Pediatric Sports Medicine Research Articles

Effect of Menstrual Dysfunction in Adolescent Concussion Patients on Length of Time to Recovery and Symptom Burden

Background:Concussions are one of the most common sport-related-injuries seen in the adolescent population. It is well known that female athletes are at higher risk for concussion, but factors that influence this risk, including hormonal influences, are not entirely known. There is no literature to date that explores the relationship between menstrual dysfunction (MD) and outcome measures of concussion.Hypothesis/Purpose:Our primary purpose is to determine if MD predicts prolonged recovery from concussion and our secondary purpose is to determine if MD predicts a higher initial symptom burden.Methods:Patients who presented to a pediatric sports medicine concussion clinic for an initial visit, were ≤18 years-old, and were at least 2 years post-menarchal were included in the study. Those who reported taking any hormonal medications, were pregnant, or who suffered symptoms greater than 180 days were excluded. Subjects who were >15 years old at menarche, experienced <10 menstrual periods per year or >35 days between cycles were categorized as having MD. Two linear regressions were analyzed to determine differences in initial symptom score and time to recovery between those with and without MD while controlling for age, history of headaches, and history of prior concussions.Results:A total of 801 participants were included in the study (697 controls and 108 MD patients). There was no statistically significant difference in time to recovery between the groups (p=0.12). However, MD patients took 5 days longer to recover than controls (51.23 vs. 46.42 days). There was no statistical difference in initial symptom score between the MD and control groups (p=0.67, 56.04 for controls and 58.47 for MD).Conclusion:No statistically significant differences were found in time to recovery after concussion or in initial symptom burden between subjects with MD and controls. Additional study is warranted to further characterize these relationships.

Findings from the Prism Concussion Rig: Does the 5P Risk Score Predict Persistent Postconcussive Symptoms in a Multi-Center Sample of Youth Athletes?

Background:Persistent postconcussive symptoms (PPCS) can negatively impact quality of life, school, and return to sport. The Predicting and Preventing Postconcussive Problems in Pediatrics [5P] clinical risk score has been validated in the Emergency Department setting to predict pediatric patients at risk of PPCS using 9 variables.Hypothesis/Purpose:To determine if the 5P risk score, obtained within 14 days of concussion, predicts which athletes seen in an athletic training or pediatric sports medicine clinic setting develop PPCS in a multi-center sample.Methods:Data were prospectively collected from participants enrolled in the Sport Concussion Outcomes in Pediatrics (SCOPE) study between September 2018-May 2021 across seven sites. Participants aged 6-18 years diagnosed with a concussion who presented within 14 days of injury were included. Demographics, medical history, and the Postconcussion Symptom Inventory (PCSI) were reviewed to calculate the 5P risk score. 5P risk scores were stratified as low (0-3 points), medium (4-8 points), and high risk (9-12 points). Participants were grouped based on symptom resolution time: PPCS (≥28 days) and no PPCS (<28 days). We compared total symptom resolution time among the 5P risk categories using one-way ANOVA and assessed the odds of developing PPCS based on 5P risk score using a binary logistic regression model.Results:We included 117 participants: 23 with PPCS (19.7%). A higher proportion of the PPCS group were female, were seen in a sports medicine clinic setting, and had a longer time to initial presentation (Table 1). Both PCSI symptom severity and 5P risk score were significantly higher in the PPCS group compared to the no PPCS group (p<0.001). Participants with high risk 5P scores had a significantly longer mean symptom resolution time compared to those with low risk scores (Figure 1; 28.4±18.2 vs 7.1±6.8 days, p=0.009). After adjusting for potential confounding variables of initial symptom severity, time to presentation, and assessment setting, each point increase on the 5P risk score was associated with a 1.7x odds of developing PPCS (odds ratio=1.66; 95% CI=1.13, 2.41; p=0.009).Conclusion:In a multi-center sample of youth athletes, the 5P risk score accurately predicted which athletes were at risk for developing PPCS. The odds of developing PPCS increases with each point increase on the risk score. The 5P risk score can help clinicians identify which athletes are likely to develop PPCS, which may aid in educating families on expectations of recovery and/or provide opportunities for targeted intervention to facilitate sooner recovery.Table 1.5 P Variables and other Patient Characteristics Comparing PPCS and no PPCS groupsFigure 1.Symptom resolution time among the three 5P risk categories (Low: n=15; Medium: n=80; High: n=25; p=0.009)

Suture-Bridge Fixation of Osteochondrial Fractures and Osteochonritis Dissecans in the Adolescent Knee: Mir Assement of Healing

