With a recent increase in running popularity, more women choose to run during and after pregnancy. Little research has examined exercise behaviors and postpartum health conditions of runners.
Antenatal and postpartum exercise is beneficial in reducing certain postpartum health conditions.
Cross-sectional study.
Level 5.
A self-administered, online survey was developed that consisted of questions regarding antenatal and postpartum exercise behaviors, maternal history, and postpartum health conditions. The survey was completed by 507 postpartum women who were running a minimum of once per week.
Seventy-two percent of participants ran regularly during pregnancy, with 38% reporting running in the third trimester. Women with musculoskeletal pain during pregnancy were more likely to experience pain on return to running postpartum (odds ratio [OR], 3.08; 95% CI, 1.64-5.88). A birth spacing of <2 years or a vaginal-assisted delivery increased the odds of postpartum stress urinary incontinence (OR, 1.71; 95% CI, 1.00-2.91 and OR, 2.08; 95%CI, 1.24-3.47, respectively), while Caesarean section delivery decreased the odds (OR, 0.58; 95% CI, 0.35-0.96). Multiparous women and those who reported a Caesarean section delivery were more likely to report abdominal separation (OR, 2.11; 95% CI, 1.08-4.26 and OR, 2.20; 95% CI, 1.05-4.70, respectively). Antenatal weight training decreased the odds of postpartum pain (OR, 0.52; 95% CI, 0.28-0.94), stress urinary incontinence (OR, 0.46; 95% CI, 0.21-0.98), and abdominal separation (OR, 0.51; 95% CI, 0.26-0.96).
Musculoskeletal pain, stress urinary incontinence, and abdominal separation are prevalent conditions among postpartum runners and are more likely to occur with specific maternal history characteristics. Antenatal weight training may reduce the odds of each of these conditions.
Strengthening exercises during pregnancy may prevent weakening and dysfunction of the abdominal and pelvic floor muscles, decreasing the odds of pain, stress urinary incontinence, and abdominal separation after pregnancy.
In the skeletally immature population, the incidence of anterior cruciate ligament (ACL) injuries and ACL reconstructions appears to be increasing. Differences in surgical techniques, physiology, and emotional maturity may alter the rehabilitation progression and impact the outcomes when compared with adults. Reports of objective strength recovery and performance-based outcome measures after pediatric ACL reconstruction (ACLR) are limited.
Retrospective case series.
Level 4.
All patients that underwent all-epiphyseal ACLR from January 2008 to August 2010 were identified. Isokinetic peak quadriceps/hamstring torque values and functional performance measures in unilateral hopping tasks were extracted and compared with the noninjured limb. A limb symmetry index (LSI) of ≥90% was considered satisfactory.
Complete data were available for 16 patients (mean age, 12.28 years; range, 8.51-14.88 years). By a mean 7 months (range, 3.02-12.56 years) postoperatively, only 9 of 16 (56%) were able to achieve a satisfactory LSI for quadriceps strength. For hamstring strength, 15 of 16 (94%) were able to achieve satisfactory LSI. By a mean of 12 months (range, 5.39-24.39 months) postoperatively, only 6 of 16 subjects (38%) were able to achieve satisfactory performance on all functional hop tests. At a mean 15.42 months (range, 8.58-24.39 months) postsurgery, only 4 of 16 (25%) subjects were able to achieve an LSI of ≥90% on all testing parameters.
For some pediatric patients, significant strength and functional deficits may be present at greater than 1 year after ACLR. This population may require more prolonged rehabilitation programs to allow for adequate recovery of strength and function because of unique characteristics of normal growth and development.
Soccer athletes are at risk for anterior cruciate ligament (ACL) injury. To date, there are limited studies on the mechanisms of ACL injuries in soccer athletes and no video-based analysis or sex-based comparison of these mechanisms.
There is no difference in ACL injury mechanisms among soccer athletes by sex.
Case series.
Level 4.
Fifty-five videos of ACL injuries in 32 male and 23 female soccer players were reviewed. Most athletes were professionals (22 males, 4 females) or collegiate players (8 males, 14 females). Visual analysis of each case was performed to describe the injury mechanisms in detail (game situation, player behavior, and lower extremity alignment).
The majority of ACL injuries occurred when the opposing team had the ball and the injured athlete was defending (73%). Females were more likely to be defending when they injured their ACLs (87% vs 63% for males, P = 0.045). The most common playing action was tackling (51%), followed by cutting (15%). Most injuries occurred due to a contact mechanism (56%) with no significant difference for sex. Females were more likely to suffer a noncontact injury in their left knee (54%) than males (33%) (P = 0.05).
Soccer players are at greatest risk for ACL injury when defending, especially when tackling the opponent in an attempt to win possession of the ball. Females are more likely to injure their ACLs when defending and are at greater risk for noncontact injuries in their left lower extremity.
Soccer ACL injury prevention programs should include proper defending and tackling techniques, particularly for female athletes.
Females with history of anterior cruciate ligament (ACL) injury and subsequent ligament reconstruction are at high risk for future ACL injury. Fatigue may influence the increased risk of future injury in females by altering lower extremity biomechanics and postural control.
Fatigue will promote lower extremity biomechanics and postural control deficits associated with ACL injury.
Descriptive laboratory study.
Fourteen physically active females with ACL reconstruction (mean age, 19.64 ± 1.5 years; mean height, 163.52 ± 6.18 cm; mean mass, 62.6 ± 13.97 kg) volunteered for this study. Postural control and lower extremity biomechanics were assessed in the surgical limb during single-leg balance and jump-landing tasks before and after a fatigue protocol. Main outcome measures were 3-dimensional hip and knee joint angles at initial contact, peak angles, joint angular displacements and peak net joint moments, anterior tibial shear force, and vertical ground reaction force during the first 50% of the loading phase of the jump-landing task. During the single-leg stance task, the main outcome measure was center of pressure sway speed.
Initial contact hip flexion angle decreased (t = –2.82, P = 0.01; prefatigue, 40.98° ± 9.79°; postfatigue, 36.75° ± 8.61°) from pre- to postfatigue. Hip flexion displacement (t = 2.23, P = 0.04; prefatigue, 45.19° ± 14.1°; postfatigue, 47.48° ± 14.21°) and center of pressure sway speed (t = 3.95, P < 0.05; prefatigue, 5.18 ± 0.96 cm/s; postfatigue, 6.20 ± 1.72 cm/s) increased from pre- to postfatigue. There was a trending increase in hip flexion moment (t = 2.14, P = 0.05; prefatigue, 1.66 ± 0.68 Nm/kg/m; postfatigue, 1.91 ± 0.62 Nm/kg/m) from pre- to postfatigue.
Fatigue may induce lower extremity biomechanics and postural control deficits that may be associated with ACL injury in physically active females with ACL reconstruction.
Rehabilitation and maintenance programs should incorporate activities that aim to improve muscular endurance and improve the neuromuscular system’s tolerance to fatiguing exercise in efforts to maintain stability and safe landing technique during subsequent physical activity.
The number of adults with osteoarthritis in the United States is expected to nearly double from 21.4 million in 2005 to 41.1 million by 2030. As a result, medical costs and associated comorbidity will exponentially increase in the coming decades. In the past decade, mesenchymal stem cells (MSCs) have emerged as a novel treatment for degenerative joint disease.
PubMed (from 1990 to 2013) was searched to identify relevant studies. Reference lists of included studies were also reviewed.
Clinical review.
Level 3.
We identified 9 animal and 7 human studies investigating the use of MSCs in the treatment of osteoarthritis, with varying levels of support for this therapy.
While MSCs have shown potential for improving function and decreasing inflammation in animal studies, translation to patients is still in question. There is a great deal of heterogeneity in treatment methods. Standardizing the manufacturing and characterization of MSCs will allow for better comparisons.
Asymmetries persist after anterior cruciate ligament reconstruction (ACLR). Physical performance tests such as the single-limb hop test have been used extensively to assess return-to-sport criteria, as they reproduce dynamic athletic maneuvers.
The single-limb hop is associated with muscle strength and kinematic and kinetic asymmetries in ACLR patients 6 to 9 months after surgery.
Controlled laboratory study.
Twenty-two men with ACLR (mean age, 28.8 ± 11.2 years) at 6 to 9 months (mean, 7.01 ± 0.93 months) after surgery completed isokinetic testing in 3 velocities (120, 180, and 300 deg/s) and a kinetic, kinematic, and functional evaluation of the single-limb hop test. Pearson correlation coefficients were used to assess the relationship between the Limb Symmetry Index (LSI) of the single-limb hop distance and each of the outcome variables.
There were significant positive correlations between the LSI of the single-limb hop distance and the LSI of the peak extension torque at 120 deg/s (P = 0.044, r = 0.37) and the peak extension torque at 180 deg/s (P = 0.042, r = 0.38) as well as a negative correlation with the peak flexion torque at 180 deg/s (P = 0.043, r = –0.38). The LSI of the single-limb hop test was not correlated with any kinetic or kinematic variable (P > 0.05).
