Expert Talk | Conservative Therapy and Rehabilitation

Treatment of Overuse Syndromes

A survey of team physicians in the top-tier Bundesliga by the “Sportärztezeitung”, carried out by Robert Erbeldinger, Masiar Sabok Sir, Dr. med. Christoph Lukas and Dr. med. Kai Fehske.

In the last edition of “Sportärztezeitung” Dr. med. Kai Fehske, vice-chairman of Bas- one in every three active professionals is (01/18), we carried out a large-scale survey ketDocs and Team Physician at s.oliver Würz- suffering from patellar tendonitis. Over half of Bundesliga football team physicians relat- burg. The two advisers have provided an (55 %) of athletes currently have or previously ing to “Treatment of muscle and tendon inju- overview of as an introduc- had in the area of the patellar tip during ries” in cooperation with our adviser Dr. med. tion to this article. their career, and even in recreational sports, Jens Enepper. This was the first time that there is an astonishingly high prevalence of most of the clubs had provided a structured people affected by this condition; 12 % in the explanation of the procedures they follow in Patellar Tendonitis in Basketball case of basketball. the event of muscle injuries. The response to the survey was extremely positive. For this Jumper’s knee is a chronic and painful over- reason, we have decided to carry out a survey Patellar tendonitis, also known as jumper’s use syndrome at the osteotendinous junction, in a similar format with the team physicians knee, is the most common overuse issue in whereby the damage caused by countless of other important sports, with the aim of basketball. As the name suggests, jumping microtraumas ultimately ends up overtaking promoting the sharing of knowledge and the is a risk factor for this condition, with rapid the tendon’s ability to regenerate. In 2008, a transfer of this knowledge to practical applica- upward motions playing a particularly impor- tendon impingement with a prominent distal tions, extending to “normal patients”. We talk tant role. An athlete’s physical anatomy is patellar pole was postulated by Lorbach as to other teams and physicians and provide also a key factor. A flat plantar arch, reduced a possible cause, which explains why the you with solutions and approaches that can movement in the ankle, muscle shortening degenerative changes are primarily found in be used in your day-to-day medical practice. and general laxity all increase the risk of the the dorsal tendon section. Over the course of condition. One classic problem is the rela- the condition, this leads to a breakdown of the This edition contains a survey of all basket- tively short preparation period for upcoming parallel collagen fiber alignment, degenera- ball team physicians of the top-tier Basket- seasons. Athletic training, tactics training and tion of the collagen tissue and replacement of ball Bundesliga relating to the treatment of pre-season games all need to be completed type-1 collagen with type-3 collagen. Despite overuse syndromes, and in particular the in a period of around six weeks. Players who the fact that the term “patellar tendonitis” syndrome referred to as jumper’s knee. We have not worked on their fitness enough dur- is still commonly used, there are in fact no would like to take this opportunity to express ing the off-season are therefore particularly inflammatory cells at a microscopic level. The our heartfelt gratitude for the dedication and susceptible to overuse injuries. condition does, however, result in vascular- active involvement of our two advisers, Dr. ization, which causes nerve fibers to conduct med. Christoph Lukas, chairman of Basket- In high-performance basketball, 32 % of play- pain sensations. Docs, Deutsche Basketballärzte e.V. and ers complain of overuse injury, meaning that

Against this backdrop, we asked all team physicians from the top-tier the following three questions:

1. Which traumatic and overuse sports injuries occur most frequently in your work with the basketball teams?

2. One-third of all training injuries occur in the two pre-season months of August and September. This could indicate an excessive training load and insufficient regeneration prior to the season, which also cause overuse syndromes such as jumper's knee to develop. How are examinations/diagnostics and therapy carried out at your practice – which conservative measures are used, and do surgical options play a role at all?

3. Prophylaxis – what do you and your team do to ensure that jumper's knee does not occur in the first place, and what preventative measures do you implement following treatment for jumper's knee? In this context, how can the issue of regeneration in basketball be improved upon and given higher priority, despite the tight schedule and large number of games?

22 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Kai Fehske | s.oliver Würzburg

1. We primarily see injuries of the lower extremities, and in particular this imaging can be accompanied by an MRI. During the acute phase ligament lesions of the ankle . We also see an accumulation of of the condition, we administer systemic (e.g. NSAIDs and Traumeel) muscle injuries, in particular the hamstrings. In the area of the upper and local anti-inflamatory treatment. The application of ice or oint- extremities, there are regular hand injuries such as fractures of the ments, such as those containing arnica, have proven successful in metacarpus or ligament lesions of the wrist joint. Typical sports injuries this phase, as has the method of wrapping the affected area in plastic occur at the knee joint (e.g. jumper’s knee) and in the back area. wrap for an hour. In the event of persistent complaints, therapy can also be expanded to include infiltrations with Traumeel or platelet-rich 2. The “pre-employment” medical check is initially targeted towards plasma. Infiltration with corticosteroids is now an obsolete practice orthopedic issues, with a particular focus on the knee joint and the due to the local side effects. In rare cases, surgery may be required muscles surrounding the knee joint, particularly given the fact that as a last resort, and involves a resection of the affected tissue and jumper’s knee is virtually an occupational disorder. We often see denervation of the patellar pole. Arthroscopic procedures have bcome shortened thigh muscles. The therapeutic approach here prioritizes established in this area. the restoration of muscular balance through manual therapy, stretch- ing and concentric strength training. However, this approach is only 3. See above. Stretching of the entire thigh musculature, concentric successful over the medium-term. Players receive physiotherapeutic strength training. In all honesty, I have up to now had very little or no treatment over the entire season. In a new case of jumper’s knee, clear influence on training planning or regeneration phases in my role as evidence is provided by means of sonography in the majority of cases. team physician. In exceptional cases, or to rule out the possibility of any other injuries,

