A Pilot Randomized Controlled Trial of Docosahexaenoic Acid for the Treatment of Sport-Related Concussion in Adolescents.

The objective was to examine the use of docosahexaenoic acid (DHA) for the treatment of sport-related concussion (SRC) in adolescent athletes. We hypothesize that participants who intake 2 g of DHA daily will not experience differences in recovery compared with participants who take a placebo. This double-blind, randomized controlled pilot trial was performed in a tertiary pediatric sports medicine clinic from 2013 to 2017 in adolescents (14-18 years) presenting with diagnosed SRC within 4 days of injury. Forty participants were randomized into DHA or PLACEBO group and were instructed to take 2 capsules twice daily for 12 weeks. Participants in the DHA group were symptom-free earlier than the PLACEBO group (11.0 vs 16.0 days, P = .08) and were cleared to begin the Return to Sport progression (14.0 vs 19.5 days, P = .12) sooner. The use of 2 g/day of DHA was well-tolerated and did not significantly affect recovery times in adolescent athletes following SRC.Clinical Trial Registration: ClincalTrials.gov, NCT01903525.

AMSSM position statement update: blood-borne pathogens in the context of sports participation.

This American Medical Society for Sports Medicine position statement update is directed towards healthcare providers of patients involved in sport and exercise. There have been significant advances in clinical and scientific research in the understanding of blood-borne pathogens (BBPs), and this update incorporates these advancements. This document is intended as a general guide to clinical practice based on the current state of the evidence, while acknowledging the need for modification as new knowledge becomes available. Confirmed transmission of BBPs during sport is exceedingly rare. There are no well-documented reports of HIV, HCV or HDV transmission during sport. There is also no evidence for universal testing for BBPs as a specific requirement for participation in sports. Competitive athletes and non-athletes should follow appropriate general public health agency recommendations for screening for BBPs, considering their individual risk factors and exposures. Standard (universal) precautions must be followed by those providing care to athletes. Exercise and athletic participation can help promote a healthy lifestyle for persons living with BBPs. Those with acute symptomatic BBP infection should limit exercise intensity based on their current health status. Education is the key tool for preventing BBP transmission. Research gaps include evaluation of the prevalence of BBP infections in competitive athletes, the effects of long-term, intense training on infected athletes and the effects of BBP treatment therapies on performance.

IMPLEMENTING A STANDARDIZED INTERVENTIONAL EXERCISE REGIMEN TO IMPROVE FUNCTIONAL MOVEMENTS IN FEMALE COLLEGIATE ATHLETES.

BACKGROUND: Interventional exercises have been developed to help athletes improve scores on the Functional Movement Screen™ (FMS™). However, there is a paucity of research on the effects of a similar program in female athletes, as well as the effects of a standardized corrective exercise regimen. The purpose of this study was to assess whether an in-season, standardized interventional exercise program improves FMS™ score asymmetry and the composite score of female collegiate athletes. STUDY DESIGN: Prospective, quasi-experimental, cohort study. METHODS: Forty-one (mean age 19.5 ± 1.2 years; body mass, 70.6 ± 11.5 kg ; height, 1.70 ± 0.083 m) NCAA Division III female soccer (n=10), softball (n=17), and basketball (n=14) players participated in this study. The athletes completed the FMS™ screens prior to their season, regularly participated in four in-season standardized corrective exercises throughout three to four month athletic seasons, and completed the FMS™ screens in the postseason. RESULTS: The average score of all athletes before the season was 15.52 ± 0.63 and 16.04 ± 0.72 after the season. While the mean score of soccer players increased from 14.80 ± 0.92 to 16.1 ± 1.52 and the mean score of softball players increased from 15.83 ± 1.89 to 16.72 ± 1.41 at the end of the season, the mean score of basketball players dropped from 15.93 ± 1.49 to 15.29 ± 1.59. Women's basketball players experienced a decrease in their composite FMS™ score ( x ¯ = -0.571, p<0.01), while women's soccer players ( x ¯ =+1.30, p<0.05) and softball players ( x ¯ =+1.12, p<0.05) experienced an increase in mean score 2.28 times and 1.96 times greater in magnitude than the decrease in basketball players' composite FMS™, respectively. Fewer total athletes demonstrated asymmetries at postseason testing, decreasing from 24 at preseason testing to 15 at postseason testing (p<0.01). Significant differences were not noted between athlete age and FMS™ scores (p>0.05). CONCLUSIONS: Standardized interventional programs during athletic teams' seasons may be used to help increase FMS™ scores and reduce asymmetry. Though more studies are warranted to address the negative effects of this standardized program in women's basketball players, this study demonstrated that the number of asymmetries significantly decreased from pre- to postseason among soccer and softball players, which may have implications for a higher resistance to injury. LEVELS OF EVIDENCE: 3.

Dropping the Hammer: An Uncommon Case of Right-Hand Pain in a Professional Hockey Player.

