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What's new in sports medicine (primary care)

Authors: Jonathan Grayzel, MD, FAAEM, James F Wiley, II, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2020. | This topic last updated: Mar 12, 2020.

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

Harm from early specialization in sports (October 2019)

Prior studies suggest that early sports specialization in youth athletes is associated with
increased injuries and burnout during childhood and adolescence, although long-term
effects are unclear. In a retrospective, observational study of over 740 professional baseball
players in the United States, baseball specialization during high school was associated with
more upper and lower extremity injuries and fewer games played as a professional
compared with players who played multiple sports in high school [1]. These findings suggest
that early specialization in baseball may increase the risk of injury into adulthood. (See
"Throwing injuries: Biomechanics and mechanism of injury", section on 'Youth throwing
athletes' and "Physical activity and strength training in children and adolescents: An
overview", section on 'General guidelines'.)

MANAGEMENT AND REHABILITATION OF MUSCULOSKELETAL

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INJURIES

Subjective assessment of readiness to return to play after ACL surgery (March 2020)

Individuals recovering from anterior cruciate ligament (ACL) surgery often return to play
based on a subjective sense that they are ready, but the safety of this approach is unclear.
In a case-control study of 452 male athletes recovering from ACL surgery, researchers
compared the results of a self-assessment questionnaire concerning psychological
readiness with measures of physical capacity and found little to no correlation between an
athlete's psychological readiness and objective measures of their strength and power [2].
While self-reported readiness is important, objective milestones of strength, mobility, and
agility should be reached before athletes are cleared to return to sport. (See "Anterior
cruciate ligament injury", section on 'Return to activity'.)

Venous thromboembolism after Achilles tendon rupture (January 2020)

Although a known complication, evidence regarding the rates of venous thromboembolism

(VTE) and associated patient risk factors after Achilles tendon rupture (ATR) are lacking.
According to a recent review of a Danish national registry, of the over 28,500 patients who
sustained an ATR between 1997 and 2015, nearly 390 (1.4 percent) were hospitalized for
VTE following treatment [3]. The risk was greatest among individuals with a history of prior
VTE (six to eight times baseline risk) or women using hormonal contraceptives (four to five
times baseline risk). Based upon these findings, patients at highest risk for VTE after ATR
may benefit from preventative thromboprophylaxis. (See "Achilles tendinopathy and tendon
rupture", section on 'Complications'.)

Return to play following ACL reconstruction (November 2019)

The best method for determining when an athlete can return to play following surgery to
reconstruct the anterior cruciate ligament (ACL) is unknown. Often, the decision is based on
the time elapsed since surgery and possibly assessments of knee strength and stability. In a
systematic review of 18 studies that included return-to-sport testing, researchers found that
the evidence supporting published testing criteria is weak and that meeting such criteria
was not associated with a significant reduction in subsequent knee injury overall but was
associated with a lower risk of ACL graft rupture [4]. Further study is needed to learn the
best methods for determining when an athlete can safely return to play following ACL

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surgery. Our recommended approach includes assessments of strength, single-leg balance,

and dynamic function, including sport-specific movements. (See "Anterior cruciate ligament
injury", section on 'Return to activity'.)

Immobilization for stable ankle fractures in adults (October 2019)

Immobilization in a cast (CI) for approximately six weeks is standard treatment for stable
ankle fractures. However, evidence is growing that shorter periods of immobilization may
permit comparable healing with a lower risk of complications. In a randomized, noninferiority
trial of 247 adults with stable fractures of the lateral malleolus, immobilization for three
weeks in a short-leg walking cast or rigid ankle orthosis reduced the short-term loss of ankle
mobility and the risk for deep vein thrombosis compared with CI, without compromising
fracture healing [5]. While further study is needed to confirm these results, three weeks of
immobilization may be a reasonable approach in healthy adults with uncomplicated
fractures. (See "Overview of ankle fractures in adults", section on 'Lateral malleolar
fractures'.)

