With days to go before the start of the World Cup in South Africa, some of football’s most-watched players are nursing injuries that will likely keep them out of play.

Michael Ballack, Germany’s captain, is suffering torn ligaments in his right ankle; Ghana’s Michael Essien and Nigeria’s John Obi Mikel are out with knee injuries, as is Spain’s top striker, Fernando Torres.

Most of these players’ injuries will probably cause them to miss the tournament, which begins June 11. But for players whose cartilaginous injuries place them on the borderline between fit and sidelined, some sports physicians are increasingly looking to injectable treatments – blood products (human and animal), substances found in synovial fluid, sugars, and even an herbal tincture – for a boost in recovery time. And they’re not waiting around for randomized controlled trials to show that they work.

Few of these injectable treatments can claim much in the way of trials supporting their efficacy. And this, said Dr. Pippa Bennett, the doctor overseeing England’s women’s football teams, illustrates one of the conundrums at the heart of football medicine, and sports medicine in general. “We need to have evidence-based medicine,” Dr. Bennett said in an interview. “However, if something is working and safe and legal and it seems to make a difference, we can’t deny the athlete the treatment.”

In sports medicine, Dr. Bennett continued, “the differences we are talking about might not be significant in a [randomized controlled trial]-type way but rather can speed up recovery by one day – for an athlete that could make a difference between being in the starting blocks or not.”

In previous decades football physicians relied heavily on corticosteroid injections, which, though effective, have adverse effects.

Now, athletes with wear and tear on their tendons are increasingly receiving autologous blood injections, a treatment in which a small amount of an athlete’s blood is spun in a centrifuge and the platelet-rich plasma, also rich in growth factors, is injected into the injury site.

Though the treatment is safe, the only randomized controlled trial (n=54) to evaluate platelet-rich plasma therapy in patients with chronic Achilles tendonopathy -- Achilles tendon injuries are among the most common football injuries -- found no significant difference between treatment and placebo (JAMA 2010;303(2):144-49).

“The science behind it is a little bit wooly,” Dr. Bennett acknowledged of “blood spinning,” as the treatment is commonly called. “But it seems to enhance the healing factors around the tendon.”

Dr. Bennett also uses injections of hyaluronic acid, a viscous substance found in synovial fluid that is thought to protect cartilage, into her players’ “dodgy knees.” Hyaluronic acid injections are increasingly common in sports medicine -- “you can bet some of the guys in South Africa have had it,” Dr. Bennett said. But its effectiveness as a knee treatment has been inconsistent from study to study; one meta-analysis (JBJS 2004 86:538-545) concluded that there was probably some benefit, but that more research was needed. Recent research has focused on different substances in synovial fluid that may prove more effective when injected.

Other injection treatments that have waxed and waned in popularity over the years include prolotherapy, a treatment developed in the 1950s and still in limited use, in which a dextrose solution is injected into the ligament or tendon, causing a localized inflammation thought to stimulate tissue repair.

Hans-Wilhelm Müller-Wohlfahrt, the longtime head doctor for Bayern Munich and a consultant to Germany’s national football team, gained notoriety in the past decade for his injections of purified animal blood products into players’ hamstrings and tendons, treatments that never really caught on outside his Munich clinic, and also for his liberal injections of a German-manufactured tincture called Traumeel, a homeopathic treatment for which the science is especially scant.

“We are all a bit skeptical of Traumeel,” Dr. Bennett said. But like many other sports physicians, she will use it anyway if there is a chance that a player will benefit, she said. Though some sports physicians have slammed Dr. Müller-Wohlfahrt as a borderline quack, Dr. Bennett credited him for pushing advancing ideas that others might have been too timid to try. “With football we’ve got to have a few people thinking outside the box,” she said.

Dr. Charlotte Cowie, team physician for the Tottenham Hotspurs, a U.K. Premier League club, said in an interview that she, too, had used most of the injectable treatments and had mixed feelings about them. “I’ve been working in sports medicine for a long time and have seen a lot of these things come and go again,” Dr. Cowie said. “Plasma therapy and prolotherapy are not without foundation. But there’s probably some placebo and desperation in there, too.

And when it comes to a pressure situation like the World Cup, “you throw everything at an injury that you can,” Dr. Cowie said. You have a few weeks to get a player right.”

Injections aside, Dr. Cowie said there are two realms of football medicine that are “fantastically evidence based” and advancing constantly: prevention and rehabilitation.

“We have a program that involves strengthening of the Achilles tendon and genuinely results in decreased pain and improved function – this has been really well researched and there are lots of these things going on,” Dr. Cowie said.

Dr. Bennett concurred. “We are incorporating a lot more prevention programs, and on the treatment side, what we can’t forget is to do the basics well: ice, compression. When someone rolls their ankle and gets injured, don’t forget the basics. People get hung up on all the fancy stuff.”

