ISSN NO: 2397-6640 SEPTEMBER 2020 | VOL 17 ISSUE 01 | BY SUBSCRIPTION ONLY

Japan’sJapan’an s ToshinariTo TakTakaokaaokka rraisesa his fisfifiststss aass he wins thetthe 220200500055 Tokyo IntInIInternationalnteerrrnn MarMMarathonaatathhon held in ToTokTokyo,yyooo, Japan.

NECKECK & BACK INJURIESJURIES LUMBAR TRANSVERSE PROCESS FRACTURE IN SPORT: RARE OR UNDERREPORTED?

CORE INJURIES MIND THE GAP: DIASTASIS RECTI IN POSTPARTUM ATHLETES

KNEE INJURIES CYCLOPS LESIONS AFTER ACL RECONSTRUCTION: SOMETHING TO KEEP AN EYE ON

INJURY PREVENTION BELIEFS AND BARRIERS TO INJURY PREVENTION IN RECREATIONAL RUNNERS IN THIS ISSUE

In this issue ISSN NO: 2397-6640 SEPTEMBER 2020 | VOL 17 ISSUE 01 | BY SUBSCRIPTION ONLY

Japan’sJapan’an s ToshinariTo TakTakaokaaokka rraisesa his fisfifiststss aass he wins thetthe 220200500055 Tokyo IntInIInternationalnteerrrnn LUMBAR TRANSVERSE PROCESS MarMMarathonaatathhon held in ToTokTokyo,yyooo, Japan. FRACTURE IN SPORT: NECKECK & BACK INJURIESJURIES RARE OR UNDERREPORTED? LUMBAR TRANSVERSE 03 PROCESS FRACTURE IN SPORT: RARE OR UNDERREPORTED?

MIND THE GAP: CORE INJURIES MIND THE GAP: DIASTASIS RECTI DIASTASIS RECTI IN POSTPARTUM 06 IN POSTPARTUM ATHLETES ATHLETES KNEE INJURIES CYCLOPS LESIONS AFTER ACL RECONSTRUCTION: SOMETHING TO KEEP CYCLOPS LESIONS AFTER ACL AN EYE ON

INJURY RECONSTRUCTION: SOMETHING PREVENTION BELIEFS AND TO KEEP AN EYE ON BARRIERS TO INJURY 10 PREVENTION IN RECREATIONAL RUNNERS

BELIEFS AND BARRIERS TO INJURY PREVENTION IN RECREATIONAL 13 RUNNERS

ALICIA TRACY CHRIS ANDREW FILLEY WARD MALLAC HAMILTON Editor Contributor Contributor Contributor

Alicia Filley Tracy is a senior Chris Mallac Andrew is a PT, MS. lives in physiotherapist is a sports sports science Houston, Texas and has 25 specialising in musculoskeletal physiotherapist, writer and researcher, specialising years’ experience working in and sports injuries within a private and strength and conditioning in sports nutrition and he has health, sports physiotherapy hospital in Aberdeen. She is a coach. He is currently the head of worked in the field of fitness performance at Aviva Premiership and rehabilitation, and sport certified Pilates Instructor and and sports performance for rugby club London Irish, and has performance. She is also a also a pilates course tutor for the over 30 years, helping athletes also worked as head of sports regular contributor to Peak APPI. She previously worked with to reach their true potential. medicine at Bath Rugby and head high level athletes for Scottish Andrew is also a lifelong Performance’s sister publication physio at Queensland Reds Super Hockey and within rugby, rowing, endurance athlete himself. As ‘Sports Injury Bulletin’. When Rugby. In addition, Chris has and triathlon. Tracy blogs about well as his role as editor of Peak not writing and researching, worked within Australian Rules pilates, fitness and rehab on her Alicia can be found putting her Football at the Brisbane Lions, Performance he is a scientific research to the test outside on website and creates videos for and with Australian women’s consultant to the fitness and the trail and inside in the gym. YouTube. hockey and softball. sports nutrition industries. BRINGING SCIENCE TO TREATMENT

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2 SPORTS INJURY BULLETIN VOL 17 ISSUE 01 NECK & BACK INJURIES Lumbar transverse process fracture in sport: rare or underreported?

