The Fortius Clinic Lecture Series - June 2015 Issue

The Wimbledon Effect

To keep up to date with Fortius news, follow us on twitter @FortiusClinicUK or like us on Facebook.Alternatively, check our news & events page on the website www.fortiusclinic.com.

In this issue:

Back Pain in Tennis

Mr Damian Fahy

Tennis Player’s Wrist

Ms Alice Bremner-Smith

Ankle in Tennis

Ms Callum Clark

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Once again it was a great turnout, with a very engaged audience. Thanks for the twitter commentary also folks, it’s great to put those positive comments out there!

Our three speakers for the evening built on the theme, delivering informative and interesting talks, which worked really well together.

Mr Damian Fahy, Consultant Spinal Surgeon, was up first, speaking on Back Pain in Tennis.

The levels of training intensity, fitness and strength are immense for Tennis professionals. Asymptomatic pars defect is common and there is a high incident of facet joint changes among elite tennis players. Only about 15% of them will have a ‘normal’ MRI scan yet most would be asymptomatic of lumbar spine problems. Professionals deal with pain all the time and learn to manage it, so Mr Fahy chose to concentrate on the keen amateur, the club player, and the regular weekend tennis enthusiast, for whom Back pain is a fairly common tennis complaint. The type of injury they experience relates to the type of movement, in this case repeated sub-maximal forces of rotation and extension, plus a lot of sprinting. When speaking about spondylolosis he emphasised that surgery should be a last resort for people who play sports and should be avoided if possible, as repairing spondylolosis often doesn’t work

Mr Callum Clark, Foot and Ankle Consultant, spoke on the Ankle in Tennis, particularly on the inversion injury,

which he called ‘the nearest thing to tennis ankle’. A recent paper investigating acute injuries at the US Open found that lower limb injuries outnumber upper limb, with the ankle being the most frequently affected part of the body, and inversion sprains the most common injury. The average incidence of ankle inversions is about one per 10,000 people per day, which equates to about 5,000 per day, about 95% of which are resolved within six weeks. Mr Clark showed some excellent videos of ankle inversions during tennis games, which had the audience gasping! He also covered ruptured Achilles tendons, which are quite widespread in sports involving sudden explosive action.

Alice Bremner-Smith, consultant hand and wrist surgeon, spoke on the Tennis Wrist. The wrist accounts for approximately 11% of male and 16% of female tennis injuries, so it is a significant problem area in this sport. A small number of injuries result from falls, but most wrist problems arise from chronic use, which particularly affects higher-level tennis players. Most injuries are ulnar-sided and ECU issues are extremely common, so Ms Bremner Smith discussed treatment, symptoms and the anatomy of ECU instability.

All in all a fascinating insight into the injuries of the tennis enthusiast and professional . We look forward to seeing you next month, when we’ll be tackling watersports.

We look forward to seeing you next month!

The Fortius Lecture EveningEvery month the Fortius Clinic hosts a lecture evening for physiotherapists and Sports & Exercise Medicine professionals, led by a different team of specialists. The evening event is held in central London. If you would like to be added to our invitation list, please email RSVP@ fortiusclinic.com.

Meghan Williams, Business Development Executive

e: meghan.williams@fortiusclinic.com t: 0203 195 2445.

JUNE TOPIC:

The Wimbledon Effect

As Wimbledon fast approaches, and the summer strawberries hit the supermarket shelves, we turn to the topical title of “The Wimbledon Effect” for our June lecture evening.

Don’t forget to follow us on Twitter @FortiusClinicUK.

You will also find us on Facebook and LinkedIn.

