vessels - Peripheral vascular disease 4.Overuse injuries o f the growth plates 5. Other pelvic organ pathology - Bowel - Bladder - Reproductive organs SPORTS MEDICINE SEPTEMBER 1996 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) a. Standing flexion test: This test detects the presence o f sacroiliac joint dys­ function. T h e patient stands in front o f th e examiner fac­ ing away from the examiner. T he examiner places the thum bs o f both hands ju st under the posterior superior iliac spines (PSIS) (over the sacroiliac joints). T he patient is instructed to bend forward slowly while the examiner detects cranial m ovem ent o f the posterior superior iliac spines. A test is positive i f one ol the PSIS m oves cranially more than the other. T h e supine long- sitting test and the prone-flexion test determ ine the direction o f the innominate bone movement. b. Supine-long sitting test: In this test the examiner first notes the relative posi­ tions (leg length difference) o f the m edical m alleoli while the patient is lying supine. T h e patient is then asked to sit up and shifts in the relative positions o f the m alleoli (moving apart or together) with respect to each other are regarded as a positive test. T h e direction o f tilt o f th e innominate bone can b e determ ined through this test. A posterior tilt o f the innominate will produce rel­ ative shortening o f the lim b on that side. c. Prone-knee flexion: This test produces similar results to the supine-long sit­ ting test. T h e examiner first approximates the heels o f the patient lying prone on a couch. T h e patient is then asked to flex bothlcnees to 90°. Any shift o f th e heels with respect to each other is a positive test. T h e results are interpreted similarly to those obtained from the supine long-sitting test. d. Posterior-superior iliac spine (PSIS) palpation: H ie patient is asked to sit on a hard surface. T h e exam­ iner palpates the PSIS on both sides. Any difference in th e heights o f th e two PSIS constitutes a positive test because it indicates tilting o f the innominate bones. Special investigations Special investigations are not very useful in th e diagno­ sis o f sacroiliac joint dysfunction. It may b e necessary7 to perform the following investigations to exclude other pathology: - X Rays - Bone scan - Blood tests (EBC, ESR, HLA typing) Management T he management o f sacroiliac joint dysfunction is con ­ servative and is aimed at: - reducing pain - treating the sacroiliac joint instability - preventing recurrence a. Pain reduction: This can b e achieved by analgesics, alteration o f activity and physiotherapeutic modalities. b. Management of the instability: Three different techniques are used: - isom etric contractions - Mobilisation - Manipulation The basis o f isom etric contractions is to use specific exercises to correct abnormalities in pelvic tilting. Posterior tilting o f the innominate bone on one side is managed by th e following exercise. The patient is requested to lie supine on a couch with the leg o f the injured side hanging over the edge o f the couch. The therapist then applies pressure with the one hand on the thigh o f the injured leg and the other hand on the anterior superior iliac spine (ASIS) o f the uninjured side. A t the same tim e the athlete perform s an isom et­ ric contraction o f the hip flexor o f th e injured side. • Anterior tilting o f the innominate is managed by the isom etric contraction o f the hip extensors on the injured side. M obilisation and manipulation techniques can also b e used by the physiotherapist to correct abnormal tilt­ ing o f the appropriate innominate bone. c. Prevention o f recurrence: T he basis o f preventing this condition is i) to eliminate any imbalances of the hip musculature and ii) to treat any structural and functional leg length discrepancies. M uscle imbalances that are associated with this condi­ tion are imbalances o f the hip flexors/extensors and hip internal/external rotators. Relative m uscle strengths o f these m uscle groups must b e assessed and imbalances corrected. TRAUMATIC OSTEITIS PTJBIS (PIJBIC SYMPHYSITIS) Introduction Traumatic osteitis pubis is a general term that has been used for several disorders o f the pubic svmph vsis. Pubic stress symphysis is an alternative term that is also used to refer to the painful, non-septic, inflammatory con d i­ tion that occurs in r u n n e r s and other endurance ath­ letes.4 For th e purposes o f this discussion, this condition will b e referred to as traumatic osteitis pubis. T he clinical entity o f “ osteitis pubis” was described for the first time in 1923 in patients after urological proce­ dures.5 A further description o f the condition was docu­ mented one year later.'1 In a number o f subsequent publi­ cations, a variety o f aetiological factors for this condition were described. These included case reports describing urinary tract infections,7 8 osteomyelitis o f the pubic sym­ physis,” abdomino-pelvic operative procedures,7101112131410,10 pregnancy,7 childbirth17 and certain arthriditis1819 as conditions that can cause this clinical syndrome. In m ore recent literature this condition is described as resulting from a variety o f sport activities.20 Before the mid seventies reports o f the lesion following athletic activity were rare. In one publication, a patient was reported as having developed osteitis pubis from a bas­ ketba ll injury.21 However, th e con d ition was also described in an Olympic road walker, '" and an interna­ tional level cricket fast bowler.23 A t present, although unusual, it is recognised as a potential consequence o f a large variety o f sport activities including soccer, i,i7.a+.as,3(i.27.s<> basketball,21 rugby,20 wrestling,2027 ice h ock ­ ey,24 ju d o,25 road walking," '" long distance running,11730 crick et,23 A m erican football,31 and h orse racing.17''1 It appears to b e m ost com m only associated with 6 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) running and kicking sports.32 A etiology o f traumatic osteitis pubis Although traumatic osteitis pubis in athletes has a con­ sistent clinical presentation, the aetiology and pathogen­ esis remains controversial. A variety o f biomechanical abnormalities are mentioned as potential aetiological factors for the development o f traumatic osteitis pubis. Varus alignment o f the lower extremities Patients with m ild to severe varum alignment o f the lower extremities com pensate by excessively pronating the ankle and subtalar joints during the support phase o f gait.1 In one study where 204 referred patients with hip and pelvic injuries were evaluated at a sports m ed i­ cine clinic, at 62.6% o f cases had significant varus align­ ment o f the lower extremities, with rearfoot varus being the m ost frequent. T he authors proposed that varus alignment o f the lower extremities predispose a patient to hip and pelvic injuries.1 Leg length discrepancy In one study, leg length discrepancy was found in 30,6% o f patients with traumatic osteitis pubis, and the authors indicated that this may cause abnormal shear forces along the pelvic joints.1 However, in this study no control group was used to assess the frequency o f leg length discrepancy in normal non-injured athletes. Loss o f hip mobility Reduced hip mobility has been reported in one study o f 12 cases o f traumatic osteitis pubis in one series.33 The loss in hip range o f motion included reduced internal and external rotation. However, once again no control group was assessed to compare hip mobility in injured and non­ injured athletes. T he authors proposed that the decrease in mobility, could result in excessive shear stress along the pelvic joints, including the pubis symphysis. Mechanism o f injury in traumatic osteitis pubis Traumatic osteitis pubis appears to as a result o f exces­ sive mechanical strain on the pubic symphysis induced by shear forces.'0 T hese shear forces can b e secondary to increased m uscle strain, m uscle weakness, decreased hip mobility, or other factors. Increased m uscle action involving the adductor m us­ cles, abdominal m uscles, abductor m uscles and the gra­ cilis m uscle may result in excessive shear force on the symphysis pubis. Shear force may b e induced by the adductor m uscles in running and kicking sports. In one report on three cases o f osteitis pubis the authors proposed that a shearing force results in a subacute periostitis w hich will present with clinical picture o f osteitis pubis.26 Extremely forceful movem ents during sideways kicking, involving mainly the adductor m us­ cles, has been regarded as the initiating event o f trau­ matic osteitis pubis in soccer players.'4 Simultaneous conditioning o f the rectus abdominus and the adductor muscles niay cause increased strain on a susceptible pubic symphysis. This has b een reported 111 a study of osteitis pubis in long distance runners w ho were involved in abdominal conditioning exercises in addition to their running program mes.30 T he unguarded force inflicted on the gracilis m uscle w hile kicking a soccerball (the leg externally rotated, adducting and violently flexing the hip) has also been postulated as a possible m echanism o f injury. In this setting, the injury m a y b e an avulsion fracture or a stress fracture at the anatomical origin o f the gracilus muscle, resulting in an internal derangement o f the symphysis pubis. This may b e a mechanism o f injury o f traumatic osteitis pubis.25 Weakness o f the abductor muscle system has also been proposed as a p ossible cause for the developm ent of traumatic osteitis p ubis.1 Weak abductor m uscles will cause excessive frontal pelvic m otion in runners in the coronal plane (functional Trendelenberg sign). This will result in increased shearing force along the sacro-iliac joints and the pubic symphysis. Running on uneven ter­ rain, varum alignment o f the lower extremities or leg length discrepancies in the athlete will contribute to this excessive shearing force.1 R estricted hip internal rotation can also cause an increased shear force on th e pelvis. During extension, a d ecreased hip internal rotation will cause m ovem ent in the saggital plane on one h a lf o f the pelvis in relation to the other. In flexion, there may b e increased movem ent in the transverse plane.133 In one study o f twelve cases o f traumatic osteitis pubis, loss o f hip m obility was dem on­ strated in all patients. T h e authors suggested that restricted hip movem ent results in excessive shearing forces w hich are the causative factor in traumatic osteitis pubis.33 Repeated minor trauma to the pubic symphysis (either directly or secondary to instability o f the sacro­ iliac joints) can also result in traumatic osteitis pubis. This has been postulated as a cause o f the condition in professional footballers.17 Shear forces transmitted to the pubic symphysis may also b e caused by horizontal side-to-side pelvic sway, resulting from excessive swing­ ing o f arms across the b od y w hile running.1 Pathology o f traumatic osteitis pubis Histopathological features seen in chronic, non-traumatic osteitis pubis include non-specific mononuclear cell infil­ trate, marked bone reabsorption and fibrous connective tissue replacement at the symphyseal flbrocartilage.19-3435 Other significant histopathological findings that have been reported include the presence o f both viable and nonviable bone fragments, extensive fibrous tissue, and the absence o f any evidence o f an infectious process.25 Clinical presentation Symptoms T h e single m ost im portant symptom o f traumatic osteitis pubis is pain,1'4-17-20-24-26-28-30'30 T h e pain is usually insidious in onset and gradually progressive in intensi­ ty.2*’ T he nature o f the pain may b e dull124 or sharp.424 T h e m ajor site o f th e pain is in one or both groins.117 24 20 20 301X1 In som e cases the pain is primarily fel- t in the suprapubic region.1 1728 T he pain may radiate from the primary site, m ost com monly along the m edial aspect o f the thigh in the region o f the adductor m uscle group,1720 but also laterally to the hip,24 towards the sacrum,24 the bladd er or the lower abdom en.17 24'38 T he pain is aggravated by movement, in particular abduction SPORTS MEDICINE SEPTEMBER 1996 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) with external rotation o f the hip.34 It is also aggravated by walking, kicking, jumping,17 sit -ups"'' and a sudden change o f running direction.17 Coughing and sneezing may also increase the pain.2*’ The pain is relieved by rest.1'17'84 A sen­ sation o f clicking might b e present, usually indicating a degree o f instability o f the pubic symphysis.717 Physical signs T h e m ost important clinical sign o f traumatic osteitis pubis is that o flo ca lis e d tenderness over the symphysis pubis and the adjacent pubic bones.1'417 20 26 28 Tenderness may also be present at other sites including the ischiop- ubic rami,17 pubic tubercles,26 pelvic insertion o f the rec­ tus abdominus m uscle,28 adductorm uscle heads,2028 gra­ cilis insertion25 and over the inguinal ligam ents.'6 Rectal and prostate examination may produce tenderness ante­ riorly, due to pressure transmitted to the overlying pubic symphysis.26 Pain can also b e elicited by the following movements: - Forced abduction with external rotation, thereby putting the adductors under strain17 24 - Forceful adduction against resistance25'262830 - Active contraction o f the rectus abdominus m uscle3628 Further physical examination may reveal biom echanical abnormalities including leg length discrepancies, varum alignment o f lower extremities, impaired hip mobility and weak hip and abdominal muscles.20 Special investigations Radiology T h e suggested views that will assist in the diagnosis o f traumatic osteitis pubis are the i) antero-posterior, lat­ eral, and oblique views o f th e pelvis,-4-0"7"” ii) single leg weight bearing views,1727 and iii) special views o f the sacro-iliac joints.20 27 R ep orted radiological features that have been described in association with traumatic osteitis pubis include the following: - Normal radiology35'30 because it may take up to 4 weeks for radiological changes to b ecom e evident. - Destructive changes including osteolytic lesions and erosions in the symphysis.2428 T h e osteolytic changes in the os pubis and ischia may b e evident around the insertions o f the gracilis and adductor longus and brevis, unilaterally or bilaterally.