The Female Athlete: Evaluation and Treatment of Sports-Related Problems

Manipulation Under Anesthesia and/or Lysis of Adhesions After Anterior Cruciate Ligament Reconstruction in Female Basketball Players: Does Race Play a Role?

BACKGROUND

Arthrofibrosis can limit function and return to sport after anterior cruciate ligament (ACL) reconstruction. Previously reported risk factors for developing arthrofibrosis after ACL reconstruction include female sex, age <18 years, time from injury to surgery <28 days, concomitant meniscal repair, prolonged immobilization, and genetic factors. There is a lack of evidence regarding whether race plays a significant role.

HYPOTHESIS

The risk of undergoing manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) after primary ACL reconstruction with bone-patellar tendon-bone (BTB) autograft in female basketball players is higher in African American players than in White players.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Using a computerized relational database, the authors identified competitive female basketball players who underwent primary ACL reconstruction with BTB autograft by the senior author over a 13-year period. Data previously entered from examinations and surgical findings were reviewed retrospectively. Univariate statistics and multivariable logistic regression were used to assess the relationship between undergoing subsequent MUA and/or LOA and study predictors.

RESULTS

A total of 186 knees (114 African American knees and 72 White knees) met inclusion criteria. The overall rate of MUA and/or LOA was 8.6%. Thirteen African American knees (11.4%) and 3 White knees (4.2%) underwent MUA and/or LOA for treatment of arthrofibrosis. No study predictor was found to have a statistically significant relationship with the rate of MUA and/or LOA on univariate analysis. However, when controlling for body mass index and previously described risk factors (age <18 years, time from injury to surgery ≤28 days, and concomitant meniscal repair) in the logistic regression model, the authors found that MUA and/or LOA was more likely in African American (odds ratio, 4.01 [95% CI, 1.01-15.92]; P = .049) than in White female players and in patients who underwent ACL reconstruction within 28 days of injury (odds ratio, 4.01 [95% CI, 1.18-13.57]; P = .026) compared with those with surgery delayed beyond 28 days.

CONCLUSION

In female basketball players, the present study found a statistically significantly increased risk for undergoing MUA and/or LOA after primary ACL reconstruction with BTB autograft in African American females compared with White females and in patients who underwent ACL reconstruction within 28 days of injury.

Chitosan-sEPDM and Melatonin-Chitosan-sEPDM Composite Membranes for Melatonin Transport and Release

Melatonin is the hormone that focuses the attention of the researchers in the medical, pharmaceutical, materials, and membranes fields due to its multiple biomedical implications. The variety of techniques and methods for the controlled release of melatonin is linked to the multitude of applications, among which sports medicine occupies a special place. This paper presents the preparation and characterization of composite membranes based on chitosan (Chi) and sulfonated ethylene-propylene-diene terpolymer (sEPDM). The membranes were obtained by controlled vacuum evaporation from an 8% sEPDM solution in toluene (w/w), in which chitosan was dispersed in an ultrasonic field (sEPDM:Chi = 1:1, w/w). For the comparative evaluation of the membranes' performances, a melatonin-chitosan-sulfonated ethylene-propylene-diene terpolymer (Mel:Chi:sEPDM = 0.5:0.5:1.0, w/w/w) test membrane was made. The prepared membranes were morphologically and structurally characterized by scanning electron microscopy (SEM), Fourier transform infrared spectroscopy (FTIR), energy-dispersive spectroscopy analysis (EDAX), thermal analysis (TG, DSC), thermal analysis coupled with chromatography and infrared analysis, and contact angle measurements, but also from the point of view of performance in the process of transport and release of melatonin in dedicated environments (aqueous solutions with controlled pH and salinity). The prepared membranes can release melatonin in amounts between 0.4 mg/cm²·per day (sEPDM), 1.6 mg/ cm²·per day (Chi/sEPDM), and 1.25 mg/cm²·per day (Mel/Chi/SEPDM).