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Fortius Clinic Imaging Department is open on a Saturday for MRI, Ultrasound and X-ray

Full Range of Musculoskeletal Imaging Examinations

Same Day AppointmentsRapid Radiology Reports

Monday-Friday 8am-8pmSaturday 8am-1pm

+44 (0) 203 195 2446imaging@fortiusclinic.com www.fortiusclinic.com

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FEATURE | Back Pain in Tennis

Tennis professionals are the fittest of any sports professionals I deal with. Their levels of training intensity, fitness and strength are immense. They deal with pain all the time and learn to manage it, so I am going to concentrate on the keen amateur, the club player, the regular weekend tennis enthusiast. Back pain is a fairly common tennis complaint, particularly in the amateur sector. A patient with tennis-related back pain wants clarity, a clear diagnosis and an effective treatment programme. But this is rarely straightforward. If the player sees several professionals, it is possible that they will all suggest a different cause and treatment plan. Unsurprisingly this is frustrating.

The main types of back painFacetogenic pain – Tennis involves rotation and extension, for overhead shots and high backhands, so by the time tennis players get to adulthood, most have abnormal facet joints. Therefore an MRI scan showing an abnormal facet joint doesn’t necessarily mean this is the cause of their back pain. Facet joint syndrome is a clinical diagnosis. When the patient gets up, they have a stiff achy back – extension and rotation are uncomfortable. It improves during the day, but deteriorates at night. Standing up following sitting causes pain, which radiates into the buttocks and posterior thighs.Discogenic pain – this is common in all sports participants and applies to tennis players as much as any other discipline, and is treated exactly the same way.Pars / Stress reactions – pars issues are more common in tennis than in football or rugby, but less than in ballet or gymnastics. Spondylolysis is not frequent but should be considered. Any sportsperson with persistent, activity-related back pain should be examined for a stress fracture unless

there is evidence to the contrary. Amateur tennis players often have disproportionate upper body strength compared to poor gluteal strength, which can cause stress reactions.

Examination and imageryFirst take the history. Then examine the patient. Investigate the level of exercise and the style of tennis stroke in your patient. Look at how they are made and identify the demands on their spine. Consider red flags– professional and amateur players can get spinal tumours, transverse myelitis and other significant conditions, so think about them at the outset. Don’t assume that an athlete with back pain is inevitably suffering from a sports injury. Imaging is often misleading but can be useful. Avoid x-rays where possible, not only because of the radiation, but also because anyone who plays a lot of sport will have an abnormal x- ray.MRI scans avoid radiation but a paper in the British Journal of Sports Medicine (Alyas et al Br J Sp. Med 2007) scanned 33 elite, adolescent tennis players- only 15% of them had normal scans. Despite being asymptomatic, pars lesions and spondylolisthesis were identified and two-thirds had abnormal facet joints. Tennis loads your facet joints – this does not necessarily signify degeneration, it’s more often the facet joint spreading the load over a wider area and increasing the size of the joint. It’s only abnormal if it has lost cartilage, if it contains a significant amount of fluid or if it shows up by signal on an MRI scan.Similarly, synovial cysts are abnormal. But a third of adolescents with synovial cysts have no pain, so the presence of these fluid-filled sacs isn’t necessarily the root of their back

Lecture by Mr Damian FahyConsultant Spinal Surgeon

Back pain in tennis is very similar to back pain in any other sport and, as with all sports, the type of injury usually relates to the type of movement, in this case repeated sub-maximal forces of rotation and extension, plus a lot of sprinting.

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Lecture by Mr Damian FahyConsultant Spinal Surgeon

Mr Damian Fahy Consultant Spinal SurgeonMr Fahy is a Consultant Spinal Surgeon specialising in spinal pain, including neck, lower back pain and sciatica.

problem.SPECT/CT scans involve a high dose of radiation, so should only be used in extreme circumstances.

PreventionStrength and conditioning exercises should be part of a normal routine. Adolescents have the muscle flexibility to get away with no conditioning but as you get older, strength and conditioning, specific to tennis, should become routine. Instead of relying on the sport to keep you fit, you keep fit in order to play. Get professional advice. Get good coaching. As a tennis player, you’re performing repetitive movements so perform them in the right way, otherwise you will injure yourself. Ask a running coach to look at the way you move and at your orthotics.