-4 - Abnormal w idth o f the symphyseal cleft, with 10mm described as the upper lim it o f normal.417'26 - Marginal irregularity o f the symphysis.4'17 25'28 '10 - Reactive sclerosis o f the pubic bones at the symphy­ seal margins are described.417'25'20'28'30 Reactive sclero­ sis o f the iliac com ponent o f the sacro-iliac joints has also been d escribed in association with trau­ matic osteitis pubis.17 - instability o f the pubic symphysis demonstrated by single leg weight bearing views.1728 A difference in height o f the superior pubic ramus on each side o f more than 2mm has b een regarded as abnormal.17 - Accentuation o f th e origins o f the gracilis m uscle in patients with pubic symphysis has been reported. Asymmetrical erosions o f the symphysis and bone frag­ ments at the bony origin o f the gracilis muscle have been reported.25 It is essential to investigate the sacro-iliac joints along wit h the symphysis pubis, as both the sacro-iliac joints and the symphysis pubis may b e involved in the same pathological process, or conversely, instability o f either sacro-iliac joints or symphysis pubis may result in pathology o f the other.17'27 28 B one scan The triple phase Technet ium bone scan finding in trau­ matic osteitis pubis is usually that of bilateral increased uptake.14 20 38 30 Positive bone scans in clinically diagnosed cases o f traumatic osteitis pubis have been reported in the presence of normal X-rays. It is suggested that bone scans can b e used to confirm early subtle forms o f osteitis pubis before changes are evident on convention­ al radiography.30 Bone scans can also b e useful to differentiate trau­ matic osteitis pubis from local soft tissue injuries, pelvic stress fractures,4 and adductor tendon avulsions. Angular and pelvic outlet views are suggested to avoid the bladd er shadow7.28 Other special investigations Magnetic resonance imaging scanning o f the pubic sym­ physis m ight b e useful in patients with traumatic osteitis pubis. Isokinetic m uscle strength testing of the hip m uscles may also reveal important aetiological fac­ tors in this condition and ’will provide a basis for reha­ bilitation o f this injury. Management and rehabilitation Treatment o f sym ptoms R est is the b est treatment to relieve the pain o f osteitis pubis.4 172428'30 M ost authors advocate a period o f rest which can vary from weeks to m onths.417-4'30"10 Recovery may b e expedited with th e addition of anti-inflammato­ ry drugs. T hese drugs m ust b e used regularly.17''’0 -'’ 30 The use o f local anti-inflammatory therapy is controversial. Local hydrocortisone injections have been used success­ fully,33 30 but should b e avoided unless the person admin­ istering it is experienced. Care must b e taken to avoid the possibility o f infection.17 High doses or oral corticos­ teroids have also been reported as being effective in treating athletes with osteitis pubis.37 Local infiltration o f the painftil area with 5-10m l of 0,5-1% Xylocaine is helpful to relieve the pain, and can also b e used as a diagnostic test for this condition.34 However, a major limitation in recom m ending the m ost effective local treatment for this condition, is the lack of controlled tri­ als. This area requires attention. Identification and correction o f underlying causes. Limited data are available on the m ethods of identifying and correcting the underlying causes o f traumatic osteitis pubis. Restoration o f hip join t m obility has been p roposed,20 33 and strengthening exercises o f all the groin m uscles are recom m ended as important factors in the rehabilitation o f patients with this condition..-0-4 Correction o f any biom echanical abnormalities is an essential com ponent o f the management. Again, no con ­ trolled clinical trials have b een published to evaluate the efficacy o f these corrective measures. 8 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) OVERUSE INJURIES OF THE H IP JOIN T A detailed discussion of overuse injuries o f the hip joint are beyond the scope o f this article. However, the hip joint, in particular degenerative osteoarthritis o f the hip joint, can m im ic many o f the overuse injuries that pre­ sent with hip and pelvic pain. T he attending doctor should be aware that osteoarthritis o f the hip can cause pain and stiffness, and investigate the athlete appropri­ ately. Certain sports may predispose the athlete to osteoarthritis o f the hip join t (Table 4). Table 4: Sports predisposing to osteoarthritis o f the hip - Ballet - Gymnastics - Running - Soccer - Track and field athletics - Racquet sports (A dap ted from Paim sh 1990, Viiigard 199 4) OVERUSE INJURIES OF THE BONES Bone stress injuries o f the hip and pelvic bones will b e discussed in a separate article in this journal. OVERUSE INJURIES OF THE SOFT TISSUES T he athlete with pain in the hip and pelvis region may also present with a chronic soft-tissue injury. These injuries are m ore com m on than bony overuse injuries and generally are easier to diagnose and treat. A few com m on chronic soft tissue injuries wall b e discussed. SNAPPING H IP SYNDROME Introduction The “ snapping hip syndrom e” refers to a condition in which athletes com plain o f hip pain associated with audible snapping during movement.38 This can b e a dif­ ficult diagnostic and therapeutic challenge and deserves attention. A etiology The precise aetiology is not known. Traditionally the “ snapping” has been described on the lateral aspect o f the hip (external snapping). In these cases it has been attributed to the slipping o f either the thick posterior border o f the iliotibial band or the anterior bord er o f gluteus maximus over the greater trochanter. However, in recent years attention has also been focused on the so-called “ internal snapping h ip ” . H ere th e aetiology has been attributed to either the slipping o f the iliop­ soas tendon over the iliopectineal em inence or snapping of the iliofemoral ligaments over the anterior hip cap­ sule. Other causes that have been listed are: ■ osteochondrom atosis - subluxation o f the hip ■ loose b odies Clinical diagnosis On history the patient complains o f hip pain associated with an audible snap a nd /or a palpable snapping sensa­ tion. T he pain is described as a dull ache. T he snapping can usually b e precipitated by extending the hip from a flexed , abd u cted and externally rotated position. Specific activities such as ballet or jogging can som e­ tim es b e associated with th e symptoms. On examination there are no discreet areas o f ten­ derness but the snap can b e reproduced b y voluntary extension o f the hip join t from th e flexed, abducted, externally rotated position. Special investigations X-rays and hip join t arthrography are usually normal. Iliopsoas bursography can demonstrate a sudden jerk ­ ing movem ent o f the iliopsoas tendon in a large p er­ centage o f cases. Management Initially conservative management is recom m ended. This includes altering the activity and possibly local steroid injection into the site. However, i f that fails, surgery is indicated. Asymptomatic audible snapping is rarely an indication for surgery. Snapping that is associ­ ated with pain and which does not respond to conserva­ tive treatment, is an indication for surgery. In one series m ost patients underwent surgery with exploration o f the iliopsoas tendon region. The following abnormalities were noted: - tight iliopsoas tendon - prominent iliopectineal eminence - visible snapping o f the iliopsoas tendon (on repro­ duction o f th e movement) Surgical procedures were perform ed to lengthen the iliopsoas a n d /or resect bony ridges on the pelvic brim. CHRONIC MUSCLE INJURIES C hronic m uscle injuries o f th e hip and pelvic m uscula­ ture are com m on. T h e m ost com m on m uscles to b e affected are gluteus m edius, ham strings, iliopsoas and the adductor m uscle group. T he m echanism o f injurv is either repetitive overload with m icroscopic tearing or secondary to scar formation following an acute m uscle strain. Clinically th e athlete will present with pain p ro ­ gressing from G rade I to IV for overuse injuries. The site o f pain is localised to th e m uscle involved and is aggravated by m ovem ents requiring contraction o f that m uscle. T h e diagnosis o f a chronic m uscle tear can b e in th e p resence o f one or m ore o f the following clinical signs: - localised tenderness in the m uscle belly - restricted range o f motion o f the m uscle - pain on passive stretching o f the m uscle - pain on restricted contraction o f th e m uscle In m ost cases it is not necessary to confirm th e diagno­ sis using special imaging techniques. However, these lesions can b e dem onstrated on Magnetic Resonance Imaging scans. Isokinetic muscle strength testing will show a strength deficit in the affected muscle, and this is useful to monitor progress during rehabilitation. T h e management o f chronic m uscle injuries is to decrease and alter the scar tissue, increase flexibility o f the muscle, deep transverse friction and correcting m us­ cle strength d e ficits / ’ This is b est perform ed by a phys­ SPORTS MEDICINE SEPTEMBER 1996 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) iotherapist followed by a m uscle rehabilitation under the guidance o f a biokineticist. T h e rehabilitation pro­ gram m e should include eccentric contraction training. ENTRAPMENT NEUROPATHIES AROUND TH E H IP AND PELVIS. P iriform is syndrom e T h e p iriform is syndrom e refers to a nerve com p res­ sion syndrom e rather than a ch ron ic m uscle tear although ch ron ic tears can obviously occu r in this m uscle. T h ere are many known anatom ical variations in th e relationship betw een th e piriform is m u scle and th e sciatic nerve. D ecrea sed flexibility' in the m u scle can som etim es cause com p ression o f th e s c i­ atic nerve w hich results in pain. T h e a th lete presents w ith hip and b u ttock pain w hich is aggravated by m ovem ents requiring external rotation o f th e h ip jo in t (stretchin g th e p iriform is). T h e d iagn osis can b e c o n ­ firm ed by M R I im aging o f th e piriform is and th e s c i­ atic nerve using special views. M anagem ent is by m ob ilising th e piriform is m us­ cle , neural stretch in g and rehabilitation. T h e use o f loca l anaesthetics and cortison e injection is con tra­ ind icated. O rth otics that prevent excessive subtalar jo in t pronation m ay b e useful as th e com pensatory internal fem oral rotation that a ccom panies excessive pronation causes eccen tric contraction o f th e p iri­ form is m uscle. Surgical relea se is required i f all oth er m easures o f conservative treatm ent fail. Lateral fem oral cutaneous nerve T h is injury is p erh a p s th e m ost com m on nerve entrapm ent around th e hip and p elvis region in letes. It is also known as “ m eralgia p aresth etica ” .40 A th letes p resen t w ith altered sensation over the an terola tera l a s p e ct o f th e th ig h . It is a w ell d e sc rib e d con d ition in w eigh t lifters as a resu lt o f tight b e lts or corsets, and in gym nasts im pacting their h ip s and thighs on parallel bars. In th ese ca ses d ealing with th e underlying cause b y avoiding im pact, or tight com pression, h as a good prognosis. R arely a loca l anaesthetic b lo c k is necessary, and surgery is generally n ot req u ired as th is is a con d ition o f a superficial nerve that is purely sensory. Fem oral nerve Fem oral nerve entrapm ent can result from repetitive flexion and extension o f th e trunk in sports such as dancing, gym nastics, ju d o , and parachuting.10 T h e site o f th e entrapm ent is assum ed to b e w here th e nerve p asses under th e inguinal ligam ent. Isola ted fem oral n europathies p rod u ce w eakness during kn ee exten­ sion and a d e p ressed knee reflex. T h ere will a lso b e sensory loss over th e anterom edial asp ect o f the thigh. E lectrom yography (EM G) is useful to d ifferen ­ tiate isola ted fem oral neuropathy from m ore proxim al lesion s (lum bar ro o t lesion ). Involvem ent o f the lu m ­ bar root will also p rod u ce w ealaiess o f th e h ip flexors (iliop soas). M anagem ent is conservative, and will inclu d e avoiding th e m ovem ents d escrib ed , m uscle strength training o f th e qua d ricep s m uscle, and m ain­ taining range o f m otion o f th e h ip join t. Surgical relea se may also b e con sid ered i f sym ptom s persist. Gluteal nerve Entrapment o f the superior gluteal nerve has also been d escrib ed as a cause of ch ron ic gluteal pain. The diag­ nosis can b e confirm ed 0 11 EMG. Conservative treat­ m en t con sistin g of stretch es, and m ob ilisa tion . Surgical release may b e indicated.40 P osterior cutaneous nerve Entrapment o f d ie posterior cutaneous nerve oi the thigh has b een d escribed in a cyclist. T h e presentation is that o f p aresthesia in the distribution o f the nerve (lower buttock and posterior thigh). Pudendal nerve Pudendal nerve entrapment has b e e n d escribed in cyclists and is due to p rolonged sitting on an incorrect saddle. Sym ptom s inclu de num bness and d ecreased sensitivity' in th e lateral aspect of the genital area (penis and scrotum in males, and labia in fem ales). O bturator nerve Obturator nerve entrapment is an uncom m on condition presenting with w eakness o f hip adduction, and pares­ thesias 0 1 1 the inner thigh. T h e diagnosis can b e con ­ firm ed by EMG, and surgical release is th e m ost effec­ tive treatment.41 CHRONIC BURSITIS IN THE REGION OF TH E HIP AND PELVIS Trochanteric bursitis Trochanteric bursitis is not as com m on as is p e r ­ ceiv ed and p robably m ost ca ses th at have previously b e e n d ia gn osed as trochanteric bursitis w ere in fact ch ron ic m u scle injuries. Trochanteric bursitis can occur in eith er the superficial (m ore com m on ) or the d eep troch an teric bursa. T h e pathology o f superficial trochanteric b ursitis is th ou gh t to b e sim ilar to that o f iliotibial b an d friction syn drom e and is related to th e repetitive rubbing o f th e iliotib ia l band on the greater trochanter. T h is results in inflam m ation in th e area. Clinically th e athlete presents with lateral hip pain associated with running (repetitive hip flexion and extension). T h ere is point tenderness over the greater trochanter and pain can b e reproduced by a repetitive hip extension flexion m ovem ent.38 It is im portant to assess for biom echan ical abnorm alities such as. - tight ITB (O bers test) - w ide h ip s/p elvis - genu varus - leg length discrepancy - forefoot and rearfoot abnorm alities Management is conservative and sim ilar to that o f iliotibial band friction syndrome. Ischial bursitis Inflammation o f the ischial bursa can b e as a result ol p rolonged sitting, or d irect trauma to the bursa. Clinically there may b e tenderness and swelling over the bursa.38 Management is to reduce th e -inflam m a­ tion, avoid the irritating factors, and surgical treat­ m ent may b e necessary in refractory cases. 