Multicentre evaluation of anxiety and mood among collegiate student athletes with concussion.

Objectives: Mental health problems are a premorbid and postinjury concern among college student athletes. Clinical phenotypes of anxiety and mood disruption are prevalent following mild traumatic brain injury, including concussion, a common sports injury. This work examined whether concussed student athletes with a history of mental health problems and higher symptoms of anxiety and mood disruption at baseline were more likely to have higher postinjury reports of mood and anxiety as well as prolonged resolution of postconcussive symptoms to near-baseline measures. Methods: This was a retrospective cohort study of a multi-institutional database of standardised baseline and postinjury assessments among college student athletes. Anxiety/mood evaluation data among varsity college athletes from four institutions over 1 year were measured and compared at baseline and postconcussion recovery using descriptive statistics and multilevel/mixed-effects analysis. Results: Data from 2248 student athletes were analysed, with 40.6% reporting at least one symptom of anxiety and/or mood disruption at baseline. Of the 150 distinct concussions, 94.7% reported symptoms of anxiety/mood disruption during recovery (recovery time=0-96 days). Higher anxiety/mood scores at baseline were significantly associated with higher scores following concussion (p<0.001). Recovery trajectories of anxiety/mood scores showed different patterns by sex and prolonged recovery. Conclusion: Symptoms of anxiety and mood disruption are common at baseline among college student athletes. These students are at higher risk for symptomatology following injury, representing a screening cohort that may benefit from early counselling. Almost all student athletes will experience symptoms of anxiety and/or mood disruption following concussion.

Risk of Concussion After a Targeting Foul in Collegiate American Football.

BACKGROUND: The targeting rule was adopted by the National Collegiate Athletic Association (NCAA) in 2008 to discourage dangerous contact during collegiate American football competition. Although targeting rules have been emphasized as a means to reduce concussion rates, there is currently no evidence that targeting plays are higher risk for concussion than other plays in American football. PURPOSE: To compare the rate of concussion occurring during targeting versus nontargeting plays in American collegiate football. STUDY DESIGN: Cross-sectional study. METHODS: Concussions occurring in games in the 2016-2019 Pac-12 Conference were classified as having occurred during either (1) a play where a targeting penalty was called or (2) all other plays. Targeting plays were further categorized to either those in which the call was upheld or those overturned by the on-field official after replay review. The number of targeting plays and the total number of plays during games were also recorded. Concussion incidence (per 1000 plays) and risk ratios were calculated. RESULTS: Overall, 538 games with 68,670 plays were reviewed, during which 213 concussions occurred (15 during plays where targeting was called and 198 on other plays) and 141 targeting penalties were called. The incidence of concussion was 106.4/1000 plays for targeting plays (including 141.2/1000 upheld targeting fouls and 53.6/1000 overturned targeting fouls) and 2.9/1000 plays for nontargeting plays. The risk of concussion during targeting plays was 36.9 (95% CI, 22.4-60.7) times greater than that for all other plays. The risk of concussion during targeting plays upheld was 49.0 (95% CI, 28.5-84.2) times greater than that for all other plays. CONCLUSION: Concussion risk was significantly higher during plays in which targeting was called, especially those in which targeting fouls were upheld. CLINICAL RELEVANCE: This study supports eliminating or reducing targeting from American football. The results of this study suggest that players should be screened for concussion after targeting plays are called.

Surveillance testing for SARS-COV-2 infection in an asymptomatic athlete population: a prospective cohort study with 123 362 tests and 23 463 paired RT-PCR/antigen samples.