Fractures of the lumbar transverse process can occur during a sporting activity and may be more common than thought. Andrew Hamilton explains and provides some guidelines for clinicians

ost of the reported transverse with chronic lower back pain, but without process fractures (TPFs) result any obvious impact trauma(11). The from high-impact traumas, researchers concluded that the most likely Msuch as traffic accidents(1-4). explanation was repeated small stresses The high-energy traumas that cause TPF on the spine associated with fast-bowling. fractures usually also result in complex underlying injuries(5). However, in athletes, TPFs happen in isolation, likely because FIGURE 1: SOCCER MATCH of a much lower-energy mechanism of FALL PRECIPITATING LUMBAR TPF (6) injury(6). Because of these differences, definitive diagnosis and injury management strategies gleaned from the general population may not apply to athletes

TPF INJURY IN SPORT: HOW COMMON? Transverse process fractures caused by stress are likely under detected since even an acute transverse process fracture requires a high index of suspicion to be correctly identified(4,7). However, since TPFs can also occur due to repetitive loading, this underreporting may be quite significant(8). Given the lack of research on sport-related TPF injuries, it is difficult to determine their frequency among the athletic population – especially since many of the studies are case studies or epidemiological reports such as: • A case of TPF in the L1 vertebra of a trainee association footballer, resulting from an impact with the goalkeeper’s knee to the player’s back, and complicated by a traumatic transverse colon rupture requiring a stay in intensive care(9). • A case of lumbar TPF at both L2 and L3 (confirmed on a CT scan) during an American football game caused by a ‘spear’ in the back(10). • A case of multiple displaced lumbar TPF Freeze-frame capture from two angles showing the fall preceding the TPF injury. *Used with permission. (L1–5) in a cricket bowler who presented

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• A retrospective study of snow-sport athletes which found 43 discreet FIGURE 2: CT SCAN OF THE LUMBAR SPINE* instances of TPF injury over five years, accounting for no less than 29% of all fractures reported. In this case, the researchers argued that these injuries were likely secondary to avulsion forces caused by an intense muscle spasm following a fall impact(12). • A 1995 review study documented 29 cases of lumbar TPF in the American National Football League(13). • A case study described a rower with a stress fracture of the left transverse process of the third lumbar vertebra(8). ETIOLOGY OF TPF INJURY As mentioned, most lumbar TPF injuries result from the impact of an external force on the lower back. This mechanism of injury usually occurs from player-to-player contact via a collision. However, a fall to the ground can generate sufficient force to cause a TPF. In a 2015 case-study paper,

Matthew Gray and Paul Catterson, working Visualized using an axial slice, showing left TPF at L2. in conjunction with the Freeman Hospital, *Used with permission. Newcastle Upon Tyne, UK, and Newcastle United Football Club, documented the case of a lumbar TPF injury suffered by a soccer absence of trauma, the muscles and player resulting from an impact with the turf their attachments played a significant following an attempted overhead kick(6). role in developing her stress fracture. In a game situation, the player attempted This mode of injury seems entirely an acrobatic overhead-kick clearance feasible since, under race conditions, female during which he landed on his left side and rowers can generate forces in the lumbar lower back (see figure 1). Suffering extreme When spine approaching or even exceeding lumbar pain, the athlete discontinued 700Newtons(14). Moreover, multiple tissues play. A magnetic resonance imaging (MRI) repeated are acting on the lumbar transverse scan the following day revealed lumbar over processes. In particular, the middle layer edema, which suggested a left-sided TPF of lumbar fascia (which attaches the of the L2 and L3 vertebrae. A computed time, transversus abdominis and internal obliques) tomography (CT) scan done 24-hours even can transmit enough force to tear off the later confirmed the initial diagnosis and lumbar transverse processes(15,16)! This rower revealed minor anterior displacement smaller also developed a relative energy deficiency of the fracture at L2 (see figure 2). The due to overtraining and restrictive eating impact forces generated by falling from a loadings habits in the 24 months before her TPF modest height onto turf are relatively low to the injury – a well-documented risk factor for compared to a motor vehicle accident, yet, stress fractures (see this article for a full large enough to result in a TPF injury. spine discussion of relative energy deficiency). When repeated over time, even smaller may loadings to the spine may result in TPF TPF DIAGNOSIS injury. In the case study involving the result in A TPF diagnosis relies on a combination rower cited above(8), the injury occurred of a physical examination to exclude other while rowing in a coxless pair during a TPF conditions that produce lower back pain, practice session. There was no reported injury. and imaging to confirm. An athlete will precipitating event or trauma, yet she likely present with lower back pain that suffered a left L3 non-displaced stress worsens with transitional movements. fracture of the transverse process one Spinal rotation may be particularly painful. month after the onset of symptoms. Palpitation of the affected side may cause The researchers postulated that in the diffuse pain, with obvious tenderness and