A 26-year-old, right-handed male professional hockey player presented for a second opinion with dysesthesia of the tips of his right third, fourth, and fifth fingers after 2 previous incidents of hyperextension injuries to his right wrist while holding his hockey stick. Radiographs and computed tomography scans were negative for fracture. After magnetic resonance angiography and Doppler ultrasound imaging, the athlete was diagnosed with hypothenar hammer syndrome (HHS) with ulnar artery aneurysm and thrombosis. He underwent successful surgery with ligation and excision of the aneurysmal, thrombosed ulnar artery and was able to return to hockey 4 weeks after surgery. HHS is thought to be a rare posttraumatic digital ischemia from thrombosis and/or aneurysm of the ulnar artery and was traditionally considered an occupational injury but has been reported more frequently among athletes. There have only been 2 previous case reports of hockey players diagnosed with HHS, and in the previous 2 case reports, both involved repetitive trauma from the hockey stick, which resulted in thrombotic HHS. We present a case of a professional hockey player diagnosed with HHS also due to repetitive trauma from the hockey stick, but this time resulting in aneurysmal HHS with thromboembolism. This case report highlights the importance of keeping HHS in the differential diagnosis in athletes with pain, cold sensitivity, and paresthesia in their fingers with or without a clear history of repetitive trauma to the hypothenar eminence, as HHS is a condition with good outcomes after proper treatment.

THE DIAGNOSTIC ACCURACY OF THE LEVER SIGN FOR DETECTING ANTERIOR CRUCIATE LIGAMENT INJURY.

BACKGROUND: An alternative physical examination procedure for evaluating the integrity of the anterior cruciate ligament (ACL) has been proposed in the literature but has not been validated in a broad population of patients with a symptomatic complaint of knee pain for its diagnostic value. PURPOSE: To investigate the diagnostic accuracy of the Lever Sign to detect ACL tears and compare the results to Lachman testing in both supine and prone positions. STUDY DESIGN: Prospective, blinded, diagnostic accuracy study. METHODS: Sixty-two consecutive patients with a complaint of knee pain were independently evaluated for the status of the ACL's integrity with the Lever Sign and the Lachman test in a prone and supine by a blinded examiner before any other diagnostic assessments were completed. RESULTS: Twenty-four of the 60 patients included in the analysis had a torn ACL resulting in a prevalence of 40%. The sensitivity of the Lever Sign, prone, and supine Lachman tests were 38, 83, and 67 % respectively and the specificity was 72, 89, and 97% resulting in positive likelihood ratios of 1.4, 7.5, and 24 and negative likelihood ratios of 0.86, 0.19, and 0.34 respectively. The positive predictive values were 47, 83, and 94% and the negative predictive values were 63, 89, and 81% respectively. The diagnostic odds ratios were 1.6, 40, and 70 with a number needed to diagnose of 10.3, 1.4, and 1.6 respectively. CONCLUSIONS: The results of this study suggest that Lever Sign, in isolation, does not accurately detect the status of the ACL. During the clinical examination, the Lever Sign should be used as an adjunct to the gold standard assessment technique of anterior tibial translation assessment as employed in the Lachman tests in either prone or supine position. LEVEL OF EVIDENCE: 2.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions.

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

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

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

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

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

Sideline management of sport-related concussions.

Concussions remain one of the most troublesome injuries sports physicians face. Studies suggest recovery takes hours to weeks, but at what point is the concussed brain no longer at increased risk for reinjury is unknown. Physicians must be alert to the symptoms of concussion and be familiar with the available tools to assess neurocognitive dysfunction. Prospectively validated signs and symptoms include amnesia, loss of consciousness, headache, dizziness, blurred vision, attention deficit, memory, postural instability, and nausea. A player with any signs or symptoms of a concussion should not be allowed to return to the current game or practice and should be monitored closely for deterioration of symptoms. Return-to-play should be individually based and proceed in a step-wise manner. The ongoing risk-benefit analysis of return-to-play must currently be based on experience, corollary data from traumatic brain injuries in animals and humans, and limited prospective data with sports-related concussions.

Iron and the athlete.

Iron is an important mineral necessary for many biologic pathways. Different levels of deficiency can occur in the athlete, resulting in symptoms that range from none to severe fatigue. Iron deficiency without anemia may adversely affect athletic performance. Causes of iron deficiency include poor intake, menstrual losses, gastrointestinal and genitourinary losses due to exercise-induced ischemia or organ movement, foot strike hemolysis, thermohemolysis, and sweat losses. A higher incidence of deficiency occurs in female athletes compared with males.

What kind of physical examination does a young athlete need before participating in sports?

Recommendations exist for preparticipation physical examinations, but there is no national standard, and the recommendations are not widely followed. The most common reasons for denying clearance to play are musculoskeletal conditions, hypertension, and visual acuity problems. Although detecting potentially life-threatening conditions is an appropriate goal, preparticipation physical examinations have only a limited ability to detect cardiac abnormalities that dispose athletes to sudden death on the playing field; fortunately, these events are very rare.

Entrapment neuropathies of the upper extremity.

Symptoms of entrapment neuropathies are often intermittent, making the diagnosis a challenge; pain, paresthesias, exertional fatigue, weakness, and atrophy may be present. An accurate, detailed history and physical examination, often after activity, is essential to make an accurate diagnosis. Laboratory, radiographic, and electromyographic studies may be helpful, but are often normal. This article reviews the etiology, evaluation, and treatment of the most common upper extremity entrapment neuropathies related to sports participation. Most conditions respond to conservative measures of rehabilitation exercises, relative rest, correction of training and equipment errors, anti-inflammatory medications, and protective padding or bracing; occasionally surgical intervention is necessary.