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What's new in sports medicine (primary care)

What's new in sports medicine (primary care)
Jonathan Grayzel, MD, FAAEM
James F Wiley, II, MD, MPH
Literature review current through: Nov 2022. | This topic last updated: Nov 07, 2022.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.


Visual and vestibular assessments in children with concussion (August 2022)

The American Academy of Pediatrics has released a new policy that highlights vision symptoms in children and adolescents with concussion [1]. The policy provides guidance on the components of a complete evaluation of the visual system after concussion (movie 1 and table 1). It also reviews the importance of identifying visual and vestibular deficits during assessment of concussion to confirm the diagnosis and to identify patients at risk for prolonged symptoms who may benefit from specific academic adjustments or specialist referral. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Physical examination'.)

Management of pediatric torus (buckle) fractures of the wrist (July 2022)

Torus fractures of the wrist are stable compression fractures that are located at the distal metaphysis or the radius or ulna, where the bone is most porous (image 1); treatment is aimed at pain relief and comfort. Immobilization with a splint is the typical approach. In a large multicenter randomized trial (nearly 1000 children 4 to 15 years old), pain at three days was similar for patients assigned to a soft elastic bandage versus splint immobilization and remained equivalent through 42 days of follow-up [2]. Functional recovery was also similar in the two groups. However, 11 percent of children assigned to a soft bandage returned to receive splint immobilization because of pain. Based upon these findings, either a soft elastic bandage or a short-arm splint provides adequate treatment for torus fractures, and the choice of treatment should be in accordance with patient/caregiver preference. Regardless of chosen treatment, clear instructions on pain management are required. (See "Distal forearm fractures in children: Initial management", section on 'Torus (buckle) fracture'.)


Success rates for meniscus repair (October 2022)

Little high-quality evidence is available about surgical repair of a torn meniscus. A newly published meta-analysis of 27 studies (primarily small case series) involving 1630 meniscal repairs reported an overall success rate of 80.5 percent at five years when modern surgical techniques were employed [3]. The study noted that success rates were higher for lateral versus medial meniscus repair (87.4 versus 76.1 percent) and that concomitant anterior cruciate ligament reconstruction did not affect the success of meniscal repair. (See "Meniscal injury of the knee", section on 'Arthroscopic or open surgery'.)

Steroid injection for Achilles tendinopathy (August 2022)

Debate continues about the appropriate role for glucocorticoid injection in the treatment of chronic tendinopathy. In a blinded, randomized trial of 100 patients with Achilles tendinopathy causing symptoms for a minimum of three months and who received exercise therapy, those assigned to glucocorticoid injection experienced greater functional and symptomatic improvement at three and six months compared with patients given placebo injections [4]. However, no significant difference in functional outcomes or tendon thickness was noted at 12 or 24 months. These findings, which are consistent with other studies, support our limited use of glucocorticoid injections as adjunct therapy early in the treatment of chronic tendinopathy. Such injections may be most helpful for patients with persistent pain who are unable to participate in physical therapy. (See "Achilles tendinopathy and tendon rupture", section on 'Local injection therapies'.)

Protein supplementation for fracture healing (July 2022)

While general guidance for patients recovering from a fracture often includes ensuring that protein intake is adequate, very few controlled trials have assessed the role of protein in fracture healing. In a single-center trial of 400 patients with pelvic or extremity fractures requiring surgical repair, those assigned to receive essential amino acid supplementation had lower overall complication rates (30.5 versus 43.8 percent) and significantly less early skeletal muscle wasting than those assigned to standard care and nutrition [5]. While the trial was not completely blinded and further study is needed, these results support guidance for adequate daily protein intake in patients with healing fractures. (See "General principles of definitive fracture management", section on 'Overview and basic measures including nutrition'.)

Management of Achilles tendon rupture (June 2022)

The relative benefits of surgical versus nonoperative management of Achilles tendon rupture are a subject of ongoing research. In a multicenter trial of 526 patients with acute Achilles tendon rupture who were randomly assigned to nonoperative management, minimally invasive surgical repair, or open surgical repair, functional outcomes were not significantly different at 12 months [6]. However, patients managed nonoperatively had a higher rate of rerupture compared with patients managed surgically (6.2 percent versus 0.6 percent). We refer all patients with Achilles tendon rupture for surgical consultation to discuss operative and nonoperative treatment options. Patients wishing to return to heavy labor or a demanding sport that involves sprinting and jumping often opt for surgical repair. (See "Achilles tendinopathy and tendon rupture", section on 'Surgery versus nonoperative treatment'.)


Undiagnosed concussion and long-term sequelae (November 2022)

Few studies have assessed the long-term risks associated with an undiagnosed sports-related concussion (SRC). In an observational study performed by the Concussion Assessment, Research, and Education (CARE) Consortium involving nearly 30,000 collegiate athletes and military personnel, individuals who described having sustained one or more undiagnosed concussions performed significantly worse on multiple neurocognitive assessments at subsequent baseline evaluations compared with those whose previous concussions were diagnosed [7]. These findings suggest possible long-term harm when SRC is not diagnosed promptly and managed appropriately. (See "Clinic-based evaluation of sports-related concussion in older adolescents and adults", section on 'Intrinsic risk factors'.

