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OBJECTIVE: Investigate MRI evidence of anterior cruciate ligament (ACL) healing, patient-reported outcomes and knee laxity in patients with acute ACL rupture managed non-surgically with the Cross Bracing Protocol (CBP). METHODS: Eighty consecutive patients within 4 weeks of ACL rupture were managed with CBP (knee immobilisation at 90° flexion in brace for 4 weeks, followed by progressive increases in range-of-motion until brace removal at 12 weeks, and physiotherapist-supervised goal-oriented rehabilitation). MRIs (3 months and 6 months) were graded using the ACL OsteoArthritis Score (ACLOAS) by three radiologists. Mann-Whitney U tests compared Lysholm Scale and ACL quality of life (ACLQOL) scores evaluated at median (IQR) of 12 months (7-16 months) post-injury, and χ2 tests compared knee laxity (3-month Lachman's test and 6-month Pivot-shift test), and return-to-sport at 12 months between groups (ACLOAS grades 0-1 (continuous±thickened ligament and/or high intraligamentous signal) versus ACLOAS grades 2-3 (continuous but thinned/elongated or complete discontinuity)). RESULTS: Participants were aged 26±10 years at injury, 39% were female, 49% had concomitant meniscal injury. At 3 months, 90% (n=72) had evidence of ACL healing (ACLOAS grade 1: 50%; grade 2: 40%; grade 3: 10%). Participants with ACLOAS grade 1 reported better Lysholm Scale (median (IQR): 98 (94-100) vs 94 (85-100)) and ACLQOL (89 (76-96) vs 70 (64-82)) scores, compared with ACLOAS grades 2-3. More participants with ACLOAS grade 1 had normal 3-month knee laxity (100% vs 40%) and returned to pre-injury sport (92% vs 64%), compared with participants with an ACLOAS grades 2-3. Eleven patients (14%) re-injured their ACL. CONCLUSION: After management of acute ACL rupture with the CBP, 90% of patients had evidence of healing on 3-month MRI (continuity of the ACL). More ACL healing on 3-month MRI was associated with better outcomes. Longer-term follow-up and clinical trials are needed to inform clinical practice.

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BACKGROUND: The use of local anesthetic painkilling injections to improve player availability is common practice in elite-level sport. OBJECTIVE: To document the published use of local anesthetic injections in sport, according to number of injections, sites of injections, and complications reported. DATA SOURCES: A systematic search of MEDLINE, Embase, CINAHL, AMED, Cochrane Database of Systematic reviews, SportDiscus, EBSCO Host, and Google Scholar. RESULTS: One thousand nine hundred seventy local anesthetic injections reported on 540 athletes in 10 studies (from rugby league, American football, Australian football, and soccer) were reviewed. The most common areas of injection were as follows: the acromioclavicular (AC) joint; hand (including fingers); sternoclavicular joint (including sternum); rib injuries; and iliac crest contusions. DISCUSSION: This review found some evidence of long-term safety for a limited number of injection sites (eg, AC joint) and some evidence of immediate complications and harmful long-term consequences for other sites. The quality of evidence is not high, with little long-term data and a lack of independent verification of the effects of the injections. Ideally, long-term follow-up should be conducted to determine whether these injections are safe, with follow-up undertaken independently of the treating physician and team. CONCLUSIONS: Based on limited publications, there is some evidence of long-term safety; however, there is a lack of clear proof of either absolute safety or long-term harm for many of these procedures. Physicians and players in professional sport should proceed with caution in using local anesthetic injections.

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BACKGROUND: There is evidence that early return to competition post-anterior cruciate ligament (ACL) injury increases risk of re-injury. AIMS: To compare subsequent ACL and other injury risks following ACL reconstruction for Australian Football League (AFL) players returning to competition at different times post-injury. METHODS: AFL players returning from ACL reconstruction in the 1992-2014 seasons were divided into three groups based on return to competition time (< 10, 10-12 and > 12 months). Non-reconstructed injuries and artificial ligament reconstructions were excluded. Subsequent ACL injury rates were calculated based on time since injury and number of return matches played. Risk of other knee and hamstring muscle injuries was also calculated. RESULTS: There were 233 ACL reconstructions that returned to play in the AFL during the time period under study and met our inclusion criteria. The per-game risk of subsequent ACL injury decreased with a log decay from 1.2 to 0.15% during the first 20 games back (R 2 = 0.43). Players returning at > 12 months had higher overall percentage of future career games missed through subsequent ACL injuries (4.8% vs. 2.4%), and through all hamstring and knee injuries combined (12.6% vs. 8.4%) than players who returned at ≤ 12 months (both P < 0.001). Players returning at > 12 months had higher risk of knee cartilage (3.7%) and patella tendon (0.6%) injury than those returning at 10-12 months (1.5%, 0.1%, respectively). CONCLUSION: Players returning from ACL reconstruction at greater than 12 months had significantly higher rates of future games missed through both subsequent ACL injuries and through all hamstring and knee injuries combined. It may be true that both early and late return to play lead to suboptimal outcomes compared to average return-to-play times.

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OBJECTIVES: To determine the rates of muscle strain injury recurrence over time after return to play in Australian football and to quantify risk factors. METHODS: We analysed Australian Football League player data from 1992 to 2014 for rates of the four major muscle strain injury types (hamstring, quadriceps, calf and groin) diagnosed by team health professionals. Covariates for analysis were: recent history (≤8 weeks) of each of the four muscle strains; non-recent history (>8 weeks) of each; history of hip, knee anterior cruciate ligament, knee cartilage, ankle sprain, concussion or lumbar injury; age; indigenous race; match level and whether a substitute rule was in place. RESULTS: 3647 (1932 hamstring, 418 quadriceps, 458 calf and 839 groin) muscle strain injuries occurred in 272 759 player matches. For all muscle strains combined, the risk of injury recurrence gradually reduced, with recurrence risks of 9% (hamstring), 5% (quadriceps), 2% (calf) and 6% (groin) in the first match back and remaining elevated for 15 weeks after return to play. The strongest risk factor for each muscle injury type was a recent history of the same injury (hamstring: adjusted OR 13.1, 95% CI 11.5 to 14.9; calf OR 13.3, 95% CI 9.6 to 18.4; quadriceps: OR 25.2, 95% CI 18.8 to 33.8; groin OR 20.6, 95% CI 17.0 to 25.0), followed by non-recent history of the same injury (hamstring: adjusted OR 3.5, 95% CI 3.2 to 3.9; calf OR 4.4, 95% CI 3.6 to 5.4; quadriceps OR 5.2, 95% CI 4.2 to 6.4; groin OR 3.5, 95% CI 3.0 to 4.0). Age was an independent risk factor for calf muscle strains (adjusted OR 1.6, 95% CI 1.3 to 2.0). Recent hamstring injury increased the risk of subsequent quadriceps (adjusted OR 1.8, 95% CI 1.2 to 2.7) and calf strains (OR 1.8, 95% CI 1.2 to 2.6). During the 'substitute rule' era (2011-2014), hamstring (adjusted OR 0.76, 95% CI 0.67 to 0.86), groin (OR 0.78, 95% CI 0.65 to 0.93) and quadriceps (OR 0.70, 95% CI 0.53 to 0.92) strains were less likely than outside of that era but calf (OR 1.6, 95% CI 1.3 to 1.9) strains were more likely than before the substitute rule era. CONCLUSION: Recent injury is the greatest risk factor for the four major muscle strains, with increased risk persisting for 15 weeks after return to play.

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