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A Review of Running Shoes

We are often asked to comment on which shoes may be most suitable for a patient. While that answer is up for debate, an important step to answering that question is understanding what is available out there. Here we will briefly outline some of the characteristics of different categories of running shoes that you may encounter.

1.) Minimalistic shoes – attempt to approximate barefoot running

General Characteristics:

  • Reduced/minimal cushioning
  • thin soles, no heel lift (traditional shoes have 10-14mm heel lift)
  • no arch support
  • wide metatarsal area/toe box
  • very flexible, generally very light

Example brands:

  • Vibram Five Fingers.
  • vivobarefoot
  • Merrell Barefoot
  • New Balance Minimus
  • Nike Free

2.) Maximalist shoes – attempt to maximize cushioning and protection of foot

General Characteristics

  • Thick cushioning
  • Rigid sole
  • Slightly reduced heel lift compared to regular shoes
  • Wide base
  • Lightweight for its size

Example brands:

  • Hoka One One
  • Merrell All Out Peak
  • Mizuno Wave Sky
  • Skechers GOrun Ultra R
  • New Balance Fresh Foam 980 Boracay

3.) Zero-drop shoes – footwear where the heel is at the same height as the ball of the foot

General Characteristics

  • Often overlaps with minimalistic shoes
  • Variable structure, but the emphasis is that there is zero heel lift

Example Brands

  • Altra Torin 3.0
  • Merrell Vapor Glove 2
  • Nike Flex Fury 2
  • Vibram FiveFingers Bikila

There are many studies out there looking into the pros and cons of each type of shoewear and whether they are effective in reducing running injuries. The jury is still out but hopefully, this will cast some light on what your patients may be talking about!

 

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

The Efficacy of Sustained Heat Treatment on Delayed-Onset Muscle Soreness

Jerrold Petrofsky, Lee Berk, Gurinder Bains, Iman Akef Khowailed, Haneul Lee, Michael Laymon

Clinical Journal of Sport Medicine, Volume 27, No. 4, July 2017

Delayed-onset muscle soreness (DOMS) is a relatively common phenomenon experienced by people who are new to exercise, or essentially anyone who exceeds their normal workout intensity. DOMS can range from mild irritation to severe pain that can form a significant barrier inhibiting performance, or exercise participation altogether. Furthermore, previous research has shown that DOMS is greater in intensity and duration in older individuals and individuals with diabetes, which is a particularly important patient population within family medicine. This cross-sectional repeated measure design study was performed to assess the impact on DOMS of heat applied for 8 hours immediately or 24 hours after exercise.

60 subjects aged 20-40 who were physically inactive for 6 weeks and had BMI’s less than 40 were divided randomly into 3 groups (control, ThermaCare heat wraps applied immediately after exercise, and ThermaCare heat wraps applied 24 hours after exercise). To provoke DOMS, the subjects completed squats in 3, 5-minute bouts with 3 minutes of rest in-between each bout.  Visual analog pain scales, blood myoglobin, muscle strength, range of motion, and stiffness of the quads were the main outcome measures of the study.

The results revealed a significant reduction in soreness in the group that had the heap wraps applied immediately after exercise (P<0.01). This was corroborated by blood myoglobin, algometer and muscle stiffness data. In addition, there was some benefit to applying the heat 24 hours after exercise when compared to control.

In summary, low-level continuous heat wraps left for 8 hours after heavy exercise can reduce the effects of DOMS (assessed by both subjective and objective measures). Although cold therapy is commonly used after heavy exercise to reduce soreness, heat seems to have the added benefit of increasing flexibility of tissue and tissue blood flow. The authors note that for the purposes of reducing joint swelling, it is still probably better to use cold therapy.

 

Sean Mindra MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

The Noisy Knee

Song, S. J., Park, C. H., Liang, H., & Kim, S. J. (2018). Noise around the Knee. Clinics in orthopedic surgery, 10(1), 1-8.

A common MSK question patients ask is “is it normal that my knee makes this sound?” While this review focuses on the knee, the approach can be generalized to any shoulder. Noise in the knee is common, and often patients are worried the noise is pathological.