Background:Preservation of articular cartilage in the setting of adolescent knee injury is paramount for long-term joint health. Achieving osseous union, minimizing implant related injury, and eliminating need for reoperation for osteochondral fracture lesions (OCL) and osteochondritis dissecans (OCD) remain a challenge for orthopedic surgeons.Hypothesis/Purpose:To evaluate MRI appearance of osseous and chondral integration following suture bridge construct. Secondarily, to assess short-term complications and outcomes of suture bridge fixation of OCL and OCD in adolescent knees.Methods:Consecutive patients (n=41) treated within a pediatric sports medicine institution who underwent suture-bridge knee fixation of an OCL or OCD from 10/2019-03/2021 were reviewed. MRI within 6 months of surgery was required. Analysis included demographics, pre-operative MRI lesion characteristics, surgical technique, suture type, Postoperative MRIs for lesion healing (Full Union: 100% cancellous/cancellous-chondral lesion continuity, Stable Union: >50% continuity with some fibrous tissue present, Un-united: < 50% continuity and extensive fibrous signal or fluid below the lesion), complications, rates and timing of return-to-sport (RTS), and short-term patient-reported outcomes (Pedi-IKDC, Pedi-FABS, KOOS Symptoms, PROMIS® ).Results:22 knees (20 patients) included 11 OCL and 10 OCD (Table 1). Lesion characteristics: OCL-mean size=248.2(140-459)mm2, mean major length=17.3(12-27)mm, osteochondral= 10(83%), all chondral= 2(17%); OCD-mean size =374.4(130-780)mm2, mean major length=19.3(10-29)mm, progeny bone present =7(70%). 91%(20/22) were treated via mini-arthrotomy, and 86%(19/22) of constructs were absorbable suture. At MRI follow up (6.7 months, 3.0-21.1), OCLs demonstrated 91.7% Full Union, 8.3% Stable Union, 0% Un-united; OCDs demonstrated 50% Full Union, 50% Stable Union, 0% Un-united. At average of 6.4 months, 19(86%) knees had RTS. Pedi-FABS demonstrated a return to similar level of activity and Pedi-IKDC indicated functional improvement in 80% on average 9.6 months post-operatively (Table 2). There were 2 (9.1%) complications (1. repeat arthroscopy for chondroplasty and marrow stimulation for 20% distal margin instability of patellar OCL secondary to patellar instability, 2. Second surgery for patellar stabilization following trochlear OCD suture-bridge in the setting of trochlear dysplasia and no stabilization at primary procedure) and no re-operations needed for suture-bridge construct.Conclusion:In this series of knee OCLs and OCDs, suture-bridge fixation demonstrates excellent rates of healing based on MRI appearance and good early outcomes with minimal short-term complications. This technique may be used by surgeons to avoid loose body removal and marrow-stimulation, and have significant benefits in comparison to metallic and non-metallic screw/tack constructs in the treatment of these challenging lesions. Longer term follow-up and investigation is warranted.Table 1.Patient Demographics and Lesion LocationTable 2.Patient Reported Outcomes

Reliability of Magnetic Resonance Imaging Interpretation of Lateral Discoid Meniscus: A Multicenter Study