OBJECTIVE: To assess the diagnostic accuracy of antigen compared with reverse transcriptase (RT)-PCR testing in an asymptomatic athlete screening programme and to monitor infection in college athletes. METHODS: Quidel Sofia-2 SARS-CoV-2 Antigen Tests were performed daily before sports participation for football, basketball, wrestling and water polo from 29 September 2020 to 28 February 2021. Paired RT-PCR and antigen tests were performed at least once a week. Positive antigen tests were confirmed with RT-PCR. RESULTS: 81 175 antigen and 42 187 RT-PCR tests were performed, including 23 462 weekly paired antigen/RT-PCR screening tests in 1931 athletes. One hundred and seventy-two athletes had a positive screening RT-PCR (0.4%), of which 83 (48%) occurred on paired testing days. The sensitivity of antigen tests varied with the frequency of RT-PCR testing and prevalence of COVID-19. The sensitivity of antigen testing was 35.7% (95% CI: 17% to 60%) and specificity 99.8% (95% CI: 99.7% to 99.9%) with once-a-week RT-PCR testing after adjusting for school prevalence. Daily antigen testing was similar to RT-PCR testing two to three times a week in identifying infection. Antigen testing identified infection before the next scheduled PCR on 89 occasions and resulted in 234 days where potentially infectious athletes were isolated before they would have been isolated with RT-PCR testing alone. Two athletic-related outbreaks occurred; 86% of total infections were community acquired. CONCLUSION: Antigen testing has high specificity with a short turnaround time but is not as sensitive as RT-PCR. Daily antigen testing or RT-PCR testing two to three times a week is similar. There are benefits and drawbacks to each testing approach.

Pac-12 CARE-Affiliated Program: structure, methods and initial results.

Sport-related concussion has garnered increasing scientific attention and research over the last decade. Collegiate student-athletes represent an important cohort in this field. As such, the Pac-12 CARE-Affiliated Program (CAP) was formed in 2017 as a regional hub of the Concussion Assessment, Research and Education (CARE) consortium. CAP is multisite, prospective, longitudinal study that aims to improve student-athlete health by identifying factors associated with concussion incidence and recovery and using this knowledge to inform best clinical practices and policy decisions. CAP employed a staggered rollout across the Pac-12, with the first four institutions enrolling in fall 2018. After receiving institutional review board (IRB) approval, these institutions began consenting student-athletes to share clinical concussion and baseline data for research purposes. Athletes completed baseline testing that included a medical questionnaire, concussion history and a battery for clinical concussion assessments. Concussed student-athletes were given the same battery of assessments in addition to full injury and return to play reports. Clinicians at each university worked with a data coordinator to ensure appropriate reporting, and the Pac-12 Concussion Coordinating Unit at the University of Colorado Boulder provided oversight for quality control of the data study wide. During year 1, CAP consented 2181 student-athletes and tracked 140 concussions. All research was conducted with the appropriate IRB approval across the participating Pac-12 institutions. Data security and dissemination are managed by the Presagia Sports Athlete Electronic Health Record software (Montreal, Quebec, Canada) and QuesGen Systems (San Francisco, California, USA).

Evaluating the performance of PROMIS and QuickDASH instruments in an intercollegiate Division 1 athlete population.

BACKGROUND: Athletes demonstrate high levels of physical function, leading to difficulties in patient-reported outcome scoring and interpretation. In particular, the ability of patient-reported outcome (PRO) instruments to adequately discriminate between high levels of upper extremity function-that is, the ceiling effect-is limited. This study evaluated performance characteristics of the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) survey and Patient-Reported Outcomes Measurement Information System (PROMIS) metrics in a population of Division 1 intercollegiate athletes, with specific attention to ceiling effects. METHODS: At a single institution, Division I intercollegiate athletes cleared for full participation in the 2018-2019 season were eligible. The following PROs were collected prospectively via tablet computer: PROMIS upper extremity (UE) computer adaptive test (CAT), PROMIS physical function (PF) CAT, QuickDASH, and QuickDASH Sports/Performing Arts Module. Descriptive statistics, and ceiling and floor effects, were calculated. The proportion of athletes with maximal scores on each PRO were compared to normative values using the 1-sample Wilcoxon signed rank test. RESULTS: A total of 268 participants were included; the mean age was 19.9 ± 1.5 years, 49% were female, and 61% were overhead athletes. Large ceiling effects were observed for the UE CAT (46%), QuickDASH (58%), and QuickDASH Sports Module (82%). The PF CAT demonstrated a relatively low ceiling effect of 6.7%. Athlete scores were all significantly better than published age-matched values from a normative population for all instruments, with the exception of no difference on the QuickDASH for males. DISCUSSION AND/OR CONCLUSION: The PROMIS UE CAT and QuickDash instruments are limited in their ability to assess and discriminate upper extremity function in highly functioning individuals such as Division I athletes. The PROMIS PF CAT, a measure of general physical function, did not suffer from a large ceiling effect.

