Midsubstance Vastus Lateralis Tear in the Young Athlete: Case Report and a Review of the Literature.

ABSTRACT: Vastus lateralis tendon tear is an infrequent cause of lateral knee pain. Previously reported cases have described acute injury in middle-aged men after eccentric quadriceps contraction. This case report discusses 2 adolescent patients with longitudinal midsubstance tears diagnosed with MRI and dynamic ultrasound and treated successfully with operative intervention.

Prepare for the Unexpected: A New Look at Trauma Triage and Care in Mass Participation Sporting Events.

ABSTRACT: Few sports medicine physicians have extensive experience in managing mass casualty trauma. Yet many, or most, of us find ourselves covering competitions, races, and events in venues where thousands of athletes and spectators gather, and these could quickly become mass casualty events in the setting of an explosion/bombing, active shooter, or similar incident. When this happens, the sports medicine team, already on site, is in a unique position to provide immediate assistance until additional resources arrive. In this article, we will discuss a framework for this initial trauma response to the mass casualty event at a mass participation sporting event.

Human Performance and Injury Prevention in Cold Weather Environments.

ABSTRACT: This article serves as a primer for those practitioners who serve as subject matter experts in cold weather medicine, whether it be medical planning for an outdoor event, making the determination "it is too cold to exercise," or investigating why an athlete is struggling to compete in a frigid environment. Cold weather exercise physiology is reviewed, and medical conditions that may impact performance at cold temperatures are briefly examined. Guidelines for cold weather risk assessment, injury prevention, and performance optimization also are discussed.

Cold Weather Injuries: Initial Evaluation and Management.

ABSTRACT: As more people take to extreme sporting activities and hobbies, the sports medicine physician should be proficient in early identification and initial sideline or field management of cold weather injuries. There is significant mortality and morbidity associated with these conditions. The most severe of these are hypothermia and frostbite, which have limited evidence for their field management. Nonfreezing cold injuries and chilblains are much rarer, although appropriate prevention and treatment strategies can be used to minimize harm to athletes. This article will provide the most updated recommendations for field or sideline evaluation and initial management of hypothermia, frostbite, nonfreezing cold injury, and chilblains.

Applying Pharmacogenomic Guidelines to Combat Medical Care.

Pharmacogenomics is a pillar of personalized medicine that has the potential to deliver optimized treatment in many medical settings. Military medicine in the deployed setting is unique and therefore warrants separate assessment pertaining to its potential capabilities and impact. Pharmacogenomics for United States Active Duty Service Members medical care in the deployed setting has not, to our knowledge, been previously reviewed. We present potential applications of pharmacogenomics to forward medical care through two comprehensive references for deployed medical care, the Tactical Combat Casualty Care Guidelines (TCCC) and Emergency War Surgery (EWS) fifth edition. All drugs within the deployment manuals, TCCC guidelines and EWS book, were identified and the list was cross-referenced to the Clinical Pharmacogenetics Implementation Consortium guidelines and genes-drugs interactions list as well as the Food and Drug Administration Table of Pharmacogenomics Biomarkers in Drug Labeling. Ten pharmacologic categories were identified, consisting of 15 drugs, along with the classes, aminogylcosides, beta-blockers, and volatile anesthetics. Drugs and pharmacogenomics liabilities were tabulated. Eight specific drugs or classes are expounded upon given the belief of the authors of their potential for impacting future treatment on the battlefield in the setting of prolonged field care. This review outlines several genes with liabilities in the prolonged field care setting and areas that may produce improved care with further study.

Femoroacetabular Impingement Syndrome.

Femoroacetabular impingement (FAI) syndrome is one of the most rapidly evolving etiologies of hip pain. The 2016 Warwick Agreement consensus statement defined FAI syndrome as a triad of symptoms, signs, and radiographic findings. Cam morphology is more likely in athletes and is associated with repetitive hip loading in maximal flexion during adolescence. Much less is known about the development of pincer morphology. Physical therapy improves pain and function, justifying a trial before pursuing surgery. Musculoskeletal injections are utilized for FAI syndrome, but the evidence is limited. Arthroscopic surgery for FAI syndrome can correct the morphological changes and address the underlying soft tissue injuries. Recent studies evaluated reliable indicators of surgical outcomes, the most reliable of which is the presurgical presence of osteoarthritis. Recent studies demonstrate the efficacy of surgery, but with the risk of complication and no guarantee of a return to the same level of sport.

Utilization of Botulinum Toxin for Musculoskeletal Disorders.

