ACUTE AND OVERUSE INJURY

applications, all subjects followed a writ- ten standardised exercise programme. The outcome measures employed were the Lower Extremity Functional Scale (LEFS), pain using a 10cm VAS and swelling, using a figure-of-eight method. Measures were taken at baseline and then at 1,2,3,4 and 6 weeks.

The authors follow the CONSORT guidelines for reporting an RCT and account for the subject flow and retention. Additionally, compliance was monitored using a treat- ment diary. Results showed that subjects in the intermittent group had significantly less pain on activity one week after injury (Figure 2). The clinical implication of this is that intermittent application may enhance the analgesic effect of ice in the acute stage. However, there were no differ- ences between groups in function, swelling or pain at rest. Interestingly, despite no differences in functional status, large num- bers of subjects in both groups had diffi- culty running on uneven ground and cut- ting at 6 weeks. The authors suggest resid- ual functional instability as a potential cause and recommend further study to assess the extent that proprioception influ- ences subjective ankle function.

This is a well designed and written study, and whilst the statistical significance of the results is limited, traditionally this might have made publication difficult. Any health care professionals thinking of undertaking research, not necessarily an RCT would do well to read this article.

Ultrasound-guided sclerosis of neovessels in painful chronic patella tendinopathy: A ran- domised controlled trial A Hoksrud, L Ohberg, H Alfredson, R Bahr American Journal of Sports Medicine 2006;34:1738-1746

Another RCT on tendinopathy, this time in the lower limb. Patella tendinopathy or ‘jumpers knee’ presents management prob- lems for those clinicians working in sports such as basketball, volleyball and team handball. For those not familiar with the sport of team handball, it is very popular in Scandinavia; it is played by an estimated 19 million people worldwide and is an Olympic sport.

Eccentric training programmes have been demonstrated to be effective in the man- agement of mid-portion Achilles tendin- opathy, but this is less certain in the man- agement of insertional tendinopathies such as ‘jumpers knee’. The majority of subjects presenting with this condition will have an area of neovascularisation that shows up on colour Doppler ultrasound examination. There is a theory that these new vessels, and the nerves that accompany them, may be attributable to the pain mechanism associated with this condition. Previous pilot work by the same authors has shown that an injection of a sclerosing agent (polidocanol) into the area of neovascular- isation has reduced the pain in Achilles tendinosis. The authors proposed that a similar mechanism may work with chronic painful patella tendinopathy.

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Figure 2: Line graph showing mean (SEM) values for ankle pain on activity for intermittent and standard groups over time

www.sportex.net week 6

intermittent standard

The authors present a randomised, double- blind, placebo-controlled study investigat- ing the effect of sclerosing injections in athletes presenting with chronic (at least 3 months) patella tendinopathy. The athletes received injections of polidocanol (treat- ment group) or lidocaine with adrenaline (placebo group). These were conducted under ultrasound guidance and each ath- lete received up to a maximum of 3 injec- tions at 3-5 week intervals. After 4 months, end of treatment phase 1, it was revealed which group the athletes were in, and any athletes with persistent pain and neovas- cularisation were offered a maximum of 3 sclerosing injections. Pain and function

were recorded at baseline, 4, 8 and 12 months after the first injection. While the analysis is complex because of the 2 differ- ent treatment phases, the treatment group reported a significant improvement in VISA score in treatment phase 1, with no change for the placebo group (Figure 3).

Once the placebo group were permitted the sclerosing injections in phase 2, it can be seen that there was a greater improvement in the VISA scores in the control group. More importantly a substantial number in both groups had returned to full time train- ing by 12 months. The authors discuss some of the strengths and limitations of the study, but I would like to raise an addi- tional issue. Trying to manage athletes with this condition conservatively whilst they continue to train has been shown to be difficult. There was no mention of any previous failed conservative management of these athletes prior to entering the study. Athletes in both groups had to reduce their activity levels according to a protocol, and there is a possibility that this contributed to the results. Now there is some evidence for conservative manage- ment of this condition, perhaps future inclusion criteria for invasive/surgical intervention should include having failed conservative treatment initially?

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Figure 3: Change in VISA score (mean 95% confidence intervals) in both groups after 4 months (after treatment period1), 8 months (after treatment period 2, the cross-over period), and 12 months (follow-up). VISA, Victorian Institute of Sport Assessment.

THE AUTHOR

Dr Zoë Hudson, MCSP, PhD, is editor of the Journal of Physical Therapy in Sport. She is associate director and senior clinical lectur- er of the Academic Department of Sports and Exercise Medicine at the Royal London Hospital.

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VISA score change