Comparison of cardiovascular screening in college athletes by history and physical examination with and without an electrocardiogram: Efficacy and cost.

BACKGROUND: Preparticipation screening for conditions associated with sudden cardiac death (SCD) is required in college athletes. Previous cost analyses used theoretical models based on variable assumptions, but no study used real-life outcomes. OBJECTIVE: The purpose of this study was to compare disease prevalence, positive findings, and costs of 2 different screening strategies: history and physical examination alone (H&P) or with an electrocardiogram (H&P+ECG). METHODS: De-identified preparticipation data (2009-2017) from Pacific-12 Conference institutions were abstracted for cardiovascular history questions, cardiovascular physical examination, and ECG result. Secondary testing, cardiac diagnoses, return to play outcomes, and complications from testing were recorded. The costs of screening and secondary testing were based on the Centers for Medicare & Medicaid Services Physician Fee Schedule. RESULTS: A total of 8602 records (4955 H&P, 3647 H&P+ECG) were included. Eleven conditions associated with SCD were detected (2 H&P only, 9 H&P+ECG). The prevalence of cardiovascular conditions associated with SCD discovered with H&P alone was 0.04% (1/2454) compared to 0.24% (1/410) when ECG was added (P = .01) (odds ratio 5.17; 95% confidence interval 1.28-20.85; P = .02). Cost of screening and secondary testing with H&P alone was $130 per athlete and in the ECG-added group was $152 per athlete. The cost per diagnosis was $312,407 in the H&P group and $61,712 in the ECG-added group. There were no adverse outcomes from secondary testing or treatment. CONCLUSION: H&P with the addition of ECG is 6 times more likely to detect a cardiovascular condition associated with SCD than without. The addition of ECG improves the cost efficiency per diagnosis by 5-fold and should be considered at college institutions with appropriate resources.

Game injuries in relation to game schedules in the National Basketball Association.

OBJECTIVES: Injury management is critical in the National Basketball Association (NBA), as players experience a wide variety of injuries. Recently, it has been suggested that game schedules, such as back-to-back games and four games in five days, increase the risk of injuries in the NBA. The aim of this study was to examine the association between game schedules and player injuries in the NBA. DESIGN: Descriptive epidemiology study. METHODS: The present study analyzed game injuries and game schedules in the 2012-13 through 2014-15 regular seasons. Game injuries by game schedules and players' profiles were examined using an exact binomial test, the Fisher's exact test and the Mann-Whitney-Wilcoxon test. A Poisson regression analysis was performed to predict the number of game injuries sustained by each player from game schedules and injured players' profiles. RESULTS: There were a total of 681 cases of game injuries sustained by 280 different players during the three years (total N=1443 players). Playing back-to-back games or playing four games in five days alone was not associated with an increased rate of game injuries, whereas a significant positive association was found between game injuries and playing away from home (p<0.05). Playing back-to-back games and away games were significant predictors of frequent game injuries (p<0.05). CONCLUSIONS: Game schedules could be one factor that impacts the risk of game injuries in the NBA. The findings could be useful for designing optimal game schedules in the NBA as well as helping NBA teams make adjustments to minimize game injuries.

Lower Leg Anterior and Lateral Intracompartmental Pressure Changes Before and After Classic Versus Skate Nordic Rollerskiing.

