Sports cardiology diagnostics is a well-established cornerstone in the care of high-performance athletes. It is used, for example, in the diagnosis of acute illness or reduced performance in athletes as well as in the regular and mandatory medical competitive exercise eligibility examinations of the various associations. One basic component of the diagnostic process is echocardiography, which nowadays allows an experienced investigator to perform both a visual high-definition and software-assisted assessment of the function of cardiac structures and function. 

The ejection fraction (EF) has long been the most important parameter in the assessment of myocardial function. It involves tracing the endocardium in diastole and systole in 2D echocardiography in a two- and four-chamber view and calculating cardiac output using Simpson’s method (see Fig. 1).

In recent years the relatively new imaging technique of speckle tracking, specifically speckle tracking echocardiography (STE), has markedly increased the diagnostic options regarding the assessment of myocardial function. It involves tracking individual or several speckles in the visualised myocardium during the cardiac cycle using the echocardiography software. This allows conclusions regarding contractility at levels that cannot be followed by the naked eye (unlike the ejection fraction). It allows, for example, calculation of longitu­dinal strain (shortening of the distance between the apex and the base of the heart) and of radial strain (thickening of the myocardium) (see Figs. 2 and 3, respectively). The calculation is performed for different myocardial segments, ultimately allowing global values for the three-dimensional left ventricle to be calculated from different 2D echocardiography settings (the same applies, to a lesser extent, to the atria andthe right ventricle). Peak strain values are thus calculated for each myocardial segment from a two-, three- and four-chamber view and combined into a simplified view, the bull‘s eye.A separate mean is calculated for the left ventricle, giving the global longitudinal strain (GLS) (see Fig. 4).

The calculation of myocardial strain is now common practice in cardiology; GLS is used as a predictor for cardiovascular mortality in healthy individuals, as a parameter in the diagnosis of cardiac amyloidosis, to assess the cardiotoxic effects of chemotherapy and to detect myocardial inflammation and pathological myocardial hypertrophy [2]. The latter two applications in particular are now part of clinical routine in sports cardiology. Ambitious athletes often neglect the necessary rest that should be observed during and after an infection, which in the further course repeatedly leads to the possibility of myocarditis. With respect to this – often complex – issue, strain analysis is a new and useful tool for sports cardiologists/sports medicine physicians. Local reduction in longitudinal strain, detectable in the bull’s eye or in segment visualisation, may indicate a local inflammatory process [2]. In high-performance athletes, myocardial hypertrophy is considerably more common than inflammatory processes. In most cases, marked thickening of the ventricular septum is clearly detectable and understandable as a sports adaptation consistent with physiologic eccentric hypertrophy (see Fig. 5). In some cases, however, other factors may suggest pathological mechanisms as a possible cause of septal hypertrophy. These include concomitant arterial hypertension, elements of concentric hypertrophy or indications of possible hypertrophic cardiomyopathy (e.g. apical hypertrophy, familial clustering or very pronounced hypertrophy). Whereas, based on current knowledge, physiological adaptation as in an athlete’s heart has no effect on cardiac strain values; various pathological mechanisms reduce these values – sometimes markedly [2, 3]. Strain analysis with speckle tracking echocardiography therefore provides sports cardiologists and sports medicine physicians with an effective new tool in daily routine diagnostics. Further research regarding the effects of sports activity on the different cardiac strain parameters is required, e.g. to study differences in the various sports disciplines or between the genders – a task that we have also set ourselves at the German Sport University in the Institute for Cardiovascular Research and Sports Medicine.

Literature

[1] Rost R (1997) THE ATHLETE’S HEART: Historical Perspectives—Solved and Unsolved Problems. Cardiology Clinics 15(3): 493 – 512. doi: 10.1016/S0733-8651(05)70355-6

[2] Collier P, Phelan D, Klein A (2017) A Test in Context: Myocardial Strain Measured by Speckle-Tracking Echocardiography. Journal of the American College of Cardiology 69(8): 1043–1056. doi: 10.1016/j.jacc.2016.12.012

[3] D’Ascenzi F, Caselli S, Solari M et al. (2016) Novel echocardiographic techniques for the evaluation of athletes’ heart: A focus on speckle-tracking echocardiography. Eur J Prev Cardiol 23(4): 437–446. doi: 10.1177/2047487315586095

The field of work psychology has already concluded that the relevance and impact of mental recovery breaks are a central issue and the benefits of such for the work context have been examined extensively [1]. In contrast, sports science has only started to pay attention to mental recovery and sports practice is increasingly giving more weight to the mental recovery aspect. The latest developments in high-performance sports underline that physical as well as mental demands have increased [2]. A holistic perspective emphasizes that athletes are exposed to multifactorial stress factors which are composed of global (e. g., sleep behaviour, insufficient recovery breaks, performance pressure), sport-specific (e. g., training and competition planning, competition travelling), and additional influencing factors (e. g., demands of sports and education). A sport-specific perspective additionally emphasizes that the stress pattern of sports like swimming, competitive shooting, or modern pentathlon which require the athlete to maintain a high cognitive as well as physical level over a prolonged time period (e.g., multiple competitions in one day) increases the risk of mental fatigue [3]. This clari­fies that the individual resources for compensation of sport-specific and external training and competition load will not be sufficient in case the individual capacity of coping with such is exceeded. The result could be a state of mental fatigue. The sport-practical necessity of focusing on mental recovery measures can be derived from this, as this can counteract an acute mental fatigue state. 

Mental fatigue and mental recovery as central terms

Essentially, mental fatigue is understood as a biopsychological state which develops due to prolonged cognitive and mental demands and can have a negative effect on athletic performance [4]. The effects of a mental fatigue state can be visible on three different levels, the psychological-subjective level, the behavioural level, and the physiological level [5]. Current research shows that mental fatigue is mainly perceived as an emotionally subjective state and effects are visible on the first two areas.
Indicators for the first level comprise an increased feeling of fatigue, lack of activation, and decreased motivation and attention [5]. Central indicator is the increased perception of exertion which negatively affects the sport-­specific performance. Key aspect on the behavioural level is the decrease of cognitive performance, which is shown in limited ability to concentrate, a plummeting accuracy of execution and a delay of reaction. A survey study with the aim to understand mental fatigue adds to these findings, as aspects like mental disengagement, limited guidance of attention, and lower discipline and enthusiasm are described as typical [6,3].

“For me personally, mental fatigue is a lack of ability to concentrate, lack of motivation or personal drive to train or take part in a competition. I was having a hard time focusing on technical elements and the actual competition when I was mentally tired.” 

(former high-performance swimmer and two-time Olympian)

The concept of mental recovery comprises the recovery process of cognitive abilities (e. g., the ability to concentrate) and the restoration of mental resources by reducing mental demands during a sufficient recovery break [7]. According to this, mental recovery includes cognitive as well as emotional processes. The aim of a short-range mental recovery is securing the willingness to perform in the following stress phases as well as the restoration of the needed resources by means of suitable recovery measures. With regard to this, the recovery break plays a crucial role in enabling the athlete to recover mentally [8]. Moreover, mental detachment seems to be especially relevant for regaining a mental balance by alternating between stress and recovery.

