Female patients have greater improvement in pain symptoms and physical activity after fasciotomy for treatment of chronic exertional compartment syndrome of the lower leg.

PURPOSE: The purpose of this study was to identify sex differences in postoperative outcomes and return-to-sport rates after fasciotomy for treatment of chronic exertional compartment syndrome (CECS) of the lower leg. It was hypothesised that male CECS patients would have a higher rate of return to sport than female CECS patients. METHODS: A retrospective cohort study was conducted involving patients who underwent primary fasciotomy of one to four leg compartments for treatment of CECS at a single centre from 2010 to 2020. Each affected leg was treated as a separate subject. Postoperative outcomes included CECS pain frequency and severity, return to sport and Tegner activity level. Multivariable regression was used to determine if sex was an independent predictor of outcomes after adjusting for demographic and clinical covariates. p < 0.05 were considered significant. RESULTS: Eighty-one legs (44 M, 37 F) of 47 unique patients (34 of whom had bilateral symptoms) were included with a mean follow-up time of 51.5 ± 31.4 months. Male subjects were older (p < 0.001) and had higher body mass index (p < 0.001) compared to female subjects. Most subjects (84.0%) underwent two- or four-compartment fasciotomies. Female sex was found to be predictive of lower overall postoperative pain severity (p = 0.007), higher odds of return to sport (p = 0.04) and higher postoperative Tegner score (p = 0.005). However, female sex was not predictive of postoperative pain frequency, odds of reoperation or odds of return to sport to at least the presymptomatic level (all p < 0.05). CONCLUSION: Female sex is independently predictive of reduced overall pain severity, higher odds of return to sport and higher postoperative improvement in Tegner score following fasciotomy for treatment of lower-limb CECS. LEVEL OF EVIDENCE: III.

Paresthesia Is Predictive of Symptom Recurrence After Fasciotomy for Exertional Compartment Syndrome of the Leg.

BACKGROUND: Exertional compartment syndrome (ECS) is an underdiagnosed cause of lower extremity pain among athletes. The condition can be managed operatively by fasciotomy to relieve excess compartment pressure. However, symptom recurrence rates after fasciotomy are considerable, ranging from 3% to 17%. HYPOTHESIS: Leg paresthesia and its distribution during ECS episodes would be a significant predictor of outcomes after fasciotomy. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: We conducted a retrospective chart review of patients who underwent fasciotomy for ECS at our center from 2010 to 2020 (institutional review board no. 21-00107). We measured postoperative outcomes including pain frequency and severity, Tegner activity level, and return to sport. Significant predictors of outcomes were identified using multivariable linear and logistic regression. P values <0.05 were considered significant. RESULTS: A total of 78 legs (from 42 male and 36 female participants) were included in the study with average follow-up of 52 months (range, 3-126 months); 33 participants (42.3%) presented with paresthesia. Paresthesia was an independent predictor of worse outcomes, including more severe pain at rest (P = 0.05) and with daily activity (P = 0.04), reduced postoperative improvement in Tegner scores (P = 0.04), and lower odds of return to sport (P = 0.05). Those with paresthesia symptoms in the tibial nerve distribution had worse outcomes than those without paresthesia in terms of preoperative-to-present improvement in pain frequency (P < 0.01), pain severity at rest (P < 0.01) and with daily activity (P = 0.04), and return to sport (P = 0.04). CONCLUSION: ECS patients who present with paresthesia have worse pain and activity outcomes after first-time fasciotomy, but prognosis is worst among those with tibial nerve paresthesia. CLINICAL RELEVANCE: Paresthesia among ECS patients is broadly predictive of more severe recurrent leg pain, reduced activity level, and decreased odds of return to sport after fasciotomy.

Clinical Presentation and Outcomes of Sacral Stress Fractures in Athletes: A Case Series of 13 Patients.

