Prevalence of Sonographic Achilles Tendon, Patellar Tendon, and Plantar Fascia Abnormalities in Division I Collegiate Athletes From a Variety of Sports

OBJECTIVE

This study aimed to determine the prevalence of ultrasound abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among a large cohort of collegiate student-athletes.

DESIGN

Observational cross-sectional study.

SETTING

Three Division I institutions.

PARTICIPANTS

243 student-athletes participated in this study. Exclusion criteria included those younger than 18 years or who underwent prior surgery/amputation of structures, including anterior cruciate ligament (ACL) surgeries with patellar tendon grafts.

INTERVENTIONS

Ultrasound examination of the Achilles tendon, patellar tendon, and plantar fascia of each leg was performed. An experienced sonographer reviewed each tendon video in a blinded manner, with a separate experienced sonographer separately reviewing to establish inter-rater reliability.

MAIN OUTCOME MEASURES

The primary outcome measured was the presence of any sonographic abnormality including hypoechogenicity, thickening, or neovascularity.

RESULTS

Ultrasound abnormalities were identified in 10.1%, 37.2%, and 3.9% of all Achilles tendons, patellar tendons, and plantar fasciae, respectively. Abnormalities were significantly associated with the presence of concurrent pain for all structures ( P < 0.01). Specifically, athletes with sonographic abnormalities were approximately 4 times [relative risk (RR) = 4.25; 95% confidence interval (CI), 2.05-8.84], 6 times (RR = 5.69; 95% CI, 2.31-14.00), and 5 times (RR = 5.17; 95% CI, 1.76-15.25) more likely to self-report pain in the Achilles tendon, patellar tendon, and plantar fascia, respectively.

CONCLUSIONS

This multi-institutional study completed at 3 Division I institutions is the largest study of its kind to identify the prevalence of sonographic abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among collegiate student-athletes of various sports.

A Rare Case Report of Exertional Leg Pain

ABSTRACT

The accurate diagnosis of exertional leg pain in athletes is often delayed because of vague presenting symptoms and nonspecific physical examination findings. This case report outlines exertional leg pain in a runner caused by combined popliteal artery entrapment and soleal sling syndromes, 2 uncommon causes of exertional leg pain. This case report highlights the overlapping clinical presentation of these 2 diagnoses and the intricate differences in diagnostic workup and surgical approach to management.

The Association Between Well-Being and Empathy in Medical Residents: A Cross-Sectional Survey

Objective: To evaluate the extent to which personal well-being may be associated with empathy, while controlling for potential confounders. Settings/Location: Residency programs throughout the United States. Subjects: A total of 407 medical residents from residencies including general medicine, surgery, specialized and diagnostic medicine participated in this study. Outcome Measures: Well-being was measured using the modified existential well-being subscale of the spiritual well-being scale. Empathy was measured using the Jefferson Scale of Empathy. Results: Well-being was found to be positively correlated with empathy when adjusted for possible confounders (p < 0.001). In addition to well-being, other factors noted to be statistically significant contributors to higher empathy scores while controlling for the others included age, gender, year in residency, specialty, and work-hours (p < 0.05 for each). After controlling for these factors, a resident's year in residency was not found to be a statistically significant contributor to empathy score. Conclusions: In this study, well-being was associated with empathy in medical and surgical residents. Empathy is a fundamental component of physician competency, and its development is an essential aspect of medical training. These findings suggest that efforts to increase well-being may promote empathy among medical residents.

Reply to Wakolbinger-Habel, R.; Muschitz, C. Comment on "Kaufman et al. Popular Dietary Trends' Impact on Athletic Performance: A Critical Analysis Review. Nutrients 2023, 15, 3511"

We appreciate Wakolbinger-Habel and Muschitz's comment [...].

Higher Triad Risk Scores Are Associated With Increased Risk for Trabecular-Rich Bone Stress Injuries in Female Runners

OBJECTIVE

Bone stress injuries (BSIs) in trabecular-rich bone are associated with greater biological risk factors compared with cortical-rich bone. We hypothesized that female runners with high Female Athlete Triad (Triad)-related risk would be at greater risk for trabecular-rich BSIs than runners with low Triad-related risk.

DESIGN

Prospective cohort study.

SETTING

Two NCAA institutions.

PARTICIPANTS

Female runners were followed prospectively for up to 5 years.

INTERVENTION

The intervention consisted of team nutrition presentations focused on optimizing energy availability plus individualized nutrition sessions. Triad Cumulative Risk Assessment (CRA) categories were assigned yearly based on low-energy availability, menstrual status, age of menarche, low body mass index, low bone mineral density, and prior BSI.

MAIN OUTCOME MEASURES

The outcome was the annual incidence of trabecular- and cortical-rich BSI. Generalized Estimating Equations (GEE, to account for the correlated nature of the observations) with a Poisson distribution and log link were used for statistical modeling.

RESULTS

Cortical-rich BSI rates were higher than trabecular-rich BSI rates (0.32 vs 0.13 events per person-year). Female runners with high Triad-related risk had a significantly higher incidence rate ratio of trabecular-rich BSI (RR: 4.40, P = 0.025) and cortical-rich BSI (RR: 2.87, P = 0.025) than women with low Triad-related risk. Each 1-point increase in Triad CRA score was associated with a significant 26% increased risk of trabecular-rich BSI ( P = 0.0007) and a nonsignificant 14% increased risk of cortical-rich BSI ( P = 0.054).

CONCLUSIONS

Increased Triad CRA scores were strongly associated with increased risk for trabecular-rich BSI. Incorporating Triad CRA scores in clinical care could guide BSI prevention.

Popular Dietary Trends' Impact on Athletic Performance: A Critical Analysis Review

BACKGROUND

Nutrition fuels optimal performance for athletes. With increased research developments, numerous diets available, and publicity from professional athletes, a review of dietary patterns impact on athletic performance is warranted.

