A sporting chance
Published on 16 July 2013
Premier League striker Rickie Lambert is backing the new £3m Arthritis Research UK £3m Centre for Sport, Exercise and Osteoarthritis, launched in June. Jane Tadman reports.
Exercise is vital to keep our bodies and musculoskeletal systems in the best possible shape. But physical activity, while essential for good health, can sometimes lead to injuries. And injury to a joint is one of the main risk factors for osteoarthritis – along with ageing and obesity.
Now teams at the new Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis are aiming to reduce the impact of sports injuries incurred by elite and recreational players and understand why some sport and exercise injuries develop into debilitating osteoarthritis in later life.
The launch of our new centre – whose mantra optimising health, minimising risk – will be welcome news for all sections of the population who have an interest in keeping fit and active. From the occasional exerciser to the recreational athlete and the elite sportsman or woman; everyone wants to reduce the chance of injury curtailing their sporting life.
Understanding the relationship between sports injuries and the development of osteoarthritis – and aiming to prevent it – will be at the heart of the new centre’s research programme. Researchers plan to develop better injury treatments and screening tools to predict an individual’s risk of developing osteoarthritis following sports injury.
The benefits of exercise outweigh the risks
The centre will concentrate on the two types of joint injury connected with sport and exercise: acute or traumatic sports injuries associated with contact or collision sports such as rugby or football, and over-use injuries associated with non-contact sports such as running, cycling or rowing.
Centre director Professor Mark Batt, consultant in sport and exercise medicine at Nottingham University Hospitals, says: “To date, research into the long-term consequences of sport and exercise injuries has been sparse, especially in the UK. There’s currently poor understanding as to why some people recover more quickly than others following sport and exercise injuries, and why some injuries develop into osteoarthritis, but others don’t.”
Professor Batt is keen to stress that the long-term benefits of exercise for overall health far outweigh the risk associated with injury. “Exercise is vital for health and to keep joints healthy, and we want to get the message over loud and clear that we want people to keep active,” he emphasises.
“Our centre aims to keep people of all sporting abilities active and injury-free by developing definitive, evidence-based advice and information to minimise the consequence of injury and to recommend effective treatments to reduce long-term damage.
“This is the first time in Europe that specialists in sports medicine and osteoarthritis are combining their expertise to understand why some sports injuries will go on to develop into osteoarthritis, and whether we can prevent or slow down degeneration of the joints.”
Predicting risk of osteoarthritis in the general public
Wouldn’t it be great to know your risk of developing osteoarthritis? Such information could let you know that you could exercise without any worries, or take steps to minimise your risk. And following an injury, it would enable you know whether you need further advice regarding how to manage your injury and future sporting activities.
Researchers are aiming to develop a series of simple screening tools – one for the general population (plus a second for recreational athletes and a third for elite sportspeople) – which will accurately predict their various levels of risk.
“We want to identify as many risk factors for osteoarthritis as possible, for example vitamin D deficiency, being overweight, having lax ligaments, and so on, put all these factors into the mix and then be able to say to the patient: Your personal risk is ‘X’,” explains Nigel Arden, deputy director of the centre and professor of rheumatic diseases at Oxford University.
“It will be an online, user-friendly tool with about 10-15 questions that patients or GPs can fill in during a consultation. Ninety-five per cent of people using the tool will be at low risk of osteoarthritis, so it will be very much about reassurance, so that people can feel confident about exercising, and that it’s good for them. That’s a very important message we’re keen to get across. If someone is deemed at high risk because they are grossly overweight for example, then they would be encouraged to lose weight to minimise their risk.”
The researchers hope that the first screening tool will be available within the next two to three years as the data necessary to complete this work is already available from national and international patient cohorts.
Developing new treatment packages for sports injuries
Based on preliminary findings from previous work, Dr Jonathan Folland and colleagues at Loughborough University will be looking at the effectiveness of explosive strength training over conventional strength training.
