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Cardiac sequelae after COVID-19 have been described in athletes, prompting the need to establish a return-to-play (RTP) protocol to guarantee a safe return to sports practice. Sports participation is strongly associated with multiple short- and long-term health benefits in children and adolescents and plays a crucial role in counteracting the psychological and physical effects of the current pandemic. Therefore, RTP protocols should be balanced to promote safe sports practice, particularly after an asymptomatic SARS-CoV-2 infection that represents the common manifestation in children. The present consensus document aims to summarize the current evidence on the cardiac sequelae of COVID-19 in children and young athletes, providing key messages for conducting the RTP protocol in paediatric athletes to promote a safe sports practice during the COVID-19 era.

The purpose of this study was to analyze patients that did not return to play (RTP) following arthroscopic Bankart repair (ABR) compared to those who did RTP, and analyze factors associated with not returning to play.A retrospective review of patients who underwent ABR, and subsequently did not RTP after a minimum of 24-month follow-up was performed. Additionally, these were pair matched in a 3:1 ratio for age, gender, sport and level of pre-operative play with a control group who RTP. Patients were evaluated for their psychological readiness to return to sport using the SIRSI score. Multivariate regression models were used to evaluate factors affecting RTP.The study included a total of 52 patients who were unable to RTP and 156 who returned to play. Ten patients (19.2 %) who did not RTP passed the SIRSI benchmark of 56 with a mean overall score of 39.8 ± 24.6, in those who returned 73.0 % passed the SIRSI benchmark of 56 with a mean overall score of 68.9 ± 22.0 (p 0.0001 for both). The most common primary reasons for not returning were 27 felt physically unable to return, whilst 21 felt it was a natural end to their career or their lifestyle had changed. Multi-logistic regression revealed that 4 of the 12 components of the SIRSI score (p 0.05 for all) and SSV (p = 0.0049), were the factors that were associated with RTP.Following ABR, those that do not return to play exhibit poor psychological readiness to return to play, with multi-linear regression revealing the SIRSI questions associated with fear of re-injury were associated with a lower rate of RTP. Additionally, functional limitations were found to be associated with a lower rate of RTP.Level III; Retrospective Comparative Cohort Study.

PurposeThe purpose of this systematic review was to summarize the available data on how surgical management of injuries to the thumb ulnar collateral ligament (UCL) complex affects athletes and their return-to-play (RTP) and postinjury performance metrics in addition to evaluating rehabilitation guidelines.MethodsA systematic search was performed on PubMed and Embase databases for articles on outcomes of surgical treatment of thumb UCL injuries in athletes. Articles with expert recommendations on postoperative management and RTP guidelines were also included separately. Study characteristics were recorded, including sport, RTP rates, and data on performance. Recommendations were summarized by sport. The Methodological Index for Non-Randomized Studies (MINORS) criteria was used to assess methodological quality. The authors also present their recommended return-to-sport algorithm.ResultsTwenty-three articles were included, including 11 with reports on patients and 12 expert opinions on guiding RTP. The mean MINORS score for the applicable studies was 9.4. In the 311 patients included, RTP was 98.1% in aggregate. No performance detriments were noted in athletes after surgery. Thirty-two (10.3%) patients had postoperative complications. The recommendations on timing to RTP vary by sport and author, but all recommended initial thumb protection when returning to sport. Newer techniques, such as suture tape augmentation, suggest the permission for earlier motion.ConclusionsReturn-to-play rates after surgical treatment of thumb UCL injuries are high, with reassuring return to preinjury level of play with few complications. Recommendations for surgical technique have trended toward suture anchors and, now, suture tape augmentation with earlier motion protocols, although rehabilitation guidelines vary by sport and author. Current information on thumb UCL surgery in athletes is limited by the low quality of evidence and expert recommendations.Type of study/level of evidencePrognostic IV.

The scoping review is examining the information around return to play/school following a concussion in age grade rugby players. Additionally the review will look at on and off field assessments and how well supported they are by research to diagnose and suggest appropriate return to play/school guidelines.

Context: The COVID-19 pandemic has had catastrophic impact on a global scale, affecting people from all walks of life including elite athletes. Objectives: The purpose of this study was to evaluate the reported rates of return to play (RTP) in conjunction with the expert-derived guidelines previously recommended to enable safe RTP post COVID-19 infection. Evidence Acquisition: Two independent reviewers searched the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, utilizing the MEDLINE, Embase, and Scopus databases. Only studies that reported rates of RTP and/or recommended guidelines for safe RTP were included. Evidence Synthesis: Overall, 17 studies (3 level III and 14 level V) were included. A total of 3 studies reported rates of RTP in a total of 1255 athletes and 623 officials; 72 (30 symptomatic) were infected with COVID-19, 100% of whom were able to RTP post COVID-19 infection. Of the 14 studies recommending guidelines for safe RTP, 3 and 9 studies recommended 7 and 14 days of rest in isolation respectively for asymptomatic patients with COVID-19 infection, prior to safe RTP. In contrast, 7 studies recommended 3 to 6 months of rest (following 14 d isolation) in cases of COVID-19-induced myocarditis as a safe timeframe for safe RTP. Of the 11 studies reporting on whether blanket testing prior to RTP was recommended, only 7 studies recommended a negative test result as mandatory prior to RTP for athletes previously infected with COVID-19. Conclusions: Although excellent rates of RTP have been reported for elite athletes post COVID-19 infection, discrepancies in recommended rest periods, requirement for mandatory negative test results, and the magnitude of screening investigations required continue to exist in the literature, with a need for further standardized international guidelines required in future. Level of Evidence: Level V; systematic review of all forms of evidence.

