Ep 279: Treat the athlete, not her scan, with Pirette Claes & Dr Pim van Klij

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[00:00:56] Dr. A very important message from our research is don't treat the X-ray, because clinicians, I think, are very quick to correlate X-ray findings with causation of symptoms. And I don't think that's fair. I think that's what our study shows, that that might not be fair in this cohort. The athletes themselves should also be aware that they might get an X-ray and see, oh, I have bony proliferations, I have sclerosis, something must be wrong. But this is very common in email athleticism.

[00:01:29] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. Hip morphology and hip injuries have been receiving growing attention, which is a good thing given their prevalence and their impact on athletes' health and performance.

[00:01:57] Today, we're combining the hip and groin field with the attention that female athletes also deserve to their health and performance. Guests, Dr. Pim van Klaay, who works with Dutch football or soccer powerhouse Ajax, and Pirette Klaes, who's starting her career in sports medicine, discuss the PROFI study, and in particular the work they've been doing to quantify the relationship between groin symptoms and pubic symphysis radiological findings and skeletal maturity.

[00:02:24] Dr. van Klaay is a sports medicine physician and assistant professor at Amsterdam University Medical Centre's Department of Orthopaedic Surgery and Sports Medicine in the Netherlands. Pirette Klaes is a medical intern at Leiden University Medical Centre in the Netherlands and an early career researcher. She began her research alongside Pim at Erasmus Medical Centre while in medical school, and she's currently focusing her work on hip and groin injuries in young football players.

[00:02:52] All right, Klaes, Dr. Pim van Klaay, welcome to JOSPT Insights. Thank you. Thank you very much for the invitation. Yeah. Thanks for making the time for us today. There's been a few analyses recently quantifying just how underrepresented female athletes are in published research, and today we're focusing on female athletes in soccer or in football. Pim, your PROFI study is obviously one brick in that very large wall of gathering more data about female athletes,

[00:03:21] and of course there's a long way to go for improving research in female athlete health and performance. I wanted to start by having you explain what the PROFI study is and why you wanted to do the study. The PROFI study stands for Professional Female. The idea basically started in 2020, so around six years ago, while I was writing the discussion of my PhD thesis, working on future perspectives and critically reviewing my time as a PhD student and the studies we performed.

[00:03:50] And yeah, I basically found out that exactly zero female athletes were included in all of these studies. So, to be honest, I felt a bit guilty at that time, especially also while I was triggered in clinical life as a doctor at Paxwolle, which is a football club in the Netherlands, where a lot of female athletes were playing football at the highest level in the Netherlands. And I saw every day that the club was trying really hard to help these female athletes to perform at the highest level,

[00:04:18] but also trying to keep up with their facilities, for example. Think about training facilities, but also doctors and physios involved. And at that time, I saw that their facilities were less compared to the male athletes, while they were having quite a strong athlete voice, but in general, they were not always heard. So that was, let's say, from a clinical and a research perspective, two things which really triggered me to start off with the Professional Female GIP study.

[00:04:44] Nothing like writing the discussion of a PhD to get you thinking about the next project when you want to get the PhD done, Pim. Let's zoom in on the hip and groin injuries specifically, because people who know your work will know that you've done a lot of work in that area, as you say, in male professional football or soccer. What do we know now about the epidemiology of hip and groin injuries in elite female football players? We know a bit more over the years, I would say.

[00:05:12] I think there's more and more research going on in this area. What we see in the most recent studies, there are a lot of things who can describe epidemiology, let's say, for example, the incidence of injuries of hip and groin injuries, which will be, in general, 0.7 injuries per 1,000 hours of match play or training. And there we see that males have somewhere around 0.9, where females have like 0.5.

[00:05:37] So there's somewhat of a 1.8 times difference in those studies. But we have to say that those systematic reviews are basically mostly based on studies which are like from years ago. Football in that period of time has changed a lot. So I would say that the most recent studies are demonstrating higher numbers than they have on average in those systematic reviews.

[00:06:01] So I always tell the students that the injuries, hip and groin injuries, are like getting more and more in female athletes. Because I think there was still some underrepresentation in these injury patterns, especially because the female athletes didn't have a physiotherapist, for example, or doctors examining their injury problems. That's improving and professionalizing over time. So I think these numbers will increase in the future. So it's a bit of, they might have already always been there, but had not been captured.

