Primary Care Sports Medicine Physicians Research Articles

Screening for Relative Energy Deficiency in Sport and Female Athlete Triad: A Survey of Pediatric Sports Medicine Professionals

BACKGROUND: Relative Energy Deficiency in Sport, or RED-S, is a multi-scale physiological response to a mismatch between energy intake and exercise energy expenditure that affects up to 50% of adolescent athletes. RED-S symptomology was first described as the Female Athlete Triad (the Triad) and includes specifically low energy availability with or without disordered eating, menstrual dysfunction, and low bone mineral density. Despite the wide impact of RED-S/the Triad, there is a lack of standardization of screening in adolescent athletes. Therefore, the purpose of this study was to assess if there are differences in practitioner demographics when screening for RED-S/the Triad in adolescent athletes. In addition, we sought to assess if providers’ screening habits differ based on specific patient characteristics. METHODS: We conducted a cross-sectional online questionnaire of members of the Pediatric Research in Sports Medicine (PRiSM) Society. PRiSM is an interdisciplinary group of professionals who are dedicated to advancing the research and medical care of young athletes. The questionnaire assessed screening tools that members used to assess for RED-S/the Triad, practices implemented when providers were concerned for RED-S/the Triad, demographic data, and type of training. RESULTS: Of 389 PRiSM members, 60 completed the survey and were included in subsequent analyses (15% response rate). Most participants were primary care sports medicine physicians (37%), orthopaedic surgeons (27%), or physical therapists (23%), and about half of respondents identified as a cis gender woman (55%). There was a trend toward more women screening for RED-S routinely than men (55% vs. 33%: p=0.10), and orthopaedic surgeons were less likely to screen than other specialties (25% vs. 52%, p = 0.06). Eating disorders (88%), menstrual dysfunction (76%), and bone stress injury (74%) were reported as specific red flags that make providers screen for RED-S/the Triad. Participants reported that lack of time (57%) and lack of resources (37%) were barriers to screen for RED-S/the Triad. The most commonly utilized tools to screen for RED-S/the Triad were the Female Athlete Screening Tool (FAST), Female Athlete Triad Risk Scale, Female Athlete Triad Consensus Panel Screening questions, and RED-S Specific Screening Tool (RST). CONCLUSION: Orthopaedic surgeons were less likely than other health care professionals to screen for RED-S/the Triad. Barriers that prevent healthcare providers from screening for RED-S/the Triad included limited time and resources. By describing current practices, we have identified gaps and areas of need to enhance screening for RED-S/the Triad across multiple sports medicine disciplines.

Utility of a Clinical Prediction Tool for Persisting Postconcussive Symptoms in a Multicenter Sample of Youth Athletes With Concussion: The Sport Concussion Outcomes in Pediatrics (SCOPE) Study

Background: A validated clinical risk tool has been developed to identify pediatric and adolescent patients at risk of developing persisting symptoms after concussion, but has not been prospectively investigated within a sample of athletes seen after concussion by primary care sports medicine physicians and/or athletic trainers. Purpose: To determine whether a validated clinical risk prediction tool for persistent postconcussive symptoms (PPCSs) predicted which patients would develop PPCSs when obtained within 14 days of concussion among a multicenter sample of adolescent athletes. Study Design: Cohort study; Level of evidence, 2. Methods: Pediatric and adolescent patients (8-18 years of age) from 7 pediatric medical centers and 6 secondary school athletic training facilities who were diagnosed with a concussion and presented ≤14 days after concussion were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit and were followed until symptom resolution. Clinical risk scores (Predicting and Preventing Post-concussive Problems in Pediatrics [5P]) and total symptom severity were obtained using the Post-Concussion Symptom Inventory at the initial visit (mean, 4.9 ± 2.9 days after concussion). Participants were then compared based on symptom resolution time: PPCS group (≥28 days to symptom resolution) and no-PPCS group (<28 days). The authors assessed the odds of developing PPCSs based on the 5P risk score using a binary logistic regression model and the utility of the clinical risk prediction tool to identify total time to symptom resolution using a Cox proportional hazards model. Results: A total of 184 participants enrolled, underwent initial evaluation, and were followed until symptom resolution (mean age, 15.2 ± 2.1 years; 35% female). The mean time to symptom resolution across the entire sample was 17.6 ± 3.7 days; 16% (n = 30) of participants developed PPCS. Those in the PPCS group had significantly greater mean initial total 5P risk scores than those in the no-PPCS group (7.9 ± 1.7 vs 5.9 ± 2.3, respectively; P < .001). After adjustment for initial symptom severity, time to assessment, and assessment setting, a higher initial total 5P risk score was associated with a significantly greater odds of developing PPCSs (adjusted odds ratio, 1.49; 95% CI, 1.07-2.08; P = .019). Furthermore, a higher 5P risk score was significantly associated with longer total symptom resolution time (hazard ratio, 0.80; 95% CI, 0.74-0.88; P < .001). Conclusion: In a multicenter sample of youth athletes seen in different outpatient health care settings, the 5P risk score accurately predicted which athletes may be at risk for developing PPCSs.

