Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement

After an anterior cruciate ligament (ACL) injury, people need secondary prevention strategies to identify osteoarthritis at its earliest stages so that interventions can be implemented to halt or slow the progression toward its long-term burden. The Osteoarthritis Action Alliance formed an interdisciplinary Secondary Prevention Task Group to develop a consensus on recommendations to provide clinicians with secondary prevention strategies that are intended to reduce the risk of osteoarthritis after a person has an ACL injury. The group achieved consensus on 15 out of 16 recommendations that address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models. We hope this statement raises awareness among clinicians and researchers on the importance of taking steps to mitigate the risk of osteoarthritis after an ACL injury.

Evidence Review for Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement

CONTEXT

The Osteoarthritis Action Alliance formed a secondary prevention task group to develop a consensus on secondary prevention recommendations to reduce the risk of osteoarthritis after a knee injury.

OBJECTIVE

Our goal was to provide clinicians with secondary prevention recommendations that are intended to reduce the risk of osteoarthritis after a person has sustained an anterior cruciate ligament injury. Specifically, this manuscript describes our methods, literature reviews, and dissenting opinions to elaborate on the rationale for our recommendations and to identify critical gaps.

DESIGN

Consensus process.

SETTING

Virtual video conference calls and online voting.

PATIENTS OR OTHER PARTICIPANTS

The Secondary Prevention Task Group consisted of 29 members from various clinical backgrounds.

MAIN OUTCOME MEASURE(S)

The group initially convened online in August 2020 to discuss the target population, goals, and key topics. After a second call, the task group divided into 9 subgroups to draft the recommendations and supportive text for crucial content areas. Twenty-one members completed 2 rounds of voting and revising the recommendations and supportive text between February and April 2021. A virtual meeting was held to review the wording of the recommendations and obtain final votes. We defined consensus as >80% of voting members supporting a proposed recommendation.

RESULTS

The group achieved consensus on 15 of 16 recommendations. The recommendations address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models.

CONCLUSIONS

This consensus statement reflects information synthesized from an interdisciplinary group of experts based on the best available evidence from the literature or personal experience. We hope this document raises awareness among clinicians and researchers to take steps to mitigate the risk of osteoarthritis after an anterior cruciate ligament injury.

Therapeutic Potential for Cannabinoids in Sports Medicine: Current Literature Review

ABSTRACT

Cannabidiol and other cannabinoids are being used more frequently for sports medicine-related conditions. This review will help sports medicine clinicians answer questions that their athletes and active patients have about the potential effectiveness of cannabinoids on common sports medicine conditions. In the article, the authors compare cannabidiol and delta-9-tetrahydrocannabinol effects, noting the difference on the endocannabinoid and nonendocannabinoid receptors. The theoretical benefits of these two compounds and the current legality in the United States surrounding cannabidiol and delta-9-tetrahydrocannabinol use also are addressed.

Do Normative Composite Scores on the Functional Movement Screen Differ Across High School, Collegiate, and Professional Athletes? A Critical Review

OBJECTIVE

The Functional Movement Screen (FMS) is a battery of 7 unloaded tests designed to rate human movement competency. Injury rates vary across the different level of a sport. The purpose of this critical review was to determine whether normative FMS composite scores differ across high school, collegiate, and professional athletic populations and to determine whether normative composite scores correlate with rates of severe injury across different collegiate sports.

DATA SOURCES

PubMed, Web of Science, and EBSCO databases from inception to September 2017 with the following syntax: "functional movement screen*" OR "movement screen*". Additional records were identified by citation tracking and hand search of articles.

STUDY SELECTION

A total of 708 records identified, of which 36 were included. Studies were included if they reported a FMS composite score for one of the groups.

DATA EXTRACTION

Two reviewers (T.R.P. and F.K.) screened records for the author and year; sample size; study design; sport(s); number, age, and sex of participants; testing conditions; methodological quality; and mean or median composite score(s).

DATA SYNTHESIS

Normative FMS composite scores were invariant to level of play, with 61% of reported scores falling between 14 and 16, despite injury rates increasing by level of play. Scores for high school, college, and professional athletes were 14.1, 14.8, and 15.7, respectively. There was a significant positive relationship between composite scores and rate of severe injury in college sports (r(11) = 0.66, P = 0.014).

CONCLUSIONS

Our findings potentially undermine the FMS's predictive validity. Although the FMS may have other applications, this critical review provides further evidence against the composite score for injury prediction in competitive athletes.