BACKGROUND: Sacral stress fractures are a rare cause of low back pain in athletes. Given the low incidence of these fractures, there is a scarcity of data on symptomatology, risk factors, and clinical outcomes. HYPOTHESIS: Patients diagnosed with sacral stress fractures would be athletes presenting with low back pain. STUDY DESIGN: Case series of 13 patients with sacral stress fractures. LEVEL OF EVIDENCE: Level 4. METHODS: We conducted a retrospective review of medical records to identify patients diagnosed with sacral stress fractures at a single academic institution. Fractures were diagnosed on noncontrast T2-weighted magnetic resonance imaging scans and categorized using the Bakker classification system. Subjects were administered an electronic survey that asked about (1) the onset, time course, and location of pain and other symptoms; (2) time to treatment and treatment modalities pursued; (3) sports performance and time to return to sport; and (4) risk factors for stress fractures. RESULTS: Of 18 eligible patients, 13 (72.2%) completed the survey with mean follow-up of 49.6 months (range, 1-144 months). Mean age was 28.0 years (range, 18-52 years); 9 patients (69.2%) were female, of whom 7 (77.8%) were premenopausal. The most common fracture type was Bakker type B (8 patients; 61.5%). Most patients presented with acute lumbosacral back pain in the setting of running/jogging activities. All patients underwent nonoperative treatment for an average of 3.8 months (range, 0-8 months) and three-quarters reported pain resolution at last follow-up. Rate of return to sport was 83.3%, but most patients reported ongoing deficits in running performance. CONCLUSION: Sacral stress fractures commonly present as acute lumbosacral back pain provoked by running sports. While the pain associated with these fractures prevents most athletes from participating in sports, nonoperative management appears to be an effective treatment modality with a high rate of return to sport.

Psychiatric Disorders Are Predictive of Worse Pain Severity and Functional Outcomes After Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg.

OBJECTIVE: To determine whether concomitant psychiatric diagnoses and medication use were associated with postfasciotomy outcomes in patients with chronic exertional compartment syndrome (CECS). DESIGN: Retrospective comparative cohort study. SETTING: Single academic medical center from 2010 to 2020. PATIENTS: All patients above 18 years old who underwent fasciotomy for CECS. ASSESSMENT OF RISK FACTORS/INDEPENDENT VARIABLES: Psychiatric history was recorded from electronic health records including disease diagnosis and medications. MAIN OUTCOME MEASURES: The 3 main outcome measures were postoperative pain using the Visual Analog Scale, functional outcomes using the Tegner Activity Scale, and return to sport. RESULTS: Eighty one subjects (legs), 54% male, with an average age of 30 years and follow-up of 52 months were included. 24 subjects (30%) had at least one psychiatric diagnosis at the time of surgery. Regression analysis found psychiatric history to be an independent predictor of worse postoperative pain severity and postoperative Tegner scores (P < 0.05). Furthermore, subjects with psychiatric disorders not on medication had worse pain severity (P < 0.001) and Tegner scores (P < 0.01) versus controls, whereas subjects with a psychiatric disorder on medication had better pain severity (P < 0.05) versus controls. CONCLUSIONS: History of psychiatric disorder was predictive of worse postoperative pain and activity outcomes after fasciotomy for CECS. Use of psychiatric medication was associated with improvement in pain severity in some domains.

Patient and Physician Satisfaction with Telehealth During the COVID-19 Pandemic: Sports Medicine Perspective.