Mental recovery strategies in sports

It can be assumed that the different levels are mutually dependent. However, it seems sensible to apply mental recovery strategies on the subjective-psychological as well as behavioural level. Typical strategies to react to mental and physical outcomes would be psychological recovery strategies such as self-regulation techniques, resource activation strategies, and relaxation measures [9]. Loch et al. have summarized the current scientific knowledge to gain more precise insights into mental recovery in high-­performance sports. Their focus hereby is on mental recovery strategies for competition breaks* [10]. Based on this, one can differen­tiate between psychologically oriented strategies (e. g., breathing regulation techniques, training of mental imagery, power nap measures, mental detachment) and complementary psychological measures (e. g., music; see Tab.1). These strategies can support reducing a stress reaction, regulating the arousal level, increasing the mental well-being, and promoting concentration, motivation, and alertness of athletes during their break to subsequently reach the individual performance optimum [3].

Recommendations for sports practice

So far, recovery measures have been separated from a physical and comprehensive-psychological consideration. Prospectively, there should be a focus on mental recovery as a distinct work field. The mediation and learning of self-regulation skills – consisting of self-awareness, self-regulation, and self-control – seem to be beneficial for the mental recovery process [11]. Especially in the light of athletes being able to realize how to prepare mentally for a stress phase (“switch on”), but at the same time not being able to use an effective mental recovery measure during their break (“switch off”) it appears necessary to summarize a first guidance for the concept of mental recovery in sports [3].

• Mental recovery is a highly individual process. Therefore, mental recovery strategies should be applied according to the individual needs.
• Athletes should learn to assess their own mental state to recognize an acute imbalance of recovery and stress.
• A regular monitoring (e. g., with psychometric instruments) of mental fatigue and recovery enables the planning and implementation of deliberate mental recovery phases.
• Chosen and pro-actively used recovery measures can enable the athlete to react in the best possible way to acute mental fatigue states and increase the recovery gain. 
• The development of a specific recovery routine (e.g., combination of physical and mental recovery strategies) for recovery breaks is helpful for optimizing the
  recovery state. 

Literature

[1] Sonnentag, S., & Fritz, C. (2015). Recovery from job stress: The stressor-detachment model as an integrative framework. Journal of Organizational Behavior, 36(S1), 72-103. doi:10.1002/job.1924

[2] Loch, F., Hof zum Berge, A., Kölling, S., & Kellmann, M. (2020). Stress states, mental fatigue and the concept of mental recovery. In M. C. Ruiz & C. Robazza (Eds.), Feelings in Sport. Theorie, research, and practical implications for the performance and well-being. Abingdon: Routledge.

[3] Loch, F. & Kellmann, M. (2020). Mentale Ermüdung und Erholung. In T. Meyer, A. Ferrauti, M. Kellmann & M. Pfeifer (Hrsg.), Regenerationsmanagement im Spitzensport (Teil 2). Bonn: Bundeinstitut für Sportwissenschaft (BISp).

[4] Boksem, M. A. S., Meijman, T. F., & Lorist, M. M. (2005). Effects of mental fatigue on attention: An ERP study. Cognitive Brain Research, 25(1), 107 – 116. doi:10.1016/j.cogbrainres.2005.04.011

[5] Van Cutsem, J., Marcora, S. M., De Pauw, K., Bailey, S., Meeusen, R., & Roelands, B. (2017). The effects of mental fatigue on physical performance: A systematic review. Sports Medicine, 47(8), 1569–1588. doi:10.1007/s40279-016-0672-0.

[6] Russell, S., Jenkins, D., Rynne, S., Halson, S. L., & Kelly, V. (2019). What is mental fatigue in elite sport? Perceptions from athletes and staff. European Journal of Sport Science, 19, 1367–1376. doi:10.1080/17461391.2019.1618397.

 [7] Balk, Y. A., de Jonge, J., Oerlemans, W. G. M., & Geurts, S. A. E. (2019). Physical recovery, mental detachment and sleep as predictors of injury and mental energy. Journal of Health Psychology, 24(13), 1828 – 1838.doi:10.1177/1359105317705980.

[8] Eccles, D. W., & Kazmier, A. W. (2019). The psychology of rest in athletes: An empirical study and initial model. Psychology of Sport and Exercise, 44, 90–98. doi:10.1016/j.psychsport.2019.05.007.

 [9] Kellmann, M., Bertollo, M., Bosquet, L., Brink, M., Coutts, A. J., Duffield, R., … Beckmann, J. (2018). Recovery and performance in sport: Consensus statement. International Journal of Sports Physiology and Performance, 13(2), 240–245. doi: 10.1123/ijspp.2017-0759.

*[10] Loch, F., Ferrauti, A., Meyer, T., Pfeiffer, M., & Kellmann, M. (2019). Resting the mind – A novel topic with scarce insights. Considering potential mental recovery strategies for short rest periods in sports. Performance Enhancement & Health, 6, 148–155. doi:10.1016/j.peh.2019.04.002.

 [11] Balk, Y. A., & Englert, C. (2020). Recovery self-regulation in sport: Theory, research, and practice. International Journal of Sports Science & Coaching, 15(2), 273-281. doi:10.1177/1747954119897528.

Additionally, in the case of competitive athletes, long years of stress have led to adaptation processes in the shoulder, which can further exacerbate sport-related shoulder problems. In these athletes, one-off injuries due to macrotrauma are not usually the cause of the symptoms. They are more likely to be due to stress-related damage caused by repetitive microtrauma. Initial treatment is usually conservative, once structural shoulder damage has been excluded by means of clinical examination and medical imaging. The conservative treatment is complex, can be protracted, and presents a major challenge for both athletes and therapists. Surgical treatment can be necessary in the presence of structural damage to the labrum, biceps tendon anchor, rotator cuff or joint capsule. 

The throwing or overhead motion (e.g. as performed in racquet sports) is a sport-specific motion, which functions in a complex kinetic chain. The key positions here are occupied by the glenohumeral joint and the often forgotten scapula as force transmitters with their muscular connection to the trunk. In the wind-up phase, the arm is brought into approximately 90 ° of abduction and maximum external rotation, in order to generate a maximum throwing speed. In the subsequent acceleration phase, there is particular activation of the anterior shoulder muscles, such as the subscapular muscle and pectoral muscle. There is a rapid glenohumeral internal rotation. In the deceleration phase of the throwing or overhead motion, there is very high force transmission onto the glenohumeral joint. 

Long-term practice of the throwing/overhead sport, perhaps while still growing, activates anatomical adaptation processes. Increased glenohumeral external rotation allows a higher throwing speed. This is achieved by enlargement of the anterior joint structures (capsules and ligaments). By contrast, contracture and thickening of the dorsal capsule/ligament structures is common and verifiable in ultrasound examination or magnetic resonance imaging (MRI). These adaptation processes can facilitate the development of structural damage, so that early clinical detection is crucially important in preventing such damage. 

The increased external rotation ability leads to pathological contact between the dorsal regions of the supraspinatus tendon and the superior glenoid and the Superior Labrum Anterior to Posterior (SLAP) complex. This mechanism is a frequent form of internal impingement and is known as posterosuperior impingement. 