What is known from the existing literature about the available interventions for pelvic floor dysfunction among female athletes? A scoping review

Background

Aim

Methods

Results

Conclusions

EPIDEMIOLOGY OF ORTHOPEDIC INJURIES IN JIU-JITSU ATHLETES

OBJECTIVE

This study aims to identify the epidemiology of orthopedic injuries in jiu-jitsu practitioners.

METHODS

Ninety-six jiu-jitsu practitioners aged between 18 and 45 years, male and female, answered a questionnaire addressing personal data and history of injuries related to the sport during the last 24 months.

RESULTS

In the period cover, 85% of the sample presented injuries related to the practice of jiu-jitsu, with an average of 60 days of absenteeism from sports practice. Fingers, shoulders, and knees were the joints most affected by orthopedic injuries.

CONCLUSION

Orthopedic injuries are quite prevalent among jiu-jitsu practitioners, often distancing athletes from the sport. Level of Evidence IV, case series / cross sectional study.

Epidemiology of surgically managed anterior cruciate ligament ruptures in a sports surgery practice

INTRODUCTION

Anterior cruciate ligament (ACL) tears are common knee injuries, especially among sportsmen and sportswomen. The aim of this study is to better understand the epidemiology of surgically managed ACL tears sustained in our institution.

METHODS

All patients who underwent arthroscopic ACL reconstruction by the senior author of this article in Singapore from 2008 to 2013 were studied. Patients who were diagnosed clinically and/or radiologically to have a complete tear of the ACL and subsequently underwent arthroscopic ACL reconstruction were included. Patients who suffered from traumatic knee dislocation were excluded. Two hundred and ninety-two patients were available for analysis. All patients were operated on by the senior author.

RESULTS

83.9% of patients were male. 60.5, 23.0, 8.46, and 8.11% were of Chinese, Malay, Indian and other origins, respectively. 69.6 and 28.7% were in white-collared and blue-collared jobs, respectively, while 1.69% were unemployed. Mean age at operation was 29.4 years. Mean body mass index was 25.3 kg/m². 82.4 and 17.6% of ACL tears were sports (contact-27.5%; non-contact-72.5%) and non-sports injuries (activities of daily living-94.2%, road traffic accidents-5.77%), respectively. The top four sporting activities causing ACL tears were soccer, basketball, racquet games and volleyball. 56.2% of ACL tears presented with concomitant knee injuries (medial meniscus-63.4%; lateral meniscus-31.1%; posterior cruciate ligament-5.49%). 84.5% were primary tears.

CONCLUSIONS

In this epidemiological review of ACL injuries, we found that ACL injuries tend to cluster within certain population subgroups. Patterns of mechanisms of injuries have been observed. These findings may lead to better preventive and treatment strategies in the management of ACL tears.

Key components and potential benefits of a comprehensive approach to women's musculoskeletal health

Over the last 40 years there has been a significant increase in the number of female athletes, as well as a rise in musculoskeletal injuries observed in women. There is sufficient evidence from past medical research identifying various musculoskeletal injuries and conditions that more commonly affect women, such as osteoarthritis, osteoporosis, stress fractures, and anterior cruciate ligament tears. Several women's sports medicine and musculoskeletal health programs have been developed throughout the United States in an attempt to provide more tailored care to the female athlete. The goal of a comprehensive approach to women's musculoskeletal health is to create an interdisciplinary team to facilitate treatment for a variety of injuries and related conditions. This manuscript outlines the musculoskeletal conditions that commonly affect women and highlights the various etiologies of these sex disparities. We discuss the role of interdisciplinary women's musculoskeletal health and sports medicine programs, and define the potential benefits of such an approach. Future studies should focus on assessing the outcomes of multidisciplinary women's sports medicine programs as current literature in this area is lacking.