Return to college academics following concussion (July 2022)

In a multisite, prospective study of >1700 college athletes in the United States with a sports-related concussion (SRC), the median time until return to full academics was six days [8]. Based upon adjusted analysis, athletes who resumed full academic work while still symptomatic were 21.5 percent less likely to return to full sport participation by 14 days and 19.1 percent more likely to experience a prolonged recovery lasting >28 days. Gradual resumption of mental and physical work without exacerbation of symptoms, along with close supervision of this process remain guiding principles for the management of older adolescents and adults recovering from an SRC. (See "Clinic-based management of sports-related concussion in older adolescents and adults", section on 'Return to learn and work'.)

Physical fitness and COVID-19-related morbidity (July 2022)

Evidence is growing that physical fitness confers benefit in those infected with COVID-19. In a retrospective, nationwide study performed in South Africa of over 65,000 people participating in a physical activity rewards program, those with high physical activity levels (>150 minutes/week) suffered substantially lower morbidity from complications of COVID-19 infection than those with low physical activity levels (<60 minutes/week) [9]. Patients with high activity levels prior to becoming infected experienced lower rates of hospitalization, intensive care unit admission, mechanical ventilation, and death. These findings emphasize the importance of maintaining exercise programs during the pandemic. (See "COVID-19: Return to sport or strenuous activity following infection", section on 'Impact of physical fitness on clinical course'.)


Risk factors for quadriceps muscle strain (July 2022)

Evidence regarding risk factors for quadriceps injuries are limited. In a systematic review of 16 prospective observational studies (over 11,000 athletes and 2400 injuries), risk factors for quadriceps strain included competitive match play (versus practice or scrimmage play), previous quadriceps injury, and recent hamstring injury [10]. The dominant kicking leg was disproportionately affected. These results should be interpreted with some caution as the large majority of studies involved elite male athletes participating in football (soccer) or Australian football. However, the findings overall are consistent with prior studies and provide a basis for the current approach to quadriceps strain rehabilitation and prevention. (See "Quadriceps muscle and tendon injuries", section on 'Risk factors for quadriceps injury'.)


Athletic benefit of caffeine supplementation does not diminish with habitual caffeine intake (October 2022)

Research suggests that caffeine supplementation, when taken in appropriate doses, can improve exercise capacity and power in some athletes. Whether habitual caffeine intake diminishes such effects has not been well studied. In a systematic review and meta-analysis of 60 studies (over 1100 athletes) that reported the effects of habitual and supplemental caffeine intake on performance, researchers found that habitual, dietary consumption of caffeine (eg, daily coffee) does not appear to diminish its ergogenic effects when taken as a supplement to improve athletic performance [11]. Consistent with other studies, the review found no added benefit from high doses (6 mg/kg). (See "Nutritional and non-medication supplements permitted for performance enhancement", section on 'Caffeine'.)

Health benefits of strength training in adults (September 2022)

Evidence for the health benefits of strength training continues to grow. In a systematic review and meta-analysis of 16 studies involving over 250,000 participants, strength training was inversely associated with the risk for cardiovascular disease, cancer, diabetes, and all-cause mortality independent of aerobic exercise [12]. The review was limited to prospective studies of individuals ≥18 years without severe health conditions at baseline and a minimum two-year follow-up, and it likely underestimates these associations as not all studies involved robust training methods. These findings support the importance of incorporating strength training into exercise programs for everyone, particularly older adults. (See "Strength training for health in adults: Terminology, principles, benefits, and risks", section on 'Mortality benefit'.)

  1. Master CL, Bacal D, Grady MF, et al. Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment. Pediatrics 2022; 150.
  2. Perry DC, Achten J, Knight R, et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet 2022; 400:39.
  3. Nepple JJ, Block AM, Eisenberg MT, et al. Meniscal Repair Outcomes at Greater Than 5 Years: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2022; 104:1311.
  4. Johannsen F, Olesen JL, Øhlenschläger TF, et al. Effect of Ultrasonography-Guided Corticosteroid Injection vs Placebo Added to Exercise Therapy for Achilles Tendinopathy: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2219661.
  5. Hendrickson NR, Davison J, Glass NA, et al. Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial. J Bone Joint Surg Am 2022; 104:759.
  6. Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med 2022; 386:1409.
  7. Lynall RC, D'Lauro C, Kerr ZY, et al. Optimizing Concussion Care Seeking: The Influence of Previous Concussion Diagnosis Status on Baseline Assessment Outcomes. Am J Sports Med 2022; 50:3406.
  8. Wiebe DJ, Bretzin AC, D'Alonzo BA, and the Ivy League–Big Ten Epidemiology of Concussion Study Investigators. Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League-Big Ten Epidemiology of Concussion Study. Br J Sports Med 2022; 56:801.
  9. Steenkamp L, Saggers RT, Bandini R, et al. Small steps, strong shield: directly measured, moderate physical activity in 65 361 adults is associated with significant protective effects from severe COVID-19 outcomes. Br J Sports Med 2022; 56:568.
  10. Pietsch S, Pizzari T. Risk Factors for Quadriceps Muscle Strain Injuries in Sport: A Systematic Review. J Orthop Sports Phys Ther 2022; 52:389.
  11. Carvalho A, Marticorena FM, Grecco BH, et al. Can I Have My Coffee and Drink It? A Systematic Review and Meta-analysis to Determine Whether Habitual Caffeine Consumption Affects the Ergogenic Effect of Caffeine. Sports Med 2022; 52:2209.
  12. Momma H, Kawakami R, Honda T, Sawada SS. Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies. Br J Sports Med 2022; 56:755.
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