The influence of a single 30-pitch session on elbow laxity in adolescent and collegiate baseball pitchers.

BACKGROUND: Ulnar collateral ligament (UCL) injuries are a source of significant injury among baseball players, and are increasingly evaluated under ultrasound. The purpose of this study is to determine the effect of a single session of pitching upon UCL thickness and laxity via a cross sectional, controlled ultrasonographic study. We hypothesize that a single session of pitching will cause the ulnar collateral ligament to thicken and become more lax. METHODS: This was a cross sectional comparative study of collegiate and high school pitchers. Pitchers underwent an ultrasonographic assessment of the UCL before and after a thirty-pitch bullpen warm-up. Laxity was measured as the change in the distance between the ulna and the trochlea with and without a 5-pound weight held in hand with the elbow at 30° of flexion. Pre- and post-throwing UCL thickness and medial laxity were statistically compared with paired tests. RESULTS: Our study included 15 pitchers, 8 collegiate and 7 high school level athletes. All played baseball at least 6 days a week, and nearly all played for at least 10 months a year. Pitchers reported a peak velocity of 89 ± 6 (77 to 98) miles per hour. In the prior season, these pitchers pitched 56 ± 33 (10 to 120) games, throwing 62 ± 34 (25-140) pitches per game on average. After throwing, there was significantly less UCL laxity (P = .013). Post-throwing laxity was significantly positively correlated with both peak pitch velocity (P = .009) and an average number of pitches thrown per game (P = .10). CONCLUSION: Throwing 30 pitches significantly decreases medial elbow laxity with stress, possibly due to flexor-pronator activation. Post-throwing medial laxity is correlated with both peak pitch velocity and average number of pitches thrown per game. Future studies should be conducted to determine the number of throws at which laxity begins to increase, as this may provide a workload management guideline for injury prevention.

Sonographic Screening of Distance Runners for the Development of Future Achilles and Patellar Tendon Pain.

OBJECTIVE: The 2 primary aims of this study were to identify ultrasonographic tendon abnormalities in asymptomatic runners and to examine the likelihood of developing pain in runners with ultrasound abnormalities compared with those without abnormalities. DESIGN: Longitudinal, prospective cohort study. SETTING: 2019 Salt Lake City Marathon. PARTICIPANTS: Recreational half-marathon and full-marathon runners. ASSESSMENT OF RISK FACTORS: The Achilles and patellar tendons of asymptomatic runners were examined with ultrasound imaging before a running event. Runners were monitored for self-reported outcomes of pain in the examined tendons at 1, 3, 6, and 12 months after the event. MAIN OUTCOME MEASURES: Development of pain based on the presence of asymptomatic tendon abnormalities. RESULTS: One hundred thirty-eight runners (36.2 ± 12.0 years, 49.3% men, and 31.2% full-marathon runners) were included. Ultrasound abnormalities of the Achilles and patellar tendons were identified in 24.6% and 39.1% of the runners before the race, respectively. Ultrasound abnormalities were significantly associated with approximately a 3-fold increase [hazard ratio (HR) = 2.55, P = 0.004] in the hazard of developing pain in the Achilles tendon and patellar tendon (HR = 1.67, P = 0.042) over the year after the race. Positive and negative predictive values of developing pain over the year were 34.1% and 87.2%, respectively, for abnormal findings in the Achilles tendon, and 22.9% and 85.0%, respectively, for the patellar tendon. CONCLUSIONS: The presence of ultrasonographic abnormalities is associated with increased development of pain in the Achilles and patellar tendons within 1 year of a marathon or half marathon.

Identification of Knee Effusions With Ultrasound: A Comparison of Three Methods.

OBJECTIVES: To determine whether simple methods can improve identification of suprapatellar joint fluid during sonographic evaluation of the knee. DESIGN: Prospective cohort study. SETTING: Outpatient orthopaedic clinic. PATIENTS: Fifty-two patients were sequentially recruited from an orthopaedic clinic. INTERVENTIONS: Bilateral sonographic evaluation of the suprapatellar recess with static scanning, parapatellar pressure, or patient-initiated quadriceps contraction. MAIN OUTCOME MEASURES: Identification of fluid in the suprapatellar recess. RESULTS: Fifty-two patients (104 knees), consisting of 57 (54.8%) painful knees, were examined. Static scanning identified 45 effusions, parapatellar pressure identified 58 effusions, and quadriceps contraction identified 77 effusions. Quadriceps contraction was superior to parapatellar pressure for identifying an effusion {P < 0.001, proportion ratio [PR] = 1.33 [95% confidence interval (CI) = 1.16, 1.52]}, painful knee effusions [P = 0.036, PR = 1.24 (95% CI = 1.06-1.44)], and painless knee effusions (P = 0.006, PR = 1.50 [95% CI = 1.16-1.93]). Both methods were superior to static scanning. Parapatellar pressure identified effusions in 16.9% of knees not seen on static scanning, whereas quadriceps contraction identified effusions in 54.2% of knees not seen on static scanning. Inter-rater reliability kappa values were 0.771 for static scanning (95% CI = 0.605-0.937), 0.686 for parapatellar pressure (95% CI = 0.531-0.840), and 0.846 for quadriceps contraction (95% CI = 0.703-0.990). CONCLUSIONS: Parapatellar pressure and patient-initiated quadriceps contraction both improve sonographic detection of suprapatellar joint fluid with high inter-rater reliability; however, quadriceps contraction was superior to parapatellar pressure when assessing for grade 1 or occult effusions.

