Online Sports Medicine Fellowship Education: The Genesis of a National Program and Year-1 Analysis.

ABSTRACT: The COVID-19 pandemic has created numerous challenges in all walks of life. One such challenge was the strain and subsequent effects on medical education, including the elimination of in-person learning opportunities. Consequently, in March of 2020, a nationwide Sports Medicine fellowship online education series was developed. Presentations were available for live and recorded viewing. Over the course of the 2020-2021 academic year, 38 presentations were offered, covering 45 topics. Live viewership totaled nearly 1600 through the year, while views of recorded lecture reached nearly 34,000. There was no statistical difference in the number of viewers for musculoskeletal versus nonmusculoskeletal topics in either the live (46.50 ± 35.37 vs. 43.38 ± 27.28 viewers, respectively; P = 0.77) or recorded formats (843.60 ± 337.66 vs 876.67 ± 624.70 viewers, respectively; P = 0.85). This article presents the novel approach to sports medicine education by the American Medical Society for Sports Medicine in the 2020-2021 academic year through the genesis the National Online Fellowship Education Program along with analyses of viewership data.

Universal Training Precautions: A Review of Evidence and Recommendations for Prevention of Exercise-Related Injury, Illness, and Death in Warfighters and Athletes.

Facing pressure to train for victory, warfighters and athletes encounter numerous health risks that are directly related to their regular physical training. The concept of universal training precautions (UTPs) signifies universal processes designed to prevent unnecessary bodily harm, including injury, illness, and death, during physical training programs. Although no formal guidelines exist for collectively implementing a defined set of UTPs to address a broad scope of exercise-related health risks, recommendations and guidelines have been published relating to preventing sudden death during high school sports and collegiate conditioning sessions. A long list of critical topics must be considered as UTPs, including physical fitness factors, transition-period accommodation, hydration, environmental factors and acclimatization, appropriate recovery, use of medications and dietary supplements, and importantly, leadership. In this article, we outline in detail, with corresponding Strength of Recommendation Taxonomy ratings, what should be considered universal recommendations to minimize the risk of warfighters and athletes coming to harm when participating in group physical activities.

Clinical Practice Guidelines for Exertional Rhabdomyolysis: A Military Medicine Perspective.

ABSTRACT: Exertional rhabdomyolysis (ER) is an uncommon condition with a paucity of evidence-based guidance for diagnosis, management, and return to duty or play. Recently, a clinical practice guideline for diagnosis and management of ER in warfighters was updated by a team of military and civilian physicians and researchers using current scientific literature and decades of experience within the military population. The revision concentrated on challenging and controversial clinical questions with applicability to providers in the military and those in the greater sports medicine community. Specific topics addressed: 1) diagnostic criteria for ER; 2) clinical decision making for outpatient versus inpatient treatment; 3) optimal strategies for inpatient management; 4) discharge criteria; 5) identification and assessment of warfighters/athletes at risk for recurrent ER; 6) an appropriate rehabilitative plan; and finally, 7) key clinical questions warranting future research.

Exertional Rhabdomyolysis and Sickle Cell Trait Status in the U.S. Air Force, January 2009-December 2018.

Sickle cell trait (SCT) is associated with incident exertional rhabdomyolysis, but its effect on disease progression and severity is poorly understood. Of 377 exertional rhabdomyolysis cases diagnosed between 2009 and 2018 in the active component of the U.S. Air Force, 200 had records available for chart review, and 185 of these had known SCT status. Pre- and post-event data were stratified by SCT status, and serum chemistry changes among SCT-positive (n=11) and SCT-negative (n=174) airmen were compared using Wilcoxon-Mann-Whitney tests. Of the 200 cases with records available for chart review, 110 (55.0%) were hospitalized; 98 (56.3%) of the 174 who were SCT-negative were hospitalized. Also hospitalized were 4 (36.4%) of the 11 who were SCT-positive, and 8 (53.3%) of the 15 with unknown SCT status. Of the 7 airmen who were admitted to intensive care, 4 required hemodialysis, and 1 underwent a fasciotomy; all 7 were SCT-negative. Alterations in creatine kinase, potassium, creatinine, troponin I, and hemoglobin were statistically equivalent between those with and without SCT. Providers should maintain a high index of suspicion for exertional rhabdomyolysis, especially in warm climates and in the context of high-intensity activities, but should not presume that the presence of SCT portends a higher risk of complications or worse clinical outcomes.