Dr. med. Lars Homagk | Mitteldeutscher BC

1. Traumatic sports injuries: the most common sports injury by far a suitable working diagnosis. Additional diagnostic tools include is a muscle injury in the sense of a muscle contusion (hematoma) or sonograpy and, if bony injury or major structural damage is suspected, a muscle strain, or less frequently a torn muscle fiber. Overall, the CT or MRI scans. We have almost always been able to use exclusively frequency of these injuries is the same whether or not an opponent conservative methods to treat these injuries, with manual therapy, is involved. However, muscle contusions are more common on match physiotherapy, radial shock waves and analgesia where necessary. In weekends, and strains during training in the week. Looking at the pat- two cases, adductor tendonitis with accompanying osteitis was addi- terns over the course of the season, we record 4 - 5 muscle injuries tionally healed using long-term treatment with ibuprofen and minimal (with low levels of structural damage) per player per season, although loading. Strengthening of the thigh and hip muscles is also of utmost there are players who are predisposed. Smaller players are more com- importance in the athletics program. The same procedure applies to monly affected. The knee is also frequently affected by distortions or jumper’s knee, although it is rarely seen. abrasions. Overuse sports injuries: a problem that is more specific to ball sports is overuse injuries to the adductors and their attachments 3. We believe that prevention in the form of optimal muscular stabiliza- to the ischium and pubis. These types of sports injuries, ranging all tion, sensomotoric orthotics and briefing of athletes is the priority here. the way through to osteitis pubis, are the most common, and not only We also try to detect potential overuse damage as early as possible as a direct result of trauma. They are followed by degenerative knee through close contact between players and physiotherapist/physician. and ankle joint damage. If signs of overuse are detected, we temporarily reduce the load for a few days and intensify the physiotherapy. Once the player is symptom- 2. The aforementioned overuse damage occurs much more frequently free, based on our specific tests, he can return to intensity training. during the pre-season. Our primary diagnostic parameters are an athlete’s medical history (how often did the player train during the off-season etc.) and the clinical examination, which can often provide

23 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Ralf Hamann | BG Göttingen

1. By far the most common traumatic sports injuries are muscle injuries (sub-)acute and chronic injury progressions. The surgical treatment and ankle joint distortions, followed distantly by injuries of the knee option is only an elective alternative in the event of persistent injury or joint (ACL rupture, meniscus tear). Overuse injuries most commonly chronification, which has a negative impact on the player. occur in the area of the patella and quadriceps tendon. 3. An intensive clinical and equipment-supported initial examination 2. In the acute phase, a clinical diagnosis is performed. Sonography and a functional analysis are carried out in order to detect any predis- is used to rule out any other injuries and to record the extent of the position factors or pre-clinical changes, in order that targeted mea- inflammation. Acute therapy consists of medication-based and local sures can then be introduced, in particular in the functional, (sports) anti-inflammatory measures, physiotherapy including muscle tonic- physiotherapy area. At the first signs of overuse, a consistent, inter- ity regulation of the ascending and descending muscle chains, FDM disciplinary approach that has been agreed upon with the coach, and techniques, shock wave therapy (ESWT) and supplementary/accom- that includes regenerative and indication-specific therapy, is essential panying K-tape application, as well as acupuncture where appropriate. in ensuring the athlete’s athletic capacity on a sustainable basis. Autologous plasma (ACP) therapy is also an established method for

Dr. med. Moritz Morawski Dr. med. Gert Schleicher | ALBA Berlin

1. The most common injuries that we see are without a doubt tendi- used as a comparison. If there is acute pain and swelling, we carry out nopathies of the patellar tendon (“patellar tendonitis”) due to the high an MRI scan, where we often see that there is already a edema (jumping) load. We also deal with cases of plantar on a rela- in the area of the patellar tip. As well as load reduction, we also use tively frequent basis. The most common injury is an UAJ (upper ankle shock wave and eccentric training as therapy, which we continue over joint) distortion with exterior ligament injury. a prolonged period. In acute cases, we are increasingly using ACP/ PRP therapy, which has proven very successful. Luckily, we have not 2. From our perspective, the main cause of this problem is the fact that yet had to resort to surgical measures. a lot of players do not train at all during the summer break, and then go all out at the start of the pre-season preparation phase without allowing 3. From our point of view, steady, continual strengthening of the entire their body to become accustomed to withstanding this load again. As a leg muscle system is the best prevention, with particular attention diagnostic measure, we carry out a sonographic examination of every being given to the hamstrings. We also believe that it is important to player at the start of the season, which often shows chronic changes incorporate targeted stabilization training and sufficient stretching, in the area of the patellar tendon origin. It is sometimes difficult to as patellar tendonitis is often associated with a “shortening” of the decide what constitutes an acute or a chronic injury, so it’s good to muscles. Eccentric training is also included in all training sessions as get a picture of the situation right from the pre-season which can be a preventive measure.

