Mass Participation and Tournament Event Management for the Team Physician: A Consensus Statement (2022 Update).

ABSTRACT: Mass participation events include endurance events (e.g., marathon, triathlon) and/or competitive tournaments (e.g., baseball, tennis, football (soccer) tournaments). Event management requires medical administrative and participant care planning. Medical management provides safety advice and care at the event that accounts for large numbers of participants, anticipated injury and illness, variable environment, repeated games or matches, and mixed age groups of varying athletic ability. This document does not pertain to the care of the spectator.

Mass Participation and Tournament Event Management for the Team Physician: A Consensus Statement (2022 Update).

ABSTRACT: Mass participation events include endurance events (e.g., marathon, triathlon) and/or competitive tournaments (e.g., baseball, tennis, football (soccer) tournaments). Event management requires medical administrative and participant care planning. Medical management provides safety advice and care at the event that accounts for large numbers of participants, anticipated injury and illness, variable environment, repeated games or matches, and mixed age groups of varying athletic ability. This document does not pertain to the care of the spectator.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement.

ABSTRACT: Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement.

ABSTRACT: Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement.

ABSTRACT: Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus articles written for the practicing team physician. This document provides an overview of select medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: a consensus statement.

Selected Issues in Sport-Related Concussion (SRC|Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus documents written for the practicing team physician. This document provides an overview of selected medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

Leadership for the Team Physician.

Physician leadership of the interdisciplinary sports medicine team depends on fundamental leadership skills that often are overlooked in medical school. These leadership skills include effective communication, emotional intelligence, teamwork, selfless service, integrity, and critical thinking while utilizing an athlete-centered approach. Development of these skills will help to navigate team management and important decisions, such as return to play. The leadership session at the Advanced Team Physician Course sought to acknowledge the gap in medical training regarding leadership education and began to address it in a forum specifically for team physicians. Here we provide a summary of the lectures and presentations from the 2018 Advanced Team Physician Course in an effort to benefit a broader physician audience. This material should act as a framework for current and future team physicians to solidify their role as the leader of the medical team in caring for the athlete.

Low- Versus High-Intensity Plyometric Exercise During Rehabilitation After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Plyometric exercise is used during rehabilitation after anterior cruciate ligament (ACL) reconstruction to facilitate the return to sports participation. However, clinical outcomes have not been examined, and high loads on the lower extremity could be detrimental to knee articular cartilage. PURPOSE: To compare the immediate effect of low- and high-intensity plyometric exercise during rehabilitation after ACL reconstruction on knee function, articular cartilage metabolism, and other clinically relevant measures. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Twenty-four patients who underwent unilateral ACL reconstruction (mean, 14.3 weeks after surgery; range, 12.1-17.7 weeks) were assigned to 8 weeks (16 visits) of low- or high-intensity plyometric exercise consisting of running, jumping, and agility activities. Groups were distinguished by the expected magnitude of vertical ground-reaction forces. Testing was conducted before and after the intervention. Primary outcomes were self-reported knee function (International Knee Documentation Committee [IKDC] subjective knee form) and a biomarker of articular cartilage degradation (urine concentrations of crosslinked C-telopeptide fragments of type II collagen [uCTX-II]). Secondary outcomes included additional biomarkers of articular cartilage metabolism (urinary concentrations of the neoepitope of type II collagen cleavage at the C-terminal three-quarter-length fragment [uC2C], serum concentrations of the C-terminal propeptide of newly formed type II collagen [sCPII]) and inflammation (tumor necrosis factor-α), functional performance (maximal vertical jump and single-legged hop), knee impairments (anterior knee laxity, average knee pain intensity, normalized quadriceps strength, quadriceps symmetry index), and psychosocial status (kinesiophobia, knee activity self-efficacy, pain catastrophizing). The change in each measure was compared between groups. Values before and after the intervention were compared with the groups combined. RESULTS: The groups did not significantly differ in the change of any primary or secondary outcome measure. Of interest, sCPII concentrations tended to change in opposite directions (mean ± SD: low-intensity group, 28.7 ± 185.5 ng/mL; high-intensity group, -200.6 ± 255.0 ng/mL; P = .097; Cohen d = 1.03). Across groups, significant changes after the intervention were increased the IKDC score, vertical jump height, normalized quadriceps strength, quadriceps symmetry index, and knee activity self-efficacy and decreased average knee pain intensity. CONCLUSION: No significant differences were detected between the low- and high-intensity plyometric exercise groups. Across both groups, plyometric exercise induced positive changes in knee function, knee impairments, and psychosocial status that would support the return to sports participation after ACL reconstruction. The effect of plyometric exercise intensity on articular cartilage requires further evaluation. REGISTRATION NUMBER: Clinicaltrials.gov NCT01851655.