Background:Owing to the COVID-19 pandemic, there has been a large shift in health care toward virtual platforms. This study analyzed patient and physician satisfaction with telehealth during the height of the pandemic within the division of sports medicine.Methods:All sports medicine patients who completed a telemedicine visit from March 30, 2020, through April 30, 2020, were sent a 14-question Likert scale (1-5/5) survey. Sports medicine physicians who used telemedicine were sent a separate 14-question Likert scale (1-5/5) survey at the end of the study period. Factors influencing patient satisfaction were determined using a multivariate linear regression model.Results:A total of 143 patients and 9 sports medicine attendings completed the surveys. Most patients were "satisfied" (4/5) or "very satisfied" (5/5) (88.8%). A multivariate linear regression determined that patients who believed they had a greater ability to adopt new technology and were more effective at communicating questions/concerns to their physicians had greater satisfaction (p = 0.009 and p = 0.015, respectively). Most physicians were either "satisfied" (4/5) or "very satisfied" (5/5) (75.0%). On average, physicians felt that physical examinations conducted through telemedicine were "moderately effective" (2.75/5.00 ± 1.3), that they were "fairly confident" (3.86/5.00 ± 0.83) in their diagnoses, and that most sports medicine attendings plan to use telemedicine in the future (87.5%).Conclusion:Telehealth emerged as a valuable tool for the delivery of health care to sports medicine patients during the COVID-19 pandemic. Patients and physicians reported high levels of satisfactions with its use, and this study further identifies areas that can improve the patient and physician experience.

Decreased Injury Rate Following Mandated Headgear Use in Women's Lacrosse.

INTRODUCTION: There has been controversy regarding whether headgear use in women's lacrosse will affect the rate of head and musculoskeletal injuries. The purpose of this study was to investigate the effect of mandated headgear use on the rate of head and musculoskeletal injuries in high school women's lacrosse. METHODS: This was a prospective cohort study of eight high school women's lacrosse teams and their game op-ponents who were mandated to wear F3137 headgear for the 2017 and 2018 seasons. Athletic trainers documented all injuries that occurred as a result of participation on the lacrosse teams. Injury rates in the headgear cohort were compared to a retrospective (control) cohort from the High School Reporting Information Online injury data reports. RESULTS: Over the study period, 17 total injuries were reported in the headgear cohort during 22,397 exposures for an injury rate of 0.76 injuries per 1,000 athlete-exposures. The headgear cohort demonstrated significant decreases in rates of in-game head and face injury (RR 0.141, 95% CI [0.004, 0.798]), in-game concussion (RR 0.152, 95% CI [0.004, 0.860]), and practice trunk and extremity injury (RR 0.239, 95% CI [0.049, 0.703]) when compared to the control cohort. CONCLUSION: Mandated use of headgear was shown to be effective at lowering the rate of head or face injury and concussions in women's lacrosse. Additionally, mandated headgear use was also shown to lower the rate of injury to body locations other than the head or face during practice. To our knowledge, this is the first study to demonstrate a decrease in injury rates associated with ASTM approved headgear in women's lacrosse.

Unexpected Hurdle in the Race: Hypophosphatasia Unmasked by the Female Athlete Triad.

Hypophosphatasia should be considered for any patient who presents with multiple metatarsal stress fractures and a low alkaline phosphatase.

MULES on the sidelines: A vision-based assessment tool for sports-related concussion.

OBJECTIVE: The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation. Measures of rapid automatic naming (RAN) have been used for over 50 years to capture aspects of vision and cognition. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. We examined MULES performance in youth, collegiate and professional athletes at pre-season baseline and at the sidelines following concussion. METHODS: Our study teams administered the MULES to youth, collegiate and professional athletes during pre-season baseline testing. Sideline post-concussion time scores were compared to pre-season baseline scores among athletes with concussion to determine degrees and directions of change. RESULTS: Among 681 athletes (age 17 ±â€¯4 years, range 6-37, 38% female), average test times at baseline were 41.2 ±â€¯11.2 s. The group included 280 youth, 357 collegiate and 44 professional athletes; the most common sports were ice hockey (23%), soccer (17%) and football (11%). Age was a predictor of MULES test times, with longer times noted for younger participants (P < .001, linear regression). Consistent with other timed performance measures, significant learning effects were noted for the MULES during baseline testing with trial 1 test times (mean 49.2 ±â€¯13.1 s) exceeding those for trial 2 (mean 41.3 ±â€¯11.2 s, P < .0001, paired t-test). Among 17 athletes with concussion during the sports seasons captured to date (age 18 ±â€¯3 years), all showed increases (worsening) of MULES time scores from pre-season baseline (median increase 11.2 s, range 0.6-164.2, P = .0003, Wilcoxon signed-rank test). The Symptom Severity Score from the SCAT5 Symptom Evaluation likewise worsened from pre-season baseline following injury among participants with concussion (P = .002). CONCLUSIONS: Concussed athletes demonstrate worsening performance on the MULES test compared to their baseline time scores. This test samples a wide network of brain pathways and complements other vision-based measures for sideline concussion assessment. The MULES test demonstrates capacity to identify athletes with sports-related concussion.