24 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Arun Chandra Dr. med. Peter Hoos | EWE

1. The most common injury in the basketball players we look after is our players during the summer break, so we can also respond quickly definitely distortion of the ankle joint, with more or less pronounced in the case of acute injuries. This of course works well for players who injuries to the fibular ligaments. However, we also frequently see bony we are already working with, but is more difficult for new players who injuries to the as a result of the high jumping loads. Overuse usually only join the team in August. We have not yet had to resort complaints tend to affect the knee , such as jumper’s knee with to surgical measures, instead working very closely with the team irritation at the patellar tip and changes to the patellar tendon. Ankle physiotherapist (with eccentric stretching and coordination training, joint complaints caused, for example, by malalignment or incorrect for example). We have also had a lot of success with ACP infiltration load bearing, are also relatively common. in conjunction with shock wave therapy.

2. There are undoubtedly a variety of different reasons for this prob- 3. Before the start of the season, we use functional tests such as the lem, which we have also observed. Following the summer break, we FMS test to look for functional deficits, including in the lower extremi- see an increase in injuries to the patellar tendon in our national players, ties. We also carry out a treadmill analysis of each player in order for example, who only have a short regeneration phase over the sum- to detect any malalignments or incorrect load bearing in good time. mer and who also play a major role within the team during the season, During the season, we focus on active regeneration. We aim to make with long periods on the court. We also occasionally see the reverse eccentric stretching exercises and targeted stability training part of happening, with injuries occurring because regenerative training with each session. An active break in the training regime to temporarily gentle aerobic sessions, coordination training and strength training include different training sessions (such as aquajogging or gentle have been neglected for almost three months. We are always there for indoor cycling) can also be very helpful.

Dr. med. Michael Volkmer |

1. The most common injuries are distortions and ligament injuries to compensate for any functional deficits using osteopathy, orthotics or the upper ankle joint, injuries to the leg muscles and, depending on individual muscular stabilization, or we use shock waves or eccentric the age of players within a team, degenerative cartilage changes in the training, but injections less so recently. ankle joint and knee. The muscle injuries are mostly minor to moderate in severity, and the cartilage changes often require individual consul- 3. Communication within the entire team, including with the coach, is tation with the player so that he can assess for himself the long-term of utmost importance here. In our club, we have a very good personal risks associated with competitive sport. relationship with coaches and managers. Acceptance of customized and active regeneration is crucial. We configure our approach by 2. We make a strict distinction between functional and structural focusing on the repeatedly examined functional deficits and self- diagnostics. As part of our health screening, we carry out a high- assessment scores, and we also interview our players in order to try resolution ultrasound examination, a 4D motion analysis and a Myoline and identify the psychological components of an imminent overuse test before the start of the training build-up phase in order to detect reaction. any imbalances that could cause problems. This information is always supplemented by the checks performed by our athletic trainer and physiotherapists. If anything concerning is detected during these tests, we carry out an MRI scan. With regard to therapy, we try to

25 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Christoph Lukas | BasketDocs e.V.

1. With regard to injuries, the most common by far are without a doubt should be examined at the earliest after six months of unsuccessful exterior ligament injuries of the ankle joint, while most overuse com- conservative therapy. plaints affect the knee, primarily patellar tendonitis, otherwise known as jumper’s knee. 3. Initially, the prevention check forms part of the medical check car- ried out when a player joins the team and the subsequent discussion 2. After a thorough clinical examination of the back and the entire of results within the medical team, together with targeted training of the lower extremities, the factors causing the problem have to be identi- weaknesses/muscle shortenings/imbalances by means of a custom- fied and eliminated. Sonography with vascular imaging is performed ized training program for the individual player. Regular physiotherapeu- as standard, along with X-ray imaging or an MRI scan if required. This tic prevention treatments are also carried out, along with regeneration is promptly followed by the start of multimodal therapy which includes, sessions following intensive training/matches. In my opinion, people depending on the requirements, arthotics, stretching exercises, phys- can only be won over to regeneration through visible results, i.e. lower iotherapy, targeted strengthening exercises and eccentric training, injury rates and higher-performing players. Otherwise, it will never be bandages or kinesiology tape, shock wave treatment, acupuncture possible to convince the coaches. and, in rare cases, infiltrations. In the case of pure patellar tendon- itis without any other accompanying injuries, the surgical indication

Dr. med. Holger Eggers | medi Bayreuth

1. The most common injuries are ligament injuries to joints, with the 3. The best injury is one that doesn’t happen in the first place. As upper ankle joint (outer ligaments) being particularly worth mentioning with a lot of other types of tendon damage, patellar tendonitis is in this regard. Apart from that, injured basketball players present with greatly influenced/caused by overuse and shortening of the (femoral) the typical injury spectrum for ball-sports athletes, with muscle injuries, muscles. These muscles are innervated from the lumbar vertebral overuse issues, bruising and back complaints. column. This is a particular focus of our prophylactic work. Throughout the entire season and particularly during the pre-season preparation 2. Absolutely crucial to the diagnosis of patellar tendonitis are a play- phase, the athletes are reminded of the importance of stable core and er’s medical history and a clinical examination. In order to accurately trunk muscles, and a suitable daily training program is implemented determine the extent of the injury (acute or chronic), we may then carry by the athletic coaches and the physiotherapy team. A lot of exercises out instrument-based diagnostics such as sonography and MRI scans. from yoga and pilates are used here. Interestingly, but also worryingly, Acute therapy consists of avoiding the acute cause, i.e. a period of most players display weakness and instability in the core muscles, abstinence from sport (overloading of the quadriceps), cryotherapy, even though they are otherwise very muscular. They are learning to special bandages (genumedi pss), oral/local NSAIDs and intensive train these core muscles for the first time. Muscle stretching, flexibility, physiotherapy. PRP infiltration (ACP) is also used on a regular basis fascial therapy and tension-release exercises are also important parts nowadays. Of course, the duration of treatment varies widely, but with of day-to-day training. short-term overuse issues, patellar tendonitis usually clears up within a few days. Surgical therapy is only considered in the event of chronic injury progressions with pronounced inflammatory changes to the bony patella revealed by MRI and complete resistance to conservative therapy (at least six months).