Noise around the knee can be separated into physiologic and pathologic causes. This is defined by whether the sound is associated with pain, swelling, and abnormal range of motion. There are also many different types of sounds which are more likely to describe one cause than another. Crepitus is a vague descriptor used to represent a sound during a joint’s range of movement. Popping is a sudden explosive and well perceived sound, usually associated with injury such as meniscal, cruciate, or collateral ligament tears. Clunking is a loud singular noise due to release against resistance, often suggestive of something that was subluxed and now relocated. Clicking is a tiny, singular noise that occurs during one cycle of knee extension and flexion, this can be associated with various causes. Grinding and grating are used to describe continuous scratching sounds and are more associated with degenerative OA and patellofemoral pain syndrome.

Physiologic Sounds:

Not associated with any history of trauma, swelling, or pain.

Tend to be sporadic in nature

No aggravation of sounds and combined symptoms

Causes include:

  • build up or bursting of tiny bubbles in the synovial fluid
  • snapping of ligaments
  • catching of the synovium or physiological plica
  • hypermobile or discoid meniscus.

One way to distinguish between these causes is whether the joint sound occurs repeated during range of motion. If it happens repeatedly, it is usually due to anatomic structures rubbing against each other, such as ligaments/tendons or plica over a bony prominence. One common is the bicep femoris tendon at the lateral aspect of the knee. If the crack has a refractory period, it is likely due to air build up in the joint, and subsequent changes in joint pressure during range of motion cause cavity formation which creates a popping sound.

Management of physiologic noise involves reassurance and stretching and strengthening of affected musculotendinous structures.

Pathologic Sounds:

Can have history of trauma or injury

Tend to be higher pitch/frequency

observed consistently, has gradual aggravation

Causes:

  • Degenerative changes
    • Structural cause such as bony spurs and cysts, meniscal tears…etc
  • Pathologic plica
    • If a plica gets irritated, it can cause synovitis and pain
  • Patellofemoral instability
    • Due to hypermobility of patella or subluxation of patella
  • Post-surgical
  • Pathologic snapping knee syndrome
    • Any extra or intra-articular structure that causes painful sounds, which can include ganglion cysts, lipoma, synovial nodules, fabella, osteochondromas, osteophytes

Management of these pathologic noises depends on the underlying cause.

Overall, noise around the knee is a common phenomenon, with one study suggesting 38.1% of women and 17.1% of men over 40. With this approach, careful evaluation of the noise can help prevent unnecessary diagnostic interventions and provide appropriate guidance for healthy patients experiencing physiologic noise.

 

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

Chronic Exertional Compartment Syndrome – An Introduction

We have all heard of compartment syndrome. This is a medical emergency where increased pressures within a compartment can lead to rapid ischemia, muscle damage, and even potential amputation after a trauma or injury.

How many of us have heard of chronic exertional compartment syndrome (CECS)?

CECS is a cause of chronic exertional leg pain. Most often seen in young runners and elite athletes, it is a relatively unknown and underdiagnosed condition. Its incidence and pathophysiology are not well understood. One theory suggests a noncompliant fascia that cannot accommodate the expansion of muscle volume during exercise, causing increased intracompartmental pressures.

Suspect CECS with athletes who present with chronic anterior/lateral leg pain that worsens with prolonged use and resolves shortly upon cessation of activity. Most cases will occur in the anterior or lateral compartments. Classically, these athletes will be able to tell you that a specific time, distance, or intensity will bring on the symptoms, characterized as burning, aching, cramping, or pressure. It usually resolves fairly shortly if they stop the activity unless they continue to push through the symptoms for longer durations. It is fairly common to be bilateral. They may have some numbness/tingling in the dermatomal distribution of the nerve that runs through the compartment and weakness of those muscle groups.

Physical exam is often normal at rest. Some people will have visible painless fascial herniations. On physical exam immediately after exercise, there may be pain on palpation of the muscles involved, pain with passive stretching of the muscles, and the compartments may be quite firm. No imaging is necessary but will commonly be done to rule out other diagnoses such as a stress fracture. The diagnosis of CECS can be made clinically but given its non-specific nature, it can be confirmed using immediate post-exercise intracompartmental pressure testing. If confirmed, a surgeon may be consulted for an ELECTIVE fasciotomy.

The differential diagnosis includes medial tibial stress syndrome (shin splints), stress fractures, fascial defects, nerve entrapment syndromes, popliteal artery entrapment syndrome, and vascular or neurogenic claudication.

It is important to note that shin splints present with pain on the medial border of the tibia. Shin splints are NEVER lateral! A high level of suspicion is required for the diagnosis of ant/lat CECS as all imaging will be reported as normal.