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hypertonicity in the paraspinal muscles. the following possible causes of pain: To make the diagnosis, obtain a detailed • Soft tissue contusion or muscle strain history of the patient’s activities before • Rib fracture the onset of pain – noting any possible • Lumbar spine bony injury impacts or falls. In the absence of trauma, • Pneumothorax clinicians should inquire about training loads • Renal trauma where the athlete participates in sports • Splenic trauma with significant spinal loading – particularly • Other intraperitoneal visceral injuries whether the athlete has increased their When TPF is suspected imaging can training volume or intensity before the confirm the diagnosis. Plain X-ray imaging onset of pain. The combination of excessive alone may miss a TPF injury(4); instead, an training and a history of poor or disordered MRI and CT scan is preferred. MRI scans are eating or efforts to lose weight can cause best visualized using T1- and T2-weighted osteopenia and increase fracture risk. axial sequences, whereupon oedema of With precipitating trauma to the the bone will likely also be observed. lumbar region, clinicians need to exclude

MANAGEMENT: CONSERVATIVE IS BEST

Because TPFs are rarely The use of a back brace during athlete is symptom-free after reported and studied, the the early stages of healing may eight weeks, they can resume light literature lacks a consensus on increase the athlete’s comfort. training that more closely reflects the appropriate management However, without evidence of their typical sporting activity. protocol. However, given that instability, these devices aren’t Advance their activity over the isolated TPF injuries in athletes necessary and may hamper the next four to six weeks as tolerated. are typically stable and not natural healing process(18). Assuming the athlete remains associated with neurological Following an initial period symptom-free, they can return to deficits, clinicians favor of rest for one to three weeks, sport at that point. Some studies conservative treatment strategies introduce low-level light activity report faster return-to-play times over surgical intervention(17). with minimal spinal loading, such than those suggested here(13), so Following a confirmed as stationary cycling. During the let the individual’s symptoms and diagnosis of TPF, evidence early stages of rehabilitation, function guide their transition suggests that the early treatment the use of compression straps back to full sporting activity. protocol should consist of oral during exercise can help increase painkillers (such as NSAIDs) comfort. Over the next six to eight along with muscle relaxants weeks, progressively increase (if spasms are present) and activity levels while avoiding gentle guarded movement(18). excessive spinal loading. If the

References 1. J Emerg Med 2005;28:147–52 2. Injury 2000;31:773–6 3. Radiology 2000;215:831–4 4. Clin Orthop Relat R 1996;327:191–5 5. World Neurosurg. 2017;104:82-88 6. Oxford Medical Case Reports. 2015; (5):288-291 7. J Manipulative Physiol Ther. 2001;24(2):123-126 8. Orthopaedic Journal of Sports Medicine 2020; 8(3), 2325967120910146 DOI: 10.1177/2325967120910146 9. Br J Sports Med 2006;40:e6 10. J Manipulative Physiol Ther 2001;24:123–6 11. SMARTT 2011;3:8 12. Am J Sports Med 2012;40:1750–4 13. Am J Sports Med. Jul-Aug 1995;23(4):507-9 14. Int J Sports Med. 2000;21(7):518-523 15. Clin Biomech (Bristol, Avon). 2010;25(6):505-509 16. Eur Spine J. 2007;16(12):2232-2237 17. World Neurosurg Nov 2018. doi: 10.1016/j.wneu.2018.11.147 18. World Neurosurg. 2017;100:336-341

5 SPORTS INJURY BULLETIN VOL 17 ISSUE 01 CORE INJURIES Mind the gap: Diastasis recti in postpartum athletes

2016 Rio Olympics – Athletics – Final – Women’s Heptathlon 800m – REUTERS/David Gray

Tracy Ward explains why even elite athletes can suffer from diastasis recti during the postpartum period, and how clinicians can comprehensively assess and treat this condition

emale athletes often experience the or exertion. In these circumstances, elite peak of their physical performance female athletes can experience persistent and their optimal fertile age postpartum diastasis recti (DR). Fsimultaneously. Many female Diastasis recti refers to the separation of athletes continue to train during pregnancy the outermost abdominal muscles due to the and the postpartum period – but even elite thinning and widening of the line alba (the female athletes are not exempt from the connective tissue between the two muscle typical musculoskeletal issues that can bellies of rectus abdominus)(1). The criteria for arise during pregnancy. These issues may the diagnosis of DR is a separation or gap of be aggravated in athletes who experience more than 1.5cm at one or more points of the vigorous loading and high volumes of impact linea alba, (see figure 1)(2).