The findings of the present study demonstrate that distance LSI of the single-limb hop test correlates with isokinetic extension peak torque LSI but not kinetic and kinematic asymmetry.
The single-limb hop test can be used as an additional tool for the recognition of muscle strength asymmetries but not for kinetic or kinematic asymmetries 6 to 9 months after ACLR.
Aquagenic syringeal acrokeratoderma is a newly described condition of the palms and soles characterized by hypopigmented papules and plaques, elicited after submersion in water. Symptoms include a burning pain and a tightening sensation in the palms, as well as hyperhidrosis. Initially thought to be rare, its frequent citation in the literature points to a more common entity. It is more often found in young women and has been linked to a number of medications and illnesses, including nonsteroidal anti-inflammatory drugs and cystic fibrosis. It is typically self-limiting, but certain medications such as topical aluminum chloride or salicylic acid ointment have been found to be an effective treatment option. This case details a collegiate-level coxswain who presented to the university athletic training room with a typical presentation of aquagenic syringeal acrokeratoderma. For an aquatic athlete, aquagenic syringeal acrokeratoderma can be a distressing condition that can limit training and athletic participation. As such, the sports medicine physician should be knowledgeable about aquagenic syringeal acrokeratoderma to provide effective counseling and treatment options for the athlete.
Injuries of the first metatarsophalangeal (hallux MP) joint can be debilitating in the athletic population. Turf toe and plantar plate injuries are typically diagnosed similarly. However, variance in injury mechanism as well as compromised integrity of soft tissue and ligamentous structures make it difficult to accurately diagnose specific hallux MP injuries. Recent literature has supported the use of both radiographic imaging and the Lachman test as reliable indicators of joint instability in the presence of hallux MP injuries. To date, research supporting specific rehabilitation interventions and return-to-play decision making for hallux MP injuries has been limited to case studies and suggested guidelines from literature reviews. There is limited evidence suggesting specific criteria for surgical and nonsurgical decision making in conjunction with rehabilitation progressions to return an athlete to sport when managing hallux MP injuries.
A literature search was performed using Medline, PubMed, and Google Scholar to find and review articles from 1970 to 2013 that addressed the basic anatomy of the plantar plate, injuries to this anatomical structure, and the evaluation, diagnosis, surgical and nonsurgical management, and rehabilitation of these injuries, specifically in the athletic population. Medical information for each case was gathered from electronic medical records from the individual athletes cited in this case series, which included imaging reports, rehabilitation documentation, and both evaluation and surgical reports. No statistical analysis was used.
Case series.
Level 4.
Treatment plans for each case varied depending on surgical and nonsurgical intervention and rehabilitation outcomes. However, each athlete was able to return to sports-specific activities.
Successful outcomes for hallux MP injuries are contingent on thorough evaluation, appropriate clinical decision making with regard to surgical versus nonsurgical treatment planning, and a multidisciplinary team approach for ensuring a safe return to sport.
C.
Collegiate football is a high-demand sport in which shoulder injuries are common. Research has described the incidence of these injuries, with little focus on causative factors or injury prevention.
Football athletes who score lower on preseason strength and functional testing are more likely to sustain an in-season shoulder injury.
Prospective, cohort study.
Level 2.
Twenty-six collegiate football players underwent preseason testing with a rotational profile for shoulder range of motion, isometric strength of the rotator cuff at 90° elevation and external rotation in the 90/90 position, fatigue testing (prone-Y, scaption, and standing cable press), and the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST). Data collected postseason included the type of shoulder injury and the side injured. Logistic regression was used to determine if the testing measures predicted injury, and a receiver operating characteristic curve was constructed to examine the relationship of CKCUEST to injury.
Six athletes sustained shoulder injuries during the season. Predictor variables could significantly predict whether that player would sustain an injury during the season for both the right and left shoulders (P < 0.05). The variables that were significantly correlated with injury of the right side were forward elevation strength, prone-Y to fatigue, and the CKCUEST (P < 0.05); on the left, only the CKCUEST was significant (P < 0.05). The area under the receiver operating characteristic curve for the CKCUEST was 0.86 ( = 0.87, P = 0.01). Using a score of 21 touches, the CKCUEST had a sensitivity of 0.83, a specificity of 0.79, and an odds ratio of 18.75 in determining whether a player sustained a shoulder injury.
For this sample, the combination of preseason strength, fatigue, and functional testing was able to identify football players who would sustain a shoulder injury during the season.
Using a battery of strength, fatigue, and functional testing may be helpful in identifying football players during preseason who are at a higher risk for sustaining a shoulder injury. This information can be used to optimize preseason testing and implementation of injury prevention programs.
Articular cartilage possesses poor natural healing mechanisms, and a variety of non-cell-based and cell-based treatments aim to promote regeneration of hyaline cartilage.
A review of the literature to December 2013 using PubMed with search criteria including the keywords stem cell, cell therapy, cell transplantation, cartilage, chondral, and chondrogenic.
Forty-five articles were identified that employed local mesenchymal stem cell (MSC) therapy for joint disorders in humans. Nine comparative studies were identified, consisting of 3 randomized trials, 5 cohort studies, and 1 case-control study.
Clinical review.
Level 4.
Studies were assessed for stem cell source, method of implantation, comparison groups, and concurrent surgical techniques.
Two studies comparing MSC treatment to autologous chondrocyte implantation found similar efficacy. Three studies reported clinical benefits with intra-articular MSC injection over non-MSC controls for cases undergoing debridement with or without marrow stimulation, although a randomized study found no significant clinical difference at 2-year follow-up but reported better 18-month magnetic resonance imaging and histologic scores in the MSC group. No human studies have compared intra-articular MSC therapy to non-MSC techniques for osteoarthritis in the absence of surgery.
Mesenchymal stem cell–based therapies appear safe and effective for joint disorders in large animal preclinical models. Evidence for use in humans, particularly, comparison with more established treatments such as autologous chondrocyte implantation and microfracture, is limited.
Cycling has become a popular recreational and competitive sport. The number of people participating in the sport is gradually increasing. Despite being a noncontact, low-impact sport, as many as 85% of athletes engaged in the sport will suffer from an overuse injury, with the lower limbs comprising the majority of these injuries. Up to 20% of all lower extremity overuse injuries in competitive cyclists are of a vascular source. A 39-year-old competitive cyclist had a 5-year history of thigh pain during cycling, preventing him from competing. The patient was eventually diagnosed with external iliac artery endofibrosis. After conservative treatment failed, the patient underwent corrective vascular surgery with complete resolution of his symptoms and return to competitive cycling by 1 year. Since its first description in 1985, there have been more than 60 articles addressing external iliac artery endofibrosis pathology.
Up to 1 billion people have insufficient or deficient vitamin D levels. Despite the well-documented, widespread prevalence of low vitamin D levels and the importance of vitamin D for athletes, there is a paucity of research investigating the prevalence of vitamin D deficiency in athletes.
We investigated the prevalence of abnormal vitamin D levels in National Collegiate Athletic Association (NCAA) Division I college athletes at a single institution. We hypothesized that vitamin D insufficiency is prevalent among our cohort.
Cohort study.
Level 1.
We measured serum 25-hydroxyvitamin D (25(OH)D) levels of 223 NCAA Division I athletes between June 2012 and August 2012. The prevalence of normal (≥32 ng/mL), insufficient (20 to <32 ng/mL), and deficient (<20 ng/mL) vitamin D levels was determined. Logistic regression was utilized to analyze risk factors for abnormal vitamin D levels.
The mean serum 25(OH)D level for the 223 members of this study was 40.1 ± 14.9 ng/mL. Overall, 148 (66.4%) participants had sufficient 25(OH)D levels, and 75 (33.6%) had abnormal levels. Univariate analysis revealed the following significant predictors of abnormal vitamin D levels: male sex (odds ratio [OR] = 2.83; P = 0.0006), Hispanic race (OR = 6.07; P = 0.0063), black race (OR = 19.1; P < 0.0001), and dark skin tone (OR = 15.2; P < 0.0001). Only dark skin tone remained a significant predictor of abnormal vitamin D levels after multivariate analysis (adjusted OR = 15.2; P < 0.0001).
In a large cohort of NCAA athletes, more than one third had abnormal vitamin D levels. Races with dark skin tones are at much higher risk than white athletes. Male athletes are more likely than female athletes to be vitamin D deficient. Our study demonstrates a high prevalence of vitamin D deficiency among healthy NCAA athletes.