Summit on Exercise Collapse Associated with Sickle Cell Trait: Finding the "Way Ahead".

ABSTRACT: Although largely benign, sickle cell trait (SCT) has been associated with exertion-related events, to include sudden death. In 2011, a summit on SCT introduced the term exercise collapse associated with SCT (ECAST). A series of ECAST deaths in military personnel in 2019 prompted reevaluation of current efforts and led to a second summit in October 2019 hosted by the Consortium for Health and Military Performance of the Uniformed Services University in Bethesda, MD. The goals were to (1) review current service policies on SCT screening, (2) develop draft procedural instructions for executing current policy on SCT within the Department of Defense, (3) develop draft clinical practice guidelines for management of ECAST, (4) establish a framework for education on SCT and ECAST, and (5) prepare a research agenda to address identified gaps.

Outcomes of Embedded Athletic Training Services Within United States Air Force Basic Military Training.

CONTEXT: Musculoskeletal injury is the leading cause of attrition from military training. OBJECTIVE: To assess the effect of an embedded athletic training musculoskeletal care model within a basic military training unit. DESIGN: Cluster randomized trial. SETTING: United States Air Force Basic Military Training, Joint Base San Antonio-Lackland. PATIENTS OR OTHER PARTICIPANTS: Military recruits randomly assigned to 1 of 3 training squadrons, 2 control and 1 experimental, between January 2016 and December 2018. INTERVENTION(S): A sports medicine care model was established in 1 squadron by embedding 2 certified athletic trainers overseen by a sports medicine fellowship-trained physician. The athletic trainers diagnosed and coordinated rehabilitation as the primary point of contact for recruits and developed interventions with medical and military leadership based on injury trends. MAIN OUTCOME MEASURE(S): Recruit attrition from basic training due to a musculoskeletal injury. Secondary outcomes were all-cause attrition, on-time graduation, rates of lower extremity injury and stress fracture, rates of specialty care appointments, and fiscal costs. RESULTS: Recruits in the athletic training musculoskeletal care arm experienced 25% lower musculoskeletal-related attrition (risk ratio = 0.75 [95% CI = 0.64, 0.89]) and 15% lower all-cause attrition (risk ratio = 0.85 [95% CI = 0.80, 0.91]), translating to a net saving of more than $10 million. The intervention reduced the incidence of lower extremity stress fracture by 16% (rate ratio = 0.84 [95% CI = 0.73, 0.97]). CONCLUSIONS: An embedded athletic training musculoskeletal care model outperformed usual care across operational, medical, and fiscal outcomes.

Overstride-Induced Medial Knee Desmopathy: An Exploration Case Series.

Nine runners with varied experience but similar running-gait forms presented with the insidious and progressive onset of medial knee pain. Functional tightness of the semimembranosus (SM) tendon appeared to be a concomitant factor in the pain presentation of these patients. When evaluating atraumatic medial knee pain in runners, clinicians must consider bone stress injuries and atypical conditions. A functionally tight SM may induce pain and desmopathy of the medial collateral ligament through direct fiber entanglement or cause entrapment of infrapatellar branches of the saphenous nerve or both. Relieving SM tension resulted in short-term pain reduction while eliminating the overstride during the running gait over the long term appeared to prevent recurrence.

Evaluating an Algorithm and Clinical Prediction Rule for Diagnosis of Bone Stress Injuries.

BACKGROUND: A novel algorithm and clinical prediction rule (CPR), with 18 variables, was created in 2014. The CPR generated a bone stress injury (BSI) score, which was used to determine the necessity of imaging in suspected BSI. To date, there are no validated algorithms for imaging selection in patients with suspected BSI. HYPOTHESIS: A simplified CPR will assist clinicians with diagnosis and decision making in patients with suspected BSI. STUDY DESIGN: Prospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 778 military trainees with lower extremity pain were enrolled. All trainees were evaluated for 18 clinical variables suggesting BSI. Participants were monitored via electronic medical record review. Then, a prediction model was developed using logistic regression to identify clinical variables with the greatest predictive value and assigned appropriate weight. Test characteristics for various BSI score thresholds were calculated. RESULTS: Of the enrolled trainees, 204 had imaging-confirmed BSI in or distal to the femoral condyles. The optimized CPR selected 4 clinical variables (weighted score): bony tenderness (3), prior history of BSI (2), pes cavus (2), and increased walking/running volume (1). The optimized CPR with a score ≥3 yielded 97.5% sensitivity, 54.2% specificity, and 98.2% negative predictive value. An isolated measure, bony tenderness, demonstrated similar statistical performance. CONCLUSION: The optimized CPR, which uses bony tenderness, prior history of BSI, pes cavus, and increased walking/running volume, is valid for detecting BSI in or distal to the femoral condyles. However, bony tenderness alone provides a simpler criterion with an equally strong negative predictive value for BSI decision making. CLINICAL RELEVANCE: For suspected BSI in or distal to the femoral condyles, imaging can be deferred when there is no bony tenderness. When bony tenderness is present in the setting of 1 or more proven risk factors and no clinical evidence of high-risk bone involvement, presumptive treatment for BSI and serial radiographs may be appropriate.