The new Mobile Universal Lexicon Evaluation System (MULES): A test of rapid picture naming for concussion sized for the sidelines.

OBJECTIVE: Measures of rapid automatized naming (RAN) have been used for over 50 years to capture vision-based aspects of cognition. The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation for detection of concussion and other neurological disorders. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. Recent changes to the MULES test have been made to improve ease of use on the athletic sidelines. Originally an 11 × 17-inch single-sided paper, the test has been reduced to a laminated 8.5 × 11-inch double-sided version. We identified performance changes associated with transition to the new, MULES, now sized for the sidelines, and examined MULES on the sideline for sports-related concussion. METHODS: We administered the new laminated MULES to a group of adult office volunteers as well as youth and collegiate athletes during pre-season baseline testing. Athletes with concussion underwent sideline testing after injury. Time scores for the new laminated MULES were compared to those for the larger version (big MULES). RESULTS: Among 501 athletes and office volunteers (age 16 ±â€¯7 years, range 6-59, 29% female), average test times at baseline were 44.4 ±â€¯14.4 s for the new laminated MULES (n = 196) and 46.5 ±â€¯16.3 s for big MULES (n = 248). Both versions were completed by 57 participants, with excellent agreement (p < 0.001, linear regression, accounting for age). Age was a predictor of test times for both MULES versions, with longer times noted for younger participants (p < 0.001). Among 6 athletes with concussion thus far during the fall sports season (median age 15 years, range 11-21) all showed worsening of MULES scores from pre-season baseline (median 4.0 s, range 2.1-16.4). CONCLUSION: The MULES test has been converted to an 11 × 8.5-inch laminated version, with excellent agreement between versions across age groups. Feasibly administered at pre-season and in an office setting, the MULES test shows preliminary evidence of capacity to identify athletes with sports-related concussion.

Orthobiologics A Comprehensive Review of the Current Evidence and Use in Orthopedic Subspecialties.

Orthobiologics are organic and synthetic materials that are used in and outside of the operating room to augment both bone and soft tissue healing. The orthobiologics portfolio has vastly expanded over the years, and it has become imperative for orthopedic surgeons to understand the role and function of this new class of biologic adjuvants. This review will highlight key components and product groups that may be relevant for the practicing orthopedic surgeon in any subspecialty. This by no means is an extensive list of the available products but provides an important overview of the most highlighted products available in the market today. Those discussed include, bone void fillers, extracelluar matrix (ECM) products, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). These are further categorized into their uses in several subspecialties including, traumatology, sports medicine, sports surgery, and spine surgery.

Rapid sideline performance meets outpatient clinic: Results from a multidisciplinary concussion center registry.

