Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement.

ABSTRACT: Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Leadership in Orthopaedic Surgery: Creating a Highly Effective Leader.

Strong leadership is associated with improved outcomes in multiple domains, including orthopaedic surgery. There are multiple leadership styles, including transformational, transactional, and laissez-faire leadership. An effective leader understands the importance of verbal and nonverbal communication, emotional intelligence, preparation, and mindset on team performance. Orthopaedic surgeons serve as leaders in the operating room, in the outpatient setting, and on committees. Leadership skills can be developed through leadership-specific evaluations and training.

Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: a consensus statement.

Selected Issues in Sport-Related Concussion (SRC|Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus documents written for the practicing team physician. This document provides an overview of selected medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

Shoulder and elbow pathology in the female athlete: sex-specific considerations.

Unique biologic and biomechanical aspects of the female body make women more prone to certain orthopedic injuries. Sex differences are well understood with regard to certain orthopedic pathologies such as anterior cruciate ligament injury, hallux valgus, carpal tunnel, and carpometacarpal joint arthritis; however, sex differences are less commonly discussed with regard to shoulder and elbow pathology. The purpose of this review is to elucidate sex differences specific to sports-related shoulder and elbow injuries in the female athlete population.

Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement.

ABSTRACT: Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus articles written for the practicing team physician. This document provides an overview of select medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

Patellar Fracture Forces Are Not Affected by Proximal Versus Distal Bone Block Anterior Cruciate Ligament Reconstruction Harvest Sites in a Cadaveric Model.

Purpose: To quantify the maximum load to fracture in patellae from which bone-patellar tendon-bone (BPTB) and bone-quadriceps tendon (BQT) autografts have been harvested for anterior cruciate ligament reconstruction in a cadaveric model. Methods: Forty-six fresh-frozen patellae were isolated and divided into the BPTB harvest and BQT harvest groups with matching based on donor age and sex. Computed tomography scans were obtained to calculate bone mineral density (BMD) and patellar height, width, and thickness. BPTB and BQT grafts were harvested from the inferior patella and superior patella, respectively, and then ramped to failure in a 3-point bend test configuration to simulate a postoperative fracture produced by a direct impact after a fall. The presence of fracture, fracture pattern, and maximum load to fracture were recorded. Donor demographic characteristics; patellar height, width, and thickness; and maximum load were compared by the Student t test. Pearson correlations were used to determine whether maximum load was affected by BMD or patellar morphology. The level of significance was set at P < .05. Results: Maximum load to fracture was not significantly different (P = .91) between the BPTB (5.0 ± 2.3 kN) and BQT (5.1 ± 2.6 kN) groups. Maximum load to fracture in the BPTB group did not correlate with BMD (P = .57) or patellar measurements (P = .57 for thickness, P = .43 for width, and P = .45 for height). Maximum load to fracture in the BQT group positively correlated with BMD and negatively correlated with patellar height. Maximum load to fracture in the BQT group did not correlate with patellar thickness or width. Fracture through the harvest site was observed in 87% of BPTB specimens and 78% of BQT specimens. Conclusions: The location of the BPTB or BQT autograft harvest site did not significantly affect patellar load to fracture in a cadaveric model. Clinical Relevance: It is important to understand patellar morphology and the effect of BPTB and BQT graft harvest-site locations on the biomechanical strength of the patella after anterior cruciate ligament reconstruction.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement.

ABSTRACT: Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Anterior cruciate ligament rupture: differences between males and females.

The rate of anterior cruciate ligament (ACL) rupture is three times higher in female athletes than in male athletes. Intrinsic factors such as increased quadriceps angle and increased posterior tibial slope may predispose girls and women to ACL injury. Compared with males, females have smaller notch widths and smaller ACL cross-sectional area; however, no conclusive correlation between ACL size and notch dimension exists, especially in relation to risk of ACL injury. Female athletes who land with the knees in inadequate flexion and in greater-than-normal valgus and external rotation are at increased risk of ACL injury. No conclusive link has been made between ACL injury and the menstrual cycle. Neuromuscular intervention protocols have been shown to reduce the rate of injury in girls and women. Females are more likely than males to have a narrow A-shaped intercondylar notch, and special surgical considerations are required in such cases. Following ACL reconstruction, female athletes are more likely than male athletes to rupture the contralateral ACL; however, males and females are equally likely to rupture the reconstructed knee. Although self-reported outcomes in the first 2 years following reconstruction are worse for females than for males, longer-term studies demonstrate no difference between males and females.

Assessing Gender Differences in Technical Skills and Confidence in Orthopaedic Surgery Residency Applicants.