Many studies indicate a significant prevalence of vitamin-D insufficiency across various populations. Recent studies have demonstrated a direct relationship between serum 25(OH)D levels and muscle power, force, velocity, and optimal bone mass. In fact, studies examining muscle biopsies from patients with low vitamin D levels have demonstrated atrophic changes in type II muscle fibers, which are crucial to most athletes. Furthermore, insufficient 25(OH)D levels can result in secondary hyperparathyroidism, increased bone turnover, bone loss, and increased risk of low trauma fractures and muscle injuries. Despite this well-documented relationship between vitamin D and athletic performance, the prevalence of vitamin D deficiency in NCAA athletes has not been well studied.
Exertional rhabdomyolysis is a relatively uncommon but potentially fatal condition affecting athletes that requires prompt recognition and appropriate management.
A search of the PubMed database from 2003 to 2013 using the term exertional rhabdomyolysis was performed. Further evaluation of the bibliographies of articles expanded the evidence.
Clinical review.
Level 3.
Exertional rhabdomyolysis (ER) is a relatively uncommon condition with an incidence of approximately 29.9 per 100,000 patient years but can have very serious consequences of muscle ischemia, cardiac arrhythmia, and death. The athlete will have pain, weakness, and swelling in the muscles affected as well as significantly elevated levels of creatine kinase (CK). Hydration is the foundation for any athlete with ER; management can also include dialysis or surgery. Stratifying the athlete into high- or low-risk categories can determine if further workup is warranted.
Exertional rhabdomyolysis evaluation requires a history, physical examination, and serology for definitive diagnosis. Treatment modalities should include rest and hydration. Return to play and future workup should be determined by the risk stratification of the athlete.
C.
Exercise-induced rhabdomyolysis related to military training, marathon running, and other forms of strenuous exercise has been reported. The incidence of acute kidney injury appears to be lower in exercise-induced cases. We present 2 cases of exercise-induced rhabdomyolysis following spinning classes, one of which was further complicated by acute compartment syndrome requiring bilateral fasciotomies of the anterior thigh and acute kidney injury. With vigorous hydration and urine pH monitoring, both patients exhibited good mobility, sensation, and renal function on discharge.
Popliteal synovial cysts, also known as Baker’s cysts, are commonly found in association with intra-articular knee disorders, such as osteoarthritis and meniscus tears. Histologically, the cyst walls resemble synovial tissue with fibrosis evident, and there may be chronic nonspecific inflammation present. Osteocartilaginous loose bodies may also be found within the cyst, even if they are not seen in the knee joint. Baker’s cysts can be a source of posterior knee pain that persists despite surgical treatment of the intra-articular lesion, and they are routinely discovered on magnetic resonance imaging scans of the symptomatic knee. Symptoms related to a popliteal cyst origin are infrequent and may be related to size.
A PubMed search was conducted with keywords related to the history, diagnosis, and treatment of Baker’s cysts—namely, Baker’s cyst, popliteal cyst, diagnosis, treatment, formation of popliteal cyst, surgical indications, and complications. Bibliographies from these references were also reviewed to identify related and pertinent literature.
Clinical review.
Level 4.
Baker’s cysts are commonly found associated with intra-articular knee disorders. Proper diagnosis, examination, and treatment are paramount in alleviating the pain and discomfort associated with Baker’s cysts.
A capsular opening to the semimembranosus–medial head gastrocnemius bursa is a commonly found normal anatomic variant. It is thought that this can lead to the formation of a popliteal cyst in the presence of chronic knee effusions as a result of intra-articular pathology. Management of symptomatic popliteal cysts is conservative. The intra-articular pathology should be first addressed by arthroscopy. If surgical excision later becomes necessary, a limited posteromedial approach is often employed. Other treatments, such as arthroscopic debridement and closure of the valvular mechanism, are not well studied and cannot yet be recommended.
Spondylolysis is a common cause of low back pain and significant loss of play in the young athlete. Its incidence in hockey players has not been reported. This study reviewed the incidence and potential causative factors of low back pain and spondylolysis in an elite junior-level ice hockey program over a 15-year period.
Because of the repetitive movements of the lower spine required by the sport, spondylolysis was expected to be a frequent cause of low back pain in hockey players.
Retrospective case review.
4.
The medical and athletic trainer records of male ice hockey players, ages 15 to 18 years, who presented with the complaint of low back pain were reviewed. This elite program consisted of 2 rosters. There were approximately 44 players total per year representing these 2 teams. For players diagnosed with spondylolysis, the following factors were reviewed: year in the program, age at presentation, symptoms and duration, studies performed, level of spondylolysis, presence of spondylolisthesis, affected side to shooting side, player position, treatment, and current level of play.
Over 9 hockey seasons, 25 players presented to medical staff with low back pain. Of those, 44% were confirmed to have lumbar spondylolysis. The majority of these cases presented in the first year of the program without clear history of trauma but rather vague pain with weight lifting or hockey. Less than half of spondylolysis cases were diagnosed on plain films. There were no cases of spondylolisthesis. Spondylolysis occurred on the shooting side in 73% of players. Sixty-four percent of players with spondylolysis were forwards. The treatment for most included rest from lifting and hockey and physical therapy. Average return to play was 8 weeks. Ninety-six percent of players continued to play at an elite level.
Spondylolysis should be strongly considered in the differential of low back pain in ice hockey players with consideration for advanced imaging. Considerable loss of play occurs with spondylolysis, but with proper treatment, excellent outcomes occur.
This study brings to light the prevalence of spondylolysis in ice hockey players. With an increased index of suspicion, the condition can be diagnosed and properly treated to allow full return to play.
Anterior cruciate ligament (ACL) reconstruction rehabilitation has evolved over the past 20 years. This evolution has been driven by a variety of level 1 and level 2 studies.
The MOON Group is a collection of orthopaedic surgeons who have developed a prospective longitudinal cohort of the ACL reconstruction patients. To standardize the management of these patients, we developed, in conjunction with our physical therapy committee, an evidence-based rehabilitation guideline.
Clinical review.
Level 2.
This review was based on 2 systematic reviews of level 1 and level 2 studies. Recently, the guideline was updated by a new review. Continuous passive motion did not improve ultimate motion. Early weightbearing decreases patellofemoral pain. Postoperative rehabilitative bracing did not improve swelling, pain range of motion, or safety. Open chain quadriceps activity can begin at 6 weeks.
High-level evidence exists to determine appropriate ACL rehabilitation guidelines. Utilizing this protocol follows the best available evidence.
The shoulder plays a critical role in many overhead athletic activities. Several studies have shown alterations in shoulder range of motion (ROM) in the dominant shoulder of overhead athletes and correlation with significantly increased risk of injury to the shoulder and elbow. The purpose of this study was to measure isolated glenohumeral joint internal/external rotation (IR/ER) to determine inter- and intraobserver reliability of a new clinical device.
(1) Inter- and intraobserver reliability would exceed 90% for measures of glenohumeral joint IR, ER, and total arc of motion; (2) the dominant arm would exhibit significantly increased ER, significantly decreased IR, and no difference in total arc of motion compared with the nondominant shoulder; and (3) a significant difference exists in total arc between male and female patients.
Case series.
Level 4.
Thirty-seven subjects (mean age, 23 years; range, 13-54 years) were tested by 2 orthopaedic surgeons. A single test consisted of 1 arc of motion from neutral to external rotation to internal rotation and back to neutral within preset torque limits. Each examiner performed 3 tests on the dominant and nondominant shoulders. Each examiner completed 2 installations.
Testing reliability demonstrated that neither trial, installation, nor observer were significant sources of variation. The maximum standard deviation was 1.3° for total arc of motion and less than 2° for most other measurements. Dominant arm ER was significantly greater than nondominant arm ER (P = 0.02), and dominant arm IR was significantly less than nondominant arm IR (P = 0.00). Mean total rotation was 162°, with no significant differences in total rotation between dominant and nondominant arms (P = 0.34). Mean total arc of motion was 45° greater in female subjects. Differences in total arc of motion between male and female subjects was statistically significant (P < 0.00).
This simple, clinical device allows for both inter- and intraobserver reliability measurements of glenohumeral internal and external rotation.
Skeletal muscle is comprised of a highly organized network of cells, neurovascular structures, and connective tissue. Muscle injury is typically followed by a well-orchestrated healing response that consists of the following phases: inflammation, regeneration, and fibrosis. This review presents the mechanisms of action and evidence supporting the effectiveness of various traditional and novel therapies at each phase of the skeletal muscle healing process.
Relevant published articles were identified using MEDLINE (1978-2013).
Clinical review.
Level 3.
To facilitate muscle healing, surgical techniques involving direct suture repair, as well as the implantation of innovative biologic scaffolds, have been developed. Nonsteroidal anti-inflammatory drugs may be potentially supplanted by nitric oxide and curcumin in modulating the inflammatory pathway. Studies in muscle regeneration have identified stem cells, myogenic factors, and β-agonists capable of enhancing the regenerative capabilities of injured tissue. Furthermore, transforming growth factor-β1 (TGF-β1) and, more recently, myostatin and the rennin-angiotensin system have been implicated in fibrous tissue formation; several antifibrotic agents have demonstrated the ability to disrupt these systems.
