Sports Health: A Multidisciplinary Approach

Context: Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited.

Evidence Acquisition: The authors conducted a MEDLINE search on tendinopathy, or “tendonitis” or “tendinosis” or “epicondylitis” or “jumpers knee” from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature.

Results: Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies.

Conclusions: Novel targeted therapies are emerging, but multicenter trials are needed to confirm the results of exercise and mini-invasive treatments.

Background: Pain and injuries suffered by youth pitchers are ongoing concerns that have been addressed through the institution of rules and recommendations regarding pitch counts and rest periods. The aim of our study was to see if coaches of youth baseball pitchers in our region were aware of the recommended guidelines and if they followed them.

Methods: An Internet-based survey consisting of 18 items including demographic information and questions concerning the USA Baseball Medical and Safety Advisory Committee pitching guidelines was sent to coaches affiliated with a local youth league to assess their knowledge of and reported compliance with these recommendations.

Results: Ninety-five of 228 coaches (41.4%) participated in the survey. On average, coaches answered 43% of questions regarding pitch count and rest periods correctly; 73% reported that they followed the recommendations, while only 53% felt that other coaches in the league abided by the recommendations. Thirty-five percent of coaches stated that their pitchers reported shoulder or elbow pain during the season, and 19% reported that one of their pitchers pitched a game with a sore or fatigued arm during the season. No coaches reported any pitching-related injuries among their players requiring surgery. Fewer than 10% of coaches reported that their players pitched in multiple leagues or participated in showcases, while 91% reported that pitchers attended camps or received specific instruction to improve their pitching form.

Conclusions: This study shows that this subset of youth baseball coaches is deficient with regard to knowledge of the USA Baseball Medical and Safety Advisory Committee pitching guidelines. This situation may put youth pitchers at increased risk for upper extremity pain and injuries.

Context: Exercise or rest is commonly prescribed as treatment for patellofemoral pain syndrome.

Study Selection: This study is based on Level I or II research studies examining the effects of exercise and rest on decreasing pain (visual analog scale) and increasing function (Kujala Scoring Questionnaire) using human participants. Articles were limited to those printed in English from PubMed (1966–September 2010), CINAHL (1982–September 2010), and SPORTDiscus (1972–September 2010).

Data Extraction: Weighted aggregate effect sizes and 95% confidence intervals were calculated from means and standard deviations extracted from 10 studies, resulting in an analysis of 433 patients.

Results: A very large effect for exercise was found for patient-reported functional outcomes (d = 2.19) and perceived pain (d = −1.24) in treated patients, which were larger than functional outcomes (d = 0.77) and pain (d = −0.14) in controls. Short-term follow-up of 191 patients from 4 data sets in 2 studies revealed a large effect for functional outcomes (d = 1.04) and pain (d = −0.82) in patients who performed an exercise intervention. One study reported moderate effect sizes for functional outcomes (d = 0.59) and pain (d = −0.35) at 3 months postintervention.

Conclusions: Exercise is the more effective treatment for immediate decrease in pain and increase in function although these differences appear to be less distinguishable over time.

Context: Prolonged transmeridian air travel can impart a physical and emotional burden on athletes in jet lag and travel fatigue. Jet lag may negatively affect the performance of athletes.

Study Type: Descriptive review.

Evidence Acquisition: A Medline search for articles relating to jet lag was performed (1990-present), as was a search relating to jet lag and athletes (1983-January, 2012). The results were reviewed for relevance. Eighty-nine sources were included in this descriptive review.

Results: Behavioral strategies are recommended over pharmacological strategies when traveling with athletes; pharmacological aides may be used on an individual basis. Strategic sleeping, timed exposure to bright light, and the use of melatonin are encouraged.

Conclusions: There is strong evidence that mood and cognition are adversely affected by jet lag. Some measures of individual and team performance are adversely affected as well.

Background: Several studies have evaluated the incidence of and risk factors for injuries among wrestlers, but there are limited data in this population. Understanding the incidence and risk factors could provide important information for educational and preventive efforts at the national and international levels.

