Can we accurately predict RTP?

or flawed fortune telling

Johannes Tol

I, Johannes Tol, or a family member(s), have relevant financial relationships to be discussed, directly or

indirectly, referred to or illustrated with or without recognition within the presentation as follows:

Grants for conducting trials on the effect of PRP in acute hamstring injuries (Arthrex)

Can we predict RTP?

Clinical examsMRI

Clinical predictors RTP?

(Schut et al. Sports Med. Published online 18 October 2016)

Level of evidence Clinical predictor

Strong -

ModerateVAS pain, self-predicted RTS,

clinician predicted RTS

LimitedVisible bruising, muscle pain during every day

activities, popping sound at injury, forced to stop

within 5 min, width of palpation pain, pain on trunk

flexion, pain on active knee flexion

Conflicting/

No…

MRI predictors RTP?

Reurink et al. Sports Med. 2014

Level of evidence MRI predictor

Strong -

ModerateMRI negative

proximal free tendon avulsion

Limited

Conflicting/

No

GRADING

Intramuscular tendon

7

Predicting RTP - MRI grading

Peetrons. et al. European Radiology 2002. 12:35-43.

Grade I Grade II Grade III

Oedema Disruption Total rupture

Injury severity

MRI grading: overlap BETWEEN Grades

Return to Play (days)

422 2217 371

Ekstrand J. et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to playBr J Sports Med 2011

Grade II: Edema with fiber disruptionGrade I: Edema without fiber disruption

Variance WITHIN MRI grades

Return to Play (days) 422 22

“Coach, based on best available evidence ….. he will play after 2 or 42 days”

Grade II: Edema with fiber disruption

Ekstrand J. et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to playBr J Sports Med 2011

1 Creighton DW, Shrier I, Shultz R, et al. Return-to-play in sport: a decision-based model. Clin J Sport Med 2010;20:379–85.

ClinicalPredictors

Enemy:Variance

The enemy of accurate prediction: unexplained VARIANCE

A new serious hamstring injury ?

The intramuscular tendon

Recurrence

4 %

vs

57-63%

Retun to play

20 vs 60 days

A new serious hamstring injury ?

The intramuscular tendon

Variance WITHIN intramuscular tendon

injuries

12818

“Coach, based on best

available evidence …..

he will play after 18 or 128

days”

Intramuscular tendon injury

Return to Play

(days)

Pollock 2014, Comin 2012

Re-injury 60%

Data from Qatar

Return to Play

(days)

499 2922 377

No intramuscular (i.m.) tendon lesion,

N = 41

Re-injury 7 % Re-injury 10 %

Yes intramuscular (i.m.) tendon lesion

N = 29

Made van der A. et al. Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following hamstring injury. Br J Sports Med 2017

Back to clinical daily practiceCan we narrow the confidence interval with MRI ?

211 45425

MRI variables:Grade II3D extent of edema3D extent of disruptionLocationFree tendon involvement

Jacobsen P, Witvrouw E, Muxart P, Tol JL, Whiteley R. The value of delayed clinical evaluation after hamstring injury. Br J Sports Med – 2016

451 21

Back to clinical daily practiceDelayed clinical evaluation (7 days)

Evolution at injury + 7 days- Vas pain injury- Days till pain free walking- Days injury till physio- Football- Palpation- Flexibility- Strength- SL Bridge pain free

Return to Play (days)

2616

Can we accurately predict RTP? NO

Trust on clinical exam

By, bye MRI

Take Home

• Acknowledgements

Guus Reurink

Adam Weir

Gert Jan Goudswaard

Maarten Moen

Mario Maas

Gino Kerkhoffs

Robbart Van Linschoten

Monique van Heumen

Jithsa Monte

Roald Bahr

Emad Almusa

Rodney Whiteley

Bruce Hamilton

Erik Witvrouw

Sirine Boukarroum

Aziz Farooq

Phillipp Jacobsen

Nicol van Dyk

Polyvios Kyritsis

Theodosia Palli

Andreas Serner

Anne D.van der Made

Arnhild Bakken

Tone Bere

Paul Dijkstra

Juan-Manuel Alonso

SMP group

Radiology Dep.

Ali Guermazi

Frank Roemer

Lotte Schut

Jolanda Maskant

Robin Vermeulen

Ozgur Kilic

Can we predict Re-injury?

Clinical examsMRI

MRI predictors for re-injury?

Van Heumen, accepted BJSM 2016

Level of evidence MRI baseline MRI at RTP

Strong

ModerateIntramuscular

tendon, biceps

femoris

Fibrosis not

associated

LimitedNo. muscles,

transverse size

edema

Presence, extent

edema

Conflicting/

No

Clinical predictors for re-injury

De Visser et al. Br J Sports Med. 2012;46:124–130.

Moderate

evidence