Clinical examination

In mobility testing, typical glenohumeral differences are already apparent when comparing the contralateral side. Glenohumeral Internal Rotation Deficit (GIRD) with additionally increased external rotation in the throwing shoulder is the most significant clinical sign. Measurement of the external and internal rotation is performed with the arm hanging down or abducted to 90 °, always in comparison to the contralateral side. Another finding on examination, due to the frequent presence of narrowing of the dorsal glenohumeral capsule, is Posterior Shoulder Tightness (PST). With the patient supine (ensuring stabilisation of the scapula), a reduced adduction ability is evident compared with the contralateral side. For both pathologies, typical treatment methods in the form of stretching exercises have been defined and investigated in the scientific literature. For patients with GIRD, sleeper stretches are described, whereas a relatively simple cross-body stretch is reported for PST. The latter, in particular, has impressively good outcomes in the literature. In contrast to contracture of the dorsal capsular structures, the anterior capsular/ligamentous structures are frequently overextended and clinically painful tests indicate anterior microinstability (e.g. relocation test, Fig. 1, painful anterior apprehension test, sulcus sign). 

The scapula plays a crucial role in every shoulder joint movement and any malfunction of its complex three-dimensional motion can be both the cause and the result of shoulder pain (Table 1). When making a diagnosis, thorough examination with the patient undressed to the waist while comparing both sides is important (Fig. 2). If the symptoms can be reduced by manual stabilisation of the affected scapula, this is highly likely to indicate a relevant scapular dyskinesis. The treatment of such scapular dyskinesis is often both protracted and difficult and requires optimal communication and cooperation between physician and physiotherapist. 

Important: Exclusion of relevant structural damage

If there is clinical suspicion of structural damage to the glenohumeral joint, medical imaging should be performed to exclude this. In our own clinical practice, this is initially ultrasound examination, which allows especially good visualisation of the rotator cuff, biceps tendon and posterior capsule. Particularly if labral and/or SLAP lesions are suspected, we consider this to constitute one of the rare indications for an MRI arthrogram using intra-articular contrast agent, as this is markedly more informative in these specific pathologies than a plain MRI scan. 

Surgical treatment of structural damage

Anterior joint capsule/labrum

The importance of surgery to reduce joint capsule volume, such as the capsular shift procedures as originally described by Jobe, has declined in this specific patient population, as it is associated with a limitation in the ability to rotate the shoulder externally. This is not always compatible with a return to a high level of throwing performance. Labral lesions, on the other hand, should be treated by means of arthroscopic refixation. 

Biceps lesions (including SLAP/pulley lesions)

Whereas refixation of the SLAP complex to the origin of the long biceps tendon became popular in the last decade, according to current knowledge, there is now considerable reluctance if a SLAP repair is indicated. The reasons for this are once again limited postoperative mobility and hence doubts about the patient’s ability to return to sport at the same level. As a rule, in the case of SLAP lesions, tenodesis of the long biceps tendon is currently recommended, as with partial lesions of the biceps tendon itself. 

Rotator cuff lesions

Due to posterosuperior impingement, which, as described, arises from increased external rotation in overhead throwing athletes, even young athletes can develop significant partial lesions on the joint side of the supraspinatus tendon (Fig. 3). In this case, the indication for surgical repair must be very carefully reviewed, as experience has shown that a return to top-level competitive sport is very difficult after rotator cuff reconstruction. 

Follow-up treatment

As with almost all reconstructive shoulder procedures, follow-up treatment always entails an immobilisation period of four to six weeks, during which passive mobility is permitted with a prescribed amount of movement. Usually, a return to full sporting activity is not possible until after six months. 

Summary

Thrower’s shoulder is not a clearly defined clinical picture, but rather a combination of various diagnoses, which can be present to varying degrees in overhead throwing athletes. Structural damage should be clinically and ­radiologically excluded. Initial treatment is usually conservative. The surgical procedures, which are rarely required, are normally performed arthroscopically and entail protracted follow-up treatment. 

Symptoms

Whereas in acute fractures sudden onset of pain is typically a cardinal symptom, in metatarsal stress fractures it generally develops gradually. Reduced loading capacity is associated with fractures irrespective of aetiology. Adequate early diagnosis and identification of risk factors are particularly detraining important in competitive sports to avoid long periods without training or competition. 

Risk factors

It is crucial to identify any predisposing factors. For example, stress fractures are more common in ballet dancers due to repeated maximum plantar flexion [36, 27]. Athletes in sports with high running or jumping loads are also at risk. As retiring from the sport is not an option for competitive athletes, it is essential to identify other possible causes. These may include changes in loading, such as increased training volumes, changes in surface, new shoes, special shoe inserts or biomechanical compensation mechanisms following prior injury [7, 21]. Systemic causes should also be considered. These include changes in hormone balance, eating disorders and malabsorption syndrome [1, 2]. The female athlete triad is a common example [33, 1]. It is therefore important to check intake of protein, calcium and vitamins D and K₂, as well as use of alcohol, opioids and tobacco [28, 10]. Nonsteroidal anti-inflammatory drugs (NSAIDs) in particular can have a negative impact on fracture healing. Use of NSAIDs has caused a significant decrease in trabecular bone mass in ectopic ossification areas due to the decreased number and activity of osteoblasts. This is caused by interference with the bone morphogenetic protein-7 (BMP-7) signalling pathway. Although trauma is the direct cause in acute fractures, the other above factors can predispose to fracture and should therefore also be considered even if the immediate cause is apparent. [32] 

Diet

Diet can have both a positive and negative effect on fracture healing. First, it is essential to avoid any toxins. Smoking and heavy drinking are associated with loss of bone mass (osteo­penia) and increased risk of fracture [28]. The available data on moderate drinking is still inconclusive [38]. In general, a fully nutritious diet is essential in any injury to ensure an adequate supply of energy and protein. In this case, 2 – 2.5 g protein / kg body weight are recommended. It is especially important to prevent micronutrient deficiencies. Vitamins D and K₂, magnesium and boron are parti­cularly important in promoting bone healing.

Vitamin D deficiency

Vitamin D plays an important role in calcium and phosphate homeostasis. Particularly in combination with calcium it helps maintain a balanced bone metabolism [18, 19]. It is therefore essential to rule out vitamin D deficiency (< 25 nmol/L) [9] and any possibility of resulting secondary hyperparathyroidism (sHPT). Prolonged sHPT is associated with impaired bone turnover [23, 17] and can also lead to loss of mineral salts [26, 17]. Guidelines reco­mmend measurement of 25-hydroxy vitamin D serum levels in all patients with sHPT [22].

Osteopenia

Osteopenia can occur alone or as a result of ­vitamin D deficiency [17]. Diagnosis mostly involves dual-energy X-ray absorptiometry (DXA). A new procedure will allow bone density to be determined without the need for exposure to radiation based on calcium homeostasis in the skeleton [9].