The ulnar collateral ligament responds to stress in professional pitchers.

BACKGROUND: Our purpose with this study was to determine the response of the ulnar collateral ligament (UCL) in professional pitchers after exposure to a season of pitching and to rest during an off-season. METHODS: In a prospective study supported by Major League Baseball, all pitchers within a single professional baseball club were enrolled. An ultrasound of the ligament was then performed by a single fellowship-trained ultrasonographer at the beginning of the season (T1), the end of the season (T2), and the beginning of the following season (T3). We measured the UCL thickness and ulnotrochlear joint opening at 30° of flexion with and without stress. Two ultrasound images were saved. Inter- and intra-rater reliability were determined. A multivariable analysis was conducted. RESULTS: A total of185 total pitchers were included: 94 pitchers at T1, 83 at T2, and 118 at T3. These pitchers had 12 [7, 15] (median [interquartile range]) years of pitching experience and had a peak velocity of 95 [93, 97] miles/hour. Intra- and inter-rater reliability were excellent. The baseline UCL thickness was associated with peak velocity (P = .031) and prior UCL reconstruction (P = .024). After accounting for pitching experience, peak velocity, and prior UCL reconstruction, thickness increased during the season (P = .002) and decreased during the off-season (P = .001). After accounting for these same variables, valgus laxity at 30° increased during the season (P = .002) and decreased during the off-season (P = .029). CONCLUSION: The UCL responds to stress in professional pitchers by becoming thicker and more lax, and responds to rest by becoming thinner and less lax.

Exercise for Athletes With Inflammatory Arthritis.

Advances in pharmacologic management of inflammatory conditions have allowed those living with these conditions to pursue fitness activities previously difficult due to functional limitations. With that said, many patients with inflammatory arthritis are still not active enough. In this article, we review specific exercise recommendations for a number of inflammatory conditions with a focus on overall health promotion and cardiovascular disease risk reduction, discuss exercise as an adjunct to pharmacologic disease management, and review potential risks of sport participation for athletes with inflammatory arthritis conditions.

Sports medicine ultrasound (US) beyond the musculoskeletal system: use in the abdomen, solid organs, lung, heart and eye.

The use of point-of-care ultrasound (US) by non-radiologists is not new and the expansion into sports medicine practice is relatively young. US has been used extensively to evaluate the musculoskeletal system including the diagnosis of muscle, tendon and bone injuries. However, as sports medicine practitioners we are responsible for the care of the entire athlete. There are many other non-musculoskeletal applications of US in the evaluation and treatment of the athlete. This paper highlights the use of US in the athlete to diagnose pulmonary, cardiac, solid organ, intra-abdominal and eye injuries.

Prospective Evaluation of Pain Flares and Time Until Pain Relief Following Musculoskeletal Corticosteroid Injections.

BACKGROUND: Corticosteroid injections are used ubiquitously within musculoskeletal medicine. One of the most common side effects is a postinjection pain flare, though little is known regarding this phenomenon. HYPOTHESIS: Some risk factors are related to postinjection pain flare following an ultrasound-guided corticosteroid injection. STUDY DESIGN: Prospective clinical research study. LEVEL OF EVIDENCE: Level 2. METHODS: Patients undergoing ultrasound-guided corticosteroid injections in an academic orthopaedic and sports medicine clinic were approached to participate. Patients completed a survey immediately following their injection and again 2 weeks later, asking them about their pain and side effects. A postinjection pain flare was defined as an increase in pain, as defined by the patient. RESULTS: A total of 140 patients completed the entirety of the study, with 29 (20.7%) patients reporting a flare of pain. There was a significant effect of younger age on the development of a pain flare after the injection, estimated as 5.5% decreased odds of developing a flare per year of age (P < 0.01). Gender, injection location, body mass index (BMI), preinjection pain, and corticosteroid type had no contributing effect. When patients obtained relief following the corticosteroid injection, 60.4% had improved pain within 3 days, whereas over 93.7% obtained relief within a week. CONCLUSION: Pain flares seem to affect approximately 1 in 5 patients. With increasing age, the likelihood of postinjection pain flare becomes less likely. Sex, injection location, BMI, preinjection pain, and corticosteroid type do not seem to significantly relate to an increase in pain following injection. CLINICAL RELEVANCE: Corticosteroid injections are common procedures in the orthopaedic and sports medicine settings. Younger patients can be counseled on the higher likelihood of a pain flare following a corticosteroid injection.

Does Anesthetic Relief Correspond to Future Pain Relief?: A Prospective Trial Examining Future Pain Relief for Ultrasound-Guided Corticosteroid-Anesthetic Injections.

