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1.  Acute tear of the fascia cruris at the attachment to the Achilles tendon: a new diagnosis 
British Journal of Sports Medicine  2014;49(21):1398-1403.
Background
The fascia cruris encloses the posterior structures of the calf and connects to the paratenon and the Achilles tendon. We describe the clinical presentation, ultrasound imaging characteristics and the time to the recovery of tears of the fascia cruris at the attachment to the Achilles tendon.
Methods
Retrospective review of 11 tears of the fascia cruris in the different legs as separate events in 9 patients (6 male and 3 female, mean age 35.52 years, range 11–48) identified using diagnostic ultrasound, after presenting with Achillodynia.
Results
11 participants presented at a mean of 4.5 weeks (range 0.5–12) after onset of symptoms. The left Achilles was more commonly injured than the right (7 : 4) and the lateral side more than the medial (6 : 4) with one case with medial and lateral presentation. Clinically, there was swelling and tenderness over the medial or lateral border in the mid to upper portion of the Achilles. 7 of the 11 (63.6%) had functional overpronation. Ultrasound appearances of a tear were identified as hypoechoic area extending from the medial or lateral border of the Achilles extending along the anatomical plane of the fascia cruris. Average return to activity was 5.2 weeks (range 1–22). Participants presenting later had longer recovery but all participants returned to full activity (r=0.4).
Conclusions
This is the first description of the clinical details and sonographic findings of a tear to the fascia cruris at its attachment to the Achilles tendon. This needs to be considered as a cause of Achillodynia in athletes as recognition will affect the management.
doi:10.1136/bjsports-2013-093273
PMCID: PMC4680126  PMID: 25202137
Achilles; Ultrasound; Soft tissue; Sporting injuries; Tendon
2.  High volume image guided injections and structured rehabilitation in shoulder impingement syndrome: a retrospective study 
Summary
Background
the aim was to establish the effect of a high volume-image guided injection and structured rehabilitation (HVIGI&SR) on both pain and function in shoulder impingement syndrome (SIS).
Methods
44 participants treated between January 2008 and January 2012 with a >3 month history of recalcitrant ultrasound-confirmed SIS were sent a retrospective questionnaire. All participants had received a HVIGI under ultrasound-guidance consisting of 20 mls of Marcaine with 50 mg of hydrocortisone, followed by a period of physiotherapist-led rehabilitation. The validated Shoulder Pain and Disability Index (SPADI) score was used to establish the change in the score between 1 week pre-injection and 3 weeks post-injection, along with an 11-point pain scale.
Results
59% of participants responded. There was a clinically and statistically significant decrease in the SPADI score of 58.7 ± 29.9 (p<0.01). 76% of participants had an improvement in their score of over 50% from their initial score. There was a clinically and statistically significant improvement in pain of 5.19 ± 2.62 (p<0.01) on the numerical rating scale of pain.
Conclusion
HVIGI&SR should be considered for short-term treatment of SIS as it showed a significant improvement in both pain and function. A prolonged period of physiotherapist-led rehabilitation can then be undertaken for long term benefits.
doi:10.11138/mltj/2015.5.3.195
PMCID: PMC4617220  PMID: 26605194
injection; rotator cuff; SPADI; ultrasound
3.  High volume image-guided injections and structured rehabilitation improve greater trochanter pain syndrome in the short and medium term: a combined retrospective and prospective case series 
Summary
Background
the aim of this study was to measure the effects of high volume image-guided injections and structured rehabilitation (HVIGI&SR) for greater trochanter pain syndrome (GTPS).
Methods
31 consecutive subjects were recruited (23 retrospectively; 8 prospectively) over 5 months. GTPS was diagnosed based on history and examination findings, alongside radiological examination. The HVI-GI used a 22-gauge spinal needle to administer 10ml of 0.5% Marcaine and 50 mg hydrocortisone just deep to the periosteum underlying the gluteal tendon insertion under ultrasound guidance, followed by structured rehabilitation. A visual analogue scale (VAS) for pain was used as the main outcome measure.
Results
the mean VAS improved from 81.7 mm (±17.6) to 42.3 mm (±28.3), (p<0.05) in the prospective subjects at a mean of 6 weeks, considered clinically significant. In the retrospective subjects the mean VAS had improved from 74.6 (±10.9) mm to 38.2(±31.2) mm at two weeks (p<0.01) and 31.3 (±27.6) mm at the final time point, a mean of 60 weeks (p<0.01). The Hip and Groin Outcome Score in the prospective group showed a non-significant increase from 173.2 to 296.1 (p=0.12).
Conclusion
HVIGI&SR should be considered when short- and medium-term pain-relieving treatment for GTPS is required. Controlled studies are warranted to fully establish effectiveness, and assess long term effects.
Level of evidence
case series.