INTRODUCTION: Variations in confidence for procedural skills have been demonstrated when comparing male and female medical students in surgical training. This study investigates whether differences in technical skill and self-reported confidence exist between male and female medical students applying to orthopaedic residency. METHODS: All medical students (2017 to 2020) invited to interview at a single orthopaedic residency program were prospectively evaluated on their technical skills and self-reported confidence. Objective evaluation of technical skill included scores for a suturing task as evaluated by faculty graders. Self-reported confidence in technical skills was assessed before and after completing the assigned task. Scores for male and female students were compared by age, self-identified race/ethnicity, number of publications at the time of application, athletic background, and US Medical Licensing Examination Step 1 score. RESULTS: Two hundred sixteen medical students were interviewed, of which 73% were male (n = 158). No gender differences were observed in suture task technical skill scores or mean difference in simultaneous visual task scores. The mean change from pre-task and post-task self-reported confidence scores was similar between sexes. Although female students trended toward lower post-task self-reported confidence scores compared with male students, this did not achieve statistical significance. Lower self-reported confidence was associated with a higher US Medical Licensing Examination score and with attending a private medical school. DISCUSSION: No difference in technical skill or confidence was found between male and female applicants to a single orthopaedic surgery residency program. Female applicants trended toward self-reporting lower confidence than male applicants in post-task evaluations. Differences in confidence have been shown previously in surgical trainees, which may suggest that differences in skill and confidence may develop during residency training.

Men's Lacrosse Injuries in the 2018 International World Championship Play.

BACKGROUND: Limited data exist on injuries in men's lacrosse at the international level. As lacrosse's popularity grows rapidly across the globe, health care providers must understand how to treat lacrosse athletes. PURPOSE: To analyze injury data from the 2018 Men's World Lacrosse Championship. STUDY DESIGN: Descriptive epidemiology study. METHODS: This study prospectively observed injuries that occurred during the 2018 Men's World Lacrosse Championship. The medical staff of each team completed injury report forms, and data were categorized into body part injury, type, mechanism, time, and location of injury. RESULTS: Over 11 days, 1019 athletes competed in 170 games, resulting in a total of 7147 athlete-exposures (AEs). A total of 140 injuries were recorded during the tournament for an injury rate of 19.6 per 1000 AEs (95% CI, 16.4-22.7). Overall, there were more contact injuries (n = 99; 70.7%) than noncontact injuries (n = 41; 29.3%) (P < .0001). Contact injuries most commonly affected the upper extremity, while noncontact injuries most commonly affected the lower extremity. Contusions were the most commonly reported injury type in the tournament (n = 41; 29.3%), followed by ligament sprains (n = 32; 22.9%) and muscle strains (n = 21; 15.0%). Although there was no difference between the first and second half of gameplay, the injury rate increased in the latter portion of each half (the first and third quarters vs the second and fourth quarters) (P < .0001). A total of 4 injuries required trips to the hospital. CONCLUSION: Lacrosse has a unique injury profile, as it includes both overhead and collision activity as well as multidirectional, cutting movements. Understanding common injury patterns may help with treatment and prevention. Fatigue may play a role in injury rate, and future research of within-game and within-tournament fatigue should explore this relationship.

Sports Medicine Considerations During the COVID-19 Pandemic.

The outbreak of the novel coronavirus (COVID-19) has resulted in upward of 14 million confirmed cases and >597,000 deaths worldwide as of July 19, 2020. The current disruption in sports activities caused by COVID-19 presents a challenge to physicians, coaches, and trainers in discerning best practices for a safe return to sport. There is a distinct need to develop and adopt consistent measures for resumption of sports activities, including training and competition, in a way that places the health and well-being of athletes at the forefront while also protecting coaches, allied staff, and spectators. This article provides an overview of the effects of COVID-19 in the athletic population and presents considerations for training during the pandemic, as well as guidelines for return to sports as restrictions are lifted.

Female Residents Give Themselves Lower Scores Than Male Colleagues and Faculty Evaluators on ACGME Milestones.

OBJECTIVE: Orthopedic surgery is one of the specialties with the lowest number of women residents and practicing surgeons. The gender discrepancy in orthopedic residency training may drive a competency bias. We asked whether female orthopedic surgery residents score themselves lower on the Accreditation Council for Graduate Medical Education (ACGME) Milestones than their male counterparts, and lower than their faculty evaluators. DESIGN: We conducted a retrospective review of ACGME Milestone data from faculty and residents over a 4-year period. The data were analyzed using a snapshot of PGY2 (n = 20 residents) and PGY4 (n = 19 residents) scores, and using a Generalized Estimation Equation (GEE) to account for additional data points from the same residents over the 4-year data collection period. SETTING: Assessment scores were compiled from a single orthopedic surgery residency at Oregon Health & Science University from 2014 to 2017. PARTICIPANTS: The residency program has 5 residents in each program year (PGY1 through PGY5); a total of 25 residents during each year of the study were included. RESULTS: On average, female residents scored themselves lower than both their male counterparts and their faculty mentors. Female PGY2 self-evaluation scores were lower than males in both patient care (p = 0.005) and medical knowledge (p < 0.001). When the GEE model was applied to 99 responses from 41 residents over a 4-year period, there were no gender-related differences in resident self-evaluation scores and in faculty scores of male and female residents, with the exception of meniscal tear. For this milestone, faculty rated female residents lower than males. Furthermore, the differences between faculty evaluation scores and resident self-evaluation scores were significantly lower for males than for females for 4 of the clinical domains, as well as the systems-based practice domains of cost and communication. CONCLUSIONS: Our results indicate female residents are at risk for a competency bias during training, as reflected by evaluations using the ACGME Milestones.