TreatmentIn general, rest is the best treatment. If tennis is causing you back pain, rest, don’t play. Get in the swimming pool, walk, cycle, allow your body to heal. Don’t rely on painkillers. You have to rest.Facetogenic pain is the most common and the best treatment is rest. Then ensure the core is strong, the patient is flexible and build up through functional rehabilitation.

Injections are the next step.The treatment for sponylolysis is rest, rehabilitation and analgesia. Stop exercising, wait for the pain to settle and then rehabilitate progressively. Only then do you consider surgery. Spondololysis repairs often fail, resulting in worse pain and a delayed return to sport. Surgery is rarely beneficial.Prolotherapy, a treatment of injured tissue using an injection of an irritant solution to relieve pain, doesn’t work. Epidural steroid injections are useful only because they make the patients feel well enough to enable correct rehabilitation. Facet joint injections are exactly the same. Radiofrequency nerve ablation, buzzing the facet joint, can help professional players to keep going. Coblation, a procedure involving the insertion of a probe into a prolapsed disc which is then heated, ablating the centre of the disc, doesn’t work. CommunicationIf a player has an injury they must allow the injury to heal through rest and a progressive rehab programme and then repair through pacing themselves, introducing strength and conditioning, mixing their sport up. Advise them that if they insist on playing tennis six times a week, they may end up playing no tennis at all.

Players with an excessive range of wrist motion (usually non-elite) are especially vulnerable. If they hit the ball late after the bounce, there is a higher loading impact. Top spin and the double-handed backhand are responsible for lots of problems. If string tension is high, to improve the power of the return, this can impact on the wrist. The Western style of grip, where it’s fully supinated, then whipped round in full pronation for top spin, has a significant effect. At the time of impact with the ball, the wrist is often in ulnar deviation which puts high stress on the ulnar side.Fractures are rare so this talk focuses on the ECU. Synovitis, tendinopathy, instability and rupture all occur, either in isolation or in combination. The action of the ECU, a long muscle on the ulnar aspect of the forearm, depends on the position of the forearm. Leaving the arm, the muscle goes through a bony groove on the back of the ulna, and it’s maintained in this groove by the retinaculum and a sub-sheath which attaches it to the ulna. This sheath is the most important stabilizing factor, as it means the ECU is fixed, unlike other tendons, so moves less freely, therefore liable to stress in pronation and especially in supination, particularly with ulnar deviation and flexion.Inflammation of the sheath, increased fluid, pain on the ulnar side of the wrist, tenderness to palpation and pain on resisted extension in ulnar deviation are all early signs of ECU tendinitis or tenosynovitis. However, with tendinopathy you get actual disintegration within the tendon collagen tissues, along a gradual spectrum from reactive tendinopathy where there is slight thickening and stiffening of the tendon, to the partial tears and tendon splitting of degenerative tendinopathy, commoner in older athletes. Symptoms include a dull ache, gradual onset of pain on the ulnar side, initial pain in the warm up, slight swelling of the sheath and discomfort on palpation. An ECU synergy test can confirm the diagnosis.ECU instability ranges from minor instability during

forearm rotation to frank dislocation with the forearm locking. This is the result of a dysfunction or disruption of the sheath, prompted by an acute traumatic event, such as a double-handed backhand. The player will experience a pop, snap or sudden pain and stop playing for a while. They may modify their game with flatter stroke action or less topspin. But pain will return if they attempt their previous technique, with rebound pain around the ulnar styloid. However, instability is not always painful – there are some chronic cases where the player has painless subluxation out of the groove. Complete rupture of the ECU is rare. It sometimes follows a tendinopathy, so there is a possible association with steroid injections in tendinopathic ECU.Symptoms of ECU instability include demonstrable subluxation, tenderness on palpation, pain on restricted active extension with ulnar daviation and some swelling in the dorso-ulnar aspect of the wrist.So how do you differentiate between these conditions? Imaging has an important role here. Ultrasound is quick, enables you to visualise the inflammation and to compare both sides. You can do dynamic testing to see what’s actually happening to the wrist, and if required, the radiologist can inject steroid at the same time. With tendonitis, you will see increased, compressible fluid in the sheath, even though the tendon may look normal. The signs for tendinopathy are initial thickening, followed by low echo areas within the tendon and finally, tendon degeneration and splitting. If it’s ruptured, there’s an empty sheath, with haematoma in the early stages or muscle atrophy later on.For instability, the tests are similar to the clinical examination. There is instability if the ECU comes out of the groove by more than 50% in flexion, supination and ulnar deviation and particularly, if it fails to go back into the groove in pronation. MRI is a useful adjunct to ultrasound to pinpoint the area on the sub-sheath where the instability has happened and to monitor recovery.

