Subacute symptoms of sports-related concussion: outpatient management and return to play

Most concussion symptoms resolve within the first week after injury. Athletes with persistent symptoms may manifest subtle behavioral and cognitive changes. The astute clinician uses various information to determine when these symptoms have cleared before allowing the athlete to return to athletic competition.     

Shoulder instability: return to play

Shoulder instability in the competitive athlete is a relatively common problem. The etiology of glenohumeral instability that can affect the athlete runs a wide spectrum, from an isolated traumatic dislocation to repeated microtrauma or congenital laxity. Although many athletes are able to adapt to a mild laxity that might only occasionally affect them, it can be much more difficult to adapt or return to play after a dislocation or repeated subluxation episodes. This article focuses on the return to play for competitive individuals after a glenohumeral dislocation or reconstructive surgery for shoulder instability.     

Infectious mononucleosis: return to play

Infectious mononucleosis most commonly affects adolescents and young adults with a febrile illness accompanied by pharyngitis,lymph node enlargement, and transient fatigue. The diagnosis is usually confirmed with demonstration of heterophile antibodies. Typical signs and symptoms are reviewed, along with pitfalls in diagnosis and management. The rare complication of splenic rupture serves to focus recommendations for returning athletes to strenuous physical activities. Because careful prospective studies of infectious mononucleosis in athletes are lacking, review of available literature suggests that clinicians may recommend a return to all sports in those without spleen enlargement 4 weeks after the onset of illness.     

Injections and return to play

The use of analgesic and anti-inflammatory injections in athletics has a long and sometimes controversial history. They have been and will continue to be utilized to decrease inflammation and pain, improve healing time, and ultimately decrease the amount of time missed from sports competition. Several authors have evaluated both the positive and negative aspects of various injectable medicines. Many questions still remain with regard to safety, tolerability, risks, complications, and side effects of these injectable medicines. This paper reviews some of the current trends regarding the use of injectable medications in athletic medicine.     

Injections and return to play

The use of analgesic and anti-inflammatory injections in athletics has a long and sometimes controversial history. They have been and will continue to be utilized to decrease inflammation and pain, improve healing time, and ultimately decrease the amount of time missed from sports competition. Several authors have evaluated both the positive and negative aspects of various injectable medicines. Many questions still remain with regard to safety, tolerability, risks, complications, and side effects of these injectable medicines. This paper reviews some of the current trends regarding the use of injectable medications in athletic medicine.     

Management and return to play of stress fractures.

OBJECTIVE: The purpose of this article is to provide the clinician an evidence/experience-based algorithm for the management of stress fractures. DATA SOURCES: Medline search of peer reviewed publications regarding stress fracture etiology, classification, treatment, and natural history. DATA SYNTHESIS/METHODS: The algorithm was developed from a review of retrospective case series, a few evidence-based papers, and the clinical experience of 4 sports medicine team physicians with a combined experience of over 40 years in the care of athletes at the college and professional level. The literature is almost entirely case series without control groups; therefore, clinical consensus is included as the next best guide to treatment. RESULTS: The emphasis of this article is to provide a clear and simple approach to the management of these fractures by classifying them as either high-risk or low-risk. This separation into 2 groups is based on the biomechanical environment and natural history of the fracture. High-risk stress fractures occur in the superolateral femoral neck, anterior tibial shaft, tarsal navicular, proximal fifth metatarsal, and talar neck. Low-risk stress fractures occur in the lateral malleolus, calcaneus, 2nd through 4th metatarsals, and the femoral shaft. CONCLUSIONS: The undertreatment of high-risk stress fractures can lead to catastrophic bone failure and/or prolonged loss of playing time. Overtreatment of low-risk stress fractures can result in unnecessary deconditioning and unneeded loss of playing time. We propose that the use of the simple and clinically relevant algorithm will help guide appropriate management and return to play decision-making as well as encourage future prospective research.     

Sudden cardiac death: Ethical considerations in the return to play

The team physician-athlete relationship prompts many basic questions in medical ethics. Return-to-play decisions form many of the core responsibilities facing team physicians, and occasionally these decisions can have overriding ethical dilemmas. Therefore, a structured ethical decision-making process is a valuable skill for every successful sports medicine physician. An ethical question is confronted here in a case presentation that weighs the risk of repeat sudden cardiac death and the potential for failed cardiac resuscitation against the athlete’s interest to play competitive basketball. The article applies a four-step framework for ethical decision making in sports medicine. The important first step includes gathering medical information and understanding the preferences of the athlete. Step 2 brings together the decision-making stakeholders, the team physician as a member, to define ethical issues and apply ethical principles: beneficence, nonmaleficence, and patient autonomy. Step 3 selects a course of action with unbiased analysis and arrives at a good choice that merits an action plan in step 4. This decision need not be perfect, but should reinforce the team physician’s responsibilities to the athlete and center on the athlete’s welfare.     

