Common sports-related musculoskeletal injuries presenting to the emergency department

Photon-Counting Detector CT Applications in Musculoskeletal Radiology

ABSTRACT

Photon-counting detectors (PCDs) have emerged as one of the most influential technical developments for medical imaging in recent memory. Surpassing conventional systems with energy-integrating detector technology in many aspects, PCD-CT scanners provide superior spatial resolution and dose efficiency for all radiological subspecialities. Demanding detailed display of trabecular microarchitecture and extensive anatomical coverage frequently within the same scan, musculoskeletal (MSK) imaging in particular can be a beneficiary of PCD-CT's remarkable performance. Since PCD-CT provides users with a plethora of customization options for both image acquisition and reconstruction, however, MSK radiologists need to be familiar with the scanner to unlock its full potential. From filter-based spectral shaping for artifact reduction over full field-of-view ultra-high-resolution scans to postprocessing of single- or dual-source multienergy data, almost every imaging task can be met with an optimized approach in PCD-CT. The objectives of this review were to give an overview of the most promising applications of PCD-CT in MSK imaging to date, to state current limitations, and to highlight directions for future research and developments.

Return-to-Play Outcomes in Elite Athletes After Cervical and Lumbar Motion Preservation Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

The primary purpose of this article was to survey the present literature and report on return-to-play (RTP) outcomes in elite athletes after undergoing motion preservation spinal surgery (MPSS).

BACKGROUND

For elite performance, athletes require adequate mobility throughout the trunk, torso, and spine to achieve maximal force production. Therefore, elite athletes who have failed conservative treatment may seek to undergo motion-preserving surgical options, such as total disc arthroplasty and lumbar microdiscectomy. Individual studies have reported on RTP outcomes following individual motion preservation surgical procedures, but no systematic reviews have formally reported on RTP outcomes, postoperative performance, and reoperation rates on these procedures in elite athletes.

MATERIALS AND METHODS

A systematic review was conducted from inception until February 2024 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. One reviewer queried PubMed for relevant studies that reported on RTP outcomes in elite athletes after MPSS based on title and abstract (n = 1404). After the original search query, an additional reviewer screened full-length articles. A total of 11 studies met the inclusion criteria. Special consideration was given to RTP rates, postoperative performance, and reoperation rates.

RESULTS

A total of 612 elite athletes from the National Basketball Association, Major League Baseball, National Football League, National Hockey League, and other professional sporting organizations underwent cervical and lumbar MPSS to treat various spinal pathologies. Various motion-sparing techniques were used to treat various pathologies. After undergoing MPSS, RTP rates ranged from 75% to 100% for lumbar cases and 83.3% to 100% for cervical cases. Postoperative performance varied with some athletes performing at the same level before surgery and some performing at a decreased level.

CONCLUSIONS

MPSS is a feasible option when properly indicated. Future studies are needed to compare return to sport rates, postoperative performance, and reoperation rates between MPSS to spinal arthrodesis.

Subchondral Bone Degeneration and Pathology 3-15 Years Following Ankle Sprain Injury in Adolescent Sport

BACKGROUND

Sport-related ankle sprains (SASs) are prevalent in adolescents (ages 10-19), increasing the risk of developing posttraumatic osteoarthritis (PTOA). Although early ankle osteoarthritis (OA) is not well defined, OA eventually includes alterations in bone mineral density (BMD), structural changes, and soft tissue pathology. This study examined the impact of SAS sustained in adolescent sport on bone and soft tissue structural outcomes 3-15 years postinjury.

METHODS

Participants (n = 10) with prior unilateral SAS in adolescent sport (HxAI) were compared to age- and sex-matched controls. To assess injury-related pathologies and BMD, 1.5-tesla (T) extremity magnetic resonance imaging (MRI) and computed tomography scans were used. Semiquantitative scores for injury patterns and OA features from MRI scans were summed and compared between groups. The talus, calcaneus, navicular, and 5% distal tibia were segmented, and BMD was measured for each bone.