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FEATURE | Tennis Players’ WristLecture by Ms Alice Bremner-Smith Consultant Orthopaedic Hand and Wrist Surgeon

The wrist accounts for approximately 11% of male and 16% of female tennis injuries, so it is a significant problem area in this sport. A small number of injuries result from falls, but most wrist problems arise from chronic use, which particularly affects higher-level tennis players. Most injuries are ulnar-sided and ECU issues are extremely common.

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Treatment for tenosynovitis or tendonitis is rest, anti-inflammatories, splints in extension and ultrasound-guided steroid injections if necessary. Treatment for tendinopathy is similar, with the additional option of long-arm casts with the wrist in pronation. Anti-inflammatories are helpful in the early stages and may reverse the process. Modifying tennis technique is advisable to manage load better. A guided steroid injection is possible but the status of the tendon must be assessed to avoid a rupture. Surgical co-compartment release is also an option – this will maintain the stability of the ECU while giving it more room, so it’s not so stressed on movement.There are various treatments for ECU instability. Early acute injuries can be dealt with non-operatively, with casts for example, and monitored by imaging. But this

may take an elite athlete out of play for too long. You can surgically reconstruct, either non-anatomically using a bit of the extensor retinaculum to form a new stabilising tunnel, or anatomically, reattaching the periosteum and tendon sheath to the distal ulna. But this procedure requires considerable rehabilitation, lasting well over a year.Finally, although you can’t repair a ruptured tendon, you can use part of another tendon, such as the palmaris longus, for reconstruction. This is a longer procedure but probably the only real option if a player wants to get back to high-level tennis.

Ms Alice Bremner -Smith Consultant Orthopaedic Hand and Wrist SurgeonHer surgical practice encompasses all aspects of hand and wrist surgery. She has a particular interest in trauma including distal radius and scaphoid injuries.

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FEATURE | Ankle in Tennis

Lecture by Mr Callum Clark Consultant Orthopaedic Foot and Ankle Surgeon

We have footballer’s ankle and dancer’s fracture, but is there such a thing as tennis player’s ankle? Tennis injuries can be divided into acute and chronic. The most common acute injury is an inversion, which also accounts for about a quarter of all musculoskeletal injuries. The inversion injury is the nearest thing to tennis ankle.

Mr Callum ClarkConsultant Orthopaedic Foot and Ankle SurgeonHe specialises management of the full range of foot and ankle conditions.His surgical interests include arthritis and deformity correction, with a special interest in sports injuries and complex bunion and toe deformities.

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In the non-competitive tennis population, we also see ruptured Achilles tendons, which are quite widespread in sports involving sudden explosive action. The common chronic injuries are ankle pain and instability, plus Achilles tendinopathy.

A recent paper investigating acute injuries at the US Open (1994 – 2009) found that lower limb injuries outnumber upper limb, with the ankle being the most frequently affected part of the body, and inversion sprains the most common injury.

As with any joint, there are both static and dynamic stabilizers in the ankle – the ankle mortise is a good bony stabilizing factor in combination with ligamentous static stabilisers. The talus is shaped like a truncated cone which enables the foot to move up, down, in and out. There is also an unusual axis motion in the ankle which means that when you dorsiflex, the foot moves out and when you plantarflex, it moves in. Injury to the syndesmosis results in a high ankle sprain but this is not a common tennis injury. The weakest ligament, and so most commonly affected, is the broad, flat, thin ATFL. The PTFL is so strong it is rarely injured and although the CFL, the calcaneofibular ligament, is important clinically, it isn’t often injured.

