The Effect of Sport Specialization on Injury Risk in NCAA Athletes: Results From the SAFE Consortium.

OBJECTIVE: Youth athletes are beginning to specialize in a single sport more often. Previous studies in sports medicine and orthopedics have shown an association between intensity of sport specialization and incidence of injuries. This study is the first of its kind to explore the effects of early sport specialization on injury risk through a multicenter framework with a concentration on NCAA athletics. DESIGN: Retrospective cohort study. SETTING: SAFE Consortium. PARTICIPANTS: A total of 211 collegiate athletes from the NCAA's 3 levels of competition: Division I, II, and III. Data were collected by the SAFE investigators. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Participants completed a questionnaire about their demographics, sport participation, specialization status, physical injuries, recovery period, and treatment method. Specialization status was calculated with a previously published 3-point scale: low, moderate, and high. Injuries were categorized as upper extremity injuries (UEIs) and lower extremity injuries (LEIs). RESULTS: Highly specialized athletes were more likely to report UEIs and LEIs than low specialized athletes (P < 0.0001). Moderate specialization, in contrast to low specialization, was associated with a higher likelihood of LEIs (P = 0.03) but not UEIs (P = 0.052). Highly specialized athletes were more likely to report an injury of any kind. CONCLUSIONS: The SAFE investigators found high specialization was associated with a history of UEIs and LEIs. Return to play was longer for highly specialized athletes versus low specialized athletes (112 days and 85 days, respectively). Highly specialized athletes were more likely to be from Division I and to require surgery.

The relationship between disordered eating behaviors and injury rates in adolescent athletes.

OBJECTIVE: To explore the relationship between disordered eating (DE) and significant sport injury in adolescent athletes. METHOD: Responses to one item of the Disordered Eating Screen for Athletes and the Eating Attitudes Test (EAT-26) items, administered to n = 308 adolescent athletes, were analyzed with data on injury. Nonparametric statistics and multiple regression analysis were used to examine differences in DE rates amongst known injured adolescent athletes. RESULTS: The EAT-26 scores of injured females, median score of 9, were significantly higher than all other groupings with H(3) = 17.26 p < .001, η2  = .047. Using regression analyses, injury significantly predicted a rise in EAT-26 score by five points in females, p = .01, R2  = .052. DISCUSSION: This evidence suggests a relationship between adolescent female sport injury and DE, but no relationship between adolescent male sport injury and DE. These results demonstrate a need to screen for DE in athletes. Given a positive screen, athletes should be educated on the risks associated with relative energy deficiency and potentially referred to a practitioner with knowledge of the associated complications.

Accessory Flexor Digitorum Longus Presenting as Tarsal Tunnel Syndrome: A Case Series.

ABSTRACT: Tarsal tunnel syndrome (TTS) typically occurs from extrinsic or intrinsic sources of compression on the tibial nerve. We present 3 cases of patients, all of whom have a prolonged time to diagnosis after evaluation with multiple specialties, with foot pain ultimately secondary to an accessory flexor digitorum longus muscle causing TTS. The literature describing the association between TTS and accessory musculature has been limited to single case reports and frequently demonstrate abnormal electrodiagnostic testing. In our series, 2 cases had normal electrodiagnostic findings despite magnetic resonance imaging (MRI) that later revealed TTS and improvement with eventual resection. A normal electromyogram should not preclude the diagnosis of TTS and MRI of the ankle; it should be considered a useful diagnostic tool when examining atypical foot pain.

Comparison of four different nerve conduction techniques of the superficial fibular sensory nerve.

INTRODUCTION: There are many different nerve conduction study (NCS) techniques to study the superficial fibular sensory nerve (SFSN). We present reference distal latency values and comparative data regarding 4 different NCS for the SFSN. METHODS: Four different NCS techniques, Spartan technique, Izzo techniques (medial and intermediate dorsal cutaneous branches), and Daube technique, were performed on (114) healthy volunteers. A total of 108 subjects with 164 legs were included. RESULTS: The mean latency of the Spartan technique was longest (3.9 ± 0.3 ms) while the Daube technique was the shortest (3.6 ± 0.7 ms). The mean amplitude of the Daube technique displayed the highest (15.2 ± 8.2 µV) with the Spartan technique having the lowest (8.7 ± 4.2 µV). Among the absent sensory nerve action potentials (SNAPs), the Spartan technique was absent only twice (1.2%) and the Izzo Medial technique was absent more than the other techniques (2.9%). CONCLUSIONS: All 4 techniques were reliable methods for obtaining the superficial fibular nerve SNAP, present in 95% of individuals. Muscle Nerve 56: 458-462, 2017.