RESULTS

All HxAI participants exhibited MRI injury pathology (median 2; IQR 1-6), whereas only 1 of 10 controls showed pathology (median 0; IQR 0-0), χ2(1, n = 20) = 16.36, P < .001. Both the injured and uninjured ankles in HxAI displayed injury pattern pathology. Additionally, 3 of 10 injured ankles and 2 of 10 uninjured ankles in the HxAI group (median 0; IQR 0-3), but none of the controls (median 0; IQR 0-0), exhibited OA features. In the HxAI group, talus BMD was lower in the injured ankle (502.4 ± 67.9 g/cm3) compared with the uninjured ankle (515.6 ± 70.1 g/cm3) (F = 13.33, P = .002), with no significant BMD differences at the calcaneus, navicular, or 5% distal tibia. No differences were observed between the ankles of the control group.

CONCLUSION

The presence of injury pattern pathology, structural changes, and reduced talus BMD suggest that degenerative changes may occur in individuals as early as 3-15 years following ankle injury.

Photon-Counting Computed Tomography: Experience in Musculoskeletal Imaging

Since the emergence of the first photon-counting computed tomography (PCCT) system in late 2021, its advantages and a wide range of applications in all fields of radiology have been demonstrated. Compared to standard energy-integrating detector-CT, PCCT allows for superior geometric dose efficiency in every examination. While this aspect by itself is groundbreaking, the advantages do not stop there. PCCT facilitates an unprecedented combination of ultra-high-resolution imaging without dose penalty or field-of-view restrictions, detector-based elimination of electronic noise, and ubiquitous multi-energy spectral information. Considering the high demands of orthopedic imaging for the visualization of minuscule details while simultaneously covering large portions of skeletal and soft tissue anatomy, no subspecialty may benefit more from this novel detector technology than musculoskeletal radiology. Deeply rooted in experimental and clinical research, this review article aims to provide an introduction to the cosmos of PCCT, explain its technical basics, and highlight the most promising applications for patient care, while also mentioning current limitations that need to be overcome.

Non-operative Management of Acute Knee Injuries

PURPOSE OF REVIEW

Acute knee injuries are commonly encountered in both the clinical and sideline setting and may be treated operatively or non-operatively. This article describes an evidence-based approach to non-operative acute knee injury. This includes history, physical exam, imaging, and initial management. In addition, the non-operative management of three such injuries-ligament injury, meniscus injury, and patellar dislocation injury-will be discussed via a case-based practical approach.

RECENT FINDINGS

Aside from grade III ACL tears, most acute knee ligament injuries, especially in the absence of other concurrent injuries, can be treated non-operatively. There is new evidence that acute traumatic meniscus tears in those younger than 40 can be successfully treated non-operatively and can do equally, as well as those that undergo surgery, at 1 year out from injury. Based on the current literature, a short period of knee bracing in extension with progression to weightbearing to tolerance is recommended after initial patellar dislocation. Many of the most common acute knee injuries, including MCL tears, meniscus tears, and patellar dislocations, can be managed non-operatively. A detailed systemic approach to initial evaluation, including pertinent history, physical exam, and appropriate imaging, is essential and complementary to the subsequent non-operative treatment algorithm.

Potential Local Mechanisms for Exercise-Induced Hypoalgesia in Response to Blood Flow Restriction Training

Overall, there is a great need within sports medicine to ensure that athletes can return from injury in an efficient, yet thorough manner. It is crucial to not avoid necessary difficulties in this process but also to ensure time-efficient rehabilitation. One of the more promising techniques to achieve timely recovery is blood flow restriction (BFR) training. BFR training is a growing and novel development that could be a vital tool to lighten the burden of recovery from injury in athletes. BFR utilizes a pneumatic tourniquet to limit blood flow in specific areas of the body. The use of BFR has been shown to potentially enhance the analgesic effects of exercise-induced hypoalgesia (EIH). By limiting pain, athletes will be less burdened by mobility and loading exercises required for them to effectively return to play. In a field where time away from sports can have massive implications, the need for tools to assist in the acceleration of the rehabilitation process is vital. Much of the work that has already been done in the field has been able to exploit the benefits of EIH and further enhance the body's capabilities through BFR. Studies have compared EIH at low- and high-intensity settings utilizing BFR with both resistance and aerobic exercise. The results of these studies show comparable beta-endorphin levels with high-intensity exercise without BFR and low-intensity exercise with BFR. Low-intensity training with BFR had greater local pain relief, perhaps indicating the promising effects of BFR in enhancing EIH. By reviewing the current literature on this topic, we hope that further progress can be made to better understand the mechanism behind BFR and its ability to enhance EIH. Currently, local metabolites are a major focus for the potential mechanism behind these effects. Mas-related G-protein-coupled receptors (Mrgprs) contribute to local pain pathways via mast cell degranulation. Similarly, chemokine receptor 2/chemokine ligand 2 (CCR2/CCL2) triggers mast cell degranulation and inflammation-induced pain. Finally, pain-reducing effects have been linked to anti-inflammatory IL-10 signaling and anaerobic metabolites via transient receptor potential vanilloid 1 (TRPV1). Through a better understanding of these metabolites and their mechanisms, it is possible to further exploit the use of BFR to not only serve athletes recovering from injury but also apply this information to better serve all patients.