OBJECTIVE: This study investigated the utility of sideline concussion tests, including components of the Sports Concussion Assessment Tool, 3rd Edition (SCAT3) and the King-Devick (K-D), a vision-based test of rapid number naming, in an outpatient, multidisciplinary concussion center treating patients with both sports-related and non-sports related concussions. The ability of these tests to predict clinical outcomes based on the scores at the initial visit was evaluated. METHODS: Scores for components of the SCAT3 and the K-D were fit into regression models accounting for age, gender, and sport/non-sport etiology in order to predict clinical outcome measures including total number of visits to the concussion center, whether the patient reached a SCAT3 symptom severity score≤7, and the total types of referrals each patient received over their course. Patient characteristics, differences between those with sport and non-sport etiologies, and correlations between the tests were also analyzed. RESULTS: Among 426 patients with concussion, SCAT3 total symptom score and symptom severity score at the initial visit predicted each of the clinical outcome variables. K-D score at the initial visit predicted the total number of visits and the total number of referrals. Those with sports-related concussions were younger, had less severely-affected test scores, had fewer visits and types of referrals, and were more likely to have clinical resolution of their concussion and to reach a symptom severity score≤7. CONCLUSIONS: This large-scale study of concussion patients supports the use of sideline concussion tests as part of outpatient concussion assessment, especially the total symptom and symptom severity score portions of the SCAT3 and the K-D. Women in this cohort had higher total symptom and symptom severity scores compared to men. Our data also suggest that those with non-sports-related concussions have longer lasting symptoms than those with sports-related concussions, and that these two groups should perhaps be regarded separately when assessing outcomes and needs in a multidisciplinary setting.

A Randomized Controlled Trial of Two Distinct Shared Decision-Making Aids for Hip and Knee Osteoarthritis in an Ethnically Diverse Patient Population.

OBJECTIVES: To evaluate the use of decision aids for hip and knee osteoarthritis (OA) regarding the potential risks and benefits of different treatment options. METHODS: A prospective, randomized controlled trial was conducted of 147 patients with advanced hip or knee OA to compare the effect of two decision aids (booklet-only vs. booklet with DVD). RESULTS: Both decision aid programs were well received and demonstrated improvements in patient knowledge and willingness to participate in treatment decisions. The decision aids, however, had a marginal effect on patient willingness to participate in OA management, with an increase of 0.11 and 0.6 on a scale of 2 (P = 0.58) between groups. CONCLUSIONS: The decision aids were accepted for most patients and effective in improving patient knowledge and willingness to participate in the decision process. Nevertheless, the addition of a more expensive DVD to the booklet program did not improve patient acceptance or knowledge.

The Masters Athlete: A Review of Current Exercise and Treatment Recommendations.

CONTEXT: With the ever-increasing number of masters athletes, it is necessary to understand how to best provide medical support to this expanding population using a multidisciplinary approach. EVIDENCE ACQUISITION: Relevant articles published between 2000 and 2013 using the search terms masters athlete and aging and exercise were identified using MEDLINE. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: Preparticipation screening should assess a variety of medical comorbidities, with emphasis on cardiovascular health in high-risk patients. The masters athlete should partake in moderate aerobic exercise and also incorporate resistance and flexibility training. A basic understanding of physiology and age-related changes in muscle composition and declines in performance are prerequisites for providing appropriate care. Osteoarthritis and joint arthroplasty are not contraindications to exercise, and analgesia has an appropriate role in the setting of acute or chronic injuries. Masters athletes should follow regular training regimens to maximize their potential while minimizing their likelihood of injuries. CONCLUSION: Overall, masters athletes represent a unique population and should be cared for utilizing a multidisciplinary approach. This care should be implemented not only during competitions but also between events when training and injury are more likely to occur. STRENGTH OF RECOMMENDATION TAXONOMY SORT: B.

Gender and age predict outcomes of cognitive, balance and vision testing in a multidisciplinary concussion center.