10 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Iliopectineal bursitis Iliopectineal bursitis presents with anterior groin pain and is often accom panied by an antalgic gait.38 On examination there is pain on deep palpitation o f the iliopsoas tendon and th e pain is aggravated on hip flex­ ion and external rotation. There may b e swelling and accompanying irritation o f the fem oral nerve. T h e d iag­ nosis can b e confirm ed by MRI scanning. Sym ptomatic treatment may b e beneficial but i f there is a large swelling with accompanying neurological signs, surgi­ cal decom pression is necessary. CHRONIC TENDINOPATHIES AROUND THE H I P AND PELVIS Introduction Chronic tendinopathies around the hip and pelvic region can give rise to ch ronic pain. T h e pathology o f these conditions may vary from peritendinosis to d egen era tive tendinopathy. In gen eral, ch ron ic tendinopathies are caused byr repetitive overload o f the ten d ons th iou g li vigorous contraction or passive stretching of the m uscles. Recently, diagnostic ultra­ sonography has b een suggested as a valuable m ethod to diagnose th ese lesions.4’ A few o f the m ore com m on sites for chronic tendinopathy around the hip and pelvis will now b e discussed. Chronic adductor tendinopathy Chron ic tend inopathy o f the adductor group o f m uscles is com m on in soccer players, h ockey players, ice skaters, breast stroke swim mers, rugby players, and cricket players (bowlers). T he m echanism o f injury is repetitive forceful contraction o f m uscles o f the a d d u c­ tor group. Patients present with uni- or bilateral groin pain. T h ere is tenderness over the adductor tendons ju st distal to their origin from the pubic ramus. T h e pain can b e precipitated by passive stretching or resist­ ed contraction o f the adductor m uscle groups. Initial treatment is to decrease th e inflanunation, and this is followed by stretching, strengthening th e adductors and a gradual return to activity.*' Isokinetic m uscle strength testing m ay b e useful to m onitor progress dur- ing the rehabilitation process. Chronic rectus fem oris tendinopathy The rectus fem oris m uscle functions as a hip flexor, and as an extensor o f the knee. R epetitive activity o f the rectus fem oris m uscle, such as during running, can cause a chronic injury to the tendon attachm ent o f the m uscle to the anterior inferior iliac spine. Athletes, often distance runners, present with anterior groin pain d m in g running. Clinical examination reveals ten­ derness over the tendon with pain in th e region during passive stretching and resisted contraction o f the muscle. Management is by conservative treatm ent consisting o f m easures to d ecrease th e inflammation, stretching and strengthening the m uscle and gradual return to activity. Chronic iliopsoas tendinopathv Chronic iliopsoas tendinopathy can be caused by repet­ itive contraction of the hip flexors (iliopsoas), or repet­ itive stretehing o f this m uscle during h ip extension such as in gymnasts. T h e patient will present with anterior groin pain w h ich is aggravated by resisted hip flexion or forced passive hip extension.44 This injury can b e associated with iliopectineal bursitis and can cause irritation o f th e femoral nerve. Treatment is con ­ servative in the first instance. Occasionally surgery is required to im prove b lood supply to a degenerative tendon. OTH ER SOFT TISSUE INJURIES Injuries to the con join t tendon/inguinal canal T h e conjoint tendon is formed by the com m on inser­ tion of the rectus abdom inis m uscle, th e internal oblique m uscle, and the transversalis fascia onto the pubic tubercle. It extends along th e superior surface o f the superior pubic ramus and forms part o f the p oste­ rior wall o f th e m edial end o f the inguinal canal. Repetitive traction resulting from kicking can produce a num ber o f different pathologies in this region. This syndrom e is also known as “ G ilm ore’s groin” . The pathology o f this condition can b e i) a tear o f the attachm ent o f the tendon at the pubic tubercle,45 ii) a tom external oblique aponeurosis causing dilatation o f the superficial inguinal ring,4" or iii) d e h is ce n ce between the inguinal ligam ent and th e torn conjoint ten don.w Patients p resent with groin pain that typically, radi­ ated into the rectus abdom inis or along the inguinal ligament. Aggravating factors are kicking and turning. T h ere is exquisite tenderness at th e site o f th e conjoint tendon or the superficial inguinal ring. Pain can be reproduced by coughing and sneezing. Investigations such as X-rays, bone scan and MRI scan generally are not helpful to diagnose this condition. H emiography, technically difficult, can b e used to dem onstrate w eak­ ness o f the m ed ial posterior wal 1 o f th e inguinal canal. Management is difficult and often surgery to repair the tear and strengthen th e posterior inguinal wal 1 has to b e con sidered.4*’ 47w CHRONIC OVERUSE INJURIES OF THE GROW TH PLATES AROUND THE H IP AND PELVIS REGION. Introduction Traction apophyTsitis sim ilar to that occurring at the tibial tubercle (O sgood-Schlatter) have been described in the pelvic bone. T h e m ost com m on site is th e iliac crest (iliac apophysitis) followed 1 >v the anterior supe­ rior iliac spine. T h e focus o f this section will therefore b e on iliac crest apophysitis. Aetiology/mechanism of injury T h e m echanism s o f injury is sim ilar to that for apophysitis in other regions. Excessive repetitive force application to the ossification center o f the area involved is the likely cause. T h e ossification center for the iliac crest first appears anterolaterally and then advances until it reach es the posterior iliac crest. The average age o f closure o f th is ossification center is d if­ ferent in boys (16 years) and girls (14 years). In iliac crest apophysitis the force is generated by the contraction o f th e oblique abdom inal m uscles, ten­ sor fascia lata and gluteus m edius. E xcessive rotation SPORTS MEDICINE SEPTEMBER 1996 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) o f th e pelvis during running may increase the risk o f injun7 ('as in athletes with excessive cross-over arm swings). Clinical diagnosis T h e athlete w ho is usually in h is /h e r m id or late teens presents with loca lized pain over th e iliac ciest. This may only occur w hile running. T h e localization of the pain may b e anterior or m ore posterior on the iliac crest. On examination there is tenderness over th e iliac crest and the pain can b e rep rodu ced on resisted con ­ traction o f the affected m uscle (eg. hip abduction - glu­ teus m edius). Special investigations In general it is advisable to X-ray the affected area to exclude fractures. M anagement T h e m anagem ent is conservative with ice, stretching, phvsiotherapv and alteration o f activity for 4 to 6 w eeks. Attention can b e given to altering running style (excessive arm swinging) it necessary. O TH E R OVERUSE INJURIES OF TH E H IP AND PELVIS IN ADOLESCENT ATHLETES T h e a dolescent athlete w ho presents with hip pain m ust b e con sidered as a special group. In addition to th e injuries that have already b e e n d iscussed the child w ith a painful hip m ust b e a ssessed carefully to exclude other pathology. A few o f the other causes o f hip pain in th is group will b e considered. P erth e’s disease T h is is a d isea se o f the younger ch ild (4 -8 years) and is m ore com m on in m ales than fem ales.'"’11 T h e a etiol­ ogy is related to shift in p red om in an t b lo o d supply from th e m etaphyseal vessels (up to 4 years) to the vessels running in th e ligam enttim teres (frilly d ev el­ op e d by th e age o f 7 years). Between the ages of 4 to 7 years th e b lo o d supply is d ep en d en t on lateral e p i­ p hyseal vessels. T h ese vessels w h ich are su sceptib le to pressure in th e jo in t w h ich can increase as a result o f n o n -s p e c ific in fe ctio n , sy n ovitis or traum a. Interruption o f th e b lo o d supply then causes avascu­ lar n ecrosis o f th e fem oral head. T h ree stages of the con d ition have b e e n iden tified accord in g to the p ro ­ gression o f th e d isea se and X -ray findings. T h e clin i­ cal p resentation is th at o f a ch ild w ith a painful lim p. On exam ination th e hip m ay b e norm al with slight m u scle w7asting. R ange o f m ovem ent can b e norm al in th e early stage w ith abduction in external rotation usually th e first to decrease. X-ravs are required to m ake the diagnosis. T h e signs v ary with th e age o f the ch ild , the stage o f the disease and the amount o f the head that was ischaem ic. Four groups have b een d escribed :4 ’ - I: No collapse, < 50% o f h e a d ischaem ic - II: No collapse, > 50% o f h e a d ischaem ic - I l l: Collapse, < 100% o fh e a d ischaem ic - IV: Collapse, 100% o f h e a d ischa em ic Management for the “ irritable h ip ” that is the sym pto­ m atic hip, is bed rest with traction until sym ptom s subside. Further treatment is controversial, but gener­ ally varies from 1 1 0 intervention (group I and II) to con ­ taining the head in th e acetabulum (abduction plaster or osteotom y) for groups III and IV. Slipped upper femoral epiphysis Slipped upper femoral epiphysis refers to a d ispla ce­ m ent o f th e growth plate resulting in coxa vara. It can occur suddenly (30% o f cases) or gradually (70%). The m echanism o f injury7 is trauma t hat is associated with an underlying abnormality. Trauma can b e a minor hip “ sprain” or a su dd en fall. Underlying causes are anatomical (the growth plate b ecom es increasingly oblique during grow th) or horm onal (growth spurt). It is im portant for th e sports physician not to miss the gradual slip o f the upper femoral epiphysis in an adolescent athlete. T he essentials o f the clinical p re­ sentation are: - age in b oys is usually 15 years (girls 12 years) - 60% o f patients are overweight and sexually under­ developed - 50% have a history o f a hip “ sprain” - groin pain associated with exercise is th e com m on ­ est presentation - shortening may be present - the leg is often externally rotated - the affected greater trochanter may b e higher and more posterior - there may b e loss o f range o f m ovem ent (usually abduction and internal rotation) - m uscle wasting may be present X-ravs are im portant to confirm the diagnosis. The main features are: A nteroposterior view: - a line along the superior surface o f the femoral neck passes over the h ead (normally passes through the h ead ) (Trethowan’s sign). - the m etaphysis is lateral to th e posterior acetabular margin; norm ally th e posterior acetabular margin cuts across th e m edial c o m e r o f the upper fem oral m etaph­ ysis (Capener’s sign). Lateral view: - deform ity is usually obvious from the beginning; the head and neck are angulated. T h e managem ent is surgical with pinning alone (minimal displacem ent) or reduction follow ed by inter­ nal fixation (unacceptable displacem ent). T h e sudden slip presents as a fractured neck o f the femur. T h e m anagem ent is reduction and internal fixation. T he com plications o f this condition are: - coxa vara - avascular n ecrosis - osteoarthritis - ch on d rolj’sis - bilateral slipping (in 15-30% o f cases there is slip ­ ping o f the other hip in th e first 2 years after the first injury7) 12 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Other conditions of the hip and pelvic region in children T h e following is a list o f other conditions o f the hip and pelvis in the ch ild that m ust b e considered: - viral synovitis - juvenile suppurative arthritis - suppurative juxta-articular osteom yelitis - system ic d isord ers (acute rheumatic fever, juvenile rheumatoid arthritis, leukaem ia, sickle cell disease, tuberculosis, psoriasis) - bone cysts and tumors REFERENCES 1. Lloyd-Smith R, Clement D B , McKenzie D C and Taunton JE: A survey o f overuse and traumatic hip and pelvic injuries in athletes. 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Lane E L and Chang IIC. Pubic and ischial necrosis following cystostom y and prostatectomy. A m J Roentgenology 19 54:71:193-212. H - Beer Periostitis and osteitis o f symphysis and rami o f pubes following suprapubic cijstostomies. J U roll928:20: 233-236. 12. Kir/. E: Osteitis pubis after suprapubic operation on bladder with report o f 10 cases. Brit J Sura 1946-34- 272-276. 13. Wheeler W K . Periostitis pubes following suprapubic prostatectomy; results with deep roentgen therapy. A m J Surg 1947;74:480-487. 14. Muschar M. Osteitis pubis following prostatectomy. J Urol 19 45:54:447-458. 15. Cibert J. Postoperative O.P.: Causes and treatment. Brit J Urol 1952;24:213-215. 1'6. Steinbach HL, Petrakis NL. Gilfdan RS, Smith Dr. Pathogenesis o f osteitis pubis. J Urol 1955;74:840-846. 17. Harris NH. Lesion o f the symphysis pubis in women. B M J 1974:4:209-211. 18. Scott DL. Estmond CJ, Wright V A comparative radiolog­ ical study oj the pubic symphysis in rheumatic disorders. A n n Rheum D ls 1979;38:529-534. 19. Hollander JL, McCarthy D L : Arthritis and Allied condi­ tions. A textbook o f Rheumatology. Philadelphia L E A and Tebiejer 1972 ;p l39 9. 20. Fricker PA, Taunton ■ I A m m a n n W. Osteitis pubis in athletes. Sports Med 1 9 9 l ;1 2 ( 4 ) -.266-279. £1■ Wiltse LL and Franc CI1. Journal o f Bone and Joint Surgery 19 56 ;38 A :500 . 22. Tlowse A JG . Proceedings o f the Royal Soc o f Medicine. 1954;57:88-90. 23. Murray and Jacobson: The radiology o f skeletal disorders. London, Churchill Livingstone 1971. 24. Smodlaka VN. Groin pain in soccer players. Phys Sportsmed 1980;8:57-61. 25. James JW. Traumatic osteitis. The gracilis syndrome. A m J Sportsmed 1983;11:363-366. 26. Hanson PG, Angevine M, Juhl JIL Osteitis pubis in sports activities. Phys Sportsmed 1978;O ct (4 ) -.111-114. 27. Liebert PL, Lombardo JA , Belhoek GH. Instability in an athlete 28. Zimmerman G: Groin pain in athletes. A u st Fam Phys 1988;17:1046-1052. 29. Sing R, Cordes R, Siberski D. Osteitis pubis in the active patient. Case Report. Physic Sports Med 1 9 9 5 :2 3 (1 2 ) ■ 67- 73. 30. Koch R, Douglas WJ. Pubis symphysitis in runners. A m J Sportsmed 1981;9:62-63. 31. Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players. Md Sci Sports Exerc 1995-27 (5)-.629-633. 32. Williams JGP, Sperryn PN. Sports Medicine Edition 2. Baltimore, Williams and Wilkens Co 1976;pp432-434. 33. Williams JGP. Limitation o f hip joint movement as a factor in traumatic osteitis pubis. Brit J Sportsmed 1978;12:129- 133. 34. A dam s RJ, Chandler F A : Osteitis pubis o f traumatic etiology. J Bone Joint Surg 19 53;35A (3 ) -.685-695. 35. Pierson E l. Osteochondritis oj the symphysis pubis. Surg Gyn and Obstet 1929;49:834-839. 36. Holt M A . James SK. Graf BK , Ilelwig DC. Treatment o f osteitis pubis in athletes. Results of corticosteroid injec­ tions. A m J Sports Med 1 9 9 5 ;2 3 (5 ) -.601-606. 37. Pyle L A . Osteitis pubis in an athlete. J A m Col Health Association 1 9 75;23:238-239. 38. Sim FII, Rock MG, Scott SG. Pelvis and hip injuries in ath­ letes: Anatom y and function. In: The lower extremity and spine (second edition) 1996. Nicholas JA , Ilershman ED (ed). Mosby, New York p p l0 2 5 -1 0 6 5 . 39. Karlsson J, Sward L, Kalebo P, Tliomee R. Chronic groin injuries in athletes. Recommendations for treatment and rehabilitation. Sports Med 19 94 ;17 (2)-.141-148. 40. Spindler KP. Pappas J. Neurovascular problems. In: A natom y and function. In: The lower extremity and spine (second edition) 1996. Nicholas J A , Ilershman ED (ed). Mosby, New York p p l3 4 5 -1 3 5 8 . ^1- Bradshaw C, McCrory P. A review of twenty cases o f obturator entrapment neuropathy as a cause o f groin pain. Med Sci Sports Exerc 1996;suppl 2 8 (5 ) 5 6 (3 3 ). 42. Kalebo P, Karlsson J, Sward L, Peterson L. Ultrasonography of chronic tendon injuries in the groin. A m J Sports Med 1 9 9 2 ;2 0 (6 ) -.634-639. 43. Martens M A , Hansen L, Mulier JC. Adductor tendinitis and muscular rectus abdominus tendopathy. A m J Sports Med 1 9 8 7 :1 5 (4 ) :353-356. 