“We’ve recently found explosive strength training to produce significant changes in the stiffness of muscle and tendon after only four weeks of regular exercise,” explains Dr Folland. “Stiffer muscles and tendons could help to improve function and performance as well as reduce the risk of injury. Stiffer tissues are considered to be better at transmitting force, which aids function and performance. They’re also thought to be more robust and less easily overstretched and damaged.
“The increased stiffness of muscles and tendons we found after just four weeks is substantially shorter than previous reports where stiffness only increased after 12 weeks of exercises, and it could be that the explosive aspect of the exercise works best for increasing stiffness.”
The researchers’ next step is to do a longer study to see if explosive exercises continue to produce greater changes in muscle and tendon stiffness over a more prolonged period and do a direct comparison of explosive strength training with conventional strength training.
Dr James Bilzon, exercise physiologist at the University of Bath, will develop a series of clinical trials aimed at testing dietary and nutritional interventions in athletes after an injury and exercise interventions to prevent and manage injury.
Dr Bilzon and colleagues will be working with the Rugby Football Union’s Injured Players’ Foundation to work with players whose careers have ended through injury and are at risk of osteoarthritis.
“Through work we’ve done in other conditions, we know we can manage chronic low grade inflammation through diet and physical interventions so we’ll be looking at testing the effects of vitamin D and omega-3 fatty acids in trials,” he explains. “We also want to find out if we can manage athletes following an injury, by working with them to manage a healthy lifestyle. It’s important that they maintain their healthy body composition and keep their weight down to reduce any post-injury symptoms.”
Ankle injuries – a new study
The ankle is the second-most commonly injured joint after the knee, and ankle injuries are common in many sports. Ben Ollivere, newly appointed trauma consultant at Nottingham University Hospital, aims to answer the question, following an ankle injury, what determines who does well and who does badly, who makes a complete recovery, and who goes on to develop osteoarthritis ?
Mr Ollivere is recruiting up to 200 people with ankle injuries from accident and emergency departments in Nottingham: 100 people with fractures and a further 100 people with ankle sprains.
Using MRI ultrasound and x-rays, and looking at biomarkers from tissue, the team will look to predict likely outcomes and will follow up this cohort for a number of years. “We don’t understand what causes post-traumatic degeneration of cartilage or when to treat or intervene, so we’re hoping this study will lay the groundwork for when to treat and intervene to offer the most benefit to patients,” says Mr Ollivere.
Working with Olympic athletes
Researchers at The University of Nottingham are in the fourth year of a study funded by UK Sport and the English Institute of Sport looking at current patterns of illness and injury in almost 550 elite sports men and women, to identify risk factors – specifically whether risk factors are related to their training activities or actual competition.
A three-year Arthritis Research UK PhD studentship will be allied to this on-going study. “The student will be surveying retired athletes from the same sports, and we’ll then do a cross-sectional analysis to identify if there are any patterns in the current data we have on these athletes who have retired who go on to develop osteoarthritis,” said research fellow Dr Deborah Palmer-Green. “The underlying assumption is that the mechanisms of injury are similar over time.”
So what exactly will the centre do?
For the general public, the centre’s research focus will aim to reassure people that they can exercise safely by:
• developing a simple method of predicting their risk of osteoarthritis in the GP surgery. As most of the population is expected to be low risk, it should encourage people to exercise without worrying that it will lead to osteoarthritis.
The centre’s research will benefit sports men and women by:
• creating a model to help predict the risk of developing osteoarthritis for those who have had a joint injury
• preventing injury by suggesting ways to avoid activities that might lead to an injury, including dietary and nutritional interventions
• treating and managing injuries more effectively
• reducing the risk of developing osteoarthritis after an injury.
Working with young and retired footballers – getting the ball rolling
Researchers want to find out why some ex-footballers who’ve had a joint injury, go on to develop osteoarthritis in later life while others don’t.
Up to 15,000 ex-players on the Professional Footballers’ Association’s (PFA) database will be asked to fill in a basic questionnaire about their training regime and history of injuries. Around 500 ex-players who have had a joint injury and developed osteoarthritis, plus another 500 who have had a joint injury but haven’t developed osteoarthritis will be x-rayed, and will undergo physical assessments and give blood samples.