CONTEXT: Chronic exertional compartment syndrome (CECS) is a debilitating condition resulting in loss of function and a decrease in athletic performance. Cases of CECS are increasing among Nordic skiers; therefore, analysis of intracompartmental pressures (ICPs) before and after Nordic skiing is warranted. OBJECTIVE: To determine if lower leg anterior and lateral ICPs and subjective lower leg pain levels increased after a 20-minute Nordic rollerskiing time trial and to examine if differences existed between postexercise ICPs for the 2 Nordic rollerskiing techniques, classic and skate. DESIGN: Crossover study. SETTING: Outdoor paved loop. PATIENTS OR OTHER PARTICIPANTS: Seven healthy Division I Nordic skiers (3 men, 4 women; age = 22.71 ± 1.38 y, height = 175.36 ± 6.33 cm, mass = 70.71 ± 6.58 kg). INTERVENTION(S): Participants completed two 20-minute rollerskiing time trials using the classic and skate technique in random order. The time trials were completed 7 days apart. Anterior and lateral ICPs and lower leg pain scores were obtained at baseline and at minutes 1 and 5 after rollerskiing. MAIN OUTCOME MEASURE(S): Anterior and lateral ICPs (mm Hg) were measured using a Stryker Quic STIC handheld monitor. Subjective measures of lower leg pain were recorded using the 11-point Numeric Rating Scale. RESULTS: Increases in both anterior (P = .000) and lateral compartment (P = .002) ICPs were observed, regardless of rollerskiing technique used. Subjective lower leg pain increased after the classic technique for the men from baseline to 1 minute postexercise and after the skate technique for the women. Significant 3-way interactions (technique × time × sex) were observed for the anterior (P = .002) and lateral (P = .009) compartment ICPs and lower leg pain (P = .005). CONCLUSIONS: Postexercise anterior and lateral ICPs increased compared with preexercise ICPs after both classic and skate rollerskiing techniques. Lower leg pain is a primary symptom of CECS. The subjective lower leg pain 11-point Numeric Rating Scale results indicate that increases in lower leg ICPs sustained during Nordic rollerskiing may increase discomfort during activity. Our results therefore suggest that Nordic rollerskiing contributes to increases in ICPs, which may lead to the development of CECS.

Utilization of the clinical laboratory for the implementation of concussion biomarkers in collegiate football and the necessity of personalized and predictive athlete specific reference intervals.

BACKGROUND: A continued interest in concussion biomarkers makes the eventual implementation of identified biomarkers into routine concussion assessment an eventual reality. We sought to develop and test an interdisciplinary approach that could be used to integrate blood-based biomarkers into the established concussion management program for a collegiate football team. METHODS: We used a CLIA-certified laboratory for all testing and chose biomarkers where clinically validated testing was available as would be required for results used in clinical decision making. We summarized the existing methods and results for concussion assessment across an entire season to identify and demonstrate the challenges with the eventual integration of a parallel process using blood-based tests for concussion management. We analyzed the results of the biomarkers chosen for trends consistent with the outcome assessments provided from the current concussion management protocols. RESULTS: Baseline samples were collected with three additional post-concussion samples collected at three separate time points from players with a diagnosed concussion (n = 12). A summary of results from currently used concussion assessment tools were compared to the representative biomarkers S100B and NSE results. Nine sport-related concussions occurred during practice and three during play. For S100B, 50 % had follow-up testing results lower than the post-injury result. In contrast, 92 % of NSE follow-up results were lower than post-injury. One hundred percent of the results for S100B and NSE were within the athlete-derived reference intervals upon return-to-play and season end. CONCLUSIONS: The reported workflow provides a framework for the eventual implementation of biomarkers for concussion assessment into existing assessment protocols and strengthens the need for reliance on clinical laboratory testing. Athlete-specific reference intervals will be required to adequately interpret results.

Style of Play and Rate of Concussions in the National Football League.

