Implementing a Sports Ultrasound Curriculum in Undergraduate Medical Education.

ABSTRACT: The utilization of sports ultrasound in the clinical practice of sports medicine physicians is growing rapidly. Simultaneously, ultrasound is being increasingly implemented as a teaching tool in undergraduate medical education. However, a sports ultrasound curriculum for medical students has not been previously described. In this article, we describe methods as well as barriers to implementing a sports ultrasound curriculum at the medical school level. Recommended content for the curriculum also is discussed. While educational goals and resources will vary among institutions, this article may serve as a general roadmap for the creation of a successful curriculum.

Sports Medicine Curricular Recommendations for Undergraduate Medical Education.

ABSTRACT: Sports medicine is a unique field encompassing many specialties and aspects of medicine. While musculoskeletal medicine is a significant aspect of sports medicine, the breadth of sports medicine extends beyond the musculoskeletal system and includes the spectrum of care for the patient who is or desires to be physically active. This article provides recommendations for sports medicine education in undergraduate medical education. The framework highlighting these recommendations uses domains of competence. Entrustable professional activities, measures that are endorsed by the Association of American Medical Colleges, were matched to domains of competence to provide objective markers of achievement. In addition to recommended sports medicine educational content, there should be consideration of both methods of assessment and implementation catered to each individual institution's needs and resources. These recommendations may serve as a guide for medical educators and institutions pursing optimization of sports medicine education.

Load-deformation characteristics of cadaver patellae: Relationship to intraosseous pressure.

BACKGROUND: Anterior knee pain can arise from several sources. One of the main sources of pain in patients with anterior knee pain is the patella. Increased patellofemoral joint loading is the prime source of patellar pain. Elevated intraosseous pressures have been measured in painful patellae and increasing the intraosseous fluid pressure in the patella causes pain. Whether elevated fluid pressure is an independent source of pain or if the patellar deformation under load leads to elevated pressure and pain has not been determined. Our hypothesis was that the patella deforms measurably under physiologic loads and that intraosseous pressure increase is related to that deformation. The relationship may be linear as measured by correlation or nonlinear as measured by the sum of squared error. METHODS: Part I: Assessment of patellar load-deformation profiles were obtained in 2 intact cadaver patellae and 1 bisected patella under physiologic loads. Part II: Measurements of intraosseous pressure were obtained in 9 cadaver patellae as the patellae were compressed with physiologic loads. Pressures were recorded at sequential levels of anterior-posterior patellar compression. FINDINGS: Cadaver patellae compress up to 3.5 mm in the anterior-posterior plane. Compression with physiologic forces raises intraosseous pressure to more than 40 mmHg. INTERPRETATION: Load-deformation of cadaver patellae results in deformation and an increase in intraosseous pressure. These findings may help explain previous studies of patellofemoral pain where elevated patellar intraosseous pressures have been found in vivo.

Quantitative Assessment of Balance for Accurate Prediction of Return to Sport From Sport-Related Concussion.

BACKGROUND: Determining when athletes are able to return to sport after sports-related concussion (SRC) can be difficult. HYPOTHESIS: A multimodal algorithm using cognitive testing, postural stability, and clinical assessment can predict return to sports after SRC. STUDY DESIGN: Prospective cohort. LEVEL OF EVIDENCE: Level 2b. METHODS: Athletes were evaluated within 2 to 3 weeks of SRC. Clinical assessment, Immediate Post Concussion and Cognitive Testing (ImPACT), and postural stability (Equilibrate) were conducted. Resulting data and machine learning techniques were used to optimize an algorithm discriminating between patients ready to return to sports versus those who are not yet recovered. A Fisher discriminant analysis with leave-one-out cross-validation assessed every combination of 2 to 5 factors to optimize the algorithm with lowest combination of type I and type II errors. RESULTS: A total of 193 athletes returned to contact sports after SRC at a mean 84.6 days (±88.8). Twelve subjects (6.2%) sustained repeat SRC within 12 months after return to sport. The combination of (1) days since injury, (2) total symptom score, and (3) nondominant foot tandem eyes closed postural stability score created the best algorithm for discriminating those ready to return to sports after SRC with lowest type I error (13.85%) and type II error (11.25%). The model was able to discriminate between patients who were ready to successfully return to sports versus those who were not with area under the receiver operating characteristic (ROC) curve of 0.82. CONCLUSION: The algorithm predicts successful return to sports with an acceptable sensitivity and specificity. Tandem balance with eyes closed measured with a video-force plate discriminated athletes ready to return to sports from SRC when combined in multivariate analysis with symptom score and time since injury. The combination of these factors may pose advantages over computerized neuropsychological testing when evaluating young athletes with SRC for return to contact sports. CLINICAL RELEVANCE: When assessing young athletes sustaining an SRC in a concussion clinic, measuring postural stability in tandem stance with eyes closed combined with clinical assessment and cognitive recovery is effective to determine who is ready to successfully return to sports.

