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Intraarticular knee injuries and subsequent posttraumatic arthritis (PTOA) are common in athletes. Unfortunately, PTOA may significantly affect performance and overall function, but this condition remains difficult to characterize. In this review, we provide an overview of imaging modalities used to evaluate PTOA among athletes and physically active individuals following knee injury, with the goal to discuss the strengths and limitations of their application in this population. A literature search was performed to identify clinical studies focusing of knee injuries in athletes and athletic persons, specifically using imaging for diagnosis or monitoring disease progression. A total of 81 articles were identified, and 23 were included for review. Studies on plain radiographs (n = 8) and magnetic resonance imaging (MRI) assessed arthritic burden (n = 13), with MRI able to depict the earliest cartilage changes. Few studies (n = 2) leveraged ultrasound. Challenges persist, particularly regarding standardization and reliability across different radiographic grading systems. Additionally, further research is needed to establish the clinical significance of techniques to assess cartilage composition on MRI, including ultrashort echo-time enhanced T2*, T1rho and T2 imaging. Addressing these challenges through standardized protocols and intensified research efforts will enhance the diagnostic utility of imaging modalities in musculoskeletal medicine and enable high-quality prospective studies.
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ABSTRACT: Achilles tendinopathy is a common overuse injury that is traditionally managed with activity modification and a progressive eccentric strengthening program. This narrative review describes the available evidence for adjunctive procedural interventions in the management of midportion and insertional AT, specifically in the athletic population. Safety and efficacy data from available literature on extracorporeal shockwave therapy, platelet-rich plasma, high-volume injectate with or without tendon scraping, and percutaneous needle tenotomy are used to propose an algorithm for treatment of Achilles tendinopathy for the in-season athlete.
Subject(s)
Achilles Tendon , Athletic Injuries , Platelet-Rich Plasma , Tendinopathy , Humans , Tendinopathy/therapy , Achilles Tendon/injuries , Athletic Injuries/therapy , Extracorporeal Shockwave Therapy , Tenotomy/methods , Athletes , AlgorithmsABSTRACT
OBJECTIVE: To determine the efficacy of extracorporeal shockwave therapy (ESWT) and investigate outcomes following the use of ESWT for athletes and physically active individuals. DESIGN: Systematic review. DATA SOURCES: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and searched four databases: PubMed (NLM), Embase (Elsevier), CINAHL Complete (EBSCO) and Web of Science (Clarivate). ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Included studies were randomised controlled trials, cohort and case-control studies, cases series and reports that evaluated outcomes following ESWT for athletes, physically active individuals and occupational groups requiring regular physical activity such as military cadets. RESULTS: 56 studies with 1874 athletes or physically active individuals were included. Using the Oxford level of evidence rating, included studies were 18 level I (32.1%), 3 level II (5.4%), 10 level III (17.9%), 13 level IV (23.2%) and 12 level V (21.4%). Based on the level I studies, ESWT may be effective alone in plantar fasciitis, lateral epicondylitis and proximal hamstring tendinopathy and as an adjunct to exercise treatment in medial tibial stress syndrome and osteitis pubis in athletes or physically active individuals. In most studies, athletes were allowed to continue activities and training and tolerated ESWT with minimal side effects. CONCLUSION: ESWT may offer an efficacious treatment alone or as an adjunct to concurrent exercise therapy in selected sports-related injuries and without major adverse events. Further high-level research is needed to better define the role and clinical outcomes of ESWT.