Sport-related concussion: factors associated with prolonged return to play.

OBJECTIVE: To assess predictive value of concussion signs and symptoms based on return-to-play timelines. DESIGN: Physician practice study without diagnosis that includes presentation, initial and subsequent treatment, and management of concussion. SETTING: National multisite primary care sports medicine provider locations. PARTICIPANTS: Twenty-two providers at 18 sites; 101 athletes (91 men, 10 women in the following sports: 73 football, 8 basketball, 8 soccer, 3 wrestling, 2 lacrosse, 2 skiing, 5 others; 51 college, 44 high school, 4 professional, and 2 recreational). MAIN OUTCOME MEASUREMENTS: Duration of symptoms, presence of clinical signs, and time to return to play following concussion. RESULTS: One hundred one concussions were analyzed. Pearson chi2 analysis of common early and late concussion symptoms revealed statistical significance (P < 0.05) of headache >3 hours, difficulty concentrating >3 hours, any retrograde amnesia or loss of consciousness, and return to play >7 days. There appeared to be a trend in patients with posttraumatic amnesia toward poor outcome, but this was not statistically significant. CONCLUSIONS: When evaluating concussion, symptoms of headache >3 hours, difficulty concentrating >3 hours, retrograde amnesia, or loss of consciousness may indicate a more severe injury or prolonged recovery; great caution should be exercised before returning these athletes to play.     

A review of spine injuries and return to play.

OBJECTIVE: To review the literature for evidence that pertains to return to play and spine injuries, including cervical spinal stenosis, congenital and developmental abnormalities of the cervical spine, stingers, herniated nucleus pulposus, and spondylolysis/spondylolisthesis. DATA SOURCES: Electronic databases, Pubmed (1966-2005) and Sport Discus (1975-2005), were searched for pertinent literature. Also, additional articles were reviewed from bibliographies. DATA SYNTHESIS/METHODS: Summation of literature is given. No formal statistical analysis is presented. RESULTS: Even though the problems addressed in this paper can be serious, the literature is lacking evidence for guidance in return to play. The majority of the literature presented is expert opinion. CONCLUSIONS: Cervical spinal stenosis continues to be controversial, with different experts giving different definitions and return to play recommendations. Authors discuss functional cervical spinal stenosis seen on MRI and how this can lead to permanent sequelae. In regard to stingers, herniated nucleus pulposus, and spondylolysis/spondylolisthesis, there are differing opinions on evaluation and treatment. These conditions have less disagreement with regard to return to play. Most experts agree that with these problems or any other problem in sports medicine, an athlete needs to be symptom-free and have full active range of motion with near to full strength, even though there is a lack of research evidence in the literature.     

Repeat mild traumatic brain injury: How to adjust return to play guidelines

Determining when it is safe for an athlete to return to play (RTP) after concussion is one of the most difficult decisions facing the team physician. There is significant variability in the evaluation and management of mild traumatic brain injury (mTBI). In the past decade, a tremendous amount of sport-specific research has improved our understanding of mTBI. The advent of neuropsychologic (NP) testing batteries designed to assess concussive injury has improved the assessment of cognitive dysfunction that occurs in the absence of structural brain abnormalities. The severity of injury is determined by the nature, burden, and duration of symptoms. Athletes must be asymptomatic and have a normal neurologic and cognitive evaluation prior to RTP. Several factors aid in making the RTP decision, including age, the severity of injury, and history of prior mTBIs. Given the potential complications of mTBI, the RTP decision must be made using a thoughtful, individualized process.     

缩窄性心包炎的MRI诊断

目的 评价MRI检查缩窄性心包炎的诊断价值。材料与方法 回顾性分析临床证实的26例缩窄性心包炎MRI表现。结果 MRI发现24例心包有增厚,2例正常。增厚的心包T1WI上20例呈中等信号,4例为低信号。右心室腔呈管状狭窄者6例,右心室前壁僵、右心室腔呈三角形者13例,5例右心室略大。11例电影MRI均显示右心室受限。右房除2例外均有不同程度的增大,左房有4例增大,19例发现有上、下腔静脉扩张。结论 MRI能直接显示极大多数病例增厚的心包,并确定其部位和范围,对诊断缩窄性心包炎和与限制性心肌病鉴别有重要价值,可在某些诊断有争议的病例中选择性应用。     

Fighting to keep a sport safe: toward a structured and sport-specific return to play protocol

Combat sports are growing in popularity, viewership, and participation. The nature of these sports involves repetitive head contact, yet unlike most other professional contact sports, there are no endorsed guidelines or mandates for graduated and systematic return to play following concussion. Here, we review the literature related to concussion and fighting sports, and propose guidelines for concussion management and safe return to play following concussion.     

