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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.
ADOLESCENT AND PEDIATRIC SPORTS MEDICINE
Early physical activity following acute concussion in children and adolescents (January 2017)
Although physical rest is routinely recommended after concussion, there are few data to determine whether avoidance of physical activity hastens recovery. In a prospective, multicenter cohort study of over 2400 children who were diagnosed with an acute concussion during an emergency department visit, early physical activity (within seven days of injury) compared with physical rest was associated with a significantly reduced risk of persistent postconcussive symptoms (PPCS) at 28 days . However, the difference in PPCS may be the result of confounding, and clinical trials are needed to confirm this result. We suggest that children and adolescents with concussions adhere to full physical rest until they have no symptoms of concussion (table 1) and normal balance or return to baseline on standardized testing. In the minority of patients with prolonged symptoms beyond seven days after injury, we introduce light, subsymptom threshold aerobic exercise (eg, light stationary bicycling), which can often be tolerated and may improve symptoms. (See "Concussion in children and adolescents: Management", section on 'Physical rest'.)
Multidisciplinary approach to children and adolescents with persistent concussion symptoms (September 2016)
For patients with prolonged post-concussion symptoms, a multidisciplinary approach that includes mental health care by a psychologist or psychiatrist is associated with better outcomes. In a randomized trial of 49 children and adolescents (11 to 17 years of age) with persistent symptoms for one month or longer after a sports-related concussion, collaborative treatment consisting of care management, cognitive-behavioral therapy, and, when needed, psychopharmacologic consultation was associated with significant reductions in postconcussive and depression symptoms at six months when compared to usual treatment . (See "Concussion in children and adolescents: Management", section on 'Persistent symptoms'.)
MANAGEMENT AND REHABILITATION OF MUSCULOSKELETAL INJURIES
Supervised or home exercise therapy following ankle sprain (February 2017)
Early exercise therapy improves outcomes following acute ankle sprain, and some trials of supervised physical therapy have shown benefit. However, a randomized trial involving 503 patients with Grade I and II acute ankle sprains compared usual care (including written instructions about standard interventions and graduated weight bearing activities) with usual care plus supervised physical therapy and found no improved outcome, functional or subjective, at one, three, or six months with the addition of supervised physical therapy . Nevertheless, supervised rehabilitation may be advantageous for patients for whom a faster return to work or sport is especially important. (See "Ankle sprain in adults", section on 'Approach and exercises'.)
Factors associated with longer recovery from hamstring injury (September 2016)
Hamstring injuries vary widely in severity, and therefore general recommendations about returning to sport following such injury are unhelpful. Nevertheless, understanding the factors associated with a prolonged recovery can be useful. According to a systematic review of 24 articles discussing return to play following an acute hamstring injury, clinical factors associated with a prolonged recovery include the following :
●Injuries requiring >1 day before normal ambulation
●Substantial deficits in range of motion
●Extensive or severe injury based on magnetic resonance imaging (MRI) or ultrasound findings
●Stretching- (as opposed to sprinting-) type injury (eg, dance-related)
These factors can be used to identify patients who may have a delayed return (several months) to sport. (See "Hamstring muscle and tendon injuries", section on 'Return to work or sport'.)
Treatment of degenerative meniscal tears (September 2016)
Acute meniscal tears often benefit from surgical treatment, but the appropriate management of chronic, degenerative tears, particularly in middle-aged adults, has been a source of debate. A recent trial randomly assigned 140 middle-aged adults (mean age 49.5) with a degenerative meniscal tear (and no evidence of osteoarthritis on magnetic resonance imaging [MRI]) to receive exercise therapy or partial meniscectomy . The trial found no clinically significant difference in knee function or pain at two years of follow-up. This finding is consistent with several other small randomized trials that have reported no clinically significant benefit from arthroscopic surgery in such patients. In the absence of persistent joint effusions or mechanical dysfunction, we suggest physical therapy as the initial management for middle-aged patients with degenerative meniscal tears. (See "Meniscal injury of the knee", section on 'Chronic degenerative meniscal injury'.)
