Patient and Physician Satisfaction with Telehealth During the COVID-19 Pandemic: Sports Medicine Perspective
Decreased Injury Rate Following Mandated Headgear Use in Women's Lacrosse
INTRODUCTION:There has been controversy regarding whether headgear use in women's lacrosse will affect the rate of head and musculoskeletal injuries. The purpose of this study was to investigate the effect of mandated headgear use on the rate of head and musculoskeletal injuries in high school women's lacrosse. METHODS:This was a prospective cohort study of eight high school women's lacrosse teams and their game op-ponents who were mandated to wear F3137 headgear for the 2017 and 2018 seasons. Athletic trainers documented all injuries that occurred as a result of participation on the lacrosse teams. Injury rates in the headgear cohort were compared to a retrospective (control) cohort from the High School Reporting Information Online injury data reports. RESULTS:Over the study period, 17 total injuries were reported in the headgear cohort during 22,397 exposures for an injury rate of 0.76 injuries per 1,000 athlete-exposures. The headgear cohort demonstrated significant decreases in rates of in-game head and face injury (RR 0.141, 95% CI [0.004, 0.798]), in-game concussion (RR 0.152, 95% CI [0.004, 0.860]), and practice trunk and extremity injury (RR 0.239, 95% CI [0.049, 0.703]) when compared to the control cohort. CONCLUSION:Mandated use of headgear was shown to be effective at lowering the rate of head or face injury and concussions in women's lacrosse. Additionally, mandated headgear use was also shown to lower the rate of injury to body locations other than the head or face during practice. To our knowledge, this is the first study to demonstrate a decrease in injury rates associated with ASTM approved headgear in women's lacrosse.
Unexpected Hurdle in the Race: Hypophosphatasia Unmasked by the Female Athlete Triad
Hypophosphatasia should be considered for any patient who presents with multiple metatarsal stress fractures and a low alkaline phosphatase.
The effectiveness of mandated headgear use in high school women's lacrosse at reducing the rate of head and face injuries [Meeting Abstract]
Objectives: There has been continued controversy regarding whether or not headgear use in women's lacrosse will increase or decrease the rate of head injuries. In 2017, the Public Schools Athletic of New York City became the first high school organization in the country to mandate ASTM standard F3137 headgear for all women's lacrosse players. The purpose of this study is to investigate the effect of mandated headgear use on the rate of head and face injuries in high school women's lacrosse.
Method(s): This was a prospective cohort study. The study group included eight varsity and junior varsity women's lacrosse teams, as well as their game opponents, who were mandated to wear F3137 headgear for all practice and game events over the course of the 2017 and 2018 seasons. Certified athletic trainers assessed and documented all injuries that occurred as a result of participation on the lacrosse teams and athlete exposures were estimated based on the number of team practice and game events. Injury rates were compared with those from the High School RIO (Reporting Information Online) injury data reports from the 2009 to 2016 seasons.
Result(s): Over the study period, 17 total injuries were reported during 22,397 exposures for an injury rate of 0.76 injuries per 1,000 athlete-exposures. Two head/face injuries, both of which were classified as concussions, were reported during the study for a head/face injury rate and concussion rate of 0.09 per 1,000 athlete-exposures. The headgear cohort demonstrated significant decreases in rates of in-game head/face injury (RR 0.141, 95% CI [0.004, 0.798]), in-game concussion (RR 0.152, 95% CI [0.004, 0.860) and practice non-head/face injury (RR 0.239, 95% CI [0.049, 0.703]) when compared to the control cohort.
Conclusion(s): Mandated use of F3137 headgear was shown to be effective at lowering the rate of head or face injury and concussions in women's lacrosse. Additionally, mandated headgear use was also shown to lower the rate of injury to body locations other than the head or face during practice
MULES on the sidelines: A vision-based assessment tool for sports-related concussion
OBJECTIVE:The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation. Measures of rapid automatic naming (RAN) have been used for over 50â€¯years to capture aspects of vision and cognition. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. We examined MULES performance in youth, collegiate and professional athletes at pre-season baseline and at the sidelines following concussion. METHODS:Our study teams administered the MULES to youth, collegiate and professional athletes during pre-season baseline testing. Sideline post-concussion time scores were compared to pre-season baseline scores among athletes with concussion to determine degrees and directions of change. RESULTS:Among 681 athletes (age 17â€¯Â±â€¯4â€¯years, range 6-37, 38% female), average test times at baseline were 41.2â€¯Â±â€¯11.2â€¯s. The group included 280 youth, 357 collegiate and 44 professional athletes; the most common sports were ice hockey (23%), soccer (17%) and football (11%). Age was a predictor of MULES test times, with longer times noted for younger participants (Pâ€¯<â€¯.001, linear regression). Consistent with other timed performance measures, significant learning effects were noted for the MULES during baseline testing with trial 1 test times (mean 49.2â€¯Â±â€¯13.1â€¯s) exceeding those for trial 2 (mean 41.3â€¯Â±â€¯11.2â€¯s, Pâ€¯<â€¯.0001, paired t-test). Among 17 athletes with concussion during the sports seasons captured to date (age 18â€¯Â±â€¯3â€¯years), all showed increases (worsening) of MULES time scores from pre-season baseline (median increase 11.2â€¯s, range 0.6-164.2, Pâ€¯=â€¯.0003, Wilcoxon signed-rank test). The Symptom Severity Score from the SCAT5 Symptom Evaluation likewise worsened from pre-season baseline following injury among participants with concussion (Pâ€¯=â€¯.002). CONCLUSIONS:Concussed athletes demonstrate worsening performance on the MULES test compared to their baseline time scores. This test samples a wide network of brain pathways and complements other vision-based measures for sideline concussion assessment. The MULES test demonstrates capacity to identify athletes with sports-related concussion.