PMCID: PMC4496022  PMID: 26261785
injection; greater trochanter pain syndrome; ultrasound; VAS scale
4.  High volume image-guided Injections for patellar tendinopathy: a combined retrospective and prospective case series 
Summary
Background:
the aim was to quantify the effect of a novel high volume-image guided injection (HVIGI) technique for recalcitrant patellar tendinopathy (PT).
Methods:
twenty patients (8 prospective; 12 retrospective) with ultrasonographically confirmed proximal PT were recruited. A HVIGI under ultra-sound guidance of 10 ml 0.5% Bupivacaine, 25 mg Hydrocortisone and 30 ml normal saline at the interface of the patellar tendon and Hoffa’s fat pad was administered. A standardised eccentric loading rehabilitation protocol was prescribed.
Results:
the VISA-P score improved from 45.0 to 64.0 (p<0.01) for all subjects, likely to be clinically significant. There was no statistically significant difference between the increase in the retrospective group of 19.9 (± 23.5) and the prospective of 16.4 (± 11.3) p = 0.7262.5% of prospective subjects agreed that they had significantly improved, with 37.5% returning to sport within 12 weeks.
Conclusions:
HVIGI should be considered in the management of recalcitrant PT. Randomised controlled trials are warranted.
PMCID: PMC4187599  PMID: 25332938
injection; patellar tendon; tendinopathy; ultrasound; VISA-P
5.  The intercalated BSc in sports and exercise medicine at Barts and The London School of Medicine and Dentistry 
Summary
Object:
To report about the intercalated Bsc(Hons) in Sports and Exercise Medicine at Barts and The London School of Medicine and Dentistry (BLSMD), Queen Mary University of London.
Design:
Educational study.
Setting:
The course is currently in its tenth year, providing medical students with the opportunity to develop knowledge in the field of Sports and Exercise Medicine (SEM) during one academic year of full time study.
Participants:
There have been more than 150 graduates, and 22 students are enrolled for the 2012–13 academic year on what has been the most popular and largest intercalated degree at BLSMD in recent years. External applicants typically make up 30–40% of entrants.
Results:
Equal weighting on taught modules and a portfolio of research activity provides a strong foundation in Sports and Exercise Medicine, and equips successful students with evidence based translational skills, and the opportunity to perform publishable research.
Conclusion:
This article outlines the increasing demand for Sports and Exercise Medicine education, and how the course prepares graduates for practising SEM as a sub-specialist interest or to compete for entry into the Specialist Trainee training route.
PMCID: PMC3838327  PMID: 24367778
education; curriculum; sports (and exercise) medicine
6.  Pre-cooling for endurance exercise performance in the heat: a systematic review 
BMC Medicine  2012;10:166.
Background
Endurance exercise capacity diminishes under hot environmental conditions. Time to exhaustion can be increased by lowering body temperature prior to exercise (pre-cooling). This systematic literature review synthesizes the current findings of the effects of pre-cooling on endurance exercise performance, providing guidance for clinical practice and further research.
Methods
The MEDLINE, EMBASE, CINAHL, Web of Science and SPORTDiscus databases were searched in May 2012 for studies evaluating the effectiveness of pre-cooling to enhance endurance exercise performance in hot environmental conditions (≥ 28°C). Studies involving participants with increased susceptibility to heat strain, cooling during or between bouts of exercise, and protocols where aerobic endurance was not the principle performance outcome were excluded. Potential publications were assessed by two independent reviewers for inclusion and quality. Means and standard deviations of exercise performance variables were extracted or sought from original authors to enable effect size calculations.
Results
In all, 13 studies were identified. The majority of studies contained low participant numbers and/or absence of sample size calculations. Six studies used cold water immersion, four crushed ice ingestion and three cooling garments. The remaining study utilized mixed methods. Large heterogeneity in methodological design and exercise protocols was identified. Effect size calculations indicated moderate evidence that cold water immersion effectively improved endurance performance, and limited evidence that ice slurry ingestion improved performance. Cooling garments were ineffective. Most studies failed to document or report adverse events. Low participant numbers in each study limited the statistical power of certain reported trends and lack of blinding could potentially have introduced either participant or researcher bias in some studies.
Conclusions
Current evidence indicates cold water immersion may be the most effective method of pre-cooling to improve endurance performance in hot conditions, although practicality must be considered. Ice slurry ingestion appears to be the most promising practical alternative. Interestingly, cooling garments appear of limited efficacy, despite their frequent use. Mechanisms behind effective pre-cooling remain uncertain, and optimal protocols have yet to be established. Future research should focus on standardizing exercise performance protocols, recruiting larger participant numbers to enable direct comparisons of effectiveness and practicality for each method, and ensuring potential adverse events are evaluated.
