Sports Medicine Training Research Articles

Evaluating Acute Sport-related Concussion In The Primary Care Setting: Are We Dropping The Ball?

Concussed athletes are increasingly introduced into the medical care continuum via the primary care setting. As such, primary care physicians (PCPs) are expected to make more decisions regarding return-to-play, symptom management, and specialist referral than ever before. Concussion-specific history and physical examination is vital for this decision-making process. PURPOSE: To review clinic documentation and determine how PCPs are evaluating concussed athletes in clinic relative to published consensus and guidelines. METHODS: We conducted a retrospective records review for all patients evaluated by PCPs with no formal sports medicine training at a single large academic medical center. We restricted our review to pediatric patients (7-18 yrs) diagnosed with sport-related concussion between 2014-2017. RESULTS: We included 490 patients (age=14.7 ± 2.2 years; 184 females). Patients presented most frequently to pediatricians (60%) at a median of 3 days from injury (range 0-64 days, IQR 1-6). Most patients participated in football (25.9%), soccer (19.8%), and basketball (15.1%). Prior concussion history was documented in 28.8% of visits. Providers documented headache presence or absence in 94% of patients, compared with nausea (52.2%), dizziness (51.8%), vision changes (45.7%), cognitive complaints (45.7%), emotional changes (17.1%), sleep difficulties (15.8%) and neck pain (13.5%). Basic neurologic examination was documented in 95.5% of visits compared to detailed neurologic assessment including strength, sensation, cranial nerves, and cerebellar function (26.9%), clinical cognitive assessment (13.5%), balance testing (41%), and neck exam (45.7%). Return-to-play was frequently discussed (94.5% of visits) and 13.1% of PCPs referred the patient to a dedicated sports medicine provider. CONCLUSIONS: Symptom-based return-to-play algorithms cannot be effective if the signs and symptoms driving their decision-making aren’t being properly evaluated and documented. The PCPs caring for the patients in our retrospective study often omit important components of the history and physical examination for concussed athletes. New tools are needed to empower PCPs to more completely evaluate and manage these patients, and PCPs should be encouraged to thoroughly document the care provided.

A Textile Sensor for Long Durations of Human Motion Capture.

Human posture and movement analysis is important in the areas of rehabilitation, sports medicine, and virtual training. However, the development of sensors with good accuracy, low cost, light weight, and suitability for long durations of human motion capture is still an ongoing issue. In this paper, a new flexible textile sensor for knee joint movement measurements was developed by using ordinary fabrics and conductive yarns. An electrogoniometer was adopted as a standard reference to calibrate the proposed sensor and validate its accuracy. The knee movements of different daily activities were performed to evaluate the performance of the sensor. The results show that the proposed sensor could be used to monitor knee joint motion in everyday life with acceptable accuracy.

Trends in Hip Arthroscopic Labral Repair: An American Board of Orthopaedic Surgery Database Study

The purpose of this study is to evaluate the trends in labral repair in American Board of Orthopaedic Surgery Part II candidates performing hip arthroscopy. Candidates who performed arthroscopic hip surgery between 2011 and 2015 during their American Board of Orthopaedic Surgery Part II board collection period were identified using Current Procedural Terminology codes (29860, 29861, 29862, 29863, 29914, 29915, 29916). The proportion of hip arthroscopy cases including labral repair (Current Procedural Terminology code 29916) were calculated for each year and analyzed by fellowship training experience. Trends in labral repair utilization were calculated using univariate and regression analyses, with significance set at P < .05. During the study period, 1,606 hip labral repair cases were performed, with a 35% increase in utilization between 2011 and 2015. Overall, labral repair was performed in 64.8% (1,606/2,480) of hip arthroscopy cases, with a significant increase between 2011 and 2015 (47.4% vs 79.2%; P < .001). Of the hip arthroscopy cases including labral repair, 80.4% (1,291/1,606) were performed by candidates with sports medicine fellowship training. The proportion of hip arthroscopy cases including labral repair was highest for surgeons with sports medicine fellowship training compared with those without sports medicine fellowship training (66.1% vs 59.8%; P=.007). Candidates with sports medicine training performing at least 1 labral repair each year increased from 68% to 89% over the study period (P= .0007). The average number of labral repairs per candidate increased significantly over the duration of the study period (P= .0072). Labral repair utilization during hip arthroscopy procedures nearly doubled from 2011 to 2015 for American Board of Orthopaedic Surgery Part II candidates, reflecting a significant change in practice. Current data suggest that nearly 80% of hip arthroscopy procedures include labral repair. These trends may reflect the current practice patterns at academic institutions with sports medicine fellowships.