Gender Disparities Among Professional Team Sports Medicine Physicians.

Although recent trends from the Accreditation Council for Graduate Medical Education (ACGME) present encouraging growth of female representation in sports medicine, the field is still lagging behind other specialties. This study investigates gender disparities among physicians providing care for professional sports teams in male and female sports leagues. Information regarding physicians providing sports medicine care to professional teams obtained by database queries (May 2021). Chi-square analysis compared gender data of orthopaedic team physicians with American Orthopaedic Society for Sports Medicine (AOSSM) and American Academy of Orthopaedic Surgeons (AAOS) membership, residency, and fellowship census data. Primary care sports medicine physicians were compared with American Medical Society for Sports Medicine (AMSSM) and primary-care sports medicine fellowship census data. Professional sports health care. Professional league physicians. None. Gender, residency, and fellowship training of professional league physicians. Among a total of 608 team physicians, 572 (93.5%) were male and 40 (6.5%) were female. Orthopedic surgeons comprised 64.7% of the physicians. Fourteen (3.6%) team orthopedic surgeons were female. Thirty-five percent of team physicians were primary care sports medicine physicians. Twenty-six primary care sports medicine physicians (11.6%) were female. Orthopaedic female team physician representation overall was comparable with AOSSM and AAOS membership but significantly less than orthopaedic surgery residents and sports medicine fellows ( P < 0.01). Women's National Basketball Association orthopaedic team physicians were more represented than female membership among AOSSM, AAOS, and orthopaedic sports medicine fellows ( P < 0.01). Except for the WNBA, Premiere Hockey Federation, National Women's Soccer League, and United States Football League, female primary care sports medicine physicians were underrepresented in professional sports compared with AMSSM membership and primary care sports fellows ( P < 0.01). Overall, female representation is poor among orthopaedic surgeons and primary care physicians providing sports medicine care to professional teams. Leagues encompassing female athletes tend to have better representation of female physicians. IV.

Sports Medicine Physicians Comfort and Competence in Caring for Transgender and Gender Nonconforming Patients and Athletes.

The purpose of this study was to explore primary care sports medicine physicians' comfort, competence, education, and scope of training in caring for transgender and gender nonconforming (TGNC) patients/athletes. Mixed-methods, cross-sectional survey. Online. In total, 4300 e-mails were successfully sent with 252 eligible responses received from the American Medical Society for Sports Medicine members. Previous relationships with TGNC persons; previous relationships with TGNC patients/athletes; frequency of care for TGNC patients/athletes. The participants completed a 38-item tool used to assess perceived comfort and competence treating TGNC patients/athletes. Physicians defined "transgender" and described their thoughts on unfair competitive advantage of transgender athletes. Most participants had worked with a TGNC patient (70.2%, n = 177), but far fewer worked with a TGNC athlete (n = 26.6%, n = 67). Among the participants who provided a definition of transgender (n = 183), only 28.4% (n = 52) of participants were able to correctly define the term, whereas most were able to partially (57.9%, n = 106) characterize the term. The most common mechanisms identified for learning about TGNC patients were reading peer-reviewed journal articles (44.8%, n = 113) and CME (41.3%, n = 104). Those with previous TGNC friend/family, patient, and athlete relationships had a significantly different level of comfort and competence treating TGNC patients/athletes. Previous care relationships with TGNC strongly influences comfort and perceived competence of primary care sports medicine physicians. Training, from unbiased peer-reviewed sources of data, is critical to improve care for TGNC patients/athletes.

Family Medicine Musculoskeletal Medicine Education: A CERA Study.