doi:10.1186/1741-7015-10-166
PMCID: PMC3568721  PMID: 23249542
Pacing; thermoregulation; internal cooling; cooling garment; cold water immersion; ice slurry ingestion
7.  The morphology and symptom history of the Achilles tendons of figure skaters: an observational study 
Summary
This cross-sectional study assessed the prevalence of Achilles tendinopathy symptoms and ultrasound (US) abnormalities in male and female ice skaters, and compared this to age-matched controls. The 20 skaters of mean (sd) age 17.3 (7.9) were recruited from British figure skating clubs. The 17 non-skaters of mean age 18.0 (3.7) were recruited from a secondary school and university. Each group had 12 females. All participants completed a questionnaire, and Achilles tendons were ultrasound-scanned for thickening, hypoechoic areas, paratenon blurring and neovascularization. Skaters experienced significantly more lifetime symptoms (p=0.012) than the control group but there were no differences in present symptoms. Mid-tendon longitudinal thickness and the coefficient of variation (CoV) for longitudinal tendon thickness were significantly greater in the skaters (p=0.001 and p=0.017 respectively). No other ultrasound abnormalities were detected in either group. Figure skaters may be at a greater risk of Achilles tendon problems than the general population and have adaptive changes in their tendons.
PMCID: PMC3666509  PMID: 23738283
Achilles; skating; sonography; tendinopathy; ultrasonography
8.  The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review 
BMC Medicine  2012;10:75.
Background
Lower limb injuries in sport are increasingly prevalent and responsible for large economic as well as personal burdens. In this review we seek to determine which easily implemented functional neuromuscular warm-up strategies are effective in preventing lower limb injuries during sports participation and in which sporting groups they are effective.
Methods
Seven electronic databases were searched from inception to January 2012 for studies investigating neuromuscular warm-up strategies and injury prevention. The quality of each included study was evaluated using a modified version of the van Tulder scale. Data were extracted from each study and used to calculate the risk of injury following application of each evaluated strategy.
Results
Nine studies were identified including six randomized controlled trials (RCT) and three controlled clinical trials (CCT). Heterogeneity in study design and warm-up strategies prevented pooling of results. Two studies investigated male and female participants, while the remaining seven investigated women only. Risk Ratio (RR) statistics indicated 'The 11+' prevention strategy significantly reduces overall (RR 0.67, confidence interval (CI) 0.54 to 0.84) and overuse (RR 0.45, CI 0.28 to 0.71) lower limb injuries as well as knee (RR 0.48, CI 0.32 to 0.72) injuries among young amateur female footballers. The 'Knee Injury Prevention Program' (KIPP) significantly reduced the risk of noncontact lower limb (RR 0.5, CI 0.33 to 0.76) and overuse (RR 0.44, CI 0.22 to 0.86) injuries in young amateur female football and basketball players. The 'Prevent Injury and Enhance Performance' (PEP) strategy reduces the incidence of anterior cruciate ligament (ACL) injuries (RR 0.18, CI 0.08 to 0.42). The 'HarmoKnee' programme reduces the risk of knee injuries (RR 0.22, CI 0.06 to 0.76) in teenage female footballers. The 'Anterior Knee Pain Prevention Training Programme' (AKP PTP) significantly reduces the incidence of anterior knee pain (RR 0.27, CI 0.14 to 0.54) in military recruits.
Conclusions
Effective implementation of practical neuromuscular warm-up strategies can reduce lower extremity injury incidence in young, amateur, female athletes and male and female military recruits. This is typically a warm-up strategy that includes stretching, strengthening, balance exercises, sports-specific agility drills and landing techniques applied consistently for longer than three consecutive months. In order to optimize these strategies, the mechanisms for their effectiveness require further evaluation.
doi:10.1186/1741-7015-10-75
PMCID: PMC3408383  PMID: 22812375
neuromuscular training; lower limb; injuries; prevention
9.  Thicker Achilles tendons are a risk factor to develop Achilles tendinopathy in elite professional soccer players 
Summary
The primary aim of this prospective cohort study was to compare the incidence of Achilles tendinopathy symptoms in elite soccer players with and without baseline asymptomatic ultrasound abnormalities. This study also investigated the relationship between baseline tendon thickness and development of symptoms. Using ultrasonography, 18 players were examined in 2009 for the existence of hypoechoicity, paratenon blurring, focal thickening and/or neovascularisation, and anteroposterior tendon thickness was measured. Symptom development during the follow-up period was assessed by interview one year later. Baseline mid-tendon thickness was greater (p=0.041) in tendons that experienced symptoms [median (IQR): 0.53 (0.51–0.55) cm] in the following year than tendons remaining asymptomatic [0.48 (0.45–0.52) cm]. No association between the existence of baseline ultrasound signs and development of symptoms in the following year was observed (Chi-Square: 1.180, p=0.277). A thicker baseline mid-tendon thickness was identified as a risk indicator for the development of Achilles tendinopathy in elite soccer players.
PMCID: PMC3666468  PMID: 23738247
tendinopathy; sonography; ultrasound; football; Achilles

Results 1-9 (9)