Purpose: To assess the incidence of and risk factors for fractures and dislocations among Greco-Roman and freestyle wrestlers in Iran.

Study Design: Prospective cohort study.

Methods: Members of 8 randomly selected wrestling clubs in Kermanshah, Iran, were followed for 12 months. Details of their training and the occurrence of fractures and dislocations were recorded. Related data on fractures and dislocations include site of injury, previous history of injury, coach supervision, and wresting technique that led to the injury.

Results: A total of 495 male wrestlers were included in the study. Seven fractures and 8 dislocations were reported. The incidence of fractures and dislocations was 1.1 per 10 000 athlete exposures, with a fracture rate of 0.5 and a dislocation rate of 0.6. Of the 15 fractures and dislocations, 11 occurred among freestyle wrestlers (0.8 per 10 000 athlete exposures) and 4 occurred among Greco-Roman wrestlers (0.3 per 10 000 athlete exposures). There was a positive correlation between the incidence of wrestlers’ fractures and dislocations and their age (P < 0.01), years of wrestling experience (P < 0.01), previous history of fracture or dislocation (P < 0.01), and age of starting to wrestle (P = 0.03).

Conclusion: The incidence of fractures and dislocations in this study was lower than that seen in previous studies. The risk of fracture and dislocation was heightened by a wrestler’s increased age and years of experience, history of previous fracture or dislocation, and younger age of starting to wrestle.

Background: Magnetic resonance imaging (MRI) is routinely used in the diagnosis of sports-related knee injuries.

Purpose: To determine the accuracy, sensitivity, and specificity of MRI compared with clinical evaluation in the diagnosis of meniscal pathology when the MRI facility and the radiologist are not preselected.

Methods: A total of 288 knee arthroscopies were retrospectively compared. Patients were divided into 3 groups: those who had MRI performed and interpreted at a single institution, MRI performed and interpreted at community facilities, or a clinical evaluation by a senior orthopaedic surgeon.

Results: The sensitivity, specificity, and accuracy of the diagnosis of medial meniscal pathology at a single institution were 90%, 59%, 76%; in community facilities, 73%, 68%, 70%; and by a clinical evaluation, 93%, 55%, 73%, respectively. For lateral meniscal pathology, the results were as follows: single institution, 75%, 76%, 81%; community facilities, 60%, 88%, 79%; and clinical evaluation, 45%, 90%, 79%, respectively. Sensitivity for medial meniscus was greater than for lateral meniscus, but specificity of diagnosis was better for lateral meniscus by MRI and clinical evaluation. While not statistically significant, there was increased sensitivity in the diagnosis of medial meniscus and lateral meniscus at SIs, but they have less specificity than at community facilities. The number of false-positive diagnoses (ie, no intra-articular pathology) that resulted in surgery was 4 of 288 (1.39%). The overall accuracy for medial meniscus by MRI was 73% vs 73% for clinical evaluation. The overall accuracy for MRI for lateral meniscus was 78% vs 79% for clinical evaluation.

Conclusion: Routine MRI may not be more beneficial than clinical evaluation when there is no preselection of MRI facility and interpreting radiologist.

Clinical Relevance: The use of MRI for diagnosing meniscal pathology should be reserved for those cases where the orthopaedic clinical examination is ambiguous.

Background: Several sports medicine reviews have highlighted a 3- to 6-month time frame for return to play after splenic lacerations. These reviews are based on several well-defined grading scales for splenic injury based on computed tomography (CT). None of the articles suggest that serial CT scanning is necessary for follow-up; some even indicate that it has no role in the management of these injuries.

Hypothesis: With proper follow-up and possibly the use of serial CT scanning or other imaging modalities, it may be possible for athletes to safely return to play sooner than what current guidelines recommend.

Study Design: The authors present 2 cases of professional hockey players who both suffered grade III splenic lacerations while playing.

Methods: Both players were treated conservatively and monitored with serial CT scanning until radiographic and clinical findings suggested complete healing.

Results: Both players were able to return to full-contact professional hockey within 2 months after suffering grade III splenic lacerations. Neither athlete suffered any complications after his return.

