Ajay S. Padaki

High variability in outcome reporting patterns in high-impact ACL literature

BACKGROUND ACL (anterior cruciate ligament) reconstruction is one of the most commonly performed and studied procedures in modern sports medicine. A multitude of objective and subjective patient outcome measures exists; however, nonstandardized reporting patterns of these metrics may create challenges in objectively analyzing pooled results from different studies. The goal of this study was to document the variability in outcome reporting patterns in high-impact orthopaedic studies of ACL reconstruction. METHODS All clinical studies pertaining to ACL reconstruction in four high-impact-factor orthopaedic journals over a five-year period were reviewed. Biomechanical, basic science, and imaging studies were excluded, as were studies with fewer than fifty patients, yielding 119 studies for review. Incorporation of various objective and subjective outcomes was noted for each study. RESULTS Substantial variability in reporting of both objective and subjective measures was noted in the study cohort. Although a majority of studies reported instrumented laxity findings, there was substantial variability in the type and method of laxity reporting. Most other objective outcomes, including range of motion, strength, and complications, were reported in <50% of all studies. Return to pre-injury level of activity was infrequently reported (24% of studies), as were patient satisfaction and pain assessment following surgery (8% and 13%, respectively). Of the patient-reported outcomes, the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores were most often reported (71%, 63%, and 42%, respectively). CONCLUSIONS Substantial variability in outcome reporting patterns exists among high-impact studies of ACL reconstruction. Such variability may create challenges in interpreting results and pooling them across different studies.

Concussion Incidence and Return-to-Play Time in National Basketball Association Players Results From 2006 to 2014

Background: Various research efforts have studied concussions in the National Football League, Major League Baseball, and the National Hockey League. However, no study has investigated the incidence and return-to-play trends in the National Basketball Association (NBA), which this study aims to do. Hypothesis: Increased media scrutiny and public awareness, in addition to the institution of a league-wide concussion protocol, may have resulted in more conservative return-to-play practices. Study Design: Descriptive epidemiology study. Methods: All concussions to NBA players that were publicly reported in the media from the beginning of the 2006 NBA season to the end of the 2014 season were included. The incidence and return-to-play statistics were generated by synthesizing information from publicly available records. Results: There were 134 publicly reported concussions to NBA players from the beginning of the 2006 season to the conclusion of the 2014 season, resulting in an average of 14.9 concussions per season. The incidence has not changed significantly during this time span. The average games missed after a concussion from 2006 to 2010 was 1.6, significantly less than the 5.0 games missed from 2011 to 2014, following the institution of the NBA concussion protocol (P = .023). Conclusion: Although the incidence of publicly reported concussions in the NBA has not changed appreciably over the past 9 seasons, the time missed after a concussion has. While players often returned in the same game in the 2006 season, the combination of implemented policy, national coverage, medical staff awareness, and player education may have contributed to players now missing an average of 4 to 6 games after a concussion. A multitude of factors has resulted in more conservative return-to-play practices for NBA players after concussions.

Factors That Drive Youth Specialization

Background: Specialization in young athletes has been linked to overuse injuries, burnout, and decreased satisfaction. Despite continued opposition from the medical community, epidemiological studies suggest the frequency is increasing. Hypothesis: Extrinsic pressures in addition to individual aspirations drive this national trend in sports specialization. Study Design: Descriptive epidemiology study. Level of Evidence: Level 3. Methods: A novel instrument assessing the driving factors behind youth specialization was generated by an interdisciplinary team of medical professionals. Surveys were administered to patients and athletes in the department’s sports medicine clinic. Results: The survey was completed by 235 athletes between 7 and 18 years of age, with a mean age of 13.8 ± 3.0 years. Athletes specialized at a mean age of 8.1 years, and 31% of athletes played a single sport while 58% played multiple sports but had a preferred sport. More than 70% of athletes had collegiate or professional ambitions, and 60% played their primary sport for 9 or more months per year, with players who had an injury history more likely to play year-round (P < 0.01). Approximately one-third of players reported being told by a coach not to participate in other sports, with specialized athletes reporting this significantly more often (P = 0.04). Half of the athletes reported that sports interfered with their academic performance, with older players stating this more frequently (P < 0.01). Conclusion: Young athletes are increasingly specializing in a single sport before starting high school. While intrinsic drive may identify healthy aspirations, extrinsic influences are prevalent in specialized athletes. Clinical Relevance: Extrinsic factors contributing to youth specialization were identified and compounded the deleterious sequelae of youth athlete specialization.