[00:06:31] As you say, there wasn't the medical support around them. Or it might also have something to do with the increasing professionalism of the sport, the higher demands on these athletes that are driving more injuries. It's hard to disentangle at this stage. Pyrrha, you are one of those clinicians who's been working in the PROFI study. I want to zoom in on the study that you've recently published in JOSPT and use that as the launch pad to talk more broadly about the PROFI study

[00:06:58] and about what this information means for clinicians who work with female athletes and particularly female football or soccer players. And you found that radiographic findings of the pubic symphysis were really common in this elite population that you studied. I think let's start by explaining the MAPS classification and the ASPITAR scoring protocol that you used when you're evaluating the morphology and evaluating or assessing the morphology and evaluating the x-rays. To break down the tools we use,

[00:07:28] both the MAPS classification and the ASPITAR protocol provide ways to systematically approach reviewing the pelvic x-rays, but they each have their own little niche within that. The MAPS stands for the Maturing Adolescent Pubic Symphysis Classification. So it defines four stages of skeletal maturation across three regions in the pubic symphysis. And then a higher stage relates with a higher age,

[00:07:56] and we found the same thing actually in female football players. But what we did see is a lot of female football players, they mature, well, women mature earlier skeletally, generally. But here we found that some females appear to be somewhat stuck, maybe in the third stage, and that did not seem to reach the third stage. So it could be a shortcoming of the MAPS, which then it shows very clearly that it was developed using only males,

[00:08:23] and it might not fully cover female maturation. But it could also be that, for example, maybe the pubic symphysis matures later in life for women. And then the ASPITAR pubic symphysis scoring protocol really looks at findings of the pubic symphysis, and it discerns a few different ones. So bone lucencies, and then if those, so if the bone is more lucent at the surface of the pubic symphysis, then it's called erosions.

[00:08:53] And if it's a bit more, if there's still some bone covering it, then you see cysts. And it also describes bony proliferations, sclerosis, and fragmentation. This has been used a lot in male studies, and we see that male football players, especially, it's very common for them to have one or more ASPITAR findings, even if they have completely zero symptoms. And also for us, we found that nearly 70% of all football players, female football players,

[00:09:22] also had one or more finding. So it's very interesting to see that what can be seen as something that's abnormal, maybe, is actually very common in this group. Yeah, and a bit like what we see with chem morphology of the hip is that many, especially in football or soccer, many players have it. And just because you have this, the morphology showing up on the x-ray doesn't mean that it's symptomatic, as you say. Why the focus on the pubic symphysis

[00:09:50] in particular for this study, Peret? Like Pim said, this study was set up for hip and groin injuries. So we also, within the PROFI study, looked at CAM morphology, which has been gaining a lot of traction. But as Pim said before, addicting-related groin injuries or symptoms are very prevalent in females and particularly pubic-related groin symptoms give a lot of time loss. And there's been attention for looking at x-rays in pubic symphysis

[00:10:20] and trying to correlate those with symptoms. But that has been mainly done for men. So there was really a lack of research looking at that very prevalent problem in female football. And then trying to correlate that with maybe something you could find on an x-ray. The study started, as Peret said, basically for hip and groin injuries in the broad perspective. And we tried to analyze not only the femoral structures, not only acetabular structures,

[00:10:46] but also analyze these pubic symphysis morphologies. But also because we know there are a lot of differences in anatomy. And at the time, in 2020, when we started up this whole idea, there was not a lot of research on this area, especially hip and groin, but nearly nothing on the pubic symphysis. So I think at that point, we were pioneering a little bit. Like, what can we maybe analyze and what can we see on these x-rays for female athletes and what does it add to the clinical perspective?

[00:11:16] And I think the message which came out now in Peret's study is a really important clinical message. So I think in the end, it maybe brought what we expected from it six years ago, that we can just tell the clinicians what we see in female athletes and what we see on imaging and what it tells us from the clinical perspective. So Peret, what are those messages that Pim's alluding to here? What would you like clinicians to take from this information to practice tomorrow?