OBJECTIVES: The aim of the study was to prospectively evaluate the association between immediate pain relief from injections of local anesthetic with corticosteroid and subsequent pain relief up to 3 mos. The secondary aim was to examine the time until subjective pain relief after these injections. DESIGN: This was a single-center, prospective study of patients undergoing ultrasound-guided corticosteroid injections for musculoskeletal pain. Subjects completed follow-up surveys at 2 wks, 1 mo, and 3 mos postinjections. χ 2 tests and sensitivity analysis were used to examine the primary outcome, at least 50% relief from the injection. Regression modeling examined the effects of demographic and injection-related variables on outcome measures. RESULTS: A total of 132 patients were enrolled (55% female, mean age 52 yrs). Response rates were 87.1% at 2 wks and 77.2% at 3 mos. The positive likelihood ratios from 50% initial pain relief ranged from 1.22 to 1.29 at the three time points, whereas the negative likelihood ratios ranged from 0.54 to 0.63. More than 75% of participants reported subjective pain relief by day 4 after injection. CONCLUSIONS: The predictive value of immediate pain relief for subsequent longer-term pain relief from corticosteroid-anesthetic injections is not particularly high. Most patients will obtain pain relief within 4 days of a corticosteroid injection.

Extended-release triamcinolone provides prolonged relief for patients who failed standard corticosteroid injection for knee osteoarthritis; a pragmatic retrospective study.

Objective: Identify if extended-release triamcinolone has a longer duration of action in a cohort of patients who have had limited duration of relief from prior corticosteroid injection. Design: Retrospective analysis of patients with knee osteoarthritis. Setting: Academic outpatient musculoskeletal practice. Subjects: One hundred and fifty patients (age 67.5 â€‹± â€‹13.7, 68.2% female) with knee osteoarthritis who had subjectively insufficient relief from a standard corticosteroid injection. Methods: Ultrasound-guided knee injections of extended-release triamcinolone were administered to all patients by experienced practitioners. The primary outcome measure was comparative duration of subjective relief from extended-release triamcinolone, compared to the patients' duration from their prior standard corticosteroid injection. The secondary outcome was the duration of relief from extended-release triamcinolone. Results: Patients reported 7.1 â€‹± â€‹8.7 additional weeks of relief from extended-release triamcinolone (t â€‹= â€‹6.50, p â€‹< â€‹0.001), with lower Kellgren-Lawrence score being the only factor associated with increased comparative duration of relief (B â€‹= â€‹-2.39, p â€‹= â€‹0.042). No factors were associated with duration of pain relief from extended-release triamcinolone. Conclusions: This retrospective study suggests that injection of extended-release triamcinolone is associated with prolonged pain relief in patients who have had insufficient duration of pain relief from a standard corticosteroid injection. Those with lower Kellgren-Lawrence grades were more likely to have an increased comparative duration of relief.

Automated electroencephalogram identifies abnormalities in the ED.

BACKGROUND: Advances in analysis of electrical signals have now made it possible to create a handheld electroencephalogram (EEG). METHODS: The BrainScope device, currently under development by BrainScope Co, Inc, Washington, DC, was used to assess 153 patients who presented to a tertiary referral hospital with headache or altered mental status. A limited array of 8 adhesive electrodes, similar to electrocardiographic leads, was applied to the forehead of the subjects. The data were analyzed, and the result given by the algorithm was compared with the clinical diagnosis given to the patient. RESULTS: One hundred fifty-three patients were enrolled. The patient was determined to be normal or abnormal using the algorithm in the device, and blinded clinicians determined whether this was accurate. The sensitivity of the device was 96% and the specificity was 87% for detecting abnormality. CONCLUSIONS: The automated EEG device may be a useful tool for identifying brain abnormality in the emergency department.

Use of brain electrical activity to quantify traumatic brain injury in the emergency department.

PRIMARY OBJECTIVE: To validate a QEEG algorithm on traumatic brain injury in an Emergency Department (ED) setting. METHODS AND PROCEDURES: EEG data were collected from 105 patients with head injury (53 CT+ and 52 CT-) and 50 ED controls. Ten minutes of eyes closed resting EEG was collected from five frontal locations. A discriminant index of the probability of belonging to the TBI CT+ group was computed. Analysis of variance was computed comparing this index across the three patient groups. Using ROC curves, the p < 0.05 confidence level was determined to compute sensitivity and specificity for the TBI CT+ population. RESULTS: CT+ patients had a mean TBI discriminant index of 80.4, CT- patients 38.9 and controls 24.5; F = 70.2, p < 0.0001. Sensitivity was 92.45% for the CT+ group and specificity was 90.00% for the control group. CONCLUSIONS: The TBI discriminant index appears to be a sensitive index of brain function. It may be used to suggest whether or not a patient presenting with altered mental status requires a CT scan. This index may aid in the triage of such patients in the ED. Such an easy to use, automated system may greatly enhance the clinical utility of EEG in the ED.