RESULTS

The Mediterranean diet is a low inflammatory diet linked to improved power and muscle endurance and body composition. Ketogenic diets are restrictive of carbohydrates and proteins. Though both show no decrements in weight loss, ketogenic diets, which is a more restrictive form of low-carbohydrate diets, can be more difficult to follow. High-protein and protein-paced versions of low-carbohydrate diets have also shown to benefit athletic performance. Plant-based diets have many variations. Vegans are at risk of micronutrient deficiencies and decreased leucine content, and therefore, decreased muscle protein synthesis. However, the literature has not shown decreases in performance compared to omnivores. Intermittent fasting has many different versions, which may not suit those with comorbidities or specific needs as well as lead to decreases in sprint speed and worsening time to exhaustion.

CONCLUSIONS

This paper critically evaluates the research on diets in relation to athletic performance and details some of the potential risks that should be monitored. No one diet is universally recommend for athletes; however, this article provides the information for athletes to analyze, in conjunction with medical professional counsel, their own diet and consider sustainable changes that can help achieve performance and body habitus goals.

Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners

Objectives

We evaluated the effect of a nutrition education intervention on bone stress injury (BSI) incidence among female distance runners at two NCAA Division I institutions.

Methods

Historical BSI rates were measured retrospectively (2010-2013); runners were then followed prospectively in pilot (2013-2016) and intervention (2016-2020) phases. The primary aim was to compare BSI rates in the historical and intervention phases. Pilot phase data are included only for descriptive purposes. The intervention comprised team nutrition presentations focused on optimising energy availability plus individualised nutrition sessions for runners with elevated Female Athlete Triad risk. Annual BSI rates were calculated using a generalised estimating equation Poisson regression model adjusted for age and institution. Post hoc analyses were stratified by institution and BSI type (trabecular-rich or cortical-rich).

Results

The historical phase included 56 runners and 90.2 person-years; the intervention phase included 78 runners and 137.3 person-years. Overall BSI rates were not reduced from the historical (0.52 events per person-year) to the intervention (0.43 events per person-year) phase. Post hoc analyses demonstrated trabecular-rich BSI rates dropped significantly from 0.18 to 0.10 events per person-year from the historical to intervention phase (p=0.047). There was a significant interaction between phase and institution (p=0.009). At Institution 1, the overall BSI rate dropped from 0.63 to 0.27 events per person-year from the historical to intervention phase (p=0.041), whereas no decline was observed at Institution 2.

Conclusion

Our findings suggest that a nutrition intervention emphasising energy availability may preferentially impact trabecular-rich BSI and depend on team environment, culture and resources.

Comparison of Ultrasonography to MRI in the Diagnosis of Lower Extremity Bone Stress Injuries: A Prospective Cohort Study

OBJECTIVE

To determine the sensitivity and specificity of ultrasound imaging (USI) compared to the reference-standard of MRI in the diagnosis of bone stress injury (BSI).

METHODS

A prospective blinded cohort study was conducted. Thirty seven patients who presented to an academic sports medicine clinic from 2016 to 2020 with suspected lower-extremity BSI on clinical exam underwent both magnetic resonance imaging (MRI) and USI. Participant characteristics were collected including age, gender and sport. Exclusion criteria included contraindication for dedicated MRI, traumatic fracture, or severe tendon or ligamentous injury. The primary outcome measure was BSI diagnosis by USI. An 8-point assessment system was utilized on USI for diagnosis of BSI, and the Fredericson and Nattiv²² criteria were applied to classify MRI findings.

RESULTS

Thirty seven participants who met study criteria were consented to participate. All participants completed baseline measures. Using MRI, there were 30 (81%) athletes with a positive and seven participants with a negative BSI diagnosis. The most common BSIs in the study were in the metatarsal (54%) and tibia (32%). Compared to MRI, USI demonstrated 0.80 sensitivity (95% confidence interval [CI], 0.61-0.92) and 0.71 specificity (95% CI, 0.29-0.96) in detecting BSI, with a positive predictive value of 0.92 (95% CI, 0.75-0.99) and negative predictive value of 0.45 (95% CI, 0.17-0.77).

CONCLUSIONS

USI is a potentially useful point-of-care tool for practicing sports medicine providers to combine with their clinical evaluation in the diagnosis of BSIs. Further research is ongoing to determine the role of USI in follow-up care and return-to-play protocols.

Female Athlete Triad Risk Factors Are More Strongly Associated With Trabecular-Rich Versus Cortical-Rich Bone Stress Injuries in Collegiate Athletes

Background:

Bone stress injuries (BSIs) are common in athletes. Risk factors for BSI may differ by skeletal anatomy and relative contribution of trabecular-rich and cortical-rich bone.

Hypothesis:

We hypothesized that Female Athlete Triad (Triad) risk factors would be more strongly associated with BSIs sustained at trabecular-rich versus cortical-rich skeletal sites.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

The study population comprised 321 female National Collegiate Athletic Association Division I athletes participating in 16 sports from 2008 to 2014. Triad risk factors and a Triad cumulative risk score were assessed using responses to preparticipation examination and dual energy x-ray absorptiometry to measure lumbar spine and whole-body bone mineral density (BMD). Sports-related BSIs were diagnosed by a physician and confirmed radiologically. Athletes were grouped into those sustaining a subsequent trabecular-rich BSI, a subsequent cortical-rich BSI, and those without a BSI. Data were analyzed with multinomial logistic regression adjusted for participation in cross-country running versus other sports.

Results:

A total of 19 participants sustained a cortical-rich BSI (6%) and 10 sustained a trabecular-rich BSI (3%) over the course of collegiate sports participation. The Triad cumulative risk score was significantly related to both trabecular-rich and cortical-rich BSI. However, lower BMD and weight were associated with significantly greater risk for trabecular-rich than cortical-rich BSIs. For every value lower than 1 SD, the odds ratios (95% CIs) for trabecular-rich versus cortical-rich BSI were 3.08 (1.25-7.56) for spine BMD; 2.38 (1.22-4.64) for whole-body BMD; and 5.26 (1.48-18.70) for weight. Taller height was a significantly better predictor of cortical-rich than trabecular-rich BSI.