The relationship between single-limb squat and jump-cut kinematics

No objective criteria exist for progressing athletes into cutting manoeuvres following ACL reconstruction (ACLR). The purpose of this study was to evaluate the relationship between a jump-cut task (JC) and the single-limb squat (SLS) in both ACLR and healthy controls. Case-control, laboratory based. Twenty-three participants with a history of ACLR (Age = 21 ± 3 years; Height = 174.5 ± 7.2 cm; Mass = 76.2 ± 9.9 kg) and 23 healthy controls participants (Age = 21 ± 3 years; Height = 173.8 ± 9.2 cm; Mass = 75.0 ± 10.5 kg) were included. Kinematics were collected bilaterally. Correlations between tasks were evaluated for kinematics. Independent sample t-tests were used to evaluate differences between groups for each dependent variable. Peak trunk rotation and medial knee displacement were strongly correlated (p < 0.001, r² = 0.63), between tasks. ACLR group performed SLS and JC tasks with less sagittal plane motion compared to healthy controls (p < 0.05). Lack of frontal and transverse plane control during SLS resulted in positions of increased lateral trunk flexion, hip adduction, and medial knee displacement during JC. The SLS may be considered for use as a clinical predictor of JC during rehabilitation following ACLR.

Sport Sampling Is Associated With Improved Landing Technique in Youth Athletes

Background:

Sport sampling is recommended to promote fundamental movement skill acquisition and physical activity. In contrast, sport specialization is associated with musculoskeletal injury risk, burnout, and attrition from sport. There is limited evidence to support the influence of sport sampling on neuromuscular control, which is associated with injury risk, in youth athletes.

Hypothesis:

Athletes who participated in only 1 sport during the previous year would demonstrate higher Landing Error Scoring System (LESS) scores than their counterparts.

Study Design:

Cross-sectional study.

Level of Evidence:

Level 3.

Methods:

A total of 355 youth athletes (age range, 8-14 years) completed a test session with a jump-landing task, which was evaluated using the LESS. Participants were categorized as single sport (SS) or multisport (MS) based on their self-reported sport participation in the past year. Their duration of sport sampling (low, moderate, high) was determined based on their sport participation history. Participants were dichotomized into good (LESS <5) or poor (LESS ≥5) categories. Chi-square tests were performed to evaluate for the association between control category (good, poor) and participation (MS, SS), as well as sport-sampling duration (low, moderate, high).

Results:

The MS group was 2.5 times (95% CI, 1.9-3.1) as likely to be categorized as having good control compared with the SS group (χ²₍₃₅₅₎ = 10.10, P < 0.01). Recreational participants in the “high” sport-sampling duration group were 5.8 times (95% CI, 3.1-8.5) and 5.4 times (95% CI, 4.0-6.8) as likely to be categorized as having good control compared with the moderate and low groups (χ²₍₂₁₆₎ = 11.20, P < 0.01).

Conclusion:

Sport sampling at a young age is associated with improved neuromuscular control, which may reduce injury risk in youth athletes.

Clinical Relevance:

Youth athletes should be encouraged to try participating in multiple sports to enhance their neuromuscular control and promote long-term physical activity.

Maturation and Sex Differences in Neuromuscular Characteristics of Youth Athletes

Understanding how neuromuscular factors that are associated with lower extremity injury risk, such as landing kinematics, muscle strength, and flexibility, change as children mature may enhance age-specific recommendations for injury prevention programs. The purpose of this study was to compare these factors in prepubertal, pubertal, and postpubertal male and female athletes. Subjects were classified on maturation stage (prepubertal: 16 males, 15 females, age: 9 ± 1 years; pubertal: 13 males, 12 females, age: 12 ± 3 years; postpubertal: 30 males, 27 females, age: 16 ± 2 years). Researchers measured lower extremity isometric muscle strength and flexibility and evaluated kinematics and vertical ground reaction forces (VGRFs) during a jump-landing task. Three-dimensional kinematics at initial contact (IC), joint displacements, and peak VGRF were calculated. Separate multivariate analyses of variance were performed to evaluate sex and maturation differences (α ≤ 0.05). Postpubertal females landed with less knee flexion at IC (p = 0.006) and demonstrated lower knee extension strength (p = 0.01) than prepubertal and pubertal females. Postpubertal males landed with less hip adduction displacement (postpubertal males = 12.53 ± 6.15°, prepubertal males = 18.84 ± 7.47°; p = 0.04) and less peak VGRF (postpubertal males = 1.53 ± 0.27% body weight [BW], prepubertal males = 1.99 ± 0.32% BW; p = 0.03) compared with prepubertal males. These findings suggest encouraging sagittal plane absorption and decreasing frontal plane motion at the hip, whereas maintaining quadriceps strength may be important for reducing injury risk in postpubertal athletes.