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change in posture reduces the integrity, FIGURE 1: LINEA ALBA AND OBSERVED mechanical control, and strength of the PATTERNS OF DIASTASIS RECTI* abdominal muscles. The abdominal muscles, including the deep transversus abdominis (TVA), the pelvic floor muscles, the multifidus, and the diaphragm work together to provide stability to the trunk; therefore, dysfunction in one of these influences the function(s) of the other(9). During physical exertion, increased intra-abdominal pressure (IAP) can cause the anterior abdominal wall to bulge at the location of the DR(8). This weakness can affect the transfer of load through the lumbar spine and pelvis, leading to low back and pelvic pain. Diastasis recti is also linked to pelvic floor muscle weakness. Pelvic floor weakness can lead to incontinence and pelvic organ prolapse. A study conducted at Andrews University found that in those with urological disorders, approximately half had DR, and 66% had pelvic floor dysfunction(10). Because DR is associated with pelvic floor instability and The ‘normal’ panel (top left) shows the typical anatomy with the linea alba. Patterns incontinence, treatment should include an of separation can vary. In a study of 92 women by Corvino et al 2019, researchers investigation of the entire abdominal girdle. A identified five distinct patterns: pattern 1 – only above navel (58.5%); pattern 2 – only below navel (1.2%); pattern 3 – at navel level (8.5%); pattern 4 – complete but wider patient may come into the clinic because they above navel (29.3%); pattern 5 – complete but wider below navel (2.4%). don’t like the ‘pooching’ in their stomach, but *diagram adapted from Corvino at al [Pol J Radiol. 2019; 84: e542–e548]. not mention the other pelvic floor issues out of embarrassment. Therefore, every complaint of Diastasis recti can occur as early as DR, even in the early postnatal period, warrants week 14 in pregnancy, and by week 35 of a full evaluation and treatment plan. gestation, 100% of women will experience some DR(3,4). Approximately half of these ASSESSMENT resolve spontaneously postpartum, or within OF A DIASTASIS RECTI the first eight weeks(5). However, up to 45% Previous DR assessments have focused solely of women may have DR that remains at six on measuring the gap between the rectus months postpartum and 32% at 12 months abdominis muscle bellies. However, this does postpartum(6). When DR fails to resolve in a not provide information on the tensile strength timely fashion, some conservative management and function of the abdominal wall, or the interventions can help. individual’s ability to control the muscles. This In those knowledge is fundamental to returning an ANATOMY AND FUNCTION athlete to function. Therefore, a more astute with The abdominal muscles support the internal evaluation should include: organs, and the linea alba (see figure 1) maintains urological 1. Tension – Tension occurs when the core the mechanical stability of the abdominal wall. disorders, and pelvic floor are engaged, and the region It is the central tissue that connects the fascia proximately becomes taught as the muscle contraction covering the rectus abdominis muscle and is the a takes up slack. Ideally, measure the tension insertion point for all three abdominal muscles(7). half had DR. in standing. Initially, palpate the line alba Collectively, the fascia and muscles help support without any contraction to identify firmness, the pelvis and lumbar spine. width of gap, and depth. As the pregnancy develops, the growth 2. Determine measurements – Quantify your of the uterus and accompanying hormonal assessment on a scale of one to five, with one changes cause an alteration in the elasticity being very poor and five being excellent in of the connective tissue, which results in a terms of muscle quality, firmness, and depth displacement of the abdominal wall(7,8). As of softness. the uterus expands outwards, the pelvis 3. Repeat with engagement – Repeat step one, compensates by tilting anteriorly, which but this time engage the core and pelvic floor elongates the abdominal and pelvic floor while palpating the line alba. Identify any muscles and stretches the linea alba(7). This changes in comparison.

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4. Compare in different positions – Repeat the widens the gap; however, if the TVA is process in different positions to identify if the pre-activated before the rectus abdominis, athlete can control their abdominal tension the combined effect is a closure of the gap and throughout, or if they lack strength in a prevention of linea alba distortion. specific postures. Therefore, focus the initial treatment on the recruitment of the deep core muscles. PPP-RL-LD Then, progressively load the abdominals to Follow the initial examination of the muscle induce muscle hypertrophy and increase integrity with an assessment of other factors metabolic demand. The results of a progressive indicated by the acronym PPP-RR-LD(11). This strengthening program include increased stands for: Focus strength, endurance, and power capacity. A •Person: Establish the individual’s history the initial program of eight weeks of deep-core stability with diastasis, goals, and rehabilitation treatment exercises produces significant reductions in the expectations to personalize their treatment on the intra-rectus distance (the anterior muscle gap) plan. and improves the quality of life(7). •Posture: Body position affects DR and recruitment That said, a return to full strength and influences the intra-recti distance (being of the deep integrity can take much longer than the wider in upright positions)(12). Some postures core average muscle hypertrophy timeframe of may also affect muscle recruitment so 12 weeks. The linea alba lacks an abundance muscles. evaluate DR’s severity in a range of different of collagen fibers. Thus, adaptation and postures. remodeling of the connective tissue can take •Patterns: Compensatory patterns, such as rib up to two years(14). flaring, abdominal gripping, or overactivity of the oblique muscles, may develop due to the REHABILITATION EXERCISES reduced abdominal muscle function. All of FOR DIASTASIS RECTI these may impact the pelvic floor and reduce the efficiency of normal movement. Primary activation: Start with foundational •Respiration: The diaphragm’s involvement exercises to ensure coordination, activation, in the synergy of core control is important postural awareness, and the ability to control to restore coordination and management of the load with the abdominal wall. IAP. Exhalation also improves recruitment • Core and pelvic floor activation (see figure 3): of the TVA, thus use breathing patterns as a strategy to influence muscle activity(13) •Ribcage: The ribcage expands outwards FIGURE 2: ABDOMINAL DOMING during inhalation and provides dynamic assistance during muscle activity. However, rib flaring during a loaded exercise is a compensation strategy and highlights abdominal weakness. •Load: Progressive loading stimulates adaptation in the muscles of the abdominal wall. Begin with the maximum loading the athlete can withstand without compensation, ie. with no doming or deviation from a neutral lumbopelvic position (see figure 2). •Defect: The DR may exacerbate postpartum defects in the abdominal wall, such as hernias. Refer these patients to a physician for diagnosis and treatment before proceeding with DR rehabilitation activities.