Chronic bilateral, lateral calf pain [Meeting Abstract]
History: A 40 year old male presents for evaluation of bilateral calf pain, left worse than right. The pain has been ongoing for one year and is localized to the lateral calf. He denies trauma or acute injury. The pain is worse with activity and is relieved by rest. For activity, he does daily walking and heavy lifting. He also often feels pain after prolonged standing. The pain does not improve with acetaminophen/ibuprofen. He denies swelling, numbness, tingling or weakness of the legs. He has been to several physicians for this pain and his work-up so far includes negative DVT and exertional ABI studies. He has been out of work for the past month due to a recent appendectomy, with a relative improvement in pain during this time. He recalls he broke his right leg when he was 13 while horse-back riding, after the horse fell on him. Physical Exam: Bilateral Lower Extremity: No redness, swelling or bruising. No knee effusion. No medial or lateral joint line tenderness. (1) TTP left lateral gastrocnemius (1) TTP over left fibular head. No tenderness along the right gastrocnemius or fibular head. Knees/ankles with FROM without pain. Negative varus/valgus stress test. Negative Lachman's, posterior drawer, McMurray. 5/5 knee and ankle strength. No pain with resisted strength testing of knee or ankle. Neutral standing alignment. Low medial longitudinal arches. Walking without a limp. (1) hop reproduces pain on left. Neuro: sensation intact to light touch, 2/4 patellar and Achilles reflexes. Skin: 21 peripheral pulses, cr < 2 seconds, no edema. Differential Diagnosis: Gastrocnemius Strain Popliteus Tendinopathy Chronic Exertional Compartment Syndrome - Lateral Common Peroneal Neuropathy Fibular Stress Reaction Test Results: XR Left Knee: No acute fracture or dislocation; MRI Tibia/Fibula: Transversely oriented incomplete stress type fracture within the left fibular head with surrounding bone marrow edema. Healed fracture deformity of the right mid/distal tibial diaphysis. Mild deformity of the right proximal fibular diaphysis which may reflect a healed fracture deformity. DXA Scan (T-score): Spine 22.3, L Femoral Neck 22.7, R Femoral Neck 22.6; Ca: 9.9 ICal: 1.40 PTH: 36 Vit D 25-OH: 50.6 Vit D 1,25-OH: 25 BMP wnl. Final Diagnosis: Incomplete Left Fibular Head Stress Fracture. Healed Right Proximal Fibular Fracture. Osteoporosis. Vitamin D Insufficiency.
Discussion(s): Most fibular stress fractures occur in the distal 1/3 of the fibula. Proximal fibular stress fractures are uncommon, making this an unusual case. In a 2009 study in Clinics in Orthopedics Surgery, 10 proximal fibular stress fractures were identified in 635 military recruits undergoing 6 weeks of training with repetitive walking/jumping in a squatting position. Our patient did not have this type of biomechanical stress. His medical history was reviewed and no risk factors for osteoporosis were identified other than poor diet. It is difficult to determine whether his healed right proximal fibular fracture occurred during his injury at age 13 or whether it was a subsequent stress fracture.
