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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
Impact of legislation on frequency of concussion in youth athletes (November 2017)
Laws designed to encourage identification of concussion and to prevent concussed youth athletes from continuing play have been enacted in the past decade in all 50 states of the United States. A new study reports that adoption of these laws has been associated with a decrease in the incidence of recurrent concussions among US high school athletes and has also been associated with increased reporting of new concussions from the prelaw through the postlaw period, likely attributable to increased awareness and identification of concussions . These laws consist of three components: 1) mandatory removal of athletes with confirmed or suspected concussion from play; 2) clearance from a licensed health professional before athletes may return to play; and 3) annual education of coaches, parents, and athletes on the signs and symptoms of concussion. (See "Concussion in children and adolescents: Management", section on 'Impact of legislation'.)
Prevalence of concussion in United States adolescents (October 2017)
A cross-sectional survey of over 13,000 United States middle and high school students found the prevalence of concussion to be approximately 20 percent . Children participating in contact sports are more likely to report having had a concussion (32 percent) compared with those reporting noncontact sports participation (18 percent) or no sports participation (11 percent). Participation in contact sports was also associated with reporting more than one concussion. These findings, consistent with other evidence, indicate that concussion is a common injury that occurs most frequently in adolescent athletes who participate in contact sports such as American football, ice hockey, rugby, or soccer. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Epidemiology'.)
IMAGING AND OTHER DIAGNOSTIC TECHNIQUES
Magnetic resonance imaging for superior labrum anterior posterior shoulder tears (October 2017)
The need for advanced imaging for the diagnosis of superior labrum anterior posterior (SLAP) tears should be decided in consultation with an experienced shoulder surgeon and typically is appropriate only for patients ≤35 years of age who are good surgical candidates. Magnetic resonance arthrogram (MRA), when available, is the preferred imaging technique for diagnosing SLAP tears . In a metaanalysis of 23 studies (over 2000 examinations) that compared modern 3-Tesla MR scanners with older 1.5-Tesla scanners, the diagnostic accuracy of 3-Tesla magnetic imaging (MRA or MRI) was comparable or better than 1.5-Tesla magnetic imaging, but whether 3-Tesla MRI has similar or better diagnostic accuracy than 1.5-Tesla MRA is not known. (See "Superior labrum anterior posterior (SLAP) tears", section on 'Magnetic resonance imaging'.)
MANAGEMENT AND REHABILITATION OF MUSCULOSKELETAL INJURIES
Nonsurgical treatment for shoulder impingement (October 2017)
Impingement is a common cause of shoulder pain and dysfunction, but evidence pertaining to the effectiveness of treatment options is limited. A recent systematic review of randomized trials of nonsurgical interventions for shoulder impingement identified the overall quality of the studies as very low, but found that physical therapy programs that emphasize specific exercises for the rotator cuff and scapular muscles to be among the most effective interventions for improving shoulder function and pain . These findings support our approach to the treatment of this condition. (See "Shoulder impingement syndrome", section on 'Physical therapy'.)
MEDICAL ISSUES RELATED TO SPORTS AND EXERCISE
Risk of sudden cardiac death in athletes (November 2017)
While sudden cardiac death (SCD) is the leading medical cause of death in athletes, its exact incidence remains unclear. Until now, best estimates have suggested an incidence of approximately 1 in 50,000 athlete-years. In a new study using 2009 to 2014 data from a Canadian database recording all out-of-hospital sudden cardiac arrests (SCA) in Ontario, Canada, the overall rate of SCA in athletes was 0.76 per 100,000 athlete-years . With 44 percent of patients surviving to hospital discharge following SCA, the overall rate of SCD was 0.42 per 100,000 athlete-years. These data suggest the incidence of SCD in athletes is one-fourth of previous estimates and raise a question about the role of preparticipation screening. (See "Athletes: Risk of sudden cardiac death", section on 'Incidence of SCD'.)
Long-term cognitive outcomes in American high school football players (October 2017)
Based on increasing concerns about risk of chronic traumatic encephalopathy (CTE) in professional American football players and other athletes, there is a need for studies to determine whether less intensive exposure to high-risk sports poses risk. In a case-control study of nearly 3000 men whose cognitive function was assessed at age 65 years, past participation in high school American football was not associated with worse cognition, mood, or other emotional symptoms compared with non-participation . Although somewhat reassuring, these data have significant limitations, and more longitudinal studies are needed to determine modifiable risk factors for CTE and other forms of dementia. (See "Risk factors for cognitive decline and dementia", section on 'Head trauma'.)