BACKGROUND: The majority of studies on concussion in the National Football League (NFL) focus on testing, evaluation, and outcomes. Meanwhile, there is a paucity of research on how a team's style of play influences the risk of concussion. HYPOTHESIS: Style of play, such as offensive and defensive strategies, is associated with the rate of concussions in the NFL. STUDY DESIGN: Descriptive epidemiology study. METHODS: The current study retrospectively analyzed data from the 2012 to 2014 NFL regular seasons. Reported numbers of concussions were stratified by each team and each position and were compared based on style of play, including offensive scheme (West Coast offense, Air Coryell offense, or other offensive schemes) and defensive alignment (3-4 or 4-3), attempts statistics, per-drive statistics, and offensive and defensive productions, along with strength of schedule (SoS) and team quality measured by simple rating system (SRS). Data analyses included descriptive statistics, 1-way analysis of variance, correlation analysis, and regression analysis. RESULTS: There were 437 documented concussions during the 2012 to 2014 NFL regular seasons, with a mean 4.6 concussions per season per team. In general, players most involved in pass plays reported more concussions. The number of concussions sustained by offensive players was significantly higher among the teams adopting the West Coast offense (mean, 3.0) than among those utilizing the Air Coryell offense (mean, 1.6; P = .006) or those with non-West Coast offenses combined (mean, 1.9; P = .004). The multiple regression analysis revealed that the West Coast offense or not, SoS, and SRS explained 25.3% of the variance in the number of concussions by offensive players. After accounting for SRS, the West Coast offense was found to be a significant predictor of the number of concussions (P = .007), while there was a tendency for SoS to be inversely associated with the number of concussions (P = .105). None of the variables for attempts statistics, per-drive statistics, and offensive production were significantly associated with the number of concussions in the regression analysis. CONCLUSION: In the NFL, players most involved in pass plays appear to be at increased risk for concussions. The West Coast offense may be associated with a greater risk of concussion. Furthermore, teams with easier schedules may have more players sustaining concussions.

Blood-based biomarkers for traumatic brain injury: evaluation of research approaches, available methods and potential utility from the clinician and clinical laboratory perspectives.

Blood-based biomarkers for traumatic brain injury (TBI) have been investigated and proposed for decades, yet the current clinical assessment of TBI is largely based on clinical symptoms that can vary widely amongst patients, and have significant overlap with unrelated disease states. A careful review of current treatment guidelines for TBI further highlights the potential utility of a blood-based TBI biomarker panel in augmenting clinical decision making. Numerous expert reviews on blood-based TBI biomarkers have been published but a close look at the methods used and the astonishing paucity of validation and quality control data has not been undertaken from the vantage point of the clinical laboratory. Further, the field of blood-based TBI biomarker research has failed to adequately examine sex and gender differences between men and women with respect to the clinical care settings, as well as differences in physiological outcomes of TBI biomarker studies. Discussions of tried-and-true laboratory techniques in addition to a few new ones already operating in the clinical laboratory are summarized with a consideration of their utility in TBI biomarker assessment. In the context of TBI biomarkers, the central concerns discussed in this review are the readiness of the clinical laboratory, the willingness of the research environment and the inherent ability of each to radically affect patient outcomes in TBI.

Interventional spine procedures in athletes.

Back pain is common in athletes and a source of missed time from practice and competition. Pain generators include muscle (strain), ligament (myofascial sprain and strain), intervertebral disc (herniation and degeneration), nerve (radiculopathy), joint (facet and sacroiliac (SI) joint), and bones (pars interarticularis defect). The goal of treatment of an athlete with back pain is to relieve symptoms and facilitate safe but rapid return to play with no change in performance. Initial conservative treatment includes relative rest, anti-inflammatory medications, and physical therapy. The use of interventional spine procedures in athletes with back pain has gained popularity as a nonoperative treatment option. Although there is lack of high-quality evidence of these procedures specifically in athletes, this article will discuss the utility of selective nerve root blocks, epidural steroid injections, intradiscal injections, pars interarticularis injection, facet joint interventions (intraarticular injection, medial branch block, and radiofrequency neurotomy), and SI joint interventions (intraarticular injection and radiofrequency neurotomy).

Hip internal rotation is correlated to radiographic findings of cam femoroacetabular impingement in collegiate football players.

