The World Cup, injury, arthritis and treatment

Domhnall MacAuleyIts not just the football. Sports docs watch the World Cup medical stories with great interest—which players are injured, what happened and how they are managed. Luis Suárez, suddenly infamous, scored two goals, effectively eliminating England, just weeks after an arthroscopy. And, with the current controversy over concussion and possible long term chronic traumatic encephalopathy, we are especially aware of head injuries. In 2010, team doctors of the 32 finalist teams reported 125 injuries in 64 matches with 104 injuries during training. Most of these injuries were not serious and the incidence of match injuries was lower than in the three preceding World Cups. So far, this year looks even better. The World Cup only offers a short window on acute soccer injuries, however, and it may be more important to look at the long term sequelae and, in particular, if soccer might lead to long term osteoarthritis. There is some evidence that it does but we await the findings of what may be the definitive study, Osteoarthritis Risk of Professional Footballers, undertaken by the Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis—a major UK and international collaboration. The World Cup is also likely to generate other tangential papers such as to how it might influence the number of ER admissions or myocardial infarctions.

Exercise in treating arthritis initially seemed counter intuitive. Rob Petrella, now at University of Western Ontario, first brought this to my attention in a poster at a medical conference, and it led to his systematic review in 2000 asking if exercise was an effective treatment for osteoarthritis of the knee. At that time there were few sufficiently powered randomised controlled trials but, overall, the evidence seemed in favour. Last year, a similar systematic review showed overwhelming evidence in favour of exercise for lower limb osteoarthritis. This was a sequential meta analysis and, what was particularly important, was that there was sufficient evidence to show physical activity was beneficial as early as 2002. It can take a long time to change our minds and integrate evidence into practice.

Evidence in treating arthritis is not always what one might expect. Just a few weeks ago, Kim Bennell and her colleagues published a high quality randomized controlled trial on the effect of physical therapy in hip osteoarthritis. Patients had 10 treatments over 12 weeks comprising education and advice, manual therapy, home exercise, and gait aid if appropriate. There was, perhaps unexpectedly, no difference in pain or function compared with sham treatment. I cannot imagine that the findings of this study were welcomed by Kim’s physiotherapy colleagues. Its not just in football where the results can be surprising, unexpected and disappointing for the supporters.

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