FactFinders for patient safety: Understanding potential procedure-related complications: RFN/multifidus atrophy, intradiscal biologics, and facet cyst rupture.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential procedure-related complications. The evidence in support of the following facts is presented: (1) Multifidus Atrophy After Lumbar Medial Branch Radiofrequency Neurotomy (LMBRFN) -- There is no conclusive published literature indicating that LMBRFN leads to increased multifidus atrophy relative to natural history. High-quality prospective studies with a natural history comparison group evaluating immediate pre-procedure as well as post-procedure longitudinal cross-sectional imaging are needed to accurately assess for any possible influence of LMBRFN on multifidus atrophy as well as the clinical relevance. (2) Intradiscal Biologics -- Although the available evidence on intradiscal biologic interventions is limited, it nonetheless shows a non-zero risk of complications. Until larger sample sizes are reported, the actual magnitude of the risk cannot be ascertained. In the meantime, physicians who perform intradiscal injections of biologics should conscientiously consider the risk-benefit of these procedures. (3) Lumbar Facet Synovial Cyst Rupture -- There have been few reports of complications secondary to lumbar facet synovial cyst rupture. Risks of may include increased pain, infection, and nerve root compression.

FactFinders for patient safety: Preventing local anesthetic-related complications: Local anesthetic chondrotoxicity and stellate ganglion blocks.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential local anesthetic-related complications. Evidence in support of the following facts is presented. (1) Chondrotoxicity: Which Local Anesthetics are Safest for Intraarticular Injection? -- There are drug-, concentration-, and time-dependent chondrotoxic effects that vary between local anesthetics. Current evidence related to commonly used local anesthetics indicates that with exposure to equivalent volumes, bupivacaine, at concentrations of 0.5 % or higher, is the most chondrotoxic agent, while ropivacaine, at concentrations equal to or less than 0.5 %, is the least chondrotoxic in vitro. There is minimal published evidence that confirms these findings in vivo. (2) Minimizing Risks with Stellate Ganglion Blocks -- Evidence suggests that fluoroscopic or ultrasound guidance reduces the risk and increases the accuracy of SGB. Utilizing ultrasound guidance has the added benefit of soft tissue visualization, especially vascular structures, which has the potential to prevent adverse outcomes when compared to the fluoroscopic technique.

FactFinders for patient safety: Motor stimulation testing in lumbar radiofrequency neurotomy and radiofrequency neurotomy in patients with posterior hardware.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the use of motor stimulation testing in lumbar radiofrequency neurotomy and performance of radiofrequency neurotomy in patients with posterior spinal hardware. The evidence in support of the following facts is presented: (1) Motor stimulation does not inherently protect against unwanted damage to the spinal nerve, exiting spinal nerve root or its ventral ramus due to a lack of sensitivity of this test for identification of electrode contact or close proximity to sensorimotor nerves. Even when motor stimulation is performed, verification of correct electrode placement with multiplanar imaging including a minimum of true anterior-posterior and lateral fluoroscopic views is a recommended safeguard. (2) The existence of posterior spinal hardware is not an absolute contraindication to radiofrequency neurotomy, but direct contact with hardware should be avoided.

Factfinders for patient safety: Anticoagulant and antiplatelet agents and cervical medial branch procedures.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the safety of anticoagulant and antiplatelet agents for cervical medial branch blocks and cervical medial branch radiofrequency neurotomy. The evidence in support of the following facts is presented: (1) In patients maintained on therapeutic anticoagulant (AC) and/or antiplatelet (AP) therapy, for whom cervical medial branch blocks (CMBBs) are being considered, there is strong evidence to guide decisions on continuing or discontinuing these AC/AP agents in preparation for the procedure. (2) Therapeutic anticoagulation (AC) and antiplatelet (APT) agents should be discontinued prior to cervical medial branch radiofrequency neurotomy (CMBRFN) due to serious hemorrhagic risks.

FactFinders for patient safety: Antithrombotics and interventional pain procedures -- lumbar transforaminal epidural steroid injections and lumbar medial branch radiofrequency neurotomy.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the safety of antithrombotics and two interventional pain procedures - lumbar transforaminal epidural steroid injections and lumbar medial branch radiofrequency neurotomy. The evidence in support of the following facts is presented: (1) The decision to withhold antiplatelet therapy prior to lumbar transforaminal epidural steroid injections should be made on a case-by-case basis, weighing the relative risk of hemorrhage versus the risk of thrombosis for each patient. (2) A clinically significant hemorrhagic complication has never been reported in the medical literature in association with a lumbar medial branch radiofrequency neurotomy procedure. (3) Discontinuing antithrombotics for lumbar radiofrequency neurotomy procedures, even for a short period of time, may lead to an increased incidence of cardiovascular and cerebrovascular events.

Relationship Between Physical Activity Participation and Recovery Outcomes in College-Aged Adults With a Concussion.