Surgical treatment of distal biceps rupture.

Rupture of the distal biceps tendon accounts for 10% of all biceps brachii ruptures. Injuries typically occur in the dominant elbow of men aged 40 to 49 years during eccentric contraction of the biceps. Degenerative changes, decreased vascularity, and tendon impingement may precede rupture. Although nonsurgical management is an option, healthy, active persons with distal biceps tendon ruptures benefit from early surgical repair, gaining improved strength in forearm supination and, to a lesser degree, elbow flexion. Biomechanical studies have tested the strength and displacement of various repairs; the suspensory cortical button technique exhibits maximum peak load to failure in vitro, and suture anchor and interosseous screw techniques yield the least displacement. Surgical complications include sensory and motor neurapraxia, infection, and heterotopic ossification. Current trends in postoperative rehabilitation include an early return to motion and to activities of daily living.

Considerations for Return to Exercise Following Mild-to-Moderate COVID-19 in the Recreational Athlete.

The COVID-19 pandemic has resulted in significant morbidity and mortality around the world. The spectrum of COVID-19 is broad, from clinical disease requiring intensive medical care to less severe symptoms that are treated with supportive care. The majority of COVID-19 cases fall into the mild-to-moderate category, with symptoms lasting less than 6 weeks. Nevertheless, the morbidity from COVID-19 is significant and can affect multiple body systems, most frequently the cardiac, pulmonary, hematologic, musculoskeletal, and gastrointestinal systems. For patients who wish to return to exercise after mild-to-moderate COVID-19, the wide range of disease expression presents a challenge for clinicians seeking to offer counsel. This literature review on return to activity following mild to moderate COVID-19 in the recreational athlete includes evidence-based considerations and recommendations for clinicians in guiding the safest return to activity.

Musculoskeletal Effects of Antineoplastic Agents.

Cancer remains a common disease with approximately 40% of Americans diagnosed with cancer in their lifetime. Medical advances in the field of oncology have led to an increased life expectancy and a decreased mortality rate. Antineoplastic agents such as taxanes and targeted therapies are indicated in the treatment of many cancers, and their use can be associated with various musculoskeletal complaints and adverse effects. Orthopaedic Surgeons are trained to identify primary bone tumors and metastasis to bones. It is also important for them to have an understanding of the profile of musculoskeletal adverse effects associated with the treatment of the more common neoplasms. This article reviews the current literature on the commonly used chemotherapeutic agents and their associated musculoskeletal effects.

Popliteal Artery Entrapment Syndrome: Bilateral Lower Extremity Involvement.

Popliteal artery entrapment syndrome is a condition in which compression of the popliteal neurovascular structures results in symptoms of lower extremity claudication by way of a constricting anatomic structure or a hypertrophied surrounding musculature. This diagnosis is often missed or misdiagnosed because popliteal artery entrapment syndrome has a presentation similar to that of exertional compartment syndrome. Popliteal artery entrapment syndrome may result in persistent disability or unnecessary morbidity or prevent athletes' return to sport. A female collegiate athlete presented with bilateral popliteal artery entrapment syndrome. She had successful surgical treatment and returned to a high level of sport. This article describes popliteal artery entrapment syndrome, emphasizes the importance of a thorough history and physical examination to elucidate the diagnosis, and provides information that may lead to the identification of individuals who will benefit from surgical intervention. [Orthopedics. 2018; 41(2):e295-e298.].

Arthrofibrosis of the knee.

Better understanding of surgical timing, improved surgical technique, and advanced rehabilitation protocols has led to decreased incidence of motion loss after anterior cruciate ligament injury and reconstruction. However, motion loss from high-energy, multiligament injuries continues to compromise functional outcome. Prevention, consisting of control of inflammation and early motion, remains the key element in avoiding motion loss. However, certain techniques, such as manipulation under anesthesia in conjunction with arthroscopic lysis of adhesions, are reliable treatment options. Open surgical débridement is rarely necessary and should be considered only as a salvage procedure. A greater understanding of the pathogenesis of arthrofibrosis and related inflammatory mediators may result in novel therapies for treating the patient with motion loss.