Injuries and abnormalities of the cervical spine and return to play criteria

Cervical spine injury has a wide spectrum of consequences for the contact athlete, ranging from minimal to catastrophic. Because of the potentially grave sequelae of cervical injury, it is incumbent on team physicians or treating spine surgeons to be knowledgeable of postinjury treatment and return-to-play algorithms. Sideline physicians must have a rehearsed, comprehensive protocol for ensuring rapid treatment should an on-field injury occur with contingency plans to transport an injured player to a medical facility if necessary. Likelihood of return to play is variable with the extent of injury, but high for stingers, relatively low for patients who suffer episodes of transient neuropraxia, and intermediate for players who undergo cervical fusion for disk herniation based on the best available evidence. However, patients must be evaluated carefully on a case-by-case basis because of the heterogeneity of injury severity and associated pathology.     

缩窄性心包炎的螺旋CT诊断

缩窄性心包炎(constrictive pericarditis,CPC)是指脏、壁层心包膜因为各种原因增厚粘连形成坚硬的纤维瘢痕,有时伴有钙化,心包腔闭塞致心脏舒张期充盈受限,而产生的血液循环障碍。螺旋CT对CPC检查效果良好,但极易误诊,笔者收集了20例经手术及其他影像学诊断临床符合的缩窄性心     

High school rugby players' understanding of concussion and return to play guidelines

Objective

To document high school players'' understanding and attitudes towards concussion return to play guidelines.

Methods

A questionnaire based survey was performed of national high school rugby players as to their knowledge of existing concussion return to play guidelines.

Results

A total of 600 male players were surveyed, and 477 responded (response rate 80%). Half (237/477) were aware of concussion guidelines, and 60% (288/477) identified the mandated stand down period that is part of the regulations governing rugby football. Players obtained their information primarily from: teachers/coaches (239 responses), medical personnel (200), and other players (116). Of those players who suspected that they had been concussed (296/477, 62%), only 66 returned to play after medical clearance.

Conclusions and implications

This sample of high school players showed a limited knowledge of the concussion guidelines covering their sport, and even when concussed did not follow recommended protocols. This indicates the need for an increased focus on player education.     

Factors influencing return to play following conservatively treated ankle sprain: a systematic review

Background: Ankle sprain is a very common injury, yet uncertainty exists in what is appropriate time to return to play (RTP). Such guidance may inform treatment pathways and effective practice.

Objectives: To determine if consensus exist about potential influencing factors for time to RTP in conservatively treated ankle sprain.

Methods: We searched AMED, CINAHL Plus, Cochrane library, EMBASE, MEDLINE (EBSCO), SPOERDiscus, PsycINFO, PEDro, Scopus, unpublished literature and ongoing trials and Google Scholar from inception until April 2017. The quality of the eligible papers was assessed using the Downs and Black tool for randomized controlled trials (RCTs) and Critical Appraisal Skills Program (CASP) for observational studies.

Results: The initial search identified 1885 articles. After screening, 14 articles were included. Of these, 11 were RCTs and 3 were prospective observational studies. Individual treatment methods that resulted in a shorter time to RTP were functional treatment, compression stockings, anteroposterior joint mobilization, hyaluronic acid injection (HA), Jump Stretch Flex Band programme (JSFB) and diclofenac medication. Prognostic factors for determining time to RTP in the included prospective observational studies were measures of Global function, SF 36PF, athlete’s ambulation status, weight-bearing activity scores and self-reported athletic ability.

Conclusion: To our knowledge, this is the first review to report influencing factors for time to RTP following conservatively treated ankle sprain. Findings from this review identified factors that influence time to RTP. However, caution should be taken in generalizing these results due to the heterogeneity of studies and inability to clearly define and list the criteria for safe RTP. The inclusion of factors such as age, sex, BMI, level of sport, injury related factors in future studies might help to understand the course of injury and therefore assist in constructing safer criteria.     

Isometric exercise during immobilization reduces the time to return to play after lateral ankle sprain

[Objectives] Immobilization reduces symptoms after lateral ankle sprain but may worsen the range of motion (ROM) of the ankle and delay return to play (RTP). We aimed to elucidate the correlation between ankle ROM and time to RTP following immobilization for lateral ankle sprain and investigated if isometric exercise during immobilization would increase ROM and shorten the time to RTP. [Participants and outcome measures] Eighty-two patients with acute lateral ankle sprain were treated by a short-leg cast with or without isometric exercise and electrical muscle stimulation (EMS); intervention group or control group, respectively. The correlation between ankle ROM at cast removal and time to RTP was analyzed. The total and side-to-side ankle ROM and the time to RTP were compared between the two groups. [Results] Side-to-side difference in total ankle ROM significantly correlated with time to RTP (r = 0.38, p = 0.02). The intervention reduced the side-to-side difference in total ROM (20° versus 31°, p = 0.01) and time to RTP (46 versus 65 days, p = 0.01) compared to the control group. [Conclusion] Increased deficiency in ankle ROM led to a longer time to RTP, and isometric exercise combined with EMS during immobilization increased the total ankle ROM and shortened the time to RTP.