While uncomfortable, there is no evidence to suggest that the pain from CECS indicates any muscle damage or has long-lasting implications. Modified activity is a reasonable treatment option. People may choose to avoid continuous running and opt to bike, swim, skate or play shorter shifts. Hopefully, this brief introduction sheds some light on the subject.

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

First-Aid Treatment for Friction Blisters: “Walking Into the Right Direction?”

Lando Janssen, Nenltje A.E. Allard, Dominique S.M. ten Haaf, Cees P.P. van Romburgh, Thijs M.H. Eijsvogels, Maria T.E. Hopman. Clinical Journal of Sports Medicine, Vol 28, No. 1, January 2018.

Trauma-induced separation within the epidermis, or friction blisters, are frequently encountered by patients choosing to be physically active to improve their overall health and well-being. Although most blisters are benign entities, complications including antalgic gait patterns, exercise-related or overuse injuries, cellulitis or sepsis can result. Thus, from the primary care physician’s perspective, the goal of treatment remains to reduce pain, facilitate healing and prevent both infection and recurrence.

However, much of the advice provided to patients regarding this topic is not evidence-based. To date, very limited research has been conducted to examine different treatment regimens for friction blisters. Furthermore, each study on this topic is limited to studying a homogenous population (elite athletes, military personnel). The purpose of this study was to compare the efficacy of fixation dressing versus adhesive tape in the first-aid treatment of friction blisters. These 2 methods were evaluated based on 1) Time of treatment application, 2) effectiveness, 3) material satisfaction in a large group of participants of the Nijmegen Four Days Marches (4DM). In addition, this study included a 1 month follow-up period to evaluate blister healing and complications when comparing treatments with different blister-covering materials.

The major findings of this prospective observational cohort study were:

  • Time of treatment application was significantly lower in the wide area fixation dressing group (41.5min, SD = 21.6min) compared to the adhesive tape group (43.4min; SD = 25.5min; P = 0.02).
  • A significantly higher drop-out rate in the 4DM was observed in the fixation dressing group as compared with the adhesive tape group (11.7% vs. 4.0%, respectively, P = 0.048)
  • There was no difference in pain intensity scores, infection rates, and the need for additional medical treatments. However, there was delayed blister healing in fixation dressing group (51.9% vs. 35.3%; P = 0.02) and a trend towards decreased satisfaction (P = 0.054) when compared to the adhesive tape group.

The authors conclude that despite a small, but significant reduction in the time of treatment application with wide area fixation dressings, these dressings resulted in delayed blister healing, a trend towards lower satisfaction, and a higher drop-out rate of in the 4DM. For these reasons, they do not recommend the use of wide-area fixation dressings in routine first-aid treatment for friction blisters and rather support the use of adhesive tape for this purpose.

Sean Mindra, MD, CCFP                                                                                                                  PGY3 – Sport and Exercise Medicine, University of Ottawa                                                      Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

 

Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis

Enke, Oliver, et al. “Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis.” CMAJ 190.26 (2018): E786-E793.

Back pain is a common issue seen in the family medicine practice that can result in significant morbidity. There are many therapies and pharmacological options available for the treatment of back pain, but high-quality studies showing efficacy are lacking for many of these options. In 2012, a BMJ review showed treatment benefit of gabapentin for low back radicular pain based on one study, and a few although not all guidelines subsequently suggested a trial of anticonvulsants for patients with acute neuropathic pain. This has resulted in a significant increase in the use of anticonvulsants in the family practice setting for low back pain. This review examines the use of anticonvulsants (topiramate, gabapentin or pregabalin) to treat low back pain with or without radicular pain. 9 studies were examined for a total of 859 participants. Of note, however, this study was not able to perform any significant subgroup analysis, such as acute vs chronic low back pain.

  1. Low back pain with or without radiating leg pain
    1. Gabapentin
      1. No effect for pain in short term. High-quality evidence.
      2. No effect for pain in the intermediate term, low-quality evidence
    2. Topiramate
      1. Small clinically significant improvement pain in short-term, moderate evidence
      2. No effect on disability in short-term
    3. Lumbar radicular pain
      1. Gabapentin or pregabalin
        1. No effect on pain in intermediate term, high quality evidence
        2. No effect on disability in short, intermediate, and long term, moderate evidence
      2. Topiramate
        1. No effect on pain or disability in short term. Low quality evidence
      3. Adverse events
        1. Higher in anticonvulsants compared to placebo, high quality evidence
        2. Most common side effects: drowsiness, somnolence, dizziness, nausea

In summary, this review suggests that anticonvulsants do not appear to improve patients’ pain or disability with regards to back pain, with or without radicular pain. While there are many nuances, the key to treating back pain without red flags remains centred on patient education, exercise therapy, and getting a multidisciplinary treatment program involved whenever possible.