Concussion-Reporting Behavior in Rugby: A National Survey of Rugby Union Players in the United States.

BACKGROUND: Rugby is the fastest growing team sport in the United States for male and female athletes. It is a contact/collision sport with an injury risk profile that includes concussions. PURPOSE: To examine the prevalence of concussions in male and female rugby players in the United States and to characterize behaviors around reporting concussions that could be a target for prevention and treatment efforts. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: An online survey distributed to active members on the USA Rugby membership list was used to examine self-reported concussions in male and female athletes. Concussion-reporting behaviors and return to play after a concussion were also explored. Statistical analysis was used to compare male with female athletes and report differences, with years of experience as a dependent variable. RESULTS: The proportion of athletes with a history of at least 1 concussion was 61.9% in all respondents. Of those who reported a concussion, 50.8% reported the concussion during the game or practice in which it occurred, and 57.6% reported at least 1 concussion to a qualified medical provider. Overall, 27.7% of participants who reported ≥1 rugby-related concussion in our survey noted that at least 1 of these concussions was not formally reported. The most commonly cited reasons for not reporting a concussion included not thinking that it was a serious injury, not knowing that it was a concussion at the time, and not wanting to be pulled out of the game or practice. Additionally, 61.0% of athletes did not engage in recommended return-to-play protocols after their most recent rugby-related concussion. CONCLUSION: US rugby union athletes may not report concussions to medical personnel or follow return-to-play protocols guided by medical advice. This could result from a lack of education on concussion recognition and the risks associated with continued play after a concussion as well as limited access to health care. Further education efforts focusing on the identification of concussions, removal from play, and return-to-play protocols are necessary in the US rugby union population.

Future Directions in Sports-Related Concussion Management.

This article focuses on 3 concepts that continue to be investigated in the search for the holy grail of concussion-a valid diagnostic test. Imaging advances are discussed with optimism that functional MRI and diffusion tensor imaging may be available clinically. Biomarkers and the use of genetic tests are covered. Sideline accelerometer use may help steer discussions of head trauma risk once technology exists to accurately estimate acceleration of the brain. In the meantime, strategies including allowing athletes to be substituted out of games for an evaluation and video review in elite sports can improve recognition of sports-related concussion.

Consensus on a video analysis framework of descriptors and definitions by the Rugby Union Video Analysis Consensus group.

Using an expert consensus-based approach, a rugby union Video Analysis Consensus (RUVAC) group was formed to develop a framework for video analysis research in rugby union. The aim of the framework is to improve the consistency of video analysis work in rugby union and help enhance the overall quality of future research in the sport. To reach consensus, a systematic review and Delphi method study design was used. After a systematic search of the literature, 17 articles were used to develop the final framework that described and defined key actions and events in rugby union (rugby). Thereafter, a group of researchers and practitioners with experience and expertise in rugby video analysis formed the RUVAC group. Each member of the group examined the framework of descriptors and definitions and rated their level of agreement on a 5-point agreement Likert scale (1: strongly disagree; 2: disagree; 3: neither agree or disagree; 4: agree; 5: strongly agree). The mean rating of agreement on the five-point scale (1: strongly disagree; 5: strongly agree) was 4.6 (4.3-4.9), 4.6 (4.4-4.9), 4.7 (4.5-4.9), 4.8 (4.6-5.0) and 4.8 (4.6-5.0) for the tackle, ruck, scrum, line-out and maul, respectively. The RUVAC group recommends using this consensus as the starting framework when conducting rugby video analysis research. Which variables to use (if not all) depends on the objectives of the study. Furthermore, the intention of this consensus is to help integrate video data with other data (eg, injury surveillance).

Telephone announcements encouraging common cold self-management reduce demand for general practice appointments.

BACKGROUND: Patients consulting with the common cold contribute to seasonal demand for general practice appointments. Seeing a community pharmacist or using self-management may have been more appropriate options. The study aimed to measure if the use of telephone announcements signposting appropriate patients with the common cold in the direction of community pharmacy or self-management reduced demand for general practice consultations. METHODS: Patients telephoning a UK general practice to request an appointment between December 2017 and March 2018 heard announcements regarding management of the common cold. The percentage of callers choosing to continue to speak to a receptionist was compared with baseline data prior to the intervention. The mean waiting time to the third available routine general practice appointment during the intervention was compared with the previous year. RESULTS: Routine calls continuing to reception reduced by 5.5 % (p<0.001) when the incidence of the common cold is at its highest and by 3.9% (p<0.001) throughout the intervention. The mean waiting time to the third available routine appointment reduced by 21%. CONCLUSION: This study has demonstrated that the use of telephone announcements signposting appropriate patients with the common cold in the direction of community pharmacy or self-management reduces calls to reception. This strongly infers that the telephone announcements reduce demand for general practice appointments and is supported by the reduced mean waiting time to the third available routine appointment. Implementation of this intervention could help general practitioners reduce seasonal demand in their own practices.