[00:11:45] A very important message from our research is don't treat the x-ray because clinicians, I think, are very quick to correlate x-ray findings with causation of symptoms. And I don't think that's fair. I think that's what our study shows, that that might not be fair in this cohort. And that the athletes themselves should also be aware that they might get an x-ray and see, oh, I have bony proliferations, I have sclerosis, something must be wrong. But this is very common and it's just very common

[00:12:15] in female athleticism. That being said, obviously, we did not compare these to healthy controls. So we don't know whether this is true for all women or like it is in men that it's just because of the high load asked of these professional female football players. Yeah, I think that's a good point. You're not trying to draw a causal link here between load and changes to the pelvis and you're simply describing that, hey, this is what we see. It doesn't look like there's a strong relationship

[00:12:44] between what you see on the x-ray and what the athletes are reporting in imaging. Tell us a little bit about the ongoing work that's happening to try to capture these longitudinal data that are so important. Yeah, so it's really challenging to get a study like this more to a longitudinal perspective. Currently, we're working to get this study to a five-year follow-up as we started it in 2020, 2021. So we're close to five-year follow-up. I think it's really important to just involve a more case control structure

[00:13:14] to also get the asymptomatics and maybe non-athletes in this study to just compare findings. And we're going to try to involve MRI scans in the future to just answer some more questions about intra but also extra-articular structures, get more insights on body composition, for example, but also the development of joints over time and also to maybe get a three-dimensional view of the pubic synthesis, which can also answer a bit more questions in the future. But yeah, as I said, it's quite challenging to get these studies funded,

[00:13:44] especially in professional sports and then especially also in female athletes, makes it even more challenging. And good to flag for our listeners because some of those questions I'm sure will have come into people's minds as we've been talking about the cross-sectional analysis and Piret, you mentioned needing to or not having the comparison to normative data. So all of these aspects of the study you're describing, Pim, will help to answer some of those important questions. I suppose there's also a bit of a movement

[00:14:13] and we've seen this particularly in the osteoarthritis field where there's a push for radiologists when they're reporting on imaging to move, shift the language they're using and I've certainly seen studies where they will test different types of language and messaging and how that's interpreted by patients. And Piret, it sounds a bit like that's what you're alluding to here is sometimes it's the language can seem really scary when you read your x-ray report and it says you've got sclerosis of the pubic symphysis, you think, oh my gosh,

[00:14:43] that seems really bad. So how do you explain what's going on to athletes and how do you break that cycle between seeing the image, seeing the report and freaking out? Yeah, I think it's very important to really emphasize that it's something you see a lot in healthy athletes as well and maybe also focus on the fact that it's not just wear and tear but that it's also just a sign of female athleticism.

[00:15:12] It's almost like celebrating the athleticism as opposed to saying you've got something wrong with your pelvis. Yeah, exactly. But I do think it's very important to point out that we need to follow these athletes over time. So to do a longitudinal study so as to see what comes out of these radiographic findings. Pian, in your clinical experience, what has worked with these conversations with athletes

[00:15:41] around imaging? Especially in professional sports, when there is somewhat of an injury, one of the first questions is, hey doc or hey physio, how much time is it going to take me? And then, yeah, we try to give them somewhat of a scientific-based answer which is kind of tricky. And then the second question is, okay, can I get an x-ray or an MRI or an ultrasound to just prove it what I have? And then the tricky part starts again because then we end up maybe with an x-ray

[00:16:11] where we see a lot of things around, for example, the pubic symphysis while having pubic-related groin pain, for example. And then we still just don't know what is causing the pain. For athletes, sometimes one-on-one is two, but it's not that easy, I would say, to just combine the clinical perspective with this additional imaging. Even MRI studies have a bit of the same issue around these morphological things. So that's the reason why we call it nowadays morphological changes and not deformities or lesions anymore

[00:16:40] because that will get the message a bit away from disease and illness. There's some difference around that area. So I would say we have to describe it. We screen it sometimes, especially if you think around red flags. Okay, of course, you need additional imaging. But if we just look into an overuse injury, we first go on the clinic and just work with clinical parameters first. And if it stagnates or gets worse, okay, then you can later on in the rehab, you can make a side path

[00:17:10] towards additional imaging. Always start first with your clinical examination and your clinical progression. And we have more and more studies that are bearing that out. I'm thinking particularly of a lot of the Aspital work in hamstring injury where really the imaging findings are not adding much, if anything, to the clinical examination. And it really speaks to having strong examination skills and working hard on developing those as a clinician as opposed to relying on the imaging.