Conclusion:

The Triad cumulative risk score was significantly associated with both trabecular-rich and cortical-rich BSI, but Triad-related risk factors appeared more strongly related to trabecular-rich BSI. In particular, low BMD and low weight were associated with significantly higher increases in the risk of trabecular-rich BSI than cortical-rich BSI. These findings suggest Triad risk factors are more common in athletes sustaining BSI in trabecular-rich than cortical-rich locations.

Botulinum neurotoxin type A improves vasti muscle balance, patellar tracking, and pain in patients with chronic patellofemoral pain

The purpose of this study was to determine the effects of botulinum neurotoxin type A (BoNT-A) on vastus lateralis:vastus medialis (VL:VM) muscle balance, patellar tracking, and pain in patients with chronic patellofemoral (PF) pain. We recruited 13 participants (9 females, 4 males) with recalcitrant PF pain who underwent ultrasound-guided BoNT-A injections into the distal third of the VL muscle, followed by a 6-week home exercise program to strengthen their VM muscle. We imaged the participants in a C-arm computed tomography (CT) scanner before and after the intervention. We calculated VL:VM ratios from CT images from a supine, nonweight-bearing condition. We obtained patellar tilt and bisect offset values from CT images from an upright, weight-bearing condition. We recorded functional pain scores before, immediately after, and 2-4 years after the intervention. We classified the participants into normal tracking and maltracking groups based on their patellar tilt and bisect offset values. BoNT-A with home exercise reduced VL:VM ratio (18%; p < 0.001), patellar tilt (19%; p = 0.020), and bisect offset (5%; p = 0.025). Four participants classified as maltrackers before the intervention transitioned to normal tracking after the intervention. Functional pain scores improved immediately after the intervention (13%, p < 0.001) and remained improved at 2-year follow-up (12%, p = 0.011). Statement of Clinical Significance: This study provides new evidence in support of BoNT-A for treatment of PF pain. Classification of patients under weight-bearing conditions may identify individuals who will most benefit from a BoNT-A treatment.

Artificial Intelligence System for Automatic Quantitative Analysis and Radiology Reporting of Leg Length Radiographs

Leg length discrepancies are common orthopedic problems with the potential for poor functional outcomes. These are frequently assessed using bilateral leg length radiographs. The objective was to determine whether an artificial intelligence (AI)-based image analysis system can accurately interpret long leg length radiographic images. We built an end-to-end system to analyze leg length radiographs and generate reports like radiologists, which involves measurement of lengths (femur, tibia, entire leg) and angles (mechanical axis and pelvic tilt), describes presence and location of orthopedic hardware, and reports laterality discrepancies. After IRB approval, a dataset of 1,726 extremities (863 images) from consecutive examinations at a tertiary referral center was retrospectively acquired and partitioned into train/validation and test sets. The training set was annotated and used to train a fasterRCNN-ResNet101 object detection convolutional neural network. A second-stage classifier using a EfficientNet-D0 model was trained to recognize the presence or absence of hardware within extracted joint image patches. The system was deployed in a custom web application that generated a preliminary radiology report. Performance of the system was evaluated using a holdout 220 image test set, annotated by 3 musculoskeletal fellowship trained radiologists. At the object detection level, the system demonstrated a recall of 0.98 and precision of 0.96 in detecting anatomic landmarks. Correlation coefficients between radiologist and AI-generated measurements for femur, tibia, and whole-leg lengths were > 0.99, with mean error of < 1%. Correlation coefficients for mechanical axis angle and pelvic tilt were 0.98 and 0.86, respectively, with mean absolute error of < 1°. AI hardware detection demonstrated an accuracy of 99.8%. Automatic quantitative and qualitative analysis of leg length radiographs using deep learning is feasible and holds potential in improving radiologist workflow.

The Impact of Supplements on Sports Performance for the Trained Athlete: A Critical Analysis

ABSTRACT

Elite athletes often use nutritional supplements to improve performance and gain competitive advantage. The prevalence of nutrient supplementation ranges from 40% to 100% among trained athletes, yet few athletes have a trusted source of information for their supplement decisions and expected results. This critical analysis review evaluates systematic reviews, meta-analyses, randomized control trials, and crossover trials investigating commonly used supplements in sport: caffeine, creatine, beta-alanine (β-alanine), branched chain amino acids (BCAAs), and dietary nitrates. By reviewing these supplements' mechanisms, evidence relating directly to improving sports performance, and ideal dosing strategies, we provide a reference for athletes and medical staff to personalize supplementation strategies. Caffeine and creatine impact power and high-intensity athletes, β-alanine, and BCAA mitigate fatigue, and dietary nitrates improve endurance. With each athlete having different demands, goals to maximize their performance, athletes and medical staff should collaborate to personalize supplementation strategies based on scientific backing to set expectations and potentiate results.

Evidence-Based Medicine Training in United States-Based Physiatry Residency Programs

ABSTRACT

Although the physiatric community increasingly embraces evidence-based medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purposes of this article are to report the results of the Association of Academic Physiatrists' surveys of physiatry residency programs in the United States, to discuss the implications of their findings, and to better delineate the "baseline" upon which sound and clear recommendations for systematic EBM training can be made. The two Association of Academic Physiatrists surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, although most respondents reported using traditional pedagogic methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core competencies and the evaluation of their impact.

Prevalence of Female and Male Athlete Triad Risk Factors in Ultramarathon Runners

OBJECTIVE

To identify the prevalence of male and female athlete triad risk factors in ultramarathon runners and explore associations between sex hormones and bone mineral density (BMD).

DESIGN

Multiyear cross-sectional study.

SETTING

One hundred-mile ultramarathon.

PARTICIPANTS

Competing runners were recruited in 2018 and 2019.