Musculoskeletal (MSK) concerns constitute up to 40% of primary care outpatient visits. Despite Accreditation Council for Graduate Medical Education (ACGME) family medicine program requirements for musculoskeletal medicine and sports medicine training, previous studies have shown that family medicine residency graduates do not have adequate training to manage common musculoskeletal conditions. Factors for this may include deficiencies in education at both the undergraduate and graduate medical education training levels. A Council of Academic Family Medicine Educational Research Alliance survey of 287 family medicine program directors assessed the current state of the delivery of musculoskeletal medicine education. Opinions were gathered on the scope and delivery of training requirements as well as potential areas for further curricular attention. Two hundred eighty-seven program directors responded to the survey (response rate 41.53%). Most (72.60%) were in university based or affiliated programs and had a fellowship-trained primary care sports medicine physician (59.85%) curricular lead. A majority (77.4%) did not feel that PGY-1 residents enter residency with the physical exam skills needed to evaluate common musculoskeletal (MSK) conditions , and most (81.15%) did not feel that there should be changes to the current ACGME requirements. An area highlighted for further investment is faculty development in point-of-care ultrasound (39.85%). Although program directors believe that current ACGME MSK curricular requirements are likely appropriate, they do not feel residents arrive with the examination skills needed to evaluate common MSK conditions.Therefore, further attention can be given to medical student education in musculoskeletal exam skills prior to residency. Future research should develop objective measures using multiple assessors-students, residents, teaching faculty, and patients-to assess both the baseline and graduating competency in MSK medicine of our residents.

Clinical considerations for the assessment, management, and treatment of concussion in females

: This review paper describes an individualized, targeted clinical care approach for the assessment, management, and treatment of sport-related concussions (SRC), and also highlights important clinical considerations for providing care to females with a SRC. Ideally, SRCs should be managed by an interdisciplinary medical team including but not limited to neuropsychologists, primary care sports medicine physicians, and physical therapists. The clinician that coordinates care should employ a multi-modal assessment approach (e.g., neurocognitive, vestibular/ocular motor, symptoms, balance, clinical exam/interview) to capture the heterogeneity of symptoms and impairments that are associated with SRC. Clinicians must also be aware of certain factors, specific to females that may complicate SRC recovery such as female preferences for clinical care, their greater risk for established risk factors (e.g., concussion history and migraine) and female sex hormone cycles that may influence multiple concussion outcomes (e.g., symptom reports and neurocognitive scores). Concussion management has moved away from a one-size-fits-all approach and clinicians must be willing to provide a comprehensive assessment that caters to the needs of females in order to individualize the treatment recommendations and avoid a prolonged recovery.

Reevaluation of Diagnostic Criteria for Exertional Rhabdomyolysis in Collegiate Wrestlers: A Case Series and Review

Rhabdomyolysis is a common and potentially fatal condition encountered by athletic trainers, coaches, primary care physicians and sports medicine physicians. Benign, or physiological, Exertional Rhabdomyolysis (ER) may resemble Delayed Onset Muscle Soreness (DOMS) and becomes clinically significant when accompanied by other morphologies including severe muscle pain and swelling, and myoglobinuria. ER is often characterized by a triad of symptoms.

Interprofessional Inconsistencies in the Diagnosis of Shoulder Instability: Survey Results of Physicians and Rehabilitation Providers.

BackgroundClinicians of many specialties within sports medicine care for athletes with shoulder instability, but successful outcomes are inconsistent. Consistency across specialties in the diagnosis of shoulder instability is critical for care of the athlete, yet the extent of divergence in its diagnosis is unknown.HypothesisPhysicians differ from rehabilitation providers in which findings they deem clinically important to differentiate shoulder instability from impingement, and in how they diagnose athlete scenarios with atraumatic shoulder instability.Study DesignCross-sectional study.MethodsPhysicians (orthopaedic surgeons, primary care sports medicine physicians) and rehabilitation providers (physical therapists, athletic trainers) were asked via an online survey to rate clinical factors used to diagnose shoulder instability. Clinicians were also asked to diagnose two athlete scenarios with concurrent clinical findings of atraumatic shoulder instability and impingement, differentiated by the absence or presence of a positive sulcus sign.ResultsResponses were recorded from 888 clinicians. Orthopaedic surgeons (N=170) and primary care sports medicine physicians (N=108) ranked physical examination factors as more important for the diagnosis of shoulder instability than patient history factors, whereas physical therapists (N=379) and athletic trainers (N=231) preferred patient history factors. Orthopaedic surgeons differed from physical therapists and athletic trainers in their clinical diagnoses for both scenarios (P≤0.001).ConclusionA lack of consistency exists among sports medicine clinicians in recognizing which clinical factors are important when used to diagnose shoulder instability and in diagnoses given with concurrent findings of impingement.Level of EvidenceLevel 3.