The effect of ankle position on the static tension in the Achilles tendon before and after operative repair: a biomechanical cadaver study.

BACKGROUND: We hypothesized that there no need to position the foot in plantarflexion after operative repair of an Achilles tendon rupture. METHODS: In five fresh cadaver lower extremity specimens, the static tension in the Achilles tendon was measured as the ankle was sequentially dorsiflexed from 30, to 20, to 10, to 0 degrees of plantarflexion. The tendon was then transected and repaired using a modified Krakow locking loop suture technique. The tension in the tendon was again measured as the foot was sequentially dorsiflexed through the same range of motion: 30, to 20, to 10, to 0 degrees. The repair was then tensile tested to failure. RESULTS: The intact Achilles tendons generated on average 10 N, 10 N, 15.8 N and 31.9.0 N of tension at 30, 20, 10, and 0 degrees of plantarflexion, respectively. After a modified Krakow locking loop repair, the tension across the repair site was 10 N, 11.46 N, 18.4 N, and 30.3 N at 30, 20, 10, and 0 degrees of plantarflexion. Thus, moving the ankle from 30 degrees to neutral placed an additional force of 21.9 N on the intact tendon and 20.3 N on the repaired tendon. The mean tensile strength of the modified Krakow repair was 598.6 N (range 167 1129 N). CONCLUSIONS: The tension in the repaired tendon at neutral position is only a small percentage (6.4%) of the strength of the tendon when operatively repaired by a modified Krakow locking loop suture technique. CLINICAL RELEVANCE: Our results suggest that the ankle joint does not have to be positioned in plantarflexion after operative repair using the described technique.

Partial-thickness rotator cuff tears.

Partial-thickness rotator cuff tears are not a single entity; rather, they represent a spectrum of disease states. Although often asymptomatic, they can be significantly disabling. Overhead throwing athletes with partial-thickness rotator cuff tears differ with respect to etiology, goals, and treatment from older, nonathlete patients with degenerative tears. Pathogenesis of degenerative partial-thickness tears is multifactorial, with evidence of intrinsic and extrinsic factors playing key roles. Diagnosis of partial-thickness rotator cuff tears should be based on the patient's symptoms together with magnetic resonance imaging studies. Conservative treatment is successful in most patients. Surgery generally is considered for patients with symptoms of sufficient duration and intensity. The role of acromioplasty has not been clearly delineated, but it should be considered when there is evidence of extrinsic causation for the partial-thickness rotator cuff tear.

Shoulder Injuries in Men's Collegiate Lacrosse, 2004-2009.

BACKGROUND: Men's lacrosse has been one of the fastest growing team sports in the United States, at both the collegiate and high school levels. Uniquely, it combines both continuous overhead and contact activity. Thus, an understanding of its injury epidemiology and mechanisms is vital. Shoulder injuries have been shown to be common in the sport, but thus far there has been no dedicated analysis of these injuries with which to better inform injury prevention strategies. STUDY DESIGN: Descriptive epidemiology study. METHODS: All athlete exposures (AEs) and shoulder injuries reported to the National Collegiate Athletic Association (NCAA) Injury Surveillance System for intercollegiate men's lacrosse athletes from 2004-2005 through 2008-2009 were collected. Type of injury was documented and the injury incidence per 1000 AEs was calculated. Event type, injury mechanism, specific injury, outcome, and time lost were recorded. Statistical analysis was performed using 95% CIs, calculated based on a normal approximation to Poisson distribution. RESULTS: There were a total of 124 observed shoulder injuries during 229,591 monitored AEs. With weights, this estimates 1707 shoulder injuries over 2,873,973 AEs, for an incidence of 0.59 per 1000 AEs (95% CI, 0.56-0.62). The incidence of shoulder injury during competition was 1.89 per 1000 AEs (95% CI, 1.76-2.02), compared with 0.35 per 1000 AEs (95% CI, 0.33-0.38) during practice. Acromioclavicular joint injuries were most common (0.29 per 1000 AEs; 95% CI, 0.27-0.31). Labral injuries and instability events were also frequent (0.11 per 1000 AEs; 95% CI, 0.10-0.13). Player-to-player contact caused 57% of all shoulder injuries, with 25% due to contact with the playing surface. The average time lost was 11.0 days, with 41.9% of all shoulder injuries requiring ≥10 days. Clavicle fractures and posterior shoulder dislocation were particularly severe, with no athletes returning to play during the same season. CONCLUSION: Shoulder injuries are common in NCAA men's lacrosse and are an important source of lost playing time. Acromioclavicular injuries were the most frequent injury in this series, but labral and instability injuries were also common. In this increasingly popular contact sport, an understanding of the epidemiology and mechanism of shoulder injuries may be used to improve protective equipment and develop injury prevention.