TREATMENT Simply activating core muscles isn’t enough to resolve DR. While rectus abdominis activation Doming occurs when there is an increase in IAP, and the abdominal wall cannot via an abdominal curl-up reduces the intra- manage the pressure sufficiently. This outpouching of the abdominal wall occurs abdominal distance of the DR, it also distorts on a continuum (see figure 2). Rather than preventing an athlete from completing an exercise if doming occurs, adapt the exercise instead. Modifying the level and the linea alba. This distortion produces less technique of core engagement, breathing pattern, and posture can reduce doming and tension and an inefficient transfer of loads provide increased abdominal control. Progress exercises gradually to ensure correct across the pelvis. Contraction of the TVA activation and control before advancing to the next harder level.

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Begin in crook lying. Engage core Functional activation: A DR causes trunk approximately 30% and lift pelvic floor from rotation and flexion deficits; therefore, the back passage, middle, to front passage, rehabilitation should address these by loading then fully release. A soft ball between the in these specific movements. These are also knees helps with awareness of these muscles. functional for everyday life and essential to • Double-leg stretch (see figure 4): Extend every sporting activity. both arms overhead and simultaneously extend one leg away from you. Use the core IN SUMMARY to return, maintaining a neutral trunk. Diastasis recti is a separation of the anterior • Abdominal preparation (see figure 5): Lift abdominal muscles and thinning of the linea upwards from the core, keeping a neutral alba, and occurs in 100% of women by the third spine until the shoulder blades are almost off trimester. Around half of the cases resolve the floor. Return to starting position. naturally, while the rest require rehabilitation. Prioritize DR rehabilitation within the first three months postpartum to avoid adverse changes FIGURE 3: CORE AND PELVIC FLOOR in posture, pelvic floor dysfunction, and low ACTIVATION back pain. The assessments should measure tension at rest and upon abdominal activation, and then expanded using the acronym PPP- RR-LD. Treatment should maximize the pre-activation of the TVA before the rectus abdominis contraction. Make the abdominal strengthening program functional and prescribe the maximum load achievable with Diastasis control of doming and lumbopelvic stability. recti... occurs References 1. J of Pelvic, Obst and Gynaecol Physiother. 2019; 124:15- in 100% 19. 2. Clinical anatomy, 2009. (6):706-711. 3. Phys Ther, of women 1996;76:750–62. 4. Manual Therapy, 2015. (1):200-205. FIGURE 4: DOUBLE-LEG STRETCH 5. Manual Therapy, 2008. 13(2):112-121. by the 6. Br J Sports Med. 2016;50:1092-1096. third 7. J Musculoskeletal Neuronal Interact. 2019; 19(1):62-68. 8. Ginekologia Polska. 2018; 89(2):97-101. trimester. 9. J Phys Therapy Science. 2015; 27(7): 2113-2115. 10. J Womens Health Phys Therap. 2009;33(2): 15-22. 11. J Pelvic, Obst and Gynaecol Physiother. 2019; 124: 15- 19. 12. Musculoskel Science and Practise. 2018; 34:1-7. DOI: 10.1016/j.msksp.2017.11.010 13. Neurourology and Urodynamics. 2007; 26(3): 362-371. 14. Clinics (Sao Paulo). 2018; 73: e319.