Quantifying Parental Influence on Youth Athlete Specialization: A Survey of Athletes’ Parents:

Background: Youth athlete specialization has been linked to decreased enjoyment, burnout, and increased injury risk, although the impact of specialization on athletic success is unknown. The extent to which parents exert extrinsic influence on this phenomenon remains unclear. Purpose/Hypothesis: The goal of this study was to assess parental influences placed on young athletes to specialize. It was hypothesized that parents generate both direct and indirect pressures on specialized athletes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A survey tool was designed by an interdisciplinary medical team to evaluate parental influence on youth specialization. Surveys were administered to parents of the senior author’s orthopaedic pediatric patients. Results: Of the 211 parents approached, 201 (95.3%) completed the assessment tool. One-third of parents stated that their children played a single sport only, 53.2% had children who played multiple sports but had a favorite sport, and 13.4% had children who balanced their multiple sports equally. Overall, 115 (57.2%) parents hoped for their children to play collegiately or professionally, and 100 (49.7%) parents encouraged their children to specialize in a single sport. Parents of highly specialized and moderately specialized athletes were more likely to report directly influencing their children’s specialization (P = .038) and to expect their children to play collegiately or professionally (P = .014). Finally, parents who hired personal trainers for their children were more likely to believe that their children held collegiate or professional aspirations (P = .009). Conclusion: Parents influence youth athlete specialization both directly and by investment in elite coaching and personal instruction. Parents of more specialized athletes exert more influence than parents of unspecialized athletes.

Pectoralis Minor Contracture in Throwing Shoulders of Asymptomatic Adolescent Baseball Players

Background: Although scapular malpositioning is commonly associated with rotational deficits and risk of injury, modifiable causes of such malpositioning in overhead athletes are not well described. Purpose/Hypothesis: The purpose of this study was to examine the scapulothoracic profile of adolescent baseball players, specifically, pectoralis minor (PM) length. We hypothesized that PM would be shorter in throwing shoulders compared with nonthrowing shoulders. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Forty-nine healthy adolescent baseball players underwent clinical screening of PM lengths in throwing and nonthrowing shoulders by means of previously described, validated techniques. PM measurements were conducted while players were supine with arms at rest, sitting with arms at rest, and sitting with shoulders in maximal external rotation; measurements were made with a digital caliper and by assessment of table-to-acromion distance. Static scapular position and range of motion measurements were recorded. Demographic information and playing history were documented. Results: All players were male, they had a mean ± SD age of 16.2 ± 1.16 years, and they predominantly threw right-handed (83.7%). Sixty-nine percent of players were pitchers, 61.2% had played baseball for 9 or more months per year, and 67.3% had played in excess of 30 games in the previous year. Significant differences were noted during side-to-side comparisons within participants. Absolute PM length was significantly shorter in throwing compared with nonthrowing shoulders when measured with players sitting with arms at rest (by 3.7 ± 11.8 mm) and with their shoulders in maximal external rotation (by 4.8 ± 15.1 mm) (P < .004 for both). The PM index was significantly reduced in throwing compared with nonthrowing shoulders while players were supine with arms at rest (P = .007), sitting with arms at rest (P = .006), and sitting with shoulders in maximal external rotation (P < .001). Mean table-to-acromion distance was increased 7.7 ± 1.26 mm in throwing versus nonthrowing arms (P < .001). The scapular index was significantly reduced in throwing compared with nonthrowing shoulders (P < .005). Conclusion: Asymptomatic adolescent baseball players have significant differences in PM length and static scapular measurements in throwing compared with nonthrowing shoulders. The clinical significance requires further investigation, but emphasis on PM stretching routines is encouraged.