Biomechanical compensation mechanisms

If the above mentioned risk factors have been ruled out or recurrent metatarsal injuries occur, structural compensation mechanisms should also be considered [8]. These mechanisms can result in an imbalance in the loading and unloading of bones and soft tissue structures, resulting in fracture [21]. From a biomechanical perspective, chan­ges in movement vectors and the resulting force vectors lead to incorrect loading e.g overloading [31]. A picture of the movement pattern and the resulting loading vectors can be gained using gait/running analysis, which allows the kinematics and kinetics of the lower extremity to be observed [5]. Use can also be made of dynamic procedures such as foot pressure measurement and gait analysis [7, 5, 11]. These allow observation of, for example, running and foot roll behaviour. 

Based on the findings, it is possible to counteract incorrect biomechanical and compensation loading with the choice of individual shoe inserts and foot muscle training

Diagnosis

Following medical history and physical examination, it is advisable to perform diagnostic ultrasound of the foot to gain a more better understanding of the fracture. In the hands of an experienced investigator, diagnostic ultrasound is just as sensitive and specific as diagnostic X-ray [4]. However, if a fracture is suspected, this should be followed by diagnostic X-ray of the foot in three planes [3]. In fractures of the base of metatarsals 1 – 4, computer tomography should also be perfor­med, as such fractures may be associated with Lisfranc dislocation fractures. In the case of stress fractures, MRI is the gold standard, as X-ray images are often falsely negative [36].

Treatment

Conservative or surgical treatment

Shaft fractures of metatarsals 2 – 5 with no or slight dislocation can be treated conservatively. Dislocations of up to 3 mm and plantar malalignment up to 10° are amenable to conservative treatment [3]. In such cases, immobilisation in a short walker with full weight bearing adjusted according to pain level is sufficient. This treatment when combined with a change of shoe to one with a rigid sole after 4 – 6 weeks has the advantage of a better functional outcome compared with immobilisation in a lower leg plaster cast [4]. Provision with a carbon sole is also a primary consideration. Fractures of the first metatarsal with dislo­cation should be surgically stabilised, as this bone plays a central role in carrying body weight and in the foot arch [4]. Fractures of more than one meta­tarsal, even with slight dislocation, require surgery [3]. In subcapital and metatarsal head fractures, axial deviations up to 10^o are similarly amenable to conservative treatment. 

Conservative treatment consists of unloading the forefoot by means of a rigid sole with full weight bearing adjusted according to the pain level. For fractures with greater dislocation and extra-articular fractures, intramedullary wires are the fracture-fixation procedure of choice [3]. Surgery should also be indicated for shortened metatarsals or rotation defects of the toes [12].

Special features of stress fractures

Stress fractures commonly involve the neck of the second and third metatarsal and the shaft of the fifth metatarsal. A very pronounced foot arch increases the risk of stress fractures of the fifth metatarsal due to increased loading [12]. It can take 3 – 6 months for the fracture to heal. As with traumatic fractures, treatment consists of initial unloading with gradual restoration of weight bearing as the bone heals [15]. Stress fractures of the fourth and fifth metatarsal in particular are more prone to non-union [36]. In a case series, 11 athletes with stress fractures of the base of the fourth metatarsal were therefore treated with plate fixation and autologous bone grafting from the calcaneus. On average, all athletes were able to return to sports after 12 weeks [30].

Procedures to promote bone healing

Non-union may occur with both acute and stress fractures. There are various treatment procedures that may be used before surgical revision needs to be considered. It is essential not to delay their use until it is too late but to initiate application as early as possible in the healing process.

Shock wave therapy

Shock waves ensure increased production of growth factors, nitrogen oxides and free radicals, which trigger the healing process. This can be exploited to treat stress fractures [15]. Shock wave therapy induces angiogenesis, and mesenchymal stem cells differentiate to osteoblasts. The periosteum is also stimulated, which plays a major role in callus formation [15]. There are a number of case series that report positive outcomes for stress fractures. These involved the use of focused medium to high energy shock waves. 

In most cases the same doses were used as for non-union. The best outcomes were achieved with 2000 impulses at 0.2 mJ/mm² in 2 sessions. For non-union, there are individual rando­mised, controlled studies as well as case series. The healing rates with shock wave therapy do not differ from those following surgery. In the studies 4000 impulses were applied at an energy flow density of 0.09 – 0.7 mJ/mm² in each of generally 3 or 4 sessions.

Pulsating electromagnetic field therapy (PEMF)

PEMF is another procedure being advocated for non-union and delayed healing. Studies have demonstrated good healing of Jones fractures with non-union, particularly when the devices have been used for more than 9 hours a day [24]. Fracture healing was more quickly achieved following surgery in the treatment group than in the group receiving placebo magnetic field therapy [34]. The evidence of the results, however, is problematic because a control group was part of the study design in only one of the studies.

Ultrasound

Studies point to improved healing in non-union, but in some there was no control group [35, 14]. Good healing rates were achieved, and individual studies indicate greater cost effectiveness compared with surgical revision [14].

Platelet rich plasma (PRP)

Animal studies have shown positive effects of PRP on fracture healing [13]. In view of these results a beneficial effect is also conceivable in humans. Clinical experience shows that additional treatment with PRP does lead to a positive course in a protracted course of fracture healing. Overall, the evidence for PRP promoting fracture healing is scarce [29]. On the other hand, injection of PRP has been successful in alleviating pain and in associated biomechanical compensation mechanisms as well as protective guarding and movement avoidance [25, 37]. However, further evidence-based studies are required for a more evidence-based and conclusive assessment [16].

Summary

The first important step in the treatment of meta­­tarsal stress fractures is to figure out the cause and identify any risk factors. It can help prevent secondary injury. This should be followed by multimodal treatment comprising modified weight bearing and optimised bone healing. The pain experienced by the patient plays a central role particularly with regard to modi­fying weight bearing. However, due to their negative effect on fracture healing, administration of NSAIDs should be avoided. Pain can be reduced, and bone healing promoted by diet, shock wave therapy and, when applicable, supplementary electromagnetic field therapy.

The pathogenesis of primary, focal osteochondral defects of the patella (PFODP) is still not fully understood. It is thought that negative stimulation due to overuse of the knee and ­local microcirculatory disturbances play a crucial role in the pathogenesis of PFODP. A wide variety of conservative/physical and drug treat­ments are used to treat PFODP. Surgery to repair the cartilage is indicated when symptoms of cartilage damage persist despite conservative and drug treatment. In summary, the therapeutic approach to PFODP largely mirrors that to osteoarthritis of the knee. However, it is still largely unclear whether combinations of conservative/physical and drug treatments for PFODP really result in better outcomes than individual measures. This question has now been investigated by a team of researchers from Germany and China (note from the editor: our scientific advisor Prof. Christoph Schmitz MD (LMU Munich) was also a member of this team). Specifically, the researchers performed a retrospective analysis of the medical records of all 81 patients with unilateral symptomatic PFODP who received treatment with either five intra-articular injections of hyaluronic acid at weekly intervals (iaHA) (n=45) or a combination of 5x iaHA and 5x radial shockwave therapy (iaHA+rESWT) (n=36) at the Center for Joint Surgery of the Third Military Academy in Chongqing/China in the period 1 January 2014 to 31 January 2018. Each intra-­articular injection of hyaluronic acid was performed using 2.5 mL ARTZ Dispo (Seikagaku Corporation, Tokyo, Japan); the rESWT involved the use of a Swiss Dolorclast (Electro Medical Systems) with an EVO Blue handpiece and a 15 mm applicator (2000 radial shock waves per treatment); working pressure 1.8 – 2.5 bar; 6 – 8 Hz). Follow-up was performed after 6 weeks (W6), 3 months (M3), 6 months (M6) and finally (F) after a minimum of 12 months (mean: 37.6 months; maximum: 59 months).