COMPLICATION ANALYSIS OF PEDIATRIC AND ADOLESCENT ACL RECONSTRUCTIONS IN THE ABOS DATABASE

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures performed in adolescents. Similarly, the rate of ACL reconstructions performed in pediatric patients has been increasing, and this population has the highest rate of primary and revision ACL Surgery. The purpose of this study was to review data on ACL reconstructions performed in patients under the age of 19 years that were submitted to the American Board of Orthopaedic Surgeons (ABOS) Part 2 examination to evaluate post-operative complications and trends over time in applicant fellowship training. METHODS: A query to the ABOS SCRIBE database was submitted for all ACL reconstructions performed in patients less than 19 years old. The database query was based on ICD-9 and ICD-10 diagnostic codes submitted by each applicant. Data included geographic region, fellowship training of the applicant, exam subspecialty, and reported complications. A subgroup analysis of complications was also performed in patients less than 15 years compared to those 15-18 and amongst different applicants based on fellowship training. RESULTS: From 2000 – 2016, 9,767 ACL reconstructions were performed by candidates taking Part 2 of the ABOS board certification process. The mean age at surgery was 16 years (reported age range 0-18) and a meniscus procedure was performed in 57% of cases. There was a 41% increase in ACL reconstructions in those under the age of 15 years between 2000 and 2016. In each age group, the incidence of ACL reconstruction in males was higher than in females (ratio 5:4) except in those 12 and 13 years old whereby the incidence was higher in females (ratio 2:1). A majority (70.5%) of ACL reconstructions were performed by candidates with a sports medicine fellowship. In patients less than 15 years old 24.5% of reconstructions were performed by candidates with a pediatric or dual pediatric and sports medicine fellowship training. The overall complication rate was 13.6% with 0.4% anesthetic related complication (0.2% related to regional anesthesia). The reoperation rate was 0.8% and the readmission rate was 0.5%. Twelve patients (0.14%) sustained a venous thromboembolic event (6 deep vein thrombosis and 6 pulmonary embolism). A majority of complications (10.83%) were related to the surgery. The most common surgery related complications were infection (1.51%) and arthrofibrosis (1.3%). The overall incidence of reported complications was not statistically different between those with sports (13.7%), pediatric (16.3%), or both sports and pediatric fellowships (17.5%). Differences in specific complications were noted when comparing those with only pediatric training and those with only sports medicine fellowship training including graft related problems (1.9% vs. 0.7%, p=0.001, respectively) and nerve palsy/injury (1.9% vs. 0.6%, p&lt;0.001, respectively). CONCLUSION/DISCUSSION: ACL reconstruction in the adolescent and pediatric age groups are primarily performed by candidates with a sports medicine fellowship. Complications rates between candidates reporting either sports medicine or pediatric fellowship training are overall comparable. Graft related complication and nerve palsy/injury were lower in those with sports medicine fellowships and both pediatric and sports medicine fellowships suggesting that additional training in sports medicine or arthroscopy may help minimize those complications. Longitudinal studies evaluating long term risks and complications after pediatric/adolescent ACL reconstruction are needed.

TRENDS IN PEDIATRIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A REVIEW OF SURGEON FELLOWSHIP, GEOGRAPHY, AND MENISCUS SURGERY IN THE ABOS PART 2 DATABASE

INTRODUCTION: An increased rate of pediatric and adolescent patients undergoing ACL reconstruction has clearly been established, and now considered one of the most common arthroscopic procedures performed in youth patients. Little knowledge exists on whether these trends truly represent an increase in ACL injury, identification, or surgical management. Trends, including surgeon training, meniscus treatment, or geographic differences, have not been reported. The purpose of this study was to review data from ACL reconstructions performed in patients under the age of 17 years, that were submitted to the American Board of Orthopaedic Surgeons (ABOS) Part 2 examination, with a goal of evaluating national treatment trends over a 16-year period. METHODS: A query to the ABOS SCRIBE database was submitted for all ACL reconstructions performed in patients less than 17 years old between 2002 and 2016. The query was designed to search for CPT procedure codes submitted by each applicant. Query data included geographic region, fellowship training of the applicant, age and sex of the patients, and associated procedures. Each case had an associated applicant number, and thus, the total number of ACL reconstructions performed by each surgeon during board collection was provided. Trends were reviewed for the aggregate data and a Mann-Whitney test was used for comparison of data between 2002 – 2009 (Early-ACL) and 2010-2016 (Recent-ACL) groups. RESULTS: Since 2002, there has been a 2.6% increase in pediatric ACL reconstructions performed by candidates applying for Part 2 of the ABOS examination. Additionally, a 193% increase in dual pediatric and sports medicine fellowship trained candidates performing pediatric ACL reconstruction since 2010 was seen. A majority of pediatric ACL procedures were performed by sports medicine trained surgeons (75.9%). During this time period, a total of 362 (or 8.3%) of pediatric ACL procedures were performed by surgeons with neither sports medicine nor pediatric orthopaedic fellowship training. Following 2009, a 44% increase in pediatric ACL reconstructions performed was noted (Figure 1A). Additionally, an increase in reconstructions performed in female patients compared to males was noted (Figure 1B). A majority of pediatric ACL reconstructions did not require additional meniscal treatment, however, meniscus repair was more likely to be performed after 2009 (p=0.0012). The number of meniscal repair procedures reported in the setting of ACL reconstruction generally increased over the study period. In 2002, 24% of ACL reconstructions required a meniscal repair compared to 41% in 2016 (Figure 1C). A majority of these repairs were performed by surgeons with sports medicine fellowship training. Geographic trends reported are based on patients &lt;16 per available census records (Figure 1D). Geographic variation exists with of the highest rates of pediatric ACL reconstructions occurring in the South (4.62 per million) and Midwest (4.07 per million) in comparison to the Southeast (1.85 per million). When adjusting for population size per year, each region saw a significant increase in reported ACL surgeries from the Early-ACL to the Recent-ACL timeframe (p=0.005). The largest increases in surgeries reported between Early-ACL and Recent-ACL were seen in the Southeast (68% increase), Midwest (50% increase) and Southwest (47% increase). Of all the providers who performed surgery, 74% submitted only 1-2 cases from 2002-2016, with 26% of providers performing more than 55% of all of the pediatric ACL reconstruction cases. More than 75% of all cases were performed by sports medicine fellowship trained surgeons However, a large change was seen in dual sports and pediatric trained surgeon case volumes over this time period, with these surgeons performing 7.5 times more surgeries from 2010 to 2016 (Recent-ACL) when compared to 2002-2009 (Early-ACL). CONCLUSION: Since 2009, pediatric ACL reconstructions are more likely to be female and are more likely to undergo a meniscal repair. Geographic variation is noticeable, with more surgeries reported to be performed in the South. Dual pediatric and sports medicine fellowship trained candidates performing ACL reconstruction have significantly increased over time, although those surgeons who are only sports medicine fellowship trained continue to perform the bulk of ACL reconstructions in young patients.