Subject(s)
Athletic Injuries , Extracorporeal Shockwave Therapy , Humans , Athletes , Athletic Injuries/therapy , Exercise/physiology , Exercise Therapy/methods , Extracorporeal Shockwave Therapy/methods , Fasciitis, Plantar/therapy , Medial Tibial Stress Syndrome/therapyABSTRACT
CONTEXT: Competitive swimmers are at high risk of overuse musculoskeletal injuries due to their high training volumes. Spine injuries are the second most common musculoskeletal injury in swimmers and are often a result of the combination of improper technique, high loads on the spine in strokes that require hyperextension, and repetitive overuse leading to fatigue of the supporting trunk muscles. The purpose of this review is to summarize the current evidence regarding swimming biomechanics, stroke techniques, and common injuries in the lumbar spine to promote a discussion on the prevention and rehabilitation of lower back injuries in competitive swimmers. EVIDENCE ACQUISITION: From a PUBMED/MEDLINE search, 16 articles were identified for inclusion using the search terms "swimming," "low back" or "lumbar," and "injury" or "injuries." STUDY DESIGN: Narrative review. LEVEL OF EVIDENCE: Levels 4 and 5. RESULTS: The trunk muscles are integral to swimming stroke biomechanics. In freestyle and backstroke, the body roll generated by the paraspinal and abdominal muscles is integral to efficient stroke mechanics by allowing synergistic movements of the upper and lower extremities. In butterfly and breaststroke, the undulating wave like motion of the dolphin kick requires dynamic engagement of the core to generate repetitive flexion and extension of the spine and is a common mechanism for hyperextension injuries. The most common lower back injuries in swimming were determined to be lumbar strain, spondylolysis and spondylolisthesis, facet joint pain, and disc disease. Most overuse swimming injuries can be treated conservatively with physical therapy and training adjustments. CONCLUSION: Managing swimmers with low back pain requires a basic knowledge of swimming technique and a focus on prevention-based care. Since most swimming injuries are secondary to overuse, it is important for providers to understand the mechanisms underlying the swimming injury, including an understanding of the biomechanics involved in swimming and the role of spine involvement in the 4 strokes that assist in stabilization and force generation in the water. Knowledge of the biomechanics involved in swimming and the significant demands placed on the spinal musculoskeletal system will aid the clinician in the diagnosis and management of injuries and assist in the development of a proper rehabilitation program aimed at correction of any abnormal swimming mechanics, treatment of pain, and future injury prevention. STRENGTH OF RECOMMENDATIONS: B. Recommendation based on limited quality or inconsistent patient-oriented evidence.
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OBJECTIVE: Compare the incidence of total knee arthroplasty (TKA) within the first 5 years after knee OA diagnoses between matched groups of individuals with or without comorbid diagnoses of obesity and/or depression. We hypothesized that the greatest incidence of TKA within 5 years of OA diagnosis would be in the cohort of individuals with combined obesity and depression. METHODS: The PearlDiver Mariner Ortho157 database was used to identify four cohorts of individuals with knee OA based on diagnosis codes that were matched by age, sex, and Charlson Comorbidity Index: a group without diagnoses associated with depression or obesity (Control), those with obesity but not depression (Obesity), those with depression but not obesity (Depression), and those with diagnoses of both obesity and depression (Depression+Obesity). The incidence of subsequent TKA within the first 5 years after the index OA diagnosis were compared between the four matched cohorts. RESULTS: Each cohort was comprised of 274,403 unique individuals (180,563 females, 93,840 males; age=55±7 y). The incidence of TKA was greatest for the Depression+Obesity group (11.9%) when compared to the Control group (8.3%, p<0.0001, RR=1.43 [95%CI:1.41,1.45]), the Obesity group (10.2%, p<0.0001, RR=1.13 [95%CI:1.11,1.14], p<0.0001) or Depression (7.8%, p<0.0001, RR=1.53 [95%CI:1.50,1.55], p<0.0001). CONCLUSION: The incidence of subsequent TKA was greatest for those with the combination of obesity and depression when compared to the Control group and those with individual diagnosis of obesity or depression.
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An athlete's health and availability to train and compete at an optimal performance level is a growing focus for professional sports organizations [...].