ASSESSMENT OF RISK FACTORS

Participants completed a survey assessing eating behaviors, menstrual history, and injury history; dual-energy x-ray absorptiometry for BMD; and laboratory evaluation of sex hormones, vitamin D, and ferritin (2019 cohort only).

MAIN OUTCOME MEASURE

A Triad Cumulative Risk Assessment Score was calculated for each participant.

RESULTS

One hundred twenty-three runners participated (83 males and 40 females, mean age 46.2 and 41.8 years, respectively). 44.5% of men and 62.5% of women had elevated risk for disordered eating. 37.5% of women reported a history of bone stress injury (BSI) and 16.7% had BMD Z scores <-1.0. 20.5% of men had a history of BSI and 30.1% had Z-scores <-1.0. Low body mass index (BMI) (<18.5 kg/m 2 ) was seen in 15% of women and no men. The Triad Cumulative Risk Assessment classified 61.1% of women and 29.2% of men as moderate risk and 5.6% of both men and women as high risk.

CONCLUSIONS

Our study is the first to measure BMD in both male and female ultramarathon runners. Our male population had a higher prevalence of low BMD than the general population; females were more likely to report history of BSI. Risk of disordered eating was elevated among our participants but was not associated with either low BMD or low BMI.

Medical and Biomechanical Risk Factors for Incident Bone Stress Injury in Collegiate Runners: Can Plantar Pressure Predict Injury?

Background:

Bone stress injury (BSI) is a common reason for missed practices and competitions in elite track and field runners.

Hypothesis:

It was hypothesized that, after accounting for medical risk factors, higher plantar loading during running, walking, and athletic movements would predict the risk of future BSI in elite collegiate runners.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A total of 39 elite collegiate runners (24 male, 15 female) were evaluated during the 2014-2015 academic year to determine the degree to which plantar pressure data and medical history (including Female and Male Athlete Triad risk factors) could predict subsequent BSI. Runners completed athletic movements while plantar pressures and contact areas in 7 key areas of the foot were recorded, and the measurements were reported overall and by specific foot area. Regression models were constructed to determine factors related to incident BSI.

Results:

Twenty-one runners (12 male, 9 female) sustained ≥1 incident BSI during the study period. Four regression models incorporating both plantar pressure measurements and medical risk factors were able to predict the subsequent occurrence of (A) BSIs in female runners, (B) BSIs in male runners, (C) multiple BSIs in either male or female runners, and (D) foot BSIs in female runners. Model A used maximum mean pressure (MMP) under the first metatarsal during a jump takeoff and only misclassified 1 female with no BSI. Model B used increased impulses under the hindfoot and second through fifth distal metatarsals while walking, and under the lesser toes during a cutting task, correctly categorizing 83.3% of male runners. Model C used higher medial midfoot peak pressure during a shuttle run and triad cumulative risk scores and correctly categorized 93.3% of runners who did not incur multiple BSIs and 66.7% of those who did. Model D included lower hindfoot impulses in the shuttle run and higher first metatarsal MMP during treadmill walking to correctly predict the subsequent occurrence of a foot BSI for 75% of women and 100% without.

Conclusion:

The models collectively suggested that higher plantar pressure may contribute to risk for BSI.

The Impacts of COVID-19 on Mental Health and Training in US Professional Endurance Athletes

OBJECTIVE

We examined how professional athletes are affected by COVID-19. Our primary aim was to assess changes in mental health that occurred after COVID-19 restrictions, and our secondary aim was to assess changes in exercise volume and intensity.

DESIGN

Cross-sectional study.

SETTING

United States.

PARTICIPANTS

Strava professional endurance athletes.

ASSESSMENT OF RISK FACTORS

Participants completed a survey, and a subset of participants consented to have their activity data analyzed. The survey included questions on COVID-19 symptoms, exercise, and mental health, as measured by a modified Patient Health Questionnaire.

MAIN OUTCOME MEASURES

Participants were asked about 2 periods in 2020: before COVID-19 (January 1-March 14) and during COVID-19 (March 15-August 25), and activity data from both periods were downloaded. Activity data consisted of Global Positioning System and self-reported uploads.

RESULTS

One hundred thirty-one male and female Strava athletes were enrolled, and a subset of athletes (n = 114) consented to have their activity data analyzed. During COVID-19 restrictions, 22.2% of participants reported feeling down or depressed and 27.4% of participants reported feeling nervous or anxious at least half the days in a week compared with 3.8% and 4.6% before COVID-19 restrictions, respectively (P < 0.0001). Activity data revealed a significant increase (P < 0.0001) in exercise minutes per day during COVID-19 (mean = 103.00, SD = 42.1) compared with before COVID-19 restrictions (mean = 92.4, SD = 41.3), with no significant changes in intensity.

CONCLUSIONS

Athletes reported significant increases in feeling down or depressed and nervous or anxious despite an increase in exercise duration during COVID-19. Future research should assess how to support athletes with mental health resources.

Sun Protective Behaviors and Attitudes of Runners

Sun exposure is a risk factor for skin cancer. Knowledge and behaviors around sun exposure protective measures are poorly described in athletes including runners. Our primary objective was to describe sun exposure behaviors and knowledge in a population of runners. A cross-sectional online survey was administered to 697 runners to measure the frequency of seven sun protective behaviors: sunscreen use on the face or body; wearing a hat, sunglasses, or long sleeves; running in shade; and avoidance of midday running. Between 54% and 84% of runners reported that they engaged in these behaviors at least sometimes, but only 7% to 45% reported frequent use. Of 525 runners who gave a primary reason for not using sunscreen regularly, 49.0% cited forgetfulness; 17.3% cited discomfort; and only a small percentage cited maintaining a tan (6.1%) or optimizing vitamin D (5.1%). Of 689 runners who responded to a question about what factor most influences their overall sun exposure habits, 39.2% cited fear of skin cancer, 28.7% cited comfort level, and 15.8% cited fear of skin aging. In addition to the seven individual behaviors, we also asked runners how frequently they took precautions to protect against the sun overall. We explored associations between participant characteristics and the overall use of sun protection using ordinal logistic regression. Overall, sun protection was used more frequently in runners who were female, older, or had a history of skin cancer. Runners appear to recognize the importance of sun protection and the potential consequences of not using it, but report forgetfulness and discomfort as the biggest barriers to consistent use. Interventions using habit-formation strategies and self-regulation training may prove to be most useful in closing this gap between knowledge and practice.