Recreational sports are more popular, with many athletes involved year-round in multiple sports and on multiple teams. Most athletes do not take proper rest, making them more susceptible to stress-related injuries. There are numerous sports-related injuries in the foot and ankle. These issues can be non-traumatic, due to chronic repetitive stresses, or traumatic. Most of these injuries are managed conservatively, and athletes do well and return to play, while some do better with operative management. This article discusses a few of the sports injuries that are common in the leg, foot, and ankle and the recovery process.

This case report describes the process of returning to play as a case of exertional rhabdomyolysis caused by excessive training by a national rugby player. The authors reported the serum analysis, urinalysis, visual analog scale for pain, and lower-extremity functional scale. The aspartate aminotransferase, alanine transaminase, and myoglobin levels in the serum analysis decreased normally during the eighth day, and creatine phosphokinase levels decreased to normal levels by the 15th day. The maximal scale of visual analog scale for pain was 10 from the third day to the fifth day, and gradually decreased from the sixth day (scale = 6.6) to the 13th day (scale = 0.9). The lower-extremity functional scale scores after the diagnosis of exertional rhabdomyolysis were 0 at the third day, 47 at the 10th day, and 80 at the 24th day. A moderate increase in water intake could help the player recover faster. To restore overall body condition for rugby performance, specific athletic therapy and training should be provided at a predetermined specific time.

To document incidence rate and severity of specific sub-categories of respiratory tract illness (RTill) in rugby players during the Super Rugby tournament.Cross-sectional study.Team physicians completed daily illness logs in 537 professional male rugby players from South African teams participating in the Super Rugby Union tournaments (2013-2017) (1141 player-seasons, 102,738 player-days). The incidence rate (IR: illness episodes/1000 player-days) and severity [%RTill resulting in time-loss, illness burden (IB: days lost to illness/1000 player-days) and days until return-to-play (DRTP)/single illness (mean: 95% Confidence Intervals)] are reported for the following specific sub-categories of RTill: non-infective respiratory tract illness (RTnon-inf), respiratory tract infections (RTinf), influenza-like illness, infective sinusitis, upper respiratory tract infections (URTinf), lower respiratory tract infections (LRTinf).The overall IR of RTill was 2.9 (2.6-3.3). IR was higher for RTinf (2.5; 2.2-2.9) vs. RTnon-inf (0.4; 0.3-0.6) (p 0.001). For sub-categories the highest IR was in URTinf (1.9; 1.7-2.2), while the % illness causing time-loss was influenza-like illness (100%), LRTinf (91.7%), infective sinusitis (55.6%), and URTinf (49.0%). IB was highest for URTinf (2.0; 1.6-2.5), and the DRTP/single illness was highest for LRTinf (3.2; 2.3-4.4), and influenza-like illness (2.1; 1.6-2.8).RTinf accounted for57% of all illness during the Super Rugby tournament, and mostly URTinf. Influenza-like illness. LRTinf caused time-loss in90% cases. URTinf, LRTinf and influenza-like illness resulted in the highest burden of illness and LRTinf caused the highest DRTP. Prevention strategies should focus on mitigating the risk of RTinf, specifically URTinf, LRTinf and influenza-like illness.

Background Achilles tendon rupture is one of the most common serious injuries in athletes. Various studies to accelerate the healing process of the Achilles tendon have been performed as it takes a longer time to repair the tissue compared to other tendons. Here, we report a case of an acute Achilles tendon rupture in a male basketball player treated by a combination of an intra-tissue injection of freeze-dried platelet-derived factor concentrate, which included a platelet-derived growth factor with an early rehabilitation protocol after the operative treatment to facilitate the biological healing of the injured tendon tissue. To the best of our knowledge, this case is the first instance that enabled the athlete to return to original sport activity at only 3-months after the injury. Case report A 23-year-old male basketball player who belonged to a university basketball team sustained an Achilles tendon rupture during running in a training match. The remaining time period until the final tournament of the university league as a senior player was only 3 months. The patient received a combination of an intra-tissue injection of freeze-dried platelet-derived factor concentrate and early rehabilitation protocol after operative treatment. Surgery was performed 4 days after the injury and the early rehabilitation protocols were applied postoperatively. A freeze-dried platelet-derived factor concentrate was injected into the ruptured site of the Achilles tendon under ultrasound guide at 4 weeks postoperatively. The patient could return to play at the pre-injury level without any symptoms and disfunctions at 3 months after surgery. At two years postoperatively, the patient could play basketball without symptoms or rerupture. Conclusions We reported a case of an Achilles tendon rupture which was treated by a combination of intra-tissue injection of freeze-dried platelet-derived factor concentrate and an early rehabilitation protocol after the operative treatment. The patient could return to play basketball at the pre-injury activity level at only 3-months after the injury, suggesting that the role of applying excessively early rehabilitation of mechanical loading could facilitate tendon tissue healing when combined with an intra-tissue injection of freeze-dried platelet-derived factor concentrate., Highlights • FD-PFC has rich growth factors such as PDGF-BB, which is a part of the PDGF growth family. • An achilles tendon rupture was treated by a combination of injection of FD-PFC and excessively postoperative rehabilitation. • The patient could return to play basketball at the pre-injury activity level at only 3-months after the injury.

Heat tolerance testing (HTT) has been developed to assess readiness for work or exercise in the heat based on thermoregulation during exertion. Although the Israeli Defense Force protocol has been the most widely utilized and referenced, other protocols and variables considered in the interpretation of the test are emerging. Therefore, the purpose of this "Current Clinical Concepts" manuscript is to summarize the role of HTT following an exertional heat stroke (EHS), assess the validity of HTT, and to provide a review of best practice recommendations to guide clinicians, coaches and researchers in the performance, interpretation, and future direction of HTT. Furthermore, we will provide the strength of evidence for these recommendations using the Strength of Recommendation Taxonomy system.

Research suggests coaches play a central role in establishing a context conducive to concussion reporting, particularly via direct verbal communication about concussion. Informed by qualitative int...