OBJECTIVE: This study examined components of the Sports Concussion Assessment Tool, 3rd Edition (SCAT3) and a vision-based test of rapid number naming (King-Devick [K-D]) to evaluate sports and non-sports concussion patients in an outpatient, multidisciplinary concussion center. While the Symptom Evaluation, Standardized Assessment of Concussion (SAC), modified Balance Error Scoring System (BESS), and K-D are used typically for sideline assessment, their use in an outpatient clinical setting following concussion has not been widely investigated. METHODS: K-D, BESS, SAC, and SCAT3 Symptom Evaluation scores were analyzed for 206 patients who received concussion care at the Concussion Center at NYU Langone Medical Center. Patient age, gender, referral data, mechanism of injury, time between concussive event and first concussion center appointment, and the first specialty service to evaluate each patient were also analyzed. RESULTS: In this cohort, Symptom Evaluation scores showed a higher severity and a greater number of symptoms to be associated with older age (r = 0.31, P = 0.002), female gender (P = 0.002, t-test), and longer time between the concussion event and first appointment at the concussion center (r = 0.34, P = 0.008). Performance measures of K-D and BESS also showed associations of worse scores with increasing patient age (r = 0.32-0.54, P ≤ 0.001), but were similar among males and females and across the spectrum of duration since the concussion event. Patients with greater Symptom Severity Scores also had the greatest numbers of referrals to specialty services in the concussion center (r = 0.33, P = 0.0008). Worse Immediate Memory scores on SAC testing correlated with slower K-D times, potentially implicating the dorsolateral prefrontal cortex as a commonly involved brain structure. CONCLUSION: This study demonstrates a novel use of sideline concussion assessment tools for evaluation in the outpatient setting, and implicates age and gender as predictors of outcomes for these tests.

Adding Vision to Concussion Testing: A Prospective Study of Sideline Testing in Youth and Collegiate Athletes.

BACKGROUND: Sports-related concussion commonly affects the visual pathways. Current sideline protocols test cognition and balance but do not include assessments of visual performance. We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels. METHODS: Participants in this prospective study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Island University. Athletes underwent preseason baseline assessments using: 1) the King-Devick (K-D) test, a <2-minute visual performance measure of rapid number naming, 2) the Standardized Assessment of Concussion (SAC), a test of cognition, and 3) a timed tandem gait test of balance. The SAC and timed tandem gait are components of the currently used Sport Concussion Assessment Tool, 3rd Edition (SCAT3 and Child-SCAT3). In the event of a concussion during the athletic season, injured athletes were retested on the sideline/rink-side. Nonconcussed athletes were also assessed as control participants under the same testing conditions. RESULTS: Among 243 youth (mean age 11 ± 3 years, range 5-17) and 89 collegiate athletes (age 20 ± 1 years, range 18-23), baseline time scores for the K-D test were lower (better) with increasing participant age (P < 0.001, linear regression models). Among 12 athletes who sustained concussions during their athletic season, K-D scores worsened from baseline by an average of 5.2 seconds; improvement by 6.4 seconds was noted for the nonconcussed controls (n = 14). The vision-based K-D test showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury (receiver operating characteristic [ROC] curve areas from logistic regression models, accounting for age = 0.92 for K-D, 0.87 for timed tandem gait, and 0.68 for SAC; P = 0.0004 for comparison of ROC curve areas). CONCLUSIONS: Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment. This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision.

Kinesiology taping and the world wide web: a quality and content analysis of internet-based information.

BACKGROUND: Due to limited regulation of websites, the quality and content of online health-related information has been questioned as prior studies have shown that websites often misrepresent orthopaedic conditions and treatments. Kinesio tape has gained popularity among athletes and the general public despite limited evidence supporting its efficacy. The primary objective of this study was to assess the quality and content of Internet-based information on Kinesio taping. METHODS: An Internet search using the terms "Kinesio tape" and "kinesiology tape" was performed using the Google search engine. Websites returned within the first two pages of results, as well as hyperlinks embedded within these sites, were included in the study. These sites were subsequently classified by type. The quality of the website was determined by the Health On the Net (HON) score, an objective metric based upon recommendations from the United Nations for the ethical representation of health information. A content analysis was performed by noting specific misleading versus balanced features in each website. RESULTS: A total of 31 unique websites were identified. The majority of the websites (71%) were commercial. Out of a total possible 16 points, the mean HON score among the websites was 8.9 points (SD 2.2 points). The number of misleading features was significantly higher than the balanced features (p < 0.001). Fifty-eight percent of sites used anecdotal testimonials to promote the product. Only small percentages of websites discussed complications, alternatives, or provided accurate medical outcomes. Overall, commercial sites had a greater number of misleading features compared to non-commercial sites (p = 0.01). CONCLUSIONS: Websites discussing Kinesio tape are predominantly of poor quality and present misleading, imbalanced information. It is of ever-increasing importance that healthcare providers work to ensure that reliable, balanced, and accurate information be available to Internet users. LEVEL OF EVIDENCE: IV.