PURPOSE: The objective of this study was to determine whether physical examinations (flexion-abduction-external rotation [FABER], impingement, range-of-motion profiles) could be used to detect the bony abnormalities of femoroacetabular impingement (FAI) in an athletic population. METHODS: We performed a prospective study of 65 male collegiate football players. Both hips were evaluated by 2 orthopaedic surgeons for radiographic signs of FAI. The alpha angle and head-neck offset were measured on frog-leg lateral films. The center-edge angle, acetabular index, crossover sign, and alpha angle were measured on anteroposterior films. Measurements were averaged for both observers. Maximum hip range of motion in flexion (supine) and internal/external rotation (supine, sitting, and prone) was measured with a goniometer. Pain provoked by the impingement and FABER tests was also recorded. Examinations were completed at 2 of 4 stations (2 duplicates), each staffed by 2 clinicians (1 examined and 1 measured). The relation between each range-of-motion and radiographic measure was determined. Data from each station were assessed separately. Only those regressions significant (P < .05) for paired stations were considered clinically significant. RESULTS: The alpha angle and head-neck offset measured on the frog-leg lateral films were significantly correlated (all P < .01) to supine, sitting, and prone internal rotation for all stations. Correlation coefficients ranged from -0.59 to -0.35 for alpha angle and 0.42 to 0.57 for head-neck offset. Although 95% of the hips had at least 1 radiographic sign of FAI, pain was reported in only 8.5% and 2.3% during the impingement and FABER tests, respectively. CONCLUSIONS: Internal rotation correlates to radiographic measures of cam FAI in this cohort of collegiate football players. Football players with diminished internal rotation in whom hip pain develops should be evaluated for underlying cam FAI abnormalities. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Radiographic prevalence of femoroacetabular impingement in collegiate football players: AAOS Exhibit Selection.

BACKGROUND: The prevalence of femoroacetabular impingement may be greater in athletes than in the general population because of increased loading of the hip during sports. This study evaluated the radiographs of collegiate football players in order to quantify the prevalence of femoroacetabular impingement in asymptomatic athletes. METHODS: Sixty-seven male collegiate football players (age, 21 ± 1.9 years) participated in this prospective study. Both hips (n = 134) were evaluated independently by two orthopaedic surgeons for radiographic signs of femoroacetabular impingement. The alpha angle and femoral head-neck offset were measured on frog-leg lateral radiographs. The lateral center-edge angle, acetabular index, crossover sign, and alpha angle were measured on anteroposterior radiographs. Data for continuous variables were averaged between observers prior to assessing prevalence. Cam femoroacetabular impingement was considered to be present if the femoral head-neck offset was <8 mm and/or the alpha angle was >50° on either radiograph. Pincer femoroacetabular impingement was considered to be present if the lateral center-edge angle was >40°, the acetabular index was <0°, and/or a positive crossover sign was detected by both observers. RESULTS: Ninety-five percent of the 134 hips had at least one sign of cam or pincer impingement, and 77% had more than one sign. Twenty-one percent had only one sign of cam femoroacetabular impingement and 57% had both signs. Fifty-two percent had only one sign of pincer femoroacetabular impingement, 10% had two, and 4% had all three signs. Specifically, 72% had an abnormal alpha angle, 64% had a decreased femoral head-neck offset, 61% had a positive crossover sign, 16% had a decreased acetabular index, and 7% had an increased lateral center-edge angle. Fifty percent of all hips had at least one sign of pincer femoroacetabular impingement and at least one sign of cam impingement. Interobserver and intraobserver repeatability was moderate or better for each measure (range, 0.59 to 0.85). CONCLUSIONS: Morphologic abnormalities associated with cam and pincer femoroacetabular impingement were common in these collegiate football players. The prevalence of cam and pincer femoroacetabular impingement was substantially higher than the previously reported prevalence in the general population.

Clinical impression versus standardized questionnaire: the spinal surgeon's ability to assess psychological distress.

