RESEARCH REVIEW

ACUTE AND OVERUSE INJURY – NEW AND OLD TREATMENT MODALITIES BY DR ZOË HUDSON MCSP, PHD

This issue of ‘Clinicians Choice’ is dedicat- ed to the latest evidence exploring some new and some older approaches to the management of soft tissue injury. Working in sport, clinicians are always seeking an accelerant to recovery that will get the athlete back to sport as quickly as possible. Management in the acute phase is an important factor in the road to recovery, and ice has been used historically as one of the initial treatments in soft tissue trauma. Whilst ice as a modality is well accepted, the length and frequency of application has been debated. The study by Bleakley presents an RCT with interesting results.

Sports physicians have used injections of Traumeel and Actovegin, a homeopathic and an ultrafiltrate of calf’s blood, respec- tively, in the management of soft tissue injuries. Corticosteroid on the other hand, was traditionally used in the management of chronic tendinosis in both the upper and lower limb. In the last five years or so there has been a move forward with regards to the underlying pathology of these condi- tions and two different types of injection are proposed by Mishra and Hoksrud, namely ‘buffered platelet-rich plasma protein’ and Polidocanol and are reviewed below.

Treatment of chronic elbow tendinosis with buffered platelet- rich plasma A Mishra, T Pavelko American Journal of Sports Medicine 2006;34:1774

Injections of platelet rich plasma (PRP) is a relatively new approach that has been proposed to promote healing in ligaments and tendons via growth hormones and cytokines. In this study Mishra and Pavelko investigate the efficacy of these injections in chronic elbow tendinosis. From a series

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of 140 patients with both medial and lat- eral tendinosis, 20 were selected who had pain for longer than three months, of at least 60-100 on a visual analogue scale (VAS) and failed previous treatment, this included a standardised rehabilitation pro- gramme. Fifteen subjects received a 2-3ml injection of PRP whilst five subjects received a 2-3ml injection of bupivicaine with epinephrine via a single skin portal and five penetrations of the tendon.

Figure 1 shows the impressive reduction in pain following PRP injection, even beyond the six week normal window of pain relief expected following a corticosteroid injec- tion. At longer term follow up of 12-38 months, subjects in the PRP group report- ed a 93% reduction in pain compared to before treatment. A mean of 99% and 94% returned to activities of daily living and work/sporting activities, respectively.

This study has several limitations regarding methodology. These include subject alloca- tion, the first 10 patients were a case series and the following 10 were ran- domised; medial and lateral tendinosis were included and there were small num- bers, especially in the control group. Not

100 90 80 70 60 50 40 30 20 10 0

Initial P=.259

4 weeks P=.258

withstanding these limitations, the early results look encouraging and the authors are proceeding with a multi-centre RCT.

Cryotherapy in acute ankle sprains: a randomised controlled study of two different icing protocols CM Bleakley, SM McDonough, DC MacAuley British Journal of Sports Medicine 2006;40:700-705

How long to ice in the acute management of soft tissue injury remains an area of debate. The ACPSM guidelines state ‘the most effective duration of application of ice appears to be 20–30 minutes, applied every two hours, although there are no specific recommendations'.

Bleakley presents a well designed RCT look- ing at the effect of a constant 20 minutes application of ice compared to an intermit- tent application of 10 minutes on/10 min- utes off/10 minutes on, every 2 hours fol- lowing acute ankle sprain. Recruited sub- jects were stratified into sports or general population and then randomised into the constant or intermittent ice group. The exclusion and inclusion criteria are clearly set out and apart from the different ice

PRP Control

8 weeks P=.001

Figure 1: Visual analogue pain scores for the group treated with PRP and the control group www.sportex.net