Hamstring muscle injuries are common amongst athletes and can result in significant time away from sport. This review article evaluates and discusses the current literature on magnetic resonance imaging (MRI) vs. musculoskeletal ultrasound (US) for prevention, diagnosis, and management of hamstring muscle injuries. MRI has commonly been used for diagnosis of hamstring injuries and can offer prognostic information regarding return to play. US offers similar clinical information with some notable advantages over MRI. US is a valuable imaging modality that can be used for diagnosis and prognosis of hamstring injuries and also help guide return to play after injury.

Successful rehabilitation of sports-related orthopedic injuries remains a challenge for both orthopedic surgeons and their patients. Team physicians are tasked with the complex problem of minimizing time away from competition, while simultaneously mitigating the risk of reinjury. Varying levels of expectation and demand between recreational and competitive athletes coupled with the already complex nature of sports-related injuries present a multifactorial challenge for the even the most experienced physicians. In the realm of sports medicine, timing of return to sport has become a controversial yet ubiquitous criterion by which treatment outcomes are measured. While accelerated rehabilitation may be desired in many cases, surgeons must also recognize the identifiable risk factors for potential reinjury. With these principles in mind, we present a summary of the available literature on data pertaining to return to sport, with coverage of injuries commonly seen within an orthopedic sports medicine practice.

Modern ACL reconstruction (ACL-R) techniques have led to improved outcomes in professional footballers. The aim of this study was to identify and assess patient, surgical and post-operative factors that affected rates and time to return to play (RTP) as well as ACL re-rupture rates. A retrospective review of consecutive ACL-R undertaken in professional footballers between 2005 and 2018. Two-hundred and thirty-two knees in 215 professional footballers (17 bilateral) were included. 205 (88.9%) were male and average age at surgery was 23.3 ± 4.4 years. Two-hundred and twenty-two (96.1%) returned to professional football, with 209 (90.1%) returning to the same or higher Tegner level. Subgroup analysis revealed three factors that independently affected RTP rate: (1) Players under 25 years had a higher rate of RTP (99.3% vs 90.2%. p = 0.001); (2) a subsequent operation prior to RTP decreased RTP rate from 98.2 to 89.7% (p = 0.009).; (3) undergoing meniscal surgery at ACL-R decreased RTP rate (p = 0.002). The mean time to RTP from surgery was 10.5 ± 3.6 months. Factors found to increase RTP time included age under 25 (11.0 vs 9.7 months, p = 0.005), recurrent effusions (11.4 vs 10.2 months, p = 0.035), and medial meniscal repair at ACL-R compared to meniscectomy (12.5 vs 9.6 months, p = 0.022). The surgical technique varied over the study period in relation to graft type, femoral tunnel position and addition of lateral extra-articular tenodesis (LET). Overall, the re-rupture rate was 8.2% at 2 years. Patella tendon autograft in an anteromedial bundle femoral tunnel position with addition of LET has the lowest re-rupture rate (2.0%). Primary ACL-R in professional footballers yields high rates of RTP (96.1%), with 90.1% at the same level or higher, at a mean 10.5 months. Patients under 25 years not only had a significantly higher RTP rate, but also had a lengthier period of rehabilitation. Level IV.

Purpose To assess the effects of surgical treatment of athletic pubalgia (AP) on game use and performance metrics in National Basketball Association (NBA) players. Methods A retrospective review of all NBA players who underwent surgical management for AP from 1996 to 2018 was performed. A matched control group was created for comparison. The index period was defined as the entire NBA season in which surgery occurred, including the corresponding offseason. Player demographics, use (games played, games started, and minutes per game) and performance (player efficiency rating) metrics were collected for all players. Statistical analysis was performed to compare data before and after return to play. Results Thirty players with a history of surgical management for AP were included in the final analysis. Following surgery for AP, NBA players were found to have a return to play (RTP) rate of 90.91% (30/33). The average RTP following surgery was 4.73 ± 2.62 months. Compared with control athletes, athletes in the AP group played significantly fewer seasons postinjury (4.17 ± 2.70 vs 5.49 ± 3.04 seasons, respectively; P = .02). During the first year following RTP, NBA players experienced significant reductions in game use and performance, both when compared with the year prior and matched control athletes (P < .05). At 3-year follow-up, players continued to demonstrate significant reductions in game use (minutes per game, P < .05) but not performance. Conclusions Following surgical treatment of AP, NBA players demonstrated a high RTP rate, but shortened career. A short-term reduction in game use and performance metrics was found the year of return following surgery. However, 3-year follow-up performance metrics normalized when compared with healthy controls. Study Design Level III; retrospective case-control study.

Rugby has the highest incidence of traumatic injuries of any sport, and glenohumeral injuries result in the lengthy delay in return to play. The purpose of this study is to survey surgeons from the American Shoulder and Elbow Surgeons (ASES), and the British Elbow and Shoulder Society (BESS) to evaluate the current state of management of anterior glenohumeral instability, and compare the differences in practices.A survey of surgeons from ASES and BESS was conducted. Treatment options were proposed in a variety of clinical scenarios of glenohumeral instability. The time of immobilization post-operatively, return to play, and attitudes on current contact regulations. Results were compared using the chi-square test or t-test.Ninety-seven surgeons responded to the survey. There was a significant difference in treatment between ASES and BESS surgeons in the setting of primary dislocation (p 0.05), but not recurrent dislocation (p 0.05). The period of immobilization following injury and surgery was different between both treating groups. There was a significant difference in return to play between ASES and BESS surgeons with arthroscopic stabilization and open Bankart repair (p 0.05), but not following conservative treatment or the Latarjet procedure (p 0.05).There remains wide variance on the management of glenohumeral instability in rugby union players among surgeons. While immobilization times post-operatively were similar, the BESS surgeons were more confident in allowing earlier return to play. There is also a significant concern that contact levels should be regulated to protect player safety.Level 4 (case series).

