Immediate functional progression program in adolescent athletes with a spondylolysis.

OBJECTIVE: To assess the preliminary evidence for the efficacy and safety of an immediate functional progression program to treat adolescent athletes with an active spondylolysis. DESIGN: Prospective single-arm trial. SETTING: Hospital-based sports medicine and physical therapy clinic. PARTICIPANTS: Twelve adolescent athletes (14.2 ± 2 years, 25% female) with an active spondylolysis. MAIN OUTCOME MEASURES: Clinical outcomes included time out of sport, Micheli Functional Scale (Function and Pain) and adverse reactions. Clinical outcomes were assessed at baseline, 1 month, 3 months and 6 months. Magnetic resonance imaging was performed at baseline and 3 months to confirm diagnosis and assess healing of lesion. RESULTS: Eleven participants (92%) fully returned to sport in a median time of 2.5 months (75 days; interquartile range 55 days, 85 days). All participants demonstrated marked improvements in pain and function by the end of the program. One participant (8%) had an adverse reaction during care with a significant recurrence of LBP and had not returned to sport by 6 months. Magnetic resonance imaging demonstrated improvement of the spondylolytic lesion in all but one participant. CONCLUSION: The immediate functional progression program appears a viable method for treating active spondylolysis and warrants future research.

Acute Knee Injuries in Children and Adolescents: A Review.

Importance: Knee injuries in children and adolescents are exceedingly common. When an active youth presents complaining of knee pain, the treating pediatrician should be comfortable with forming a working differential diagnosis and should be able to manage many such injuries or recognize when it is necessary to make an appropriate referral. Observations: Knee injuries typically present after acute trauma. Appreciating the likely etiologies pertaining to a particular case is best achieved with a thorough history and physical examination. This review discusses the etiologies of acute injuries including fractures that are unique to skeletally immature individuals, patellar dislocations, ligamentous injuries, and meniscal tears. Imaging findings and management of these conditions are also reviewed. Conclusions and Relevance: This review summarizes the more common acute knee injuries seen in active children and adolescents. Given how frequently such conditions present, this overview of diagnosis and management will provide a useful resource for the nonspecialist.

An Alternative Model of Care for the Treatment of Adolescent Athletes with Extension-Based Low Back Pain: A Pilot Study.

BACKGROUND AND PURPOSE: Half of adolescent athletes report low back pain (LBP) and there is a significant risk of vertebral injury in this population. The current model of care for adolescent athletes with LBP is to first confirm a medical diagnosis of spondylolysis which frequently requires advanced imaging. However, routine use of advanced imaging increases cost, delays treatment, and can expose the athlete to radiation. PURPOSE: The purpose of this pilot study was to assess the viability of a physical therapist guided functional progression program to manage low back pain (LBP) in adolescent athletes. STUDY DESIGN: Non-randomized, controlled clinical trial. METHODS: Sixteen adolescents (15 ± 1.8 years, 50% female) with extension-based LBP were assigned to the biomedical model or physical therapy first model. The biomedical model sought to determine a spondylolysis diagnosis to guide treatment. In the physical therapy first model, patients began early therapeutic exercise and their ability to functionally progress determined the course of care. Dependent variables were change in Micheli Function Score, use of imagining, days out of sport, and ability to return to sport. Adverse events were monitored in order to assess safety. Descriptive statistics were completed to assess the viability of the alternative model. RESULTS: Both models had similar improvements in pain and function. The physical therapy first model reduced use of advanced imaging by 88% compared to the biomedical model. Patients in the biomedical model who did not sustain a vertebral injury returned to sport sooner than the physical therapy first model (3.4 days versus 51 days), while those with a vertebral injury took longer in the current model (131 days versus 71 days). All of the patients in the physical therapy first model and 88% of patients in the current model made a full return to sport. Two adverse events occurred in the biomedical model, and none were noted in the physical therapy first model. CONCLUSION: This pilot study demonstrated that the physical therapist guided functional progression program may be a viable method for treating young athletes with LBP and further research is warranted. LEVEL OF EVIDENCE: 3b.

Overuse Knee Pain in the Pediatric and Adolescent Athlete.