Results

Compared with patients who received treatment with iaHA alone, those treated with iaHA+rESWT had statistically significantly lower mean VAS pain scores at W6, M3 and M6 (each 7.0 at baseline), significantly lower mean WOMAC scores at W6, M3 and F (59 and 62 at baseline) and a significantly smaller mean area of bone marrow oedema on sagittal MRI images of the patella at M3, M6 and F (no MRI was performed at M3) (69 mm2 and 75 mm² at baseline). The decrease in the mean values between baseline and final follow-up in the patients treated with iaHA+rESWT was 82 % (VAS), 66 % (WOMAC) and 75 % (area of bone marrow oedema). No serious adverse reactions were observed.

Conclusion

The results of this study indicate for the first time that the combination of iaHS+rESWT to treat PFODP is safe and more effective than iaHA alone. This outcome, which is also of great interest for the treatment of other forms of osteoarthritis of the knee, is now also being further investigated in adequate, randomised controlled studies. 

The preprint of the study is available at https://doi.org/10.1101/2020.07.29.20164111.

Conflict of interest: Prof. Schmitz acted as a part-time advisor to Electro Medical Systems (Nyon, Switzerland) up until the end of 2017. His research on rESWT at the LMU Munich has been supported with materials freely supplied by Electro Medical Systems since the beginning of 2018. Electro Medical Systems has had no influence on the content and design of this article, the acquisition, analysis and interpretation of the data presented and the decision to publish this article.

Cooperation with the Chinese Basketball Association (CBA)

Recently, CityReha has concluded a cooperation with the CBA and China-Life-Insurance. As part of this cooperation, CityReha completes an initial isokinetic assessment with the majo­rity of the professional CBA athletes in order to ascertain the functional status and condition of the players and to identify possible neuromuscular deficits and to create better conditions for the prevention of further injuries by means of appropriate instructions or a training plan.

Sophisticated Equipment from Germany & USA

City Reha Shouhou is equipped with the latest and most sophisticated devices in China and probably even worldwide. From a health risk assessment (Cardioscan), through assessments of endurance and balance capabilities to comprehensive isokinetic multi-joint (Biodex System 4), spine & trunk assessments by tergumed, the facility has all relevant options to identify all physical deficits and accordingly design tailor-made training measures for each patient individually. 

With AlterG and vacumed CityReha also offers high class treatment &training with NASA technologies. AlterG provides an individual gait therapy for orthopedic & neurologic patients as well as a cardiovascular performance training for athletes. Vacumed offers a vascular training, regeneration, and stimulation of blood circulation. For further regeneration, CityReha offers cardioscan Airzone. With Airzone, one breathes in alternating oxygen-reduced and ambient air. Having less oxygen available, the body reacts with adaptation and self-healing processes. Among other things, the powerful mitochondria multiply, which leads to an improved energy supply and slowing down the aging process.

Membership program for Milon Micro Center 

CityReha Shouhou complements its services with attractive prevention and memberships programs. For special target groups a completely new training area is designed: 

Our NEW MILON MICRO CENTER is also high-level equipped with Cardioscan, Milon Circuit Training, Sensopro and Wonderwall. Here, our members receive an individual but targeted and very efficient training plan tailored to their personal needs based on the Milonizer BodyScan and a Milonizer Fitness check-up. This combines strength training including an endurance part with a coordination and mobility training. 

Sorehsa AG continues to follow its vision to grow

Sorehsa AG is still following its vision and reacted counter-cyclically by investing into the future with the opening of CityReha Shouhou in Beijing. Antoni Mora, CEO of Sorehsa Ag Group, stated with regards to this project: “The planning and implementation of this project in uncertain times was a demanding for the project team which is – due to the pandemic – partly located in Switzerland. Now we are looking forward to ta successful future.”

Sibylle Mora Head of Business Development, Sorehsa AG Basel

General Manager, CityReha Beijing
sibylle.mora@sorehsa.chwww.cityreha.com

The patient first presented in February 2019 approximately 3 months after full manifestation of characteristic symptoms with pain and swelling in individual finger joints. There was a history of the disease in both the mother and grandmother, the disease fully manifesting in both at approximately 50 – 55 years of age. 

The findings of the thorough clinical examination conducted at first presentation were as follows:

Marked swelling in both hands with more pronounced swelling in individual finger joints, particularly in the metacarpophalangeal (MCP) joints. Severe pain in these joints on pressure, e.g. when shaking hands (VAS 9 – 10) and on movement (VAS 6 – 8); full extension of fingers not possible or only with pain. Flexion restricted, complete closure of the fist not possible due to pain and swelling. Early deformation of the DIP joint of the left index finger. Blood circulation, motor skills, sensitivity without findings, no numbness or paraesthesia of the hands. The patient was unable to wear her wedding ring at first presentation.

Due to the history and identical symptoms of her mother and grandmother, the patient declined to have an X-ray examination or MRI scan for further clarification. However, the clinical signs and massive discomfort provided and provide clear evidence of familial polyarticular arthritis. The patient had been previously treated with just various NSAIDs, novaminsulfone drops, paracetamol, vitamin D, hot and cold hand baths, squeeze balls and rest. Under this treatment, the patient was never without pain and the fingers were always swollen. She usually needed to spend about 10 minutes every morning exercising her fingers to improve mobility and be able to start work.

Normally at this point, options for further treatment would primarily include a period of unloaded rest, cortisone (topical and oral), physiotherapy, further intake of high dose NSAIDs and, where applicable, even treatment with methotrexate. However, as the previous treatment had been unsuccessful in all respects, in close consultation with the patient we opted for radial extracorporeal shockwave therapy (rESWT), which was then combined in the further course with high-energy laser treatment. We know of many cases of patients with polyarticular arthritis where ESWT had very often rapidly alleviated pain even when the polyarthritis had previously been refractory to treatment. Unfortunately, however, there are to date no conclusive scientific studies on the successful effect of radial shockwave therapy in polyarticular arthritis of the hands. Similarly, there are no scientific studies on combination therapy with high-energy laser λ = 905 nm and ESWT.

The rESWT was performed using a Swiss Dolor­Clast device (Electro Medical Systems; Nyon, Switzerland) and the EVO Blue handpiece (36 mm applicator). The laser is a high-energy pulsed laser with a wavelength of λ = 905 nm and 300 W maximum output. At the start of treatment in February 2019 approx. 5000 rESWs (radial extracorporeal shock waves) were applied per hand at 0.3 bar (36 mm applicator) around the MCP joints, then the fingers, followed by the palms and the carpometacarpal joint of the thumb. The rESWs were always applied at 20 Hz, i.e. 20 rESWs per second, and always at the end also as a form of deep lymphatic drainage massage, moving the handpiece always from distal to proximal over the carpal tunnel. Treatment was initially performed weekly. From the third treatment session onwards, we were able to increase the working pressure to 0.6 bar, and the patient reported a distinct improvement in pain and swelling, and after the fifth session was even able to wear her wedding ring again. However, in the more severely affected left hand the working pressure could not be increased beyond 1.2 bar and in the less affected right hand beyond 1.6 bar. The patient was then fully without pain for approx. 3 weeks before the swelling and pain returned. 