Safety of Qigong: Protocol for an overview of systematic reviews.

Background:Qigong, as one of the essential elements of Traditional Chinese exercises, has been used to improve physical and psychological health and combat diseases in China for thousands of years. In recent years, the beneficial effects of Qigong on different medical conditions are becoming more accepted by both patients and health care providers. Although it is a common impression that Qigong and related therapies are generally safe procedures, but the current understanding of its adverse events is fragmented. Thus, we conducted this overview to synthesize comprehensively existing systematic reviews on adverse events associated with Qigong and related therapies, and our findings can be used to informing clinicians, Qigong practitioner, and patients alike on applying such treatments or interventions in clinical treatment and daily life training mindful manner, and provide a guideline for researchers in future.Methods:A systematic review of reviews will be performed. A literature search strategy designed by a number of specialists in the fields of Traditional Chinese Medicine (TCM), sports medicine, health information, and Qigong training will be carried out in relevant English and Chinese electronic database. The date range of search will start from inception to the search date. Two reviewers will identify relevant studies, extract data information, and then assess the methodical quality by Assessment of Multiple Systematic Reviews (AMSTAR) tool. Any types of systematic review that summarized adverse effects related to Qigong and related therapies in human will be included. Any safety-related outcomes will be considered as the primary outcomes of this overview. Where objectives from 2 or more reviews overlap, we will assess the causes of any noted discrepancies between reviews. An overall summary of results will be performed using tabular and graphical approaches and will be supplemented by narrative description.Results:This overview will identify any adverse events associated with nonstandardized Qigong and related therapies procedures based on current relevant literature evidence of safety for Qigong.Conclusion:Our overview will provide evidence to help synthesize the broad degree of information available on furthering the knowledge, safety, and application of Qigong.Ethics and dissemination:Formal ethical approval is not required, as this study is an overview based on the published systematic reviews. The result of this overview of systematic reviews will be published in a peer-reviewed journal or disseminated at national and international conferences.PROSPERO registration number:PROSPERO CRD42018109409

Factors Affecting the Preferred Surgical Technique in Pediatric Anterior Cruciate Ligament Reconstruction.

Background:Despite several well-described operative techniques, the optimal management of anterior cruciate ligament (ACL) injuries in pediatric patients remains unclear.Purpose:To identify surgeons’ preferred ACL reconstruction techniques and postoperative protocols for pediatric patients of various ages.Study Design:Cross-sectional study.Methods:An electronic survey was administered to surgeons in the Pediatric Research in Sports Medicine (PRiSM) society, resulting in a cohort of experienced respondents who performed a relatively high volume of ACL reconstructions in skeletally immature patients. Surgeon and practice demographic information was recorded. The survey presented the scenario of a patient who had a physical examination and imaging consistent with an acute, isolated ACL tear. The respondents were asked to select their preferred reconstruction technique for female and male patients at consecutive skeletal ages from 8 to 15 years. Surgeons were also asked about postoperative protocol.Results:Of 103 surgeons, 88 (85%) responded to the survey, the majority of whom (68%) performed more than 25 pediatric ACL reconstructions annually. The greatest variation in technique was from ages 11 to 13 years in female patients and from 11 to 14 years in male patients. The modified MacIntosh was the most frequently used technique for patients aged 8 to 10 years. An all-epiphyseal technique was preferred over a broader age range in male patients than female patients, with peak use at age 11 in both. A partial transphyseal (hybrid) technique was preferred in slightly older patients, with peak use at age 12 in female patients and 13 in male patients. The transphyseal technique was most widely used at age 13 and older in female patients and 14 and older in male patients. The impact of fellowship training (pediatrics, sports, or both) on technique preference was statistically significant for male patients aged 11 to 13 and female patients 11 and 12 (all P < .05). Surgeons with pediatric orthopaedic training tended to prefer an all-epiphyseal reconstruction, while those with both pediatric and sports medicine training preferred the modified MacIntosh.Conclusion:The preferred ACL reconstruction technique varied considerably, especially for patients aged 11 to 13 years. The modified MacIntosh reconstruction was favored in patients aged 10 years or younger, while the transphyseal technique was preferred in female patients aged 13 years and older and in male patients 14 years and older. The surgeon’s fellowship training was significantly associated with his or her preferred surgical technique.

