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Archive for the ‘tendonitis’ Category

The weekend before Memorial Day weekend, I helped to cover a soccer tournament. We have a good group of folks that work together and it is fun to work with a group of athletic trainers in the athletic setting. Usually the event is rather – well, uneventful. Not so this last go around.

Unfortunately the kids were dropping like flies and there were plenty of weekend ending (and more) injuries – fractured clavicle, probable ACL rupture, two nasty concussions, and more.

One of the injuries that occurred on an opposite field from me was a nasty hip injury. We did get confirmation that the player did suffer at minimum an avulsion fracture (my guess is an apophyseal avulsion)- 3rd and 4th hand information is sometimes hard to decipher.

I bring that particular injury up because in the most recent edition of the Journal of Sports Health there is an excellent submission speaking on this exact subject. Here is a link to the study that is complete with radiographs and MRI images.

So let’s take the rest of post to discuss apophyseal avulsion fractures in youth athletes so that we can be more quick to recognize these injuries.

The submission I will look at is entitled Orthopaedic Magnetic Resonance Imaging Challenge: Apophyseal Avulstions at the Pelvis.

The particular case that spurred the research on was a 15 year old soccer player presenting with left hip pain and weakness for 4 weeks. Radiographs and MRI revealed regularities at the ASIS. The diagnosis was an apophyseal avulsion of the left ASIS.

The authors note that apophyseal injuries of the hip and pelvis account for 10-24% of athletic injuries in children. You guessed it – soccer was one of the primary contributors to that figure. Other injuries with higher incidence are running and ballet. Football, baseball, track, gymnastics and cheerleading can also produce simmilar injuries.

When dealing with youth athletes we need to be more cognizant of the bone-tendon-muscle junction. Often times, the weak link in youth is the physis – the myotendinous junction. In adults, the failure point is more commonly in the tendon. So when we see a strain-type injury in youth athletes, we need to be ever cognitive of this dynamic.

As far as the most commonly affected apophyses that we need to be aware of:

  • Ischial tuberosity – hamstrings
  • AIIS – straight head of rectus femoris
  • ASIS – sartorius and TFL
  • Pubic symphysis – adductor brevis, longus, and gracilis

Mechanism of injury: The most common mechanism is a sudden contraction (eccentric or concentric) during running, jumping, or kicking which causes traction on an unfused apophysis. Other mechanisms can be extreme passive stretching or microtrauma.

With an acute injury, the athlete may experience a “pop” and immediate pain. Ecchymosis, swelling, weakness and an altered gait are all signs and symptoms.

Often times, individuals may be referred for x-rays. It is important to understand however that if the avulsion is non-displaced or the apophysis is not yet ossified, radiographs may be negative. So, MRI is probably superior in that allows for view of the tendon attached to the avulsed apophysis. If surgery is a further consideration, the authors noted that CT scan is an even better option than MRI.

In regards to imaging, x-rays can show an avulsion at the apophysis if it is ossified. If not, radiographic imaging may be inconclusive. So if this is the case and an avulsion is still suspected – MRI is the imaging of choice.

Now a couple of specific considerations with MRI that the authors relay that are probably handy to note:

  • Fat-suppressed T2 weighted and STIR MRI sequences are best for acute injuries
  • T1-weighted sequences are more useful for chronic conditions

As far as treatment considerations, nondisplaced avulsions are usually treated conservatively and the athlete can gradually return to activity after symptoms subside (4-6 weeks for resolution). Displaced avulsion fractures of more than 2cm are considerations for surgery, as are malunited or hypertrophied fragments.

Overall, this was an excellent read and something that anyone who works (even if it is only twice a year covering a soccer tournament) with athletes should be aware of. So let me give a few summary take-home points to wrap this post up:

  • Apophyseal avulsions are a common injury, especially within that middle school to high school age range athlete
  • The most commonly avulsed apophysis at the hip are the ischial tuberosity, AIIS, and ASIS.
  • X-rays may be initially negative depending on whether or not the avulsion is non-displaced or non-ossified; so be diligent if symptoms persist, even if x-rays have already been taken, and understand that an MRI may be a more appropriate test
  • Understanding the locations of the apophyses and signs and symptoms to watch for will help you make better decisions for your athletes.