Effective repair of skeletal muscle after severe injury is unlikely to be achieved with a single intervention. For full functional recovery of muscle there is a need to control inflammation, stimulate regeneration, and limit fibrosis.
B
Wolff-Parkinson-White (WPW) is a cardiac conduction system disorder characterized by abnormal accessory conduction pathways between the atria and the ventricles. Symptomatic patients classically present with palpitations, presyncope, or syncope that results from supraventricular tachycardia. While rare, sudden cardiac death may be the first manifestation of underlying disease and occurs more frequently in exercising individuals.
Medline and PubMed databases were evaluated through 2012, with the following keywords: WPW, Wolff-Parkinson-White, pre-excitation, sudden cardiac death, risk stratification, and athletes. Selected articles identified through the primary search, along with relevant references from those articles, were reviewed for pertinent clinical information regarding the identification, evaluation, risk stratification, and management of WPW as they pertained to the care of athletes.
1b.
Diagnosis of WPW is confirmed by characteristic electrocardiogram changes, which include a delta wave, short PR interval, and widened QRS complex. Utilization of the electrocardiogram as part of the preparticipation physical evaluation may allow for early identification of asymptomatic individuals with a WPW pattern. Risk stratification techniques identify individuals at risk for malignant arrhythmias who may be candidates for curative therapy through transcatheter ablation.
WPW accounts for at least 1% of sudden death in athletes and has a prevalence of at least 1 to 4.5 per 1000 children and adults. The risk of lethal arrhythmia appears to be higher in asymptomatic children than in adults, and sudden cardiac death is often the sentinel event. The athlete with WPW should be evaluated for symptoms and the presence of intermittent or persistent pre-excitation, which dictates further consultation, treatment, and monitoring strategies as well as return to play.
Antibiotics are the mainstay of treatment for bacterial infections in patients of all ages. Athletes who maximally train are at risk for illness and various infections. Routinely used antibiotics have been linked to tendon injuries, cardiac arrhythmias, diarrhea, photosensitivity, cartilage issues, and decreased performance.
Clinical review.
Level 3a.
Relevant articles published from 1989 to 2012 obtained through searching MEDLINE and OVID. Also, the Food and Drug Administration website was utilized.
The team physician should consider alternative medications in place of the "drug of choice" when adverse drug effects are a concern for an athlete’s health or performance. If alternative medications cannot be selected, secondary preventative measures, including sunscreen or probiotics, may be needed.
Physicians choose medications based on a variety of factors to help ensure infection resolution while limiting potential side effects. Extra precautions are indicated when treating athletes with certain antibiotics.
The hand-behind-back method is the accepted technique to evaluate shoulder internal rotation, is highly popular, and is endorsed by the American Academy of Orthopaedic Surgeons. It remains, however, subject to intra- and interexaminer discrepancy and has been challenged by several recent publications.
Internal rotation behind the back can be evaluated with a measurable angle, which eliminates the need to estimate spinal level, decreases the effect of unrelated joints, and allows collection of numeric rather than categoric data.
Descriptive laboratory study.
We defined the internal rotation behind-the-back (IRB) angle as that between the ulna and the line of gravity. A pendulum is attached to a standard goniometer. The patient is asked to reach the highest point along the midline of the back. The goniometer is centered over the pisiform, and the angle between the ulnar axis and the pendulum is measured. Two examiners assessed both shoulders of 60 volunteers with no shoulder pathology using this technique on 2 occasions. Both examiners were blinded to each other’s values. We applied the paired Student t test and calculated Pearson correlation coefficients and weighted Cohen kappa values.
The IRB angles ranged from 50° to 125°. The difference of the mean, as measured with the Student t test, was 0.6° (95% confidence interval: 0.1°, 1.3°) and 0.6° (95% confidence interval: –0.8°, 1.8°); the Pearson correlation coefficients were 0.98 and 0.92; and the weighted kappa values were 0.88 and 0.77 for interobserver and intraobserver analyses, respectively.
The IRB angle is easy to measure, is reproducible, and does not rely on determination of spinal level. It provides numeric data and may eliminate some of the uncertainty associated with the estimation of spinal level.
The IRB angle may eliminate some of the uncertainty associated with the estimation of spinal level.
Sternoclavicular (SC) dislocation is a rare injury of the upper extremity. Treatment of posterior SC dislocation ranges from conservative (closed reduction) to operative (open reduction with or without surgical reconstruction of the SC joint). To date, we are unaware of any literature that exists pertaining to this injury or its treatment in elite athletes. The purpose of this case report is to describe a posterior SC joint dislocation in a professional American football player and to illustrate the issues associated with its diagnosis and treatment and the athlete’s return to sports. To our knowledge, this case is the first reported in a professional athlete. He was treated successfully with closed reduction and returned to play within 5 weeks of injury.
Although the majority of Major League Baseball teams use an orthopaedic rating system to evaluate draft picks, little has been published on the topic.
Our goal was to assess the attitudes among Major League Baseball physicians regarding 3 common diagnoses in pitching prospects, through the use of an orthopaedic rating system. Our hypothesis was that the assigned orthopaedic grades would vary among physicians, diagnoses, and operative-versus-nonoperative and recent-versus-past treatment.
Survey.
A survey in the form of 12 clinical vignettes was used to query Major League Baseball physicians regarding ulnar collateral ligament (UCL) injuries, type II superior labrum anterior posterior (SLAP) tears, and internal impingement. Respondents graded draft picks using an orthopaedic rating system. The vignettes covered both operative and nonoperative and recent and past treatment (successful return to pitching for 1 year).
The orthopaedic grades assigned by respondents were as follows (minimal, moderate, severe risk): past UCL reconstruction (73%, 27%, 0%), recent UCL reconstruction (19%, 77%, 4%), past UCL strain (28%, 60%, 12%), recent UCL strain (0%, 48%, 52%), past SLAP repair (52%, 48%, 0%), recent SLAP repair (4%, 64%, 32%), past SLAP nonoperative (28%, 60%, 12%), recent SLAP nonoperative (0%, 36%, 64%), past internal impingement operative (24%, 68%, 8%), recent internal impingement operative (8%, 32%, 60%), past internal impingement nonoperative (24%, 68%, 8%), and recent internal impingement nonoperative (4%, 48%, 44%).
Team physicians are optimistic regarding the outcome of UCL reconstruction. In contrast, UCL strains, type II SLAP lesions, and internal impingement carry a guarded prognosis. For all diagnoses, regardless of treatment, the prognosis improved if a player returned to pitching for 1 full season.
This study represents a first step toward developing a standardized orthopaedic rating system that will facilitate more accurate player assessment and clearer communication among physicians.
The curveball is regarded by many as a potential risk factor for injury in youth baseball pitchers.
To critically evaluate the scientific evidence regarding the curveball and its impact on pitching biomechanics and the overall risk of arm injuries in baseball pitchers.
Systematic review.
Ovid MEDLINE from 1946 to 2012.
Ten biomechanical studies on kinematic or electromyographic analysis of pitching a curveball were included, as well as 5 epidemiologic studies that assessed pain or injury incidence in pitchers throwing the curveball.
When possible, demographic, methodology, kinetics, and kinematics variables and pain/injury incidence were compiled.
Two biomechanical studies found greater horizontal adduction of the shoulder at ball release and less shoulder internal torque during the curveball pitching motion. Two studies demonstrated less proximal force and less torque at the elbow as the arm accelerated when throwing a curveball compared with a fastball, as well as greater supination of the forearm and less wrist extension. Electromyographic data suggested increased activity of extensor and supinator muscles for curveballs. No studies found increased force or torque about the elbow or shoulder. Three epidemiologic studies showed no significant association between pitching a curveball and upper extremity pain or injury. One retrospective epidemiologic study reported a 52% increase in shoulder pain in pitchers throwing a curveball, although this may have been due to confounders.
Despite much debate in the baseball community about the curveball’s safety in youth pitchers, limited biomechanical and most epidemiologic data do not indicate an increased risk of injury when compared with the fastball.
Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions.
Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers.
The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction.
Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing.
Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B.
Sideline management of sports-related joint dislocations often places the treating medical professional in a challenging position. These injuries frequently require prompt evaluation, diagnosis, reduction, and postreduction management before they can be evaluated at a medical facility. Our objective is to review the mechanism, evaluation, reduction, and postreduction management of sports-related dislocations to the shoulder, elbow, finger, knee, patella, and ankle joints.
A literature review was performed using the PubMed database to evaluate previous and current publications focused on joint dislocations. This review focused on articles published between 1980 and 2013.