26 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Daniel Dornacher Dr. med. Tugrul Kocak |

1. According to our internal team statistics, the most common injuries or Osgood-Schlatter disease. The only surgical treatment of an over- that we see are “distortions of the ankle joint”. use reaction of the knee-extensor apparatus that we have carried out was in the case of young player with Osgood-Schlatter disease that 2 + 3. If an injury does not occur on the playing field but rather during proved resistant to conservative therapy. With our professional play- training, or if there are signs of overuse issues, the first step involves ers, there have been no cases of therapy resistance or chronification talking to team physiotherapist Andi Lacher. He will give us a detailed during conservative treatment, possibly thanks to the standardized, medical history and an initial assessment of the problem. As both of comprehensive pre-season screening and the measures implemented us team physicians are based at the University Orthopedic Clinic at as a result. Depending on their personal risk profiles, players perform the RKU (University and Rehabilitation Clinics Ulm), it is possible to a customized prehab session during a designated period (approx. carry out an MRI scan immediately after clinical examination, which is 15 minutes) prior to training, which is developed by athletic coach often accompanied by a sonographic examination. It therefore takes Sebastian Sieghart. This session is adapted over the course of the less than an hour to make a diagnosis, e.g. in relation to the extent of season, based on the results of the short test. After training, tension- trauma inside the knee. The medical team (physiotherapists, athletic release treatment is carried out by means of foam-rolling or stretch- coaches and rehabilitation trainers) are all informed of this diagnosis, ing exercises, often followed by cryotherapy. Unfortunately, unlike and the planned treatment tailored to the injury in question. In Ulm, the in non-team sports, the busy schedule of matches in the Basketball orthopedic clinic is directly linked to the rehabilitation clinics, meaning Bundesliga does not allow for ideal planning of compensation times for that players can receive daily treatment before and after training both regeneration. Athletic coach Sebastian Sieghart is keen to stress the at the training and in the clinic. importance of compensatory training after heavy match days.

In definite cases of jumper’s knee, we would discuss physical mea- A lot of foam-rolling and muscle-stretching programs are also used. sures (ultrasound, gel iontophoresis) and manual therapy treatment Collaboration with a local swimming pool means that balneolophysi- in addition to load reduction (high-load activities). Patella bandages cal measures (contrast baths, aquajogging) can also be carried out. are only used in rare cases. We do not use any injection treatment Another element involves teaching the players about sport-specific or shock wave therapy here. As we also provide medical care for the nutrition and hydration (composition, timing), with nutrition plans also youth squad, we often see overuse syndromes in young players in developed on a case-by-case basis. conjunction with ossification disorders of the knee-extensor apparatus, which clinically present in accordance with Sinding-Larsen syndrome

Alexander Poblotzki | Eisbären Bremerhaven

1. The most common injuries are bruises, followed by overuse injuries 3. Our athletic coach gave the guys some exercises to do at home such as jumper’s knee or achillodynia. in order to improve their mobility. Each training program includes a stretching routine to be performed before and after each work session. 2. Clinical examination and sonography, with the following procedure Each training session also includes preventive eccentric exercises for usually based on the POLICE principle. With enthesopathies, this is the Achilles tendon and the patellar tendon. Each player has also been then followed by treatments involving PRP/ACP. Intensive physical taught a simple patella mobilization technique. therapy is also carried out. We have thankfully not had any injuries that required surgery.

27 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Dr. med. dent. Andreas Först |

1. The most common injuries affect the ankle joint (contact and non- this therapy, we also use ice, cross-fiber friction, electrical current and contact injuries) and fingers (contact injuries), followed by injuries to ultrasound, as well as cupping techniques and possibly acupuncture. the back and LPH complex, as well as primarily contact injuries in the At the same time, the focus of athletic training is adapted, with more shoulder area. emphasis on eccentric training and antagonist training. These exer- cises are compulsory and must be performed by players before each 2. The high training load during the pre-season preparation phase training session or game. Players continue to take part in normal team directly following an extended break is a likely cause of the high injury training wherever possible. Depending on the duration and intensity rates in August and September. It is important to emphasize here of the symptoms, local ESWT therapy is also carried out at an early that, in our team, we do not see a disproportionately high injury rate in stage, usually involving a combination of focused and radial shock the months of August and September. In order to avoid this (foresee- waves. If the injury persists or is chronic and recurring, we perform able) problem, each player who is staying with the team receives an injection therapy with PRP. individual training plan that must be completed in order to maintain a basic athletic muscle tone. Players who are new to the team undergo 3. Within a training plan, a lot of importance is given to regenerative a detailed orthopedic and functional-athletic diagnostic examination sessions with intensive flexibility and core-stability exercises. Tailored from a basketball-specific perspective together with video documenta- training is still performed, based on the number of matches played by tion, and this information is used to create individual training plans. If individual players. In addition, attempts are also made to stick to a a player is exhibiting acute overuse symptoms, MRI diagnostics are routine despite sometimes having three games in five days, alternately carried out at an early stage so that structural tendon changes and home and away, and to keep the length of time spent away from home accompanying pathologies (Hoffa’s syndrome, cartilage damage), to a minimum through appropriate journey planning. In terms of nutri- which are particularly relevant in the context of jumper’s knee, can tion, the hotels where the players stay are given precise guidelines be detected and treated in a targeted manner. In terms of therapy, we for the menus and players are provided with a continual supply of attach a lot of importance to the treatment of the ventral chain (LPH supplements. We also work together with a restaurant where players complex/iliopsoas, quadriceps), patella centering, tension release of can go for high-quality and balanced meals at any time when at home. the iliotibial band, leg-axis rotation and alignment/stabilization of the arch of the foot in order to remove torsion in the lower leg. Alongside