The research article has several pictures of diagnostic tests that also give you some additional information as well.

It was an excellent piece that certainly any athletic trainers working with athletes should read and brush up on. I highly recommend that you give it a read.

Have you had any experience yourself with an apophyseal avulsion with any athletes in your care? Does some of the information in this blog post ring true with your experience?

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A little over a year ago, I wrote a blog post reviewing a study that compared crushed ice, cubed ice, and wetted ice and their effect on tissue cooling. The conclusion of the study was that wetted ice was the most effective in providing both surface temperature and tissue cooling.

So, if the goal was to produce the most tissue cooling – the choice would have been to use cubed ice and add about a cup of room temp water to get your wetted ice treatment.

Now, let’s fast forward to phase two that will help us even make better evidence-based decisions when we choose ice as a treatment modality.

The most recent edition of the Journal of Athletic Training published a study entitled: The Magnitude of Tissue Cooling During Cryotherapy With Varied Types of Compression.

This study compared the use of no compression, Flex-i-Wrap, and an elastic wrap as compression methods when applying ice. The study looked at both surface temperatures and intramuscular cooling. An interesting side note was that this study utilized crushed ice. (This is not a criticism – simply an observation that we can take into account at the end of the study when developing some take home points of note).

Going into the study we would probably surmise that an ice bag secured with any type of compression would produce greater tissue cooling than no compression. This was largely true but there were some additional interesting findings.

In respect to surface temperature cooling, there was a statistically significant difference with compression using an elastic wrap and no compression. However, there was no statistically significant difference between using Flex-i-Wrap and no compression or Flex-i-Wrap versus the elastic wrap. So, from this we can conclude that compression with an elastic wrap provides the greatest amount of surface temperature cooling. (Although we must also note that skin temperature is not necessarily a direct reflection of what is happening intramuscularly).

When comparing intramuscular tissue temperature at approximately 2 cm below the skin, again compression with an elastic wrap produced greater intramuscular tissue cooling than both the Flex-i-Wrap and no compression.

This to me was a bit of a surprise. I would not have expected much difference in means of compression. Many athletic trainers utilize Flex-i-Wrap or similar type product for several reasons. Apparently, the elastic wrap adds a level of insulation that is not necessarily provided with the Flex-i-Wrap.

Another point that was also driven home in the study I reviewed last year, was that tissue cooling continues after the ice is removed. Ice, in this study, was applied for 30 minutes and the coldest tissue temperatures were measured at 40 minutes post treatment. So the tissue cooling continues for approximately 10 to 15 minutes following ice treatment.

Please read the study in depth – it was well done and again helps us toward more evidence based practice.

So when we look at this study and compare it with the previous study, what sort of best practices can we establish when using ice as a treatment modality?

  • Cubed, wetted ice is the treatment of choice – crushed ice is probably the least “effective” in comparing the methods of cryotherapy using ice
  • Use compression over no compression – so instead of simply laying an ice bag on an ankle, calf, knee, etc – make sure to secure it with a compression wrap
  • Use an elastic wrap as the choice of compression – This method is more effective than using other plastic wrap methods
  • Both studies utilized treatment times of 30 minutes so this probably serves as a great reference point as well

Following these evidence-based parameters will help athletic trainers provide their athletes and patients with proven methodologies that will ultimately provide more effective treatment. If you have these elements at your disposal, the research shows these are more effective.

Thanks again to the authors of this study and to David Tomchuk, MS, LAT, ATC, CSCS who took extra time to answer questions that I had about this study.

What are your thoughts? Do this studies change the way you think about the application of ice?

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