Outcome(s): He was started on calcium and vitamin D. Physical therapy and insoles were recommended to help correct bio-mechanical forces contributing to his injury. He was unwilling to be non-weight bearing. He took additional weeks off from work with reported improvement in pain. He underwent rheumatology and endocrine consultations for osteoporosis. Further lab testing was sent which was unremarkable. Follow-up: Given the improvement in his pain with relative rest, he has returned to work which requires prolonged standing and walking. He continues to avoiding heavy lifting and impact activities. He has follow-up scheduled with rheumatology for a denosumab injection to treat his osteoporosis. He is scheduled to follow-up with us in 6 weeks. He has not yet started a course of physical therapy
MULES on the Sidelines: A Vision-Based Assessment Tool for Sports-Related Concussion [Meeting Abstract]
Orthobiologics A Comprehensive Review of the Current Evidence and Use in Orthopedic Subspecialties
Orthobiologics are organic and synthetic materials that are used in and outside of the operating room to augment both bone and soft tissue healing. The orthobiologics portfolio has vastly expanded over the years, and it has become imperative for orthopedic surgeons to understand the role and function of this new class of biologic adjuvants. This review will highlight key components and product groups that may be relevant for the practicing orthopedic surgeon in any subspecialty. This by no means is an extensive list of the available products but provides an important overview of the most highlighted products available in the market today. Those discussed include, bone void fillers, extracelluar matrix (ECM) products, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). These are further categorized into their uses in several subspecialties including, traumatology, sports medicine, sports surgery, and spine surgery.
The new Mobile Universal Lexicon Evaluation System (MULES): A test of rapid picture naming for concussion sized for the sidelines
OBJECTIVE:Measures of rapid automatized naming (RAN) have been used for over 50â€¯years to capture vision-based aspects of cognition. The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation for detection of concussion and other neurological disorders. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. Recent changes to the MULES test have been made to improve ease of use on the athletic sidelines. Originally an 11â€¯Ã—â€¯17-inch single-sided paper, the test has been reduced to a laminated 8.5â€¯Ã—â€¯11-inch double-sided version. We identified performance changes associated with transition to the new, MULES, now sized for the sidelines, and examined MULES on the sideline for sports-related concussion. METHODS:We administered the new laminated MULES to a group of adult office volunteers as well as youth and collegiate athletes during pre-season baseline testing. Athletes with concussion underwent sideline testing after injury. Time scores for the new laminated MULES were compared to those for the larger version (big MULES). RESULTS:Among 501 athletes and office volunteers (age 16â€¯Â±â€¯7â€¯years, range 6-59, 29% female), average test times at baseline were 44.4â€¯Â±â€¯14.4â€¯s for the new laminated MULES (nâ€¯=â€¯196) and 46.5â€¯Â±â€¯16.3â€¯s for big MULES (nâ€¯=â€¯248). Both versions were completed by 57 participants, with excellent agreement (pâ€¯<â€¯0.001, linear regression, accounting for age). Age was a predictor of test times for both MULES versions, with longer times noted for younger participants (pâ€¯<â€¯0.001). Among 6 athletes with concussion thus far during the fall sports season (median age 15â€¯years, range 11-21) all showed worsening of MULES scores from pre-season baseline (median 4.0â€¯s, range 2.1-16.4). CONCLUSION/CONCLUSIONS:The MULES test has been converted to an 11â€¯Ã—â€¯8.5-inch laminated version, with excellent agreement between versions across age groups. Feasibly administered at pre-season and in an office setting, the MULES test shows preliminary evidence of capacity to identify athletes with sports-related concussion.
Rapid sideline performance meets outpatient clinic: Results from a multidisciplinary concussion center registry
OBJECTIVE: This study investigated the utility of sideline concussion tests, including components of the Sports Concussion Assessment Tool, 3rd Edition (SCAT3) and the King-Devick (K-D), a vision-based test of rapid number naming, in an outpatient, multidisciplinary concussion center treating patients with both sports-related and non-sports related concussions. The ability of these tests to predict clinical outcomes based on the scores at the initial visit was evaluated. METHODS: Scores for components of the SCAT3 and the K-D were fit into regression models accounting for age, gender, and sport/non-sport etiology in order to predict clinical outcome measures including total number of visits to the concussion center, whether the patient reached a SCAT3 symptom severity score=7, and the total types of referrals each patient received over their course. Patient characteristics, differences between those with sport and non-sport etiologies, and correlations between the tests were also analyzed. RESULTS: Among 426 patients with concussion, SCAT3 total symptom score and symptom severity score at the initial visit predicted each of the clinical outcome variables. K-D score at the initial visit predicted the total number of visits and the total number of referrals. Those with sports-related concussions were younger, had less severely-affected test scores, had fewer visits and types of referrals, and were more likely to have clinical resolution of their concussion and to reach a symptom severity score=7. CONCLUSIONS: This large-scale study of concussion patients supports the use of sideline concussion tests as part of outpatient concussion assessment, especially the total symptom and symptom severity score portions of the SCAT3 and the K-D. Women in this cohort had higher total symptom and symptom severity scores compared to men. Our data also suggest that those with non-sports-related concussions have longer lasting symptoms than those with sports-related concussions, and that these two groups should perhaps be regarded separately when assessing outcomes and needs in a multidisciplinary setting.