Prevalence of Posttraumatic Stress Disorder Symptoms Among Young Athletes After Anterior Cruciate Ligament Rupture

Background: The risk of depression and the fear of reinjury were documented in recent investigations of patients after anterior cruciate ligament (ACL) ruptures. The extent of psychological trauma accompanying these injuries among young athletes, however, has never been assessed. Hypothesis: Posttraumatic stress disorder (PTSD) symptoms after ACL injury are present among young athletes with high athletic identities. Study Design Case series; Level of evidence, 4. Methods: Patients ≤21 years of age who had suffered an acute ACL rupture were consecutively recruited at a tertiary care center. Patients completed the Horowitz Impact of Event Scale - Revised (IES-R) to analyze for PTSD symptomatology, the Athletic Identity Measurement Scale, and an athlete specialization instrument created at the authors’ institution. Results: A total of 24 patients were consecutively recruited. The mean patient age was 14.5 ± 2.7 years, and 50% of patients were male. More than 87.5% of patients experienced avoidance symptoms, 83.3% acknowledged symptoms of intrusion, and 75% had symptoms of hyperarousal. Patients aged 15 to 21 years incurred a higher severity of PTSD symptoms than younger patients (P = .033). Female patients experienced greater emotional trauma than male patients (P = .017). Finally, patients with high athletic identities experienced greater emotional trauma than those with lesser athletic identities, but this finding was not statistically significant (P = .14). Conclusion: Following ACL rupture, young athletes experience significant emotional trauma, including symptoms of avoidance, intrusion, and hyperarousal. High school and college athletes, female athletes, and patients with high athletic identities may be most susceptible.

Defining Platelet-Rich Plasma Usage by Team Physicians in Elite Athletes:

Background: The indications for the use of platelet-rich plasma (PRP) are vaguely defined despite the frequency of its use as a treatment for athletes. While select studies have advocated for its efficacy, the majority of orthopaedic research conducted on the topic has been equivocal. Purpose: To define the use of PRP in elite athletes by team physicians from professional sports leagues. Study Design: Cross-sectional study. Methods: A survey assessing treatment timing, usage patterns, indications, and complications was generated by fellowship-trained sports medicine orthopaedic surgeons. The survey was distributed to team physicians from the National Football League, National Basketball Association, Major League Baseball, National Hockey League, Major League Soccer, and the “Power 5” Division I conferences of the National Collegiate Athletic Association. From a compilation of publicly available email addresses and those available from professional team physician associations, 149 team physicians were sent this PRP assessment tool. Results: Of the 149 professional and collegiate team physicians contacted, 59 started the survey and 46 completed it, resulting in a 39.6% participation rate and a 30.9% completion rate. Approximately 93% of physicians stated that they use PRP in their practices, and 72% use ultrasonography for injection guidance. On average, collegiate team physicians and National Football League physicians treated the most players per season with PRP (69.4 and 60.4 players, respectively), while National Hockey League physicians treated the fewest (18.0 players). The majority of respondents reported no complications from PRP injections (70%), with pain being the most common complication reported (26%). There was no consensus on the most important aspect of PRP formulation, with the top 2 responses being platelet concentration (48%) and white blood cell concentration (39%). When grading the importance of indications to use PRP, physicians found athlete desire on average (7.5 ± 2.2 [SD]; out of 10) to be more important than reimbursement (2.2 ± 2.2) (P < .001). Importantly, physicians stated that they moderately (5.4 ± 2.3) believed in the evidence behind PRP. Physicians listed hamstring injuries as the most common injury treated with PRP. Hamstring injuries were treated with a mean 3.14 PRP injections, as opposed to 2.19 injections for nonhamstring injuries. Conclusion: Professional and collegiate team physicians frequently use PRP despite a lack of consensus regarding the importance of the formulation of the product, the timing of treatment, and the conditions that would most benefit from PRP treatment.