Background:Lateral discoid meniscus (LDM) often present with complex morphology that can be challenging to assess and treat arthroscopically. Preoperative magnetic resonance imaging (MRI) is frequently used for diagnosis and surgical planning, however it is not known whether surgeons are reliable and consistent in their interpretation of MRI findings.Hypothesis/Purpose:We hypothesize that surgeons experienced in treating LDM are able to reliably interpret discoid pathology using MRI, with the exception of evaluating dynamic factors (i.e. instability).Methods:Forty five discoid meniscus MRI selected from a pool of surgical discoid meniscus cases were included in this review. Five reviewers (experienced pediatric sports medicine surgeons) who were not involved in the MRI selection process performed independent review of each MRI to determine discoid meniscus classification. More than 4 weeks later, a second reading was performed by 3 of the 5 reviewers. Interobserver and intraobserver reliability of the primary (width, presence of instability or tear) and secondary (location of instability or tear, tear type) rating factors was assessed using the Fleiss κ coefficient, designed for multiple readers with nominal variables (reliability: fair, 0.21–0.40; moderate, 0.41–0.60; substantial, 0.61–0.80; excellent, 0.81–1.00). Reliability is reported as κ (95% CI).Results:Interobserver reliability of assessment of meniscal width was substantial 0.67 (0.58-0.76), and intraobserver was moderate 0.52 (0.35-0.69). Assessment of presence of peripheral instability had moderate interobserver reliability 0.54 (0.45-0.63) and substantial intraobserver 0.61 (0.44-0.78). Presence of tear had fair interobserver reliability 0.39 (0.29–0.48) and substantial intraobserver 0.68 (0.51-0.85). When identifying location of instability or tear, interobserver reliability was moderate while intraobserver agreement was substantial for assessment of anterior instability (0.47 (0.37-0.56) and 0.68 (0.51-0.85), respectively); posterior instability (0.56 (0.47-0.65) and 0.62 (0.45-0.79), respectively); and posterior tear (0.41 (0.32-0.50) and 0.69 (0.52-0.86), respectively). The exception was identifying anterior tear, with fair interobserver reliability 0.33 (0.23-0.42) and moderate intraobserver 0.56 (0.39-0.73); Interobserver reliability was fair for tear type 0.34 (0.28-0.41) and intraobserver reliability moderate 0.55 (0.43-0.67).Conclusion:Orthopaedic surgeons experienced in the treatment of LDM vary from each other in their classification using MRI, especially with regard to assessment of meniscus tears. MRI evaluation may be helpful to diagnose discoid by width and identify presence of instability, two major factors in the decision to proceed with surgery. However, definitive treatment should be guided by a comprehensive arthroscopic evaluation.

Relationship Between Ankle Dorsiflexion Mobility and Functional Return to Sport Test Performance in Athletes Who Have Undergone ACL Reconstruction

Background:Limited ankle dorsiflexion (DF) range has been associated with knee injuries and altered biomechanics during functional squatting and landing tasks. Prior studies correlating weight-bearing DF with altered landing mechanics have primarily used advanced motion capture technology, with limited research using clinically validated scoring tools.Hypothesis/Purpose:To assess the relationship between decreased DF and functional testing performance in youth athletes who have undergone anterior cruciate ligament reconstruction (ACLR).Methods:A retrospective review of standardized data was conducted on patients who had undergone ACLR at a pediatric sports medicine practice that had completed functional testing between December 2017 and November 2020. Patients with testing completed at a minimum of five months post-operatively, and who planned to return-to-sport (RTS) were included. Functional testing included validated protocols for the Y-Balance Test (YBT) and the Landing Error Scoring System (LESS), as well as a modified Single-Leg Squat Endurance Test (SLSET) utilizing the VAIL sports test scoring criteria. DF was measured in a weight-bearing lunge position off the front foot. Subjects were categorized into a pass or fail group based on their YBT and LESS scores (YBT≥94%, LESS≤4), and t-tests were performed to identify significant differences in DF between groups (α=0.05). Lastly, Pearson correlations were performed to identify potential relationships between DF and SLSET total score as well as normalized anterior reach collected as a component of the YBT (α=0.05).Results:303 patients (148 (48.8%) males, 15.94±2.15 years, 7.46±2.11 months post-operative) were included for analysis. Significant correlations were identified between DF and YBT composite score (p <0.001) and LESS total score (p <0.001; Table 1). Additionally, positive relationships were found between DF and both SLSET total score (p <0.001, r = 0.296) and anterior reach (p <0.001; r =0.400). Average values for DF, YBT, and LESS can be found in Table 2.Conclusion:In this pediatric ACLR population, decreased ankle dorsiflexion is associated with high risk movement patterns during functional testing. This study adds to the literature by identifying clinically applicable DF thresholds associated with passing scores on the YBT and LESS functional tests. Clinical interventions aimed at improving ankle dorsiflexion to >36° may be an important component of ACL rehabilitation.Table 1.Ankle dorsiflexion (Mean ± SD) across patients and by functional test scoresTable 2.Average values per measure (Note: Asymm = side-to-side differences)

Return to Play Rates of Young Athletes After Patellofemoral Instability Treatment