Researchers in Nottingham will then investigate the factors that differentiate these two groups.
Preventing common groin injuries in young footballers
More than 80% of footballers suffer hip pain during their careers, and young footballers are at particular risk from a potentially career-ending form of groin injury called femoroacetabular impingement (FAI). We don’t know the cause of this problem, but over-training as the bones are developing may play a role. In FAI the head of the femur (thigh bone) rubs against the socket, leading to intermittent groin or hip pain in the short term, and potentially osteoarthritis of the hip in the longer term.
As part of the centre’s research looking at risk factors of injury in adolescent athletes, young footballers aged of nine and upwards, from a number of professional football academies, will be scanned, using state-of-the-art MRI, for signs of FAI, every two years. They will be compared to two other same-age groups – ordinary schoolboys and also young elite athletes from other sports.
The boys will also undergo a number of clinical tests in the lab to measure muscle activity and to measure the biomechanics of their movement.
“The benefit of using extremely sophisticated MRI is that you can pick up holes or cracks in cartilage much earlier, and as well as detecting structural damage it also picks up metabolic changes to cartilage and bone,” explains Mr Sion-Glyn Jones, consultant orthopaedic surgeon and senior clinical lecturer at Oxford University.
“By measuring and monitoring the activities these youngsters are doing during training that may give rise to these hip deformities, they could then be modified or avoided to prevent the injury occurring.”
This research feeds into a sports injuries preventative study led by Maria Stokes, professor of musculoskeletal rehabilitation at the University of Southampton, who is working closely with Southampton Football Club and others to design targeted training programmes aimed at reducing the incidence of injuries among academy and first-team players and protecting them from developing arthritis in later life.
This is a concept known in the sports medicine world as “pre-habilitation” and will involve developing ways of improving training and warm-ups to reduce the incidence of injuries such as pulled muscles and tendons, to ensure that players use their muscles correctly and don’t overload their joints during matches and in training. They hope their research will enhance current FIFA guidelines on warming-up.
Researchers will also take players into the biomechanics laboratory at the university and make precise measurements of their movements during various activities such as kicking a ball, using state-of-the-art 3-D technology.
Dr Martin Warner, senior research fellow at the Southampton centre, said: “It’s important to determine the movements that are associated with this problem to fully understand the demand on the joints. This will help to inform which type of exercises are needed to correct the problem and reduce the load through the joints.”
One of the first pieces of research to literally kick off during 2013 will be a small clinical trial to test the effectiveness of surgery on FAI. Around 100 people under the age of 40 will be recruited in centres in Oxford and Reading. Half will undergo a hip arthroscopy, in which parts of the hip bone are removed or shaved, and the other half will have no surgery. The level of cartilage damage in the hip in both groups will be measured over a four-year period, via MRI.
Star striker Rickie Lambert, who has experienced hip pain but has managed it successfully through exercise, is backing the new centre. He says: “Hip pain is one of the most common injuries among footballers, and some players have to retire early if they don’t get the correct treatment. I’ve been very lucky at my club; I’ve been given certain exercises that have helped me and improve the problems I’ve had.
The fact that Rickie is the joint top English goal scorer in the Premier League in the 2012-13 season is testament to the success of his treatment.
He added: “Making sure young footballers get the right treatment in their teens is massively important and will improve their chances of succeeding in the game. If these problems can be picked up early by automatic testing, the better for everyone. On behalf of all professional footballers I’d like to show my support for the new centre’s research.”
Mo Gimpel, head physiotherapist at Southampton FC, added: "We’ve found that players' hip and groin pains, including FAI symptoms, can be resolved through exercise specifically developed for the individual.
"To make this treatment even more effective, we need to examine these findings in a more robust and academic way with experienced researchers to help develop the knowledge base of our profession, and improve the care of players."
The centre is currently looking for people to help with their research into sport, exercise and osteoarthritis by joining their patient and public involvement advisory panel. This panel will help researchers to identify important and relevant research questions, ensure they ask the right questions in the right way, and assist with designing their research studies. For more information please contact Vikki Develin on 0115 8231719 or email Victoria.email@example.com