Sideline coverage: when to get radiographs? A review of clinical decision tools.

CONTEXT: Sidelines coverage presents unique challenges in the evaluation of injured athletes. Health care providers may be confronted with the question of when to obtain radiographs following an injury. Given that most sidelines coverage occurs outside the elite level, radiographs are not readily available at the time of injury, and the decision of when to send a player for radiographs must be made based on physical examination. Clinical tools have been developed to aid in identifying injuries that are likely to result in radiographically important fractures or dislocations. EVIDENCE ACQUISITION: A search for the keywords x-ray and decision rule along with the anatomic locations shoulder, elbow, wrist, knee, and ankle was performed using the PubMed database. No limits were set regarding year of publication. We selected meta-analyses, randomized controlled trials, and survey results. Our selection focused on the largest, most well-studied published reports. We also attempted to include studies that reported the application of the rules to the field of sports medicine. STUDY DESIGN: Retrospective literature review. LEVEL OF EVIDENCE: Level 4. RESULTS: The Ottawa Foot and Ankle Rules have been validated and implemented and are appropriate for use in both pediatric and adult populations. The Ottawa Knee Rules have been widely studied, validated, and accepted for evaluation of knee injuries. There are promising studies of decision rules for clinically important fractures of the wrist, but these studies have not been validated. The elbow has been evaluated with good outcomes via the elbow extension test, which has been validated in both single and multicenter studies. Currently, there are no reliable clinical decision tools for traumatic sports injuries to the shoulder to aid in the decision of when to obtain radiographs. CONCLUSION: Clinical decision tools have been developed to aid in the diagnosis and management of injuries commonly sustained during sporting events. Tools that have been appropriately validated in populations outside the initial study population can assist sports medicine physicians in the decision of when to get radiographs from the sidelines.

Platelet rich placebo? Evidence for platelet rich plasma in the treatment of tendinopathy and augmentation of tendon repair.

Platelet rich plasma (PRP), an autologous sample of blood with a platelet concentration above baseline values, is hypothesized to augment soft tissue healing. Its use in sports medicine has risen dramatically, with common applications including the treatment of refractory tendinopathy and augmenting tendon repair. Many commercial preparation systems are available, but the optimal preparation remains unknown. Increasing numbers of clinical studies evaluating PRP have been reported and have provided both positive and negative evidence for its effectiveness. Well-designed, controlled studies are still lacking, but PRP may have a benefit for patients with tendinopathy that is refractory to other non-surgical treatments. Its use in tendon repair is currently not supported. Randomized, controlled studies with documentation of platelet, white blood cell, and growth factor concentration in the PRP preparation are necessary for future comparative research. Use of PRP should be approached judiciously until further evidence is available.

Platelet-rich plasma: current concepts and application in sports medicine.

Platelet-rich plasma is defined as autologous blood with a concentration of platelets above baseline values. Platelet-rich plasma has been used in maxillofacial and plastic surgery since the 1990s; its use in sports medicine is growing given its potential to enhance muscle and tendon healing. In vitro studies suggest that growth factors released by platelets recruit reparative cells and may augment soft-tissue repair. Although minimal clinical evidence is currently available, the use of platelet-rich plasma has increased, given its safety as well as the availability of new devices for outpatient preparation and delivery. Its use in surgery to augment rotator cuff and Achilles tendon repair has also been reported. As the marketing of platelet-rich plasma increases, orthopaedic surgeons must be informed regarding the available preparation devices and their differences. Many controlled clinical trials are under way, but clinical use should be approached cautiously until high-level clinical evidence supporting platelet-rich plasma efficacy is available.