44. Weiker GG, Mannings F. Selected hip and pelvis injuries. Phys Sportsmed 1 9 9 4 ;2 2 (2 ) :96-106. 45. Bloomfield J, Fricker PA, Filch K D (ed). Textbook o f Science and Medicine in Sport. Blackwell Scientific Publications, 1992. 46. Williams I! Foster ME. “Gilmore’s groin” - or is it? B r J Sports Med 1 9 9 5 ;2 9 (3)-.206-208. 4 / . Lovell G. Conjoint tendon injury - the sportsman’s hernia. Proc Sports Med Sem, Australian Sports Medicine Federation (S A ) 1990. 48. Taylor DC, Meyers WC, Moylan JA , Bassett F K , Garrett WE. Abdominal musculature abnormalities as a cause o f groin pain in athletes. A m J Sports Med 19 91;19 (3 ):2 3 9 - 242. n SPORTS MEDICINE SEPTEMBER 1996 13 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Stress fractures and bone stress injuries of the hip and pelvis Dr EW Derman MBChB PhD FACSM Dr M P Schwellnus MBBCh MD FACSM INTRODUCTION Stress fractures and b on e stress injuries o f th e hip and pelvis encom pass stress injuries o f the femoral neck, sacrum, ilium, ischium and pubic bone. Many term s have b een interchangeably with “ stress fractures including march fractures, insufficiency fractures and fatigue fractures, and therefore controversy7 exists regarding the term “ stress fracture” . A stress fracture can b e d escribed as a m icrofracture o f bony tissue w hich occurs as a result o f either i) excessive load cy cles (number, duration, frequency) p la ced upon norm al bone; or ii) normal load pla ced on suboptim al or weak b o n e .1,2'3 We prefer Jones term b one stress reaction” as th e term used to d escribe th e continuum o f changes in b one, from rem odelling to a frank fracture4 and th erefore th is term w ill b e u sed throughout this review. T h e grading o f b one stress injury according to th e pathology, clinical symptoms, X -ray and bone scan findings is shown in Table 1. All b on e stress injuries o f th e hip and pelvis can present in the athlete as persistent hip and groin pain. Although they are fairly uncom m on overuse injuries, there are special considerations, including prolonged disability and p ossible com plications o f a displaced fracture (in th e case o f the fem oral n eck stress fracture), w hich m ake th ese injuries im portant to diagnose early. However, b on e stress injuries are often difficult to diagnose and can b e frustrating to treat. INCIDENCE B one stress injuries com prise approximately 10% o f sports injuries and are m ore commonly7 seen in athletes participating in w eight bearing sports.3*’ Bone stress injuries o f th e femoral n eck are unusual but not rare injuries in athletes.78 T hey account for approximately 5% o f all b on e stress injuries.9 Bone stress injuries o f th e pelvis are rare and com prise only approxim ately 1.25% o f all b one stress injuries. T h ese injuries are found m ost frequently in long distance runners and generally occur at the inferior pubic ramus / ischium junction, near the symphysis pu b is.101112,13 W hilst bone stress injuries o f the sacrum have been associated with bony insufficiency in th e non-athletic population,1415 few reports o f sacral b one stress injuries in athletes, exclusively runners, exist in th e m edical Address for correspondence: Dr EW Derman Sport Science Institute o f South Africa, P O Box 225, Newlands, 77 25 South Africa. literature.161718 However, this injury7 is probably m ore com m on than its lack o f docum entation suggests. Only isolated cases o f b one stress injuries o f the os ischium and th e acetabulum have b een rep orted , m ostly occurring in osteoporotic b on e.19 -0 AETIOLOGY AND PATHOLOGY T h e detailed principles o f the aetiology7 and pathology o f b one stress injuries and stress fractures have been previously7 review ed4' 1 and are bey7ond the scope o f th e present review. R isk factors for stress fractures and bone stress injury: fem ale gender;23 Caucasian race;24 increasing age;24 insufficient dietary7 calcium intake;'5 history o f am m enorrhoea;25 20 insufficient ca loric intak e/eating disorders; p oor physical fitness;27 intense or prolonged w eigh t b ea rin g activity428 and b io m e ch a n ica l abnorm alities.829 Identical principles governing the aetiology7 and pathology o f the m ore com m on bone stress injuries o f the lower lim b, apply to the b one stress injuries o f the hip and pelvis. However, th e special classification o f femoral n eck b on e stress injury, particularly stress fractures o f th is area, based on th e m echanism and site o f injury, d eserves m ore attention. Bone stress injuries o f th e fem oral n eck occur in distance runners, dancers, military recruits, hurdlers, football, soccer and rugby play7ers and cross country skiers. T h e proxim al femur is subject to loads o f up to six tim es b o d y w eigh t during walking with high com pressive loads occurring on concave sid e o f the femoral neck and tensile load s on the convex side. Loading increases substantially during running.so T h ree classification system s have b een p roposed for stress fractures o f th e femoral neck.2-9 31 All th e system s incorporate th e biom echanical nature of the injury7 and fracture displacem ent. T h e classification by Fullerton and Snowdy (19 88 ) is the m ost popular: a) Compression stress fractures: T h ese refer to undisplaced stress fractures on the com pression s id e o f the n eck of the femur (inferior side, located at th e cortex o f th e lower m edial margin o f the fem oral n eck ) and are m ore com m on in young athletes.32 T h is fracture seld om displaces unless stress continues. Fractures can vary in t heir staging according to X-ray and b on e scan findings. T he spectrum o f injury starts with a negative X-ray b u t positive b one scan (com pressive sid e, stage 1), followed by bony sclerosis w ith a bsen ce o f cortica l fracture (stage 2). T h is p rogresses to a cortical fracture and finally widening o f the fracture line (stage 3). b) Tension fractures: T h ese refer to undisplaced stress fractures on the tension sid e (superior) o f th e femoral n eck and are m ore com m on in m ilitary recruits and elderly patients. 14 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Tension stress fractures have a worse prognosis than com pression stress fractures as delayed union, non­ union and avascular necrosis o f the femoral head are recognized com plications. Early diagnosis is essential as th e consequences o f a delay in the initiation o f treatm ent may seriously affect the athletes career." T h e stages o f this injury are as previously indicated: p ositive b on e scan and negative X -ray (stage 1), endosteal or periosteal callus wit h no visible fracture line (stage 2), follow ed by a visible fracture line and finally widening of t he fracture w ithout displacem ent (stage 3). c) Displaced fractures: This refers to fractures where there is com plete stress fracture displacem ent evident on X-rays. CLINICAL PRESENTATION Bone stress injuries o f the hip and pelvis can b e difficult to diagnose and require a high index o f suspicion. A careful history usually reveals a significant increase in training intensity, duration or frequency, or altered training footwear or running surface, preceding the onset o f pain. More unusual causes m ust b e sought including dietary and endocrine factors. In fem ale athletes, a b r ie f gynaecological history should b e obtained. Common presenting symptoms and signs o f bone stress injuries o f the hip and pelvis are shown in Table 2. Bone stress injury in these regions usually causes the patient pain, which is the most common presenting symptom.5’ The pain is usually gradual in onset and develops during activity, m ost commonly running, or follow's a period o f increased training. The pain progresses until the athlete is unable to run or bear weight on the affected limb. Nocturnal pain can be present. The pain is relieved by rest or non-weight bearing. Fem oral neck T h e athlete with bone stress iryury o f the fem oral neck usually presents 6-8 w eeks after increasing training load, with pain in the region o f th e anterior groin. T he pain m ight radiate to th e thigh and knee. T here is often an antalgic gait and the athlete may not b e able to b ea r w eigh t on the a ffected lim b. Physical examination may reveal swelling in the affected area, tenderness to d eep palpation or pain elicited by percussion or com pression of* the heel or th e greater trochanter. Often there are no positive findings on physical examination b e sid e s pain at th e extrem ities o f hip jo in t movement. T h e different diagnosis should include a d d u ctor/iliop soas tendinopathy or m uscle tear, inguinal-femoral herniation, osteitis pubis, hip bursitis or synovitis and referred lum bosacral pain. Table I: Classil Ication o f b one stress injury. M odified from J on es et al., 1989. Grade 0 I II III IV N omenclature Normal rem odelling M ild stress reaction M oderate stress reaction Severe stress reaction Severe fracture Clinical signs and sym ptom s Nil Mild pain with or after activity7 Not tender on palpation M oderate pain with activity M ild palpable tenderness Severe pain with activity Marked palpable tenderness and mass Pain at rest M arked palpable tenderness and m ass X-ray findings Negative Negative Positive/N egative Positive Positive B one Sean findings N eg/P os Positive Positive Positive Positive Table 2: sign/sympt Clinical sii om ; / / = *ns and sym ptom s o f b on e stress injuries o f the hip and pelvis. ✓✓✓ = m ost com m on presenting com m on presenting sign/symptom; ✓ = less com m on presenting sign/symptom. Persistent groin pain Persistent posterior lumbar sacral pain Pain radiating to diigh and knee Nocturnal pain Onset o f pain following long run or increased activity Pain upon weight bearing on affected limb Pain at extremes of range of motion Antalgic gait Pain oil deep palpation over injury Femoral neck / / ✓ / / / ✓✓ S S S Sacrum l4'1" / / / S S S S Pubis "’•'a-13 / / ✓✓ ✓✓ S ✓✓ Ischium / / ✓✓ ✓✓ SPORTS MEDICINE SEPTEMBER 1996 15 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) The saciiun A thletes with bone stress injuries o f the sacnun may present with persistent and progressive pain in the buttock, groin or sacroiliac regions following period of increasing or intense physical activity. On physical examination the patient may have an antalgic gait. D eep palpitation over the sacral and gluteal regions might elicit pain. Patients with this injury usually have full range o f motion o f the hip, and examination of the lumbar" spine is usually n orm a l.1 D ilfeien tia l diagnosis includes sacroiliac join t pathology, gluteal and other hip m uscle injiuics, m etabolic bone disease and osseous neoplasms. The pubis and iscliiiuii Athletes with bone stress injuries o f the pubis and ischium can also present, with a history of peisistent and progressive groin pain. On physical examination, pain may be clicitcd by d eep palpitation in the legion o f the inferior pubic ramus near the symphysis. Weight bearing on the lim b on the side of the injiuy produces discom fort and pain (positive standing sig n ).1' Pain may limit abduction and external rotation o f the hip. T he differential diagnosis should include abductor m uscle tendinopathy, adductor m uscle tear, osteitis pubis, trochanteric bursitis, tendinopathy and muscle tears o f the hamstrings, degenerative pathology of the hip and referred pain from the lumbosacral spine. SPECIAL INVESTIGATIONS Laboratory m easurem ent o f alkaline p hosphatase, calcium , phosphorous and erythrocyte sedim entation rate have not proven helpful and therefore should not be routinely p erform ed .” X-rays are diagnostic in only' 30% o f cases and is a poor test to perform if (he primary aim is to diagnose a bone stress injury' o f the hip or p elvis.1’ However, radiography d o e s have a role in the initial investigation o f the athlete as bone tumours or other lesion s mav be e x clu d ed if the investigation is negative. Som e authors advocate the use of follow-up radiographs 2-4 weeks after the diagnosis is made, to monitor cortical callus formation. The bone scan is nearly 100% sensitive for bone stress injury and is by far the best p io e c d u ie to perform for the diagnosis o f these injuries.** Specificity is however poor, but the triple- phase bone scan may improve the s p e c ific ity '7 This investigation may be positive as earlv as 6 to 72 hours after the onset o f the injury.™ I f the diagnosis o f a bone stress injury o f the hip or pelvis is suspected, we feel that this is one indication where more liberal use o f the bone scan is justified. Examples o f positive bone scans in athletes with bone stress injuries of the pelvis are shown in Figures 1, 2 & 3. Magnetic Resonance Imaging (M RI) is beginning to gain acceptance as an im portant adjim ct in the diagnostic imaging of bone stress injuries, particidarly in the region o f the hip and pelvis.” 4" MRI will often show abnorm alities within 24 hours o f the injury.41 Li ad d ition , th ere is b etter soft-tissu e and bone resolution with MRI com pared with bone scans.4' Cost o f the investigation is h ow ever an im portant consideration. Because o f its high definition, image clarity and axial vision, Com puter tom ography reveals bone stress injiuics (Gr III-HO more effectively than traditional tomography and might be useful in imaging sonic femoral and tarsal navicidar bone stress in ju rie s /’ Bone scan and MRI remain the special investigations o f ch oice for the diagnosis o f bone stress injury of the hip and pelvis. A 11 T P E L V I S _____________________ ______ Figure 1. Bone scan image o f the anterior pelvis o f a long distance runner. The scan shows increased radioisotope uptake in the right sacroiliac region suggestive of a right sacral bone stress injury (G r Il-I II). There is also increased uptake in the right pubic bone (G r I). Figure 2. Bone scan image o f the posterior pelvis of a marathon runner. The scan sh ow s increased radioisotope uptake bilaterally in the sacroiliac regions suggestive o f bilateral bone stress injury. (Right Gr 111- IV. Left Gr II-III). 