Background:Following non-operative or operative treatment, many young patients with patellofemoral instability (PFI) desire to return to sport. The rate of return to play in young athletes following PFI treatment is not well known.Hypothesis/Purpose:To examine the return to play rates of skeletally immature and mature patients after either non-operative or operative treatment for PFI.Methods:Patients from a pediatric sports medicine clinic diagnosed with PFI prospectively followed over a 4+ year time frame were evaluated. Patients who had documented physical exam follow-up with a recorded date of return to play (RTP) were included in the study. Demographics, skeletal maturity, type of treatment, and physical exam details were included in the analysis.Results:Within this cohort of 62 knees, 35 of the 54 knees that played a primary sport (63.4%; mean age=14.87±2.02) ultimately returned to activity. 28 were skeletally immature (45.2%) and 34 were mature (54.8%). 5 knees received non-operative treatment (8.06%), and 57 received operative treatment (91.94%), including medial patellofemoral reconstruction, tibial tubercle osteotomy, and lateral release, among other procedures. 75.81% of patients were female, and 24.19% were male. The average time from PFI treatment to return to play was 236.48 days (±108.95). This time did not significantly differ between males and females, nor skeletally immature or mature knees (p=0.485; p=0.629). No physical exam points, such range of motion, J-sign, or patellar apprehension, were significant. Residual signs and symptoms were infrequent, but not absent at RTP: 11.1% positive apprehension, 8.5% mild J-sign, and 5.2% continued pain or instability in one or more locations on their knee at RTP. Significantly fewer skeletally mature patients returned to their primary sport after treatment (95.5% immature vs 40% mature, p<0.0001) not necessarily related to their knee or treatment. 32.76% of knees included had bilateral instability, which could increase average RTP if these athletes were not receiving simultaneous treatment.Conclusion:Over half of young athletes treated at a sports medicine clinic returned to play following PFI treatment.

Sagittal Plane Mobility in Adolsents with Femoroacetabular Impingment

Background:Femoroacetabular impingement (FAI) is a dynamic degradative condition of the hip joint characterized by classic physical exam findings in combination with abnormal radiographs and/or MRI. Although this abnormal morphologic relationship contributes to FAI, the role of physical therapy to mitigate symptoms by improving strength and mobility of the hip remains the first line treatment. Despite this common treatment algorithm, limited knowledge exists on the effects of sagittal balance, lumbopelvic mobility, and its role in the development of treatment for symptomatic FAI.Hypothesis/Purpose:To review lumbopelvic mobility from standing to sitting position in adolescent athletes who present with clinical signs of FAI.Methods:Pelvic radiographic measurements in the sagittal plane were performed on a retrospective series of consecutive patients who presented with clinical diagnosis of FAI at a pediatric sports medicine institution from April 2019-March 2021. Standardized EOS dynamic lateral pelvic images were performed in standing and sitting positions to evaluate the differences in sacral slope, pelvic tilt, and pelvic incidence. Data from bi-positional radiographs were combined with standard measurements for FAI obtained on AP pelvis (lateral center edge angle, acetabular inclination) and 45 degree Dunn views (alpha angle), and patient reported outcomes (PROs) (mHHS, HOOS, UCLA). Differences in sacral slope from pre-treatment radiographs were used to determine comparison groups: those with a change vs. those with limited change between a sitting and standing position.Results:76 adolescent patients (mean age 15.7 years [12-24]; 71.5% females) with sitting/standing lateral pelvis radiographs and a clinical diagnosis of FAI were identified. Between sitting and standing positions, there was no change in pelvic incidence, while significant differences were noted in sacral slopes and pelvic tilt (Table 1). Variability in sacral slope differences between sitting and standing were identified with 10 (13.9%) patients having minimal (<10o) change, while 8 (11.1%) demonstrated changes > 40o (Figure 1). Adolescent patients with FAI who demonstrated more mobility from sitting to standing position had a higher sacral slope in the standing position. No correlations were noted between pelvic incidence or sacral slope and radiographic measures associated with FAI, PROs or differences in those with variable changes in sacral slope from sitting to standing position.Conclusion:Lateral pelvic imaging may be an important tool for understanding dynamic hip impingement. In adolescent patients signs and symptoms with clinical FAI, significant variability exists in lumbopelvic mechanics, regardless of the severity of radiographic values.Table 1.Radiographic measurements performed on a sitting and standing lateral pelvic radiographs using EOS. Values listed are mean (standard deviation; range).Figure 1.Sitting and Standing lateral pelvic images from 2 patients. Top row: Standing lateral pelvis (A) and sitting lateral pelvis (B) with a significant change in sacral angle and pelvic tilt with no changes in pelvic incidence. Not the change in lumbar lordosis in this patient. Bottom row: Standing lateral pelvic (A) and sitting lateral pelvic (B) without significant change in lumbosacral position.

Pediatric Orthopedics and Sports Medicine: A Handbook for Primary Care Physicians, 2nd Edition.