Nature and risk factors of injury hospitalization in young adults: A follow-up of 135,987 military conscripts

Aims: This study attempted to investigate the nature and risk factors of injury hospitalization among Finnish conscripts in 1998—2002. Methods: Altogether 135,987 military conscripts, including 2,044 (1.5%) women, were followed during their 6-to 12-month service in 1998—2002. Data on injury hospitalizations were obtained from the National Hospital Discharge Register. Outcome variables were injury hospitalization, multiple injury hospitalization, and hospitalization due to lower limb injury. Background variables consisted of conscripts' service and physical fitness data. Results: Injury hospitalization occurred among 6,059 (4.5%) conscripts, in 530 (0.4%) of them more than once. The total number of hospitalizations was 7,187, of which 50% were due to lower limb injuries. Most injuries (57%) were dislocations and sprains of joints and ligaments. The strongest risk factors for injury hospitalization in the multivariate logistic regression models were female sex (OR 2.3, 95% CI 1.9—2.7), and overweight (OR 1.4, 95% CI 1.2—1.7). These odds ratios increased when multiple injuries were investigated separately. Excellent aerobic fitness was a specific risk factor for lower limb injury (OR 1.3; 95% CI 1.1— 1.5). Conclusions: Women were markedly more likely than men to be hospitalized for injury. Moreover, overweight predicted an increased injury risk. Generalizable to the young adult population, the findings should be considered when identifying targets for injury prevention measures.

Common injuries in athletes' knee: experience of a specialized center

OBJECTIVE:

The present cross-sectional study aims to identify the most common knee injuries in athletes cared at a Specialized Outpatient Clinics.

METHOD:

Analysis of patients cared at the Knee Outpatient Clinics of a Sports Trauma Center, divided by gender, age and diagnosed injury.

RESULTS:

Initially 440 patients were divided into 33 types of sports; after excluding the less statistically significant practices, nine sports remained. The most frequently performed sports were football with almost 50% of total patients presenting anterior cruciate ligament (ACL) injury, and road runs with great frequency of meniscal injury. There was no correlation of the disorder with the type of sports performed but a correlation was found with patient's age/gender.

CONCLUSION:

The complete ACL rupture was the most common injury found in football, basketball and volleyball players, followed by meniscal injury in street runners.

Level of Evidence IV, Study Transversal.

Sports-related injuries in the young female athlete

The number of females participating in sports continues to increase. Adolescent and preadolescent females are at a risk injury to both their open growth plates as well as their joints. The purpose of this article is to review the common injuries seen with the most popular sports with females. Mt Sinai J Med 77:307-314, 2010. (c) 2010 Mount Sinai School of Medicine.

Patellofemoral instability in athletes: treatment via modified Fulkerson osteotomy and lateral release

BACKGROUND

Surgical treatment of patellofemoral instability can successfully diminish episodes of subluxation and dislocation, as well as symptoms of pain and instability.

HYPOTHESIS

Surgical treatment of lateral patellar instability in a strictly athletic population will facilitate return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From 1999 to 2004, 41 Fulkerson osteotomies combined with an arthroscopic lateral release were performed in 34 athletes for patellofemoral instability. Three patients were lost to follow-up. All patients participated in sports at least 3 times per week in at least one sport for 4 months of the year. There were 4 male and 30 female patients; 7 patients underwent bilateral, staged procedures. There were 14 high school, 12 collegiate, and 8 recreational athletes. Results were obtained by an independent examiner.

RESULTS

The mean age was 20.05 years (range, 14-54 years) with a mean follow-up of 46 months (range, 22-71 months). Patients averaged 1.3 dislocations before reconstruction (range, 0-6). The average Lysholm score was 91.8 (range, 67-100) at follow-up. The International Knee Documentation Committee (IKDC) scores were A (normal) in 27 knees, B (near normal) in 12, and C (abnormal) in 2. Seventeen patients had symptomatic hardware removed at an average of 8 months. There were 2 complications: one saphenous neuroma that resolved, and one recurrent dislocation in a patient later diagnosed with Ehlers-Danlos syndrome.