FIGURE 5: ABDOMINAL PREPARATION

9 SPORTS INJURY BULLETIN VOL 17 ISSUE 01 KNEE INJURIES Cyclops lesions after ACL reconstruction: something to keep an eye on

Cyclops lesions are a common cause of range irst described in 1990 by Jackson of motion limitations after ACL econstruction. and Schaefer(1), a cyclops lesion is a defines the malady, explores the reasonably common complication Chris Mallac Ffollowing anterior cruciate ligament causes, and suggests ways to prevent this reconstruction (ACLR), with the majority syndrome from occurring. being benign and asymptomatic(2). These lesions can also develop in knees that have had ACL injury without a reconstruction(3). These nodes lead to a loss of terminal extension, ongoing anterior knee pain, and altered gait and landing mechanics.

CYCLOPS LESION ANATOMY

The term ‘cyclops lesion’ comes from the arthroscopic appearance of the lesion, which resembles an eye. Seen as an ovoid-shaped mass with venous vessels in the center(1), these lesions are usually found in the femur’s intercondylar notch(4,5). They occur in an estimated 10-25% of knees after ACLR(5,6). Lesions typically form within the first six months post-ACLR surgery and remain fairly constant in size over the two years following surgery. Lesions have an average size of 14mm x 8mm and result in a loss of about 19 degrees of extension(5). They consist of a fibrovascular nodule of tissue that forms anterolateral to the tibial tunnel of the ACLR graft. Fibrous with a dense proliferation of vessels, the lesions are either hard and comprised of bone tissue(1,5), or soft and made of fibrocartilage. The latter is called a cyclopoid lesion(5). Their occurrence does not correlate with an athlete’s age, sex, the time between injury and surgery, or the

2010 Ledley King with Rehabilitation and Conditioning Coach Nathan Gardiner, type of graft fixation (patella versus hamstring Action Images / Peter Cziborra Livepic graft)(6-8). Whether the lesion is hard or soft may determine whether a patient loses range of movement in knee extension. The size of the node also affects the incidence of mechanical

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symptoms. Cyclops syndrome occurs if the joint cartilage degeneration and early-onset lesion causes a loss of terminal extension osteoarthritis. due to an impingement at the intercondylar notch(1,5,9,10). This loss of extension range, IMAGING theoretically caused more often by hard Magnetic resonance imaging (MRI) offers the lesions, can be as great as 30º(9-11). However, best diagnostic test for cyclops lesions with a the differential diagnosis must include other sensitivity of 85%, a specificity of 84.6%, and reasons for a loss of extension following ACLR accuracy of 84.8%(18,19). Lesions appear as like(12): well visualized nodules with a convex anterior • Reflex inhibition due to joint effusion. border. On T1-weighted images, they appear • Excessively anterior tibial tunnel placement. with low to intermediate signal intensity. • Fixation of the graft at high knee flexion On ultrasound, they present as a soft tissue angles. mass within the intercondylar notch that • Generalized arthrofibrosis. has heterogenous hypo-echogenicity and hyperemia(13). ETIOLOGY OF CYCLOPS LESIONS Several factors contribute to the development MANAGEMENT of cyclops lesions(9,13): OF CYCLOPS LESIONS 1. Bone debris from drilling during the ACLR. Unfortunately for the clinician, a symptomatic 2. Anteriorly positioned graft. cyclops lesion causing loss of terminal 3. ACL stump remnants. extension – with or without a painful 4. Partially torn anterior graft fibers. clunk – cannot be rehabilitated. Instead, 5. Graft hypertrophy from impingement. A management consists of surgical debridement Wang and Yingfang proposed that the via arthroscopy followed by intensive lesion may develop due to an aggressive symptomatic physiotherapy to maintain the regained knee inflammatory process started at the graft cyclops extension. site of biologic grafts following surgery(14). lesion However, some suggest the most significant Research reveals the incidence is very low risk factor for developing an obstructive (2.5%) in those who receive a non-biologic causing cyclops lesion is the failure to regain full graft, such as a Leeds-Keio prosthesis, thus loss of extension in the early postoperative period(2,20). supporting this hypothesis(15). However, terminal The extension deficit at this early stage is likely non-biologic grafts also share similar risks as due to autogenic muscle inhibition (AMI)(21). biologic grafts, such as bone debris and less extension This phenomenon is a reflex loop whereby than optimal graft placement. cannot be the articular receptors are discharged due to Most cyclops lesions occur in single bundle rehabilitated. pain, inflammation, and capsular distention. grafts. The lesion’s location in single bundle This cycle leads to central nervous system- grafts is near the tibial tunnel, anterior to mediated changes in hamstring muscle tension the reconstructed graft, in the front of the and quadriceps deactivation(22). intercondylar notch, or from the tibial tunnel to The theory holds that if this reflex cycle the graft. In all instances, however, the cyclops becomes established, the limited range may lesion will adhere to the graft(4). Interestingly, in give space for the cyclops lesion to form and double-bundle grafts, the cyclops is found on eventually mechanically block extension. the roof of the intercondylar notch (16). Therefore, clinicians should focus on regaining terminal extension and breaking the AMI cycle SIGNS AND SYMPTOMS by minimizing effusion following ACLR surgery The primary complaint of an athlete suffering as quickly as possible (see box 1). from cyclops syndrome is a loss of knee extension with catching and snapping during REGAINING KNEE EXTENSION walking(16). The patient may also feel or hear There are many ways that clinicians can a ‘clunk’ with or without pain during terminal attempt to regain knee extension following extension(12). A study at the University of ACLR. These consist of a mix of passive California showed that patients with a cyclops stretching methods, soft tissue massage to the lesion demonstrate altered gait mechanics(17). posterior muscles such as hamstrings, popliteus These patients possessed sagittal plane loading and gastrocnemius, and active quadriceps patterns, which are different when compared exercises to facilitate knee extension (see to ACLR patients without a cyclops lesion. The figures 1 and 2). changed way of walking places higher peak loads on the knee, possibly leading to medial