Medicine & Science in Sports & Exercise: April 2022 - Volume 54 - Issue 4 - p 707 doi: 10.1249/MSS.0000000000002879

Validity of the McMurray Test for Meniscal Tear in Pediatric and Adolescent Patients.

The aim of this study was to identify the accuracy of the McMurray test in the adolescent and pediatric population. Retrospective case series. Tertiary care, institutional. Inclusion criteria included patients who presented with unilateral knee pain and were seen by pediatric sports medicine physicians. Patients were excluded if their knee pain was related to any underlying conditions. Three hundred patient charts were reviewed, and 183 patients (age range: 8-18 years, mean: 14 years; 74 male) met the inclusion criteria. Symptoms at initial visit (knee pain). Presence of a meniscal tear using the McMurray test. Eighty-four percent (160/191) of patients had a McMurray test documented as performed by the physician, and 17% (27/160) elucidated a positive response. Of 26 patients who had a positive McMurray and underwent magnetic resonance imaging (MRI), 16 (62%) showed a meniscal tear on their MRI. However, of the 87 patients who had a negative McMurray and still underwent MRI, 25 (29%) had a positive meniscal tear. The sensitivity, specificity, positive predictive value, and negative predictive value were 39%, 86%, 62%, and 71%, respectively. In a pediatric and adolescent population, the McMurray test was negative for 61% (23/38) of meniscal tears identified on MRI. Although the test can be a useful tool as a part of a thorough evaluation, combining it with mechanical symptoms, patient history and imaging may be more helpful to diagnose a meniscus tear.

Rhythmic gymnasts’ injuries in a pediatric sports medicine clinic in the United States: a 10-year retrospective chart review

ABSTRACT Objectives Rhythmic gymnastics injuries have not been studied thoroughly especially in the United States. Existing research studies are predominantly from Europe or Canada or from more than 15 years ago. The purpose of our study was to provide an updated description of injury patterns among rhythmic gymnasts in the United States. Methods A retrospective chart review was conducted of 193 rhythmic gymnastics injuries in 79 females, ages 6–20. Patients were seen between January 2010 and March 2020 in a hospital-based pediatric sports medicine clinic. Gymnast demographics, injury locations, and injury types were collected as available. Descriptive and bivariate statistical analysis was performed using general linear mixed models. Results Our cohort had a mean age of 14.61 2.61 years. Overuse injuries (76.7%) were more common than acute injuries (23.3%). The most common injury types were strain (20.7%), nonspecific pain (15.5%), and tendinitis/tenosynovitis (10.36%). The most frequently injured body regions were lower extremity (75.1%), followed by trunk/back (19.2%), upper extremity (4.7%), and head/neck (1.0%). The most common injured body parts were foot (24.9%), ankle (15.5%), knee (15.0%), lower back (14.0%), and hip (13.0%). General linear mixed models revealed that older age (p = 0.001) and higher competitive level (p = 0.016) were associated with a greater number of diagnoses. Gymnasts with foot injuries were older than gymnasts with ankle (p = 0.026), hip (p < 0.0001), and knee (p = 0.002) injuries. Gymnasts with higher BMI-for-age percentile were more likely to have acute injuries than overuse (p = 0.035). Conclusion Our data showed that injuries among rhythmic gymnasts were most frequently located in the lower extremities, specifically the foot, followed by trunk/back. Additionally, the most frequent injury types were strains and nonspecific pain, and overuse was the most prevalent mechanism. Gymnasts with foot injuries were older than gymnasts with ankle, hip, and knee injuries. Higher BMI is a predictor of acute injuries.

Medical perspectives on pediatric sports medicine–Selective topics

Selective medical perspectives of pediatric sports medicine are explored in this issue and behavioral perspectives of pediatric sports medicine are discussed in a subsequent journal issue. Concepts are considered now dealing with sports readiness involving the child and adolescent that involve understanding the limits imposed by growth and development at different ages as well as pubertal stages. Specializing in one sport too soon is not recommended. Sports readiness also involves understanding and counseling about proper diet and nutrition for maximum sports activity as well as overall health benefits.As clinicians understand sports readiness they can provide a beneficial pre-participation sports examination and deal with qualifications for sports play. Various medical conditions arise in dealing with pediatric persons involved in sports and these are considered in this discussion. They include the female athlete triad, iron deficiency anemia, sports anemia, musculoskeletal overuse injuries, obesity, sudden cardiac death, return to learning after sports-related concussion, epilepsy, asthma, diabetes mellitus, gastrointestinal disorders, genitourinary disorders and dermatology disorders in sports. Clinicians can be very helpful to these young athletes and work with them to ensure the full benefits of sport activities.