Moving on to the peroneal musculotendinous unit, this is the dynamic stabilizer. Lots of studies have shown that the peroneal muscles react too slowly to stop an inversion injury happening – they haven’t started to contract by the time the injury has happened. Their role is to prevent the injury happening in the first place by holding the foot in the correct position. With tennis players, what is particularly relevant is the position of the foot when they land or slide. If it’s slightly inverted or internally rotated, this can cause lateral ligament sprains, a really common injury. So if tennis players can be trained to land with their feet in a neutral position, these injuries will be avoided.

About 5000 ankle inversions happen every day in England alone. Worldwide consensus is that approximately 95% of them resolve within six weeks. An elite athlete may push for surgery but the evidence is that there isn’t a great deal of difference in return to play between acute repair and conservative functional treatments. Functional rehabilitation is the best cure and even if this is a home exercise programme, there is a 35% reduction in the risk of re-injury.

Taping is a controversial ankle treatment. On one side there is evidence of minor skin problems in almost a third of patients, with a reduced range of motion and a reduction in the efficacy of the support after as little as 200 steps. On the positive side, some studies have shown that taping prevents re-injury, if used in the acute stages of the problem.

The evidence for bracing is much better, particularly if it’s

long-term, over a year for instance. The lace-up brace is very supportive but patients are resistant, due to the time taken lacing them. The Airsport, Aircast , A60 or A80 braces are fairly comfortable, fairly supportive, fairly effective and popular. Very comfortable braces are completely useless.

So what about the 5% who don’t recover quickly? ? Our job is to explore associated injuries such as fractures, peroneal retinacular injuries and articular cartilage damage, as well as investigating the possibility of longer term sequelae, including impingement and instability. We need to unpick the reasons why the patient hasn’t recovered..

If the patient has recurrent inversion injuries, they have ankle instability of some sort. This can be either functional instability, without lax ligaments, or mechanical instability, where the ankle gives way and the ligaments are loose. Potentially, if the patient has loose ligaments, we can tie them up again.

If neuromuscular rehabilitation hasn’t worked, surgery may be the only option. In the past the usual operation to anchor a tendon to a bone was a tenodesis. This operation was non-isometric, involved long incisions, frequently resulted in stiffness post-op and only 50% of them were satisfactory, with two-thirds of the patients not returning to sport.

The operation of choice now is the modified Brostrom-Gould procedure. The surgeon goes into the ankle, finds what’s left of the ligament and attaches it to the fibula through drill holes or via suture anchors.Then the ATFL and the CFL can be re-attached back on to the bone and tightened. An arthroscopy is usually performed at the same time to deal with any synovitis or impingement. One benefit of this method is that it doesn’t over-tighten the joint. However, if the patient has a varus heel, it won’t work, unless combined with a heel-shift osteotomy to realign the biomechanics. Some surgeons are combining the arthroscopic Brostrom Gould with thermal capsular shrinkage, but I am not yet convinced of its benefit. What I have found useful, particularly for patients with hypermobility syndrome, is putting a little carbon fibre brace on top of the Brostrom reconstruction. These work as an internal brace to prevent the Brostrom from stretching out too tight.

The Brostrom-Gould procedure is performed as a day case procedure. The patient elevates their foot at home for ten days, wound protected in a non-weight bearing splint. Next they use a brace, an Airsport for example, to start weight bearing. Physio commences after six weeks and training after three to four months. A recent paper studying 55 of these operations found that over three years later, 96% had returned successfully to their sport.