Safety of Intra-Articular Hyaluronic Acid for Knee Osteoarthritis: Systematic Review and Meta-Analysis of Randomized Trials Involving More than 8,000 Patients

OBJECTIVE

The objective of this systematic review and meta-analysis was to report the safety of intra-articular hyaluronic acid (IAHA) in patients with symptomatic knee osteoarthritis (OA).

METHODS

We identified randomized controlled trials reporting the safety of IAHA versus IA saline in adults with symptomatic knee OA. Main safety outcomes were adverse events (AEs), local AEs, serious adverse events (SAEs), study withdrawals, and AE-related study withdrawals.

RESULTS

A total of 35 randomized controlled trials with 38 group comparisons comprising 8,078 unique patients (IAHA: 4,295, IA saline: 3,783) were included in the meta-analysis. Comparing IAHA with IA saline over a median of 6 months follow-up, there were no differences in the risk of AEs (42.4% vs. 39.7%, risk ratio [RR] = 1.01, 95% CI = 0.96-1.07, P = 0.61), SAEs (1.8% vs. 1.2%, RR = 1.44, 95% CI = 0.91-2.26, P=0.12), study withdrawals (12.3% vs. 12.7%, RR = 0.99, 95% CI = 0.87-1.12, P = 0.83), or AE-related study withdrawals (2.7% vs. 2.1%, RR = 1.37, 95% CI = 0.97-1.93, P = 0.08). Local AEs, all of which were nonserious, were more common with IAHA vs. IA saline (14.5% vs. 11.7%, RR = 1.21, 95% CI = 1.07-1.36, P = 0.003) and typically resolved within days.

CONCLUSION

IAHA was shown to be safe for use in patients with symptomatic knee OA. Compared with IA saline, IAHA is associated with an increased risk of nonserious, transient local reactions. There was no evidence to suggest any additional safety risks of IAHA.

Physical Examination and Patellofemoral Pain Syndrome: an Updated Review

PURPOSE OF REVIEW

Patellofemoral pain syndrome (PFPS) accounts for 25 to 40% of all knee disorders. Diagnosis of PFPS is primarily based on history and physical examination, but the findings on physical examination are often subtle and do not consistently correlate with symptoms described. Yoon and Fredericson published a review article in 2006 detailing the physical examination maneuvers most frequently used to assist clinicians in the accurate diagnosis and treatment of PFPS, and our aim in this review is to provide an update on this previous article focusing on the literature published over the past 15 years regarding the topic.

RECENT FINDINGS

Since publication of Fredericson's original review article, there have been studies building on the literature specifically surrounding Q angle, patellar tilt, crepitus, strength and functional testing, and physical examination maneuver clustering. Additionally, multiple studies have been conducted on the use of musculoskeletal ultrasound (US) as a diagnostic tool for PFPS. Recent literature has further supported Q angle (when measured utilizing a standardized protocol), crepitus, weakness of hip abductors and extensors, and weakness detected in functional testing as predictors of PFPS while finding inconsistent evidence behind lateral patellar tilt as a predictor of PFPS. The reliability of most physical examination tests alone remain low, but clustering physical examination findings may provide better sensitivities and specificities in diagnosing PFPS. Musculoskeletal US is rapidly gaining popularity, and decreased vastus medialis obliquus (VMO) volume, asymmetry in gluteus medius thickness, intra-articular effusions, and quadriceps and patellar tendon thicknesses have shown value in diagnosing those with PFPS. Additionally, US has the advantage of providing dynamic examination as well as evaluation of the patellofemoral joint in newborns and infants as a predictor of future patellofemoral instability. Further studies are needed to establish the gold standard for diagnosing PFPS and what US findings are truly predictive of PFPS.

The Physiatry Workforce in 2019 and Beyond, Part 2: Modeling Results

OBJECTIVE

The aim of this study was to assess the current and future adequacy of physiatrist supply in the United States.

DESIGN

A 2019 online survey of board-certified physiatrists (n = 616 completed, 30.1% response) collected information about demographics, practice characteristics, hours worked, and retirement intentions. Microsimulation models projected future physiatrist supply and demand using data from the American Board of Physical Medicine and Rehabilitation, national and state population projections, American Community Survey, Behavioral Risk Factor Surveillance System, Medical Expenditure Panel Survey, and other sources.

RESULTS

Approximately 37% of 8853 active physiatrists indicate that their workload exceeds capacity, 59% indicate that workload is at capacity, and 4% indicate under capacity. These findings suggest a national shortfall of 940 (10.6%) physiatrists in 2017, with substantial geographic variation in supply adequacy. Projected growth in physiatrist supply from 2017 to 2030 approximately equals demand growth (2250 vs. 2390), suggesting that without changes in care delivery, the shortfall of physiatrists will persist, with a 1080 (9.7%) physiatrist shortfall in 2030.

CONCLUSION

Without an increase in physiatry residency positions, the current national shortfall of physiatrists is projected to persist. Although a projected increase in physiatrists' use of advanced practice providers may help preserve access to comprehensive physiatry care, it is not expected to eliminate the shortfall.

Markers of Low-Iron Status Are Associated with Female Athlete Triad Risk Factors

PURPOSE

The Female Athlete Triad (Triad) is common in female athletes. The Triad is caused by low-energy availability (EA), which is often difficult to measure and has been postulated to be associated with low-iron status. Here, we explore whether markers of low-iron status may be associated with indicators of low EA including Triad risk factors.