Purpose The purpose of this study is to evaluate differences in game utilization or performance following primary anterior cruciate ligament (ACL) reconstruction between National Football League (NFL) players with and without a second ACL injury. Methods NFL players who underwent ACL reconstruction between 2013 and 2017 were identified. Players were classified as having one injury (“tear”) or having later sustained a subsequent second (reinjury or contralateral) ACL injury (“retear”). Players were excluded if they tore their ACL prior to the NFL, did not return to play (RTP), did not play the season before injury, or had concomitant injuries. Demographic characteristics, game utilization statistics, and season approximate value (SAV) performance metrics were recorded. Statistical analysis compared data after RTP from primary ACL reconstruction (seasons +1, +2, and +3) relative to the season before injury (season −1) between cohorts using mean differences and relative percentages. Results Analysis included a total of 45 players, 32 in the “tear” group and 13 in the “retear” group. Demographics, level of play, and time to RTP after primary ACL reconstruction did not differ between the groups (P > .05). Tear and retear groups demonstrated similar utilization and performance metrics the season prior to injury (−1) and the 3 seasons following RTP (season of injury is “0”). Both groups had a similar decrease (relative percentage) in games played and started, snap counts, and SAV during the 3 seasons following RTP compared to baseline (P > .05). The draft pick position was correlated with the relative percentage of games started the first season after RTP (r = .6, P = .02). Conclusions Game utilization and performance metrics following ACL reconstruction were not associated with a subsequent second ACL injury. Players with a higher draft pick position were more likely to return to the starting lineup following primary ACL reconstruction. Ultimately, player game utilization and performance following primary ACL reconstruction is not predictive of a subsequent second ACL injury. Level of Evidence Level III, retrospective case-control study

Purpose To compare the outcomes of athletes who have been treated for either primary or recurrent anterior shoulder instability with arthroscopic Bankart repair (ABR). Methods A retrospective review of patients who underwent ABR for anterior shoulder instability, with a minimum of 24 months’ follow-up, was performed. Those who underwent ABR for primary instability were matched in a 1:1 ratio for age, sex, sport, and level of preoperative play to those who underwent ABR for recurrent instability. The rate, level, and timing of return to play (RTP), as well as the Shoulder Instability–Return to Sport After Injury score, were evaluated. Additionally, the recurrence rate, visual analog scale score, Subjective Shoulder Value, Rowe score, satisfaction, and whether patients would undergo the same operation again were compared. Results After analysis of 467 patients, 100 athletes who underwent ABR for primary instability were identified and subsequently pair matched to 100 patients who underwent ABR for recurrent instability, with a mean age of 27.2 years, 87% male patients, 68% collision athletes, and a mean follow-up period of 61.9 months. There was no significant difference between the groups in the rate of RTP (80% vs 79%, P = .86) or RTP at the preinjury level (65% vs 65%, P >. 999); however, there was a significant difference in time to RTP (6.9 ± 2.9 months vs 5.9 ± 2.5 months, P = .02). There were no significant differences in visual analog scale score, Shoulder Instability–Return to Sport After Injury score, Subjective Shoulder Value, Rowe score, patient satisfaction, and whether patients would undergo the operation again (P > .05 for all). There was no difference in the rate of recurrent instability after ABR (10% vs 16%, P = .29). Conclusions ABR results in excellent clinical outcomes, high rates of RTP, and low recurrence rates for both athletes with primary instability and those with recurrent instability. Level of Evidence Level III, retrospective comparative cohort study.

In 2020, the COVID-19 pandemic forced global lockdowns. Herein, we examine the effect of a lockdown exercise programme in a case-study of youth Australian A-league academy football players.Fifty-five u13-u15 age-grade players were provided with a 110 minute exercise programme including technical, tactical, cardiovascular and muscle strengthening exercises to perform 4 per week at home during the 10-week COVID-19 lockdown.Pre/Post lockdown, maximum aerobic speed was determined via the 30-15 intermittent fitness test (IFT). Exercise compliance was high (78.5% CI72.2-83.8) with an average of 3.15 sessions completed each week. All time-loss (TL) and medical attention (MA) injuries were recorded. Pre/Post lockdown, no difference in the mean incidence or burden of total time-loss (TL), match TL, training TL or medical attention (MA) injuries or injury rate ratio (1.21 CI:0.85-2.74) was observed. Similarly, no difference was observed in any injury incidence or burden data or the injury rate ratio (1.53 CI:0.85-2.74) when comparing the 9-week period prior to lockdown with the first 9 weeks post lockdown (9v9 only). A 9.6% (p = 0.01) increase was also observed in Pre/Post 30-15 IFT composite scores (18.7 CI: 18.3-19.1 to 20.5 CI:20-21).In this case study, compliance to the home-based exercise programme was high and no increase in injury was apparent. These findings must however be considered alongside the limitations associated within this case-study.

Background: Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR. Methods: Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated. Results: All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength. Conclusion: The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort. Level of Evidence: Level II, prospective cohort case series study.

Higher education institutions responded quickly to the Coronavirus (COVID-19) pandemic. The majority of the research conducted primarily focuses on understanding the well-being of collegiate athlet...

The objective of this study was to examine neurocognition, postural control, and symptomology at multiple timepoints following concussion. We hypothesized that collegiate athletes would perform similar to or better than their baseline in terms of each outcome at both timepoints.This was a retrospective study of 71 collegiate athletes (18.3 ± 0.89 years old; 182.2 ± 10.05 cm; 84.2 ± 20.07 kg) to observe changes in outcomes from a previously established clinical protocol.Participants were administered ImPACT™, the Sensory Organization Test (SOT), and the revised head injury scale (HIS-r) prior to their seasons (baseline); upon reporting symptom-free following concussion (post-injury); and approximately 8-months after return-to-play to establish a new baseline.There were no changes in ImPACT scores or HIS-r reporting over time. ImPACT total symptom score (TSS) decreased over time (Our data suggest no decline in neurocognition, balance, or symptom burden approximately eight months post-injury. As clinicians continue to explore "best practices" for concussion management and potential long-term implications of these injuries it is important to monitor outcome measures longitudinally.