CONCLUSION

This series is the largest to date documenting the successful treatment of patellofemoral instability in athletes with concomitant Fulkerson osteotomy and arthroscopic lateral release. Forty-nine percent of patients in our series required removal of screws from the osteotomy site.

Risk factors for bone stress injuries: a follow-up study of 102,515 person-years

PURPOSE

The aim of the present study was to assess the risk factors for magnetic resonance imaging (MRI)-detected bone stress injuries in the pelvis, hip, thigh, and knee in a large cohort of Finnish conscripts during a follow-up of 102,515 person-years.

METHODS

An epidemiologic prospective cohort study of 152,095 conscripts, including 2345 (1.5%) females, was conducted. Localized pain in the pelvis, hip, thigh, or knee resulted in an orthopedic surgeon's consultation and subsequent MRI examination at the Central Military Hospital, Helsinki, Finland. Risk factors were systematically collected from 1998 to 2004, including data on conscripts' physical fitness and body composition measured at the beginning of their military service.

RESULTS

Altogether, 319 MRI-detected bone stress injuries of the pelvis, hip, thigh, or knee were identified in our cohort; thus, the incidence was 311 (95% CI: 277-345) per 100,000 person-years. The female:male ratio varied substantially, depending on the anatomic location of the injury; it was highest for sacral injuries (female:male ratio = 51.1) and lowest for injuries of the femoral condyle (female:male ratio = 0.8). In univariate Cox regression analysis, poor muscle strength and a poor result in a 12-min run were significantly associated with bone stress injuries. In multivariable analysis, the strongest risk factors for bone stress injuries were female gender (hazard ratio 8.2; 95% CI: 4.8-14.2) and higher age (hazard ratio 2.1; 95% CI: 1.4-3.1).

CONCLUSIONS

Female military trainees have a highly increased risk of bone stress injuries of the pelvis and hip compared with male conscripts. Sacral stress fractures are typical bone stress injuries in female military recruits. Physicians should remember the possibility of bone stress injury, especially when examining stress-related pain symptoms of the pelvic area in physically active young adult females.

Incidence of major tendon ruptures and anterior cruciate ligament tears in US Army soldiers

BACKGROUND

Although a rare event, the prevalence of major tendon rupture has increased in recent decades. Identification of risk factors is important for prevention purposes.

HYPOTHESIS

Race is a risk factor for major tendon ruptures.

STUDY DESIGN

Cohort study (prevalence); Level of evidence, 2.

METHODS

All patients admitted for surgical management of a rupture of a major tendon at Womack Army Medical Center, Fort Bragg, North Carolina, in 1995 and 1996 were identified and evaluated for risk factors.

RESULTS

The authors identified 52 major tendon ruptures: 29 Achilles, 12 patellar, 7 pectoralis major, and 4 quadriceps tendon ruptures. All patients were active-duty soldiers, and 1 was a female soldier. Forty-one tendon ruptures occurred among black soldiers, 8 occurred among white soldiers, and 3 occurred among Latino soldiers. The population at risk included 93,224 exposures during the 2-year period, of which 67.1% were white, 24.5% were black, and 8.4% were self-classified as other race. The rate ratio for tendon rupture, adjusted for gender and age, was 13.3 (95% confidence interval, 6.2-28.5) between blacks and whites and 2.9 (95% confidence interval, 0.8-10.9) between Latinos and whites.

CONCLUSION

The rate of major tendon rupture was 13 times greater for black men in this study population when compared with whites. Interventions among those at a higher risk for injury should be considered.

Spontaneous globe subluxation in a patient with hyperemesis gravidarum: a case report and review of the literature

Globe subluxation, or anterior dislocation of the eyeball, is rarely encountered by emergency physicians. We report a case of subluxation of the globe secondary to severe vomiting followed by a discussion of globe subluxation, potential causes, procedure for reduction, and treatment for recurrent episodes. Early treatment by emergency physicians may prevent long-term complications and limit patient discomfort and anxiety.