Association of Sickle Cell Trait and Hemoglobin S Percentage with Physical Fitness.

PURPOSE: This study aimed to determine the association between sickle cell trait (SCT) as a binary variable and hemoglobin S percentage as a stratified categorical variable with aerobic and anaerobic fitness. METHODS: This retrospective cohort study included all recruits who entered US Air Force Basic Training between January 2009 and December 2014. Fitness parameters among recruits with and without SCT were compared using a standardized fitness assessment of a 1.5-mile timed run, 1 min of push-ups, and 1 min of sit-ups. Performance was further compared by stratifying those with SCT by their hemoglobin S percentage (20%-29.99%, 30%-39.99%, and ≥40%). RESULTS: Of all recruits (N = 210,461) who entered training during the surveillance period, 2161 (1.0%) had SCT. After adjusting for age, sex, race, body mass index, and ambient temperature while conducting the fitness assessment, recruits with SCT were slower on their initial run than their peers without SCT by a mean (standard error) of 9.4 s (2.6 s) (P < 0.001) and completed 0.5 (0.3) fewer push-ups (P < 0.05); sit-up completion was statistically equivalent between the two groups. When retested 6 wk later, recruits with SCT improved their run time by a margin of 4.3 s (2.1 s) over their counterparts without SCT (P < 0.05). Baseline physical fitness was largely consistent across strata of hemoglobin S percentages; increased percentages were modestly correlated with faster run times (R = 0.374) and fewer push-ups (R = 0.339). CONCLUSIONS: As compared with their peers, recruits with SCT had slightly inferior aerobic fitness and similar anaerobic fitness at the outset of basic training, and gaps further narrowed over 6 wk of training. Stratifying recruits by their hemoglobin S percentage did not dramatically change the strength or direction of association.

Consensus Statement- Prehospital Care of Exertional Heat Stroke.

Exertional heat stroke (EHS) is one of the most common causes of sudden death in athletes. It also represents a unique medical challenge to the prehospital healthcare provider due to the time sensitive nature of treatment. In cases of EHS, when cooling is delayed, there is a significant increase in organ damage, morbidity, and mortality after 30 minutes, faster than the average EMS transport and ED evaluation window. The purpose of this document is to present a paradigm for prehospital healthcare systems to minimize the risk of morbidity and mortality for EHS patients. With proper planning, EHS can be managed successfully by the prehospital healthcare provider.

Abdominal Circumference Versus Body Mass Index as Predictors of Lower Extremity Overuse Injury Risk.

BACKGROUND: Abdominal circumference (AC) is superior to body mass index (BMI) as a measure of risk for various health outcomes. Our objective was to compare AC and BMI as predictors of lower extremity overuse injury (LEOI) risk. METHODS: Retrospective review of electronic medical records of 79,868 US Air Force personnel over a 7-year period (2005-2011) for incidence of new LEOI. Subjects were stratified by BMI and AC. Injury risk for BMI/AC subgroups was calculated using Kaplan-Meier curves and Cox proportional-hazards regression. Receiver operating characteristic curves with area under the curve were used to compare each model's predictive value. RESULTS: Cox proportional-hazards regression showed significant risk association between elevated BMI, AC, and all injury types, with hazard ratios ranging 1.230-3.415 for obese versus normal BMI and 1.665-3.893 for high-risk versus low-risk AC (P < .05 for all measures). Receiver operating characteristic curves with area under the curve showed equivalent performance between BMI and AC for predicting all injury types. However, the combined model (AC and BMI) showed improved predictive ability over either model alone for joint injury, overall LEOI, and most strongly for osteoarthritis. CONCLUSIONS: Although AC and BMI alone performed similarly well, a combined approach using BMI and AC together improved risk estimation for LEOI.