METHODS

A total of 239 female National Collegiate Athletic Association Division I athletes completed preparticipation examinations that included Triad risk factors, medication/supplement use, diagnosis of anemia, and elected to complete dual-energy x-ray absorptiometry scan to measure bone mineral density. The association of markers of low iron (defined as self-report of iron supplementation and/or history of anemia) with each component of the Triad risk assessment score was assessed by stratifying low-iron status across different levels of Triad risk category. Differences across iron status groups were assessed using Fisher exact testing.

RESULTS

Every component of the Triad risk assessment score excluding delayed menarche was associated with low-iron status. The proportion of women who reported low iron was 11.5% in the low-risk EA group compared with 50% in the moderate-risk and 66.7% in the high-risk EA groups (P = 0.02); respectively. These numbers were 11.6%, 25.0%, and 66.7% (P = 0.02) for body mass index; 9.7%, 16.7%, and 25.0% (P < 0.05) for oligomenorrhea; 10.3%, 45.5%, and 50.0% (P < 0.01) for bone mineral density; and 10.4%, 20.8%, and 30.8% (P = 0.03) for history of stress reaction or fracture. Lean/endurance athletes were more likely to have low-iron status than other athletes (15.5% vs 3.4%, P = 0.02).

CONCLUSIONS

Markers for low-iron status were associated with Triad risk factors. Our study suggests that female athletes with a history of anemia or iron supplementation may require further screening for low EA.

Low-Energy Availability and the Electronic Preparticipation Examination in College Athletes: Is There a Better Way to Screen?

ABSTRACT

The electronic preparticipation physical examination (ePPE) is commonly used to identify health conditions that would affect participation in sports for athletes, including disordered eating and/or low energy availability (EA). A secondary analysis was performed using a cohort study of female college athletes attending a Division 1 university between 2008 and 2014. Descriptive statistics and logistic regression analyses were used to explore the association between responses to questions on the ePPE related to eating behaviors and Female Athlete Triad (Triad). Risk categories (low, moderate, or high) were assigned to 239 athletes participating in 16 sports. The majority of responses on the ePPE did not identify athletes associated with moderate-/high-risk categories. Our findings suggest that ePPE may not sufficiently identify athletes at elevated risk for health concerns of the Triad. Our findings suggest that future ePPE may consider validated screening tools for disordered eating to help identify athletes at risk of low EA.

The Physiatry Workforce in 2019 and Beyond, Part 1: Results From a Cross-sectional Survey

OBJECTIVE

The aim of the study was to describe the current physiatrist workforce in the United States.

DESIGN

An online, cross-sectional survey of board-certified physiatrists in 2019 (N = 616 completed, 30.1% response) collected information about demographic and practice characteristics, including age, sex, practice area, practice setting, hours worked, patient characteristics, staffing, and work responsibilities. Physiatrists were stratified by substantive practice patterns using a cluster analysis approach. Survey responses were arrayed across the practice patterns and differences noted.

RESULTS

The practice patterns identified included musculoskeletal/pain medicine, general/neurological rehabilitation, academic practice, pediatric rehabilitation, orthopedic/complex conditions rehabilitation, and disability/occupational rehabilitation. Many differences were observed across these practice patterns. Notably, primary practice setting and the extent and ways in which other healthcare staff are used in physiatry practices differed across practice patterns. Physiatrists working in musculoskeletal/pain medicine and disability/occupational rehabilitation were least likely to work with nurse practitioners and physician assistants. Physiatrists working in academic practice, general/neurological rehabilitation, and pediatric rehabilitation were most likely to have primary practice settings in hospitals.

CONCLUSIONS

Physiatry is an evolving medical specialty affected by many of the same trends as other medical specialties. The results of this survey can inform policy discussions and further research on the effects of these trends on physiatrists and physiatry practice in the future.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis

ABSTRACT

The Male Athlete Triad is a syndrome of 3 interrelated conditions most common in adolescent and young adult male endurance and weight-class athletes and includes the clinically relevant outcomes of (1) energy deficiency/low energy availability (EA) with or without disordered eating/eating disorders, (2) functional hypothalamic hypogonadism, and (3) osteoporosis or low bone mineral density with or without bone stress injury (BSI). The causal role of low EA in the modulation of reproductive function and skeletal health in the male athlete reinforces the notion that skeletal health and reproductive outcomes are the primary clinical concerns. At present, the specific intermediate subclinical outcomes are less clearly defined in male athletes than those in female athletes and are represented as subtle alterations in the hypothalamic-pituitary-gonadal axis and increased risk for BSI. The degree of energy deficiency/low EA associated with such alterations remains unclear. However, available data suggest a more severe energy deficiency/low EA state is needed to affect reproductive and skeletal health in the Male Athlete Triad than in the Female Athlete Triad. Additional research is needed to further clarify and quantify this association. The Female and Male Athlete Triad Coalition Consensus Statements include evidence statements developed after a roundtable of experts held in conjunction with the American College of Sports Medicine 64th Annual Meeting in Denver, Colorado, in 2017 and are in 2 parts-Part I: Definition and Scientific Basis and Part 2: The Male Athlete Triad: Diagnosis, Treatment, and Return-to-Play. In this first article, we discuss the scientific evidence to support the Male Athlete Triad model.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play

ABSTRACT

The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

Narrative Review - Knee Pain in the Pediatric Athlete

PURPOSE OF REVIEW

This review article seeks to highlight common youth athlete knee conditions due to overuse or trauma and elucidate differences from the adult populations.

RECENT FINDINGS

Overuse conditions presented include apophysitis, osteochondritis dissecans plica syndrome, and discoid meniscus. Traumatic conditions presented include patellar instability, patellar sleeve fracture, and patellofemoral osteochondral fractures. Knee injuries affect a significant proportion of youth athletes. These injuries place athletes at higher risk of chronic pain and potentially osteoarthritis. We have reviewed common overuse and traumatic knee injuries and differentiating factors between the adult population to improve and expedite the diagnosis, treatment, and prognosis for youth athletes with knee injuries.