Coding Challenges in Common Pediatric Sports Surgeries of the Shoulder, Elbow, and Ankle

Pediatric Sports Medicine is a relatively new subspecialty within Pediatric Orthopaedics, with continually evolving surgical techniques. As a result, many of the procedures performed may not have well-established corresponding CPT codes, leading to considerable variability in how different surgeons code for the same procedure. This article presents case scenarios for common shoulder, elbow, and ankle pathologies treated surgically by pediatric orthopaedic surgeons. The intent is to clarify some discrepancies in coding for these procedures and aid the surgeon in proper billing. It is important to note that the following scenarios are hypothetical and therefore ultimate code selection should always reflect the operative report documentation.

Improving the Diagnosis of Menstrual Dysfunction through Quality Improvement.

Introduction:Prevalence of menstrual dysfunction (MD) in high school athletes ranges from 7% to 54%. Early recognition and intervention are crucial to prevent future consequences. The purpose of this Quality Improvement project was to optimize the institution’s Epic Best Practice Advisory (BPA) screening tool and synthesize new patient questionnaires to diagnose MD in athletes greater than 12 years of age presenting to a pediatric sports medicine clinic.Methods:Using Quality Improvement methodology, we evaluated clinic flow, the Epic BPA tool, and actions by the physician following the appropriate triggering of the BPA. Diagnoses targeted were primary amenorrhea, oligomenorrhea, or irregular menstruation unspecified. Areas for intervention were global staff education, patient education, and provider alert fatigue. Our team implemented interventions using monthly Plan-Do-Study-Act cycles to address our key drivers. Proper implementation of questionnaire data and restructuring of the Epic BPA promoted identification and diagnosis of MD. The clinician discussed the diagnosis with the patient and family and provided an educational handout on MD.Results:The rate of appropriate diagnosis of MD in athletes greater than 12 years of age seen at a pediatric sports medicine clinic increased from a baseline of 2.1% to 30% over ten months. Identification of three key drivers ultimately drove the success and achievement of our aim.Conclusions:Using Quality Improvement methodology, we optimized the EPIC BPA and subsequently increased the rate of appropriate diagnosis of MD. Identification of the proper diagnosis improves our patient education. Ultimately, this project provided the framework for applicable discussion, interventions, and work-up for at-risk athletes.

Should headers be banned in children's and youth soccer?

A few months ago, a high school graduate contacted me with a request for an interview for her “Matura thesis”. The topic of her thesis was the (possible) ban on headers in children and adolescents in soccer. Shortly afterwards, the same question came up at the general assembly of the Society for Paediatric Sports Medicine (GPS): why are headers banned in youth soccer in England/US, but not in Germany and Switzerland? Reason enough to take a closer look at this topic and try to find evidence-based answers to this question. Soccer is the world’s most popular sport with more than 265 million players, of which 22 million are youth players [1]. Headers are deliberately used to influence the game. Headers are a fundamental part of the sport of soccer. It is also unique in sport to use a header to influence the game. However, there is a recurring question in the literature as to whether headers have an impact on brain function and brain structures [2-6]. In the US, headers were banned for children up to 11 years of age following a lawsuit by parents of children playing soccer.

Current practice trends in the surgical management of patellofemoral instability: a survey of the Paediatric Research in Sports Medicine (PRiSM) Society.

PurposePatellofemoral instability (PFI) in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. The purpose of this study was to identify trends in management of PFI in children and adolescents in the United States and nationwide.MethodsA 27-question multiple choice survey was distributed in 2018 to the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding treatment of PFI in paediatric and adolescent patients.ResultsIn all, 56 of the respondents who were orthopaedic surgeons that manage patellar instability in children and adolescents and had performed PFI surgery more than five times in the past year completed the entire survey. A total of 41% of respondents reported that surgery for fragment refixation or loose body removal was indicated when a loose body or osteochondral fragment was evident, regardless of fragment size. Overall, 74% reported that if surgery was performed for an osteochondral loose body, primary repair (36%) or reconstruction (38%) of medial patellofemoral ligament (MPFL) was also completed. A total of 89% of members reported MPFL reconstruction in the absence of alignment or rotational abnormalities, tibial tubercle lateralization or trochlear dysplasia in skeletally immature patients; 59% reported performing the MPFL reconstruction with hamstring allograft, while 30% prefer autograft (hamstring, quadriceps). For patients with significant trochlear dysplasia, 87% reported no surgical management of trochlea in first-time or in revision surgery.ConclusionThere is a lack of consensus regarding optimal diagnostic and treatment algorithms in the management of PFI, however, consistent trends have emerged among paediatric sports medicine surgeons.Level of EvidenceLevel V – survey of expert opinion and experience