Return to sport after forearm fractures in children: A scoping review and survey

Purpose

A common question faced by clinicians is when a child may return to sport after treatment for a pediatric forearm fracture. There are few published recommendations and fewer supported by evidence. The aims of this study were to summarize existing published recommendation for return to sport after pediatric forearm fractures and to conduct a survey to determine usual clinical recommendations.

Methods

A scoping review was performed on Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Google Scholar in accordance with the Joanna Briggs Institute guidelines. In addition, 64 orthopedic surgeons were anonymously surveyed asking for recommendations regarding return to sport after pediatric forearm fractures. Participants were to assume children were 9 years old and played a sport with an average risk of forearm injury.

Results

Twenty-two publications for return to sport were retrieved. Children with distal radius buckle fractures safely commonly returned to sport by 4 weeks after initial injury, while survey respondents recommended over 6 weeks. Survey respondents valued fracture stability the highest when making return to sport recommendations. Children with simple, metaphyseal, single-bone fractures were usually allowed to return to sport at 8-10 weeks post-injury. Diaphyseal and complete fractures were prescribed longer return to sport intervals. Australian respondents also prescribed longer return to sport intervals.

Conclusion

Children with distal radius buckle fractures may return to sport by 4 weeks after initial injury, sooner than recommended. Published recommendations remain limited for other fractures. However, our survey suggests children with simple, metaphyseal, single-bone fractures may return to sport at 8-10 weeks. Children with diaphyseal and complete fractures should abstain from sport for longer than metaphyseal and greenstick fractures, respectively.

Level of evidence

level V.

Treatment Variability and Complications Associated With Pediatric Lateral Ankle Injuries: A POSNA Quality, Safety, and Value Initiative Survey

Background

Isolated pediatric lateral ankle injuries, including ankle sprain (AS) and nondisplaced Salter-Harris type 1 (SH-1) distal fibular fracture, are common orthopaedic sports-related injuries. Variability in treatment is suspected among pediatric orthopaedic surgeons. Complications from medical treatment or lack thereof have not been reported in this population.

Purpose

The purpose of this study was to investigate treatment variability and associated complications after pediatric AS and SH-1 via a survey of members of the Pediatric Orthopaedic Society of North American (POSNA).

Study Design

Cross-sectional study. Level of evidence, 5.

Methods

A voluntary, anonymous survey was distributed to POSNA membership (approximately 1400 members) via email. Survey questions, specific to both grade 1 or 2 AS and nondisplaced or minimally displaced SH-1 injuries in skeletally immature patients, focused on initial evaluation, immobilization, return to sports, and complications. We analyzed variability both in treatment between AS and SH-1 injury and in respondent characteristics. For statistical analysis, chi-square or Fisher exact test was used for categorical variables, and analysis of variance was used for continuous variables.

Results

The survey response rate was 16.4% (229/1400). Of the respondents, 27.7% used examination only to distinguish between AS and SH-1, whereas 18.7% performed serial radiography to aid with diagnosis. A controlled ankle motion boot or walking boot was the most common immobilization technique for both AS (46.3%) and SH-1 (55.6%); the second most common technique was bracing in AS (33.5%) and casting in SH-1 (34.7%). Approximately one-third of all respondents recommended either outpatient or home physical therapy for AS, whereas only 11.4% recommended physical therapy for SH-1 (P < .01). Results showed that 81.2% of respondents reported no complications for SH-1 treatment and 87.8% reported no complications for AS treatment. Cast complications were reported by 9.6% for SH-1 and 5.2% for AS. Rare SH-1 complications included distal fibular growth arrest, infection, nonunion, late fracture displacement, and recurrent fracture.