Jim Niu PGY3 Sport and Exercise Medicine Fellow

Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport Med

Physical activity should be a focus from childhood

Article reviewed: Timing of the decline in physical activity in childhood and adolescence: Gateshead Millennium Cohort Study

 

Mohammed Abdulaziz Farooq,1,2 Kathryn N Parkinson,3 Ashley J Adamson,3,4

Mark S Pearce,3 Jessica K Reilly,4 Adrienne R Hughes,1 Xanne Janssen,1

Laura Basterfield,4 John J Reilly1

 

It has been well shown in research and preached in our world community that physical activity is an essential component to well being. Studies show a clear dose-response relationship between increased levels of physical activity and associated health benefits. Canadian guidelines for physical activity including those for children and adolescents encourage participation in a variety of physical activities that support their natural development and promote their well-being. The Canadian guidelines for physical activity note that health benefits will be felt by children and adolescents who do at least 60 minutes of moderate to vigorous physical activity (MCPA) on a daily basis. General consensus in previous studies has suggested that as we grow up, physical activity levels decline. In particular, it is a common belief amongst those involved in healthcare that in adolescent years this decline was the most drastic and important to target. It was also believed that this decline was more serious in girls than in boys. This article assessed the validity of these perceptions by reviewing the literature on this topic and by performing a longitudinal cohort study to assess physical activity decline over time from age 7 to 15.

On review of the evidence, the authors concluded that there was insufficient proof that both total volume physical activity and MVPA declines with the onset of adolescence nor to prove that this decline is more marked in girls than boys. The main reasons for this were a lack of objective measurements in the previously done research, the amount of follow-up and the lack of present-day applicability of the studies, which were mainly done before the year 2000.

The longitudinal cohort study included 545 individuals from the Gateshead Millennium Study over 8 years of follow-up, from North-East England. The cohort was studied at ages 7, 9, 12 and 15 years of age to assess the progression of their physical activity in terms of habitual total volume of physical activity and MVPA. To do this, they used an Actigraph accelerometer to get objective measures over 5–7 day intervals at each year of collection. The analysis of the cohort was done by looking at a trajectory of physical activity to be able to assess whether there was a significant drop in adolescence. As well this trajectory method of analysis allowed the authors to identify subgroups within the cohort who may have had different changes in physical activity over time.

Four trajectories of change in terms of total volume of physical activity and four trajectories as well for MVPA were identified for boys. There was one trajectory of change in the total volume of physical activity and three trajectories of change in MVPA for girls. All of these trajectories showed a decline from age 7 to the age of 15 years old in all the participants. There was no evidence of a steep decline starting in adolescence for both total volumes of physical activity and for MVPA.

This study showed that in all forms of objective data that were used as measurements showed declines in physical activity from as early as age 7. These measures are commonly used in similar studies. In recent years, since the beginning of this study, there have been other studies that fit the conclusion of these findings. These other studies either did not include childhood or failed to prove the previously held belief that physical activity begins to decline at adolescence more rapidly and declines more rapidly in girls than boys.

The strengths of this study were its longitudinal design, the size of the cohort, the objective nature of its results and the fact that it represents a contemporary sample of children. The fact that this study was located only in the North-East of England makes it possible that different results may be found in a different cohort living in a different part of the world with different physical activity policies and perspectives.

In conclusion, the present study contradicts the currently held belief that there is a significant decline in physical activity in adolescence as opposed to earlier in a child’s life. The main implication of these findings is that current policy is not founded in evidence-based findings. Thus, there is a need for future research and change in public health policy with a greater emphasis on the child rather than adolescent physical activity, and on both for boys and girls. Specifically, healthcare professionals including primary care physicians may need to consider their focus on promoting physical activity in early childhood for both sexes.