Conclusions: With CT scanning, 2 athletes were able to return to play earlier (2 months) than previously recommended (3-6 months) without compromising their safety.

Clinical relevance: Additional cases must be examined before outlining more definitive recommendations regarding splenic lacerations in sports, but it is possible that elite athletes may return to play sooner than what the current literature recommends.

Context: Rowing is one of the original modern Olympic sports and was one of the most popular spectator sports in the United States. Its popularity has been increasing since the enactment of Title IX. The injury patterns in this sport are unique because of the stress applied during the rowing stroke.

Evidence Acquisition: This review summarizes the existing literature describing the biomechanics of the rowing stroke and rowing-related injury patterns. Data were obtained from previously published peer-reviewed literature through a search of the entire PubMed database (up to December, 2011) as well as from textbook chapters and rowing coaching manuals.

Results: Rowing injuries are primarily overuse related. The knee, lumbar spine, and ribs are most commonly affected. The injury incidence is directly related to the volume of training and technique.

Conclusion: Familiarity of the injury patterns and the biomechanical forces affecting the rowing athlete will aid in prompt diagnosis and appropriate management.

Context: Competitive swimmers are predisposed to musculoskeletal injuries of the upper limb, knee, and spine. This review discusses the epidemiology of these injuries, in addition to prevention strategies that may assist the physician in formulating rehabilitation programs for the swimmer following an injury.

Evidence Acquisition: A literature search was performed by a review of Google Scholar, OVID, and PubMed articles published from 1972 to 2011.

Results: This study highlights the epidemiology of injuries common to competitive swimmers and provides prevention strategies for the sports health professional.

Conclusions: An understanding of swimming biomechanics and typical injuries in swimming aids in early recognition of injury, initiation of treatment, and design of optimal prevention and rehabilitation strategies.

Background: The relationship between biological tissue healing following knee injury or surgery and long-term clinical outcome has come to the forefront of sports medicine practice. This has led many knee surgeons to incorporate biologically mediated healing factors into the management of knee injuries. In particular, the clinical use of mesenchymal stem cells has opened new horizons.

Evidence Acquisition: Relevant studies were identified through a search of PubMed from January 2000 to April 2011, combining the term mesenchymal stem cells with articular cartilage, anterior cruciate ligament, and meniscus. Relevant citations from the reference lists of selected studies were also reviewed.

Results: Knee injury treatment with mesenchymal stem cells shows potential. Most reports represent animal model studies; few advances have been translated to human clinical applications.

Conclusion: Mesenchymal stem cell use to promote healing following knee injury is likely to increase. There are scientific methodological concerns and ethical and legal issues regarding mesenchymal stem cell use for treating knee injuries.

Background: Thousands of children and adolescents attend high-intensity athletic camps each year; the rate and type of injuries sustained are unknown.

Hypothesis: Participants in a high-intensity athletic camp would have significant, identifiable health care needs associated with injuries and illnesses.

Study Design: Retrospective, observational study.

Methods: Acute medical care for camp participants was primarily provided in an academic medical center emergency department (ED). All participants treated in the ED or by a volunteer camp physician were included in the study. Medical and camp records for camp participants were reviewed and described.

Results: In sum, 263 participants attended the high-intensity wrestling camp in 2009. Seventy-eight (30%) were treated in the ED; median age was 15.8 years. Sixteen were seen more than once, totaling 96 visits. Thirty-four percent of visits included x-ray and 25% laboratory studies. Forty-four percent were skin complaints. One patient had methicillin-resistant Staphylococcus aureus infection; none had positive viral skin cultures. Musculoskeletal or facial trauma occurred in 37%, with 5 fractures. Injury rate was 1.9 per 1000 athlete exposures. Overall, 47% of campers sought medical care during camp; 11 (4.2%) left camp early because of illness or injury. Few wrestlers received follow-up care.

Conclusions: Illnesses and injuries requiring medical attention were common in this high-intensity sports camp. While many ED patients could have been treated in a clinic, 50% required ED medical resources for diagnosis or care.