Overuse knee pain is common in young athletes. There are many potential overuse injuries which present with insidious onset of pain that can challenge sports medicine providers, including Osgood-Schlatter's disease, patellofemoral syndrome, osteochondritis dissecans, and stress fractures. The differential diagnosis of insidious onset knee pain also includes malignancies, infections, and rheumatologic issues. A thorough history and physical examination can guide the treating provider in making a diagnosis and appropriate treatment plan. Although not always necessary, imaging is often helpful in overuse knee pain, and laboratory workup may be necessary. Conservative treatment is often the first recommendation in the management of overuse knee pain in young athletes, and this may include activity modification, ice, anti-inflammatory medications, bracing, and physical therapy. This review summarizes common overuse knee injuries seen in pediatric and adolescent athletes.

Musculoskeletal Low Back Pain in School-aged Children: A Review.

Importance: Low back pain (LBP) in children and adolescents is a common problem. The differential diagnosis of LBP in this population is broad and different from that seen in the adult population. Most causes of LBP are musculoskeletal and benign in their clinical course. Clinicians should have an understanding of the relevant anatomy and the most commonly encountered etiologic factors of LBP in children and adolescents to provide effective care. Observations: Low back pain is rarely seen in youth before they reach school age. Subsequently, rates of LBP rise until age 18 years, at which age the prevalence of LBP is similar to that in adults. The differential diagnosis of LBP in this population is broad, and individual etiologic factors are most often associated with musculoskeletal overuse or trauma. Sinister etiologic factors are rare. The patient's history and physical examination are the foundation of evaluating a child with LBP. The indication for and timing of specific imaging or other studies will vary depending on the etiologic factor of concern. Most treatment of LBP in this population is centered on relative rest, rehabilitation, and identification of predisposing risk factors. Pharmacologic treatment may be used but is typically a brief course. Orthopedic, rheumatologic, and other subspecialty referrals may be considered when indicated, but most of these patients can be managed by a general pediatrician with a good understanding of the principles described in this article. Conclusions and Relevance: Low back pain in children and adolescents is a common problem. It is most often nonspecific, musculoskeletal, and self-limiting. Pediatricians should recognize the importance of a proper history, physical examination, and general knowledge of the lumbar spine and pelvic anatomy relevant to the child in their evaluation with this presenting symptom.

Timing of Physical Therapy Referral in Adolescent Athletes With Acute Spondylolysis: A Retrospective Chart Review.

OBJECTIVES: The purposes of this study were (1) to determine whether the duration of rest before referral to physical therapy (PT) affects the time to make a full return to activity for patients with an acute spondylolysis, (2) to assess the safety of an early referral to PT in patients with an acute spondylolysis. STUDY DESIGN: Retrospective chart review. SETTING: Hospital-based sports medicine clinic. PATIENTS: The medical charts of 196 adolescent athletes (mean age = 14.3 ± 1.8 years) with an acute spondylolytic injury met the inclusion criteria and were reviewed. INDEPENDENT VARIABLE: Patients were subgrouped based on physician referral to PT. PATTERNS: An aggressive referral group (<10 weeks) and a conservative referral group (>10 weeks). MAIN OUTCOME MEASURES: Duration of rest before clearance to a full return to activity and the frequency of adverse reactions during the course of treatment. Safety was assessed by calculating the risk of experiencing an adverse reaction in each group. RESULTS: Median days to a full return to activity for aggressive referral group (115.5 days, interquartile range 98-150 days) and conservative referral group (140.0 days, interquartile range 114.5-168 days) were significantly different (P = 0.002). Eleven patients had adverse reactions during the course of treatment. The risk of adverse reaction was not statistically significant between groups (P = 0.509). CONCLUSIONS: Patients with acute spondylolysis in the aggressive referral group were able to make a full return activity almost 25 days sooner. No differences in the risk of adverse reactions were noted between aggressive and conservative referral groups.

Long-Term Clinical Outcomes and Factors That Predict Poor Prognosis in Athletes After a Diagnosis of Acute Spondylolysis: A Retrospective Review With Telephone Follow-up.