Home use of topical anesthesia to control pain from corneal abrasions (August 2017)
In a retrospective study of 444 patients with corneal abrasions given a 24-hour supply of topical tetracaine at the initial emergency department visit, there were no documented serious complications or uncommon adverse events . However, definitive outcomes were only known for 120 patients who returned for rechecks. Patients receiving topical tetracaine were more likely to return for emergency department reevaluation compared with patients who did not receive tetracaine. Topical analgesia was prescribed inappropriately in one-third of patients, for lesions other than simple corneal abrasion (eg, large corneal abrasions, retained rust rings, herpes keratitis, anterior uveitis, and corneal erosions). Because of the possibility of overuse (ie, use beyond 24 hours) and the risk of inappropriate administration, we favor other means of pain control and discourage the prescribing of topical anesthetic agents. More evidence is needed to establish the safety of this practice in patients with simple corneal abrasions. (See "Corneal abrasions and corneal foreign bodies: Management", section on 'Pain control'.)
Consensus statement from 5th International Conference on Concussion in Sport (July 2017)
Recently, the 5th International Conference on Concussion in Sport published a consensus statement . Concussion remains a clinical diagnosis that is best approached through multidimensional testing. The consensus statement endorses the new 5th edition of the Sport Concussion Assessment Tool (SCAT5) for sideline assessment of athletes 13 and older, and the Child SCAT5 for athletes 5 to 12 years old. Consistent with prior iterations, the statement emphasizes immediate removal from play followed by a careful systematic evaluation whenever concussion is suspected. Athletes diagnosed with a concussion should rest, but strict absolute rest is not necessary, and patients can be encouraged to become more active in a gradual manner as their symptoms permit. (See "Sideline evaluation of concussion" and "Concussion in children and adolescents: Clinical manifestations and diagnosis" and "Acute mild traumatic brain injury (concussion) in adults" and "Sideline evaluation of concussion", section on 'Assessment instruments'.)
PREVENTION AND BIOMECHANICS OF MUSCULOSKELETAL INJURIES
Warmup program and risk of shoulder injuries in team handball (September 2017)
Although it is widely accepted that a proper warmup reduces the risk of injury among overhead throwing athletes, little high-quality evidence is available to inform the design of warmup programs. In a cluster-randomized trial involving 45 elite handball teams and 660 players (a population of throwing athletes with a shoulder injury profile similar to baseball pitchers), a preparticipation warmup consisting of five exercises reduced shoulder injuries (28 percent lower risk) in the intervention group compared with controls over the course of the seven-month season . We suggest that all throwing athletes perform injury prevention exercises regularly, including an appropriate warmup. (See "Throwing injuries of the upper extremity: Treatment, follow-up care, and prevention", section on 'Exercise and throwing programs for treatment and injury prevention'.)
Minimalist running shoes and injury risk (June 2017)
Although running shoes with minimal padding (minimalist shoes) have gained popularity in recent years, few studies of the effects of training in such shoes have been performed. In a recent randomized trial, 61 trained runners with a habitual rearfoot strike were randomly assigned to minimalist or standard running shoes, and then gradually increased the time spent running in the designated shoes over 26 weeks . Of 27 injuries sustained by participants, 16 occurred in runners using minimalist shoes and 11 in runners using conventional running shoes. The risk of injury was increased twofold among runners with increased body mass using minimalist shoes. We suggest that runners over 85 kg (187 pounds) not use minimalist shoes, and that other runners avoid excessive training in such shoes. (See "Overview of running injuries of the lower extremity", section on 'Running barefoot or with minimalist shoes'.)
- Yang J, Comstock RD, Yi H, et al. New and Recurrent Concussions in High-School Athletes Before and After Traumatic Brain Injury Laws, 2005-2016. Am J Public Health 2017; 107:1916.
- Veliz P, McCabe SE, Eckner JT, Schulenberg JE. Prevalence of Concussion Among US Adolescents and Correlated Factors. JAMA 2017; 318:1180.
- Symanski JS, Subhas N, Babb J, et al. Diagnosis of Superior Labrum Anterior-to-Posterior Tears by Using MR Imaging and MR Arthrography: A Systematic Review and Meta-Analysis. Radiology 2017; 285:101.
- Steuri R, Sattelmayer M, Elsig S, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med 2017; 51:1340.
- Landry CH, Allan KS, Connelly KA, et al. Sudden Cardiac Arrest during Participation in Competitive Sports. N Engl J Med 2017; 377:1943.
- Deshpande SK, Hasegawa RB, Rabinowitz AR, et al. Association of Playing High School Football With Cognition and Mental Health Later in Life. JAMA Neurol 2017; 74:909.
- Waldman N, Winrow B, Densie I, et al. An Observational Study to Determine Whether Routinely Sending Patients Home With a 24-Hour Supply of Topical Tetracaine From the Emergency Department for Simple Corneal Abrasion Pain Is Potentially Safe. Ann Emerg Med 2017.
- McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017.
- Andersson SH, Bahr R, Clarsen B, Myklebust G. Preventing overuse shoulder injuries among throwing athletes: a cluster-randomised controlled trial in 660 elite handball players. Br J Sports Med 2017; 51:1073.
- Fuller JT, Thewlis D, Buckley JD, et al. Body Mass and Weekly Training Distance Influence the Pain and Injuries Experienced by Runners Using Minimalist Shoes: A Randomized Controlled Trial. Am J Sports Med 2017; 45:1162.