The clinician should weigh the benefits and risks of on-field reduction based on their knowledge of the injury and the presence of associated injuries.
When properly evaluated and diagnosed, most sports-related dislocations can be reduced and initially managed at the game.
Altering the weight of baseballs for youth play has been studied out of concern for player safety. Research has shown that decreasing the weight of baseballs may limit the severity of both chronic arm and collision injuries. Unfortunately, reducing the weight of the ball also increases its exit velocity, leaving pitchers and nonpitchers with less time to defend themselves. The purpose of this study was to examine impact probability for pitchers and nonpitchers.
Reducing the available time to respond by 10% (expected from reducing ball weight from 142 g to 113 g) would increase impact probability for pitchers and nonpitchers, and players’ mean simple response time would be a primary predictor of impact probability for all participants.
Nineteen subjects between the ages of 9 and 13 years performed 3 experiments in a controlled laboratory setting: a simple response time test, an avoidance response time test, and a pitching response time test.
Each subject performed these tests in order. The simple reaction time test tested the subjects’ mean simple response time, the avoidance reaction time test tested the subjects’ ability to avoid a simulated batted ball as a fielder, and the pitching reaction time test tested the subjects’ ability to avoid a simulated batted ball as a pitcher.
Reducing the weight of a standard baseball from 142 g to 113 g led to a less than 5% increase in impact probability for nonpitchers. However, the results indicate that the impact probability for pitchers could increase by more than 25%.
Pitching may greatly increase the amount of time needed to react and defend oneself from a batted ball.
Impact injuries to youth baseball players may increase if a 113-g ball is used.
Knee injury among young, active female patients remains a public health issue. Clinicians are called upon to pay greater attention to patient-oriented outcomes to evaluate the impact of these injuries. Little agreement exists on which outcome measures are best, and clinicians cite several barriers to their use. Single Assessment Numerical Evaluation (SANE) may provide meaningful outcome information while lessening the time burden associated with other patient-oriented measures.
The SANE and International Knee Documentation Committee (IKDC) scores would be strongly correlated in a cohort of young active female patients with knee injuries from preinjury through 1-year follow-up and that a minimal clinically important difference (MCID) could be calculated for the SANE score.
Observational prospective cohort.
Two hundred sixty-three subjects completed SANE and IKDC at preinjury by recall, time of injury, and 3, 6, and 12 months postinjury. Pearson correlation coefficients were used to assess the association between SANE and IKDC. Repeated-measures analysis of variance was used to determine differences in SANE and IKDC over time. MCID was calculated for SANE using IKDC MCID as an anchor.
Moderate to strong correlations were seen between SANE and IKDC (0.65-0.83). SANE, on average, was 2.7 (95% confidence interval, 1.5-3.9; P < 0.00) units greater than IKDC over all time points. MCID for the SANE was calculated as 7 for a 6-month follow-up and 19 for a 12-month follow-up.
SANE scores were moderately to strongly correlated to IKDC scores across all time points. Reported MCID values for the SANE should be utilized to measure meaningful changes over time for young, active female patients with knee injuries.
Providing clinicians with patient-oriented outcome measures that can be obtained with little clinician and patient burden may allow for greater acceptance and use of outcome measures in clinical settings.
The female athlete triad is the interrelatedness of energy availability, menstrual function, and bone density. Currently, limited information about triad components and their relationship to musculoskeletal injury in the high school population exists. In addition, no study has specifically examined triad components and injury rate in high school oral contraceptive pill (OCP) users.
To compare the prevalence of disordered eating (DE), menstrual irregularity (MI), and musculoskeletal injury (INJ) among high school female athletes in OCP users and non-OCP users.
Retrospective cohort study of 291 high school female athletes competing on 33 interscholastic high school teams.
The subject sample completed the Eating Disorder Examination-Questionnaire (EDE-Q) and Healthy Wisconsin High School Female Athletes Survey (HWHSFAS). Athletes were classified by OCP use and sport type.
Of the participants, 14.8% reported OCP use. There was no difference in MI and INJ among groups. The prevalence of DE was significantly higher among OCP users as compared with non-OCP users; OCP users were twice as likely to meet the criteria for DE (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.20-5.09). OCP users were over 5 times more likely to have a global score that met criteria for DE as compared with non-OCP users (OR, 5.36; 95% CI, 1.92-14.89).
Although MI and INJ rates are similar among groups, there is a higher prevalence of DE among high school female athletes using OCPs as compared with non-OCP users.
Because OCP users may be menstruating, clinicians may fail to recognize the other triad components. However, DE exists in the menstruating OCP user. As such, clinicians should be vigilant when screening for triad components in high school OCP users, particularly DE.
Field expedient screening tools that can identify individuals at an elevated risk for injury are needed to minimize time loss in American football players. Previous research has suggested that poor dynamic balance may be associated with an elevated risk for injury in athletes; however, this has yet to be examined in college football players.
To determine if dynamic balance deficits are associated with an elevated risk of injury in collegiate football players. It was hypothesized that football players with lower performance and increased asymmetry in dynamic balance would be at an elevated risk for sustaining a noncontact lower extremity injury.
Prospective cohort study.
Fifty-nine collegiate American football players volunteered for this study. Demographic information, injury history, and dynamic balance testing performance were collected, and noncontact lower extremity injuries were recorded over the course of the season. Receiver operator characteristic curves were calculated based on performance on the Star Excursion Balance Test (SEBT), including composite score and asymmetry, to determine the population-specific risk cut-off point. Relative risk was then calculated based on these variables, as well as previous injury.
A cut-off point of 89.6% composite score on the SEBT optimized the sensitivity (100%) and specificity (71.7%). A college football player who scored below 89.6% was 3.5 times more likely to get injured.
Poor performance on the SEBT may be related to an increased risk for sustaining a noncontact lower extremity injury over the course of a competitive American football season.
College football players should be screened preseason using the SEBT to identify those at an elevated risk for injury based upon dynamic balance performance to implement injury mitigation strategies to this specific subgroup of athletes.
A healthy adolescent male soccer player sustained a radiograph-negative, effusion-negative physeal injury of the proximal tibia from a ground-level fall with traumatic occlusion of the popliteal artery. Orthopaedic evaluation and arteriography were delayed for 72 hours after the injury. He arrived at a tertiary referral center in multisystem organ failure secondary to lower extremity ischemic necrosis, septic pulmonary thromboembolism, and systemic shock. Emergent medical evaluation, a high index of suspicion, and a careful neurovascular examination are imperative after every closed knee injury in the young athlete.
Femoroacetabular impingement (FAI) alters hip mechanics, results in hip pain, and may lead to secondary osteoarthritis (OA) in the maturing athlete. Hip impingement can be caused by osseous abnormalities in the proximal femur or acetabulum. These impingement lesions may cause altered loads within the hip joint, which result in repetitive collision damage or sheer forces to the chondral surfaces and acetabular labrum. These anatomic lesions and resultant abnormal mechanics may lead to early osteoarthritic changes.
Relevant articles from the years 1995 to 2013 were identified using MEDLINE, EMBASE, and the bibliographies of reviewed publications.
Improvements in hip arthroscopy have allowed FAI to be addressed utilizing the arthroscope. Adequately resecting the underlying osseous abnormalities is essential to improving hip symptomatology and preventing further chondral damage. Additionally, preserving the labrum by repairing the damaged tissue and restoring the suction seal may theoretically help normalize hip mechanics and prevent further arthritic changes. The outcomes of joint-preserving treatment options may be varied in the maturing athlete due to the degree of underlying OA. Irreversible damage to the hip joint may have already occurred in patients with moderate to advanced OA. In the presence of preexisting arthritis, these patients may only experience fair or even poor results after hip arthroscopy, with early conversion to hip replacement. For patients with advanced hip arthritis, total hip arthroplasty remains a treatment option to reliably improve symptoms with good to excellent outcomes and return to low-impact activities.
Advances in the knowledge base and treatment techniques of intra-articular hip pain have allowed surgeons to address this complex clinical problem with promising outcomes. Traditionally, open surgical dislocations for hip preservation surgery have shown good long-term results. Improvements in hip arthroscopy have led to outcomes equivalent to open surgery while utilizing significantly less invasive techniques. However, outcomes may ultimately depend on the degree of underlying OA. When counseling the mature athlete with hip pain, an understanding of the underlying anatomy, degree of arthritis, and expectations will help guide the treating surgeon in offering appropriate treatment options.
This report presents 2 cases of subtle injuries to the subtalar joint, specifically, osteochondral defects of the middle facet of the talus and concomitant involvement of the middle talocalcaneal articulation sustained while snowboarding. The 3T magnetic resonance image revealed fracture of the lateral talar process with osteochondral lesions of the middle talocalcaneal articulation. This injury can lead to severe and chronic disability if undetected and could ultimately end athletic participation prematurely.