Basketball injuries: caring for a basketball team

Basketball is a popular sport in North America and worldwide. Most injuries are lower extremity injuries to the ankle and knee. In this article, injuries common to basketball and, from our experience, injuries that escape injury surveillance systems are discussed from the physician and athletic trainer's perspective. Both treatment and prevention of injuries are discussed.

A survey of state medical licensing boards: can the travelling team physician practice in your state?

This was a study that surveyed state medical licensing boards in the USA, to see if they have laws or exemptions for travelling team physicians to practice medicine on their own team, while travelling to that state. Surveys were sent to 58 medical boards, with legislative data being obtained for 54. Eighteen states (33%) allow team physicians travelling with their team to practice medicine with their home-state license. Thirty-six states (67%) do not have a legal pathway to allow the practice of medicine without a license: 27 (50%) do not allow the practice of medicine without a license from their state, 6 (11%) have an exemption for a 'consultant' to act in concert with a home-state physician (though this is not applicable to the team physician) and 3 (6%) do not have an exemption, but recognise that it happens without their involvement. A second survey was sent to 20 malpractice carriers, identified by an internet search to represent a diverse sample, to see if these companies offered policies that would cover the team physician, and if they also had licensure requirements. Of the 11 that responded, only 2 companies would provide coverage regardless of individual state licensing requirements, 5 companies would provide coverage to a provider who travels, but would require the provider to be licensed in any state they travel to and 4 companies would not provide coverage out of the home state, regardless of licensure. The American Medical Society for Sports Medicine is working on a Federal patch for this problem.

Timing of lower extremity frontal plane motion differs between female and male athletes during a landing task

BACKGROUND

Female athletes are at a greater risk for noncontact anterior cruciate ligament injuries than male athletes. Gender differences in frontal plane kinematics (hip adduction, knee valgus, and ankle eversion) and temporal relationships that make up the components of dynamic knee valgus may explain this discrepancy.

HYPOTHESIS

The authors hypothesized that women would reach peak frontal plane kinematic values earlier during landing compared with their male counterparts.

STUDY DESIGN

Controlled laboratory study.

METHODS

Hip, knee, and ankle 3-dimensional kinematics were measured using high-speed motion capture in 10 National Collegiate Athletic Association Division I female athletes and 10 male practice squad athletes during a drop-jump landing. Independent t tests were used to analyze each dependent variable to identify differences between genders.

RESULTS

Maximum hip adduction, knee valgus, and ankle eversion occurred earlier in women than in men (mean differences 33.7% of stance [95% CI, 20.2%-47.2%], 41.7% [95% CI, 31.5%-51.6%], 16.5% of stance [95% CI, 7.3%-25.6%], respectively). Maximum hip adduction and knee valgus occurred before maximum knee flexion in women and after in men (mean differences 0.11 seconds [95% CI, 0.05-0.18 seconds], 0.19 seconds [95% CI, 0.13-0.25 seconds], respectively). Maximum ankle eversion occurred earlier in women than in men (mean difference 0.06 seconds [95% CI, 0.01-0.11 seconds]). There was a significant difference between genders for angular velocity of knee valgus (mean difference = 25.53 deg/sec [95% CI, 8.30-42.77 deg/sec]).

CONCLUSION

Frontal plane kinematic temporal relationships at the hip, knee, and ankle differ between genders. The components of dynamic knee valgus peak during the deceleration phase in women and during the acceleration phase in men during a drop-jump landing. These data suggest that men and women employ a completely different kinematic landing/jumping strategy and that women land and collapse very rapidly into valgus compared with their male counterparts.

CLINICAL RELEVANCE

The differences in timing of the components of dynamic knee valgus between women and men may contribute to the increased risk of noncontact anterior cruciate ligament injuries in female athletes. There may be implications for neuromuscular reeducation training in those at risk for anterior cruciate ligament injury so the components of dynamic valgus occur later in the landing phase of jumping.