28 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Detlef Stanek | Science City Jena

1. When it comes to acute injuries, the most common ones that we in the area of the feet, the tibio-fibular connections and the pelvis, as see are ankle joint distortions and muscle contusions and sprains, well as for imbalances of the hamstrings, the rectus femoris, the vas- particularly in the area of the thigh, as well as knee-joint contusions. tus lateralis, the tensor fasciae latae and the iliotibial band, and takes The main chronic symptoms we see are pain in the lumbar spine- the form of myofascial release techniques, Typaldos therapy (Fascial pelvis region, overuse-related pain in the foot and heel area, such as Distortion Model) or flossing therapy. Stabilization of the foot and leg metatarsalgia, of the Achilles tendon or knee joint in axis is also required by means of physical therapy (e.g. sensorimotor the form of jumper’s/runner’s knee as well as chondropathy of the knee facilitation as per Janda) or functional training, but also the use of joint and the femoropatellar joint. knee-joint bandages, correction and tape bandages and sensomo- toric arthotics. This usually takes place throughout the entire season. 2. With the diagnosis and treatment of jumper’s knee, it is important, as If chondrial changes have been detected, the use of intra-articularly a first step, to determine whether the pain is due to a functional prob- administered hyaluronic acid and oral preparations containing glucos- lem or whether there is already a structural issue. In our experience, amine or chondroitin sulfate should also be discussed. complaints of the patellar tendon do not usually start with immediate inflammatory responses at the knee tendon, but mostly occur in the 3. As an initial step, a detailed clinical examination is carried out at the parapatellar and/or peritendinous regions, and often at the medial start of the pre-season preparation phase, which consists of an ortho- edge of the patellar tip and in the region somewhat above and at the pedic section focusing on differential manual-medical, artho-muscular front medial joint space and at the prepatellar bursa. In order to diag- and myofascial functional diagnostics. In order to make a more detailed nose a dysfunctional knee joint, an evaluation needs to be carried out assessment of their particular circumstances, each player undergoes of the player’s body statics, leg axis, arthro-ligamentous stability and a Janda muscle function test, including dynamic testing of the motor muscle balance. The following structures and functions (expressed stereotype, a Cook FMS test, a video-supported treadmill analysis, a in simplified form) are assessed as part of the examination: the lower 4D optical spine and posture analysis and a dynamic foot-pressure extremity, lumbar spine and pelvis, muscles and fasciae in this area measurement. When evaluating the results of these tests, the physi- with regard to tension and trigger/tender points. The results of this cian, physiotherapist and athletic coach work together to come up with examination usually indicate muscular imbalances, fascial restrictions focus points for each player, which lead to the partial customization and chains of functional impairments that often lead to a lot of tension of the athletic training program or warm-up routines and the physio at the patella tendon, with the patella tending towards lateralization as prophylaxis, and/or the provision of appropriate orthotics. In the pre- well as functional medial instability, and therefore pain. In this case, we season preparation phase, and also subsequently during the season, very often find initial impairments in the functioning of the lower ankle the athletic coach and physiotherapist keep daily online records of the joint and the pelvic joints. If the findings from the examination indicate subjective loading and current symptoms in order that any emerging structural lesions, we also carry out imaging-based diagnostics using overuse symptoms can be detected in good time. The training load MRI scanning in order to assess or rule out any tendinous and osteo- is customized and physioprevention is designed on the basis of this chondral changes. The therapy we use is very varied. In the case of information. Thanks to cooperation with the company Bauerfeind, acute injury, we initially prescribe immobilization using kinesiology each player is provided with knee and ankle joint bandages at the tape and knee support, and where necessary, a rest period of 1 - 2 start of the season. The use of cryotherapy or ice baths is a routine days or more without sport, depending on the injury progression. We option either during or after training sessions. Preparations contain- also use dressings with ointments containing arnica or NSAIDs, zinc ing micronutrients are used for regeneration and substitution, along paste, Retterspitz Äußerlich liquid and cold applications. Systemically, with minerals and vitamin D. Situations with a very large number of the use of Wobenzym, NSAIDs or Cox 2 inhibitors is considered, as individual or team games or matches require changes to the training is the paratendinous application of Traumeel/Procain injections. For plan, with a reduction in leg loading. This can be achieved, for example, further treatment, or in the event of chronic injury progressions, con- by the introduction of water gymnastics, aquajogging or aquacyling, sistent reduction of the arthro-muscular functional deficits is required or by ensuring suitable forms of gynmastics and changing the type of by means of appropriate physiotherapy or manual medical/osteopathic surface/flooring used for running training. interventions. This is of particular relevance to functional impairments

29 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Wolfgang Leutheuser | Gießen 46ers