16 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ANT m 0 % *■ % r> OUTLET Figure ;i. B o n e scan im a g e o f th e p e lv ic ou tlet o f a sprinter. The scan s h o w s in crea sed r a d io iso to p e u p ta k e in th e left p u bic ra m u s s u g g e s tiv e o f a p u b ic h on e s tr e s s injury ( O r I l - H l ) . MANAGEMENT General principles o f management Conservative management o f bone stress injuries is generally successful, but management b ecom es more aggressive as the grading o f the bone stress injurv increases. We feci that it is important that a m ulti­ disciplinary team is involved in (lie management o f the athlete with bone stress injury. The dietitian, sport psychologist, physiotherapist, biokincticist and coach all have important roles to play in the successful rehabilitation o f the athlete. The first important principle o f management in treating al] bone stress injuries o f the lower limb, is avoidance o fa ll activities which involve impact loading of the bone (and therefore cause pant). Weight bearing can usually be maintained if it d oes not cause pain. I f pain is present at rest, it is often necessary to im m obilize the affected limb. Analgesic agents and ice can be used in the uiitial management o f the athlete to decrease pain. U liilst the athlete must suspend the sporting activity which caused the bone stress injury, other 110 11- weight bearing ex ercises including cycling, aqua- jogging, swim m ing and upper b o d y exercises arc en couraged. T h is will limit the phvsical deconditioning and psychological stress which can often accom pany bone stress injiuy. It is important that the athlete should be pain free during participation in any physical exercise undertaken during the period of rehabilitation. The second important principle o f management o f the athlete with bone stress injury is to identify and correct the risk factors d iscu ssed previously. In particular, inadequate dietary calcium intake and hormonal unbalances must be corrected if necessary. We are of the opinion that it is not possible to give the athlete an indication o f a specific period after which tunc normal sporting activity can be resum ed, as this varies greatly depending 0 11 the grading o f bone stress injury and individual variation in response to treatment. When the athlete has been pain free for 2-4 weeks; palpitation and percussion over the bone d oes not illicit discom fort; fidl weight bearing is normal and th cic is radiographic evidence of bone healing, (he athlete can gradually reliun to sport, using pain as the criterion for m onitoring recovery. T h e role o f electrom a g n etic current and h yperbaric oxygen theiap\ in the management of bone stress injiuy is still under investigation. Surgical management is indicated if there is non­ union and p ersisten t pain d esp ite adequate conservative management. Specific management ol femoral neck stress fractures The management of femoral neck Grade IV bone stress injuries (stress fractiues) is more aggressive. The following treatment protocol has been suggested bv Fullerton and Snowdv (1988): C o m p r e ssio n t y p e str e ss fr a ctu re s: a. Stage 1 (positive scan, negative X-rav): ( rutehes - 11011 weight bearing followed bv gradual return to activity b. Stage 2 (sclerosis): Bed rest until the athlete is asymptom atic followed Im­ partial weight bearing and gradual return to activity c. Stage 3 (C rack but no widening): llosp ita liza tion and en forced bed rest (internal fixation if it is not practical) followed bv gradual return to sporting activity cl. Stage 4 (( rack and widening): Internal fixation. Tension ty p e str e ss fr a c tu re s: The management of stages 1 to 4 is the same as for the com pression type. D isp la c e d str e ss fr a ctu re s: Hie treatment of choice is em ergency reduction and internal fixation. C onclusion Bone stress injuries o f the hip and p elvis arc uncommon injuries in the athletic population, and arc difficult to diagnose. A high index of suspicion o f these conditions is required, particularly iji the evaluation o f distance athletes who present with persistent, ill defined groin, hip or sacroiliac pain. Bone scan and MRI remain the “ gold standard" o f diagnosis. Whilst con sen a liv e management by a m ulti-disciplinary team is usually effective for most bone stress injuries o f the hip and pelvis, som e stress fractures especially those of the femoral neck might require surgery. It is inipoi tant that risk factors for bone stress injury be identified and corrected to ensure that the injuiy d oes not recur. REFERENCES 1. McBryde AM. Stress fractures in athletes. ,\m ,1 Sports Med 1975:3:212-217. 2. Uei'd.s MB. In: Stress fractures. Edinburgh: Churchill Lii ingstone. 1975:p I l:i. 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James SL, B a tes BR , Osternig LR. Injuries to runners. A m J Sports Med 1 9 7 8 :1 4 8 :6 6 6 -6 6 7 . 30. Oh I, Harris WTI. Proximal strain distribution in the loaded femur. A n in vitro comparison o f the distributions in the intact femur and after insertion o f different hip- replacements femoral components. J Bone Joint Surg 19 7 8 ;6 0 A : 75-85. 31. BlickenstajJ L D , Morris JM. Fatigue'fracture o f the femoral neck. J Bone Joint Surg 1 9 6 6 ;4 8 A :1 0 3 1 -1 0 4 7 . 32. Kaltsas DS. Stress fractures o f the femoral neck in young adults. J Bon e Joint Surg 1 9 8 1 :63 B :33 -3 7. 33. Johnson AW, Weiss CB. W h e e l e r DL. Stress fractures o f the femoral shaft in athletes - more common than expected. A new clinical teat. A m J Sports Med 1 9 9 4 ;2 2 ( 2 ) -.248-256. 34. LeRoi) R. Fullerton JR. Femoral Neck Stress Fractures. Sports Med 1 9 9 0 :9 ( 3 ) : 192-197. 35. Greaney RB, Gerber FH. Laughlin R L et al. Distribution and natural history of stress fractures in US Marine recruits. Radiology 19 83 :1 4 6 :3 3 9 -3 4 6 . 36. Sterling JC, Webb RF, Meyers MC, Calvo K D . False negative bone scan in a female runner. Med Sci Sports Exerc 1 9 9 3 :2 5 ( 2 ) : 179-185. 37. Rupani IID . Holder LE, Espinola D A , Semra IE. Three- phase radionuclide bone imaging in sports medicine. Radiology 1 9 8 5 ;15 6:1 87-19 6. 38. Matheson GO, Clement DB, McKenzie D C et al. Stress fractures in athletes. A study o f 3 2 0 cases. A m J Sports Med 1987 ;15 :46 -5 8. 39. Rizzo PF, Gould ES, Lyden JP, A sn is SE. Diagnosis o f occult fracture about the hip. J Bone Joint Surg 19 9 3 :7 5 A (3 ) -.395-401. 40. Keene JS, Lash E G . Negative bone scan in a femoral neck stress fracture. A case report. A m J Sports Med 1 9 9 2 :2 0 (2 ):2 3 4 -2 3 6 . 41. Martin SD. Healey JII. Horowitz S. Stress fracture MRL. Orthop 1 9 9 3 :1 6 ( 1 ) :/5 - /8 . 42. Reid JS. Joyner DM. Misdiagnosis o f femoral stress fracture based on M R I scan: a c a s e report. Clin Sports Med 1 9 9 0 ;2:8 3-89 . 43 . Markey KL. Stress fractures. Clin Sports Med 1987 ;6: 40 5 -4 2 5 . D 18 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Rights, Obligations and Utility in Sports Medicine Research S Olivier MA (R h od es) University o f Zululand ABSTRACT Sports Medicine is concerned with rehabilitation and perform ance in b oth elite and nonelite a thletes. Continued research is crucial towards progress in these areas, and subjects are increasingly being subjected to manipulative and invasive experimental methods. In exam ining current research p ra ctices, this p a p er questions whether we ought to rank consequentialist principles over nonconsequentialist ones. The history o f cases of abuse o f human subjects is considered, and the argument is presented that official endorsement is not a sufficient guarantee against exploitation. The concept o f Informed Consent is examined in som e detail, and guidelines are presented as to when obtaining consent is deemed necessary. Further, journ al review results seem to indicate that in a large number o f cases, consent is either not reported, or is not obtained. Finally, the p aper discusses the use o f “ca p tive” subject populations, and here issues such as coercion and sanction are examined. Whilst cautioning against an over-cautious approach to research ethics, the p ap er holds that researchers should be aware o f the potential for conflict between virtue and self-interest. Finally, it is concluded that Sports Medicine researchers should be guided by deontologic rather than consequentialist ethical principles. Sports M edicine and Research Sports M edicine is primarily concerned with the rehabilitation and perform ance o f both elite and nonelite athletes. Both areas depend on research in order to m ake progress, and this research may b e either therapeutic or nontherapeutic, both form s (but particularly th e latter) contributing to im provem ents in sports perform ance. This paper focu ses on non­ th era p eutic resea rch in S ports M ed icin e, and evaluates the practice o f research eth ics in term s o f consequentialist and d eontologic approaches. R esearch per se is concerned with (usually) novel te ch n iq u es u sed to d ev elop or con trib u te to g en eraliza ble k n o w le d g e .1 R e se a rc h in Sports Address for correspondence: Steve Olivier HMS Department, University o f Zululand, South Afri ca Tel: 2 7 351 9 3 9 1 6 e-mail: solivier@pan, uzulu. ac.za M edicine can b e seen to b e critical and exhaustive investigation th a t aim s, th rou g h system atic ob serva tion or exp erim entation , to e lic it new inform ation about human perform ance. From th is it follow s th a t w h ile p roced u res m ay b e rigorously evaluated and controlled, results and p ossible negative co n seq u en ces ca n n ot always b e accurately predeterm ined. R ecen t d eca d es have w itnessed a dram atic increase in research across disciplines, and Sports M edicine is no exception. T h e com m only a cce p te d “ p ro g r e s s im p erative” view o f scie n ce d em a n d s th a t resea rch su bjects b e increasingly su bjected to m anipulative and p o ss ib ly invasive experimental m ethods. Such procedures, w hilst increasing knowledge, may b e m aleficent, and it is necessary' to question w hether otu- research ranks consequentialist principles over n on con seq u en tia list on es. R ifkin- con ten d s that Western m edical science continues to m ove towards utilitarianism. On the other hand, B rodie & St.opanr' state that current societal opinion reflects the present ethical b e lie f that it is m ore im portant to avoid risk to a subject than to gain future benefit or advance knowledge. T h ere is thus perhaps a need to examine w h eth er resea rch in S p orts M ed icin e p ra ctises bottom -line’ eth ics which is concerned only with winning and losing, or virtue ethics w hich is also concerned with how you play the game. The abuse o f human subjects H istory provides num erous chilling exam ples o f the abuse o f hum an subjects, such abuses com m only ju s t ifie d through a pp eals to th e b en eficia l consequences o f m edical research. Space precludes going into detail - suffice to say, that evidence exists reg ard in g th e harm ful exp loita tion o f resea rch subjects, such as th e Tuskegee stud}7, experim ents on concentration cam p inm ates in Nazi Germany, and experim ents conducted by7 th e Japanese on ‘prisoners- of-war.M In som e cases utilitarian rationalisation p rotected researchers from prosecution, the argument being that the benefits to m ed ical science far outweighed the harm to a few individuals. T h e rationalisation behind this was that such valuable results were unobtainable elsew here due to m ore stringent controls. T hese ca s e s m entioned exem p lify extrem e exa m p les o f human subject abuse, but d o bring to the fore issues such as m aleficence and a d isrespect for subjects as persons. Furthermore, a broad issue that ought to SPORTS MEDICINE SEPTEMBER 1996 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) concern all researchers utilising human subjects is raised, namely that o f th e conflict between moral principles and s e lf interest. Given the rise to prom inence o f B ioethics, it could b e argued that a repeat o f abuses m entioned above is not likely to occur. Caution should how ever b e exercised b efore accepting such an argument, as progress dem ands, and society continues to encourage, hum an experimentation. An examination o f pre-World War II Germany shows that regulations on m edical ethics were com prehensive and protective towards subjects, yet physicians perpetrated abuses, indicating th at official endorsem ent is not a sufficient guarantee against exploitation o f human subjects. Pettit" concurs with this, contending that self-regulation offers the m ost effectiv e p ro te ctio n for resea rch subjects. Formalising ethical practices may thus b e a necessary, but not sufficient, condition for th e prevention o f subject abuse. I f this is accepted, then research involving human subjects n eeds to b e constantly reviewed and justified after consideration o f ethical principles such as resp ect for persons, beneficence, non m aleficence, ju s tice , veracity, fidelity, privacy, confidentiality and universalizability. Inform ed consent In form ed C onsent is a controversial con cep t. D ifficulties with adequate com pliance exist, and critics contend that as generally understood and applied, it is o f lim ited value in protecting research subjects from p o s s ib le abuse. A d v oca tes for In form ed C on sen t however counter that research subjects are at present better protected than was d ie case in th e past, and that the im perfections o f d ie con cept should not necessarily result in us d iscarding the process. D espite debate about the m erits and adequacy o f the concept, th ere d oes nevertheless seem to b e con siderable consensus about th e moral im portance o f Informed Consent in Western M edical research. Inform ed Consent has been d efin ed as th e knowing consent o f an individual ... able to exercise free power or ch oice w ithout inducem ent or any elem ent o f force, fraud, deceit, duress, or other form o f constraint or coercion .(i<|,vi> In the Inform ed Consent process, subjects m ust b e fully inform ed o f the risks, procedures, and potential benefits, and that they are free to end their participation in d ie study with no penalty whatsoever.' Further, the com m unication p rocess in an Informed Consent context requires that ‘ ... it is given in th e full, or clear, realization o f what th e tests involve, including an aw areness ... o f risk attached to w hat takes place.*1’203’ When should Inform ed C onsent b e obtained? A policy statem ent in M edicine & Science in Sports and Exercise0*1’'0, states that ... any experim ental subject or clinical patient w ho is exposed to p ossib le physical, psychological, or social injury m ust give Inform ed Consent prior to participating in a proposed p roject.’ In addition, th e journal has a publication requirement w hich necessitates that authors take all appropriate steps in obtaining the Inform ed C onsent o f any and all human subjects em ployed by investigators submitting m anuscripts for review7, and authors are required to indicate that consent was obtained. Lastly, what elem ents should b e included in the construction o f an Inform ed Consent docum ent? Kroll!K,,:ls> sum m arises a set o f b asic elem ents that ought to b e included in an Inform ed Consent docum ent as follows: “ A statem ent that the study involves research, an explanation o f the purposes o f the research and th e expected duration o f the subject’s participation, a description o f the procedtu es to b e follow ed, and id en tifica tion o f any p ro c e d u re s th a t are experimental. A description o f any reasonably foreseeable risks or discom forts to the subject. A description o f any benefits to the subject or to others that may reasonabfv be expected from the research. A disclosure o f appropriate alternative procedtu es or courses o f treatment, i f any, that m ight be advantageous to the subject. A statement describing the extent, if any, to w hich confidentiaiity o f record s identifying the subject will b e maintained. For research involving m ore than m inim al risk, explanations as to w h eth er any com pensation will be provided in case o f injury and w hether any m edical treatments are available i f injury occurs and, i f so, what they consist o f or w here further information may b e obtained. An explanation o f w hom to contact for answers to pertinent questions about the research and research subjects’ rights, and w hom to contact in th e event o f a research-related injury to th e subject. A statem ent that participation is voluntary, refusal to participate will involve no penalty or loss o f benefits to w h ich th e subject is otherw ise entided , and the subject may discontinue participation at any time w ithout penalty or loss o f benefits to which d ie subject is otherw ise e n tid e d .” Earlier it was noted that general agreem ent exists as to d ie m oral im portance o f obtaining subject consent in Western research. It was also however noted that critics feel that, as generally ap p lied , In form ed C onsent offers inadequate p rotection to research subjects. T h e latter scenario is plausible i f the obtaining o f Inform ed Consent is largely cerem onial. Journal reviews indicate that in som e cases the p roced iu e is either not reported (a serious om ission in its own right) (see Table I), or is not obtained. Focusing 0 11 cases where it is obtained, we n eed to q uestion w h eth er or n ot th ere is a m eaningful exchange o f information. T h e p rocess should ideally b e participatory (i.e. a two-way process), and the inform ation p resen ted s h o u ld b e clea r and com p reh en sib le. Clarity and com p reh en sion are particularly im portant in a multicultural society such as South Africa, and researchers should consider the potential n eed to present inform ation in th e subjects’ preferred language * 20 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Having examined the con cep t o f Inform ed Consent, we can now explore the issue o f w hether or not the p rocess, as described , is applied in research in the field. A review of' the literature reveals that many studies either d o not take cognisance of, or m erely pay lip-service to the principles w hich form the construct o f a co d e o f ethics. Pettit5 reports that in 1966 Henry B eecher o f Harvard M edical School published a survey o f ethical behaviour in clinical research in the New England Journal o f Medical R esearch. In an examination o f th e major journals, h e found 50 exam ples o f ethically dubious research on human subjects. Consent was m entioned in only two o f these articles. Table I indicates that in selected journal searches conducted by the author, Inform ed Consent was reported in relatively few pap ers.1 'For the purp oses o f the South A frican journal review it was deemed not necessary to obtain consent f o r p apers concerned with ca se histories, analyses o f injuries, technical or biochem ical information, surveys, review articles, m athem atical models, and research on nonhumans. I t was considered necessary fo r research utilising ‘c a p tiv e’ p opu lation s such as students, school children, tou rn a m en t p a r tic ip a n ts , em p loyees, patien ts, inm ates etc, where subtle form s o f coercion may op erate even i f that is not the intention. A ls o , in research concerning minors, it was deem ed necessary f o r written paren tal informed con sen t to be obtained. On th e p ositive sid e in th e South African reviews, som e authors ind ica ted that som e form o f consent was elicited , that subjects were volunteers, or that E thics C om m ittee approval had b een obtained. It m ust b e stressed th a t th e negative results d o not necessarily m ean that con sen t was n ot obtained, nor that subjects w ere abused or exp loited . T h e potential for abuse how ever exists, and ‘ ... w e m ust b e aware o f th e rights o f subjects and not take th e exp ed ien t route to con d u ct our research V 1'’05’ Again w h ilst not indicating abuse, th e review s above introd uce the p ossibility that many resea rchers either d o not take cog n isan ce of, or m erely pay lip -serv ice to, th e p rincip les which form the construct o f a c o d e o f ethics. From th is the conclu sion cotdd b e drawn that in s u fficie n t a tten tion is b e in g p aid to th is controversial yet necessary facet o f research ethics. Perhaps th e resea rch ers or their d efen d ers wotdd cou nter th a t con sen t was ob tain ed b u t was not reported in th e m anuscripts. T h is however will not do. Non-reporting raises d ou b t about th e om ission o f a com m only a ccepted resea rch eth ics practice. Captive populations T h e con cep t o f Inform ed C onsent has im portant im plications for research hi Sports M edicine, where subjects are often drawn from ‘captive’ populations, such as patients, students, tournament participants, team m em bers etc. Such subjects m ay either perceive an elem ent o f coercion in participation, or an elem ent of sanction attached to non-participation. In cases such as this, th e issue b ecom es one o f how free subjects are, rather than ju st one o f how inform ed they are, and researchers need to question w hether or not utility' trum ps th e right to self-determ ination o f subjects. In th ese scenarios it is necessary to consider w hether the autonom ous ch oice o f subjects is valued intrinsically rather than extrinsically. In other w ords, is autonomy valued for its own sake or m erely used towards justification for research. P atrick'"','i;m states that ‘ ... critical to scientific su ccess is a ready supply o f experimental subjects ....’ . T h e crucial phrase h ere is ‘ready supply’ , and it is acknowledged that recruitm ent is easiest i f one has a large cap tive p op u la tion in an institution, or presum ably i f one has access to such a population, e.g. patients, participants in a tournament etc. C oercion and sanction are th e im portant elem ents to con sid er when recruiting volunteers from captive popidations. Z elazn ik7 reports that regulations at P urdue U niversity p r e c lu d e in v estiga tors from recru itin g s u b je cts for resea rch from cla s s e s con d u cted by the investigator. T h e reason for th is is obvious: Students could p erceive that volunteering may im prove tlieir grade, or conversely that not volunteering co id d b e to their disadvantage. Thus e ith e r c o e r c io n or s a n ctio n or b o t h c o u ld b e p erceived . T h is requirem ent obviously lim its th e am ount o f research, and investigators w d l contend th a t it ham pers their p roductivity and retards the advancem ent ol k now ledge. T h ere may b e sym pathy for such claim s, b u t th e issue is n ot w h eth er research is con d u cted , b u t w h eth er subjects are coerced . T h ere is a further, m ore subtle form o f coercion th a t u ndoubtedly takes p la ce in resea rch settings. In Sports M ed icm e for exam ple, an authority figure (e.g. coa ch , adm inistrator etc) cou ld tacitly approve a study by malting contact w ith th e subjects on b e h a lf of the researcher. R elatively uninform ed individuals are likely to ignore a violation o f th eir autonom y i f th e p ossibility ol sanction is p erceived . I f such an authority figure gives perm ission for p erson s to b e Table I: Reporting o f Inform ed Consent in selected journals. B rodie & Stopani (1990) Journal Consent Appropriate Consent Reported % Reported SA Medical Journal (1994) 42 9 21.4 SA Journal for Sport, PE & Ree (1982 -1992) 109 14 12.8 Ergonomics SA (July 1989 - July 1993) 20 1 5 SA Journal of Sports Medicine (1990-) 13 9 69.2 British Journal of Sports Medicine3 81 14 17.3 SPORTS MEDICINE SEPTEMBER 1996 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Pevaryl The Topical Antifungal u tilis e d as re se a rch s u b je c ts , s h o u ld a r e s e a r c h e r p r o c e e d w ith data c o ll e c t io n ? I he a n sw er is no. In d iv id u a ls s h o u ld co n s e n t, and c o e r c io n or th rea t ol s a n ctio n sh o u ld not be e le m e n t s in the p ro c e s s . F urther, su ch a u th ority fig iu c s sh o u ld not be involved in the re se a rch p r o c e s s in any way, n or s h o u ld th ey have any a c c e s s to d a ta .' T h is is not to suggest that p ro g re ss in research sh o u ld be reta rd ed through petty regulations. R ather, re se a rch e rs sh o u ld be left w ith the th ou gh t that they ou ght to be aware of the potential for co n flic t betw een virtue and self-in terest, and that resea rch sh o u ld be g u id ed bv d c o n to lo g ic rath er than c o n s cq u cn tia lis t eth ica l p rin cip les. C o n clu sio n T h e p a p e r h a s r e p o r t e d g u id e lin e s as to w h en o b ta in in g co n s e n t is d e e m e d a p p ro p ria te , and h as p r e s e n te d e v id e n c e that in d ic a te s that r e s e a r c h e r s e it h e r d o not o b ta in co n se n t (o r at least d o n ’ t report it), or that th ey m e re ly pay lip -s e r v ic e to the c o n c e p t. W ith regard to "ca p tiv e’ su b je ct p o p u la tio n s , the a b s e n ce o f c o e r c io n and th reat of’ sa n ctio n in the c on sen t p r o c e s s lias b e e n e m p h a s iz e d . It h a s been n o te d that S p o r t s M e d ic in e r e lie s h e a v ily on r e s e a r c h , and that its s u b je ct ba se is often draw n fr o m " c a p t iv e ’ p o p u la t io n s s u c h a s p a t ie n t s , tou rn am en t p a rticip a n ts e tc. P ro g re ss h as d e m a n d e d th a t s u c h s u b je c t s be in c r e a s in g ly s u b je c t e d to invasive p r o c e d u r e s , and the h isto ry ol re se a rch in the tw en tieth cen tu ry p r o v id e s abu n d an t e v id e n c e s u p p o rtin g (lie co n te n tio n that in d iv id u a ls are op en to e x p lo ita tio n . W h ilst it is p r o b le m a tic , In fo rm e d C on se n t as a p rin cip le is in te n d e d to sa fegu a rd e x p e rim e n ta l s u b je c ts from a b u se s. A s s u c h , it s h o u ld serv e as a r e m in d e r to r e s e a r c h e r s th at they o u g h t to be aw are o f the p o te n tia l lo r c o n flic t betw een se lf-in te r e s t and virtue. REFER EN CE S 1. Veatch IiM (e d ) (1 9 8 9 ). M ediad Ethics. Jones & Bartlett Publishers. Boston. 2. Rifkin J. quoted in Ethics in Embryo: u symposium (1 9 8 8 ). Ilarpcrs Magazine 3 : 57-03. 3. Brodie VA and Stopani K (1 9 9 0 ). Experimental ethics in sports medicine research. Sports Medicine 9 ( 3 ) : 143-150. 4. I'ailcn RR & Beauchamp TL (1 9 8 0 ). .1 history and theory of informed consent. Oxford University Press. 5. Pettit P (1 9 9 3 ). Instituting a research ethic: cliilliny & cautionary tales. Bioethics 6 ( 1 ) . 89-112. 0. Medicine & Science in Sports & Exercise. (1 9 9 0 ). Policy Statem ent. Vo! 2 2 ( 1 ) . i’i. 7. Zelaznik HN (1 9 9 3 ). Ethical issues in conducting & reporting research: a reaction to Kroll. Matt & Safrit. Quest 45. 02-68. 8. Mahon J (1 9 8 7 ). Ethics & drug testing in human beings, in Moral Philosophy & Contem porary Problems. 199-211 (e d ) E rans JDG . Royal Institute o f Philosophy. 9. Kroll U’ (1 9 9 3 ). Ethical issues in human research. Quest 45, 3 2 - n . 10. Patrick JM (1 9 8 3 ). Volunteers or pressed men: human subjects in science. Ergonomics 2 6 ( 7 ) : 637-038. 22 ZTzH. The Topical Antifungal most prescribed by Dermatologists' If you wish to see more, call your Roche Syntex Division Representative at (0 1! ) 974-5335 Tinea capitis Otitis externa Tinea b a rb o e Prophylactic treatment R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Sports-related head injuries: A neuropsychological perspective S I Anderson MSe (Clin Psych) (Natal) N o t e : An earlier version o f this paper was presented at the 6th International SASMA Conferenee held in Durban, March 22-24, 1995 S U M M A R Y Mild head injuries occur across a range o f different com petitive and recreational sports. Concern has been expressed regarding the ou tcom e o f th ese injuries, and it is generally accep ted that what has until recently been regarded as relatively minor or trivial head injuries (c o n c u s s io n s ). can give rise to long-term and possibly even perm anent neurocognitive effects. This may occur in the absence o f direct impact or loss o f consciousness. Moreover, the effects o f many minor blotvs or concussion s may be cumulative. However, despite an acknow ledgem ent o f p ossible residual neu­ rocognitive effects arising from concussion, these are often inadequately evaluated by medics and coaches, and the sym ptom s th ereo f may he minimized by a com ­ p etitive a th lete who is keen to be declared fit to return to the game. This paper reviews the nature o f sports- related head injuries, p ossible neurocognitive sequ e­ lae. and discusses the evolving role o f the neuropsy­ chologist in the evaluation and m anagem ent of indi­ viduals with such injuries. R ISK AMD PREVALENCE OF SPORTS-RELATED HEAD INJURY Brain injiuies represent one o f t he most catastrophic athletic injuries1 and there appear to be few sports that do not carry som e risk o f a concussion or mild head injury. Obviously the risk is greatest in contact sports such as boxing and wrestling, the martial arts, rugby and soccer. Indeed, blows to the head may be exp ect­ ed or even intentional in some o f these sp oils.- A high risk o f injury also exists in sports using equipment to propel people or objects at high speed; representative exam ples include motor sports, cycle-racing, ice-skat­ ing, cricket, sluing, horse-riding, hockey, and g o l f Sports that involve height (e.g. diving, sky-diving, clim bing, and equestrian events) also present more o f a risk than sports that are played with both feet on the grou n d /1 Som e recent literatim: has focused on the more recreational sports such as skateboarding and Address for correspondence: SJ Anderson Depart men t o f psych ology, University o f Natal ( PMB) P. Bag X01. Scottsville, 3209 Tel: (0 3 3 1 ) 260-5372 e-Mail: A NDERSONS @PS Y. UNP.ac.za b lade-skating,J cycling,511 and je t-s k is .7 Given that acceleration forces acting on the brain may be poten­ tially damaging.'-" sports such as bungee jiunping may not be entirely free o f risk."1 Generally speaking, sports-related head injuries account for only a small percentage o f all head inju ries," although estim a tes range from 3-66% depending on study s ite .1’ 11 Assessing the prevalence o f sports-related concussion or mild head injiu v is problem atic for the sim ple reason that m ost eases go lu u e p o ite d ,11 and it has even been suggested that many diagnosed eases o f facial lacerations and contu­ sions should be considered as undiagnosed eases o f c o n c u s s io n .1’ The in cid en ce of such craniofacial injuries in sports is high, with one recent study citing its occurrence in 8% o f consecutive adm issions to a London hospital (N =950)."’ Statistics suggest that the sports carrying the greatest risk varies according to factors such as age, sex, and study site. For example, in the United States, it is American football (although gymnastics, ice-hockey and wrestling are also well rep­ resented); in England, soccer, rugby and horse-riding; and in Scotland, g o l f " ''’ There is increasing concern that yoim gstcrs inidcr 16 years represent a high risk group for sustaining head injuries in a variety o f sport­ ing and recreational activities.1" As a result, this group has been targeted for prophylactic intervention.