Implementing a Physical Activity Consultation Clinic during a Global Pandemic.

Ten percent of all premature deaths and 117 billion dollars in annual health care costs are attributable to physical inactivity in America. The positive impact exercise can have on overall health is irrefutable. While it is the responsibility of health care providers to assess and counsel for exercise, there are logistical, structural, and educational barriers preventing this counseling. A physical activity consultation clinic led by primary care sports medicine physicians would allow for focused exercise counseling by appropriately trained providers to motivated patients. While previously there have been many institutional and logistical barriers to establishing such a clinic, the COVID-19 pandemic has created a window of opportunity for doing so within a large academic medical center. This article reviews the importance of exercise on overall health, outlines the barriers for establishing a clinical experience dedicated to counseling for physical activity, and details how overcoming those barriers was facilitated by the COVID-19 pandemic.

A-13 Return-to-Learn: Academic Accommodations for Concussion Recovery

Abstract Objective To evaluate academic accommodations offered to student athletes following a concussive injury. Method Participants were identified during regularly scheduled visits to the participating fellowship-trained, board-certified primary care sports medicine physician (D.B.). A total of 127 participants (mean ± SD age, 14.8 ± 1.5 years [range, 12–18 years]) diagnosed with a concussion from December 2018 to October 2019 were surveyed. The participants were provided a questionnaire in which the following information was collected: age at injury, date of injury, locations of treatment, cognitive symptoms experienced, academic accommodations received, implementation of accommodation by educators, and school related problems. Results Cognitive symptoms were reported by 117 (92.1%) participants with trouble concentrating (81.2%), and feeling “slow” (78.7%) being the most common. Participants treated at the participating, sports-medicine concussion center had the highest rate of receiving academic accommodations (95.3%), while those also treated at an emergency or acute care center, primary care physician, or pediatrician’s office had significantly lower rates (&amp;lt;5%). Participants reported their accommodations as helpful (94.5%), with extra time (88.2%), and ability to take breaks (80.3%) having the highest frequency of recommendation. While symptomatic, 110 (86.6%) participants reported having difficulty completing school work and tests, 58 (45.7%) reported experiencing anxiety about completing their school work, and 55 (43.3%) reported a decline in their grades. Conclusions These data display the high frequency of cognitive symptoms and hindered academic performance associated with concussion recovery. The implementation of academic accommodations was demonstrated to be beneficial; however, not all medical centers are providing accommodations.

Improving Concussion Management by Including Driving Recommendations for Adolescents with Concussions: A Quality Improvement Project.

Introduction:Motor vehicle collisions are the leading cause of death in adolescents. A concussion is a common injury sustained by adolescents and may impair their driving abilities during the acute phase of recovery. Healthcare providers do not consistently perform counseling of adolescents regarding driving after a concussion. This quality improvement project’s goal was to increase the incidence of primary care sports medicine physicians providing driving recommendations to 75% of adolescents who suffered from concussions.Methods:Between August 2017 to August 2018, a “smart phrase” implemented in the electronic health record system reminded providers during office visits to provide driving recommendations to patients 15 years old and older who presented to the sports medicine clinic for evaluation of concussion. Performing monthly retrospective chart reviews determined the frequency of patients who received driving recommendations during the initial visit.Results:We achieved the goal of providing driving recommendations to 75% of concussed patients by the second month. This progress was maintained through the remainder of the year, except for 1 month (December). Forty-three percent of patients with concussions evaluated met inclusion criteria, and of those, 48% were actively driving before their concussion. The most common medical reason for restricting driving was vestibular or ocular dysfunction.Conclusion:This quality improvement project showed that providing driving instructions to concussion patients by implementing a smart phrase into the electronic health record system was impactful and sustainable.

