All eyes are on the World Cup in South Africa as 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 began on 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.”
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