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BOX 1: THE IMPORTANCE OF REMOVING EFFUSIONS FIGURES 1 AND 2: Knee joint effusion is a result of an intra-articular pathology which REGAINING EXTENSION VIA triggers the synovial membrane to secrete excessive synovial fluid. Otherwise known as joint swelling, the excess fluid is the body’s STRETCHING AND RESISTED attempt to remove any offending intra-articular debris. QUADRICEPS ACTIVATION The presence of an effusion is problematic for both the clinician and the athlete. Small volumes of excess fluid (as little as 20mls to 30mls) increase the pressure within the joint and inhibit muscle function by 50% to 60%(23-26). Furthermore, swelling alters the knee joint mechanics during landing tasks(27). Individuals with a knee effusion experience greater ground reaction forces and greater knee extension on landing, resulting in more force transferred to the knee joint and its passive restraints. Ways to manage and remove effusions include: 1. Assess the knee for effusions regularly, especially before loading. If the load is new or progressive, monitor the knee joint for the next 24 hours. 2. Remove the effusion if present. Conventional methods include elevation, compression with donut felt, effusion massage, and limited weight-bearing. Recommend medically-directed interventions such as non-steroidal anti-inflammatory medication (NSAIDs) or direct needle aspiration if indicated. Removing the internal fluid will significantly reduce the internal pressure within the knee and improve quadriceps strength. 3. Select appropriate exercises, like quadriceps exercises performed in positions of partial (20°) knee flexion or isometric squats in 20-30° flexion. These exercises allow muscle recruitment without increasing the intra-articular pressure associated with full knee extension. 4. Early pool work also provides hydrostatic pressure to aid with effusion drainage.

SUMMARY Cyclops lesions are reasonably common, usually occurring as a benign consequence of a biologic ACLR. If they form a hard and large mass, they may eventually block knee extension in the six months following ACLR causing pain, discomfort, and altered knee mechanics with gait and landing movements. A keen clinician will recognize them when terminal extension remains resistant. Help athletes avoid suffering a lesion that limits extension by actively working to regain early extension and reducing any the effusion.

1. Wrap a strong elastic resistance band around References the shin (band pulling backward – see figure 1). Place the band on the shin and not the 1. 1990;6(3):171-178 2. The American Journal of Sports Medicine 2020;48(3):565–572 thigh to create a relative posterior shear effect 3. Knee Surg Sports Traumatol Arthrosc. 2007; 15:144–146 4. 2009; 25:626–631 to the knee (ACLR protective). 5. Knee Surgery, Sports Traumatology, Arthroscopy. 1999; 7:284–289 6. European Radiology. 2016:1–10 7. Eur Radiol. 2017 August ; 27(8): 3499–3508 8. Current Orthopaedic Practice. 2. Step forward so that the band takes up the stretch. Allow the band to create an extension 31(1). 36-40 9. 1992;8(1):10-18 10. 1998;14:869-876 11. Knee Surg Sports Traumatol effect for 1 minute. Place the other foot behind Arthrosc, 2014. 22:1090–1096 12. Current Orthopaedic Practice. 2011, 22(4). 327-332 the heel to prevent the heel sliding. 13. J of Chiro Med. 15(3). 214-217 14. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2009. 25(6), 2009: 626-631 15. Knee Surg, Sports Traumatol, Arthroscopy, 3. Turn around and wrap the bad around the 1992. 2: 76-79 16. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2010. posterior thigh (band pulling forwards – see figure 2). This also creates a posterior shear 26(11), 1483-1488 17. J Orthop Res. 2017 October ; 35(10): 2275–2281 18. AJR Am effect. J Roentgenol. 2000, 174:719–726 19. Skelet Radiol. 2012. 41:997–1002 20. Orthop J Sports Med. 2017;5(1) 21. Annals of Rheumatic Diseases, 1993. 52: 829-834 22. Ortho 4. Step backward to increase the thigh band Res. 2011;29(9):1383-1389 23. The Journal of Bone and Joint Surgery, 1988. 70-B(4): p. tension. Now perform 15 repetitions of knee 635- 638 24. Journal of Athletic Training, 2010. 45(1): p. 87-97. 3 25. Quarterly Journal of extension movements. Place the other foot in front to prevent the foot sliding. Experimental Physiology, 1988. 73: p. 305-31426. Clinical Physiology. 1990. 10(5): p. 489-500 27. American Journal of Sports Medicine. 2007. 35(8): 1269-1275 5. Continue this for as many rounds as desired.