Concussion risk factors and strategies for prevention.

Concussion in children is frequently related to participation in sports. It requires a traumatic event to occur that transmits acceleration to the brain. Some children may have intrinsic risk factors that place them at greater risk for this type of injury. Comorbidities such as attention-deficit/hyperactivity disorder, migraine headaches, and mood disorders may place athletes at increased risk of more severe injury. A previous concussion is probably the most important influence on risk for future injury. Extrinsic risk factors include coaching techniques, officiating, and choice of sport. Helmet choice does not diminish concussion risk, nor does the use of mouth guards. Education of athletes, coaches, parents, and physicians is very important in improving recognition of potential concussive injury and helping child athletes and their parents understand the risks involved in sport participation.

Return to play after liver and spleen trauma.

CONTEXT: Sport-related spleen and liver injuries pose a challenge for the physician. Although rare, these injuries can have serious and even life-threatening outcomes if not accurately diagnosed and managed in a timely fashion. Currently, there are no evidence-based guidelines on duration and intensity of restricted activity and return to play after spleen and liver injury. In addition, there is controversy on follow-up imaging after injury. EVIDENCE ACQUISITION: PubMed was searched using the terms splenic or spleen and trauma and hepatic or liver and trauma from 1980 to 2013. The citations from sentinel papers were also reviewed. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: Ultrasound is ideal in the unstable athlete. Nonoperative management of blunt splenic and hepatic injuries is recommended for hemodynamically stable patients regardless of injury grade, patient age, or presence of associated injuries. Follow-up imaging is not routinely recommended unless clinically indicated. Athletes may engage in light activity for the first 3 months after injury and then gradual return to unrestricted activity as tolerated. High-level athletes may choose splenectomy or serial imaging for faster return to play. CONCLUSION: Intravenous contrast-enhanced computed tomography is the diagnostic imaging modality of choice in stable athletes with blunt abdominal trauma. STRENGTH-OF-RECOMMENDATION TAXONOMY: C.

Blunt bladder injury.

Bladder injury should be suspected when trauma is followed by gross hematuria, suprapubic or abdominal pain, and difficulty in voiding or the inability to void. Bladder rupture with blunt abdominal trauma is uncommon; however, because of its high mortality rate, recognition of the early signs and symptoms can be life saving. The most common type of injury is a bladder contusion, which is a diagnosis of exclusion. Extraperitoneal bladder ruptures are almost exclusively associated with a pelvic fracture.

Closed head injury.

Closed head injuries vary from the very minor to the catastrophic. It is often difficult to differentiate the severity at initial presentation. Serial assessment is very valuable. Awareness of facial injuries is aided by familiarity with facial bone anatomy and the clinical presentation of orbital, zygomatic, maxillary, and mandibular fracture. Functional injury such as concussion may coexist with other injuries. This article will discuss closed head trauma and outline specific injuries to the face, brain, skull, and its surroundings.

Neck strength imbalance correlates with increased head acceleration in soccer heading.

BACKGROUND: Soccer heading is using the head to directly contact the ball, often to advance the ball down the field or score. It is a skill fundamental to the game, yet it has come under scrutiny. Repeated subclinical effects of heading may compound over time, resulting in neurologic deficits. Greater head accelerations are linked to brain injury. Developing an understanding of how the neck muscles help stabilize and reduce head acceleration during impact may help prevent brain injury. HYPOTHESIS: Neck strength imbalance correlates to increasing head acceleration during impact while heading a soccer ball. STUDY DESIGN: Observational laboratory investigation. METHODS: Sixteen Division I and II collegiate soccer players headed a ball in a controlled indoor laboratory setting while player motions were recorded by a 14-camera Vicon MX motion capture system. Neck flexor and extensor strength of each player was measured using a spring-type clinical dynamometer. RESULTS: Players were served soccer balls by hand at a mean velocity of 4.29 m/s (±0.74 m/s). Players returned the ball to the server using a heading maneuver at a mean velocity of 5.48 m/s (±1.18 m/s). Mean neck strength difference was positively correlated with angular head acceleration (rho = 0.497; P = 0.05), with a trend toward significance for linear head acceleration (rho = 0.485; P = 0.057). CONCLUSION: This study suggests that symmetrical strength in neck flexors and extensors reduces head acceleration experienced during low-velocity heading in experienced collegiate players. CLINICAL RELEVANCE: Balanced neck strength may reduce head acceleration cumulative subclinical injury. Since neck strength is a measureable and amenable strength training intervention, this may represent a modifiable intrinsic risk factor for injury.