PREVENTION AND BIOMECHANICS OF MUSCULOSKELETAL INJURIES

Warmup for youth baseball players and risk of throwing injury (November 2019)

Few randomized trials have assessed the effectiveness of warmups for reducing injury in
throwing athletes, particularly youth players. In a cluster randomized trial involving 16
Japanese baseball teams (nearly 240 players, 9 to 11 years of age), teams that performed a
warmup designed to prevent throwing injuries experienced substantially fewer shoulder and
elbow injuries over the ensuing 12 months than teams that performed their usual warmup
(1.7 versus 3.1 injuries per 1000 athlete-exposures) [6]. These findings support the use of a
thrower-specific warmup for youth athletes that includes strength, mobility, and balance
exercises. (See "Throwing injuries of the upper extremity: Treatment, follow-up care, and
prevention", section on 'Active warm-up program for shoulder, arm, and forearm'.)

Nordic hamstring lowering exercises and prevention of hamstring strain (November

2019)

In a recent systematic review and meta-analysis of 15 studies (7 randomized trials) that

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included nearly 8500 athletes who ranged in age from 12 to 40 years and played a number
of different sports, Nordic hamstring lowering exercises (picture 1A-B), either alone or as
part of a more comprehensive prevention program, reduced the overall risk of hamstring
strain by 51 percent [7]. Of note, four studies included in the analysis reported compliance
rates below 50 percent, suggesting that the injury rates may be even lower with better
adherence. These findings support Nordic hamstring lowering as an important exercise to
include in any hamstring injury prevention program. (See "Hamstring muscle and tendon
injuries", section on 'Eccentric hamstring strengthening'.)

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REFERENCES

1. Confino J, Irvine JN, O'Connor M, et al. Early Sports Specialization Is Associated With
Upper Extremity Injuries in Throwers and Fewer Games Played in Major League
Baseball. Orthop J Sports Med 2019; 7:2325967119861101.

2. O'Connor RF, King E, Richter C, et al. No Relationship Between Strength and Power
Scores and Anterior Cruciate Ligament Return to Sport After Injury Scale 9 Months
After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2020; 48:78.

3. Pedersen MH, Wahlsten LR, Grønborg H, et al. Symptomatic Venous

Thromboembolism After Achilles Tendon Rupture: A Nationwide Danish Cohort Study
of 28,546 Patients With Achilles Tendon Rupture. Am J Sports Med 2019; 47:3229.

4. Webster KE, Hewett TE. What is the Evidence for and Validity of Return-to-Sport
Testing after Anterior Cruciate Ligament Reconstruction Surgery? A Systematic
Review and Meta-Analysis. Sports Med 2019; 49:917.

5. Kortekangas T, Haapasalo H, Flinkkilä T, et al. Three week versus six week

immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-
inferiority clinical trial. BMJ 2019; 364:k5432.

6. Sakata J, Nakamura E, Suzuki T, et al. Throwing Injuries in Youth Baseball Players:

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Can a Prevention Program Help? A Randomized Controlled Trial. Am J Sports Med

2019; 47:2709.

7. van Dyk N, Behan FP, Whiteley R. Including the Nordic hamstring exercise in injury
prevention programmes halves the rate of hamstring injuries: a systematic review and
meta-analysis of 8459 athletes. Br J Sports Med 2019; 53:1362.

Topic 101594 Version 9461.0

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GRAPHICS

Nordic lower: Starting position

The Nordic lower exercise strengthens the hamstring muscles and many other
muscles of the posterior kinetic chain. Maintain the thighs and torso in a straight
line throughout the exercise.

Courtesy of Karl Fields, MD; Spencer Copland, MD; and John Tipton, MD.

Graphic 76640 Version 2.0

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Nordic lower: Descent

During the Nordic lower exercise, descent should be steady and gradual. This is
often a difficult exercise for those with a weak posterior chain.

Courtesy of Karl Fields, MD; Spencer Copland, MD; and John Tipton, MD.

Graphic 56698 Version 2.0

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Contributor Disclosures
Jonathan Grayzel, MD, FAAEM Nothing to disclose James F Wiley, II, MD, MPH Nothing to
disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,
these are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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