A Scale Measuring Academic-Related Anxiety Following Concussion

Does academic-related anxiety contribute to an adolescent’s recovery process and return to activity after experiencing a concussion? The authors created a novel measure of academic-related anxiety (Mularoni Measure of Academic Anxiety following Concussion [MMAAC]) and administered it to adolescents following concussion in outpatient pediatric sports medicine clinics. Two previously validated measures of anxiety were also administered, and results were compared with the MMAAC scores as well as the lengths of time for return to school and sports. Results show that higher MMAAC scores positively correlate with the length of time an adolescent needs to return to school. Study results indicate that the MMAAC reliably measures academic-related anxiety in adolescents suffering from concussions and can be helpful in predicting a basic timetable for return to school. The authors believe that this brief survey can be used by physicians in clinic to evaluate anxiety and assist with return to school expectations to provide comprehensive recovery support.

Symptom and clinical recovery outcomes for pediatric concussion following early physical activity.

Recent research supports initiating physical activity as soon as 24 to 48 hours after concussion to reduce persistent postconcussive symptoms. However, this practice has not been widely adopted. The objective of this study was to evaluate the association of early physical activity with patient-reported and functional outcomes for pediatric patients following a concussion. A retrospective cohort of patients who presented to a pediatric sports medicine clinic (48% female, mean age14.3 ± 2.6 years, and mean 9.8 ± 5.7 days postconcussion) were evaluated. Patients were grouped based on whether they reported engaging in physical activity prior to presenting to the clinic. Patient- and parent-reported symptom frequency (Health and Behavior Inventory), 11 different clinical outcomes (including missed school, memory recall, and balance assessments), the presence of symptoms persisting beyond 28 days, and a subgroup analysis of those patients receiving exercise versus symptom-limiting activity prescriptions were examined. Outcomes were compared between physical activity groups using the Mann-Whitney U-test and the chi-square test. To adjust for the effect of potential confounders, a logistic binary regression model was constructed. In total, 211 pediatric patients were included, 35 (17%) of whom reported early physical activity. A greater proportion of the no physical activity group reported a headache (85% vs 60%, p = 0.001). The no physical activity group also reported higher patient-reported (23.1 ± 13.4 vs 15.0 ± 13.4, p < 0.001) and parent-reported (19.4 ± 12.7 vs 11.2 ± 10.3, p = 0.001) symptom frequency at the initial visit. The early physical activity group had a lower proportion of patients with persistent symptoms (44% vs 22%, p = 0.02) and a shorter time to symptom resolution (15.6 ± 12.4 days vs 27.2 ± 24.2 days, p = 0.02). After adjusting for potential confounders, early physical activity was associated with 5.8 lower odds of experiencing persistent symptoms (adjusted OR 5.83, 95% CI 2.05-16.61; p = 0.001). A significant association between early physical activity and decreased symptom burden was observed. A lower proportion of those patients who engaged in early physical activity experienced persistent symptoms 28 days postinjury. However, low rates of early physical activity prior to the initial clinic visit were also observed, indicating that this approach may not be well known by acute care or primary care providers, or is not widely adopted by patients and families.

Coding Challenges in Common Pediatric Sports Surgeries of the Knee

Coding and billing for procedures is necessary but possibly the least enjoyable aspects of performing surgery. Additionally, proper documentation is crucial to support procedural coding and billing. Unfortunately, these are also areas in which orthopaedic surgeons receive the least consistent training, which can lead to enormous variability in how different surgeons code and bill for the same procedure. Pediatric sports medicine is a relatively younger subspecialty within pediatric orthopaedics and as such, techniques and approaches to surgery continue to evolve. As a result, many of the procedures performed may not have well established—or indeed any—corresponding CPT codes.&#x0D; This article presents case scenarios for common knee pathologies often treated surgically by pediatric orthopaedic surgeons. The intent is to clarify some discrepancies in coding for these procedures and aid the surgeon in proper billing. It is important to note that the following scenarios are hypothetical and therefore ultimate code selection should always reflect the operative report documentation.

Treatment Decisions in Pediatric Sports Medicine: Do Personal and Professional Bias Affect Decision-Making?