-" I IIE NATURE OF MILD HEAD INJURY Problem s o f Definition and Evaluation Any discussion o fh e a d trauma must con sider severity as a defining characteristic and predictor o f outcom e. Head trauma exists on a continuum with mild bum ps causing uo overt sym ptom s representing one end o f the continumn, and veiy severe head injiu ies causing pro­ longed com a at the other. Likewise, a variety o f descriptors are used to d escribe position on this con ­ tinuum. For exam ple, a head injury may be described as mild or very mild (often referred to as concussion or trivial head traiuna) through m oderate, severe, to very severe.-1-' Traditional m easiues o f severity and out­ com e include the evaluation o f the presence and dura­ tion o f unconsciousness (com m only nieasined by the Glasgow Coma Seale) as well as the period o f post- traumatic amnesia (PTA), although there is som e question o f their validity and reliability in assessing mild head traiuna.IS The evaluation o f concussion is even more con tro­ versial, and there appears to be no universally accept­ ed definition o f concussion or o f its severity. The previ­ ously held assertion in the definition proposed bv the Congress o f Neurological Surgeons (1966)' (' The defi­ nition proposed by the Committee o f H ead Injury Nomenclature was ~a clinical syndrome characterized by immediate and transient post-traum atic impairment o f neural functions, such as alteration o f consciousness, disturbance o f vision, equilibrium, etc. due to brain stem SPORTS MEDICINE SEPTEMBER 1996 23 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) involvement".) that the sym ptom s o f concussion are transient, has been questioned by research that has found m ore protracted p eriods o f recovery and persis­ tence o f cognitive effects,l'! ii and there have been calls for a revised definition to accom m odate this evi­ d ence.24 Traditionally, the severity o f concussion had been d escribed in terms o f loss o f consciousness (LOC) and extent ol PTA, although it has been noted that other sym ptom s such as changes in orientation, lack o f co-ordination or balance, com plaints o f d ouble or blurred vision, and urinary incontinence may also b e d iagnostic.'4 T h e possibility o f delayed sym ptom atol­ ogy should b e con sidered in som e cases, and m ight include hypothalam ic disturbance (such as eating or sleeping disturbance), sensitivity to alcohol, and neu- rocogn itiv c dysfu n ction .14 T h e co n ce p t o f delayed effects is supported by research indicating that slow ­ ing o f cerebral b lood flow, when present, b ecom es m ax­ imal only several days after a concussion.15 One o f the problem s facing sports m edicine practi­ tioners lies in the assessm ent o f concussion, and there are indications that accurate and reliable assessm ent o f severity is d ifficu lt to attain in practice (D r J G odlonton, personal com munication, D ecem ber 1994). R ecognition o f the need for a m ore accurate grading ol concussion has been add ressed in recent p ublica­ tion s,1 14 although the system offered by Cantu appears to b e th e m ost useful in this regard. T h ree grades o f severity are described: (1) M ild - characterized by no LOC and PTA < 30 min. (2) M oderate - characterized by LOC < 5 inin. and PTA 30 min - < 24 hours (3) Severe - characterized by LOC > 5 min. and PTA > 24 hours. T h e problem s o f accurate evaluation are com pounded by th e finding that G rade 1 or m ild concussions account for 90% o f all concussions,1 yet these are probably the m ost difficult to assess. It has been sug­ gested that m ild concussion may not b e recognized by th e person him sell and that it is often a team m ate or opponent who notices behavioural sym ptom s.1 Other clinicians em p h asize th e im portance o f assessing p ossible confusion, and recom m end questions such as “ what is the s c o r e ? ” or “ what is the name ol the opposing team ” , or questions relating to the athlete’s background.25 T h e use o f sim ple neurological measures such as finger-to-nose, lieel-to-toe standing, and stand­ ing on one foot with the other suspended have also b een recom m ended, since they may b e failed in up to 50% o f concussed individuals.85 M echanism s o f injury It is w idely accepted that cerebral concussion can arise t o m b oth im pact and n on -im p act injuries. T h e neuropathology associated with im pact injuries is well d escribed in the literature, and may include both primary" and secondary' effects.20 By com parison, the n eu rop ath ological effects arising from non-im pact head injuries is less well understood. Nevertheless, there is recognition that cerebral brain dam age may occur: (1) without im pact to the head, and solely through exposure to acceleration forces; and (2) in the absence o f PTA or LOC.!l In th e majority o f cases, the neuropathology in im pact and non-im pact injuries can b e attributed to the m ovem ent o f the brain inside the skull.21 In both rapid deceleration injuries (e.g. when a moving head is suddenly brought to rest) and sequential acceleration- deceleration injuries (i.e. whiplash), shearing planes mav b e set up, giving rise to diffuse axonal injury (D A I). Such injuries may b e easily sustained w hen an athlete com es adrift o f a horse or b icycle, or when a rugby or soccer player is tackled roughly from behind. T h e significance o f these types o f forces in causing con ­ cussion is em phasized in research that indicates that while the brain is tolerant o f the com pressive and ten­ sile forces giving rise to coup and contra coup injuries, it is relatively intolerant o f acceleration-induced shear­ ing forces.1 It has even b een suggested that concussion b e redefined as an a cceleration/deceleration injury to th e head.27 However, a major source o f difficulty for the clinician attempting to evaluate concussion is the lack o f correlation betw een th e m agnitude o f the b io m e ­ chanical forces, th e nature and severity o f neuropath o- logical dam age, and the behavioural m anifestations.14 T he postconcussive syndrom e A num ber o f sym ptom s have been observed to occur subsequent to concussion or m ild head trauma and are collectively referred to as postconcussive syndrome (PCS). T h e range o f possibfe sym ptom s that may b e experienced is sum m arized in Table 1, although it is noted that con siderab le inter-individual variability exists.8'111 12 15 22 28 29 W hile sym ptom s such as vomiting, nausea, drow siness, and blurred vision may disappear within a few days o f the injury, other PCS sym ptom s (particularly the neurocognitive ones), may persist for weeks, months, or even years in a small num ber o f individuals.12 Table 1: Range o f sym ptom s associated with p ostcon ­ cussive syndrom e (PCS) Somatic: headache, dizziness, vertigo, insomnia, vomiting, fatigue and weakness, loss of appetite, drowsiness, blurred vision, strabismus, menstrual irregularities, sleep irregularities, decreased noise tolerance, sensitivity to medications and alcohol, restlessness, clumsiness, and postural changes (associated with disturbed sensorimotor syndrome) Neurocognitive: impaired attention and eoneentration, memory and learning disorders, reduced mental flexibility, slowed reaction time, impaired decision making, cognitive impiilsivity, speech difficulties, mental latigne. Neuropsychiatric: depression, anxiety, emotional lability, irritability, lowered frustration tolerance, somatization and liypochondriaisis, denial o f symptoms, apathy or lack ol spontaneity, personality change. Although the notion o f perm anency o f som e ol these effects has been m entioned in recent studies,2'-29 this concept rem ains controversial. A recent study on South African university-level rugby players investigated pre- and post-season neuropsychological functioning in con ­ cussed and non-concussed players and found p ersist­ 24 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ing deficits at the 3 month follow-up in th e form er.“ 'In another study com paring college soccer players with tennis players on a battery o f neuropsychological tests, there were no significant group differences on these measures although the soccer players dem onstrated a significant negative correlation betw een num ber o f gam es played and perform ance on the Paced A uditory Serial A ddition Test.30 W hile causality was not estab­ lish ed in this study, it has b een pointed out that a s o c­ cer player could head the ball som e 2 ,00 0 tim es d ur­ ing a soccer career, and that this practice may not be free o f r i s k / 1 W hile it has been found that m ost co n ­ cussed adults regain prem orbid functioning within one to three m onths post-injury,15 th is pertains to young adults without a history o f previous head injury. The negative outcom e o f cumulative effects o f numerous m inor brain assaults has been dem onstrated in studies on boxers and other athletes exposed to repeated con ­ cussions.23 A cknow ledgem ent o f th e persisting effects following concussion and th e im portance o f neuropsychological testing, is apparent in the recently published DSM-IV, 28 w h ich now includes these as part o f th e research cri­ teria for postconcussional disord er (see Table 2). Table 2: Extracts from DSM -IV criteria for p ostcon ­ cussional d isorder A. A history o( head traiuna causing significant cerebral concussion (likely manifestations of concus­ sion include loss o( consciousness, post-traumatic amnesia, and less commonly, posttraumatic onset of seizures. The specific method of defining this criterion needs to be established by further research). B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory (learning or recalling information). C. Three or more ol the following symptoms which occur shortly alter to the trauma and last at least 3 months: fatiguability; sleep disturbance; headache; vertigo or dizziness; irritability or aggression on little or no provocation; anxiety, depression, or affective lability, personality change, apathy or lack of spontaneity. T h e pathophysiology associated wit h PCS is thought to reflect possible damage or dysfunction at the level o f the basal frontal and upper brain stem structures - the sites o f lim b ic and hypothalam ic connections." T hese areas are particularly prone to rapid a ccelera tion / d ecelera tion -in d u ced traum atic brain injury,™ and there is som e suggestion that th e sam e regions may be affected in w hiplash injuries.9 The detection o f such pathophysiology is problem atic and has contributed to th e widely h eld view that in the absence o f LOC or dem onstrable neurological indicators, th e sym ptom s o f PCS are functionally-related. However recent research indicates that such a view is no longer tenable. For exam ple, one group o f researchers studied 21 patients with whiplash injuries using a range o f investigations (neurological, X-ray, EEG, BAEP MRI, ontoneurological and neuropsycho­ logical ).H Cognitive dysfunction was dem onstrable in 20 patients at a 3-month follow-up, and 4 o f these contin­ u ed to experience cognitive dysfunction at a 12-month follow-up. O f significance in this and other studies o f PCS, is th e relative insensitivity o f conventional ra d io­ logical and el ectrophysiological investigations in co m ­ parison with neuropsychological testing.” 22'32 T h e manifestation o f PCS-related neurocognitive deficits is variable, although on th e basis o f mild head injury research, d eficits in the areas o f attentional focusing/arousal, red uced speed and quality o f infor­ mation processing, difficulties in mental tracking, and impaired m em ory acquisition can b e expected.21 At a behavioural level, one m ight see a range o f symptoms including: behavioural inconsistency (at tunes the p er­ son perform s well yet at others he may make inexplic­ able m istakes); difficulty in filtering out irrelevant or background information or failure to attend to the m ost important or crucial aspects o f a situation; loss o f focus in conversations; difficulty in calculating and thinking through a plan or solution; difficulty in sus­ taining intense mental activity for an extended p eriod o f tim e (i.e. fatiguability); difficulty in shifting o n e ’s focus o f attention back and forth among various tasks, or to m onitor various tasks simultaneously; unreliable m em ory.21,20'33 T h e information processing and m em ory deficits m entioned above could increase vulnerability to fur­ ther injury. In this regard, it has been noted that split- second decision malting is required in many sports and that a com prom ise in this ability could result in an ath­ lete habitually being in the “ wrong place at the wrong tim e ” .11 S om etim es, neu rocogn itive d e ficits may only b ecom e apparent in th e context o f mental or physical stress. For exam ple, a frequently cited study by Gronwall & W rightson34 on mild head injury found that com parative neuropsychological deficits (m em ory and mental vigilance) only b ecam e apparent w hen the sub­ je c ts were p laced under the stress o f artificial altitude (3,8 00 feet in a hyperbaric environment). In another s ' udv, the failure o f neuropsychological tests to d etect im pairm ent in som e individuals was attributed to the relatively undem anding and short duration o f an assessm ent; som e individuals may b e able to recruit enough resources to com plete the tests successfully, only to exp erien ce su b seq u en t exhau stion and fatigue.15 ROLE OF THE NEUROPSYCHOLOGIST IN THE ASSESSMENT OF SPORTS-RELATED HEAD INJURIES Given the established persistence o f neurocognitive effects in PCS as well as th e need for neuropsycholog­ ical evidence in th e DSM -IV criteria, th e rationale for the involvement o f a neuropsychologist in the assess­ m ent o f sports-related h ead injuries is already sub­ stantiated. T h e relative sensitivity and precision o f neuropsychological m easurem ents make them well suited for assessing the neurocognitive deficits that may accom pany mild head traiuna.11 In th e assessm ent o f PCS, neuropsychological testing is not only cost- effective, but also the only feasible way o f providing objective evaluation o f possible subtle cognitive dys­ function. Som e em phasis should b e placed on the fact that sequelae are likely to be very subtle, i f detectable at all, and this requires carefi.il selection o f test p roce­ dures (recom m en ded tests and their areas o f assess­ SPORTS MEDICINE SEPTEMBER 1996 25 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) m ent are sum m arized in Table 3). To som e extent, th ese tests may b e con sidered m ea­ sures o f overall cerebral efficiency, and are th ereloie likely to b e accurate ind ices o f th e neurocognitive d if­ ficulties that characterize PCS. A ssessm ent o f som atic sym ptom s may b e m ade using th e SCL-90-R, a rating scale sensitive to anxiety, depression, and cognitive failu res com m on ly a ssocia ted w ith m ild head injuries.'1 Apart: from giving som e objective validation to an ath­ le te ’s subjective com plaints following concussion, the m ain use o f a neuropsychological assessm ent w ill b e to provid e th e trainer, coach, or sports m edicine practi­ tioner with relevant inform ation about th e nature and severity o f possible neurocognitive deficits. In a d d i­ tion, repeated or serial assessm ents m ay docum ent the rate and extent o f recovery. Notwithstanding the advantages o f neuropsycholog­ ical assessm ent, there are a num ber oi pitfalls w hich may b e encom itered by th e neuropsychologist. T hese include: use o f instruments which lack requisite sensi­ tivity or are inappropriate to the nature o f the assess­ ment; failure to consider dem ographic variables in the interpretation o f test scores (education, occupation, age, sex and socio-econ om ic status are all important determ inants o f n eu rop sych ological perform ance). T h is may lead to over/under-interpretation o f test scores (e.g. patients with superior prem orbid abilities are often able to com pensate for m ild neurocognitive deficits through increased effort).’’