Comparison of pediatric sports fracture outcomes based on provider type

ABSTRACT Objective: Pediatric primary care sports medicine physicians and pediatric sports medicine orthopedic surgeons, in conjunction with physician assistants (PAs), often manage patients with fractures. We sought to determine if pediatric patients with fractures seen by primary care sports medicine physicians had similar outcomes and satisfaction as those seen by orthopedic surgeons. Methods: We performed a retrospective chart review of four to 18-year-old patients who were treated by a sports medicine provider (primary care or orthopedic surgeon/PA) for a fracture of the radius, ulna, tibia, or fibula. Patients or their parents completed a patient satisfaction survey (Short Assessment of Patient Satisfaction [SAPS]) and an injury location-specific patient-reported functional outcome tool: the Foot and Ankle Ability Measure (FAAM) or the Disabilities of the Arm, Shoulder, and Hand (DASH) Scale. Results: Fifty-seven (70%) of the 82 patients were treated by pediatric primary care sports medicine physicians and 25 (30%) were treated by a pediatric sports medicine orthopedic surgeon or surgical PA. The median time from injury to clinically confirmed healing was similar between the two groups (47 vs 60.5 days; p = 0.54), as was the patient satisfaction (SAPS median score = 26 [range = 19–28] vs 24 [range = 9–28]; p = 0.12). Patient-reported outcomes did not differ significantly between groups for the functional outcome tools. Conclusions: Patients seen by pediatric primary care sports medicine physicians and sports medicine orthopedic surgeons have similar patient-reported fracture outcomes and similar satisfaction with care. Pediatric patients with fractures will likely have favorable outcomes when cared for by either of these subspecialty providers.

FEASIBILITY AND RELIABILITY OF MUSCULOSKELETAL ULTRASOUND MEASUREMENT OF THE MEDIAL PATELLOFEMORAL LIGAMENT

BackgroundThe medial patellofemoral ligament (MPFL) is an important soft tissue constraint to preventing patellar dislocations in young athletes. The anatomy of the MPFL has been investigated in cadaveric studies and magnetic resonance studies. No studies to date have provided anatomical data of the MPFL on ultrasonography.PurposeTo investigate the feasibility of musculoskeletal ultrasonography for the evaluation of the MPFL, and to determine interrater and intrarater reliability for MPFL ultrasound measures.MethodsTen control participants (20 knees) 20 to 50 years underwent ultrasonography performed by 3 researchers (musculoskeletal ultrasound radiologist, athletic trainer/biomechanist, primary care sports medicine physician) from 3 different institutions for interrater reliability testing. Intrarater reliability testing was performed at 2 separate institutions by 4 physicians, each performing the same knee ultrasound protocol on 20 knees in 10 study participants 2 to 3 weeks apart. In total, 180 images were created for interrater reliability, and 480 images for intrarater reliability. Examinations were performed with linear high-frequency transducers (10-18 MHz) with the participant in the supine position and the extremity flexed at 45°. Measurements included ligament length (long axis to ligament) from the patellar to the femoral attachment sites, ligament width (short axis to ligament) at the patellar attachment, and ligament thickness (long axis to ligament) midway between the patella and femur. Mean and SD were calculated for all measurements. Intraclass correlation coefficient (ICC) analysis was used to assess intrarater and interrater reliability. ICC values < 0.40 indicated poor reliability, whereas those between 0.40 and 0.75 indicated fair to good reliability, and those > 0.75 indicated excellent reliability.ResultsThe mean US value for MPFL length was 44.83mm (SD 6.68), mean thickness 2.66mm (SD 0.85), and mean width 11.76mm (SD 2.99). The overall ICC values for interrater reliability testing indicated fair to good reliability for length measures (0.7) and poor reliability for thickness (–0.1) and width (0.3; Table 1.1). Overall ICC values for intrarater reliability indicated fair to good reliability for length (0.5), excellent for thickness (0.9), and poor reliability for width (–0.3; Table 1.2).ConclusionsMusculoskeletal ultrasonography is a feasible and reliable office-based method of measuring MPFL length and thickness. These quantitative measures set the groundwork for establishing normative anatomical measures of the MPFL in athletes and establish a protocol for testing and measuring the MPFL using musculoskeletal ultrasonography.Table 1.1.Intraclass Correlation Coefficients (ICC) for testing reliability between physicians (inter-rater). ICC Length Thickness Width Overall0.708(0.291, 0.898)-0.047(-0.452, 0.442)0.253(-0.179, 0.652)xx vs xx0.833(0.562, 0.937)-0.055(-0.312, 0.309)0.062(-0.389, 0.498)xx vs xx0.297(-1.246, 0.776)-0.014(-0.385, 0.447)0.253(-0.130, 0.672)xx vs xx0.707(0.053, 0.907)0.032(-2.554, 0.704)0.286(-0.874, 0.756)*Data analyzed using two-way mixed, absolute agreement analysis. Expected value is shown, along with lower and upper bounds of 95% confidence intervals.Table 1.2.Intraclass Correlation Coefficients (ICC) for test-retest (intra-rater) reliability among individual physicians. Length Thickness Width Overall 0.492*(0.190, 0.681) 0.858(0.772, 0.912) -0.319(-0.056, 0.566)Physician 10.589(-0.024, 0.842)0.400(-0.300, 0.754)0.386(-0.241, 0.756)Physician 20.014(-0.393, 0.447)0.260(-0.965, 0.722)-0.097(-0.683, 0.432)Physician 3-0.085(-2.104, 0.604)0.463(-0.228, 0.786)-1.910(-7.683, -0.027)Physician 40.792(0.467, 0.918)0.634(0.053, 0.857)-0.224(-1.272, 0.435)*Data analyzed using two-way mixed, absolute agreement analysis. Expected value is shown, along with lower and upper bounds of 95% confidence intervals.