1. Upper ankle distortions and overuse damage to the knee joint. patella tip or distal attachment at the tibial tuberosity b) MRI Therapy: physiotherapy, ACP, muscle building, coordination training. 2. Starting off at too high a training load. Players are mostly not in peak form after the break, but try to show high intensity to the coach 3. Evaluation of weak points within the body: thoracic stability? Lumbo- and the club. Essentially, injuries then occur as a result of insufficient coxal junction? Leg axes? Muscular insufficiencies and imbalances? preparation and an excessively high initial training load. Diagnostics: Gait analysis and incorrect foot positioning? jumper’s knee – a) Clinical examination: proximal attachment at the

Dr. med. Andreas Mehling, Dr. med. Jürgen Fritz, Prof. Dr. med. Philip Kasten, Dr. Bernhard Schewe Amei Röhner-Zangiabadi | WALTER Tigers Tübingen

1. The most common symptoms that players complain of are patel- and an individual treatment and training plan is devised for the pre- lar tendonitis, (attachment) tendinoses of the Achilles tendon and season preparation phase. If the results from the pre-season examina- . We also frequently see complaints in the groin area. tions show that surgery is required, we will not allow the player to be The most common injuries are bruises and ruptures of the capsular signed for the team. ligament apparatus on the ankle joint and in the finger area. We also occasionally see fatigue fractures to the metatarsals or the tibia and 3. Players suffering from will be treated with ice packs on the shoulder dislocations. affected areas after loading. Warm-down is required on a regular basis following games and training sessions. Fasciae are also stretched 2. All players undergo general medical and orthopedic examinations using the Blackroll foam roller carried by all players in their sports before the start of the season. Often, the results of these examinations bags. Prophylaxis includes eccentric stretching exercises on the slant mean that players cannot be signed for medical reasons. As part of the board; one is even carried on the team bus. Intensive physiotherapy examination, we check the usual trigger points and carry out specific is standard practice if symptoms occur. For affected players, we also function tests. Conspicuous but acceptable findings are discussed keep an electric heated cushion behind the bench, which can be used within the team (physicians, coach, fitness trainer, physiotherapists), to keep tendons warm during half time.

30 sportärztezeitung 02/2018 | www.thesportgroup.de Expert Talk | Conservative Therapy and Rehabilitation

Dr. med. Wolfgang Raussen | FRAPORT SKYLINERS

1. More than half of all injuries that occur in basketball statistically only short-term administration of NSAIDs and/or Bromelain. Also affect the lower extremities, with approximately 30 % affecting the K-tape/bandages, local and/or segmental infiltration treatments, X-ray upper extremities. In descending order of frequency, the remaining stimulus radiation (radiotherapy), with surgical interventions only used injuries consist of injuries to the head, torso and spinal column. as a last resort. Isokinetic testing is also used to monitor the progress and success of treatment. 2. Jumper’s knee is diagnosed as part of the prompt performance of clinical diagnostics. Sonography and MRI scans may also be used, 3. To prevent jumper’s knee, players are provided with customized depending on the symptoms and injury progression. A number of orthotics and shoes in order to rectify any malposture and the result- different treatment measures are applied for conservative therapy: ing non-physiological peak loads. A sport-specific physiotherapeutic training modification (intensity adaptation, reduction in peak loads, training and stretching program is also followed, with the aim of rectify- adhering to and possibly extending recovery times, endurance training ing any muscular imbalances and ensuring targeted muscle building vs. high-speed training), customized orthotics provision, physiotherapy with simultaneous local and segmental tension release. Furthermore, with manual therapy, massage, coordination and stabilization training, we also ensure that regeneration times are complied with and that eccentric muscle function training, stretching, proprioceptive training, the correct flooring is selected for the sports hall, and training times ultrasound, iontophoresis and laser treatments, magnetic field therapy, and training load intensities are also taken into account (including for shock waves, cryotherapy and acupuncture. Medication: if at all, then strength training).

Dr. med. Florian Langhoff | MHP

1. The most frequently occurring injuries that we see are bruises and paratendinous infiltrations with Meaverin, Traumeel, Hyaluron or PRP contusions. By the nature of the sport, we of course also see upper where appropriate. We also use ESWT to treat chronic changes. ankle joint distortions on a regular basis, although fortunately these Regular eccentric loading is incorporated into the training plan. Surgi- often do not involve any structural damage. We also occasionally cal options are only considered if an examination has found there to be see locking of the facet joints or the sacroiliac joint, and in intensive major intratendinous calcifications, etc. However, surgery game phases, non-structural muscle lesions, with the very occasional is only performed after a positive subacromial space injection test and structural muscle lesions. if all conservative measures have failed.

2. In these cases, our physical examination begins with a local exami- 3. Our athletic coach and the physiotherapists ensure that players nation of the knee joint, and in particular a check of the patella center- carry out regular stretching and tension-release of the loaded muscles, ing, the extensor/flexor strength ratio, the elasticity of the quadriceps in particular the quadriceps and the ischiocrural muscles. Regenera- (comparison of the distance between heel and buttock on either side tion naturally includes ice baths, active stretching, foam rolling and when in a face-down position) and the tension of the IT band. In terms physiotherapy. We also use a regeneration drink for games. Despite of the function chains, we then also check the ankle joint, the pelvis all recommendations, regeneration phases are always rather too short position/hip mobility and the sacroiliac joint mobility. Our diagnostic in a full game schedule in the BBL and Champions League. process primarily involves X-ray images and sonography, using the Power Doppler technique if at all possible. If inflammatory or degen- erative changes are already visible at this stage, we also carry out an MRI scan. We design the course of therapy based on the results of the examination and diagnostics. With acute cases, we start with the systemic and local administration of NSAIDs, accompanied of course by physiotherapy (stretching, strengthening, leg-axis stabili- zation, IT band tension release). To reduce pain under load, we first prescribe orthotics (e.g. Kasseler bandages), and we also perform