BACKGROUND: Psychological distress can affect spine surgery outcomes. A majority of spinal surgeons do not use standardized questionnaires to assess for psychological distress and instead rely on their clinical impressions. The ability of spinal surgeons to properly assess patients with psychological distress has not been adequately evaluated. Our hypothesis was that the clinical impressions of spinal surgeons were not as accurate as a standardized questionnaire in assessing for psychological distress. METHODS: A prospective study was performed with eight physicians, four spinal surgeons and four nonoperative spine specialists, who evaluated 400 patients. All patients completed the Distress and Risk Assessment Method (DRAM) questionnaire for the evaluation of psychological distress. The eight physician subjects, blinded to the results of this questionnaire, performed their routine clinical evaluation and categorized the patients' psychological distress level. The results of the Distress and Risk Assessment Method questionnaire and the surgeons' assessments were compared. RESULTS: In the study population of 400 patients, 64% (254 of 400) were found to have some level of psychological distress. Twenty-two percent (eighty-seven of 400) of the patients were found to have high levels of distress. Overall, the physicians' rate of sensitivity when assessing patients with high levels of distress was 28.7% (95% confidence interval: 19.5%, 39.4%) with a positive predictive value of 47.2% (95% confidence interval: 33.3%, 61.4%). Nonoperative spine specialists had a significantly higher sensitivity rate when assessing highly distressed patients (41.7% [95% confidence interval: 25.5%, 59.2%]) than surgeons (19.6% [95% confidence interval: 9.8%, 33.1%]) (p = 0.03). The sensitivity rates between experienced (greater than ten years in practice) (14.7% [95% confidence interval: 5.0%, 31.1%]) and less experienced (less than two years in practice) (29.4% [95% confidence interval: 10.3%, 56.0%]) spinal surgeons was not significant (p = 0.27). CONCLUSIONS: A large percentage of patients (64%) presenting for spine evaluation have some level of psychological distress. When compared with a standardized questionnaire designed to screen for psychological distress, spinal surgeons had low sensitivity rates to detect this distress. The routine use of a standardized questionnaire to screen for psychological distress should be considered.

Use of knee magnetic resonance imaging by primary care physicians in patients aged 40 years and older.

BACKGROUND: Criteria are needed for primary care providers such that they can evaluate age-related knee pain in a cost-effective manner. This study examined (1) in what percentage of patients are appropriate radiographic views of the knee ordered before magnetic resonance imaging (MRI) for knee pain, (2) specialists' retrospective evaluation for appropriate utilization of MRI in knee pain, and (3) in what manner would the MRIs have altered diagnosis and management of knee disorders. HYPOTHESIS: Primary care providers underuse appropriate radiographs-especially, flexion weightbearing posteroanterior films-and overuse MRIs when evaluating older patients with knee pain. STUDY DESIGN: Case control. METHODS: The authors performed a retrospective analysis of 100 patients older than 40 years with knee MRIs. Patient encounters with primary care physicians were reviewed. Given available information, specialists then formulated a pre- and post-MRI diagnosis and treatment plan and indicated whether the MRI would have altered their treatment. RESULTS: Only 12 of 100 MRIs would have been ordered by an orthopaedist given the documented data. No MRIs would have been ordered in the 19 patients aged 60 years or older. Among 44 radiographs ordered, only 7 were flexion weightbearing. The most common pre-MRI diagnoses made by primary care providers were joint pain (22%) and meniscus injury (24%); the most common post-MRI diagnoses were osteoarthritis (40%) and degenerative meniscus injury (23%). In contrast, the 2 most common pre- and post-MRI diagnoses by specialists were osteoarthritis (28% and 37%, respectively) and degenerative meniscus injury (23% and 24%, respectively). Also, referrals to specialists increased from 9% pre-MRI to 76% post-MRI. CONCLUSION: Primary care providers may be overusing knee MRIs and underusing flexion weightbearing posteroanterior radiographs in patients older than 40 years with knee pain. CLINICAL RELEVANCE: Primary care providers should strongly consider not ordering knee MRI in patients with radiographic evidence of degenerative changes.

Acromioclavicular joint disorders.

The acromioclavicular (AC) joint is a highly used, versatile, and complex joint that provides stability and increases function. Acute and chronic dysfunction at the AC joint can have debilitating effects that should be treated appropriately and expediently to preserve function. The historical, physical examination, and radiographic findings are generally very consistent and lead to both diagnosis and well-established treatment protocols. With few exceptions, injuries can be treated nonoperatively with a high degree of success. When indicated, surgical outcomes are also successful but have an overall higher rate of complications. A physician should be well versed in both acute and chronic conditions to ensure the patient has the best opportunity to reclaim function, return to sport, and avoid pain, restriction in range of motion, and need for further surgery.