Clinical Results of Ultrasound‐Guided Carpal Tunnel Release Performed by a Primary Care Sports Medicine Physician

The purpose of this study was to determine the safety and efficacy of ultrasound-guided carpal tunnel release (USCTR) in a consecutive group of patients treated by a single primary care sports medicine physician. The study group consisted of 35 USCTRs performed on 22 consecutive patients for whom clinical outcomes were available before USCTR and at 1 to 2 weeks, 1 month, and 3 months after USCTR. All procedures were performed by the same operator using a single USCTR technique. Outcomes included complications, Quick Disabilities of the Arm, Shoulder, and Hand scores, Boston Carpal Tunnel Questionnaire symptom severity and functional status scores, and a 5-point global satisfaction score. The 22 patients included 13 female and 9 male patients (ages 31-82 years). Eleven patients (22 wrists) had bilateral simultaneous USCTRs; 2 patients (4 wrists) had staged bilateral USCTRs; and 9 patients had unilateral USCTRs. No complications occurred in any patient. Statistically and clinically significant reductions in Quick Disabilities of the Arm, Shoulder, and Hand scores and Boston Carpal Tunnel Questionnaire symptom severity and functional status scores occurred by 1 to 2 weeks after USCTR (mean 1- to 2-week changes, -29.23, -1.74, and -1.18, respectively), and further improvements occurred during the 3-month follow-up period (mean 3-month changes, -51.11, -2.29, and -1.91; P < .0001 for all values versus before USCTR). Mean global satisfaction scores at 1 to 2 weeks and 3 months were 4.63 and 4.66. Ultrasound-guided CTR is a safe and effective procedure that can be performed by an experienced primary care sports medicine physician and typically results in significant improvements within the first 2 weeks after the procedure. Furthermore, bilateral simultaneous USCTRs are feasible and may provide significant advantages for patients who are candidates for bilateral CTRs.

Analysis of the referral pattern and wait time for hip arthroscopy in a single payer publicly funded health care system.

To analyse the referral pattern for hip pain and to investigate the wait time for an orthopaedic assessment by a hip arthroscopy surgeon in a single payer health care system. We hypothesized that a significant delay from time of onset of symptoms to time of assessment by a hip arthroscopy surgeon exists. Retrospective review of prospectively collected data in an academic hospital in a single payer health care system. An electronic database analysis was conducted searching for all referrals for hip pain between February 2017 and June 2017. Data were then analysed with the aim to identify the most common reason for hip referral, calculate the duration of symptoms between onset and orthopaedic assessment, and categorize previous investigations and treatments. A total of 96 patients were included (47 male and 49 female). Main source of referrals was Family Medicine Physicians in 37% of cases and Primary Care Sports Medicine Physicians in 35%. The most common reason for referral was labral tear in 44.7% of cases followed by combined femoroacetabular impingement and labral tear in 21.8%. The duration of symptoms was longer than 2years in 42% of cases and between 1 and 2years in 40% of cases. Twenty percent of patients had previous intra-articular injection while 53% of patients had physiotherapy treatment (64% of patient underwent physiotherapy for longer than 6months). In the Canadian single payer health care system, a significant delay from the time of onset of symptoms to the time of assessment by a hip arthroscopy surgeon exists with the vast majority of patients in our cohort waiting more than 1year. It is unknown if this delay affects the patient outcomes. This will require further investigation. Certainly, based on our findings, we should advocate for a better screening process, centralized referrals to hip arthroscopy specialists, and appropriate patient work-up.