Bloom et al. (2020) advocated that mental performance consultants (MPCs) can play an important supporting role in the psychosocial recovery and well-being of concussed athletes. The rapid advanceme...

OBJECTIVES To examine the rates of concussion and recovery time over the course of 2 seasons of the National Rugby League (NRL). DESIGN Descriptive cohort study. SETTING The NRL match play concussion injury surveillance system. PARTICIPANTS All NRL players who participated in the 2017 and 2018 season. MAIN OUTCOME MEASURES The (1) frequency of sideline injury surveillance identified head impact events in real-time during the games, (2) frequency of head injury assessments conducted by the medical staff, (3) frequency of medically diagnosed concussions, (4) number of days to medical clearance to return-to-play, and (5) number of games missed after concussion. MAIN RESULTS There were 472 head injury assessments conducted during the games and 149 medically diagnosed concussions over the course of 2 NRL seasons (1 concussion every 2.70 games). The median number of days until medical clearance was 6 (M = 6.85, SD = 8.03, interquartile range = 4-7; range = 0-79 days). There was a statistically significant difference in the number of days to be medically cleared to return to full contact or match play between seasons (U = 3517.00, P = 0.001), and the percentage of players medically cleared to return-to-play at 5 days after injury was 60.6% in 2017 and 27.6% in 2018. Most players (87.9%) did not miss a game after injury. CONCLUSIONS There is approximately one concussion sustained for every 3 games in the NRL. Most players are medically cleared to return-to-play in 4 to 7 days.

AIM To describe trends in the incidence of match concussions and time to return-to-play in professional rugby union. METHODS Match concussion incidence (injuries per 1000 player-match-hours) and time to return-to-play (mean and median days absence) were recorded in 3006 male professional rugby union players over 16 seasons (2002/03 - 2018/19). RESULTS From 2002/03 to 2009/10, incidence of concussions was stable at 4.3/1000 player-match-hours. From 2009/10 to 2018/19, there was an increase in concussion incidence, with the highest incidence in 2016/17 at 20.9/1000 player-match-hours (95% CI: 17.9-24.3). Annual prevalence of concussion also increased, suggesting more players were concussed rather than the same players sustaining more concussions. Before the introduction of standardized graduated return-to-play (GRTP) guidelines in 2011, 27% of players returned to play in

Background: The treatment of traumatic anterior shoulder instability in professional Australian Football League (AFL) players is challenging, with an emphasis on early return to play and avoidance of instability recurrence. Purpose: To investigate return-to-sport (RTS) outcomes and complications after 2 different procedures for traumatic anterior shoulder instability in professional AFL players. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively reviewed our surgical database for professional AFL players who underwent capsulolabral stabilization or open Latarjet procedure by a single surgeon between 2006 and 2017. Outcomes included RTS, on-field performance, and complications. Between-group analyses for RTS and complications were estimated using Kaplan-Meier survival analyses. Within-group analyses for on-field performance data were performed using paired t tests with significance set at .05. Results: A total of 58 capsulolabral stabilization procedures in 54 players and 32 Latarjet procedures in 29 players were included in the analysis; 93.1% of capsulolabral patients and 96.9% of Latarjet patients returned to professional AFL. The median RTS time was 6.8 months for the capsulolabral group and 7.3 months for the Latarjet group. There was no significant difference in RTS rates between the 2 groups ( P = .270). Of those undergoing surgery early in the season, 75% of the capsulolabral and 71% of Latarjet group were able to RTS within the same season, at a mean time of 16.9 weeks and 18.8 weeks, respectively. There was a significant difference in instability recurrence, with 19% for the capsulolabral group and no recurrence in the Latarjet group ( P = .017). There was no significant reduction in player on-field performance in either group ( P < .05). Conclusion: In this study, the median RTS in AFL players was approximately 7 months after capsulolabral and Latarjet surgery with no compromise to on-field performance. Instability-related complications occurred only in the capsulolabral group, and the incidence increased with time.

Athletes in tackle-collision teams are at high risk of musculoskeletal injuries resulting in absence from play due to the high impact nature of the sport. There is a paucity of research to guide the management and assessment methods needed to facilitate the return to play (RTP) process. This review aimed to describe, synthesise and evaluate RTP protocols implemented for musculoskeletal injuries in tackle-collision teams. A systematic search of Scopus, PubMed, Web of Science and Ebsco Host was conducted for RTP management protocols and assessment modalities following upper and lower limb musculoskeletal injuries in tackle-collision team athletes. Prospective and retrospective quantitative controlled trials, cohort, case-control, case-series and cross-sectional observation studies published between January 2000 and March 2020 were considered. The main outcome measures were the proportion of athletes to RTP, associated time-loss and reinjury risk. 5265 articles were screened. 34 studies met the eligibility criteria of which 23 involved management and 11 assessment modalities. Management involved surgical or conservative strategies along with exercise-based rehabilitation. Assessment modalities included radiographic assessment, clinical evaluation and subjective ratings. Promising RTP management included progressive weight-bearing and exercised-based rehabilitation for ankle sprains as well as surgery, the use of a sling and exercise-based rehabilitation for shoulder instability. MRI scans showed promise in predicting time-loss following hamstring and calf strains in tackle-collision athletes. There are currently no clear guidelines for RTP after musculoskeletal injuries in tackle-collision sports. Future research should investigate efficient management strategies evaluated through valid and reliable assessment methods to better guide clinicians.