Epididymitis and orchitis: an overview

Epididymitis and orchitis are commonly seen in the outpatient setting. Men between 14 and 35 years of age are most often affected, and Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens in this age group. In other age groups, coliform bacteria are the primary pathogens. Men with epididymitis and orchitis typically present with a gradual onset of scrotal pain and symptoms of lower urinary tract infection, including fever. This presentation helps differentiate epididymitis and orchitis from testicular torsion, which is a surgical emergency. Typical physical findings include a swollen, tender epididymis or testis located in the normal anatomic position with an intact ipsilateral cremasteric reflex. Laboratory studies, including urethral Gram stain, urinalysis and culture, and polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae, help guide therapy. Initial outpatient therapy is empirical and targets the most common pathogens. When C. trachomatis and N. gonorrhoeae are suspected, ceftriaxone and doxycycline are recommended. When coliform bacteria are suspected, ofloxacin or levofloxacin is recommended.

Injuries in women's basketball

Women's basketball has changed over time. It is a faster paced game than it was 30 years ago. Greatplayers, like Anne Meyers,who was the first, and only, woman to be signed to an NBA contract, would agree today's game is different. The game is played mostly "below the rim" but with players like Candice Parker, Sylvia Fowles and Maya Moore able to dunk the ball, the game is still changing. The one thing that remains constant in basketball, especially women's basketball, is injury. The majority of injuries in women's basketball are similar to those in men's basketball. Studies at the high school and college level show similar injury rates between women and men. ACL injuries are one exception, with female athletes having atwo to four times higher rate ofACL injuries. In this article, we review the common injuries in women's basketball. We discuss treatment issues and possible preventive measures.

Knee valgus during drop jumps in National Collegiate Athletic Association Division I female athletes: the effect of a medial post

BACKGROUND

Female athletes land from a jump with greater knee valgus and ankle pronation/eversion. Excessive valgus and pronation have been linked to risk of anterior cruciate ligament injury. A medially posted orthosis decreases component motions of knee valgus such as foot pronation/eversion and tibial internal rotation.

HYPOTHESIS

We hypothesized a medial post would decrease knee valgus and ankle pronation/eversion during drop-jump landings in NCAA-I female athletes.

STUDY DESIGN

Controlled laboratory study.

METHODS

Knee and ankle 3-dimensional kinematics were measured using high-speed motion capture in 10 National Collegiate Athletic Association Division I female athletes during a drop-jump landing with and without a medial post. Analysis of variance was used to determine differences in posting condition, t tests were used to determine dominant-nondominant differences, and the Pearson correlation coefficient was used to determine relationships between variables.

RESULTS

Significant differences were found for all measures in the posted condition. A medial post decreased knee valgus at initial contact (1.24 degrees , P < .01) and maximum angle (1.21 degrees , P < .01). The post also decreased ankle pronation/eversion at initial contact (0.77 degrees , P < .01) and maximum angle (0.95 degrees , P = .039).

CONCLUSION

The authors have demonstrated a significant decrease in knee valgus and ankle pronation/eversion during a drop jump with a medial post placed in the athletes' shoes.

CLINICAL RELEVANCE

A medial post may be a potential means to decrease risk of anterior cruciate ligament injury.

Dupuytren's disease: diagnosis and treatment

Dupuytren's disease is a progressive condition that causes the fibrous tissue of the palmar fascia to shorten and thicken. The disease is common in men older than 40 years; in persons of Northern European descent; and in persons who smoke, use alcohol, or have diabetes. Patients present with a small, pitted nodule (or multiple nodules) on the palm, which slowly progresses to contracture of the fingers. The disease initially can be managed with observation and nonsurgical therapy. It will regress without treatment in approximately 10 percent of patients. Steroid injection into the nodule has been shown to reduce the need for surgery. Surgical referral should be made when metacarpophalangeal joint contracture reaches 30 degrees or when proximal interphalangeal joint contracture occurs at any degree. Timing of surgical intervention varies, but surgery is usually performed when the metacarpophalangeal joint contracture exceeds 40 degrees or when the proximal interphalangeal joint contracture exceeds 20 degrees. In-office percutaneous needle aponeurotomy is an alternative to surgery.

Exercise and colon cancer: primary and secondary prevention

Many studies have demonstrated the effects of exercise on both primary and secondary prevention of colon cancer. Exercise appears to have a dose-response reduction in the rate of colon cancer. The mechanism by which exercise provides this benefit is not known, but increase in insulin-like growth factor-binding protein and reduction of prostaglandins appear to be the likely cause. Once a person develops colon cancer the benefits of exercise appear to continue both by increasing quality of life and reducing cancer-specific and overall mortality.