Trends in the Surgical Management of Acromioclavicular Joint Arthritis Among Board-Eligible US Orthopaedic Surgeons

(1) Define the epidemiologic trend of distal clavicle excision (DCE) for acromioclavicular (AC) joint arthritis among board-eligible orthopaedic surgeons in the United States, (2) describe the rates and types of reported complications of open and arthroscopic DCE, and (3) evaluate the effect of fellowship training on preferred technique and reported complication rates. The American Board of Orthopaedic Surgery (ABOS) database was used to identify DCE cases submitted by ABOS Part II Board Certification examination candidates. Inclusion criteria were predetermined using a combination of ICD-9 and CPT codes. Cases were dichotomized into 2 groups: open or arthroscopic DCE. The 2 groups were then analyzed to determine trends in annual incidence, complication rates, and surgeon fellowship training. From April 2004 to September 2013, there were 3,229 open and 12,782 arthroscopic DCE procedures performed and submitted by ABOS Part II Board Eligible candidates. Overall, the annual incidence of open DCE decreased (78-37 cases per 10,000 submitted cases, P= .023). Although the annual number of arthroscopic DCE remained steady (1160-1125, P= .622), the percentage of DCE cases performed arthroscopically increased (65%-79%, P= .033). Surgeons without fellowship training were most likely to perform a DCE via an open approach (31%) whereas surgeons with sports medicine training were more likely to perform DCE arthroscopically compared with other fellowship groups (88%, P<.001). Open DCE was associated with a higher surgical complication rate overall when compared with arthroscopic DCE (9.4% vs 7.6%, respectively; P < .001). When compared with other fellowship-trained surgeons, sports medicine surgeons maintained a lower reported surgical complication rate whether performing open or arthroscopic DCE (5.5%, P= .027). In recent years, open management of AC joint arthritis has declined among newly trained, board-eligible orthopaedic surgeons, possibly because of an increased complication rate associated with open treatment. Fellowship training was significantly associated with the type of treatment (open vs arthroscopic) rendered and complication rates. Level IV, case series.

Should We Be Concerned About Who Is Performing Hip Arthroscopy?: Commentary on an article by Kyle R. Duchman, MD, et al.: "Who Is Performing Hip Arthroscopy? An Analysis of the American Board of Orthopaedic Surgery Part-II Database".

Commentary The utilization of hip arthroscopy surgery has increased by 365% in the United States in recent years, with the majority of cases performed in patients 20 to 39 years of age1. The increased rate can most likely be attributed to increased awareness of the procedure, diagnostic improvements, technical advances that make hip arthroscopy easier to perform, a broadening of indications to treat conditions that were previously treated with open procedures (e.g., femoroacetabular impingement [FAI]), and an increase in the number of fellowship programs offering hip arthroscopy training1,2. Duchman et al. used the American Board of Orthopaedic Surgery (ABOS) Part-II database to design their study, with the primary aim of providing an update on hip arthroscopy utilization by ABOS Part-II candidates and the secondary aim of describing the fellowship training experiences of candidates performing hip arthroscopy. This study is an extension of work done by Colvin et al., who had used the same database2. The study by Duchman et al. demonstrated that utilization of hip arthroscopy by ABOS Part-II candidates has continued to rise at a significant rate: from 5.3% in 2006 to 10.3% in 2015. This increase was attributed to more candidates performing hip arthroscopy and less so to an increasing number of hip arthroscopy procedures being performed by individual candidates. Duchman et al. found that the procedure was most common among candidates who had received any sports medicine training, as they accounted for 74.5% of all candidates who performed the procedure. High-volume hip arthroscopists (candidates who performed ≥20 procedures) accounted for 6.5% of all candidates who performed hip arthroscopy, and the most common fellowship training among these high-volume candidates was also sports medicine. This information is important to educators as a call to create a hip-preservation curriculum for sports medicine trainees that is commensurate with improved clinical and radiographic outcomes. Careful patient selection with definition of proper indications is important to avoid the overuse of hip arthroscopy. A candidate’s training period is the most important time for learning such information. Gupta et al.3 and Harris et al.4 reviewed complications that can arise from hip arthroscopy, including neurapraxia, heterotopic ossification, iatrogenic cartilage scuffing, labral penetration, abdominal fluid extravasation, instrument breakage, and reoperations (revision hip arthroscopy for residual FAI or conversion to total hip arthroplasty). The rates of major and minor complications were 0.58% and 4.1%, respectively, and the reoperation rate was 6.3%. The learning curve for hip arthroscopy was directly related to the rates of reoperations and minor complications. The authors concluded that technique-related complications can be minimized by surgeon experience3,4. Avoiding these complications is important to enable patients to return to their normal life and sports activities. Defining the learning curve for hip arthroscopy is especially important as we know from the article by Duchman et al. that more and more sports-medicine-trained candidates are performing the procedure. Colvin et al. found that fellows are exposed to <20 hip arthroscopy cases in their fellowship training program2. The number of cases needed to achieve proficiency during the training period needs to be defined. The Accreditation Council for Graduate Medical Education (ACGME) has established minimum procedure volumes for shoulder and knee arthroscopy in residency programs but not for arthroscopy in other joints5. However, we are seeing a rise in hip arthroscopy elsewhere in the literature: Gil et al. found a 588.9% increase in hip arthroscopy procedures performed by residents during their training period5. Future Directions It would be helpful if we could evaluate outcomes (clinical scores, complications, revision hip arthroscopy procedures, and conversion procedures) of patients who were treated with hip arthroscopy by ABOS Part-II candidates. Outcomes could then be compared among candidates on the basis of the numbers of hip arthroscopy procedures that they performed during their fellowship training. This could help educators both outline a hip arthroscopy curriculum and set target goals for the numbers of cases that candidates need to perform to achieve proficiency. The numbers of hip arthroscopy procedures performed during the training period can be calculated on the basis of self-reporting and by incorporating the ACGME training case log database, which lists procedures logged during residency and fellowship. Combining the data from the ACGME training log with data from the ABOS Part-II database may provide greater clarity in defining the learning curve for early-career surgeons and creating a curriculum for hip arthroscopy in sports medicine programs.