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July lecture: WatersportsLectures by:

Mr Nick Savva

Consultant Foot & Ankle Surgeon

Mr Ali NarvaniConsultant Shoulder and Elbow Surgeon

Mr David HargreavesConsultant Hand and Wrist Surgeon

To be added to the invite list please email: RSVP@fortiusclinic.com

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Fortius International Sports Injury ConferenceTreatment, recovery and return to play

For more information please visit the FISIC website: www.fisic.co.uk or call Harriet Webb on 0203 195 2434 (harriet.webb@fortiusclinic.com)

Bone healthThe biology of bone repair; bone health in the female athlete; vitamin D deficiency, supplements & use as a hormone to enhance injury recovery; medical treatments to aid bone repair; the use of exogen - science and clinical application.

ConcussionDr Bob Cantu, Dr Caroline Finch, Dr Jon Patricios and Dr Willie Stewart from World Rugby advisory board discuss the science of concussion, how to recognise and remove it, including management of the difficult case and what do we know of the potential long-term consequences.

Disability sportCovering topics such as: sports science and coaching in sports medicine; performance physiotherapy for disability sport; the athlete/paralympian perspective; complexity of sports psych in disability sport; athlete classification and ethical issues in disability sport.

Muscle injuries Science of muscle injuries & repair going on to Acute injuries: Best medical management for successful RTP; imaging acute lower limb muscle injuries: Predicting return to play; best management & optimising RTP following contusion injuries & myositis ossificans; chronic recurrent tears and return to function; surgical indications for hamstring injury.

Return to play The psychology and nutritional aspects of return to play; RTP post max-fax injuries; the environment needed to facilitate smooth RTP; objective criteria for safe return to play.

Rugby sessionA look at the player anthropometrics, match & training events/demands & volumes that characterise the modern game of 15’s; an overview of the known injury risk, injury profile and current trends in injury in professional 15 a

side rugby, community & age-group rugby; the skills needed to work pitch-side in rugby union; how individual practitioners can reduce the risk of injury to a team.

The Adolescent AthleteCovering: Spinal pain in adolescent sports, strength and conditioning training; apophysitis and soft tissue injuries; CL tears and reconstruction in children & adolescents; osteochondritis dissecans and imaging the adolescent athlete.

The future of cell therapies - Fact or fiction• Current status of stem cell therapies in cartilage repair - the science and the realities • From equine to human – bone marrow aspirate and cell therapies • Debate regarding the efficacy of PRP

Joint specific sessionsThere will also be a wide range of joint specific sessions including knee, foot & annkle, shoulder, spine, hip & groin and hand & wrist sessions.

Programme highlights for Physios and Sports Exercise professionals include:

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Radiology Team| Thanks to our specialist orthopaedic imaging consultants and state-of-the-art facilities, we can quickly and accurately diagnose musculoskeletal complaints.

Our advanced technology enables us to provide a rapid diagnosis from high quality images, be it for elite athletes in a variety of sports or for those with injuries or troublesome conditions.

For more information please visit our website: www.fortiusclinic.com or call +44(0) 203 195 2442

Dr Adam MitchellMB BS FRCS FRCR

Dr Jeremiah HealyMA MB BChir FRCP FRCR FFSEM

Dr Justin LeeBSc MB BS MRCS FRCR

Dr Chris WilliamsBSc MBBS MRCP FRCR Dr Monica Khanna

MBBS BSc (Hons) MRCS FRCR

Dr Charles WakeleyBsc MBBS FRCSed FRCS FRCR

Dr Richard HughesMA BMBCh MRCP FRCR

Dr Jonathan BrantMA MB BChir (Cantab) MRCP FRCR

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For further information or to book an appointment, please contact us:

t: +44 (0) 203 195 2442 f: 0203 070 0106 e: appointments@fortiusclinic.comw: www.fortiusclinic.com

Don’t forget to follow us on Twitter @FortiusClinicUK.

You will also find us on Facebook and LinkedIn

How to find us:Fortius Clinic is situated in Central London, close to Selfridges, and just off Manchester Square.

17 Fitzhardinge Street London W1H 6EQ

Dr Jeremiah HealyMA MB BChir FRCP FRCR FFSEM