This case study describes a Major League Baseball player who was diagnosed with an axillary artery thrombosis due to arterial compression from throwing. The purpose of this article is to create awareness as to the signs and symptoms associated with arterial positional compression and the rehabilitative implications to surgical intervention.
Anterior cruciate ligament (ACL) rupture is a significant injury in National Basketball Association (NBA) players.
NBA players undergoing ACL reconstruction (ACLR) have high rates of return to sport (RTS), with RTS the season following surgery, no difference in performance between pre- and postsurgery, and no difference in RTS rate or performance between cases (ACLR) and controls (no ACL tear).
Case-control.
NBA players undergoing ACLR were evaluated. Matched controls for age, body mass index (BMI), position, and NBA experience were selected during the same years as those undergoing ACLR. RTS and performance were compared between cases and controls. Paired-sample Student t tests, chi-square, and linear regression analyses were performed for comparison of within- and between-group variables.
Fifty-eight NBA players underwent ACLR while in the NBA. Mean player age was 25.7 ± 3.5 years. Forty percent of ACL tears occurred in the fourth quarter. Fifty players (86%) RTS in the NBA, and 7 players (12%) RTS in the International Basketball Federation (FIBA) or D-league. Ninety-eight percent of players RTS in the NBA the season following ACLR (11.6 ± 4.1 months from injury). Two players (3.1%) required revision ACLR. Career length following ACLR was 4.3 ± 3.4 years. Performance upon RTS following surgery declined significantly (P < 0.05) regarding games per season; minutes, points, and rebounds per game; and field goal percentage. However, following the index year, controls’ performances declined significantly in games per season; points, rebounds, assists, blocks, and steals per game; and field goal and free throw percentage. Other than games per season, there was no significant difference between cases and controls.
There is a high RTS rate in the NBA following ACLR. Nearly all players RTS the season following surgery. Performance significantly declined from preinjury level; however, this was not significantly different from controls. ACL re-tear rate was low.
There is a high RTS rate in the NBA after ACLR, with no difference in performance upon RTS compared with controls.
An era of increased awareness of sports concussions may decrease a provider’s ability to diagnose the athlete’s actual condition and may ultimately prolong the restriction of the injured athlete from sports. Trauma-triggered migraine is a source of headaches, especially in athletes with a family history of migraines.
Research articles were primarily obtained through the electronic database PubMed from 1993 to August 2012. Primary research parameters included trauma-induced headaches, trauma-induced migraines, and posttraumatic migraine. The secondary search parameters included concussions, migraine treatments, and traumatic migraine treatments.
There are no symptoms that distinguish trauma-triggered migraines from concussions, as headache is the most common complaint for both conditions. There is a paucity of studies that offer treatment guidelines for athletes with recurring headaches after trauma sustained during sporting events. Preventive treatment of migraines has been validated and proven effective.
Trauma-triggered migraine should be considered in the differential for recurrent trauma-induced headaches. There is a lack of research evaluating efficacy and side effects of treatment of trauma-triggered migraine, and no information was found directing when an athlete can safely return to play.
Anterior cruciate ligament (ACL) reconstruction is a safe, common, and effective method of restoring stability to the knee after injury, but evolving techniques of reconstruction carry inherent risk. Infection after ACL reconstruction, while rare, carries a high morbidity, potentially resulting in a poor clinical outcome.
Data were obtained from previously published peer-reviewed literature through a search of the entire PubMed database (up to December 2012) as well as from textbook chapters.
Treatment with culture-specific antibiotics and debridement with graft retention is recommended as initial treatment, but with persistent infection, consideration should be given to graft removal. Graft type likely has no effect on infection rates.
The early diagnosis of infection and appropriate treatment are necessary to avoid the complications of articular cartilage damage and arthrofibrosis.
The current study explored the relationship between fighting behavior and passage of time, across games and seasons, in an attempt to assess if violent behavior in hockey is impulsive or intentional.
Before engaging in fighting behavior, players assess the utility of their actions and thus will fight less when the game is on the line (third period) and when champions are crowned (postseason).
An archival exploration utilizing open access databases from multiple Internet sources.
During the 2010-2011 National Hockey League (NHL) season, players were significantly less likely to be involved in a fight as the game was coming to a close than in its early stages. In addition, data from the past 10 NHL seasons showed that players were significantly more violent in preseason games than during the regular season. They were also least likely to be involved in a fight during the postseason.
The converging evidence suggests that players take into account the penalties associated with fighting and are less likely to engage in violence when the stakes are high, such as at the end of a game or a season. This implies, in turn, that major acts of aggression in the league are more likely to be calculated rather than impulsive. The findings suggest that a more punitive system should diminish fighting behavior markedly.
There has been increased interest in the number of concussions occurring in college football over the past year. In April 2010, the National Collegiate Athletic Association (NCAA) published new guidelines for the diagnosis and treatment of concussions in student athletes.
To determine the number of concussions that occurred on 3 collegiate Division I military academy football teams prior to and following recent changes in the NCAA concussion management policy.
Descriptive epidemiology study.
Injury reports were reviewed from 3 Division I military academy football teams. The number of concussions that occurred over the 2009-2010 and 2010-2011 seasons, including those sustained in practice and game situations, was determined for each team. Incidence rates were compared using the exact binomial method.
The combined concussion incidence rate doubled from 0.57 per 1000 athlete exposures in the 2009-2010 season to 1.16 per 1000 athlete exposures in the 2010-2011 season (incidence rate ratio, 2.04; 95% CI, 1.2-3.55; P = 0.01). The combined numbers of concussions for the 2009-2010 and 2010-2011 seasons were 23 (40,481 exposures) and 42 (36,228), respectively.
The combined incidence rate of concussions for the 2010-2011 season doubled from the previous season after the implementation of new NCAA policies on concussion management. While the institution of a more formalized concussion plan on the part of medical staff is one possible factor, another may have been the increased recognition and reporting on the part of players and coaches after the rule change.
Ankle injuries are the most common high school basketball injury. Little is known regarding the utilization of ankle injury prevention strategies in high school settings.
To determine high school basketball coaches’ utilization of ankle injury prevention strategies, including prophylactic ankle bracing (PAB) or an ankle injury prevention exercise program (AIEPP).
Cross-sectional survey.
The survey was distributed to all high school basketball coaches in Wisconsin. Fisher exact and Wilcoxon rank sum tests were used to determine if the injury prevention strategies utilized differed according to school size, sex of the team, years of coaching experience, and the coach’s education level.
Four hundred eighty (55%) coaches from 299 (74%) high schools completed the survey. Thirty-seven percent of the coaches encouraged or required their players to use PAB. School enrollment of the coaches’ teams did not affect their stance on the use of PAB (P = 0.30), neither did the sex of the team (P = 0.16), years coaching (P = 0.09), nor the coach’s education (P = 0.49). Fifty percent (n = 242) of the coaches indicated they do not utilize an AIEPP, with no difference based on school enrollment (P = 0.47), team sex (P = 0.41), years coaching (P = 0.78), or the education level (P = 0.44). Barriers to utilization of AIEPP included a lack of time, awareness, and expertise. Coaches preferred an AIEPP that was specific to basketball, combined injury prevention and performance enhancement components, was performed 2 to 3 days per week, and lasted 5 to 15 minutes.
Less than half of the coaches encouraged use of PAB, and half did not utilize an AIEPP. Coaches had specific preferences for the type of AIEPP they would implement.
Sports medicine providers should promote ankle injury prevention strategies but need to address why prevention strategies may not be utilized in high school basketball settings.
Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings.
Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete.
Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving.
A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient.
Attention deficit hyperactivity disorder (ADHD) is common in the general population, and many individuals with this condition participate in sports activity at all competition levels.
Related studies were selected through literature searches of PubMed, MEDLINE, and Cochrane databases for the years 1991 to 2011. Key search terms were ADD, ADHD, sports, athletes, athletics, guidelines, NCAA, WADA, IOC, college, concussion, diagnosis, management, treatment, evaluation, return-to-play, pharmacotherapy, adult, adolescent, student, screening, injury, risk, neuropsychiatry, TBI, traumatic brain injury, and epidemiology.
ADHD usually has an early onset, with delayed diagnosis in some patients due to heterogeneous presentations. Suspected cases can be evaluated with available diagnostic tools and confirmed clinically. Athletes with ADHD may participate at all competition levels.
Athletes with ADHD are able to participate at all competition levels by following published guidelines and requirements. Exercise benefits many athletes with ADHD. The relationship between ADHD and concussion syndromes is currently under investigation.
Orofacial and dental trauma continues to be a commonly encountered issue for the sports medicine team. All sports have some risk for dental injury, but "contact sports" presumably incur more risk. Immediate evaluation and proper management of the most common injuries to dentition can result in saving or restoration of tooth structure. Despite the growing body of evidence, mouth guard use and dental protection have not paralleled the increase in sports participation.