Background:Personal and professional biases can affect decision-making regarding important issues in pediatric sports medicine. Gaining insight into the opinions of health care professionals who specialize in pediatric sports medicine will provide information that may be useful for directing ongoing research in this field.Hypothesis:It was hypothesized that surgeons would demonstrate bias toward early surgical intervention versus nonsurgeons. In addition, it was hypothesized that youth sports medicine professionals who were parents of a child with a previous major sports injury or concussion would be less likely to allow their child to play American tackle football or return to football after a concussion.Study Design:Cross-sectional study.Methods:An online survey was provided to the active members of the Pediatric Research in Sports Medicine Society. We used both professional background information and responses to questions related to personal experiences with youth sports injuries to determine potential factors associated with underlying biases. Survey responses among subgroups were compared using the Fisher exact test. The Pearson correlation coefficient was used to evaluate years in practice versus opioid use.Results:Of the survey participants, 62.5% were pediatric surgeons, and 37.5% represented different nonsurgical youth sports medicine professions. Surgeons were less likely than nonsurgeons to agree to allow their child to return to football after sustaining a concussion and completing a concussion protocol (48% vs 76%, P = .013). Surgeons were more likely than nonsurgeons to agree to both elective shoulder stabilization after a first-time dislocation and elective drilling of a stable knee osteochondritis dissecans (OCD) before nonoperative treatment (41% vs 10%, P = .003 and 52% vs 23%, P = .013, respectively). Those who reported having a child with a concussion history were more likely to support him or her returning to football after a concussion (65% vs 33%, P = .026).Conclusion:Surgeons were more likely to favor elective shoulder-stabilization surgery after a first-time dislocation and drilling of a stable knee OCD instead of nonoperative management. Personal experience of having a child who sustained a major sports injury or concussion did not demonstrate a bias against participation in football or return to football after a concussion.

HOW MANY PAIN PILLS DO WE PRESCRIBE: A SURVEY OF PARTICIPANTS IN SCORE: A QUALITY IMPROVEMENT INITIATIVE (204)

Objectives:The public health opioid abuse epidemic has led to nationwide interest in judicious use and close monitoring of opioid pain medication. Knee arthroscopy(KA) and anterior cruciate ligament reconstruction(ACLR) are common procedures in adolescent patients for which narcotics have been historically utilized for post-operative pain management. The purpose of this study is to investigate pain management strategies following basic KA or ACLR by pediatric sports surgeons who contribute to a multi-center quality improvement initiative(SCORE).Methods:Surgeon participants in SCORE represent fifteen U.S. institutions from primarily academic teaching hospitals who specialize in pediatric sports medicine. Surgeons contribute all ACLR and other KA-related cases. A RedCap survey was distributed to all SCORE surgeon participants in December 2019. A KA (defined as a knee arthroscopy that does not include a ligament reconstruction or a cartilage procedure other than chondroplasty) represented a less invasive procedure, while the ACLR represented a more invasive procedure. Survey results were collected and analyzed for both practice patterns of regional anesthesia utilization and post-operative narcotic prescribing volumes.Results:Twenty-eight SCORE surgeon participants completed the survey, a 100% response rate. A planned prescription of a mean of 16.4 pain pills (range 0-40 pills) were reported for pain management following a KA, only 32.1% of surgeons reported adjunctive regional anesthesia techniques for this procedure in addition to general anesthesia. Following an ACLR, surgeons reported a planned prescription of a mean 23.8 pain pills (range 0-40 pills) and most (92.3%) reported utilization of regional anesthesia for their peri-operative analgesia strategy. Of those using adjunctive regional anesthesia, significant variability was reported: 30.7% reported indwelling catheter placement for peripheral nerve block following ACLR as opposed to a single shot injection method, and several block locations were reported to be utilized of which adductor canal (67.9%) block was the most common (see Figure 1). For both procedure types, variability in multi-modal pain management was noted, with incomplete adoption of the use of additional non-narcotic medication (acetaminophen, 64.2%; and NSAIDS, 75%). Cryotherapy devices were applied/prescribed in 75.0% of knee arthroscopy procedures and 92.8% of ACLR.Conclusions:Despite evidence for effective adjunctive pain management strategies, incomplete adoption of multi-modal techniques and reliance on narcotic medication remains a significant component of pediatric sports surgical practice; with on average > 15 pills prescribed following these procedures. Opportunities for reducing practice variability, adoption of multi-modal analgesia strategies, and decreasing post-operative narcotic use following common adolescent knee procedures exist for this subset of pediatric sports medicine specialists