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Prolotherapy is a nonsurgical regenerative technique that allows small amounts of irritant solution to be injected into the site of painful tendon and ligament insertions to promote the growth of healthy cells and tissues. The goal of prolotherapy is to stimulate growth factors that may strengthen attachments and reduce pain. Prolotherapy injection technique is centered around a focused physical examination and strong anatomic knowledge for maximized results. Prolotherapy is beneficial in a variety of different musculoskeletal conditions, including, but not limited to, lateral epicondylosis, rotator cuff tendinopathy, plantar fasciitis, Achilles tendinopathy, osteoarthritis, low back pain, sacroiliac joint pain, and TMJ laxity.
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Achilles Tendon , Low Back Pain , Musculoskeletal Pain , Prolotherapy , Tendinopathy , Humans , Prolotherapy/methods , Tendinopathy/therapyABSTRACT
OBJECTIVE: Despite the increased use of platelet-rich plasma in the treatment of osteoarthritis, whether and how age of the platelet-rich plasma donor affects therapeutic efficacy is unclear. DESIGN: In vitro, male osteoarthritic human chondrocytes were treated with platelet-rich plasma from young (18-35 yrs) or old (≥65 yrs) donors, and the chondrogenic profile was evaluated using immunofluorescent staining for two markers of chondrogenicity, type II collagen and SOX-9. In vivo, we used a within-subjects design to compare Osteoarthritis Research Society International scores in aged mouse knee joints injected with platelet-rich plasma from young or old individuals. RESULTS: In vitro experiments revealed that platelet-rich plasma from young donors induced a more youthful chondrocyte phenotype, as evidenced by increased type II collagen ( P = 0.033) and SOX-9 expression ( P = 0.022). This benefit, however, was significantly blunted when cells were cultured with platelet-rich plasma from aged donors. Accordingly, in vivo studies revealed that animals treated with platelet-rich plasma from young donors displayed a significantly improved cartilage integrity when compared with knees injected with platelet-rich plasma from aged donors ( P = 0.019). CONCLUSIONS: Injection of platelet-rich plasma from a young individual induced a regenerative effect in aged cells and mice, whereas platelet-rich plasma from aged individuals showed no improvement in chondrocyte health or cartilage integrity.
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Osteoarthritis, Knee , Osteoarthritis , Platelet-Rich Plasma , Humans , Male , Mice , Animals , Collagen Type II/metabolism , Osteoarthritis/therapy , Chondrocytes , Aging , Platelet-Rich Plasma/metabolism , Osteoarthritis, Knee/therapy , Injections, Intra-ArticularABSTRACT
Orthobiologic therapies show significant promise to improve outcomes for patients with musculoskeletal pathology. There are considerable research efforts to develop strategies that seek to modulate the biological environment to promote tissue regeneration and healing and/or provide symptomatic relief. However, the regulatory pathways overseeing the clinical translation of these therapies are complex, with considerable worldwide variation. The introduction of novel biologic treatments into clinical practice raises several ethical dilemmas. In this review, we describe the process for seeking approval for biologic therapies in the United States, Europe, and Japan. We highlight a number of ethical issues raised by the clinical translation of these treatments, including the design of clinical trials, monitoring outcomes, biobanking, "off-label" use, engagement with the public, marketing of unproven therapies, and scientific integrity.
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ABSTRACT: Knee extensor mechanism tendinopathy, including patellar and quadriceps tendinopathy, is common among athletes and those involved in jumping sports. It is largely a clinical diagnosis that presents as anterior knee pain and stiffness with associated tenderness over the affected tendon. Imaging modalities, including ultrasound and/or magnetic resonance imaging, may be helpful with the diagnosis of difficult cases or in the planning of interventional procedures. Focused and structured rehabilitation using eccentric or heavy slow resistance exercise in conjunction with load management is important for recovery. Adjuvant therapies (e.g., injections or surgery) may be necessary in recalcitrant cases or those with insufficient response to rehabilitation efforts. Prevention strategies focus on improving biomechanics, landing mechanism and lower-extremity balance, flexibility, and strength.
