Katherine Rae

Injury classification systems are generally used in sports medicine (1) to accurately classify diagnoses for summary studies, permitting easy grouping into parent categories for tabulation and (2) to create a database from which cases can be extracted for research on specific injuries. Clarity is most important for the first purpose, whereas diagnostic detail is particularly important for the second. An ideal classification system is versatile and appropriate for all sports and all data collection scenarios. The Orchard Sports Injury Classification System (OSICS) was developed in 1992 primarily for the first purpose, a specific study examining the incidence of injury at the elite level of football in Australia. As usage of the OSICS expanded into different sports, limitations were noted and therefore many revisions have been made. A recent study found the OSICS-8, whilst superior to the International Classification of Diseases Australian Modification (ICD-10-AM) in both speed of use and 3-coder agreement, still achieved a lower level of agreement than expected. The study also revealed weaknesses in the OSICS-8 that needed to be addressed. A recent major revision resulted in the development of the new 4-character OSICS-10. This revision attempts to improve interuser agreement, partly by including more diagnoses encountered in a sports medicine setting. The OSICS-10 should provide far greater depth in classifications for the benefit of those looking to maintain diagnostic information. It is also structured to easily collapse down into parent classifications for those wanting to preserve basic information only. For those researchers wanting information collected under broader injury headings, particularly those not using fully computerized systems, the simplicity of the OSICS-8 system may still suffice.

Objective Our aim was to investigate the diagnostic accuracy of the clinical presentation of ankle syndesmosis injury and four common clinical diagnostic tests. Design Cross-sectional diagnostic accuracy study. Setting 9 clinics in two Australian cities. Participants 87 participants (78% male) with an ankle sprain injury presenting to participating clinics within 2 weeks of injury were enrolled. Methods Clinical presentation, dorsiflexion-external rotation stress test, dorsiflexion lunge with compression test, squeeze test and ankle syndesmosis ligament palpation were compared with MRI results (read by a blinded radiologist) as a reference standard. Tests were evaluated using diagnostic accuracy, sensitivity, specificity and likelihood ratios (LRs). A backwards stepwise Cox regression model determined the combined value of the clinical tests. Results The clinical presentation of an inability to perform a single leg hop had the highest sensitivity (89%) with a negative LR of 0.37 (95% CI 0.13 to 1.03). Specificity was highest for pain out of proportion to the apparent injury (79%) with a positive LR of 3.05(95% CI 1.68 to 5.55). Of the clinical tests, the squeeze test had the highest specificity (88%) with a positive LR of 2.15 (95% CI 0.86 to 5.39). Syndesmosis ligament tenderness (92%) and the dorsiflexion-external rotation stress test (71%) had the highest sensitivity values and negative LR of 0.28 (95% CI 0.09 to 0.89) and 0.46 (95% CI 0.27 to 0.79), respectively. Syndesmosis injury was four times more likely to be present with positive syndesmosis ligament tenderness (OR 4.04, p=0.048) or a positive dorsiflexion/external rotation stress test (OR 3.9, p=0.004). Conclusions Although no single test is sufficiently accurate for diagnosis, we recommend a combination of sensitive and specific signs, symptoms and tests to confirm ankle syndesmosis involvement. An inability to hop, syndesmosis ligament tenderness and the dorsiflexion-external rotation stress test (sensitive) may be combined with pain out of proportion to injury and the squeeze test (specific).

OBJECTIVES: To determine the rates of muscle strain injury recurrence over time after return to play in Australian football and to quantify risk factors. METHODS: We analysed Australian Football League player data from 1992 to 2014 for rates of the four major muscle strain injury types (hamstring, quadriceps, calf and groin) diagnosed by team health professionals. Covariates for analysis were: recent history (≤8 weeks) of each of the four muscle strains; non-recent history (>8 weeks) of each; history of hip, knee anterior cruciate ligament, knee cartilage, ankle sprain, concussion or lumbar injury; age; indigenous race; match level and whether a substitute rule was in place. RESULTS: 3647 (1932 hamstring, 418 quadriceps, 458 calf and 839 groin) muscle strain injuries occurred in 272 759 player matches. For all muscle strains combined, the risk of injury recurrence gradually reduced, with recurrence risks of 9% (hamstring), 5% (quadriceps), 2% (calf) and 6% (groin) in the first match back and remaining elevated for 15 weeks after return to play. The strongest risk factor for each muscle injury type was a recent history of the same injury (hamstring: adjusted OR 13.1, 95% CI 11.5 to 14.9; calf OR 13.3, 95% CI 9.6 to 18.4; quadriceps: OR 25.2, 95% CI 18.8 to 33.8; groin OR 20.6, 95% CI 17.0 to 25.0), followed by non-recent history of the same injury (hamstring: adjusted OR 3.5, 95% CI 3.2 to 3.9; calf OR 4.4, 95% CI 3.6 to 5.4; quadriceps OR 5.2, 95% CI 4.2 to 6.4; groin OR 3.5, 95% CI 3.0 to 4.0). Age was an independent risk factor for calf muscle strains (adjusted OR 1.6, 95% CI 1.3 to 2.0). Recent hamstring injury increased the risk of subsequent quadriceps (adjusted OR 1.8, 95% CI 1.2 to 2.7) and calf strains (OR 1.8, 95% CI 1.2 to 2.6). During the 'substitute rule' era (2011-2014), hamstring (adjusted OR 0.76, 95% CI 0.67 to 0.86), groin (OR 0.78, 95% CI 0.65 to 0.93) and quadriceps (OR 0.70, 95% CI 0.53 to 0.92) strains were less likely than outside of that era but calf (OR 1.6, 95% CI 1.3 to 1.9) strains were more likely than before the substitute rule era. CONCLUSION: Recent injury is the greatest risk factor for the four major muscle strains, with increased risk persisting for 15 weeks after return to play.

AIMS: To determine whether a single ultrasound-guided platelet-rich plasma (PRP) injection into the anterior inferior tibiofibular ligament (AITFL) reduces the time for rugby athletes to return to function and match play following MRI confirmed ankle syndesmosis injury. METHODS: Cohort controlled pilot study. 10 Rugby Union players were recruited during the 2014 season, and consented to receive a single autologous PRP injection into the AITFL within 14 days of MRI confirmed ankle syndesmosis injury. A historical control group included 11 comparable Rugby Union players between 2011 and 2013 who were treated conservatively with the same inclusion criteria and rehabilitation protocol as the intervention group. Participants followed a standardised rehabilitation protocol involving simple milestones for progression. Early functional tests were performed 2 weeks after the removal of the CAM (controlled ankle motion) boot. Time to return to play was recorded. Repeat functional testing occurred within 1 week of return to play. RESULTS: Groups were comparable in anthropometrics, playing position and MRI injury severity. Time to return to play was significantly less in the intervention group (p=0.048). Following return to play, athletes in the intervention group showed higher agility (p=0.002) and vertical jump (p=0.001). There was a lower level of fear avoidance associated with rugby in the intervention group (p=0.014). CONCLUSIONS: This pilot study shows that, following ankle syndesmosis injury, a single autologous PRP injection may accelerate safe and successful return to Rugby Union, with improved functional capacity and reduced fear avoidance. It demonstrates the feasibility of a randomised controlled trial to further assess this therapy. TRIAL REGISTRATION NUMBER: ANZCTRN12614000055606.