Die Qualitatsbeurteilung gewinnt auch in der Sportorthopadie und Sporttraumatologie eine immer grosere Bedeutung. Dabei werden Struktur‑, Prozess- und Ergebnisqualitat als zentrale Qualitatsdimensionen in der gesundheitlichen Versorgung unterschieden. Unter Strukturqualitat werden Fahigkeiten der an der Patientenversorgung beteiligten Institution mit ihren personellen und materiellen Ressourcen verstanden. Strukturqualitat kann uber Institutionszertifikate (z. B. Kniezentrum der Deutschen Kniegesellschaft [DKG]) oder Personenzertifikate (z. B. Kniechirurg der DKG) erfasst werden. Prozessqualitat bewertet alle arztlichen, pflegerischen und administrativen Tatigkeiten, die am Versorgungsprozess beteiligt sind. Die Ergebnisqualitat beschreibt Veranderungen des Gesundheitszustandes des Patienten, die den arztlichen, pflegerischen und physiotherapeutischen Masnahmen zuzuschreiben sind. Die Messung der Ergebnisqualitat lasst sich in objektive und subjektive Parameter gliedern. Bei den subjektiven Parametern spielen „patient reported outcome measures“ (PROMs) eine grose Rolle. Eine weitere Qualitatsinitiative der letzten Jahre ist in der Versorgungsforschung zu sehen. Dabei sind medizinische Register wichtig, bei denen Gesundheitsdaten prospektiv im Langsschnitt erfasst werden. Hier geht es um Daten zur Prozess- und Ergebnisqualitat. Die Ergebnisqualitat steht auch im Fokus wertbasierter Erstattungssysteme.

Background Golf is a common sporting activity that patients continue to participate into older age, including after joint replacement surgery. The influence of shoulder replacement on golf performance remains unclear. We hypothesized that patients undergoing anatomic total shoulder arthroplasty (TSA) would have significantly better return to play rates and better performance metrics, including handicap, driving distance, and 7-iron distance, after shoulder replacement relative to those treated with reverse total shoulder arthroplasty (RTSA). Methods Patients were retrospectively surveyed after anatomic TSA and RTSA with regards to return to golf and golf performance before and after shoulder replacement. Patients reported if they were able to return to golf after shoulder replacement, timing of return to golf, and driving distance, 7-iron distance, handicap, and difficulty with specific shot types upon returning to golf. Significance was defined as P Results The survey was completed by 31 patients with a total of 37 replaced shoulders (68.0 ± 8.1 years; 87% male) out of 44 patients who indicated they played golf. The overall return to golf rate was 74%. Patients undergoing anatomic TSA returned at a significantly higher rate relative to patients treated with RTSA (93% [14 of 15] vs. 56% [9 of 16], P= .037). There was no difference between groups with regards to drive distance, 7-iron distance, and handicap. There were also no differences between preoperative and postoperative values for patients who were able to return to golf. Overall, patients played golf less frequently afterward than they did prior to shoulder replacement (P= .013). Conclusion Patients are able to return to golf after shoulder replacement, at an overall rate of 74%, including a rate of 93% for patients with anatomic TSA and 56% for patients with RTSA. Golf performance was similar before and after shoulder replacement surgery for both groups among those who were able to return to play, though overall frequency was decreased after shoulder replacement. Level of Evidence Level III; Retrospective Cohort Comparative Study

Study design Case Report. Background Groin pain in athletes is considered a common condition among males participating in sports that require sprinting, twisting, pivoting and kicking activities. While the condition is considered self-limiting, it often keeps athletes away from sport for a prolonged period of time. Much controversy exists regarding the pathogenesis of groin pain. This conflict translates to disagreement regarding diagnostic criteria, reporting and management strategies. Case presentation a 28-year old recreational soccer player presented with a five-month history of groin pain that was resistant to passive care. With reference to the current conservative management literature, the athlete was progressed through an individualized multimodal program of care. Outcomes Following 10-weeks of care, the athlete was able to return to sport participation pain-free. Conclusion It is suggested that groin pain in athletes is likely multifactorial and therefore the management should reflect its multifactorial nature. Conservative therapy can evidently reduce the time to return to play however the benefits of incorporating plyometrics into the rehabilitation program should be investigated.

Lumbar disk herniation is the most common surgical condition of the spine. High-level athletes participate in activities that place extreme loads on the intervertebral disks. These repetitive loads may lead to an elevated risk for degenerative disk disease, which in turn predisposes to disk herniations. Treatment algorithms for athletes with disk herniations are similar to those in the nonathletic population; however, success in the athletic population is often measured in the ability to return to play. Both nonoperative and operative treatment show a high success rate in return to play in athletes treated for disk herniations.

A methodology paper demonstrating the use of change point analysis to identify significant change points during the rehabilitation process of a football player.

1.0 Objective To map the various ways in which ultrasound technology has been used to guide rehabilitation decisions and Return To Play (RTP) following hamstring muscle injuries, and summarise the evidence. To do this, we have extended our search to muscle injuries of the lower limb. 2.0 Questions (i) Can ultrasound be used to guide return to play (RTP) or rehabilitation decisions following hamstring muscle injuries? (ii) how has ultrasound been used to guide RTP decisions in other lower-limb muscle groups, and can these principles be applied to hamstring muscle injuries? (iii) What forms of ultrasound have been tried to guide RTP decisions following muscle injury?