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Patellar Ligament , Tendinopathy , Humans , Knee , Knee Joint , Lower Extremity , Tendinopathy/diagnosis , Tendinopathy/prevention & controlABSTRACT
OBJECTIVE: Knee osteoarthritis (KOA) is a common musculoskeletal condition that particularly afflicts women in menopause. The purpose of this review is to describe the pathophysiology and treatment considerations for this subset of the population. METHODS: Medline/PubMed indexed articles related to the pathophysiology, diagnosis, and management of osteoarthritis were included in this narrative review. RESULTS AND CONCLUSION: Menopause has a multitude of effects that affect KOA, including hormonal shifts; loss of bone mineral density, muscle mass, and tendon strength; and changes to pain perception. Here, we discuss how a practitioner can assess the factors that are known to worsen KOA symptoms, including postural (spine, pelvic, and knee) alignment and functional muscle strength. The development of an effective exercise program is at the forefront of management. Optimizing other lifestyle factors including nutrition and sleep are particularly important in this patient population. Sleep disturbance from vasomotor symptoms can also increase perception of knee pain, for which pharmacologic options such as gabapentin or duloxetine may be pursued. In total, these interventions have large ramifications in decreasing pain and increasing function through improved range of motion, body composition, and walking speed in women with KOA.
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Osteoarthritis, Knee , Female , Humans , Knee Joint , Muscle Strength , Osteoarthritis, Knee/complications , Osteoarthritis, Knee/therapy , Pain , Range of Motion, ArticularABSTRACT
Aging athletes, those 60 years and older, are a growing population of mature, active individuals who value sports and exercise participation throughout their lifespan. Although recommendations for younger and masters athletes have been extrapolated to this population, there remains a paucity of specific guidelines, treatment algorithms, and considerations for aging athletes. The benefits of living an active lifestyle must be weighed against the risks for unique cardiovascular, metabolic, and musculoskeletal injuries requiring diagnostic and therapeutic interventions. In this article, we review the unique cardiovascular and muscular physiology of aging athletes and how it influences the risk of specific medical conditions. We also discuss general prevention and treatment strategies. Finally, we identify areas of future research priorities and emerging treatments.
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Athletes , Sports , Aging/physiology , Exercise/physiology , Humans , Life StyleABSTRACT
The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.
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ABSTRACT: Many sports medicine physicians are currently considering introducing regenerative medicine into their practice. Regenerative medicine and the subclassification of orthobiologics are a complicated topic and have produced widely varying opinions. Although there is concern by government regulators, clinicians, scientists, patient advocacy organizations, and the media regarding the use of regenerative medicine products, there is also excitement about the potential benefits with growing evidence that certain regenerative medicine products are safe and potentially efficacious in treating musculoskeletal conditions. Sports medicine physicians would benefit from decision-making guidance about whether to introduce orthobiologics into their practice and how to do it responsibly. The purpose of this position statement is to provide sports medicine physicians with information regarding regenerative medicine terminology, a brief review of basic science and clinical studies within the subclassification of orthobiologics, regulatory considerations, and best practices for introducing regenerative medicine into clinical practice. This information will help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine and orthobiologics in their practice.
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Musculoskeletal Diseases , Sports Medicine , Humans , Regenerative Medicine , Societies, Medical , United StatesABSTRACT
ABSTRACT: Achilles tendinopathy is a common overuse condition that is characterized by degenerative, cumulative tissue microtrauma. It is largely a clinical diagnosis in which the patient typically presents with localized pain that is worse with tendon-loading activities. Imaging modalities may be helpful with the diagnosis of difficult cases or in the planning of interventional procedures. Midportion (noninsertional) and insertional tendinopathy have distinct features and differences for therapeutic paradigms. Overall, Achilles tendinopathy has a good clinical prognosis with most patients improving with activity modification and rehabilitation, with a focus on progressive tendon-loading. Recalcitrant cases may require adjuvant treatment with procedures (e.g., injections, shockwave therapy) and rarely surgical intervention.