The effects of estrogen on material and mechanical properties of the intra- and extra-articular knee structures

BACKGROUND

Female athletes have a higher incidence of anterior cruciate ligament injuries than do male athletes in similar sports. Hormones, particularly estrogen, have been indicated by some studies to be correlated with the disproportionate number of anterior cruciate ligament injuries in female athletes.

HYPOTHESIS

Estrogen does not affect the mechanical or material properties of primate anterior cruciate ligaments or patellar tendons.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-six cynomolgus monkeys (Macaca fascicularis) were divided into 2 groups: sham operated (estrogen maintained, n = 12) and ovariectomized (estrogen deficient, n = 14). After 2 years, the animals were sacrificed, and various properties of ligaments were tested. Two different ligaments were studied, the anterior cruciate ligament and patellar tendon.

RESULTS

No differences were found between the sham-operated (sham) and ovariectomized group for failure load (anterior cruciate ligament: sham, 394 +/- 67 N; ovariectomized, 392 +/- 96 N; P > .74), stiffness, elongation at failure, ultimate stress (anterior cruciate ligament: sham, 115 +/- 30 MPa; ovariectomized, 128 +/- 36 MPa; P > .58), ultimate strain, modulus, failure sites, or energy to failure.

CONCLUSION

Endogenous estrogen does not directly affect the mechanical or material properties of the anterior cruciate ligament or the patellar tendon of cynomolgus macaques.

CLINICAL RELEVANCE

This study supports the idea that knee ligament injury in female athletes is not a direct result of estrogen's effect on ligament properties.

Comparison Between Custom and Noncustom Spinal Orthoses

Although economically priced OTS orthoses can and should be used under certain prescribed conditions to satisfy carefully described treatment objectives, they cannot control motion as well as custom-molded TLSOs. Patients should not pay for expensive products that cannot help to ensure the best possible clinical outcome. The custom-molded TLSO provides superior fit and support relative to its OTS relative and induces better compliance among its wearers because of its simplicity. It is also the most cost-effective option.

Stress fractures of the femoral shaft in women's college lacrosse: a report of seven cases and a review of the literature

BACKGROUND

Stress fractures do not often occur in the shaft of the femur. They are more common in the femoral neck, the tibial shaft, the metatarsals, and other bones of the foot. In female athletes, stress fractures classically afflict the distance runner, the ballerina, the gymnast, and the figure skater.

OBJECTIVES

To describe the clinical presentation, diagnosis, treatment, and outcome of seven college female lacrosse players with femoral shaft stress fractures, and review the literature.

RESULTS

The unusual results of this study support the principle that clinical suspicion should be high when treating any female athlete regardless of the sport. In this case series, an abrupt change in the quality of the running surface during the competitive training season was the only underlying common thread among the athletes.

CONCLUSION

The findings suggest that risk factors for the female athlete are variable and are no longer limited to the undernourished or overtrained.

Bone stress injuries causing exercise-induced knee pain

BACKGROUND

No comprehensive studies of bone stress injuries in the knee based on magnetic resonance imaging findings have been published.

PURPOSE

Assess the incidence, location, nature, and patterns of bone stress injuries in the knee in military conscripts with exercise-induced knee pain.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

During a period of 70 months, 1330 patients with exercise-induced knee pain underwent magnetic resonance imaging of the knee. A total of 1577 knees were imaged; the images with bone stress injury findings were retrospectively reevaluated with respect to location and type of injury. The person-based incidence of bone stress injuries in the knee was calculated, based on the number of conscripts within the hospital's catchment area.

RESULTS

Of the 1330 patients, 88 (7%) met the inclusion criteria, and 141 bone stress injuries were found in the 110 knees imaged. The incidence of bone stress injuries was 103 per 100 000 person-years. Of the patients, 25% had bilateral bone stress injuries; 28% had 2 solitary bone stress injuries in the same knee simultaneously, all situated in the femoral condyle and tibial plateau. The most common anatomical location for a bone stress injury was the medial tibial plateau (31%), which was also the most typical location for a more advanced injury. After the commencement of military service, a bone stress injury in the medial tibial plateau caused knee pain earlier than did a bone stress injury elsewhere in the knee (P = .014).