Preventing Exertional Death in Military Trainees: Recommendations and Treatment Algorithms From a Multidisciplinary Working Group.

Despite aggressive prevention programs and strategies, nontraumatic exertional sudden death events in military training continue to prove a difficult challenge for the Department of Defense. In November 2014, the 559th Medical Group at Joint Base San Antonio-Lackland, Texas, hosted a working group on sudden exertional death in military training. Their objectives were three-fold: (1) determine best practices to prevent sudden exertional death of military trainees, (2) determine best practices to establish safe and ethical training environments for military trainees with sickle cell trait, and (3) develop field-ready algorithms for managing military trainees who collapse during exertion. This article summarizes the major findings and recommendations of the working group.

Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries.

CONTEXT: Lower extremity stress fractures among athletes and military recruits cause significant morbidity, fiscal costs, and time lost from sport or training. During fiscal years (FY) 2012 to 2014, 1218 US Air Force trainees at Joint Base San Antonio-Lackland, Texas, were diagnosed with stress fracture(s). Diagnosis relied heavily on bone scans, often very early in clinical course and often in preference to magnetic resonance imaging (MRI), highlighting the need for an evidence-based algorithm for stress injury diagnosis and initial management. EVIDENCE ACQUISITION: To guide creation of an evidence-based algorithm, a literature review was conducted followed by analysis of local data. Relevant articles published between 1995 and 2015 were identified and reviewed on PubMed using search terms stress fracture, stress injury, stress fracture imaging, and stress fracture treatment. Subsequently, charts were reviewed for all Air Force trainees diagnosed with 1 or more stress injury in their outpatient medical record in FY 2014. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: In FY 2014, 414 trainees received a bone scan and an eventual diagnosis of stress fracture. Of these scans, 66.4% demonstrated a stress fracture in the symptomatic location only, 21.0% revealed stress fractures in both symptomatic and asymptomatic locations, and 5.8% were negative in the symptomatic location but did reveal stress fracture(s) in asymptomatic locations. Twenty-one percent (18/85) of MRIs performed a mean 6 days (range, 0- 21 days) after a positive bone scan did not demonstrate any stress fracture. CONCLUSION: Bone stress injuries in military training environments are common, costly, and challenging to diagnose. MRI should be the imaging study of choice, after plain radiography, in those individuals meeting criteria for further workup.

Description and Rate of Musculoskeletal Injuries in Air Force Basic Military Trainees, 2012-2014.

CONTEXT: Musculoskeletal injuries are common in military trainees and have significant medical and operational effects. OBJECTIVE: To provide current musculoskeletal injury epidemiology data for US Air Force basic military trainees. DESIGN: Descriptive epidemiologic study with cross-sectional features. SETTING: US Air Force Basic Military Training, Joint Base San Antonio-Lackland, Texas. PATIENTS OR OTHER PARTICIPANTS: All recruits who entered training between July 1, 2012, and June 30, 2014. MAIN OUTCOME MEASURE(S): Incidence density rate of all musculoskeletal injuries (stratified by body region and type) and factors and costs associated with injuries. RESULTS: Of the 67 525 trainees, 12.5% sustained 1 or more musculoskeletal injuries. The overall incidence density rate was 18.3 injuries per 1000 person-weeks (15.1 for men and 29.4 for women). The most common diagnosis (n = 2984) was Pain in joint, lower leg, as described in the International Classification of Diseases, Ninth Revision, Clinical Modification, code 719.46. Injuries were more common among those with lower levels of baseline aerobic and muscular fitness. Injured trainees were 3.01 times (95% confidence interval = 2.85, 3.18) as likely to be discharged, and injured trainees who did graduate were 2.88 times (95% confidence interval = 2.72, 3.04) as likely to graduate late. During the surveillance period, injuries resulted in more than $43.7 million in medical ($8.7 million) and nonmedical ($35 million) costs. CONCLUSIONS: Musculoskeletal injuries, predominantly of the lower extremities, have significant fiscal and operational effects on Air Force Basic Military Training. Further research into prevention and early rehabilitation of these injuries in military trainees is warranted.