Dietary Supplement Use According to Sex and Triad Risk Factors in Collegiate Endurance Runners

ABSTRACT

Barrack, MT, Fredericson, M, Dizon, F, Tenforde, AS, Kim, BY, Kraus, E, Kussman, A, Singh, S, and Nattiv, A. Dietary supplement use according to sex and Triad risk factors in collegiate endurance runners. J Strength Cond Res 35(2): 404-410, 2021-This cross-sectional study evaluated the prevalence in the use of dietary supplements among elite collegiate runners among 2 NCAA Division I cross-country teams. At the start of each season from 2015 to 2017, male and female endurance runners were recruited to complete baseline study measures; the final sample included 135 (male n = 65, female n = 70) runners. Runners completed a health survey, web-based nutrition survey, and Triad risk assessment. The prevalence of dietary supplement use and Triad risk factors, including disordered eating, low bone mass, amenorrhea (in women), low body mass index, and stress fracture history, was assessed. A total of 78.5% (n = 106) runners reported taking 1 or more supplements on ≥4 days per week over the past month, 48% (n = 65) reported use of ≥3 supplements. Products used with highest frequency included multivitamin/minerals 46.7% (n = 63), iron 46.7% (n = 63), vitamin D 34.1% (n = 46), and calcium 33.3% (n = 45). More women, compared with men, used iron (61.4 vs. 30.8%, p < 0.001) and calcium (41.4 vs. 24.6%, p = 0.04); men exhibited higher use of amino acids and beta-alanine (6.2 vs. 0%, p = 0.04). Runners with bone stress injury (BSI) history, vs. no previous BSI, reported more frequent use of ≥3 supplements (61.5 vs. 32.8%, p = 0.001), vitamin D (49.2 vs. 19.4%, p < 0.001), and calcium (47.7 vs. 19.4%, p = 0.001). Low bone mineral density was also associated with higher use of vitamin D and calcium. Most runners reported regular use of 1 or more supplements, with patterns of use varying based on sex, history of BSI, and bone mass.

A Genome-wide Association Study for Concussion Risk

PURPOSE

This study aimed to screen the entire genome for genetic markers associated with risk for concussion.

METHODS

A genome-wide association analyses was performed using data from the Kaiser Permanente Research Bank and the UK Biobank. Concussion cases were identified based on electronic health records from the Kaiser Permanente Research Bank and the UK Biobank from individuals of European ancestry. Genome-wide association analyses from both cohorts were tested for concussion using a logistic regression model adjusting for sex, height, weight, and race/ethnicity using allele counts for single nucleotide polymorphisms. Previously identified genes within the literature were also tested for association with concussion.

RESULTS

There were a total of 4064 cases of concussion and 291,472 controls within the databases, with two single nucleotide polymorphisms demonstrating a genome-wide significant association with concussion. The first polymorphism, rs144663795 (P = 9.7 × 10-11; OR = 2.91 per allele copy), is located within the intron of SPATA5. Strong, deleterious mutations in SPATA5 cause intellectual disability, hearing loss, and vision loss. The second polymorphism, rs117985931 (P = 3.97 × 10-9; OR = 3.59 per allele copy), is located within PLXNA4. PLXNA4 plays a key role is axon outgrowth during neural development, and DNA variants in PLXNA4 are associated with risk for Alzheimer's disease. Previous investigations have identified five candidate genes that may be associated with concussion, but none showed a significant association in the current model (P < 0.05).

CONCLUSION

Two genetic markers were identified as potential risk factors for concussion and deserve further validation and investigation of molecular mechanisms.

Topical diclofenac vs placebo for the treatment of chronic Achilles tendinopathy: A randomized controlled clinical trial

INTRODUCTION

The application of topical diclofenac has been suggested as a possible treatment for Achilles tendinopathy. Our aim was to answer the question, is topical diclofenac more effective than placebo for the treatment of Achilles tendinopathy?.

METHODS

67 participants with persistent midportion or insertional Achilles tendinopathy were randomly assigned to receive a 4 week course of 10% topical diclofenac (n = 32) or placebo (n = 35). The a priori primary outcome measure was change in severity of Achilles tendinopathy (VISA-A score) at 4 and 12 weeks. Secondary outcome measures included numeric pain rating, and patient-reported change in symptoms using a 7 point scale, from substantially worse to substantially better. Pressure pain threshold (N) and transverse tendon stiffness (N/m) were measured over the site of maximum Achilles tendon pathology at baseline and 4 weeks.

RESULTS

There were no statistically or clinically significant differences between the diclofenac and placebo groups in any of the primary or secondary outcome measures at any timepoint. Average VISA-A score improved in both groups (p<0.0001), but the improvements were marginal: at 4 weeks, the improvements in VISA-A were 9 (SD 11) in the diclofenac group and 8 (SD 12) in the placebo group, and at 12 weeks the improvements were 9 (SD 16) and 11 (SD13) respectively-these average changes are smaller than the minimum clinically important difference of the VISA-A.

CONCLUSION

The regular application of topical diclofenac for Achilles tendinopathy over a 4 week period was not associated with superior clinical outcomes to that achieved with placebo.

Assessing Diagnostic and Severity Grading Accuracy of Ultrasound Measurements for Carpal Tunnel Syndrome Compared to Electrodiagnostics

BACKGROUND

The combined sensory index (CSI) is the most sensitive electrodiagnostic criteria for carpal tunnel syndrome (CTS), and the CSI and Bland criteria have been shown to predict surgical treatment outcomes. The proposed ultrasound measurements have not been assessed against the CSI for diagnostic accuracy and grading of CTS severity.

OBJECTIVE

To investigate the use of ultrasound evaluations for both diagnosis and assessment of severity grading of CTS in comparison to electrodiagnostic assessment.

DESIGN

All patients underwent an electrodiagnostic evaluation using the CSI and Bland severity grading. Each patient underwent an ultrasound evaluation including cross-sectional area (CSA), the change in CSA from the forearm to the tunnel (∆CSA), and the wrist-forearm ratio (WFR). These measurements were assessed for diagnostic and severity grading accuracy using the CSI as the gold standard.