 

Dr. Mickey Moroz M.D.C.M. CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Med

Marijuana and Its Effects on Athletic Performance: A Systematic Review

Kien V. Trinh, Dion Diep, Hannah Robson

Clinical Journal of Sport Medicine, Volume 28, No. 4, July 2018

Currently, many sporting organizations including the International Olympic Committee (IOC) prohibit the use of any substance that has an ergogenic (performance enhancing) effect, poses a risk to the use of the user’s health and safety, or violates the spirit of sport. The legalization of marijuana in Canada is tentatively set for October 2018, which may increase the use and normalization of the drug. Thus, it is vital that primary care physicians remain up to date regarding the rules and regulations surrounding marijuana use, as well as its effects on users. Much of the literature points to marijuana being more of an ergolytic drug, where it impairs rather than improves one’s physical performance, stamina, or recovery. Despite patient beliefs that that marijuana use can improve their performance, it’s ergogenic potential remains poorly understood.  The purpose of this study was to determine the effects of marijuana on athletic performance.

This systematic review included any primary study of any design of any clinically or laboratory-relevant outcomes on athletic performance. Studies included both male and female participants of any athletic background, between the ages of 18 and 65 with no other comorbid conditions. All studies used marijuana cigarettes for the intervention group and all studies utilized a control group (participants that were not given marijuana cigarettes). Vital signs, pulmonary measures, physical work capacity, grip strength, and exercise duration were chosen to be relevant outcomes. After identifying and screening 929 citation postings, only 3 trials met the inclusion criteria.

The effects of marijuana on heart rate, blood pressure and exercise duration remains unclear. Low-quality evidence exists for marijuana having an ergogenic on effect on exercise by inducing bronchodilation and increasing FEV1 after exercise compared to inactive controls. There was no significant difference in grip strength between treatment, sham and inactive control groups. Additionally, there is low-quality evidence that suggests marijuana use is associated with decreased physical work capacity compared with sham and inactive control groups.

There are several limitations to this study. Firstly, there were only 3 trials (one observational, one crossover, and one crossover randomized control trial) that met the inclusion criteria. When comparing these 3 trials, clear heterogeneity is noted between study type, intervention, and outcomes. Thus, no meta-analyses were performed. Furthermore, despite various available forms of consumption (e.g. edible, vaporization, tinctures, oils), all studies only assessed smoked marijuana as their treatment. There is a clear paucity of current research on marijuana and its effects on athletic performance. The banning of substances in competition is a highly debated and ever-changing field. With its legalization in Canada looming, further research is warranted on marijuana and its effect on athletic performance to help investigate and justify current and future doping policy.

Sean Mindra, MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

Different ways of promoting physical activity

 Article reviewed: 

Physiotherapist-Led Physical Activity Interventions Are Efficacious at Increasing Physical Activity Levels: A Systematic Review and Meta-analysis

Breanne E. Kunstler, MPhty, Jill L. Cook, PhD, Nicole Freene, PhD, Caroline F. Finch, PhD, Joanne L. Kemp, PhD, Paul D. O’Halloran, PhD, and James E. Gaida, PhD

As per the Canadian Institute for Health Information, in 2017, total health expenditures in Canada are expected to represent 11.5% of Canada’s gross domestic product (GDP). Physicians and health care professionals continue to promote preventative care as one way to tackle the ever-growing cost of health care. Primary prevention is generally low cost and has wide-reaching benefits. Specifically, physical activity has been shown to reduce the burden of disease and decrease the progression of many common non-communicable diseases (NCDs). In 2013, just over 2 in 10 adults and 1 in 10 children and youth in Canada met the Canadian Physical Activity Guidelines, which requires adults to achieve 150 to 300 minutes of moderate intensity of physical activity or 75 to 150 minutes of vigorous intensity physical activity, or an equivalent combination of both each week, as well as muscle-strengthening activities on at least 2 days each week. With so many people in Canada being physically inactive and with the rise in preventable diseases, primary care providers, including allied health professionals, have a critical role to promote physical activity and well-being. Physiotherapists are particularly well trained and positioned to promote physical activity in patients as their treatment plans often involve some type of physical activity.

This article did a systematic review of studies that assessed the efficacy of one-on-one, physiotherapist-led physical activity (PLPA) interventions at increasing physical activity levels among adults in clinic-based private practice, primary care, and outpatient settings. The eight studies that met this articles inclusion criteria looked at adults over the age of 18 who either had MSK injuries, risk factors for NCDs or who were suffering from NCDs. The studies either used subjectively (questionnaire) or objectively (accelerometry) quantified change in physically activity. A meta-analysis was conducted to look at the correlation of PLPA interventions at different follow-up times, as well as looking at success rates of PLPA interventions meeting minimum recommended physical activity levels. It also looked at the effect that the length of the therapy session had on the PLPA interventions success.