[00:17:39] I suppose it's hard when a lot of professional teams now are investing in imaging within the team setup so it becomes expected. Yeah, because nowadays sometimes the third question is going to be after four weeks, can I get an MRI again to just track my progress or a new x-ray? Yeah, we know also from science but also from clinical perspective that it doesn't always really help, especially when the athlete is symptom-free. You make an MRI and there's still some edema, for example, that can create a lot of new noise.

[00:18:09] And the other way around, your x-ray findings from the pubic symphysis will stay there. So after somewhat of a rehab and yeah, you'll make an x-ray again that doesn't add anything to the clinical perspective for the patient. Now, I think speaking about resources in clubs is a nice segue into the final part of our conversation, which is where I want to talk with both of you about things like how salaries and playing conditions, they're certainly improving, they're definitely changing

[00:18:38] and I think changing for the better for female athletes in soccer, in football and in other sports. Often though, still these athletes are having to work another job to make ends meet or they don't have access to all of the health and performance support or facilities as their male counterparts. We've also seen some athletes who have successfully taken maternity leave and come back to their sport. As clinicians, how do you exist in all of this environment?

[00:19:07] How do you approach working with female athletes and what advice would you share with our listeners? Yeah, so I can see in the clubs where I worked before, let's say I worked for a couple of years ago, I worked in a club which was more on the right side of the table as we call it and nowadays maybe a club which is more on the left side of the table and you can see a lot of financial differences around these clubs but also the money they invest to improve female football. Nevertheless, I can see on general line that there's an improvement

[00:19:36] of professionalism. Female football made big steps especially in the Netherlands over the last years but I compare it with the situation where I'm working now there are like multiple facial therapists on the first female team there's a team doctor involved with a part-time job for example and just to cover the medical structure around the team so and improve it over time and most female football players at our club are there on full-time base so that will help them to just not have to work next to their football career which yeah maybe gives a better focus also

[00:20:06] on prevention of injuries also I recognize the thing in the smaller clubs people who have part-time contracts but I think there are some improvements in general in the Netherlands. Perrette, you're doing your internship as a doctor in this new environment of sports medicine what does this mean for you? How do you think about the work you do and the opportunities that are available to you working in professional sport? Yeah, I think during my internships you still see that a lot of doctors or clinicians

[00:20:35] are very focused on the male athletes especially if you're not near centers where there's big professional football clubs including women so I think at least definitely working on this project has given me a lot of insight in oh they say this is how things are always done but this is how things are always done with men and maybe how certain doctors approach their athletes works well for men but it could be different for women for example just like how they approach

[00:21:05] things such as like you said maternity leave as soon as hormones start to play a role I think a lot of sports medical professionals that I've worked with back off a little bit and think oh well there's not a lot of research done there even though maybe that's a big opportunity to combine fields to gain more insight into how to properly treat those female patients and how to have those chats absolutely and we have to have those chats because if we don't if we say oh look there's no

[00:21:34] research I don't know what to do it can feel a bit like the medical staff are walking away and abandoning the athletes and that's not a good position for athletes to find themselves in oh definitely Privet also knows that we are currently in our academic hospital we are working on a project to just try to get somewhat of a clinical and research platform to unite all the initiatives around female athlete health in general so not only football players but also other athletes and not only professionals

[00:22:04] but also amateur athletes and I think it's really important that we get a clear overview of experts in the field and we have a small country so you know you've been here Claire so you know but I think it's important that there are so many different female related questions like for example breast health or pelvic floor issues but also musculoskeletal issues like ACL injuries but also dysplasia and I think what Priyat said if we involve for example internal medicine but also gynecology cardiology I think there are so many

[00:22:34] crossover links where we can add on each other and find really clinically relevant questions to just work out in the future I think we can really help the field moving forward and in the end improve the care of our female athletes and I think that would be probably the main message especially for me but also I think for Priyat today if I speak a bit for her for our clinicians and the clinicians who are listening to this podcast today interdisciplinary care when it works well it's really about bringing people together to support the

[00:23:04] athlete isn't it and I think I'd add neurology in there too with what we're learning more and more about concussion and differences sex differences in concussion Priyat and Pim it's been wonderful hearing about the PROFY study and how you see this work evolving all of the work that's going on in the Netherlands so we're really fortunate to have both of you leading work in this area Priyat Clay Dr. Pim Van Clay thanks for joining me on JOSPT Insights Thank you so much for the opportunity

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