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Achilles Tendon , Tendinopathy/therapy , Achilles Tendon/anatomy & histology , Humans , Physical Examination , Prognosis , Return to Sport , Tendinopathy/diagnosis , Tendinopathy/diagnostic imaging , Tendinopathy/etiologyABSTRACT
ABSTRACT: The Association of Academic Physiatrists, the home of academic physiatry, is interested in advancing industry partnerships in research among academic physiatrists. There are limited existing resources that outline opportunities for academic physiatrists in engaging the translational research continuum through industry partnerships and the skill sets that academic physiatrists need to successfully navigate these partnerships. In 2019, then President of the Association of Academic Physiatrists, John Chae, MD, ME, assembled a group of interested physician-scientists in physical medicine and rehabilitation to form the Research and Industry Partnerships Task Force to address this problem. The Task Force implemented a live educational session titled "Collaborating with industry" at Physiatry '19, the Annual Meeting of the Association of Academic Physiatrists held in Puerto Rico. To extend the reach of this valuable information, the Task Force is creating resources that can be easily distributed and accessed by all physiatrists. The goal of this white paper is to provide a roadmap to help academic physiatrists begin to navigate the field of academia-industry relationships with the ultimate goal of accelerating discovery for the benefit of physiatry and rehabilitation patients.
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Biomedical Research , Industry , Physical and Rehabilitation Medicine , Translational Research, Biomedical , Advisory Committees , HumansABSTRACT
INTRODUCTION: Extracorporeal shockwave therapy (ESWT) has a wide variety of clinical applications ranging from urology to orthopedics. Extracorporeal shockwave therapy is of particular interest to military medicine in the treatment of diverse musculoskeletal injuries, including recalcitrant tendinopathy. Much of the evidence for ESWT is from studies in the civilian population, including athletes. A few investigations have been conducted within military personnel. Musculoskeletal conditions within military personnel may contribute to pain and physical limitations. Optimal functional outcomes could be achieved through ESWT. The purpose of this narrative review is to summarize the current evidence on the efficacy of ESWT the in management of lower extremity musculoskeletal injuries in the military. Further, we explore the relative efficacy of ESWT compared to regenerative medicine procedures, including studies with treatment using platelet-rich plasma. MATERIALS AND METHODS: A literature review was performed in April 2020 to identify studies evaluating the use of ESWT for lower extremity conditions commonly observed in military personnel, including plantar fasciitis, Achilles tendinopathy, patellar tendinopathy, medial tibial stress syndrome, and knee arthritis. The literature search was completed by two researchers independently, using PubMed and Embase databases and same search terms. Disagreements were adjudicated by a senior author. Due to the paucity of relevant search results, the search term parameters were expanded to incorporate active participants. RESULTS: Two studies evaluated the use of ESWT in a military population for lower extremity injuries. This included a randomized control trial in active military with medial tibial stress syndrome and an unblinded retrospective study for the chronic plantar fasciitis condition. Both studies in the military had favorable outcomes in the use of ESWT compared to other treatment arms. The remaining studies predominantly included athletes. Although heterogeneity on the quality of the studies may prevent meta-analysis and limit the generalization of the findings, the majority of studies demonstrated an improvement in pain and return to activity using ESWT. Two studies using platelet-rich plasma as a treatment arm identified similar short-term outcomes compared to ESWT for Achilles tendinopathy and patellar tendinopathy. CONCLUSION: Our findings suggest that ESWT is a safe and well-tolerated intervention with positive outcomes for lower extremity conditions commonly seen in the military. The few studies comparing ESWT to PRP suggest regenerative benefits similar to orthobiologics in the shorter term. More robust quality designed research may enable the evaluation of ESWT efficacy within the military population. In summary, the use of ESWT may provide pain reduction and improved function in active populations with lower extremity musculoskeletal injuries. Further research in the military is needed to evaluate shockwave efficacy in order to advance musculoskeletal care and improve outcomes.