-1" W hile th ese are unlikely to p ose m uch o f a difficulty for the experi­ enced neuropsychologist, th e risk o f m isinterpretation is increased in assessm ents con d u cted by inexperi­ en ce d clin icia n s.2 (~ The South A frica n Clinical Neuropsychology A ssociation (SACNA.) was set up in 1984 to represent the profession o f neuropsychology in this country, and at present there are 34 accredited full members. D etails of members practising in the various provinces may be obtained from the SAC N A membership secretary, Prof. D. Griesel, Institute fo r Behavioural Sciences, TJnisa, Tel: 012-429 6 0 6 3 ). A further role o f th e neuropsychologist lies in d eter­ mining th e safe return to training or com petitive sport. T h e im portance o f such d ecisions cannot b e underesti­ mated, since there is evidence that a concussed athlete is at risk for further concussions.1 Moreover, there is th e risk o f a second im pact syndrom e with potentially fatal con seq uen ces.14 T h ere are no clear guidelines on when it may b e safe to return an athlete to the game following a concussion. Cantu recom m ends resumpt ion o f sport i f asym ptom atic for 1 w eek (i.e. absence o f PCS sym ptom s during rest or exertion ).1 T his period is lengthened in the face o f severe or previous concussion. Other m ore conservative opinions are that a concussed player sh ould not b e allowed to play for at least 3 to 4 weeks after th e injury, especially i f the sport requires split-second timing or decision making.~'v,n Current neuropsychological opinion is that athletes should abstain from com petitive sport until all neurocognitive svm ptom s have disappeared; this view is com patible with the recognition that the persistence o f neuropsy­ chiatric sym ptom s a n d /o r positive results on relevant diagnostic tests sue contra-indications for resumption o f com petitive sport.114 Ultimately, th e return to sport is a decision based on clinical ju d gem en t although it seem s important to establish that the athlete p oses no risk o f injury to h im self or oth ers.14 It is clear that a neuropsychological assessm ent may allow for m ore confident decision-m aking on the part ol th e sports m edicine practitioner. A final role for th e neurop sychologist lies in ed u ca ­ tion, n ot only o f athletes at risk, b u t also o f coa ch es, trainers, and sports m ed icin e practitioners w h o may b e unaware o f th e nature o f sports-related head injuries. K now ledge about th e nature o f assessm ents p erform ed by n europ sychologists is lacking in a large proportion o f South African trained m ed ica l practi­ tioners, and m arketing o f th e neuropsychological pro­ fession in South A frica appears to have lagged behind our overseas counterparts. T h is is probably d ue to the small num ber o f a ccred ited n europsychologists, an even sm aller num ber o f educators, and relative pauci­ ty o f local research. In line with overseas trends, som e effort should b e m a de in preventative p ro­ gram m es that create p u b lic awareness about safety in sport. G overnm ent legislation (with accom panying su bsid isation ) for th e com pulsory use of h elm ets by ch ild ren and adolescen ts is appropriate, as is the tar­ geting o f injury prevention through sch ool-b a sed ed u ­ cational p rogram s.'11 Ultimately, th e num ber o f sports- related head injuries can only b e red u ced through effective preventative m easures. H ere, recom m en d a ­ tions have inclu d ed: th e use o f h elm ets in recreation ­ al sports; th e n eed to d iscard w orn-out or dam aged equipm ent; p e rio d ic reviews o f rules and coaching techniques; the n eed for com p eten t instruction and close supervision o f ch ild ren , a d olescen ts and b eg in ­ ners in any sport; and adequ ate con d ition ing (fatigue and less than optim al fitness have b een m entioned as contributory factors to con cu ssion in som e studies, w h ile con d ition ing o f th e n eck m u scles has b een m en ­ tio n e d as a p reven ta tive m ea su re for w h ip la sh inju ries).1-1,181 T a b le 3: S u g g e s te d n e u r o p sy c h o lo g ic a l b a tte r y for ev alu ation o f PCS Sensory/motor: Quick Neurological Screening Test - Revised (QiVST) Attention: Digits forwards and backwards Reaction time or letter/number cancellation lest* Information processing and cognitive flexibility: Symbol Digit Modalities Test (SDMT) Trail Making Test Stroop Colour Word Test Paced Auditory Serial Addition Test (PASAT) Memory/new learning: Rev Auditory Verbal Learning Test (RAVLT) Rey Visual Design Learning Test (RVDLT)* Executive functioning: Austin Maze Short Category Test* Wisconsin Card Sorting Test* Neuropsychiatric: Symptom Checklist 90 (SCL-90-R) * optional inclusions 26 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) A final point likely to b e endorsed by all sports psy­ chologists is a com m ent by Tem pler & Drew who rec­ om m end th e n eed for a “ constructive philosophy that m akes sport enrich and refresh rather than dom inate and debilitate” (p.3 9 ).31 To this extent, the desirability o f com pulsory participation in contact sports at sch ool level has been questioned b o th overseas and in this cou n try .''" REFERENCES 1. Cantu R C : Cerebral concussion in sport. Sports Med 1992; 1 4 ( l ) :6 4 - 7 4 . 2. Zemper E D , Pieter W: Injury rates during the 1988 US Olympic team trials for taekwondu. Br J Sp Med 19 8 9 :2 3 ( 3 ) .1 61-16 4. 3. Drew KT1, Templer D I: Contact sports. In: Templer DI, Hartlage LC, Cannon WG, eds. Preventable brain damage - brain vulnerability and brain health, New York: Springer Publishing Company, 1 9 92 ; 15-29. 4. Schieber R A , Branch-Dorsey CM, Ryan GW: Comparison o f in-line skating injuries with rollerskating and skate­ boarding injuries. J A M A 1994:271 (2 3 ) -.1856-1859. 5. Olkkonen S, Laiidenranta U, Slatis P, Honkanen R: Bicycle accidents often cause disability - an analysis o f medical and social consequences o f nonfatal bicycle acci­ dents. Scand J Soc Med 1993;21 (2 ):9 8 -1 0 6 . 6. Gerberich SG, Parker D, Dudzik M : Bicycle-motor vehicle collisions - epidemiology o f related injury incidence and consequences. Minn Med 1 9 9 4 ;7 7 (4 ):2 7 -3 1 . 7. Hamman BL, Miller FB, Fallal ME, Richardson J D : Injuries resulting from motorized personal watercraft. J Pediatr Surg 1 9 9 3 ;2 8 (7 ):9 2 0 -9 2 2 , 8. Ettlin TM, Kischka U, Reichmann S, Radii EW, H eim S. Wengen D et ah Cerebral sym ptom s after whiplash injury o f the neck - a prospective clinical and neuropsychological study o f whiplash injury. J. Neurol Psi/chiatry 1992;55- 94 3-94 8. 9. Sweeney JE: Nonimpact brain injury - grounds for clinical study o f the neuropsychological effects o f acceleration forces. Clin Neuropsychologist 1 9 9 2 ;6 (4 ):4 4 3 -4 5 7 . 10. Mees K : Horstorungen nach Bungee-Springen (Hearing disorders after Bungee jum p ing?) Larijncjorhinootologie 1994; 7 3 ( 3 ) :1 4 6 -1 48. 11. Ingersoll CD: Long term effects o f closed head injuries in sport. Sports Med 1 9 9 3 ;1 6 (5 ) 34 2-35 4. 12. M oes E : Neuropsychiatric aspects o f head injury. In: Ellison JM, Weinstein CS, Hodel-Malinofslcy T, eds. The psychotherapists guide to neuropsychiatry - diagnostic and treatment issues. Washington, D C : Am erican Psychiatric Press, 1 9 94 ;21 7-254 . 13. Levin HS, Benton A L , Grossman R G ; Neurobehavioural consequences o f closed head injury. New York: Oxford University Press, 1982. 14. Henderson JM, Browning D G : Head trauma in young ath­ letes. Med Clinics North America 1 9 9 4 ;7 8 ( 2 ) -.289-303. 15. Binder LM, Rattok J: A ssessm ent o f the postconcussive syndrome after mild head trauma. In: Lezak MD, ed. A ssessm ent of the behavioural consequences o f head trau­ ma. New York: A lan Liss, Inc. 1989;37-48. 16. Hussain K , Wijetunge DB, Jackson IT: A comprehensive analysis o f craniofacial trauma. J Trauma 1 9 9 4 ;3 6 (1 ) :3 4 -4 7 . 17. Lindsay KW , McLatchie GR, Jennet B : Serious head injury in sport. BM J 1 9 8 0 ;2 8 1 :7 8 9 -7 9 1 . 18. Trettin II: Schadel-hirn-traumen durch sport ( Cranuxxrcbral trauma caused by sp orts). J Lymphol 1 9 9 3 ;1 7 (2 ):3 6 -4 0 . 19. Schmidt B. llollwarth M E : Sportunfalle im kindes-und jugendaltei (Sports accidents in children and adoles­ cents). J Kinderchir 19 8 9 ;4 4 :3 5 7 -3 6 2 . 20. Wilson PD, Testani-Dufour L: Bicycle safety proqrams - targeting injury prevention through education. Pediatr Nurs 1 9 9 3 ;1 9 ( 4 ) -.343-346. 21. Lezak M D : Neuropsychological assessment. 3rd Edition. New York: Oxford University Press, 1995. 22. Boll TJ, Barth J: Mild head injury. Psychiatr Developm 1983 ;3:2 63 -2 75. S3. Templer DI, Hartlage LC, Cannon WG, eds. Preventable brain damage - brain vulnerability and brain health. New York: Springer Publishing Company, 1992;lv-xv. 24. Maddocks DL, Saling M M : Neuropsychological sequelae following concussion in Australian Rules Footballers. [Paper presented at the INS-Australian Society for the Study of Brain Impairment Pacific Rim Conference. Gold Coast, Queensland, Australia: July 13-16 1 9 9 1 ]. 25. McLatchie G, Jennet B: Head injury in sport. B M J 1994- 3 0 8 :1 6 2 0 -1 6 2 4 . 26. K a y T, Lezak M D : The nature o f head injury, In: Corthell D , ed. Traumatic brain injury and vocational rehabilita­ tion. Menomonie, Wisconsin: Stout Vocational Rehabilitation Institute, 1990:22-65. 27. Rutherford WII: Postconcussion sym ptom s - relationship to acute neurological indices, individual differences, and circumstances of injury. In: Levin HS, Eisenberg HM , Benton A L , eds. Mild head injury. New York: Oxford University Press, 1 9 8 9 ;2 1 7-228. 28. American Psychiatric Association: Diagnostic and statis­ tical manual o f mental disorders. 4th edition. Washington, D C : American Psychiatric Association, 1994;70 4-706 . 29. Shuttleworth-vlordan A B , Puchert J, Balarin E: Negative consequences of mild head injury in rugby - a matter wor­ thy of concern. [ Paper presented at the 5th National Neuropsychology Conferences (S A C N A ). Durban: Julu 14-16, 19 9 3 }. 30. Abreau F: Psychological assessment o f attention and con­ centration in soccer players. [ Dissertation] . California School o f Professional Psychology. Fresno, California: (cited Templer DI, Drew R H : Contact sports. In: Templer D I, Hartlage LC, Cannon WG, eds. Preventable brain damage - brain vulnerability and brain health. New York: Springer Publishing Company, 19 92;30-40. 31. Templer D I, Drew R H : Contact sports. In: Templer D I. Hartlage LC, Cannon WG. eds. Preventable brain damage brain vulnerability and brain health. New Yirk: Springer Publishing Company. 1992:30-40. 32. Casson IR, Siegel O, Sham R, Campbell E A , Tarlau M, DiDomenico A : Brain damage in modern boxers. J A M A 1984:251 (2 0 ) :2 6 6 3 -2 6 6 7 . 33. Hartlage LC, Rattan G: Brain injury from motor vehicle accidents. In: Templer DI, Hartlage LC, Cannon WG, eds. Preventable brain damage - brain vulnerability and brain health. New York: Springer Publishing Companu 1992- 3-14. 34. Gronwall D, Wrightson P: Cumulative effects o f concus­ sion. Lancet 1 9 75 ;2:9 95 -9 97. 35 . Gronwall D , Wrightson P, Waddell P: Head injury - the facts. A guide for families and care-givers. Oxford: Oxford University Press, 1990. □ SPORTS MEDICINE SEPTEMBER 1996 27 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) PRODUCT NEWS ELECTRIFYING BREAKTHROUGH IN PAIN RELIEF Each year, South Africans spend more money on analgesics than on any other pharmaceutical drug, including cardiovascular and antibiotic treatments. W hat is perhaps not fully realised, however, is the associated and cumulative toll this takes in terms o f side effect related problems, not least o f which is the large scale im pact on productivity. A new, highly effective and safe treatment for pain has been developed using a scientific breakthrough in bio-analgesic m embrane therapy. Awarded a gold medal at the 35th Eureka World Trade Fair for Invention, Acustat Rx therapeutic membrane provides micro-current (1 0 -3 0 m icro-am p) stim ulation to soothe traumatised muscles and joints and injuries associated with sprains, strains, inflammation and swelling, arthritis, bursitis, soft tissue injuries, neck and lower back problems. Micro-current therapy works at a sub-sensor level to trigger the body’s own bio-chemical and electro-physiological healing processes so that intra-cellular fluid levels are restored, electrolyte levels replenished, nutrients taken in and healing commenced. Pain is effectively reduced through the introduction of a negative charge to the injured area. T h is stim ulates protein synthesis, production o f important amino acids and adenosine triphosphate (ATP) and increases the transfer o f calcium into the cells, thereby electro-balancing these injured cells and aiding tissue repair. Acustat Rx is a high-tech synthetic polymer membrane which retains electric activity. Its micro-amp charge is released when brought into contact with the skin and works effectively over a period of at least 4 8 hours. This is far greater than any traditional single OTC analgesic dosage, with additional curative properties and no known side effects. The Acustat Rx electro-m em brane also effectively stim ulates reduction o f muscular inflammation and oedem a, thereby further reducing patient distress and discomfort. The patch is attached by means o f a self- adhesive strip, available from your chemist, or, on joint areas, by means o f a gauze or crepe bandage. Health care professionals worldwide have accepted this advances electro-analgesic product with great enthusiasm. Its unique pain control, soft tissue healing and anti­ inflammatory properties are proving to be a successful combination in more cost effective patient treatment. The product’s obvious safety features, ease of application, and therapeutic action are all of additional benefit to the patient. Acustat Rx’s drug-free efficacy allows the patient to largely continue his or her work or sports activities with minimal impairment. F or fu r th er inform ation, p le a s e c o n ta c t Susan Drinkwater a t ( 0 2 1 ) 6 85 -7862 or 082-499-6229. EH 28 SPORTS MEDICINE SEPTEMBER 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. )