CONTEXT: Previously, the most common treatment for a concussion was prolonged physical and cognitive rest. Recently, researchers have suggested that earlier physical activity (PA) may be better at promoting recovery. Researchers have not evaluated the relationship between free-living PA (eg, walking) and symptom reporting or recovery duration. OBJECTIVE: To assess the relationship between free-living PA participation and 2 recovery outcomes in college-aged adults with a concussion. DESIGN: Prospective cohort. SETTING: National Collegiate Athletic Association Division I and III universities. PATIENTS OR OTHER PARTICIPANTS: Thirty-two college-aged adults (68.8% female, age = 19.8 ± 1.4 years) with a concussion. MAIN OUTCOME MEASURE(S): Participants completed a postconcussion symptom evaluation at visits 1 (<72 hours from concussion) and 2 (8 days later). Between visits, each participant's PA was monitored using an Actigraph GT9X Link PA monitor and expressed as total PA (counts per minute) and percentage of PA time spent in moderate-to-vigorous intensity (%MVPA). Recovery time was the number of days from injury occurrence to medical clearance. With separate hierarchical multiple regressions, we evaluated the relationship between total PA and each recovery variable (visit 2 symptom severity, recovery time). Additionally, with separate exploratory hierarchical multiple regressions, we evaluated the relationship between %MVPA and each recovery variable. Statistical significance was set a priori at P ≤ .05. RESULTS: Participants averaged 2446 ± 441 counts per minute and spent 12.1% ± 4.2% of their PA performing MVPA. Participants yielded median (interquartile) symptom severities of 28 (24) and 2 (8) for visit 1 and 2, respectively. Average recovery time was 14.7 ± 7.5 days. Total PA did not significantly contribute to the model for visit 2 symptom severity (P = .122) or recovery time (P = .301). Similarly, %MVPA had little contribution to the model for visit 2 symptom severity (P = .358) or recovery time (P = .276). CONCLUSIONS: We suggest that free-living PA may not be enough to reduce symptoms or shorten recovery. Thus, clinicians may need to provide patients with more structured PA protocols mimicking findings from previous researchers.

Diagnosing and Managing Sacroiliac Joint Pain.

ABSTRACT: Sacroiliac joint pain commonly occurs because of anatomic disruption within the joint. Sacroiliac joint pain and sacroiliac joint mimics create a broad differential, adding difficulty to diagnosis. Clinically, this disruption presents with a mobility limitation relative to baseline and sharp pain inferolateral to the posterior superior iliac spine. While attempting to rule out other causes of low back pain, provocation tests such as FABRE, distraction, thigh thrust, sacral compression, Gaenslen's, and sacral thrust can be a useful diagnostic tool for the diagnosis of sacroiliac joint pain. Although recently, the provocation tests' validity has been challenged. Currently, the most accurate way to assess sacroiliac joint pain is with image-guided injections of local anesthetic. Pain reduction after the injection indicates the pain originating from the sacroiliac joint. Once confirmed, it is recommended to use a patient-centered approach that focuses on pain control, followed by restoration of function through noninvasive measures such as therapeutic exercise, manual medicine, sacroiliac joint belts, and orthotics. If these noninvasive procedures have not provided adequate treatment, then more invasive procedures should be considered.

Incidence of injury and illness during the 2013 world dwarf games.

BACKGROUND: Dwarfism, or skeletal dysplasia, is a term used to describe short stature. Injuries to athletes with disabilities and medical co-morbidities, such as those present in the dwarf population, can have significant consequences on functionality. The main objectives of this retrospective descriptive study were to 1) evaluate the safety of athletic participation among athletes with skeletal dysplasia, 2) investigate the incidence and characteristics of injuries and illnesses among athletes with skeletal dysplasia during the 2013 World Dwarf Games held on the campus of Michigan State University, 3) describe details and overview of the World Dwarf Games, and 4) identify possible safety and rule issues to improve safety at future World Dwarf Games. METHODS: This was a retrospective review of case series interactions between dwarf athletes and the medical staff present at the 2013 World Dwarf games from August 3-10, 2013. Injury incidence rates were calculated by dividing the number of incident injuries by total athlete-competitions. Epidemiologic incidence proportion calculations were used to measure average injury risks. RESULTS: A total of 24 competition related injuries were recorded among the 409 athletes. Only 1 illness (otitis media) was reported during the week of games. The overall injury incidence rate was found to be 0.78 injuries per 100 athlete-competitions. The overall epidemiologic incidence proportion was 5.9% (7.2% for males, 3.0% for females). The most common type of injury was a muscle/tendon strain (41.7% of all injuries). The sport with the most reported injuries was soccer with 4.63 injuries per 100 athlete-competitions. CONCLUSIONS: Based on the data collected, it does appear that athletes with skeletal dysplasia can safely participate in the events offered during the World Dwarf Games. None of the reported injuries or illnesses precluded the athletes from returning to play. Data collected at future competitions will help identify trends, which may lead to rule changes to improve safety and a decrease in injuries. Adding a designated spectator area for athletes as well as modifying rules to prevent excessive physical contact in soccer and basketball competitions may reduce the incidence of injury.