Rehabilitation from musculoskeletal injuries is challenging with multiple intrinsic and extrinsic factors influencing athletes, conditions, and length of recovery. Multidisciplinary treatment strategies aim to address pathophysiology, mechanical, and psychosocial factors of injuries. An essential element in the recovery from musculoskeletal injuries is pain control and the return of physiologic function. There have been significant advancements in the understanding of pain and, therefore, new techniques and management strategies are being used. Botulinum neurotoxin (BoNT) has demonstrated valuable biopharmaceutical properties to provide neuromuscular blockade, which, in some cases, can help to return biomechanical and functional physiologic loss. There is developing literature in BoNT's ability to block pain in the treatment of painful musculoskeletal conditions. Critical analysis of the literature is necessary given the paucity of high-quality, evidence-based literature in the treatment of these conditions. This article reviews the utilization of BoNT in chronic exertional compartment syndrome, osteoarthritis, lateral epicondylosis, plantar fasciopathy, and myofascial pain syndrome.

Nerve Blocks: Part II. Lower Extremity.

Family physicians use anesthesia to provide diagnostic and procedural analgesia for conditions such as neuropathies, fracture reduction, foreign body removals, and complex wound management. Local infiltration of anesthetics is commonly used in this setting because of the ease of use, safety, and effectiveness of the procedure. Nerve blocks are a specific regional anesthesia technique that blocks nerve function distal to the injection site. An understanding of the sensory distribution of the peripheral nervous system is essential in determining the safest and most effective nerve block for the procedure. There are various nerve block techniques, including landmark-guided and ultrasound-guided. Ultrasound guidance increases the effectiveness of the nerve block while decreasing complications when compared with other techniques. Depending on the required area of anesthesia for the procedure, various points throughout the lower extremity can be used to block the lateral femoral cutaneous, common peroneal, saphenous, tibial, deep peroneal, superficial peroneal, and sural nerves.

Nerve Blocks: Part I. Upper Extremity.

Procedural anesthesia is administered by family physicians for a variety of conditions, including neuropathies, fracture reduction, foreign body removals, and complex wound management. A nerve block may be preferred because it provides effective regional anesthesia with less anesthetic. Nerve blocks require a thorough understanding of relevant anatomy, aiding the physician in optimizing the anesthesia effect while minimizing complications. Nerve blocks can be guided by bony landmarks, peripheral nerve stimulation, or ultrasonography. Ultrasound-guided nerve blocks are superior in decreasing procedural complications and procedure time. Physicians should be aware of these techniques to appropriately counsel their patients on procedural options. Nerve blocks of the ulnar, median, and radial nerves at the wrist and elbow provide effective anesthesia for a wide range of medical procedures in the upper extremity.

Musculoskeletal Therapies: Musculoskeletal Injection Therapy.

Injections often are used in the management of common musculoskeletal conditions. Physicians should understand the disease pathophysiology and evidence supporting available injections when determining appropriate therapy. These therapies include corticosteroid injections (CSIs), hyaluronic acid (HA) injections, hypertonic dextrose prolotherapy, platelet-rich plasma (PRP) injections, mesenchymal stem cell (MSC) injections, and trigger point injections (TPIs). CSIs are recommended conditionally by the American College of Rheumatology for osteoarthritis (OA) management. CSIs are associated with short-term improvement in pain and function in patients with OA, although cartilage volume loss can occur with repetitive, frequent use. CSIs show no long-term benefit in the management of lateral epicondyle pain. For knee OA, HA injection shows prolonged improvement of pain and function compared with CSI. Studies of HA injection for other joints show the injection to be no more effective than placebo. Evidence for prolotherapy and PRP injection shows long-term improvement of pain and function in knee OA and tendinopathies. There is low-quality evidence showing MSC injections improve pain and function in OA and tendinopathies. It is unclear whether TPIs are effective because of a lack of high-quality evidence. Ultrasonography guidance has been shown to improve accuracy of delivery and clinical outcomes in injection therapies.

Treatment of Acute Carpal Bone Fractures.

Carpal bone fractures are common hand fractures that can be complicated by concomitant damage to surrounding structures, chronic comorbidities, or delays in diagnosis. This article provides an overview of wrist anatomy, an expedited review of the athlete's presenting condition, and a systematic approach to the evaluation of the wrist. Recommended treatment plans are based on a review of the literature and an evidence-based approach to imaging studies. It is imperative that sports medicine providers be aware of current literature for carpal bone fractures and collaborate with other medical subspecialties and the athlete to provide recommendations for a safe return to play.