Managing the athlete with type 1 diabetes

Type 1 diabetes is a chronic disease that can lead to many serious complications if not properly managed. The patient and physician must work together to optimize glucose control involving both insulin administration and caloric intake. Exercise has numerous benefits and the type 1 diabetic should take advantage of these benefits. Athletes with type 1 diabetes are capable of undertaking a wide array of exercise activities and there are no longer firm contraindications to certain sports for diabetic patients. This article will aid the sports physician in understanding the effects of exercise on diabetes, educating patients to exercise safely, advising when exercise is contraindicated, and providing guidelines for optimal management of the diabetic athlete.

The anterior cruciate ligament tear rate varies by race in professional Women's basketball

BACKGROUND

Female basketball players are more likely to tear their anterior cruciate ligament than are their male counterparts. Many causes are postulated for the difference observed in the rate of anterior cruciate ligament tears between genders. However, little is known about the differences in tears within gender.

HYPOTHESIS

The rate of anterior cruciate ligament tears is different in White European American female basketball players and non-White European American players.

STUDY DESIGN

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

METHODS

The authors investigated the differences in anterior cruciate ligament tears by risk exposure in women of different racial or ethnic backgrounds playing in the Women's National Basketball Association for the 1999 through 2003 seasons. Using the injury surveillance data from the Women's National Basketball Association, the authors compared anterior cruciate ligament injuries in White European American and non-White European American players to determine differences in the rate of anterior cruciate ligament tears between racial groups.

RESULTS

The anterior cruciate ligament tear rate for White European American players was 0.45 per 1000 athletic exposures, whereas for non-White European American players (black or African American, Hispanic, and Asian players) the rate was 0.07. The odds ratio of anterior cruciate ligament tears in White European American versus non-White European American players was 6.55 (95% confidence interval, 1.35-31.73).

CONCLUSION

Our retrospective study shows that the anterior cruciate ligament tear rate for White European American players was 0.45 per 1000 athletic exposures, whereas tear rates in the Women's National Basketball Association vary by racial group, with White European American players having more than 6 times the anterior cruciate ligament tear rate of other ethnic groups combined. Further prospective studies of athletes are needed to validate this finding and shed light on possible reasons.

Single leg balance test to identify risk of ankle sprains

BACKGROUND

Ankle sprains are a common and potentially disabling injury. Successful prediction of susceptibility to ankle sprain injury with a simple test could allow ankle sprain prevention protocols to be initiated and help prevent disability in the athletic population.

OBJECTIVE

To investigate the ability of the single leg balance (SLB) test, carried out at preseason physical examination, to predict an ankle sprain during the autumn sports season.

DESIGN

Prospective cohort study

SETTING

High school varsity athletics and intercollegiate athletics.

MAIN OUTCOME MEASURE

Ankle sprains in athletes with positive SLB tests.

RESULTS

The association between a positive SLB test and future ankle sprains was significant. Controlling for confounding variables, the relative risk for an ankle sprain with a positive SLB test was 2.54 (95% confidence interval, 1.02 to 6.03). Athletes with a positive SLB test who did not tape their ankles had an increased likelihood of developing ankle sprains. The relative risk for ankle sprain for a positive SLB test and negative taping was 8.82 (1.07 to 72.70). A history of previous ankle injury was not associated with future ankle sprains in this study. The kappa value for interrater reliability for the SLB test was 0.898 (p<0.001).

CONCLUSIONS

An association was demonstrated between a positive SLB test and ankle sprain. In athletes with a positive SLB test, not taping the ankle imposed an increased risk of sprain. The SLB test is a reliable and valid test for predicting ankle sprains.

Anterior and posterior cruciate ligament injuries

Knee pain is a common complaint in the primary care setting, and ACL and PCL injuries are common causes of knee pain. Therefore, it is important for the primary care physician to be skilled in the diagnosis and initial management of these injuries and to be aware of potential associated knee injuries. By understanding the history, mechanism of injury, physical examination maneuvers, and imaging modalities related to ACL and PCL injuries, primary care physicians can prepare themselves to make an accurate diagnosis. Then they can counsel the patients on the available treatments, initiate conservative treatment if appropriate, and facilitate an effective referral to a primary care sports medicine physician or orthopedic surgeon.

Ankle sprains expedient assessment and management

Most ankle injuries occur from excessive inversion, but it is important to be able to differentiate a simple inversion sprain from a potentially disabling injury. Expedient diagnosis includes first screening for deformities and then performing specific tests like the anterior drawer and side-to-side test. To optimize assessment, the examiner needs to take advantage of the preswelling period on the sidelines. Physicians can treat most ankle injuries nonoperatively, taking steps to ensure a quick return to play. Fracture signs and treatment are covered in a comprehensive table.