Conclusion

Significant variability was found in primary treatment of pediatric AS and SH-1 injuries. Rare complications from injury, treatment, and neglected treatment after SH-1 and AS were reported.

The aging athlete

Aging athletes, those 60 years and older, are a growing population of mature, active individuals who value sports and exercise participation throughout their lifespan. Although recommendations for younger and masters athletes have been extrapolated to this population, there remains a paucity of specific guidelines, treatment algorithms, and considerations for aging athletes. The benefits of living an active lifestyle must be weighed against the risks for unique cardiovascular, metabolic, and musculoskeletal injuries requiring diagnostic and therapeutic interventions. In this article, we review the unique cardiovascular and muscular physiology of aging athletes and how it influences the risk of specific medical conditions. We also discuss general prevention and treatment strategies. Finally, we identify areas of future research priorities and emerging treatments.

Acute Musculoskeletal Sports Injuries in School Age Children in Britain

OBJECTIVES

To determine the relative number of acute musculoskeletal injuries sustained by children due to different sports in a region of the UK, and assess the burden upon the NHS, through a cross sectional study.

METHODS

Collection of data for every child aged 6-18 seen at the Peterborough City Hospital fracture clinic, whose sports injury was from 1^st September 2018 - 31^st August 2019 (1 school year; n=689). Data was gathered throughout the year by three children's orthopaedic surgeons, who consulted the clinic records, notes and x-rays of all children who had attended clinic.

RESULTS

Boys were 2.7 times more likely to sustain injury than girls. Children aged 6-9 had few injuries (mean 24 injuries each year group), 10-15 had a large number of injuries (mean 84), and 16-18 again had few injuries (mean 35). Football and rugby were responsible for the majority of injuries (61% between them), as well as the majority of physiotherapy appointments (72%). Sports with the highest likelihood that an injury will be sufficiently serious to require surgery were equestrian (42% of injuries required surgery), gymnastics (27%), ice skating (25%) and rugby (22%). Popular sports in which injuries were relatively rare include swimming, athletics, cricket, hockey, tennis and badminton.

CONCLUSION

The sports that caused the most injuries were football and rugby. Considering relative participation in different sports, it is clear that rugby has a disproportionate number of musculoskeletal injuries in total, of severe injuries requiring surgery, and requiring rehab from physiotherapy.

Identifying Range-of-Motion Deficits and Talocrural Joint Laxity After an Acute Lateral Ankle Sprain

CONTEXT

Approximately 72% of patients with an ankle sprain report residual symptoms 6 to 18 months later. Although 44% of patients return to activity in less than 24 hours after experiencing a sprain, residual symptoms should be evaluated in the long term to determine if deficits exist. These residual symptoms may be due to the quality of ligament tissue and motion after injury.

OBJECTIVE

To compare mechanical laxity of the talocrural joint and dorsiflexion range of motion (DFROM) over time (24 to 72 hours, 2 to 4 weeks, and 6 months) after an acute lateral ankle sprain (LAS).

DESIGN

Cross-sectional study.

SETTING

Athletic training research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 108 volunteers were recruited. Fifty-five participants had an acute LAS and 53 participants were control individuals without a history of LAS.

MAIN OUTCOME MEASURE(S)

Mechanical laxity (talofibular interval and anterior talofibular ligament length) was measured in inversion (INV) and via the anterior drawer test. The weight-bearing lunge test was conducted and DFROM was measured. The data were analyzed using repeated-measures analysis of variance, independent-samples t tests, and 1-way analysis of variance.