Trends in Management and Complications of Anterior Cruciate Ligament Injuries in Pediatric Patients: A Survey of the Prism Society

Background:Anterior cruciate ligament (ACL) injuries have been recognized and treated with increasing frequency in children and adolescents. ACL reconstruction (ACLR) in skeletally immature patients has unique considerations and there is a large practice variation in the management of these injuries. The purpose of this study was to survey the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding their experience with the management and complications of pediatric ACL injuries. Methods:A 15-question survey was distributed to 71 orthopaedic members of the Pediatric Research in Sports Medicine study group. Results:Regarding treatment of an 8-year-old child with a complete ACL tear, 53% of respondents recommended iliotibial band reconstruction, 33% recommended all-epiphyseal reconstruction, and only 3% would treat nonoperatively in a brace. In adolescent patients with 2 years of growth remaining, 47% of respondents recommended a physeal “respecting” technique, 31% recommended a physeal-sparing technique, and 19% would perform an adult-style ACLR. There were 29 new cases of growth arrest reported. Conclusions:This study demonstrates that there have been major changes in the trends in pediatric ACLR over the past 15 years, and the most treatment variability is found among adolescent patients with about 2 years of growth remaining. The study also demonstrates that while the overall incidence of growth disturbance after ACLR remains low, new cases of growth disturbance continue to be identified. Level of Evidence:Level V—survey of expert opinion and experience.

Can We Reduce the Epidemic of Elbow Injuries in Youth Throwers

As participation in youth sports continues to increase across the nation, more adolescents are participating in Little League baseball in the United States than ever before. Accompanying this increased participation is an epidemic of upper extremity injuries in young throwers. In this Viewpoint, the authors discuss the impetus behind the youth thrower elbow injury epidemic and how to best evaluate these patients. J Orthop Sports Phys Ther 2018;48(5):354-357. doi:10.2519/jospt.2018.0607.

The Psychosocial Trauma of ACL Ruptures in Young Athletes

Objectives: Sustaining severe injuries requiring operative fixation causes emotional harm in addition to physical damage in young athletes. While the fear of re-injury following an anterior cruciate ligament ruptures and reconstruction has been established, the extent of the psychosocial trauma, including hyperarousal and intrusion, is largely unknown. We hypothesize that post-traumatic stress disorder symptoms are present young athletes with strong athletic identities following ACL ruptures. Methods: The impact of events scale, the athletic identity measurement score, and a novel specialization instrument were administered to 7 to 21 year old patients following ACL rupture. These instruments represent a modified post-traumatic stress disorder screening tool psychometrically validated in children, a validated tool to measure athletic identity, and an athlete specialization questionnaire designed by the authors respectively. Athletes were recruited from the sports medicine clinic at the senior authors’ academic institution and the instruments were administered upon the patients’ first orthopedic visit following the diagnosis of an ACL rupture. The full extent of the knee injury and any history of prior knee injuries were also assessed. Results: Twenty-one patients with a mean age of 14.9 ± 2.9 years completed the emotional trauma assessment and 52.2% of respondents were female. The most common concurrent injury was a meniscal tear (47.8%) and 9.5% of patients reported a prior ACL rupture and reconstruction. Regarding specialization, one-third of athletes played one sport only, 52.4% of athletes played multiple sports while focusing on one above the others, and 14.2% of athletes balanced their sports equally. Single-sport athletes scored significantly higher on the athletic identity questionnaire (single-sport mean 57.2; multi-sport mean 52.1; p = .02). The majority of patients experience traumatic symptoms in all three major categories as 86.4% endorsed avoidance symptoms, 81.8% admitted intrusion symptoms, and 81.8% admitted hyperarousal symptoms. Older athletes were significantly more likely to experience stronger emotionally traumatic symptoms (p = .03) as 16 - 21 year old athletes scored a mean of 62.6 on the Impact of Events Scale compared to 39.6 for 7 - 15 year old athletes. While male patients experienced stronger traumatic symptoms than female patients, the separation was not found to be statistically significant (male 50.2; female 43.6; p = .12). Conclusion: The emotional trauma for young athletes following ACL ruptures extends beyond the avoidance symptoms that have been previously established. Psychological evaluation and support is imperative to providing holistic care following this injury. Demographics and Psychosocial Symptom Prevalence Age 14.9 ± 2.9 Female 52.8% Male 47.2% Meniscal Injury 47.2% Prior ACL Injury 9.5% Traumatic Symptoms: Avoidance 86.4% Intrusion 81.8% Hyperarousal 81.8%