Completion of Multiple Fellowships by Orthopedic Surgeons: Analysis of the American Board of Orthopaedic Surgery Certification Database.

Orthopedic surgeons have become increasingly subspecialized, and recent studies have shown that American Board of Orthopaedic Surgery (ABOS) Step II applicants are performing a higher percentage of their cases within their chosen subspecialties. However, these studies focused exclusively on surgeons who have completed a single fellowship; little data exist on those who pursue a second fellowship. All applicants to the ABOS Part II examination from 2004 to 2016 were classified by their self-reported fellowship training history using the ABOS Part II examination database. Trends in the number of applicants completing multiple fellowships and the types of fellowships combined were analyzed. In addition, cases performed by applicants who had performed multiple fellowships were analyzed to determine what percentage were within their chosen subspecialties. A total of 9776 applicants to ABOS Part II were included in the database from 2004 to 2016, including 444 (4.5%) applicants who completed more than one fellowship. There were 43 different combinations of fellowships; the most common additional fellowships were trauma (40.1%), sports medicine (38.7%), and joints (30.4%). The most common combinations were joints and sports medicine (10.6%) and foot and ankle and sports medicine (10.1%). A significant increase occurred in physicians training in both pediatric orthopedics and sports medicine (P=.02). The percentage of cases within the applicants' chosen specialties ranged from 91.4% in sports to 73.6% in tumor. Multiple fellowship applicants represent a small percentage of all applicants, and although subspecialization in orthopedics is increasing, no increasing trend toward multiple fellowships within this dataset was observed. However, the significant increase in applicants who combined pediatric orthopedic and sports medicine fellowships suggests an increasing interest in treating this increasing patient population in addition to social and economic factors. [Orthopedics. 2018; 41(1):e33-e37.].

Trends in Surgical Treatment of Lateral Epicondylitis Among Recently Trained Orthopaedic Surgeons

Lateral epicondylitis (LE) is common and often responds to nonsurgical treatment in 80-90% of patients. For those who proceed with surgery, much regarding the ideal technique remains unclear. The purpose of this study was to review the recent trends in open and arthroscopic surgical management of LE among newly trained orthopaedic surgeons in the United States. The American Board of Orthopaedic Surgery (ABOS) database was utilized to identify LE surgical cases submitted by Part-II Board Certification examination candidates from 2004-2013. Inclusion criteria were predetermined using a combination of ICD-9 and CPT codes. Cases were dichotomized into open and arthroscopic groups and analyzed to determine trends in surgeon fellowship training, complication rates, types of complications, and concomitant procedures. In total, 1,150 surgeons submitted 2,106 surgical cases for the treatment of LE. On average, surgeons with hand fellowship training performed more surgical cases (2.4) per 6-month collection period than those with shoulder and elbow (1.9) and sports medicine (1.5) training (p<0.001). Among all cases, 92.2% were open, and 7.8% were arthroscopic (Table 1). Since 2008 (after implementation of more specific CPT codes for open treatment), percutaneous tenotomy, debridement only, and debridement with tendon repair/reattachment consisted of 6.0%, 46.2%, and 47.8% of open treatment, respectively. Surgeons with shoulder and elbow (18.1%) and sports medicine (11.4%) fellowship training were more likely to perform surgeries arthroscopically compared to those with hand fellowship training (6.1%). There was no difference in overall complication rates for open (4.4%) versus arthroscopic (5.5%) procedures. Concomitant radial tunnel release was performed infrequently but when performed, 83.8% were by surgeons with hand fellowship training. Concomitant synovectomy and removal of loose body were performed in 13.4% and 4.3% of arthroscopic cases, respectively. Surgical management of LE varies depending on surgeons’ fellowship training. Short-term complication rates appear comparable between open and arthroscopic treatment.