Looking at 3 out of the 8 studies included in the review, there was a significant finding that PLPA interventions were efficacious at assisting adults achieve the minimum recommended physical activity levels with an OR of 2.15. The other 5 studies included in the review showed a significant finding that PLPA interventions had only a small effect on patient’s physical activity level in short and medium term follow-up which was not seen past 1 year of follow-up. When comparing the length of intervention seen in the different studies there was no difference in efficacy of PLPA interventions on the improvement physical activity level. Overall, the improvement in PA seen by PLPA interventions ranged from increasing vigorous, moderate and low-intensity PA.

In this article, it was highlighted that there was a lack of analysis on the content as opposed to the length of the interventions. There was also no emphasis on the importance of maintaining the level of physical activity achieved over time. As it was shown, the benefits of the PLPA interventions were not seen in the majority of the studies in long-term follow-up. The one study that did use intervention techniques geared towards maintenance of PA improvements resulted in such maintenance. Even though there was improvement of PA in most patients who received PLPA, the benefits of preventative lifestyle changes such as PA is truly seen when maintained over time and integrated into a person’s weekly routine.

In summary, patients ultimately are responsible for the maintenance of their lifestyles. To help them integrate physical activity into their daily lives primary care providers can play an important role. This article shows that training physiotherapists and primary care health care professionals in behavioral changing counseling can help tackle the growing rate of inactivity and ultimately decrease the risks of NCDs.

  1. Moroz M.D.C.M. CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Med

 

Return to Driving After Hip Arthroscopy

Amit M. Momaya, Despina Stavrinos, Benjamin McManus, Shannon M. Witting, Benton Emblom, Reed Estes

Clinical Journal of Sport Medicine, Volume 28, No. 3, May 2018

Hip arthroscopy represents one of the most common procedures performed to help alleviate hip pain and improve quality of life. Driving represents one of the most important topics that patients will ask physicians about, especially in the primary care setting after they have been discharged from hospital and are looking to get back to their daily routine. The purpose of this study was to use a modern driving simulator and assess patients’ braking performance after undergoing a right hip arthroscopy.

This prospective study involved 14 patients scheduled to undergo right hip arthroscopy (perfumed by a single surgeon at 1 institution) and a control group (healthy volunteers who denied musculoskeletal problems) of 17 participants to account for a potential learning phenomenon. The two groups did not differ in age, sex, height, weight, and driving experience as measured by years since licensure. The control group did not undergo any type of surgical procedure. All were between the ages of 16 and 60, licensed drivers, and regularly drove using automatic transmission. All participants drove in the simulator initially to establish a baseline, and then at 2, 4, 6, and 8 weeks post-operatively. The following variables were measured:

  • Initial reaction time (IRT): time between stimulus and initiation of release of accelerator
  • Throttle release time (TRT): time from initiation to full release of foot from accelerator
  • Foot movement time (FMT): time between release of accelerator and initial contact with brake
  • Brake travel time (BTT): time to apply 200N of force from initial brake press
  • Braking reaction time (BRT): the sum of IRT + TRT + FMT
  • Total braking time (TBT): the sum of BRT + BTT

The results of the study revealed that the experimental group exhibited significant improvements in INT, TRT, FMT, and BRT at between the pre-operative and 2 weeks post-operative driving sessions in the simulator, however there was no significant change thereafter. There was no significant change in BTT in the experimental group over the 8-week period. No learning phenomenon was noted in the control group.

This study, which was the first to address driving after hip arthroscopy, suggests that most patients may return to driving at the 2 week mark, as indicated by breaking performance. However, there are several limitations to this study. Perhaps the most obvious limitation is that the participants are operating in a simulation and not in an actual vehicle. In addition, despite the fact that all patients in the experimental arm underwent a hip arthroscopy, the procedures themselves differed with respect to degree of soft tissue and bony surgery. For example, an osteoplasty may affect braking performance significantly more than a simple debridement. The relatively small sample size was a barrier to attempt to look at whether these differences existed. Also, it is important to note that currently, there are no single legally mandated or universally accepted numbers for BRTs. While this study provides some evidence for driving after right hip arthroscopy, it is recommended that primary care physicians, surgeons and patients communicate openly with one another to create individualized timelines for safe return to driving.

Sean Mindra, MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine