Preliminary Evaluation of a Novel Point of Care Diagnostic Device for Sports-Related Concussion.

OBJECTIVE: Visinin-like protein 1 (VILIP-1) is a neuron-specific calcium sensor protein rapidly released into blood after mild traumatic brain injury (mTBI) and may be a suitable biomarker for identification of sports-related concussion (SRC). The objective of the study is to test if quantification of a specific post-translationally modified (ubiquitinated) form of VILIP-1 (ubVILIP-1) from a fingerstick blood sample using a point of care (POC) lateral flow device (LFD) can be used to rapidly identify athletes with SRC. DESIGN: Prospective cohort study. SETTING: Side-line blood collection at football, soccer, and volleyball games/practices. PARTICIPANTS: Division I athletes with/without SRC. MAIN OUTCOME MEASURES: Blood ubVILIP-1 concentrations. RESULTS: Data collected over 2 athletic seasons from non-SRC athletes (controls) show a small but statistically significant elevation of ubVILIP-1 over an individual season for male athletes (P = 0.02) dependent on sport (P = 0.014) and no significant changes in ubVILIP-1 levels between seasons. For SRC athletes, the data show ubVILIP-1 levels substantially increase above baseline as soon as 30 minutes postdiagnosis with peak concentrations and times postinjury that vary based on injury severity. CONCLUSION: Results of the study suggest quantification of blood ubVILIP-1 levels measured using an LFD may provide an objective identification of athletes with SRC, setting the stage for further study with a larger number of SRC patients.

A Case Series and Literature Review: Isolated Traumatic First Rib Fracture in Athletes.

OBJECTIVE: To present a case series of 14 isolated traumatic first rib fractures sustained in sport and review the literature on clinical presentation, mechanism of injury, diagnosis, and management of sport-related traumatic first rib fractures. DESIGN: We compiled a series of isolated traumatic first rib fractures seen in 2 Division 1-associated sports medicine clinics. We also performed a literature search for additional publications of isolated traumatic first rib fractures in sport. SETTING: Patients in our case series were all evaluated and treated at 2 tertiary care center sports medicine clinics. PATIENTS: Patients were those who sustained isolated traumatic first rib fracture during sport. INTERVENTIONS: None. MAIN OUTCOME MEASURES: None. RESULTS: None. CONCLUSIONS: Traumatic fracture of the first rib in sport is certainly not a common diagnosis, but it is likely more widespread than sports medicine providers realize. Considering the diagnosis of first rib fracture for athletes with shoulder pain after trauma is essential for identifying this injury. Although more study is likely needed to make definitive recommendations on treatment and return to play protocols, the case series and literature review presented suggests that rehabilitation and return to play when the patient is asymptomatic may be appropriate care.

Effect of Pitching Restrictions and Mound Distance on Youth Baseball Pitch Counts.

Background: Studies have shown that higher pitch counts are directly related to a greater incidence of elbow and shoulder pain among youth baseball pitchers. Purpose/Hypothesis: The purpose of this study was to examine the effect of different pitching restriction rules on the number of pitches thrown in youth baseball leagues. We hypothesized that more pitches would be thrown in leagues with inning restrictions versus leagues with pitch count restrictions as well as in leagues with a longer mound distance (from pitching mound to home plate). Study Design: Cohort study; Level of evidence, 2. Methods: Pitch count data were collected for 2 consecutive years over a 10-week season from 3 different leagues of 9- to 12-year-old baseball players in a single city. The Eastern league had a pitch count restriction and 46-ft (14.02-m) mound distance. The Southeastern and South leagues' pitching restrictions were based on innings per week. The Southeastern league had a 50-ft (15.24-m) mound distance, while the South league had a 46-ft mound distance. Comparisons of total seasonal pitches thrown were made of the 3 highest-volume pitchers on each team. League averages for each value were then compared utilizing analysis of variance with Bonferroni post hoc analysis. The number of pitchers in each league who threw >600 pitches per season was compared using the chi-square test. Results: No significant difference in seasonal pitch counts or innings pitched was noted between the Eastern and South leagues, which differed only in their pitching restrictions. The Southeastern league, with a longer mound distance, was found to have higher seasonal pitch counts per thrower (598 ± 195 pitches) than the South league (463 ± 198 pitches) for the 3 highest-volume throwers for each team (P = .004). The Southeastern league also had a significantly larger number of pitchers who threw >600 pitches per season (33 vs 20 for Eastern and 13 for South; P = .009). Conclusion: There was no significant difference in seasonal pitch counts when the leagues in this study differed based on pitching restrictions. However, the league with a greater mound distance (Southeastern) had higher seasonal pitch counts for the highest-volume throwers. Pitching restrictions based on pitch counts, as opposed to innings, may be advisable.

Pulmonary infections in the athlete.

Despite their general high level of health, athletes are not free from the threat of developing pulmonary infection. Prompt diagnosis and proper treatment are important given the effects of pulmonary infection upon athletic performance and time away from training. This article reviews common etiologies of community-acquired pneumonia and a more in-depth discussion of mycoplasma pneumonie and influenza. Current treatment guidelines, acute bronchitis, fungal pulmonary infection, and return to play principles also are discussed.

Mononucleosis and athletic participation: an evidence-based subject review.

Infectious mononucleosis (IM) is a common medical condition that afflicts thousands of young athletes each year. Despite the self-limited nature of this disorder, the variability of the clinical presentation and the rare risk of splenic rupture routinely present sports medicine clinicians with difficult return-to-play decisions. Currently there are no evidence-based guidelines regarding the management of the athlete with IM. This review discusses the available research data pertaining to the management of IM in young athletes and develops questions for future clinical research.

Evaluation and management of stress fractures of the pelvis and sacrum.

Most stress fractures of the pelvis and sacrum can be treated nonoperatively with activity modification and thorough assessment of training activities and nutritional factors.

Nitric oxide therapy: fact or fiction?

Nitric oxide (NO) has been the topic of many studies regarding its therapeutic benefit in patients with cardiac disease. Recent studies are now revealing potential advantages for healthy individuals and endurance athletes. This article discusses current research focused on NO augmentation in relation to muscular strength and endurance. Arginine, an NO precursor, has been more extensively studied as a supplement for performance enhancement. Its role in cardiovascular endurance and strength training is assessed in individuals with various athletic backgrounds. The therapeutic role of NO in the treatment of tendinopathies is also reviewed.

Ergogenic aids: an update on ephedra.

Ephedra has been used medicinally for thousands of years dating back to ancient Chinese medicine. Since its introduction to Western medicine in the 20th century, ephedra has been used for various ailments. The amphetamine-like activity of ephedra made it a popular supplement for promotion of weight loss and enhancement of athletic performance, despite limited supporting data. With the implementation of the Dietary Supplement Health and Education Act of 1994, the US Food and Drug Administration's (FDA) regulation of ephedra-containing supplements diminished. As these products became increasingly available, adverse effects associated with their use also increased. These adverse effects are mainly a result of ephedra's sympathomimetic activity and have been manifested by premature cardiovascular and central nervous system disease. With mounting evidence concerning the unsafe nature of these products, the FDA was able to ban the sale of ephedra-containing dietary supplements in April of 2004.

Medial and lateral collateral injuries: prognosis and treatment.

This article presents a comprehensive review of medial and lateral knee ligament injuries. It reviews the basic anatomy, physical examination, imaging techniques, and current treatment of medial and lateral knee injuries. It includes a step-by-step guide to proper physical examination of the knee as well as MRI images. Current treatment of medial and lateral knee injuries is extensively reviewed to aid the primary care physician in diagnosis and provision of care.

Soft-tissue injuries of the lower extremity.

A diverse set of conditions affect the lower extremities in athletes. Good history taking and knowledge of the anatomy of the affected areas can aid in accurate diagnosis. Most conditions can be treated conservatively with great success. Familiarity with rehabilitation strategies can assist physicians in working with physical therapists. New advances, especially in the therapy of plantar fasciitis, may aid physicians in more rapid treatment of conditions of overuse. Surgery can provide definitive relief from symptoms for athletes with whom conservative measures have failed.

Sudden cardiac death.

Sudden cardiac death is a rare but devastating event. The majority of cases in young athletes are caused by congenital cardiac abnormalities that are routinely clinically silent before causing sudden death. An optimal screening practice to help identify underlying asymptomatic cardiac abnormalities has met with much debate. Beyond the American Heart Association's recommendations for cardiovascular screening guidelines for the preparticipation physical examination [47], there are conflicting views regarding the use of more advanced diagnostic screening tests. Athletes in whom a potentially life-threatening cardiovascular abnormality is found face the probability of being restricted from participating in certain types of athletic activity. Participation guidelines for athletes with cardiovascular disease are detailed in the recommendations of the 26th Bethesda Conference [36]. Future goals should continue to focus on the prevention of SCD. The development of a cost-effective screening process that incorporates the use of echocardiography, although having its own set of inherent limitations, may prove to be the most viable option.

Medical aspects of sports: epidemiology of injuries, preparticipation physical examination, and drugs in sports.

The epidemiology of sports injuries helps identify the necessity for medical event coverage, injury risk factors, and potential prevention strategies. The preparticipation examination provides an opportunity for the team physician to identify athletes at risk of injury, to teach injury prevention, and to address athlete wellness. Knowledge of performance-enhancing drugs, nutritional supplements,and banned and legal medications is critical in caring for athletes.

The ergogenics of fluid and electrolyte balance.

Fluid and electrolyte balance within a fairly narrow range is a requirement for human life. Athletes, particularly endurance athletes, routinely stress their bodies to the point of altering fluid and electrolyte levels. In some cases, significant fluctuations can lead to deterioration in performance and even the athlete's health. The body's physiologic response to such fluctuations of fluid and electrolyte levels is complex and not completely understood. This article examines how the body copes with changes in fluid and electrolyte balance and how these changes may be minimized via replacement to sustain athletic performance.

Trends in concussion return-to-play timelines among high school athletes from 2007 through 2009.

CONTEXT: Whereas guidelines about return-to-play (RTP) after concussion have been published, actual prognoses remain elusive. OBJECTIVE: To develop probability estimates for time until RTP after sport-related concussion. DESIGN: Descriptive epidemiology study. SETTING: High school. PATIENTS OR OTHER PARTICIPANTS: Injured high school varsity, junior varsity, or freshman athletes who participated in 1 of 13 interscholastic sports at 7 area high schools during the 2007-2009 academic years. INTERVENTION(S): Athletic trainers employed at each school collected concussion data. The athletic trainer or physician on site determined the presence of a concussion. Athlete-exposures for practices and games also were captured. MAIN OUTCOME MEASURE(S): Documented concussions were categorized by time missed from participation using severity outcome intervals (same-day return, 1- to 2-day return, 3- to 6-day return, 7- to 9-day return, 10- to 21-day return, >21-day return, no return [censored data]). We calculated Kaplan-Meier time-to-event probabilities that included censored data to determine the probability of RTP at each of these time intervals. RESULTS: A total of 81 new concussions were documented in 478 775 athlete-exposures during the study period. After a new concussion, the probability of RTP (95% confidence interval) was 2.5% (95% confidence interval = 0.3, 6.9) for a 1- to 2-day return, 71.3% (95% confidence interval = 59.0, 82.9) for a 7- to 9-day return, and 88.8% (95% confidence interval = 72.0, 97.2) for a 10- to 21-day return. CONCLUSIONS: For high school athletes, RTP within the first 2 days after concussion was unlikely. After 1 week, the probability of return rose substantially (approximately 71%). Prognostic indicators are used to educate patients about the likely course of disease. Whereas individual symptoms and recovery times vary, prognostic time-to-event probabilities allow clinicians to provide coaches, parents, and athletes with a prediction of the likelihood of RTP within certain timeframes after a concussion.

Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To determine if females with patellofemoral pain syndrome (PFPS) who perform hip strengthening prior to functional exercises demonstrate greater improvements than females who perform quadriceps strengthening prior to the same functional exercises. BACKGROUND: Although PFPS has previously been attributed to quadriceps dysfunction, more recent research has linked this condition to impairment of the hip musculature. Lower extremity strengthening has been deemed an effective intervention. However, research has often examined weight-bearing exercises, making it unclear if increased strength in the hip, quadriceps, or both is beneficial. METHODS: Thirty-three females with PFPS performed either initial hip strengthening (hip group) or initial quadriceps strengthening (quad group) for 4 weeks, prior to 4 weeks of a similar program of functional weight-bearing exercises. Self-reported pain, function, and functional strength were measured. Isometric strength was assessed for hip abductors, external rotators, and knee extensors. A mixed-model analysis of variance was used to determine group differences over time. RESULTS: After 4 weeks, there was less mean ± SD pain in the hip group (2.4 ± 2.0) than in the quad group (4.1 ± 2.5) (P = .035). From baseline to 8 weeks, the hip group demonstrated a 21% increase (P<.001) in hip abductor strength, while that remained unchanged in the quad group. All participants demonstrated improved subjective function (P<.006), objective function (P<.001), and hip external rotator strength (P = .004) from baseline to testing at 8 weeks. CONCLUSION: Both rehabilitation approaches improved function and reduced pain. For patients with PFPS, initial hip strengthening may allow an earlier dissipation of pain than exercises focused on the quadriceps.

Infectious disease and the collegiate athlete.

Collegiate athletes are common reservoirs for infectious disease agents. Specific training regimens, living arrangements, and high-risk behaviors may influence the athlete's risk of contracting a variety of infectious diseases. The sports medicine physician plays an important role in recognizing, appropriately treating, designing prevention strategies for, and making return-to-activity decisions for athletes who have infectious diseases.