Speed, not magnitude, of knee extensor torque production is associated with self-reported knee function early after anterior cruciate ligament reconstruction.

PURPOSE: To examine the magnitude and speed of knee extensor torque production at the initiation of advanced anterior cruciate ligament (ACL) reconstruction rehabilitation and the associations with self-reported knee function. METHODS: Twenty-eight subjects who were 12 weeks post-ACL reconstruction and 28 age- and sex-matched physically active controls participated in this study. Knee extensor torque was assessed bilaterally with an isokinetic dynamometer at 60°/s. The variables of interest were peak torque, average rate of torque development, time to peak torque and quadriceps symmetry index. Knee function was assessed with the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). RESULTS: Peak torque and average rate of torque development were lower on the surgical side compared to the non-surgical side and controls. Quadriceps symmetry index was lower in subjects with ACL reconstruction compared to controls. On the surgical side, average rate of torque development was positively correlated with IKDC-SKF score (r = 0.379) while time to peak torque was negatively correlated with IKDC-SKF score (r = -0.407). CONCLUSIONS: At the initiation of advanced ACL reconstruction rehabilitation, the surgical side displayed deficits in peak torque and average rate of torque development. A higher rate of torque development and shorter time to peak torque were associated with better self-reported knee function. The results suggest that the rate of torque development should be addressed during advanced ACL reconstruction rehabilitation and faster knee extensor torque generation may lead to better knee function. LEVEL OF EVIDENCE: III.

The effect of sterilization on mechanical properties of soft tissue allografts.

One major concern regarding soft tissue allograft use in surgical procedures is the risk of disease transmission. Current techniques of tissue sterilization, such as irradiation have been shown to adversely affect the mechanical properties of soft tissues. Grafts processed using Biocleanse processing (a proprietary technique developed by Regeneration Technologies to sterilize human tissues) will have better biomechanical characteristics than tissues that have been irradiated. Fifteen pairs of cadaveric Achilles tendon allografts were obtained and separated into three groups of 10 each. Three treatment groups were: Biocleanse, Irradiated, and Control (untreated). Each specimen was tested to determine the biomechanical properties of the tissue. Specimens were cyclically preloaded and then loaded to failure in tension. During testing, load, displacement, and optical strain data were captured. Following testing, the cross sectional area of the tendons was determined. Tendons in the control group were found to have a higher extrinsic stiffness (slope of the load-deformation curve, p = .005), have a higher ultimate stress (force/cross sectional area, p = .006) and higher ultimate failure load (p = .003) than irradiated grafts. Biocleanse grafts were also found to be stiffer than irradiated grafts (p = .014) yet were not found to be statistically different from either irradiated or non-irradiated grafts in terms of load to failure. Biocleanse processing seems to be a viable alternative to irradiation for Achilles tendon allografts sterilization in terms of their biomechanical properties.

Aseptically processed and chemically sterilized BTB allografts for anterior cruciate ligament reconstruction: a prospective randomized study.