At the start of July 2020, we had the opportunity to attempt combination therapy with high-energy laser (λ = 905 nm) and rESWT. After a 3-minute anti-inflammatory laser programme (applied using a flexible arm) applied to the 2 – 3 main pain areas in the more severely affected left hand, we were immediately able to increase working pressure up to 2.0 bar after a five-minute break and continued to apply rESWT at the usual 1.5 – 1.6 bar in the less affected right hand. The effect on the left hand was immediately felt to be greater according to the patient and the pain relief induced by rESWT even markedly better than before. 

At follow-up after 5 weeks the otherwise worse left hand was still very good, whilst the patient was once again already experiencing pain in the right hand.

At the next treatment session, a break of 1 hour was observed between the laser and rESWT treatments, which enhanced the effect even more! We were able to apply rESWT this time at 2.5 bar in the left hand and at 2.4 bar in the right hand (this time also preceded by laser treatment). The follow-up this time after 8 weeks (05.10.2020) was reason to celebrate, as the patient even after this length of time was still without pain and the hands were no longer swollen and were freely movable.

Conclusion

Radial shockwave therapy is a very successful and reliable treatment option for polyarticular arthritis und has proved itself countless times in our practices. The combination of high-­energy laser at λ = 905 nm and subsequent rESWT can markedly further enhance the positive effect. This is due to the pain-allevia­ting effect of the laser, which would be comparable to that of topical ibuprofen. As a result, subsequent rESWT can be performed at a markedly higher working pressure and thus a stronger and markedly longer lasting effect can be achieved. The two treatment modalities should ideally be applied 1 hour apart, but the effect can be already observed, albeit weaker, after a break of 5 minutes. This combination treatment allows, for example, chronic symptoms of polyarticular arthritis to be treated significantly even more effectively and longer lasting than before. 

On MRI, both the anterior talofibular and calcaneofibular ligaments were no longer constantly defined and there was a marked high-signal swelling of the surrounding soft tissue. Mild joint effusion in the tibiotalar joint. Hyperintense bone marrow oedema in the medial talus and dorsomedial and dorsolateral tibial epiphysis. 

Treatment

The player received initial treatment on the pitch using the RICE method.  As acute treatment he also received 600 mg oral ibuprofen as required, forearm crutches to relieve the right leg from weight and provide pain relief and cold compresses to reduce swelling.

From day 2 after the initial injury, the patient wore an ankle brace with a compression component, lateral stabilisation and straps to reduce anterior translation of the talus.

Combination therapy with high-energy pulsed laser (λ = 905 nm and 300 W maximum output) was also initiated at this time to provide local pain relief in preparation for the radial shockwave therapy to allow application at a markedly higher energy intensity using a Swiss DolorClast machine (Electro Medical Systems; Nyon, Switzerland) and the EVO Blue handpiece. The treatment regimen was as follows: laser programmes for pain relief and absorption of oedema and shockwave application using a 36 mm applicator, frequency 20 Hz, 5000 impulses per session, 2 bars of pressure, applied over the lateral and medial malleolus areas to approximately the distal third of the lower leg and the anterior ankle area with the aim of pain relief and oedema absorption. 

The patient was already without free of pain following the first combination therapy session in conjunction with the cold applications mentioned above. At the same time, upper body and trunk training was also initiated to maintain physical fitness.

The above combination therapy was performed daily, followed by cold compression using a therapy machine and bandages, until day 5 after the initial injury. After the third therapy session with laser and rESWT, there was no longer any swelling in the ankle joint and full weight-bearing without support was possible. 

Between day 6 and day 18, therapy was continued 3 times a week as follows: 

• laser programme for pain relief in preparation for rESWT
• applied with a 15 mm applicator, frequency 20 Hz, 4500 impulses per session applied to the tears. The pressure was increased in the further course from 2.0 bar to 3.0 bar. Treatment was followed by
  2 x 3-minute cold therapy with Cryolight.
• applied with a 36 mm applicator, frequency 20 Hz, 4500 impulses per session, applied over the surrounding lateral malleolus area. The pressure was increased in this area in the further course from 2.5 bar to 3.2 bar. 

From day 6 after the initial injury, it was already possible to initiate relaxed cycling, i.e. low linear weight-bearing for collagen alignment, and from day 10 simple ankle stabilisation exercises. From day 12 post trauma, the player had his first running sessions with carefully managed jumping exercises and full taping around the ankle, depending on the RTA (return to activity) phase attained at the time. 

Twenty days after injury, the player passed his RTS (return to sports) test and was permitted to carry out ball work, sprint training and late­ral movement sequences with taping applied.

Laser and rESWT therapy over the injury site were continued in parallel as follows: pain ­relief programme with laser and rESWT, applied with a 15 mm applicator, frequency 20 Hz, 4000 impulses per session applied to the tear sites, 3.5 bar.

As part of the gradual increase in weight-bearing, the athlete was reintroduced to all aspects of team training before the end of week 4 post trauma, with taping applied. Having passed the RTC (return to competition) test on day 27 post trauma, the player was permitted to fully participate in team training without restriction, but with full taping applied. He played his first league match 34 days after his initial injury.

He received further treatment for 2 weeks as follows:

laser (pain relief programme) to prepare the tissue and rESWT applied with a 36 mm applicator, frequency 20 Hz,  4500 impulses per session, over the surrounding lateral malleolus area, 4 bar, with the aim of supporting full healing, the stability of the ligament complex and the absorption of the bone marrow oedema as secondary prophylaxis.

Conclusion:

High-energy laser and rESWT in combination are an outstanding method of providing effective and above all long-lasting treatment of injuries to the lateral ligament complex of the ankle.  The major advantage of this method is the pain relief provided by the laser, which, unlike other medication, has no adverse impact on the effect of rESWT, but allows the energy intensity to be increased, thereby further enhancing its effect. This combination therapy can be equally used in a wide variety of indications, such as insertion tendinopathy, muscle injuries, fractures and many others.

On the one hand, ankle trauma can cause changes in the sense of bone marrow edema (bone bruise) due to the mechanical aspect of the mode of injury; on the other hand, injuries to the cartilage of the talus (chondral lesions) or combined bone-cartilage injuries (osteochondral lesions) can also occur as a result of the trauma. Osteochondral lesions of the talus can be accompanied by subchondral cysts. Patients affected complain of ankle pain, some of which is unrelated to pressure being applied, of restricted ankle movement, some of swelling and locking-up, as well as instances of functional instability [4]. In addition to the symptoms described above, clinical examination of the patient may reveal unstable syndesmoses, problems in the area of the medial and lateral capsular ligament apparatus, and axial deviations in the hindfoot, requiring further treatment [5].