Current Trends in Ulnar Collateral Ligament Reconstruction Surgery Among Newly Trained Orthopaedic Surgeons.

Ulnar collateral ligament (UCL) reconstructions are being performed with an increasing annual incidence. The purpose of this study was to evaluate trends in UCL surgery among recently trained orthopaedic surgeons. The American Board of Orthopaedic Surgeons (ABOS) database was used to identify all UCL reconstructions from 2004 to 2013. Procedures were identified by Current Procedural Terminology (CPT) codes and verified by International Classification of Disease, Ninth Revision (ICD-9) codes. Data on surgeon fellowship, practice location, concomitant surgical procedures, and complications were collected. One hundred sixty-four UCL reconstructions were performed by 133 ABOS Part II candidates. The annual incidence increased from 1.52 to 3.46 cases per 10,000 (P = 0.042). Reconstructions were most commonly performed by surgeons with fellowship training in sports medicine (65.9%), hand and upper extremity (18.9%), and shoulder and elbow (9.1%). Most reconstructions were performed in isolation (57.3%), or with ulnar nerve transposition (32.9%) or elbow arthroscopy (9.8%). Concomitant elbow arthroscopy rates decreased significantly (P = 0.022). Complications occurred in 9.8% of cases, although the rates did not significantly change (P = 0.466). UCL reconstructions are being performed with increasing frequency. Concomitant procedure rates remained the same, although arthroscopy was less commonly performed. Complication rates did not change considerably over the observed period. Further study of the surgical trends and associated long-term outcomes is warranted. Level IV.

The Perceived Demands of CrossFit®

Rhabdomyolysis is the breakdown of muscle tissue causing myoglobin, creatine kinase, and other intracellular proteins and electrolytes to leak into circulation, disrupting cell homeostasis. Exertional rhabdomyolysis (ER) occurs after extremely rigorous physical training that could include high amounts of strenuous eccentric exercise. There has been an increase in reports for mild to severe ER as well as other musculoskeletal injuries as the popularity of extreme conditioning programs (e.g., CrossFit®) increases. PURPOSE: The main purposes of this investigation were to identify: primary risk factors associated with ER during CrossFit®, CrossFit® workouts that might induce a higher risk for the development of ER, and ratings of perceived exertion (RPE) for CrossFit® vs. American College of Sports Medicine (ACSM) training guidelines. METHODS: An online questionnaire (Qualtrics, Qualtrics, LLC) was completed by 101 CrossFit® participants and 56 ACSM guided participants (n = 157). Statistical analysis utilized an independent t-test analysis via SPSS (IBM® SPSS® Statistics Version 21). This was used to compare the statistical significance of the means for each group related to the average RPE for workouts, the number of weeks the individual participated in the program, and the perceived average number of hard days completed during a week. RESULTS: CrossFit® and ACSM groups reported significantly different RPEs of 7.29 ± 1.74 and 5.52 ± 1.35 (p ≤ 0.001), and performed significantly different hard days per week of 3.99 ± 1.07 and 3.55 ± 1.39 (p = 0.044), respectively. The top five perceived hardest workouts based on frequency were Fran (47), Murph (27), Fight Gone Bad (10), Helen (9) and Filthy 50 (9). One occurrence of ER was reported out of 101 CrossFit® participants. CONCLUSION: The overall risk of developing ER may be minimal, especially if a participant understands their body’s limitations in regard to the intensity of CrossFit®. Supported by Northern Michigan University Spooner Grant Winter 2014

Rates and Determinants of Return to Play After Anterior Cruciate Ligament Reconstruction in National Collegiate Athletic Association Division I Soccer Athletes