CONCLUSION

The incidence of bone stress injuries in the knee with exercise-induced knee pain is relatively high in conscripts. Multiple and bilateral injuries can occur. For accurate diagnosis and to ensure appropriate treatment, magnetic resonance imaging is recommended as a routine imaging method when a physical activity can be regularly associated with the onset of symptoms.

Fatigue injuries of the femur

The purpose of this study was to describe the anatomical distribution and incidence of fatigue injuries of the femur in physically-active young adults, based upon MRI studies. During a period of 70 months, 1857 patients with exercise-induced pain in the femur underwent MRI of the pelvis, hips, femora, and/or knees. Of these, 170 patients had a total of 185 fatigue injuries, giving an incidence of 199 per 100 000 person-years. Bilateral injuries occurred in 9% of patients. The three most common sites affected were the femoral neck (50%), the condylar area (24%) and the proximal shaft (18%). A fatigue reaction was seen in 57%, and a fracture line in 22%. There was a statistical correlation between the severity of the fatigue injury and the duration of pain (p = 0.001). The location of the pain was normally at the site of the fatigue injury. Fatigue injuries of the femur appear to be relatively common in physically-active patients.

The female athlete triad. A growing health concern

The number of female athletes participating at the high school, collegiate, and elite levels has increased nearly 10-fold since the passage of Title IX. President Nixon signed title IX into law in 1972. It required that all schools receiving federal funding provide equal opportunities for men and women. With this large increase in high-level female athletes comes a special set of medical and orthopaedic issues. One of the most important is the female athlete triad. The triad consists of disordered eating, amenorrhea, and premature osteoporosis. Currently, this problem is largely unrecognized. The purpose of this article is to help to educate orthopaedic nurses about this important issue so that we can detect the triad early and help address this growing national health issue.

Spondylolisthesis in the athlete

The diagnosis and appropriate management of spondylolysis and spondylolisthesis in the athlete can be challenging for the treating orthopaedic surgeon. With an increase in the number of skeletally immature athletes competing at more demanding levels of competition, an associated increase in the number of such cases may be seen. Management strategy is directed by the symptoms, the age of the patient, and the severity of the spondylolisthesis.

Effects of ovariectomy on intramuscular energy metabolism in young rats: how does sports-related-amenorrhea affect muscles of young female athletes?

The purpose of this study was to evaluate the effects of ovariectomy on intramuscular energy metabolism in young rats. Twenty-four Sprague-Dawley rats (7 weeks old) were used. Twelve of them underwent ovariectomy (OVX), and the others were sham-operated on. Seven OVX rats were examined 1-week after surgery (OVX-1 group), and the other five, 4 weeks after surgery (OVX-4 group). The gastrocnemius-plantaris-soleus (GPS) muscles group was subjected to the following measurements, and the data were compared with those of the sham group (Sham-1: n = 7, or Sham-4 group: n = 5). From the 31P-MR spectra of the GPS muscles group at rest and during electric stimulation, the muscular oxidative capacity was measured. Maximum tension and wet weight of the whole GPS muscles group were also measured. Body weight in the OVX-4 group was significantly (p < 0.01) larger than that in the Sham-4 group. The weights of the whole GPS muscles group in the Sham-1, Sham-4, OVX-1 and OVX-4 groups were 1.17, 1.51, 1.25 and 1.71 (g), respectively. The muscle weight in the OVX group tended to be greater than that in the Sham group (p < 0.10). The maximum tension and oxidative capacity did not differ significantly among the groups. These data indicated that in young rats, ovariectomy induced an increase in body and muscle weight, but did not affect the maximum tension nor oxidative capacity.