12 SPORTS INJURY BULLETIN VOL 17 ISSUE 01 INJURY PREVENTION Beliefs and barriers to injury prevention in recreational runner By Alicia Filley

People run at the start of the annual City to Surf fun race in Australia, August 12, 2018. REUTERS/David Gray

early 85% of runners experience program for recreational runners. a running injury in their lifetime(1). As part of the INSPIRE trial, the subjects of While researchers continue this study were runners who registered for Nto look for exact mechanisms a recreational race in 2017. The researchers of injury in runners, a group from the provided the intervention group with an online Netherlands investigated the factors injury prevention program. This program that make an injury prevention program informed them about risk factors for injury and successful(1). They undertook a randomized advised the runners on how to reduce that controlled trial of the effectiveness risk. After training and racing (about seven of a multifactorial online prevention months after the event), the subjects filled

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out follow-up questionnaires to assess the among runners, the current approaches to program’s effectiveness. The study defined prevention may not be working. a running-related injury (RRI) as one that: The incidence of RRIs may be due to the • Affects the musculoskeletal system; fact that the prevention information obtained • Was caused by running; by runners is false or insufficient. This study • Prompted the runner to run more slowly showed that recreational runners believe that or less often for at least a week; training, technique, and shoes contribute to • Required medication to reduce symptoms; the prevalence of RRIs. However, while certain • Resulted in an appointment with a aspects of training and technique contribute medical professional or physio. to RRIs, shoes likely do not. The pervasiveness The follow-up questionnaires assessed of the belief that particular shoes or features the efficacy of the prevention program, and of shoes prevent or cause injury is likely due they also asked about the way the runners to good advertising. Therefore, clinicians accessed and used the prevention program. have much work to do in the area of patient They included what prevented the runner from education. integrating the information and assessed their Because runners typically become preferred means of receiving information. The more interested in injury prevention after researchers gave the same questionnaire to they’ve already been hurt, physios have a runners without access to the running injury At the crux unique opportunity to correct a patient’s prevention program and compared them to of the study misinformation or misconception about how those who did. to stay healthy. The study offers insight into Of the 2378 runners who participated is the how to deliver this information. Men like to in the INSPIRE study, 1034 completed the need for a learn at their own pace via an app or receiving questionnaire. These runners were older, more personalized education in email. On the other hand, women experienced, and more often male than those prefer a more personal delivery model, perhaps who did not fill out the survey. Nearly 75% approach allowing them to ask questions. of respondents agreed on the importance of that provides Despite these preferences, many still said injury prevention and cited the progression information, they hesitated to train in a way that reduced of their training program, running shoes, and injuries because they weren’t sure what to do. technique as the most significant influencers of assures an Therefore, at the crux of the study is the need injury(1). Over half of those surveyed searched understanding for a personalized approach that provides for and performed some injury prevention of the information, assures an understanding of the activity. Most often, these activities included: information, and provides accountability for • Changing their training schedule; information, actually doing the things needed to reduce • Warming up and cooling down; and provides risk. As those with a previous RRI are the most • Stretching accountability interested in injury prevention, clinicians can Those who didn’t participate in any injury use this three-pronged prevention model prevention stated, “Not knowing what to for actually to design a program that acts as a bridge do,” and never having suffered an RRI as the doing the between therapeutic activities and a full return most significant barriers to implementing a things needed to running. risk-reduction strategy(1). In fact, over half of to reduce the respondents didn’t try to reduce injury Reference risk until they had already suffered an injury. risk. 1. 2019 Oct;49(10):736 Interestingly, men preferred to receive their information via an app or in an email. Women, however, wanted the information dispensed from a trainer or running store salesperson. Younger runners, those under 35-years-old, found free offers or financial compensation as an enticement to instigate injury reduction tactics.

PRACTICAL APPLICATIONS This study demonstrates that injury prevention is an important topic for recreational runners. Nearly 70% of the participants actively sought information on injury prevention, and over 80% implemented some prevention measure(1). However, with the continued high rate of injury

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