A PubMed search from 1960 through April 2012 was conducted, as well as a review of peer-reviewed online publications.
Common dental injuries in sports include tooth (crown) fractures; tooth intrusion, extrusion, and avulsion; and temporomandibular joint dislocation. Mouth guards help prevent most injuries and do not significantly affect ventilation or speech if fitted properly.
A working knowledge of the presentation as well as management of commonly encountered dental trauma in sports is essential to the immediate care of an athlete and returning to play. Mouth guard use should be encouraged for athletes of all ages in those sports that incur significant risk.
Aging changes the biology, healing capacity, and biomechanical function of tendons and ligaments and results in common clinical pathologies that present to orthopedic surgeons, primary care physicians, physical therapists, and athletic trainers. A better understanding of the age-related changes in these connective tissues will allow better patient care.
The PubMed database was searched in December 2012 for English-language articles pertaining to age-related changes in tendons and ligaments.
The mature athlete faces challenges associated with age-dependent changes in the rotator cuff, Achilles tendon, lateral humeral epicondylar tendons, quadriceps tendon, and patellar tendon. The anterior cruciate ligament and the medial collateral ligament are the most studied intra-articular and extra-articular ligaments, and both are associated with age-dependent changes.
Tendons and ligaments are highly arranged connective tissue structures that maintain joint motion and joint stability. These structures are subject to vascular and compositional changes with increasing age that alter their mechanotransduction, biology, healing capacity, and biomechanical function. Emerging research into the etiology of age-dependent changes will provide further information to help combat the age-related clinical complications associated with the injuries that occur to tendons and ligaments.
Sudden cardiac death (SCD) events are tragic. Secondary prevention of SCD depends on availability of automated external defibrillators (AEDs). High school athletes represent a high-risk group for SCD, and current efforts aim to place AEDs in all high schools.
The prevalence of AEDs and emergency planning for sudden cardiac arrest (SCA) in Vermont high schools is similar to other states. Understanding specific needs and limitations in rural states may prevent SCD in rural high schools.
Cross-sectional survey.
A survey was distributed to all 74 Vermont high school athletic directors. Outcome measures included AED prevalence, AED location, individuals trained in cardiopulmonary resuscitation (CPR) and AED utilization, funding methods for AED attainment, and the establishment of an emergency action plan (EAP) for response to SCA.
All schools (100%, 74 of 74) completed the survey. Of those, 60 (81%) schools have at least 1 AED on school premises, with the most common location for AED placement being the main office or lobby (50%). Larger sized schools were more likely to have an AED on the premises than smaller sized schools (P = 0.00). School nurses (77%) were the most likely individuals to receive formal AED training. Forty-one schools (55%) had an EAP in place for response to SCA, and 71% of schools coordinated AED placement with local emergency medical services (EMS) responders.
In Vermont, more than two-thirds of high schools have at least 1 AED on school premises. However, significant improvement in the establishment of EAPs for SCA and training in CPR and AED utilization is essential given the rural demography of the state of Vermont.
Rural high schools inherently have longer EMS response times. In addition to obtaining AEDs, high schools must develop a public access to defibrillation program to maximize the chance of survival following cardiac arrest, especially in rural settings.
The past 2 decades have shown a dramatic increase in the number of pelvic and hip injuries in female athletes. Accurate diagnosis of hip pain in active women has proven to be a challenge, as there is an extensive differential including both musculoskeletal and visceral problems. While the incidence of pelvic congestion syndrome (PCS) is not known, this condition may manifest as chronic hip pain in this patient population.
A PubMed search was undertaken for articles published in English from 1980 to 2012. Additional references were accrued from reference lists of research articles.
Diagnosis was established using magnetic resonance imaging. Both women were evaluated and treated by interventional radiology with gonadal vein embolization. Initial evaluation and subsequent follow-up was completed in the Sports Medicine Clinic to monitor chronic hip pain symptoms. Both patients experienced significant alleviation of chronic hip pain symptoms within several months after gonadal vein embolization, allowing for a return to the previous level of activity.
Although PCS most commonly presents as pelvic pain, it is important to consider this condition in athletes with persistent hip pain. PCS may also present with the primary symptom of hip pain as in the 2 case reports described. With more awareness of this condition and appropriate diagnosis, PCS as an unusual etiology of chronic hip pain may be effectively treated with gonadal vein embolization.
Enhancing core stability through exercise is common to musculoskeletal injury prevention programs. Definitive evidence demonstrating an association between core instability and injury is lacking; however, multifaceted prevention programs including core stabilization exercises appear to be effective at reducing lower extremity injury rates.
PubMed was searched for epidemiologic, biomechanic, and clinical studies of core stability for injury prevention (keywords: "core OR trunk" AND "training OR prevention OR exercise OR rehabilitation" AND "risk OR prevalence") published between January 1980 and October 2012. Articles with relevance to core stability risk factors, assessment, and training were reviewed. Relevant sources from articles were also retrieved and reviewed.
Stabilizer, mobilizer, and load transfer core muscles assist in understanding injury risk, assessing core muscle function, and developing injury prevention programs. Moderate evidence of alterations in core muscle recruitment and injury risk exists. Assessment tools to identify deficits in volitional muscle contraction, isometric muscle endurance, stabilization, and movement patterns are available. Exercise programs to improve core stability should focus on muscle activation, neuromuscular control, static stabilization, and dynamic stability.
Core stabilization relies on instantaneous integration among passive, active, and neural control subsystems. Core muscles are often categorized functionally on the basis of stabilizing or mobilizing roles. Neuromuscular control is critical in coordinating this complex system for dynamic stabilization. Comprehensive assessment and training require a multifaceted approach to address core muscle strength, endurance, and recruitment requirements for functional demands associated with daily activities, exercise, and sport.
Cutaneous infections are common in wrestlers. Although many are simply a nuisance in the everyday population, they can be problematic to wrestlers because such infections may result in disqualification from practice or competition. Prompt diagnosis and treatment are therefore important.
Medline and PubMed databases, the Cochrane Database of Systematic Reviews, and UpToDate were searched through 2012 with the following keywords in various combinations: skin infections, cutaneous infections, wrestlers, athletes, methicillin-resistant Staphylococcus aureus, skin and soft tissue infections, tinea corporis, tinea capitis, herpes simplex, varicella zoster, molluscum contagiosum, verruca vulgaris, warts, scabies, and pediculosis. Relevant articles found in the primary search, and selected references from those articles were reviewed for pertinent clinical information.
The most commonly reported cutaneous infections in wrestlers are herpes simplex virus infections (herpes gladiatorum), bacterial skin and soft tissue infections, and dermatophyte infections (tinea gladiatorum). The clinical appearance of these infections can be different in wrestlers than in the community at large.
For most cutaneous infections, diagnosis and management options in wrestlers are similar to those in the community at large. With atypical presentations, testing methods are recommended to confirm the diagnosis of herpes gladiatorum and tinea gladiatorum. There is evidence to support the use of prophylactic medications to prevent recurrence of herpes simplex virus and reduce the incidence of dermatophyte infections in wrestlers.
Despite the crucial role of referees in a soccer match, few researchers have targeted the injury profile of referees in their studies. Understanding the incidence, nature, and pattern of injuries could provide important information for educational and preventative efforts at the international level.
The incidence rate and patterns of acute injuries to official referees of the Iranian Premier Football League during the 2009-2010 season are similar to those reported among referees in short-term international competitions such as FIFA World Cup.
Prospective cohort study.
Demographic data for 74 referees, including 30 main referees and 44 assistant referees, were collected at the beginning of the season. To record injuries and refereeing time, weekly contact was made by a physician.
In total, 102 injuries were reported by referees during the football season. The incidence rates of injuries among referees during training and matches were 4.6 and 19.6 injuries per 1000 hours, respectively. Muscular and tendon injuries were found to be the most common type of injury, and the most common site of injury was the lower leg followed by the hip and groin.
The results of this study are consistent with similar prospective studies evaluating injuries to referees over the course of a short-term tournament.
These findings provide a base for suggesting possible preventive recommendations in future studies.
There are significant data comparing elite and nonelite athletes in anaerobic field and court sports as well as endurance sports. This review delineates specific performance characteristics in the elite athlete and may help guide rehabilitation.
A Medline search from April 1982 to April 2012 was undertaken for articles written in English. Additional references were accrued from reference lists of research articles.
In the anaerobic athlete, maximal power production was consistently correlated to elite performance. Elite performance in the endurance athlete is more ambiguous, however, and appears to be related to the dependent variable investigated in each individual study.
In anaerobic field and court sport athletes, maximal power output is most predictive of elite performance. In the endurance athlete, however, it is not as clear. Elite endurance athletes consistently test higher than nonelite athletes in running economy, anaerobic threshold, and VO2max.