SETTING

Tertiary academic center.

PARTICIPANTS

All patients referred for electrodiagnostic evaluation for CTS were eligible for the study. Only those with idiopathic CTS were included and those with prior CTS treatment were also excluded. Ninety-five patients were included in the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary study outcome measure was concordance between CSI diagnosis and severity categories and the ultrasound measurements. Both outcomes were also assessed using Bland criteria.

RESULTS

Optimal cut-points for diagnosis of CTS were found to be CSA ≥12 mm² , ∆CSA ≥4 mm² , WFR ≥1.4. Using these cut-points, C-statistics comparing diagnosis of CTS using ultrasound measurements versus using the CSI ranged from 0.893-0.966. When looking at CSI severity grading compared to ∆CSA, however, the C-statistics were 0.640-0.661 with substantial overlap between severity groups.

CONCLUSIONS

Although ultrasound measurements had high diagnostic accuracy for CTS based on the CSI criteria, ultrasound measurements were unable to adequately distinguish between CSI severity groups among patients with CTS.

Vitamin D for Improved Bone Health and Prevention of Stress Fractures: A Review of the Literature

Vitamin D is a vital nutrient and hormone needed for many essential functions in overall health. There is growing literature examining the role of vitamin D not only in the general population but also in athletes. The most predominantly studied area of vitamin D pertains to bone health. Recently, there has been increased investigation into the relationship of vitamin D and stress fractures, including genetic polymorphisms, levels of 25-hydroxyvitamin D, and bioavailable vitamin D. This review will address the most recent developments of vitamin D research and its important role in bone health in athletes.

Youth running consensus statement: minimising risk of injury and illness in youth runners

Despite the worldwide popularity of running as a sport for children, relatively little is known about its impact on injury and illness. Available studies have focused on adolescent athletes, but these findings may not be applicable to preadolescent and pubescent athletes. To date, there are no evidence or consensus-based guidelines identifying risk factors for injury and illness in youth runners, and current recommendations regarding suitable running distances for youth runners at different ages are opinion based. The International Committee Consensus Work Group convened to evaluate the current science, identify knowledge gaps, categorise risk factors for injury/illness and provide recommendations regarding training, nutrition and participation for youth runners.

Lower Trabecular Bone Score and Spine Bone Mineral Density Are Associated With Bone Stress Injuries and Triad Risk Factors in Collegiate Athletes

INTRODUCTION

Determinants of bone health and injury are important to identify in athletes. Bone mineral density (BMD) is commonly measured in athletes with Female Athlete Triad (Triad) risk factors; the trabecular bone score (TBS) has been proposed to predict fracture risk independent of BMD. Evaluation of TBS and spine BMD in relation bone stress injury (BSI) risk has not been studied in female collegiate athletes.

OBJECTIVE

We hypothesized that spine BMD and TBS would each independently predict BSI and that the combined measures would improve injury prediction in female collegiate athletes. We also hypothesized that each measure would be correlated with Triad risk factors.

DESIGN

Retrospective cohort.

SETTING

Academic Institution.

METHODS

Dual energy x-ray absorptiometry (DXA) of the lumbar spine was used to calculate BMD and TBS values. Chart review was used to identify BSI that occurred after the DXA measurement and to obtain Triad risk factors. We used logistic regression to examine the ability of TBS and BMD alone or in combination to predict prospective BSI.

RESULTS

Within 321 athletes, 29 (9.0%) sustained a BSI after DXA. BMD and TBS were highly correlated (Pearson correlation r = 0.62, P < .0001). Spine BMD and TBS had similar ability to predict BSI; the C-statistic and 95% confidence intervals were 0.69 (0.58 to 0.81) for spine BMD versus 0.68 (0.57 to 0.79) for TBS. No improvement in discrimination was observed with combined BMD + TBS (C-statistic 0.70, 0.59 to 0.81). Both TBS and BMD predicted trabecular-rich BSI (defined as pelvis, femoral neck, and calcaneus) better than cortical-rich BSI. Both measures had similar correlations with Triad risk factors.

CONCLUSION

Lower BMD and TBS values are associated with elevated risk for BSI and similar correlation to Triad risk factors. TBS does not improve prediction of BSI. Collectively, our findings suggest that BMD may be a sufficient measure of skeletal integrity from DXA in female collegiate athletes.

Taping, Bracing, and Injection Treatment for Patellofemoral Pain and Patellar Tendinopathy

PURPOSE OF REVIEW

This article will focus on additional treatment options for the two most common causes of anterior knee pain, patellofemoral pain syndrome, and patellar tendinopathy. Conservative management is the first-line treatment for these conditions. For clinicians to maximize the efficacy of conservative treatment options for their patients, they must understand the most up-to-date literature evaluating the potential benefit of taping, bracing, and injections as adjunctive treatments for maximizing treatment success.

RECENT FINDINGS

Recent studies of bracing and taping have found them to be helpful for patients in the short-term management of pain and improving function. However, less is known about their exact mechanism but studies are encouraging that they have a subtle role in changing patellofemoral biomechanics. Injections remain a commonly used treatment for musculoskeletal conditions; however, the evidence for their use in patellofemoral pain and patellar tendinopathy is limited. The use of platelet-rich plasma (PRP), sclerosing, high volume, or stem cell injections is an exciting new area in the treatment of patellar tendinopathy. However, evidence at this time to recommend these treatments is lacking, and more well-designed studies are needed. The treatment of patellofemoral pain and patellar tendinopathy consists of a multi-faceted approach of physiotherapy and physical modalities. There is evidence for short-term use of taping and bracing for these conditions. The evidence for injections at this time is limited and remains under investigation. Future well-designed randomized controlled studies will provide insight into the efficacy of several different types of injections in the treatment of patellar tendinopathy. Physicians should feel comfortable integrating taping and bracing into their anterior knee pain treatment paradigm while making cautious use of invasive injections as adjunctive therapy.