PURPOSE: To compare the clinical outcomes of bone-patellar tendon-bone (BTB) allografts processed via a novel sterilization system with the traditional aseptically processed BTB allografts for anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 67 patients undergoing ACL reconstruction at 6 independent investigation sites were randomized into one of two intervention groups, BioCleanse-sterilized or aseptic BTB allografts. Inclusion criteria included an acute, isolated, unilateral ACL tear, and exclusion criteria included prior ACL injury, multi-ligament reconstruction, and signs of degenerative joint disease. Post-op examiners and patients were blinded to graft type. Patients were evaluated at 6, 12, and 24 months. Clinical outcomes were compared using the IKDC, a KT-1000 knee arthrometer, level of effusion, and ranges of motion (ROM). RESULTS: After randomization, 24 patients received aseptic BTB allografts and 43 patients received BioCleanse-sterilized allografts. Significant improvement in IKDC scores (P < 0.0001) as well as KT-1000 results (P < 0.0001) was noted over the 24-month period for both groups. IKDC or KT-1000 results were not significantly different between groups at any time point. Active flexion ROM significantly improved from pre-op to 24-month follow-up (P < 0.0001) with no difference between groups at any time point. Active extension ROM did not differ significantly between the two groups. CONCLUSIONS: These results indicate that the sterilization process, BioCleanse, did not demonstrate a statistical difference in clinical outcomes for the BTB allograft at 2 years. The BioCleanse process may provide surgeons with allografts clinically similar to aseptically processed allograft tissue with the benefit of addressing donor-to-recipient disease. LEVEL OF EVIDENCE: II.

Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment, and self-report measures.

STUDY DESIGN: Cross-sectional cohort. OBJECTIVES: (1) To examine differences in clinical variables (demographics, knee impairments, and self-report measures) between those who return to preinjury level of sports participation and those who do not at 1 year following anterior cruciate ligament reconstruction, (2) to determine the factors most strongly associated with return-to-sport status in a multivariate model, and (3) to explore the discriminatory value of clinical variables associated with return to sport at 1 year postsurgery. BACKGROUND: Demographic, physical impairment, and psychosocial factors individually prohibit return to preinjury levels of sports participation. However, it is unknown which combination of factors contributes to sports participation status. METHODS: Ninety-four patients (60 men; mean age, 22.4 years) 1 year post-anterior cruciate ligament reconstruction were included. Clinical variables were collected and included demographics, knee impairment measures, and self-report questionnaire responses. Patients were divided into "yes return to sports" or "no return to sports" groups based on their answer to the question, "Have you returned to the same level of sports as before your injury?" Group differences in demographics, knee impairments, and self-report questionnaire responses were analyzed. Discriminant function analysis determined the strongest predictors of group classification. Receiver-operating-characteristic curves determined the discriminatory accuracy of the identified clinical variables. RESULTS: Fifty-two of 94 patients (55%) reported yes return to sports. Patients reporting return to preinjury levels of sports participation were more likely to have had less knee joint effusion, fewer episodes of knee instability, lower knee pain intensity, higher quadriceps peak torque-body weight ratio, higher score on the International Knee Documentation Committee Subjective Knee Evaluation Form, and lower levels of kinesiophobia. Knee joint effusion, episodes of knee instability, and score on the International Knee Documentation Committee Subjective Knee Evaluation Form were identified as the factors most strongly associated with self-reported return-to-sport status. The highest positive likelihood ratio for the yes-return-to-sports group classification (14.54) was achieved when patients met all of the following criteria: no knee effusion, no episodes of instability, and International Knee Documentation Committee Subjective Knee Evaluation Form score greater than 93. CONCLUSION: In multivariate analysis, the factors most strongly associated with return-to-sport status included only self-reported knee function, episodes of knee instability, and knee joint effusion.

Preliminary results of patient-defined success criteria for individuals with musculoskeletal pain in outpatient physical therapy settings.