Study Design Retrospective review with telephone follow-up. Background Acute spondylolytic injuries have a dramatic impact on the young athlete. Excellent short-term clinical outcomes have been observed, but not enough is known about long-term clinical outcomes. Objectives (1) To report long-term clinical outcomes for patients diagnosed with acute spondylolysis, and (2) to assess the prognostic ability of retrospective variables for long-term outcomes. Methods Patients from 2010 through 2013 were retrospectively reviewed to identify patients and to obtain demographic, baseline, and short-term outcomes. Long-term follow-up data were collected by telephone from patients diagnosed with acute spondylolysis to assess recurrence rate of low back pain, perceived outcome, pain, and functional ability. Patients were categorized as having a good or poor long-term outcome based on these measures. Logistic regression analysis was performed to assess the prognostic ability of the retrospective variables for long-term outcomes 3.4 years (range, 1.5-5.6 years) after treatment. Results One hundred twenty-one (71.6%) patients completed the follow-up questionnaire (48 female; mean age at baseline, 14.4 years). At follow-up, 81 (66.9%) patients were able to maintain their same or a higher level of sport. Recurrence of significant symptoms was reported by 55 (45.5%) patients, with 41 (33.9%) requiring medical treatment. The final logistic regression model revealed that female sex, adverse reaction during care, and multilevel injury were significant predictors of poor long-term outcome (R2 = 0.22). Conclusion Although excellent short-term outcomes were noted, 42% of patients reported a poor outcome at long-term follow-up. Female sex, multilevel injury, and experiencing an adverse reaction during care were significant predictors of poor long-term clinical outcome for patients diagnosed with acute spondylolysis. Level of Evidence Prognosis, level 4. Registered January 15, 2015 at www.clinicaltrials.gov (NCT02332200). J Orthop Sports Phys Ther 2016;46(12):1029-1036. Epub 8 Nov 2016. doi:10.2519/jospt.2016.7028.

Return to Drive Counseling After Sports-Related Concussion: A Quality Improvement Project.

INTRODUCTION: Concussion is a common injury in adolescent athletes, many of whom also drive. Counseling athletes and their families about driving risks post concussion is a potentially significant intervention. The aim of this quality improvement project was to increase driving recommendations for concussed athletes in a pediatric sports medicine clinic. METHODS: Patients in this quality improvement project were seen in the sports medicine concussion clinic between February 2014 and August 2015. We determined how often driving recommendations were documented through a retrospective chart review. Once the "return to drive" project was introduced to the sports medicine staff, multiple interventions were completed including handing out flyers to remind families about driving and creating changes to the electronic medical record. RESULTS: At baseline, 9.3% of visits had driving recommendations documented. After an intervention requiring clinical documentation in the electronic medical record, 97% of patients received driving recommendations. CONCLUSIONS: The quality improvement effort was successful at increasing the frequency of delivery of appropriate driving recommendations provided to concussed athletes.

Overuse injuries.

Tendinopathy and chronic tendon issues related to tendinosis are conditions difficult to treat. These conditions often lead to patients' quality of life declining because of the inability to participate in exercise, occupation-related activities, and activities of daily living. By better understanding the pathophysiology related to the development of tendinosis, clinicians will be better able to understand the treatment options available and their limitations while allowing novel therapies to be developed. Conservative treatment of tendinosis starting with a sound rehabilitation program seems to be the best place to start while reserving surgical approaches for cases that have failed conservative management.

Infectious disease and the collegiate athlete.

Collegiate athletes are common reservoirs for infectious disease agents. Specific training regimens, living arrangements, and high-risk behaviors may influence the athlete's risk of contracting a variety of infectious diseases. The sports medicine physician plays an important role in recognizing, appropriately treating, designing prevention strategies for, and making return-to-activity decisions for athletes who have infectious diseases.

Iron as an ergogenic aid: ironclad evidence?

Iron supplementation for the iron-depleted nonanemic athlete is a controversial issue. Athletes may be iron deficient due to poor dietary intake, significant or obligatory blood loss, or deficiency via increased need secondary to intense physical activity. Athletes who are found to be anemic secondary to iron deficiency do benefit and show improved performance with appropriate iron supplementation. There is contradictory evidence for iron supplementation and improving performance in the iron-depleted nonanemic athlete. An athlete's iron status is usually monitored via serum ferritin. Currently, there is no standardized ferritin level at which supplementation is recommended, nor is there a consensus as to the appropriate maintenance of ferritin. Screening endurance athletes or female athletes in general for iron deficiency and also educating these athletes regarding the importance of a balanced diet to maximize performance would seem prudent and beneficial. Based on the literature, supplementation for the iron-depleted nonanemic athlete does not appear to be justified to solely improve performance.

Training room management of medical conditions: infectious diseases.

Management of infectious diseases in athletes encompasses a wide range of pathogens, clinical presentations, and treatment options. Certain athletic activities and training regimens may predispose athletes to increased risk of contracting infectious diseases, some of which may limit athletic participation and pose the threat of significant morbidity. The sports medicine physician plays an important role as a first line of defense in preventing, recognizing, and appropriately treating infectious diseases in athletes.