ASSESSING PATIENT OUTCOMES FOLLOWING A FRACTURE

Background: Both primary care sports medicine physicians and orthopedic surgeons, in conjunction with advanced practice providers, often manage young patients with fractures. To our knowledge, no investigations have evaluated patient outcomes based on the type of provider they see for fracture management. This study examined fracture management, patient outcomes, and patient satisfaction in pediatric and adolescent patients with fibula, tibia, radius and ulna fractures. Specifically, we sought to determine if there were differences between patients seen by a primary care sports medicine physician or orthopedic surgeon/physician assistant (PA) on measures of time to clearance from the injury, patient-reported functional outcomes, and patient satisfaction. Methods: A retrospective chart review was performed for 4-18 year-old patients who were treated by a sports medicine provider (primary care or orthopedic surgeon/PA) for a fracture of the radius, ulna, tibia or fibula over the course of three months. We contacted patients approximately 10 months post-injury. Patients or their parents completed a patient satisfaction survey (Short Assessment of Patient Satisfaction [SPAS]) and an injury location-specific patient reported functional outcome tool: the Foot and Ankle Ability Measure (FAAM) was used for patients with fibular or tibia fractures; the Disabilities of the Arm, Shoulder, and Hand (DASH) Scale was used for patients with radius or ulna fractures. The SPAS is scored from 0-28 with higher scores indicating higher satisfaction. The DASH is scored from 0-110, while the FAAM is scored from 0-140. For the DASH and FAAM, 0 indicates the least disability. Results: 83 of 139 (60%) of patients who were contacted completed the study. 58 (70%) of patients were treated by pediatric primary care sports medicine physicians and 25 (30%) were treated by a pediatric sports medicine orthopedic surgeon or the surgeon’s PA. Both patient groups (Table 1) were of similar age (10.3±3.1 vs. 8.9±3.9 years; p= 0.09), proportion of females (47% vs. 36%; p= 0.47), proportion of upper extremity injuries (67% vs. 80%; p= 0.30), and number of x-rays obtained (3.2±3.5 vs. 3.5±1.8; p= 0.60). The median time from injury to clinically-confirmed healing was similar between the two groups (47 vs 60.5 days; p=0.54), as was the overall patient satisfaction (Table 2) on the SPAS (median score = 26 [range = 19-28] vs 24 [range 9-28]; p = 0.11). In addition, the patient reported outcomes did not differ significantly between the two groups for the DASH (median score=0 [range= 0-11] vs. 0 [range= 0-43], p= 0.47), or the FAAM (median score= 0 [range= 0-47] vs. 0 [range= 0-0], p= 0.36). A greater proportion of patients that were treated by sports medicine primary care physicians reported they would prefer to see a sports medicine primary care physician for future care relative to the pediatric sports medicine surgeon group (Table 3; 74% vs. 20%; p&lt; 0.001). In contrast, those seen by a sports medicine surgeon or PA indicated they would prefer to see a pediatric PA or pediatric nurse practitioner in the future relative to the pediatric sports medicine primary care group (28% vs. 2%; p= 0.001). Conclusion/Significance: Pediatric primary care sports medicine physicians and pediatric sports medicine orthopedic surgeons, with their PAs, have similar outcomes when caring for young patients with fractures of the radius/ulna and tibia/fibula. Patients report equal satisfaction with their care. Patients will likely have favorable outcomes when they are cared for by any of these providers. Tables and Figures: [Table: see text]

Rotator cuff tendon calcific tendinitis treatment algorithm for primary care musculoskeletal physicians.