Treatment options up till now have involved conservative and surgical measures. Conser­vative measures include relief using forearm crutches, taking NSAIDs, physiotherapy exercise, providing ankle orthoses and shoe insoles, and perhaps intra-articular corticosteroid injections. Surgical treatment options are roughly divided into bone marrow stimulation, cartilage repair and cartilage regeneration measures. In recent years, injections with hyaluronic acid preparations and platelet rich plasma (PRP) preparations have been attracting more and more attention in the treatment of osteochondral lesions of the talus. Various studies have demonstrated improved joint mobility and reduced post-op pain where growth factors and bioactive components, contained in the PRP, were injected intraoperatively during ankle operations. Interestingly, these studies have shown that the improvement in the above factors is independent of the surgical technique [3]. Below, we discuss some new techniques for treating bone marrow edema, and chondral and osteochondral defects of the talus. 

Biological basis

As already described above, use of PRP for this type of injury has become more prominent in the last ten years due to the positive outcomes achieved. To better understand the effect of PRP, it is necessary to look more closely at the physiology of tissue regeneration. The healing mechanism generally applies in equal measure to all tissue types and following haemostasis is in three phases:

Inflammatory response

Platelets and leukocytes in the blood clot release growth factors and numerous other cytokines, which trigger the inflammatory response. Endothelial cells also present then guide the inflammatory processes to the injury site [7]. Complex metabolic cycles involving neutrophils and macrophages, amongst others, ensue [8]. The latter, activated by messenger substances from leukocytes, then initiate the release of healing factors such as TGF-ß, bFGF, PDGF and VEGF [9].

Proliferation

Released VEGF stimulates plasma proteins to lay down a provisional matrix, into which stromal progenitor cells, guided by cytokines released by the immune cells, then grow. The progenitor cells differentiate depending on the growth factors and cytokines present, developing into the predominant tissue-specific cell type (approx. 3 – 5 days after injury). Stimulated by PDGF, IGF and TGF ß, these cells also produce collagen, proteoglycans and other components of the extracellular matrix [10].

Remodelling

Collagen deposition peaks approx. 2 – 3 weeks after injury and the transition to the remodelling phase begins. A balance develops between synthesis, accumulation and degradation. Small capillaries join to form larger vessels. Water content, cell density and metabolic activity fall. The type, quantity and organisation of collagen change significantly, resulting in increased firmness. The initially deposited collagen III becomes collagen I, and the physiological ratio of 4:1 (collagen 1 to 3) is restored [11]. If this physiological healing cascade is disturbed at some point by intrinsic or extrinsic factors, various pathologies result depen­ding on severity and tissue type.

Platelet-Rich Plasma – PRP

PRP, usually produced from whole blood by centrifugation, features a greater concentration of platelets and so also greater concentration of the growth factors it contains. When PRP is injected into the affected region, the greater concentration of growth factor has a positive effect on cell proliferation, differentiation, chemotaxis, and angiogenesis [11]. Impaired healing processes start up again and affected tissue is stimulated into recovery.

Use in Bone Regeneration

Like in other tissues, PRP has positive effects on cell proliferation, differentiation, chemo­taxis, and angiogenesis in bone healing. With platelets having a lifespan of 7 – 10 days, it is assumed that PRP supports early bone healing rather than influencing late bone formation [12]. There is increasing evidence that platelet-­induced inflammation response plays a major role in the early stages of recovery, and that effective regeneration cannot occur without it [12]. Excessive inflammation, however, can have a negative effect on recovery. Here, PRP has a positive effect on both the extent and duration of the inflammation, through the growth factors TGF-β1, IL-4, HGF and TNF-α [12], such that recovery is channeled in the right direction at an early stage.

Use with Cartilage Damage

Cartilage has only very limited self-healing capacity when damaged, due to its inherent avascularity, which therefore leads to cartilage damage and osteoarthritis. However, numerous growth factors play a central role in the development and homeostasis of cartilage, suggesting the use of PRP in cartilage regeneration. Anabolic factors, such as TGF-ß1 or IGF-I, stimulate chondrocytes into synthesizing proteoglycans, aggrecan and collagen II. They induce proliferation of synoviocytes and mesenchymal stem cells. At the same time, the catabolic effects of, for example, Interleukin 1 (IL-1) or matrix metalloproteinases (MMPs) are reduced [13].

Bone Marrow Edema of the Talus

Bone marrow edema is a pathological increase in interstitial fluid in the bone, and can be detected early using an MRI scan, if there is vague joint pain (Fig. 2). There are various causes of bone marrow edema. Persistent joint pain is called bone marrow edema syndrome (BMES), which is defined as lasting from 3 to 18 months [14 – 16]. It is worth mentioning that distinguishing it from osteonecrosis of the talus can be difficult. As a rule, however, osteo­necrosis follows a fulminant disease progression. Bone marrow edema can roughly be classified as vascular ischemic, mechanical or traumatic, and reactive bone marrow edema. Bone marrow edema of the talus is often visible on an MRI scan following trauma. How and why bone marrow edema syndrome develops from bone marrow edema remains unclear [17].

Clinical Symptoms

Clinical symptoms manifest themselves as acute pain and significant impairment of function, and swelling in or on the ankle. There are normally no signs of local inflammation.

Imaging Procedures

Diffuse osteopenia can sometimes be seen in the affected area on unenhanced x-rays. Bone scans with detectable tracer accumulation in bone marrow edema are an indication of increased bone regeneration activity. If it is uniform, the surrounding soft tissues are not affected. Sensitivity is around 60 % [18]. Magnetic resonance imaging is the method of choice for confirming the diagnosis. MRI scans have 100 % sensitivity. In order to differentiate osteonecrosis from bone marrow edema, using a gadolinium-based contrast agent is recommended [19].

Therapy

Basically, a conservative management approach is preferable. Treating the symptoms, taking pressure off the side affected, and taking anti-­inflammatory drugs, as well as manual therapy and physiotherapy should be tried first. Recent studies show that IV administration of iloprost or bisphosphonates (such as ibandronate) can lead to a significant improvement in symptoms. Administration of the drugs mentioned above is intended to improve blood circulation (iloprost) or to inhibit osteoclasts (bisphosphonates) [20 – 23]. It is vital to pay attention to the adverse drug reactions which can occur with IV administration of iloprost and bisphosphonates. In particular, localized osteonecrosis of the jaw and atypical femoral fractures should be mentioned, especially when bisphosphonates are being administered [26].

During surgical procedures, the affected bone area is drilled (core decompression) [24, 25]. Symptoms can be improved through the reduction in pressure that results from drilling, as the pain is reduced. It is furthermore assumed that drilling can lead to increased blood flow or even revascularization. The effect of PRP on bone healing has already been described in the biological basis. This also applies to bone marrow oedema. Like in other tissues, PRP has positive effects on cell proliferation, differentiation, chemotaxis, and angiogenesis in bone healing. These connections lead us to a new therapeutic approach. In addition to the pressure relief from surgery described above, by drilling into the bone, platelet-rich fibrin (PRF) made from PRP and autologous thrombin solution is also infused into the affected bone areas. Only material from the patient themselves is used to produce the PRF.