31 sportärztezeitung 02/2018 | www.thesportgroup.de Conservative Therapy and Rehabilitation

Muscle Injuries Treatment Options in Basketball

In the last edition of “Sportärz- We generally treat Grade IIIb injuries conser- Further diagnostics include not only the tezeitung”, we gained an interest- vatively. We start by estimating a recovery detection of the muscle injury but also the time of six weeks, which should be used as detection of functional and static dysfunc- ing insight into the treatment of an initial guide for everyone involved. Pri- tions and imbalances. The absence of trauma muscle injuries from the perspec- mary care entails the use of a compres- means that an explicit examination of the axial tive of Bundesliga team doctors, sion bandage with “heat and ice”, and putting skeleton will need to be performed. Incorrect with the survey getting a really the injured leg into a relaxed position, as posture or incorrect functioning of the pelvis great response. So we wanted to well as prompt anti-inflammatory measures and spinal column in particular, as well as look at this same issue in our bas- such as muscle-relaxing manual therapy and neuroregulatory dysfunctions of the lumbar lymph drainage, lymph tape and medication- plexus, may be the cause of non-traumatic ketball series too. We are there- based support such as the administration of muscle injuries. Unfortunately, the literature fore delighted that Oliver Pütz, enzymes (zinc/Mg/Bromelain). We do not use is not much help here. There are no studies Team Physician for the German NSAIDs. Depending on the patient’s symp- that point to a functional or anatomical leg national basketball team, and Dr. toms, we use forearm crutches to eliminate length discrepancy or a static malalignment Andreas Först, Team Physician or reduce weight bearing and make sure that of the pelvis (ventral/posterior ilium etc.) as at Brose Bamberg, have agreed the injured muscle is in a relaxed position. a cause of muscle injury. Nevertheless, it An ultrasound test is always followed by an appears from an empirical perspective that to tell us about their choices of MRI of the injured muscle, and the injury is careful observation of muscle tonicity and treatment for Grade IIIb muscle classified using the Müller-Wohlfarth et al the statics of the spinal column and pelvis injuries. classification system. This information is then are of critical importance here. In the case of used to roughly estimate the further treatment recurring muscle injuries, functional malalign- and recovery time, depending on the par- ments in the area of the spinal column are ticular circumstances. In my opinion, a rigid found remarkably often, which were clinically treatment regime is not a sensible option in asymptomatic, and remain so. In addition to Suppose you find that a player this case. Treatment times may be longer or herniated discs and intraforaminal stenoses, has a Grade III injury of the ham- shorter depending on the affected muscles, these malalignments primarily take the form string (supporting leg), i.e. a mus- any collateral damage and the athlete’s fit- of spondylolisthesis or spondylolysis, which cle bundle injury at the proximal ness level. If there is a hematoma, this should often lead to hyperlordosis of the lumbar musculotendinous junction. What be punctured, depending on the size. In this spine and forward tilting of the pelvis, and is your treatment strategy and case, the sonographically monitored injec- secondarily to lumbosacral instability. If this tion treatment with PRP/ACP can be started is suspected to be the case, an MRI of the what criteria do you use to assess immediately. Depending on the clinical and lumbar spine is carried out, and X-ray images whether the player is able to con- sonographic progress, 3 - 5 injections are taken of the pelvis with functional imaging of tinue with training and competi- given at three-day intervals. Muscle-relax- the lumbar spine. Depending on the spinal tion? Which of these do you later ing injection therapy with local anesthetics dysfunction, various injection therapies are apply with your therapists and and Traumeel is also administered distally used here, such as muscle-relaxing injections team of trainers in subsequent and proximally to the lesion in the event of into the paravertebral muscles, periscapular, increased muscle tightness. In ACP therapy, periligamentous or, if necessary, intra-articu- preventative therapy, in addition the problem lies in the considerable analgesic lar injections (SIJ). We often accompany this to specific training (and how)? effect. This analgesic effect means that the with radial ESWT for the treatment of the tho- pain that would normally act as a warning racolumbar fascia, as well as various muscle sign during a clinical examination or when trigger points. A good approach in the preven- checking the patient’s subjective pain percep- tion of muscle injuries seems to lie in regular tion during rehabilitation can be significantly examinations of the spinal column and pelvis. reduced or even completely non-existent, There is also (still) a lack of evidence here. → which could lead to premature loading dur- ing rehabilitation. This should be taken into account during treatment.