Purpose:Calcific tendinitis of the shoulder is a common pathology encountered by primary care sports medicine physicians and orthopedic surgeons. Understanding the patient demographics responsible for calcific tendinitis outcomes from various treatment modalities may lead to greater understanding of appropriate management.Methods:This was a retrospective study on patients who were diagnosed with calcific tendinitis by imaging (radiographs, MRIs) at our institution from 2014 to 2016. The data collection included patient demographics, clinical signs and symptoms management. Treatment outcomes were assessed by whether symptoms resolved and the number and type of treatment.Results:A total of 250 medical records were reviewed out of which 237 were involved in the data analysis. There were 95 male and 141 female patients with a mean age of 54.9 ± 11.5 years. In all, 120 patients complained of right shoulder pain and 117 of left shoulder pain. Smokers had a higher VAS Pain at Rest and Activity of 6.1 ± 3.5 and 8.2 ± 2.4, respectively, with non-smokers scoring a lower VAS Pain Rest score of 4.2 ± 3.1 and 7.9 ± 2.0 (P = 0.18). The VAS Pain Rest score after follow-up from corticosteroid injection, ultrasound-guided injection with needling, and surgery were 3.9 ± 3.0, 3.5 ± 3.0, and 0.7 ± 1.4, respectively.Conclusion:An algorithm constructed from our results recommends initial management with a subacromial corticosteroid injection with physical therapy followed by ultrasound-guided injection with needling and PT if the initial treatment fails. Surgical management is considered when the patient is recalcitrant to the first two forms of non-operative treatment.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations, and Future Directions: Erratum.

Cardiovascular (CV) screening in young athletes is widely recommended and routinely performed before participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for CV screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation CV screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal CV screening strategy for all athletes including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate CV screening strategy unique to their athlete population, community needs, and resources. The decision to implement a CV screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. American Medical Society for Sports Medicine is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

Rehabilitation After Medial Patellofemoral Ligament Reconstruction

Patellar instability resulting from subluxation or dislocation is a painful and commonly recurring condition. Retinacular restraints control patellar tracking, limiting the movement of the patella in the trochlear groove. The medial patellofemoral ligament (MPFL) is considered the main soft tissue stabilizer against lateral displacement. Few studies of patellar instability discuss rehabilitation after MPFL reconstruction. In this review, we discuss the phases of rehabilitation after MPFL reconstruction, typical interventions by rehabilitation specialists, and patient-specific guidelines for return to prior level of function. The Musculoskeletal Institute at The Johns Hopkins Hospital (a collaboration of orthopedic surgeons, primary care sports medicine physicians, and clinicians from the Department of Physical Medicine and Rehabilitation) presents its rehabilitation protocol with phase-specific guidelines for progression after MPFL reconstruction. This evidence-based protocol is a generalized approach that is customized for each patient's needs.

Patient Throughput in a Sports Medicine Clinic With the Implementation of an Athletic Trainer: A Retrospective Analysis.

Background:Orthopaedic clinics have acquired a multitude of health professionals to improve clinic efficiency. More recently, athletic trainers (ATs) have been utilized to improve clinical efficiency and patient care because of their extensive background in musculoskeletal injuries and anatomy. Improved clinical efficiency allows for increased patient visits, potentially enhancing patient access and downstream revenue via relative value units (RVUs).Hypothesis:The addition of an AT into a sports medicine physician’s clinic will increase total patient throughput and overall RVU production.Study Design:Retrospective analysis.Level of Evidence:Level 4.Methods:Patients seen by each of the 2 primary care sports medicine physicians at St Luke’s Sports Medicine for a 2-year period were retrospectively evaluated. The initial clinic model included the physician and a medical assistant; during the second year of analysis an AT was added to the clinic staffing model. Two-tailed t tests were used to determine significant differences in patient volume between the 2 periods of data collection.Results:Through the implementation of an AT, patient throughput increased by 0.7 patients per hour over 2 half-day clinics, a 25% increase (P < 0.01). Physician B patient visits increased by 21%, or 3.8 patients per 6.5-hour clinic day (P < 0.01). Additionally, RVU production increased by 3.23 per half-day and 4.3 per full day for physicians A and B, respectively.Conclusion:Clinical efficiency was improved with the addition of an AT. Total physician RVUs improved, thereby raising the potential revenue of both the physician and health care institution. Employing ATs in a sports medicine clinic may improve clinical productivity and financial stability, thereby validating the incorporation of ATs into the established clinical model.Clinical Relevance:Limited research exists measuring patient throughput with an AT in a sports medicine clinic. This study investigates patient throughput and the subsequent increase in work-based RVUs.