This study explored sport-related concussion (SRC) return-to-play (RTP) behaviours and attitudes of medical team staff working in elite football in the United Kingdom. Usage and awareness of The Football Association (FA) guidelines, concussion education rates of players and coaching staff, and collection of baseline concussion assessments. Additionally, confidence in managing RTP post-SRC, perceived player under-reporting of symptoms, use of enhanced RTP pathways, and coaching pressure on RTP were investigated.A cross-sectional questionnaire study was distributed online by organisations including or representing medical staff working in elite football in the United Kingdom.A total of 112 responses were gathered. High awareness rates of the FA guidelines were found (96%) with variable rates of player and coaching staff concussion education. Baseline concussion assessments were collected by 80% of respondents with 93% feeling very confident or confident in managing the RTP of a player with a SRC. 60% rarely or never experienced coaching pressure around player RTP, and 24% felt players always or very often under-reported symptoms to expedite their return. 90% had a moderate to high confidence in the Sport Concussion Assessment Tool-5 (SCAT-5) as a RTP decision tool, and 66% always or very often used an enhanced RTP pathway.Confidence in managing player RTP post SRC and use of enhanced RTP pathways were high, as was confidence in the SCAT-5 as a RTP decision tool. Respondents raised concerns around player under-reporting of symptoms to accelerate RTP post-SRC, and perceived coaching pressure around decision making.

Background The aim of the current investigation was to establish the positional physical characteristics of elite inter-county camogie players and compare them to current female field sport athlete norms. Methods Forty-five elite inter-county camogie players (age: 23.31 ± 3.47 years; height: 168.97 ± 5.60 cm; body mass: 68.37 ± 7.44 kg) completed pre-season physical performance testing. Physical characteristics including Isometric Mid-Thigh Pull (IMTP) peak force, IMTP relative peak force, countermovement jump (CMJ) height, 10 to 5 repeated jump test Reactive Strength Index (RSI), 5-, 10- and 20 m sprint times and Yo-Yo Intermittent Recovery Test Level 1 (Yo-Yo IR1) accumulated distance were assessed. All players were sub-divided into their playing positions (Defenders, Mid-Fielders, Forwards) by self-reported means, to investigate if any positional differences existed. Results A multivariate analysis of variance (MANOVA) and Kruskal-Wallis H tests revealed no significant positional difference for any physical tests (p>0.05). Moderate main effects for RSI between mid-fielders and forwards (ES= 0.64) and for 20m sprint time between defenders and mid-fielders (ES= 0.63) were noted. Trivial to small main positional effects were evident for all other tests (ES= 0.03-0.60). Conclusions The relative homogeneity of results across performance measures indicates no obvious position specific characteristics within this cohort. This data will provide normative values for coaches to better inform training and return to play practices in camogie.

Background The rates of athletic anterior cruciate ligament rupture (ACLRu) and subsequent surgical reconstructions are on the rise. Given the associated sub-optimal return to play (RTP) and re-injury rates, alternative management strategies, such and non-operative management, are being increasingly explored. Research demonstrates that there may be a subset of patients with ACLRu, who will benefit from non-surgical management. Objectives In this case report, we aim to detail the comprehensive management involved in a 26.5-week RTP program for an athlete whose ACLRu was rehabilitated without surgical reconstruction. Clinical features The patient suffered a left knee injury resulting in mild knee pain and effusion, with mild stiffness at the end range of knee flexion. On further examination, a slight left knee strength deficit with positive anterior drawer and Lachman's tests were found consistent with ACLRu, which was confirmed with MRI. Interventions and outcomes The patient was classified as an ACL deficient coper after an initial 8-week conservative rehabilitation approach to the injury. The patient completed their RTP protocol over a total of 26.5 weeks, inclusive of initial strength and neuromuscular control training, a gradual return to restricted non-competitive training, through to competitive unrestricted training and eventual RTP. The RTP was without incident, with the patient achieving sufficient limb strength and power symmetry (>90%), adequate patient-reported outcomes and psychological readiness score before RTP. Conclusion In select sportspeople, the non-operative ACLRu management may represent a viable and accelerated management strategy for successful RTP. However, more detailed guidelines are needed to guide the RTP process.

Objective The goals of this study were to assess the ability of salivary non-coding RNA (ncRNA) levels to predict post-concussion symptoms lasting ≥ 21 days, and to examine the ability of ncRNAs to identify recovery compared to cognition and balance. Methods RNA sequencing was performed on 505 saliva samples obtained longitudinally from 112 individuals (8–24-years-old) with mild traumatic brain injury (mTBI). Initial samples were obtained ≤ 14 days post-injury, and follow-up samples were obtained ≥ 21 days post-injury. Computerized balance and cognitive test performance were assessed at initial and follow-up time-points. Machine learning was used to define: (1) a model employing initial ncRNA levels to predict persistent post-concussion symptoms (PPCS) ≥ 21 days post-injury; and (2) a model employing follow-up ncRNA levels to identify symptom recovery. Performance of the models was compared against a validated clinical prediction rule, and balance/cognitive test performance, respectively. Results An algorithm using age and 16 ncRNAs predicted PPCS with greater accuracy than the validated clinical tool and demonstrated additive combined utility (area under the curve (AUC) 0.86; 95% CI 0.84–0.88). Initial balance and cognitive test performance did not differ between PPCS and non-PPCS groups (p > 0.05). Follow-up balance and cognitive test performance identified symptom recovery with similar accuracy to a model using 11 ncRNAs and age. A combined model (ncRNAs, balance, cognition) most accurately identified recovery (AUC 0.86; 95% CI 0.83–0.89). Conclusions ncRNA biomarkers show promise for tracking recovery from mTBI, and for predicting who will have prolonged symptoms. They could provide accurate expectations for recovery, stratify need for intervention, and guide safe return-to-activities.

The calf muscle group is a common area for injury within the professional athlete population. Anatomical and biomechanical differences between the different component muscles vary their individual predispositions to and patterns of injury. However, there is a common unifying factor: injuries involving tendinous components have greater clinical implications with regards to rehabilitation, potential intervention, length of time to return to play, and re-injury rates. As such, accurate understanding of the underlying anatomy and subsequent interpretation of the injury patterns carry significant clinical ramifications. Ultrasound is a useful tool but has limitations, particularly when assessing soleus. As such, magnetic resonance imaging remains the workhorse in calf injury investigation.