Doping has been pervasive throughout the history of athletic competitions and has only recently been regulated by organizations such as the World Anti-Doping Agency (WADA), US Anti-Doping Agency (USADA), and the National Collegiate Athletic Association (NCAA). These regulatory bodies were created to preserve fair play and maintain the safety of the participants. Their updated 2013 lists of banned substances and practices include a variety of drugs and practices that could cause harm to an athlete or give one an unfair competitive advantage.
Published websites for the WADA, USADA, and NCAA were investigated. These governing bodies update and publish their lists annually.
The WADA, USADA, and NCAA monitor anabolic steroids, hormones, growth factors, β-agonists, hormone and metabolic modulators, masking agents, street drugs, manipulation of blood and blood components, chemical and physical manipulation, gene doping, stimulants, narcotics, glucocorticosteroids, and β-blockers. Some substances may be used by athletes but require formal exemption. The WADA has also recently created a category of nonapproved substances that have yet to be identified to curb athletes from experimenting with new doping agents.
The lists of banned substances and practices per the WADA, USADA, and NCAA are in place to ensure the integrity of sports and maintain safe competition. Health care providers who work with athletes under the jurisdiction of these organizations should review updated lists of banned substances when prescribing medications.
Over 33 chronic disease states and health disorders, including obesity and type 2 diabetes, are grouped into what is known as sedentary death syndrome. All these conditions are positively affected by 30 minutes of brisk exercise daily. In addition, only 30% of aging is based on genetics, with 70% on lifestyle. Therefore, a large majority of aging is controlled by individual health behaviors. Exercise is a powerful tool for healthy aging of the body and the mind. Courses of short- and long-term exercise provide benefits to musculoskeletal and cardiovascular health and can prevent age-related brain structural and functional losses. This review examines the evidence in support of mobility as an inexpensive and effective protective factor in maintaining brain health and preventing cognitive decline in aging adults.
A PubMed search was performed for articles in English from 1990 to 2012. Reference lists were also reviewed and relevant articles obtained.
Evidence suggests that maintaining a high level of cardiopulmonary fitness and mobility exhibits protective effects on structural changes that occur with aging in areas of the brain associated with memory, attention, and task completion. Chronic exercise is also associated with preservation of overall cognitive functioning and prevention of dementia.
In combination with other preventative measures, physical mobility can assist in preventing or slowing cognitive decline in aging adults.
The minimal repair technique for sports hernias repairs only the weak area of the posterior abdominal wall along with decompressing the genitofemoral nerve. This technique has been shown to return athletes to competition rapidly. This study compares the clinical outcomes of the minimal repair technique with the traditional modified Bassini repair.
Athletes undergoing the minimal repair technique for a sports hernia would return to play more rapidly compared with athletes undergoing the traditional modified Bassini repair.
A retrospective study of 28 patients who underwent sports hernia repair at the authors’ institution was performed. Fourteen patients underwent the modified Bassini repair, and a second group of 14 patients underwent the minimal repair technique. The 2 groups were compared with respect to time to return to sport, return to original level of competition, and clinical outcomes.
Patients in the minimal repair group returned to sports at a median of 5.6 weeks (range, 4-8 weeks), which was significantly faster compared with the modified Bassini repair group, with a median return of 25.8 weeks (range, 4-112 weeks; P = 0.002). Thirteen of 14 patients in the minimal repair group returned to sports at their previous level, while 9 of 14 patients in the Bassini group were able to return to their previous level of sport (P = 0.01). Two patients in each group had recurrent groin pain. One patient in the minimal repair group underwent revision hernia surgery for recurrent pain, while 1 patient in the Bassini group underwent hip arthroscopy for symptomatic hip pain.
The minimal repair technique allows athletes with sports hernias to return to play faster than patients treated with the modified Bassini.
Currently, no consensus exists for grading the severity of concussions. Identification of risk factors that may affect concussion risk and the likelihood of prolonged recovery can be of value to providers who manage concussion.
Relevant studies were identified through MEDLINE (1996-2011) using the keywords concussion, postconcussive syndrome, and risk or risk factor. Targeted searches for specific risk factors were conducted with additional keywords, such as gender and migraine. Manual review of reference lists was also performed to identify pertinent literature.
For risk factors of concussion, history of prior concussion and female sex have the most supporting evidence. Sports with consistently high risk for sustaining a concussion include football, men’s ice hockey, and women’s soccer. Younger athletes appear to be more susceptible to concussion, but data are limited and inconsistent. Protective equipment does not definitively alter concussion risk, though it protects against other injuries. Symptoms such as long headaches, migraines, amnesia, and multiple symptoms appear to be associated with prolonged recovery. Younger age may also increase the risk of prolonged concussion.
High-quality evidence for risk modifiers in concussion remains sparse. Prior concussion, collision sports, female sex, and women’s soccer are the strongest known risk factors. Evidence for most other factors is inconclusive.
Achilles tendon (AT) rupture in athletes is increasing in incidence and accounts for one of the most devastating sports injuries because of the threat to alter or end a career. Despite the magnitude of this injury, reliable risk assessment has not been clearly defined, and prevention strategies have been limited. The purpose of this review is to identify potential intrinsic and extrinsic risk factors for AT rupture in aerial and ground athletes stated in the current literature.
A MEDLINE search was conducted on AT rupture, or "injury" and "risk factors" and "athletes" from 1980 to 2011. Emphasis was placed on epidemiology, etiology, and review articles focusing on the risk for lower extremity injury in runners and gymnasts. Thirty articles were reviewed, and 22 were included in this assessment.
Aerial and ground athletes share many intrinsic risk factors for AT rupture, including overuse and degeneration of the tendon as well as anatomical variations that mechanically put an athlete at risk. Older athletes, athletes atypical in size for their sport, high tensile loads, leg dominance, and fatigue also may increase risk. Aerial athletes tend to have more extrinsic factors that play a role in this injury due to the varying landing surfaces from heights and technical maneuvers performed at various skill levels.
Risk assessment for AT rupture in aerial and ground athletes is multivariable and difficult in terms of developing prevention strategies. Quantitative measures of individual risk factors may help identify major contributors to injury.
Shoulder instability is a common problem in American football players entering the National Football League (NFL). Treatment options include nonoperative and surgical stabilization.
This study evaluated how the method of treatment of pre-NFL shoulder instability affects the rate of recurrence and the time elapsed until recurrence in players on 1 NFL team.
Retrospective cohort.
Medical records from 1980 to 2008 for 1 NFL team were reviewed. There were 328 players included in the study who started their career on the team and remained on the team for at least 2 years (mean, 3.9 years; range, 2-14 years). The history of instability prior to entering the NFL and the method of treatment were collected. Data on the occurrence of instability while in the NFL were recorded to determine the rate and timing of recurrence.
Thirty-one players (9.5%) had a history of instability prior to entering the NFL. Of the 297 players with no history of instability, 39 (13.1%) had a primary event at a mean of 18.4 ± 22.2 months (range, 0-102 months) after joining the team. In the group of players with prior instability treated with surgical stabilization, there was no statistical difference in the rate of recurrence (10.5%) or the timing to the instability episode (mean, 26 months) compared with players with no history of instability. Twelve players had shoulder instability treated nonoperatively prior to the NFL. Five of these players (41.7%) had recurrent instability at a mean of 4.4 ± 7.0 months (range, 0-16 months). The patients treated nonoperatively had a significantly higher rate of recurrence (P = 0.02) and an earlier time of recurrence (P = 0.04). The rate of contralateral instability was 25.8%, occurring at a mean of 8.6 months.
Recurrent shoulder instability is more common in NFL players with a history of nonoperative treatment. Surgical stabilization appears to restore the rate and timing of instability to that of players with no prior history of instability.
Context: Intramuscular hemangiomas are common in the general population and often present at medical and surgical clinics. Unfortunately, unfamiliarity with these lesions has led to a high percentage of misdiagnoses, inappropriate workup, and unnecessary referrals.
Evidence Acquisition: A literature search was performed using Medline, Embase, PubMed, and Cochrane. The relevant articles and referenced sources were reviewed for additional articles that discussed the epidemiology, pathophysiology, investigation, and management of intramuscular hemangiomas. Clinical experience from experts in orthopaedics, musculoskeletal pathology, and musculoskeletal radiology was compared. The selected case studies are shared cases of the authors.
Results and Conclusion: The pathophysiology of these lesions is not completely understood, but much can be implied from their underlying vascular nature. Isolated lesions are benign tumors that never metastasize but tend to enlarge and then involute over time. Magnetic resonance imaging is the imaging modality of choice. If a systemic disorder or malignancy is not suspected or has been ruled out, conservative management is the treatment of choice for most intramuscular hemangiomas.