38 sportärztezeitung 02/2018 | www.thesportgroup.de Conservative Therapy and Rehabilitation

A detailed examination of the axial skeleton the athlete’s progress, as well as medical and in consultation with our physiotherapists and physiotherapeutic checks, such as checking osteopaths, in particular before and during muscle tonicity and any previously detected Oliver Pütz each season, helps to ensure that preventa- imbalances or static malalignments. tive measures can be implemented in good Oliver Pütz is a specialist in orthopedics time in the event of muscle complaints (e.g. Subjective parameters using instrument- and trauma surgery, as well as a medical increased muscle tonicity) and tendon issues, based diagnostics are established by means osteopath with additional qualifications which may in turn help to prevent muscle of EMG or EMG biofeedback training and in sports medicine and chirotherapy. He injuries. isokinetic tests. The problem with isokinetic works in Cologne as a resident sports tests lies in the fact that the test procedure orthopedic physician at the “Orthopädie An initial rest period of 5 - 7 days is usu- is not very functional or sport-specific, but am Gürzenich“ private practice for ortho- ally applied. The focus here lies firstly on these tests should be used regardless. Static pedics, sports medicine and foot sur- the aforementioned injection therapies and problems of the spinal column and pelvis are gery, spinal column and sport. His spe- accompanying physiotherapeutic or osteo- verified by a photo-optic 4D spinal column cialist area is the conservative treatment pathic treatment (lymph drainage, kinesiology measurement and are also referred to over and prevention of acute and chronic dis- tape, treatment of vertebrogenic dysfunction the course of treatment as a way of monitor- orders and sports-orthopedic injuries of using mysofascial techniques, ESWT). The ing progress. Image-based checks of the the entire musculoskeletal system, in injured muscle is not treated directly during muscle injury by means of MRI appears not particular muscle and tendon injuries in this time so as to prevent any mechanical to be essential, as this examination cannot connection with malalignments and poor irritation (risk of myositis ossificans). Depend- provide any information on the muscle quality posture of the pelvis and spinal column. ing on the responsiveness of the muscles, or its functional strength. Sonographic checks the treatment of agonistic/antagonistic imbal- appear to be sufficient here. The rehabilita- Oliver Pütz is also the Team Physician ances begins from the second week using tion period is, of course, also used to review for the German national basketball team body weight exercises and passive manual the athlete’s lifestyle. There is often found to (A team) and for the RheinStars Köln stretching of the agonist/antagonist, staying be considerable prevention potential here, team. within the pain-free range. From the third in particular in the area of sleeping habits/ week, exercise machines and aquajogging regeneration and nutrition. Personal stress are introduced, as well as the AlterG anti- factors will also be looked at, whether these gravity treadmill where appropriate. Depend- relate to the athlete’s private or sporting life. ing on the clinical and functional findings, this seems to be the earliest possible moment for Oliver Pütz, Team Physician for the German the reintroduction of running load. Particular national basketball team emphasis is placed on neuromuscular activa- tion. We usually reintroduce running load in the fourth week, in terms of a functional resto- ration of the affected muscle through loading with full body weight (coordination, balance, basic running drills). In weeks 5 - 6, training specific to the particular sport discipline is reintroduced, together with an increase in load, depending on the subjective and objec- tive parameters and/or the clinical symptoms. There is no rigid training regime regarding the load increase. The approach set out above is intended more as a guide for all involved parties. It may of course be the case that the load is increased either earlier or later than this point, depending on the specific findings. Close communication takes place between the physician, physiotherapists, athletic coaches and the athlete’s trainers. All load phases are accompanied by weekly sonographic examinations in order to monitor

39 sportärztezeitung 02/2018 | www.thesportgroup.de Conservative Therapy and Rehabilitation

In the event of a Grade III muscle injury in the The return to training takes place on a area of the hamstring, we start by carrying out step-by-step basis: early (and possibly repeated) MRI diagnostics Dr. med. Dr. med. dent. in order to rule out any secondary increase in • Upper body and antagonist training: Andreas Först the extent of the injury. This is accompanied from day 1 by daily sonographic screening as a simpler Dr. med. Dr. med. dent. Andreas Först is • Individual training with no jumps or abrupt way of monitoring the athlete’s progress dur- an orthopedic physician, trauma surgery stops, as well as specific strength training: ing the course of treatment. In some cases, specialist and osteopath (MDO) with his after complete resorption of the edema it may be sensible to determine the CK value own practice in Hirschaid. He heads up and AlterG at 80 % body weight in order to obtain information on the muscle the Conservative Therapy and Sport metabolism. The therapeutic procedure is • Non-contact team training: after phase 2 work group at the German Society for performed based on the MRI findings, tar- and when flexibility tests can be performed Foot and Ankle Surgery (GFFC), and geted towards the damaged muscle tissue, pain-free also studied dentistry after completing the induced hematoma and the surrounding his degree in Human Medicine. • Return to play: once phase 3 has been edema, and is always decided on a case- successfully completed. by-case basis. Factors such as the athlete’s constitution, the geometry of the leg-pelvis After successful reintegration, attention is axis and any existing pathologies in the LPH primarily on flexibility within the LPH complex, complex will need to be taken into account as well as flexibility in the area of the dorsal when deciding on the therapeutic procedure. chain. These elements are, however, also an integral part of athletic training. Acute therapy in the form of cryotherapy, compression and strain-relief is usually car- Dr. med. Dr. dent. med. Andreas Först, ried out for three days, but at least until the Team Physician at Brose Bamberg results of the MRI have been received. Dur- ing the first three days, local infiltrations with Meaverin and Traumeel/Zeel are performed. This is accompanied by lymph drainage and medication-based therapy with arnica, vita- min C, magnesium, muscle relaxants and a protein-rich diet. If the athlete is in a lot of pain or there is a local reaction, Tramal and ibupro- fen are administered during the initial phase. Infiltrations with PRP are performed on the 2nd, 3rd and 7th day. As soon as no further increase in the size of the edema is recorded, active movement exercises are performed, such as on the AlterG anti-gravity treadmill at 30 % body weight, which is increased by 10 % every one to two days.

40 sportärztezeitung 02/2018 | www.thesportgroup.de