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

再过几天，南非世界杯战火就将点燃，一些最受关注的足球运动员眼下还在疗伤，以避免届时因伤缺阵。

 

德国队队长迈克尔·巴拉克目前正饱受右踝韧带撕裂的困扰；加纳的迈克尔·埃辛、尼日利亚的约翰·奥比·米克尔和西班牙的一流前锋费尔南多·托雷斯也都因膝伤而无法出战。

 

多数这些球员将可能因损伤而错过6月11日揭开战幕的本届大赛。有些球员的软骨损伤可能使其处于正选与替补的边缘。对于这类球员，一些运动医师正寻求通过注射治疗来加快其恢复。注射用药包括人和动物的血液制品、关节液内含物、糖、甚至是中药酊剂。这些运动医师通常无暇等待随机对照试验对它们的功效进行证实后才使用。

 

这些注射治疗很少能够通过试验的方式来确凿证明自身的疗效。对此，英格兰女子足球队的队医Pippa Bennett博士指出了足球医学及一般运动医学领域中的诸多核心难题之一。Bennett博士在接受采访时说：“我们需要循证医学。然而，如果某种治疗安全有效、合法且能带来改善，那么我们就没有理由不给运动员实施这种治疗。”

 

Bennett博士继续说道，在运动医学中，“我们在此所说的改善可能在随机对照试验中并不显著，但却能够在一天内加快运动员的恢复，这种改善就如同在其脚下加垫了一个起跑器一样。”

 

过去数十年来，足球运动医师在很大程度上依赖于有效但具有不良反应的糖皮质激素注射。

 

目前，自体血注射正越来越多地用于治疗肌腱磨损和撕裂的运动员，即将来自该运动员的少量经过离心分离且富含血小板和生长因子的自体血注射入损伤部位。

 

尽管这种治疗较为安全，但唯一一项评价富血小板血浆治疗慢性跟腱损伤患者(n=54)的随机对照试验发现，该治疗与安慰剂之间无显著差异(JAMA 2010;303(2):144-49)。在足球运动员中，跟腱损伤是最常见的损伤。

 

Bennett博士承认，通常所说的这种“血液分离”疗法的科学依据不是很明确。“但其似乎可增强肌腱周围的愈合因素。”

 

Bennett博士还使用透明质酸来对球员的受伤膝关节进行注射。透明质酸是关节液内含有的一种黏性物质，被认为具有保护软骨的作用。透明质酸注射在运动医学领域的应用越来越常见。Bennett博士说：“可以打赌，南非世界杯的一些参赛球员就注射透明质酸。” 但透明质酸注射治疗膝关节损伤的疗效在不同研究中存在不一致性；一项Meta分析(JBJS 2004 86:538-545)总结说，透明质酸注射可能具有一定益处，但仍需要进行更多研究加以证实。近期研究着重于探讨通过注射关节液所含的其他不同物质是否能够取得更好的疗效。

 

数年来，流行程度历经盛衰的其他注射治疗包括增生疗法，即将葡萄糖液注射入韧带或肌腱中，引起被认为可刺激组织修复的局部炎症。这是一种20世纪50年代开发的治疗，其应用目前仍较有限。

 

长期担任拜仁慕尼黑队头号医师兼德国国家足球队顾问的Hans-Wilhelm Müller-Wohlfahrt在过去十年因对球员的腘绳肌腱注射纯化动物血液制品(这种治疗在其慕尼黑诊所之外并未真正得以流行)及因随意注射一种名为Traumeel的德国产酊剂(这是一种科学依据特别不足的顺势疗法)而臭名昭著。

 

Bennett博士表示：“我们所有人都对Traumeel有所质疑。” 但与许多其他运动医师一样，她表示如果运动员可能获益，她还是会使用Traumeel。尽管一些运动医师抨击Müller-Wohlfahrt博士是个不入流的庸医，但Bennett博士赞赏其能够勇于推行其他人过于胆小而不敢尝试的超前理念。她说：“因为足球，我们之中产生了一些治疗理念不因循守旧的人。”

 

英超俱乐部托特纳姆热刺队的队医Charlotte Cowie博士在接受采访时表示，她也使用了大部分上述注射治疗，对这些治疗的感受也是五味陈杂。Cowie博士说：“我在运动医学领域一直工作多年，亲眼目睹了许多这些疗法流行一时后又逐渐不再使用。血浆疗法和增生疗法并非没有依据。但这些疗法也可能只是起到了安慰剂的作用，并且使用它们也可能是无奈之举。”

 

Cowie博士表示，在世界杯这样的高压态势下，“为了治疗损伤，医生会尽可能地将一切能用的治疗都用上。你只有几周的时间使球员恢复。”

 

Cowie博士表示，除了注射治疗之外，在足球医学领域中，预防和康复这两个方面的“循证程度非常高”，并且不断取得进展。

 

Cowie博士说：“我们在一项研究中发现，强化跟腱真的可以缓解疼痛及改善功能，这方面的研究确实已经非常深入，并且许多这类研究正在进行中。”

 

Bennett博士对此表示赞同，她说： “我们正在整合更多的预防研究，并且在治疗方面，我们不能忘记要妥善采取基本处理措施：冰敷。球员扭伤了脚踝，别忘了进行这一基本处理。 人们通常热衷于使用精密的设备，但其实普通的冰块很值得信赖。”

 

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