RESULTS

Of the 55 LASs, 21 (38%) were grade I, 27 (49%) were grade II, and 7 (13%) were grade III. Increases were noted in DFROM over time, between 24 and 72 hours, at 2 to 4 weeks, and at 6 months (P < .05). The DFROM was less in participants with grade III than grade I LASs (P = .004) at 24 to 72 hours; INV length was greater at 24 to 72 hours than at 2 to 4 weeks (P = .023) and at 6 months (P = .035) than at 24 to 72 hours. The anterior drawer length (P = .001) and INV talofibular interval (P = .004) were greater in the LAS group than in the control group at 6 months.

CONCLUSIONS

Differences in range of motion and laxity were evident among grades at various time points and may indicate different clinical responses after an LAS.

Questionnaires and scales for assessment of ankle function: a systematic review of instruments translated and validated for Brazilian Portuguese

PURPOSE

Several questionnaires have been used for functional evaluation. They must be translated and adapted transculturally, these instruments need to be valid, reliable, and sensitive according to the population. This review identified the questionnaires which were adapted transculturally in Brazilian Portuguese, to verify the methodological quality.

METHODS

A search was performed in the PubMed, BIREME, SportDiscus, SciELO, Scopus, Science Direct, and Web of Science. The methodological quality was evaluated by the COnsensus-based Standards for Health Measurement INstruments (COSMIN) Risk of Bias checklist. For cross-cultural translation and adaptation studies, the properties of measurement of structural validity, internal consistency (IC), cross-cultural validity, reliability, measurement error, and criterion validity were analyzed.

RESULTS

A total of 4564 articles were found; 10 fulfilled the inclusion criteria. The psychometrics properties verified were IC; criterion validity; reproducibility; floor/ceiling effect and responsiveness. Criterion validity was the best criterion evaluated. The main failures were related to sample size, and the most deficient properties were IC, reliability, and error of measure.

CONCLUSIONS

The studies verified presented "inadequate" final score using COSMIN. Although specific questionnaires for ankle evaluation have been cross culturally validated in Brazilian Portuguese, their methodological quality was generally low, as verified through the analysis of their psychometric properties. IMPLICATIONS FOR REHABILITATION The questionnaires which were cross culturally adapted to Brazilian Portuguese were shown to be of low methodological quality. In using them careful consideration needs to be given to the psychometrics of each measure. Caution should be exercised in making clinical decisions drawn from the results.

Epidemiologic comparison of ankle injuries presenting to US emergency departments versus high school and collegiate athletic training settings

BACKGROUND

Ankle sprains account for a large proportion of injuries presenting to both United States (US) emergency departments (EDs) as well as high school (HS) and collegiate school athletic training settings. The epidemiologic differences across these settings by both sport and diagnosis have not been well differentiated. Ankle injury data from 3 national surveillance datasets. Athletic training setting data from the National High School Sports-Related Injury Surveillance System and the National Collegiate Athletic Association Injury Surveillance Program was from academic years 2009/10 through 2013/14 and the US Consumer Product Safety Commission's National Electronic Injury Surveillance System (ED setting) data was from calendar years 2009 through 2013. Data was analyzed for patients 14-22 years old participating in 12 sports (male football, baseball, basketball, lacrosse, soccer, and wrestling, and female softball, basketball, lacrosse, soccer, volleyball, and field hockey). We calculated sport-specific injury rates, proportions, and rate ratios (RRs) with 95% confidence intervals (CI).

RESULTS

During the study period, the surveillance systems captured 20,261 ankle injuries presenting to EDs plus 5546 HS and 2725 collegiate injuries presenting to school athletic training settings. Rates were higher in collegiate compared to HS athletes presenting in the athletic training setting. Football accounted for the largest proportion of ankle injuries presenting to HS (31.2%) and college (41.0%) athletic training settings; male basketball accounted for the largest proportion presenting to EDs among both HS (41.0%) and college (65.8%) aged patients. Sprains/strains accounted for over 80% of injuries in all three settings. Fractures accounted for a larger proportion of ankle injuries presenting to EDs (9.5%) compared to HS (3.8%) and college (0.8%) athletic training settings. There was no change in injury rates during the study period across the three settings.

CONCLUSIONS

Injury rates and patterns varied by sport and presentation setting, with athletic trainers evaluating more ankle injuries overall in the collegiate setting compared to the high school setting. Ankle injuries presenting to EDs were more commonly fractures, suggesting that more severe injuries present to this setting. Understanding the epidemiology of such patterns will help readers interpret differences in publications reporting data from varied clinical settings.

Incidence, costs, and temporal trends of sports injury-related hospitalisations in Australian children over a 10-year period: A nationwide population-based cohort study

OBJECTIVES

To quantify and describe the incidence, cost, and temporal trends of sports injury-related hospitalisations in Australian children over a 10-year period.

DESIGN

Retrospective population-based cohort study.

METHODS

This study used linked hospitalisation and mortality data of children aged ≤16 years who were hospitalised for sports-related injury in Australia from 1 July 2002 to 30 June 2012. Age-standardised incidence rates were calculated with 95% confidence intervals (CI). Negative binomial regression was used to examine change in temporal trends in incidence rates.

RESULTS

There were 130,167 sports injury-related hospitalisations during the 10-year study period. The overall annual incidence rate was 281.0 (95%CI: 279.5, 282.6) per 100,000 population. Males and older children were more frequently hospitalised than their female and younger counterparts. The most common sports activities resulting in hospitalisation were team ball sports (43.1%) and wheeled non-motor sport (22.3%). There was no significant annual decline in the overall incidence rate during the 10-year study period (-1.0% [95%CI: -3.0%, 1.0%]). The estimated total hospital treatment cost was $396 million, with an estimated mean cost per injured child of $3058.

CONCLUSIONS

There has been no significant decline in sports injury-related hospitalisation rates among Australian children during 2002-03 to 2011-12. This may suggest that sports injury prevention initiatives in Australia to date have been inadequate to produce population-level reduction in sports injury-related hospitalisations. It is recommended that a national injury prevention strategy to reduce the burden of sports injuries among Australian children is developed and implemented.

Fc receptor-like 3 (-169T>C) polymorphism increases the risk of tendinopathy in volleyball athletes: a case control study

Background

Tendinopathy pathogenesis is associated with inflammation. Regulatory T (Treg) cells contribute to early tissue repair through an anti-inflammatory action, with the forkhead box P3 (FOXP3) transcription factor being essential for Treg function, and the FC-receptor-like 3 (FCRL3) possibly negatively regulating Treg function. FCRL3 –169T>C and FOXP3 –2383C>T polymorphisms are located near elements that regulate respective genes expression, thus it was deemed relevant to evaluate these polymorphisms as risk factors for tendinopathy development in athletes.

Methods

This case-control study included 271 volleyball athletes (146 tendinopathy cases and 125 controls) recruited from the Brazilian Volleyball Federation. Genotyping analyses were performed using TaqMan assays, and the association of the polymorphisms with tendinopathy evaluated by multivariate logistic regression.

Results

Tendinopathy frequency was 63% patellar, 22% rotator cuff and 15% Achilles tendons respectively. Tendinopathy was more common in men (OR = 2.87; 95% CI = 1.67–4.93). Higher age (OR = 8.75; 95% CI = 4.33–17.69) and more years of volleyball practice (OR = 8.38; 95% CI = 3.56–19.73) were risk factors for tendinopathy. The FCRL3 –169T>C frequency was significantly different between cases and controls. After adjustment for potential confounding factors, the FCRL3 –169C polymorphism was associated with increased tendinopathy risk (OR = 1.44; 95% CI = 1.02–2.04), either considering athletes playing with tendon pain (OR = 1.98; 95% CI = 1.30–3.01) or unable to train due to pain (OR = 1.89; 95% CI = 1.01–3.53). The combined variant genotypes, FCRL3 –169TC or –169CC and FOXP3 –2383CT or –2383TT, were associated with an increased risk of tendinopathy among athletes with tendon pain (OR = 2.24; 95% CI: 1.14–4.40 and OR = 2.60; 95% CI: 1.11–6.10). The combined analysis of FCRL3 –169T>C and FOXP3 –2383C>T suggests a gene-gene interaction in the susceptibility to tendinopathy.

Conclusions

FCRL3 –169C allele may increase the risk of developing tendinopathy, and together with knowledge of potential risk factors (age, gender and years playing) could be used to personalize elite athletes’ training or treatment in combination with other approaches, with the aim of minimizing pathology development risk.