OBJECTIVES: (1) To investigate patient-defined parameters of treatment success in an outpatient physical therapy setting with musculoskeletal pain, (2) to determine whether patient-defined treatment success was influenced by selected demographic and clinical factors, and (3) to examine whether patient subgroups existed for ratings of importance for each treatment outcome domain. DESIGN: Cross-sectional study. SETTING: Outpatient physical therapy clinic. PARTICIPANTS: Consecutive patients (N=110) with complaints of musculoskeletal pain. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: We reported patient-defined treatment success targets for pain, fatigue, emotional distress, and interference with daily activities using the Patient-Centered Outcomes Questionnaire (PCOQ). We also investigated whether patient subgroups existed based on perceived importance of improvement for these same outcome domains. RESULTS: Patient-defined criteria for treatment success included mean reductions (from baseline scores) in pain of 3.0 points, in fatigue of 2.3 points, in emotional distress of 1.4 points, and in interference with daily activities of 3.4 points. There were no differences in patient-defined criteria for treatment success based on sex, age, postoperative rehabilitation, prior physical therapy, other prior health care interventions, duration of symptoms, and anatomical location of symptoms (P>.01). Cluster analysis of the PCOQ importance ratings indicated a 2-cluster solution. The multifocused subgroup demonstrated higher importance for improvement ratings in each treatment outcome domain when compared with the pain-focused subgroup (P>.05). CONCLUSIONS: These data indicate that patient-defined criteria for treatment success required greater reductions in the studied outcome domains to be considered successful. These data suggest the potential existence of patient subgroups that either rate improvement in all outcome domains as important or rate pain relief as the most important outcome.

Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction.

BACKGROUND: Evidence in the musculoskeletal rehabilitation literature suggests that psychosocial factors can influence pain levels and functional outcome. OBJECTIVE: The purpose of this study was to examine changes in select psychosocial factors and their association with knee pain and function over 12 weeks after anterior cruciate ligament (ACL) reconstruction. DESIGN: This was a prospective, longitudinal, observational study. METHODS: Patients with ACL reconstruction completed self-report questionnaires for average knee pain intensity (numeric rating scale [NRS]), knee function (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF]), and psychosocial factors (pain catastrophizing [Pain Catastrophizing Scale], fear of movement or reinjury [shortened version of the Tampa Scale for Kinesiophobia (TSK-11)], and self-efficacy for rehabilitation tasks [modified Self-Efficacy for Rehabilitation Outcome Scale (SER)]). Data were collected at 4 time points after surgery (baseline and 4, 8, and 12 weeks). Repeated-measures analyses of variance determined changes in questionnaire scores across time. Hierarchical linear regression models were used to examine the association of psychosocial factors with knee pain and function. RESULTS: Seventy-seven participants completed the study. All questionnaire scores changed across 12 weeks. Baseline psychosocial factors did not predict the 12-week NRS or IKDC-SKF score. The 12-week change in modified SER score predicted the 12-week change in NRS score (r(2)=.061), and the 12-week change in modified SER and TSK-11 scores predicted the 12-week change in IKDC-SKF score (r(2)=.120). LIMITATIONS: The psychometric properties of the psychosocial factor questionnaires are unknown in people with ACL reconstruction. The study focused on short-term outcomes using only self-report measures. CONCLUSIONS: Psychosocial factors are potentially modifiable early after ACL reconstruction. Baseline psychosocial factor levels did not predict knee pain or function 12 weeks postoperatively. Interventions that increase self-efficacy for rehabilitation tasks or decrease fear of movement or reinjury may have potential to improve short-term outcomes for knee pain and function.

Primary ACL reconstruction using allograft tissue.

While bone-patellar tendon-bone (BPTB) autograft continues to be the "gold standard" and most popular graft choice for primary anterior cruciate ligament (ACL) reconstructions, the use of allograft tissues in ACL reconstruction has steadily increased over the last 2 decades. Advantages of allograft include a lack of donor-site morbidity, unlimited available sizes, shorter operative times, availability of larger grafts, smaller incisions, improved cosmesis, lower incidence of postoperative arthrofibrosis, faster immediate postoperative recovery, and less postoperative pain. Disadvantages include the potential for disease transmission and prolonged graft healing. Presented in this article are 2 techniques used at the authors' institution for primary ACL reconstruction with allograft. With the proper indications, knowledge of graft preparation and handling, and technique, allograft tissues in ACL reconstructions can provide the surgeon with clinical results equal to those of autograft reconstructions.