MEDICAL ISSUES RELATED TO SPORTS AND EXERCISE
Rhabdomyolysis and sickle cell trait (August 2016)
Sickle cell trait is a benign carrier condition with a normal life expectancy. However, concerns have been raised regarding an increased risk of rhabdomyolysis and sudden death with prolonged physical activity. These risks were addressed in a cohort study of almost 50,000 black soldiers in the United States army for whom sickle cell trait status and other clinical information was available . While the risk of rhabdomyolysis was increased (hazard ratio, 1.5), this magnitude of risk is similar to that conferred by obesity or smoking and less than that due to antipsychotic or statin medications. Mortality was not increased over that in black soldiers without sickle cell trait, and the sole death from rhabdomyolysis occurred in an individual without sickle cell trait. Interventions to reduce exertion-related injuries should be aimed at all athletes and members of the military, regardless of sickle cell trait status. (See "Sickle cell trait", section on 'Rhabdomyolysis and sudden death during strenuous physical activity'.)
PREVENTION AND BIOMECHANICS OF MUSCULOSKELETAL INJURIES
Running shoe heel-to-toe drop and injury risk (February 2017)
The role of running shoes in preventing or causing injury remains controversial. In a trial of over 500 recreational runners randomly assigned to use identical running shoes that differed only in drop (the change in height from heel to forefoot) and followed for six months, the overall injury rate did not differ by group . However, in a stratified analysis based on running frequency, the risk of injury was higher in regular runners using low rather than high drop shoes. This finding suggests that some recreational runners may benefit from the reduced impact associated with a larger drop, but further study is needed to confirm this finding. (See "Overview of running injuries of the lower extremity", section on 'Barefoot running, minimalist shoes, and shoe drop'.)
Anticoagulant thromboprophylaxis not warranted in nonmajor lower limb orthopedic surgery (January 2017)
Whether anticoagulation thromboprophylaxis is indicated for patients with lower leg immobilization from below knee casting or undergoing arthroscopy was evaluated in a randomized trial . The rate of symptomatic venous thromboembolism (VTE) was low (<2 percent) and not affected by the administration of anticoagulant prophylaxis. Risk factors in addition to the surgery itself were present among the few patients who did develop thrombus. This trial supports the current recommendation that, for patients with lower leg immobilization due to below knee casting or arthroscopy who do not have additional risk factors for VTE, anticoagulant prophylaxis is not warranted. (See "Prevention of venous thromboembolic disease in surgical patients", section on 'Orthopedic surgery'.)
OTHER PRIMARY CARE SPORTS MEDICINE
Structured exercise program and mobility disability in older adults (January 2017)
The randomized multicenter LIFE study, comparing a structured exercise program with a health information program among sedentary adults aged 70 to 89 years without major mobility disability at baseline, had previously reported that exercise decreased the incidence of major mobility disorder (MMD) and risk for permanent MMD. In a new report, the structured exercise also increased the likelihood of transition from MMD, if it occurred, to no MMD . Preserving mobility is essential for maintaining independence and quality of life among older adults. These findings indicate that exercise both prevents initial mobility disability and promotes restored mobility in those who become disabled. (See "Physical activity and exercise in older adults", section on 'Benefits of physical activity'.)
- Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA 2016; 316:2504.
- McCarty CA, Zatzick D, Stein E, et al. Collaborative Care for Adolescents With Persistent Postconcussive Symptoms: A Randomized Trial. Pediatrics 2016; 138.
- Brison RJ, Day AG, Pelland L, et al. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ 2016; 355:i5650.
- Fournier-Farley C, Lamontagne M, Gendron P, Gagnon DH. Determinants of Return to Play After the Nonoperative Management of Hamstring Injuries in Athletes: A Systematic Review. Am J Sports Med 2016; 44:2166.
- Kise NJ, Risberg MA, Stensrud S, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ 2016; 354:i3740.
- Nelson DA, Deuster PA, Carter R 3rd, et al. Sickle Cell Trait, Rhabdomyolysis, and Mortality among U.S. Army Soldiers. N Engl J Med 2016; 375:435.
- Malisoux L, Chambon N, Urhausen A, Theisen D. Influence of the Heel-to-Toe Drop of Standard Cushioned Running Shoes on Injury Risk in Leisure-Time Runners: A Randomized Controlled Trial With 6-Month Follow-up. Am J Sports Med 2016; 44:2933.
- van Adrichem RA, Nemeth B, Algra A, et al. Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting. N Engl J Med 2016.
- Gill TM, Guralnik JM, Pahor M, et al. Effect of Structured Physical Activity on Overall Burden and Transitions Between States of Major Mobility Disability in Older Persons: Secondary Analysis of a Randomized Trial. Ann Intern Med 2016; 165:833.