Background: Factors and details regarding return to play in elite, collegiate female soccer athletes after an anterior cruciate ligament (ACL) injury and reconstruction have not been well studied. Purpose: To evaluate return to play among collegiate female soccer players, specifically examining the effect of surgical and individual athlete characteristics on the return-to-play rate. Study Design: Descriptive epidemiology study. Methods: Sports medicine and athletic training staff at institutions from the National Collegiate Athletic Association Southeastern Conference (SEC) were contacted to request participation in the study. All institutions were sent a standardized spreadsheet with response choices and instructions regarding athlete inclusion criteria. Athlete, injury, surgical technique, and return-to-play data were requested for ACL reconstructions performed on female soccer athletes at the participating institutions over the previous 8 years. χ2 analyses were used to compare the return-to-play rate by year in school, scholarship status, position, depth chart status, procedure, graft type, graft fixation, concomitant procedures, and previous ACL injuries. Results: All 14 of the SEC institutions chose to participate and provided data. A total of 80 ACL injuries were reported, with 79 surgical reconstructions and return-to-play data for 78 collegiate soccer athletes. The overall return-to-play rate was 85%. There was a statistical significance in return-to-play rates favoring athletes in earlier years of eligibility versus later years (P < .001). Athletes in eligibility years 4 and 5 combined had a return-to-play rate of only 40%. Scholarship status likewise showed significance (P < .001), demonstrating a higher return-to-play rate for scholarship athletes (91%) versus nonscholarship athletes (46%). No significant differences in return-to-play rates were observed based on surgical factors, including concomitant knee procedures, graft type, and graft fixation method. Conclusion: Collegiate female soccer athletes have a high initial return-to-play rate. Undergoing ACL reconstruction earlier in the college career as well as the presence of a scholarship had a positive effect on return to play. Surgical factors including graft type, fixation method, tunnel placement technique, concomitant knee surgeries, and revision status demonstrated no significant effect on the return-to-play rate.

Physical Education, Exercise, Fitness and Sports: Early PM&R Leaders Build a Strong Foundation

Physical Education, Exercise, Fitness and Sports: Early PM&R Leaders Build a Strong Foundation

Physician provider type influences utilization and diagnostic utility of magnetic resonance imaging of the knee.

Magnetic resonance imaging of the knee is expensive and is neither needed nor useful for all patients presenting with knee pain. Our objective was to determine the completeness of evaluation prior to ordering magnetic resonance imaging of the knee correlated to the ordering providers' postgraduate medical training and the rate of positive findings on the subsequent magnetic resonance imaging. Six hundred consecutive knee magnetic resonance images were reviewed, including 200 consecutive knee magnetic resonance imaging examinations from each of three provider types: orthopaedic surgeons, non-surgical physicians with sports medicine training, and primary care providers. Positive findings on magnetic resonance imaging were recorded as well as a history of present illness, a physical examination, and radiographs made prior to ordering magnetic resonance imaging of the knee. Patient and injury factors were recorded. Differences in patient factors, evaluation before magnetic resonance imaging, and positive findings were examined. A modified Poisson regression approach was used to determine predictors of a proper evaluation before magnetic resonance imaging and positive findings on knee magnetic resonance imaging. Orthopaedists and non-surgical sports physicians were significantly more likely to document a physical examination, to evaluate radiographs made prior to ordering a magnetic resonance image, and to identify positive findings on the magnetic resonance image (all p < 0.001). In multivariate models, orthopaedists were more likely to document a history of present illness (relative risk, 1.05; p = 0.043). Compared with primary care physicians, a physical examination was more likely to be documented by both non-surgical sports medicine physicians (relative risk, 1.61; p < 0.001) and orthopaedists (relative risk, 1.60; p < 0.001) and positive magnetic resonance imaging findings were more likely to be found by non-surgical sports medicine physicians (relative risk, 1.41; p = 0.012) and by orthopaedists (relative risk, 1.44, p = 0.009). Other independent predictors of a magnetic resonance imaging study with positive findings were the presence of an acute injury by history (relative risk, 2.04; p < 0.001) and younger age (relative risk, 0.99; p = 0.021). Orthopaedists and non-surgical sports physicians are more likely to perform and to document a complete evaluation prior to ordering a knee magnetic resonance image with a positive finding. More musculoskeletal training may be useful to enable primary care physicians to use magnetic resonance imaging of the knee in a more efficient manner.

History and application of the AHA 12 points for assessing cardiovascular risk in athletes.