Producing the biologic substances (see Fig. 3): PRP (ACP Autologous Conditioned Plasma). 15 ml ACP can be produced from 45 ml of venous blood, using 3 ACP double syringes (Arthrex GmbH). Autologous thrombin solution: The Thrombinator System (Arthrex GmbH) is used to produce the thrombin solution. The Thrombinator process uses the blood-clotting cascade mechanism to produce an autologous thrombin serum, avoiding the use of aggressive chemical reagents such as ethanol. The design of the Thrombinator eliminates the need for prolonged incubation times and heating. The autologous thrombin solution is produced from PRP in roughly 15 minutes directly at the point of use.

Application of Biologic Substances in Bone Marrow Edema

This can be performed as a minimally invasive surgical procedure (arthroscopic). With the retrograde drilling, placing a targeting tool intra-articularly over the affected cartilage-bone areas is recommended, in order to allow drilling in a targeted manner. If necessary, intra­operative X-rays can be used for checking. First, retrograde drilling using the targeting tool (GPS system, Arthrex GmbH) (Fig. 4 + 5). Platelet-rich fibrin is then infused into the hole using a tapered inserter. The taper prevents the PRF from flowing back before gelling when pressed gently into the hole. Finally, the blind hole is sealed up using bone filler (INNOTERE Paste-CPC, Arthrex GmbH). Platelet-rich fibrin is prepared by mixing PRP and autologous thrombin solution, simulating the final step in the coagulation cascade, in which a stable amount of fibrin is produced from fibrinogen (contained in PRP) and thrombin. Patients use walkers and forearm crutches to relieve pressure post-op until the wound has healed. Full weight bearing is usually possible immediately once the wound has healed, provided there has been no surgery on associated injuries. In one observational study, patients showed pain reduction using the visual analogue scale, from an average of VAS 9 to VAS 1, 14 days after the combined surgical procedure of drilling the bone and infusing PRF intraosseously.

Chondral Lesions and Osteochondral Lesions of the Talus

Chondral or osteochondral lesions of the talus occur particularly in young patients as a result of trauma, in most cases sprain trauma. Flick and Gould’s studies of 500 recorded cartilage-­bone injuries to the talus show a distribution of 98 % lateral talar dome lesions and 70 % medial talar dome lesions. The authors were able to demonstrate that the causes can be acute trauma as well as repetitive microtraumas affecting talar cartilage.

Clinical Symptoms 

The focus is again on ankle pain, which shows no improvement even after prolonged immobilization or physical therapy measures. The pain indication is localized either medially or laterally, some patients reporting feelings of locking-up, and there may be clinically significant swelling and effusion in the ankle joint. The medical history almost always reveals an accident that occurred only recently.

Imaging Procedures

Imaging procedures include unenhanced X-rays in 3 planes under load (AP mortise view) [27]. If there are specific uncertainties concerning assessment of the hindfoot, a Salzmann image may be needed as well. CT scans are particularly important where bony structures are involved, and help to determine the depth of the lesion [28, 29]. For some time now, digital volume tomography has been used to obtain three-dimensional images of the ankle with pressure applied. These images with pressure applied have the advantage that treatment planning is more precise, since the bone position changes in situations with pressure applied. Standard procedures include MRI scans, which can map articular cartilage using cartilage-sensitive pulse sequences. It is possible to see changes in cartilage in the MRI scan, as well as changes in subchondral bone, which cannot be detected in normal X-rays. The sensitivity and specificity for cartilage changes in the talus is given as 96 % [30]. dGEMRIC sequences allow us to measure directly the concentration of GAG (glycosaminoglycan). However, this procedure requires intravenous injection of gadolinium-based contrast agents. In recent years, the so-called SPECT procedure has gained popularity [31]. SPECT stands for Single Photon Emission Computed Tomography, and is a special type of CT scan used to differentiate between active lesions of the cartilage bone complex on the talus, and inactive cartilage bone lesions on the talus.

Treatment

Treating the chondral lesion on the talus depends on the size of the cartilage damage. Cartilage damage smaller than 1 cm² and less than 5 mm thick is usually treated with microfracture or nanofracture (bone marrow stimulation) [27]. Cartilage damage larger than 1.5 cm is usually treated using autogenous bone graft techniques or, if possible, autologous chondrocyte implantation [5]. Refixation can be carried out for intact, chondral fragments at least 3 mm thick. Refixation is carried out in such cases using biodegradable compression screws, darts or pins [27]. Treatment of osteochondral lesions usually involves both building up the damaged bone area and treating the affected cartilage area. Cartilage has only very limited self-healing capacity when damaged, due to its inherent avascularity, which can therefore lead to osteo­arthritis. Here, too, the thinking is to combine the surgical procedure with PRP and thrombin.

Surgical Procedure

With chondral lesions, care should be taken to ensure that the cartilage defect is debrided and prepared appropriately. Look out for clean, healthy cartilage edges.

AutoCart™ Procedure (Fig. 6 – 9)

Chondral fragments are harvested from the cartilage margin using a 3 mm shaver (Sabre 3 mm, Arthrex GmbH). Alternatively, cartilage chips can also be removed from non-load-bearing areas on the knee as required. Fragments are harvested in a GraftNet tissue collector (Arthrex GmbH) and then transferred to a 1 ml syringe with a Luer lock connection. The chondral fragments are then mixed with PRP in a ratio of 3:1 using a female to female adapter. On the one hand, this creates a homogeneous paste-like mass, and on the other hand, the ACP contains the fibrinogen needed for clotting. The 1 ml syringe is connected to the application cannula and the fragments transferred into the cannula. The fragments are then carefully pushed to the cannula tip using the cannula trocar, until they appear in the opening. The arthroscopic fluid should then be drained from the ankle joint and the lesion dried as much as possible. The fragments mixture is now carefully pushed forward with the trocar and applied into the defect. The fragment paste is then carefully covered drop by drop with the prepared thrombin serum. The Thrombinator method relies on the blood clotting cascade mechanism. The combination of the fibrinogen contained in the paste and the thrombin applied creates a stable clot that holds the mixture in place in the lesion. For the seal, mix the PRP with thrombin in the ratio 1:1. After mixing, apply the mixture quickly to the lesion drop by drop. Then wait about 2 minutes. The joint should be carefully moved under visual control, to check the congruence of the joint components.

Figures 10 and 11 show intra-operative images of a chondral lesion being treated using AutoCart. When treating osteochondral lesions, the stable clot mentioned earlier, consisting of fragmented cartilage and PRF, is placed and fixed onto the spongiosaplasty after surgical reconstruction (Fig. 12 + 13). Here, too, the joint should also be carefully moved under visual control following infusion, to check the congruence of the joint components. The patient uses a walker with 20 kg partial weight load for six weeks post-op. A splint with a 20-0-20 dorsiflexion/plantar flexion range of motion is recommended. Lymphatic drainage and, if necessary, analgesia should be prescribed. NSAIDs should be avoided due to their fibrocystinhibiting effect. From the 7th week, depending on the clinical picture, more pressure can start to be applied. In an observational study, both procedures (arthroscopic as well as open with spongiosaplasty) proved to be safe, at least in the short term, and easy to carry out. Long-term results will show how tissue regeneration is progressing.

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