The cardiovascular (CV) evaluation, one important part of the preparticipation physical examination (PPE), is the focus of this special communication. Cardiac events during sporting events, albeit rare, can be fatal, and these events are often very public (5,7,10). In the United States, most athlete PPE for ages 6 to 24 years are performed by family physicians and pediatricians (8), some with subspecialty training in sports medicine. Often, the PPE is the first encounter with the health care system for adolescents and serves as the sole opportunity for general screening, risk factor evaluation, and health education. This may be especially true for adolescents in lower income strata. The PPE is intended to reduce the risk of adverse outcomes without unduly restricting athlete participation. A thorough history examination can uncover a large portion of the athlete’s risk for injury or illness, and the physical examination unveils other abnormalities. There are very few proven screening methods that assure an athlete’s health, but the PPE provides a framework to assess and stratify sport participation risk. The intent of these evaluations is to deliver to health care providers pertinent information to educate athletes and parents and enable them to make an informed participation decision. The first PPE monograph was published in 1992 by five organizations (American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine). The American College of Sports Medicine joined for the third edition in 2005, and the fourth edition was published in 2010 (1). The American Heart Association (AHA) developed CV preparticipation screening recommendations for young athletes in 1996 and updated the statement in 2007 (8). The AHA and the American College of Cardiology have reaffirmed their position regarding the CV PPE and electrocardiography (ECG) screening in healthy 12- to 25-year-old young people with a comprehensive review that endorses the 12-element history and physical examination in the 2014 Scientific Statement (9). This recent document added two elements regarding palpitations and previous evaluations similar to those in the fourth PPE. The question sets from the two examination recommendations are similar, and the fourth PPE monograph uses the same general questions, with some differences in syntax and depth of question content. The question wording of the third PPE monograph was based on input from parent and high school athlete focus group sessions to enhance the “understandability” of the questions for the end users. Of note, the question sets are based on expert opinion and have not been subjected to scientific study. In the late 1990s, after surveys showed poor compliance with both the use of consensus-based forms and the AHA question set, some high schools and colleges across the country incorporated the elements of the PPE and the AHA questions (3,9) in their athlete evaluations. Despite progress, however, a 2013 Washington state survey showed that only 47% of physicians understood the AHA guidelines (4). This is unfortunate, given the evidence that supports the efficacy of adopting a standardized PPE form (10).The 12-Step Questionnaire Recommendations for Health Care Providers for Preparticipation Cardiovascular Screening in Athletes (8)Understanding and utilizing the AHA 12-point CV examination and its constellation of responses is essential to make logical, cost-effective decisions regarding additional evaluations, consultations, and sport participation recommendations (1,9). This document is intended to direct the use of diagnostic testing, including ECG, and reduce reflex use of consults and diagnostics along the lines of the American Medical Association “Choosing Wisely” campaign (6) and encourage the implementation of either the AHA 12-point or the PPE-4 CV screening tools as the minimal standard for athlete screening, not to endorse one questionnaire over the other. The AHA 12-point question/examination set and the fourth-edition PPE monograph 13 history questions and five physical examination points are outlined as follows. Both emphasize the importance of personal and family history. This Special Communication will provide the reader, and particularly primary care providers conducting the PPE, a framework to address positive responses to questions and findings reveled during the examination. This will help reduce the risk of adverse outcomes and allow athletes to participate in activities that best fit their risk profile. Positive responses to the CV questions require additional history and sometimes diagnostic investigations to rule out CV problems that put athletes at undo risk. Individual questions will be highlighted in a case presentation to illustrate the significance of each question. Informed analysis of the questions and judicious use of diagnostics will be the key to risk reduction, cost control, and unnecessary athlete restriction. The burden of these decisions rests on the shoulders of the physicians performing the PPE.

Accuracy and reliability testing of two methods to measure internal rotation of the glenohumeral joint

We compared accuracy and reliability of a traditional method of measurement (most cephalad vertebral spinous process that can be reached by a patient with the extended thumb) to estimates made with the shoulder in abduction to determine if there were differences between the two methods. Six physicians with fellowship training in sports medicine or shoulder surgery estimated measurements in 48 healthy volunteers. Three were randomly chosen to make estimates of both internal rotation measurements for each volunteer. An independent observer made objective measurements on lateral scoliosis films (spinous process method) or with a goniometer (abduction method). Examiners were blinded to objective measurements as well as to previous estimates. Intraclass coefficients for interobserver reliability for the traditional method averaged 0.75, indicating good agreement among observers. The difference in vertebral level estimated by the examiner and the actual radiographic level averaged 1.8 levels. The intraclass coefficient for interobserver reliability for the abduction method averaged 0.81 for all examiners, indicating near-perfect agreement. Confidence intervals indicated that estimates were an average of 8° different from the objective goniometer measurements. Pearson correlation coefficients of intraobserver reliability for the abduction method averaged 0.94, indicating near-perfect agreement within observers. Confidence intervals demonstrated repeated estimates between 5° and 10° of the original. Internal rotation estimates made with the shoulder abducted demonstrated interobserver reliability superior to that of spinous process estimates, and reproducibility was high. On the basis of this finding, we now take glenohumeral internal rotation measurements with the shoulder in abduction and use a goniometer to maximize accuracy and objectivity.

Sports Medicine Training and Practice Opportunities for Emergency Physicians

BackgroundThere is growing interest among emergency physicians to seek additional training in Sports Medicine (SM) and to add it to their clinical practice. This presents unique training and practice management issues. The majority of Primary Care SM fellowship programs list that they will accept emergency physicians, and approximately one-third have already had an emergency physician as an SM fellow. ObjectivesThe objective of this article is to provide an overview of the key elements for emergency physicians to consider as they pursue SM career goals. DiscussionTraining needs such as continuity of care as it pertains to the athlete, SM skills development, and practice management are reviewed. Practice challenges such as malpractice insurance and billing issues are discussed. Examples of several practice models are presented. Evolving trends in SM practice and training opportunities for emergency physicians are discussed as well. ConclusionsSports Medicine is a viable career option for emergency physicians and may complement their skills set in the management of acute injuries. Practice and training opportunities will continue to evolve as this pathway into the practice of SM gains further recognition.

American Medical Society for Sports Medicine Position Statement

Abstract:Sport-related concussion (SRC) is a common injury in recreational and organized sport. Over the past 30 years, there has been significant progress in our scientific understanding of SRC, which in turn has driven the development of clinical guidelines for diagnosis, assessment, and managemen