Achilles tendinopathy is one of the most common ankle and foot overuse injuries, especially among athletes. Despite this, the management of this injury lacks an evidence-based support, and patients are at risk of long-term morbidity with unpredictable clinical outcome. Recently, injective approach has gained more and more attention, and in particular the intratendinous injection with adipose-derived stromal vascular fraction. We report a case of an insertional Achilles tendinopathy in a high-level professional athlete, who was treated avoiding surgical treatment in favor of this innovative biological approach. Patient's satisfaction and return to play was prospectively evaluated for a period of 6 months of follow-up. An improvement of all functional scores was yet appreciated after 1 month from the treatment, with a crescent trend until the last 6-month follow-up. The patient was able to return to train after 34 days, and returned to match after 68 days, playing 20 minutes. She returned to the complete full game 72 days after treatment. However subsequent ultrasound and MRI evaluations failed to show any substantial changes in the characteristics of the lesion from the preoperative images. This case report opens a new window for the treatment of insertional Achilles tendinopathy in competitive athletes. The current outcome deserves further investigation with higher quality studies in order to confirm the validity of this fascinating therapeutic option.

Background: Rates of reinjury, return to play (RTP) at the preinjury level, and hamstring strain injuries in male soccer players after anterior cruciate ligament reconstruction (ACLR) remain unsatisfactory, due to multifactorial causes. Recent insights on intramuscular hamstring coordination revealed the semitendinosus (ST) to be of crucial importance for hamstring functioning, especially during heavy eccentric hamstring loading. Scientific evidence on the consequences of ST tendon harvest for ACLR is scarce and inconsistent. This study intended to investigate the repercussions of ST harvest for ACLR on hamstring muscle function. Hypothesis: Harvest of the ST tendon for ACLR was expected to have a significant influence on hamstring muscle activation patterns during eccentric exercises, evaluated at RTP in a population of male soccer athletes. Study Design: Controlled laboratory study. Methods: A total of 30 male soccer players with a history of ACLR who were cleared for RTP and 30 healthy controls were allocated to this study during the 2018-2019 soccer season. The influence of ACLR on hamstring muscle activation patterns was assessed by comparing the change in T2 relaxation times [ΔT2 (%) = [Formula: see text]] of the hamstring muscle tissue before and after an eccentric hamstring loading task between athletes with and without a recent history of ACLR through use of muscle functional magnetic resonance imaging, induced by an eccentric hamstring loading task between scans. Results: Significantly higher exercise-related activity was observed in the biceps femoris (BF) of athletes after ACLR compared with uninjured control athletes (13.92% vs 8.48%; P = .003), whereas the ST had significantly lower activity (19.97% vs 25.32%; P = .049). Significant differences were also established in a within-group comparison of the operated versus the contralateral leg in the ACLR group (operated vs nonoperated leg: 14.54% vs 11.63% for BF [ P = .000], 17.31% vs 22.37% for ST [ P = .000], and 15.64% vs 13.54% for semimembranosus [SM] [ P = .014]). Neither the muscle activity of SM and gracilis muscles nor total posterior thigh muscle activity (sum of exercise-related ΔT2 of the BF, ST, and SM muscles) presented any differences in individuals who had undergone ACLR with an ST tendon autograft compared with healthy controls. Conclusion: These findings indicate that ACLR with a ST tendon autograft might notably influence the function of the hamstring muscles and, in particular, their hierarchic dimensions under fatiguing loading circumstances, with increases in relative BF activity contribution and decreases in relative ST activity after ACLR. This between-group difference in hamstring muscle activation pattern suggests that the BF partly compensates for deficient ST function in eccentric loading. These alterations might have implications for athletic performance and injury risk and should probably be considered in rehabilitation and hamstring injury prevention after ACLR with a ST tendon autograft.

Resumen Introducción: El objetivo de este estudio fue describir las tasas de retorno al deporte y el nivel alcanzado por los pacientes con inestabilidad de hombro luego del procedimiento abierto y artroscópico de Latarjet. Materiales y Métodos: Seguimos un protocolo prespecificado y registrado en PROSPERO. Evaluamos la calidad de los estudios y utilizamos el sistema GRADE para evaluar la calidad general de la evidencia obtenida en los resultados. Incluimos estudios que evalúan el retorno al deporte de los pacientes luego de una cirugía de Latarjet con un seguimiento mínimo de 2 años. Resultados: Se incluyeron 24 estudios, con 1436 atletas, todos con cirugía y un seguimiento promedio de 57 meses (rango 24-240). La tasa general de retorno al deporte varió del 65% al 100% de los pacientes, de ellos, el 23-100% retornó al mismo nivel. El tiempo promedio de retorno al deporte fue de 6 meses (rango 1-36). El nivel de evidencia fue bajo debido a las características de los estudios incluidos (nivel de evidencia IV), las limitaciones de los estudios y sus inconsistencias. Conclusiones: La mayoría de los atletas con luxación recidivante de hombro sometidos a una cirugía de Latarjet retoman la práctica deportiva; sin embargo, el nivel alcanzado varía sustancialmente. El tiempo promedio de retorno al deporte fue de 6 meses, y no hubo diferencias significativas entre los deportistas competitivos y recreacionales. Abstract Background: The purpose of this study was to describe rates of return to sports and the level achieved by patients after a Latarjet procedure. Methods: We followed a protocol registered in PROSPERO (registration number CRD42018107606). A literature search was performed in May 2019 in MEDLINE, EMBASE, CENTRAL and clinical trials records. We used the GRADE approach for the assessment of the overall quality of the evidence per outcome. We included studies (evidence level I to IV) evaluating return to sports following shoulder stabilization with the Latarjet procedure with a minimum of 2-year follow-up. Results: We included 24 studies, including 1436 athletes, all treated surgically after an average follow-up of 57 months (range 24 to 240). The overall rate of return to sport ranged from 65% to 100%, including 23% to 100% at an equivalent level of play. The average time for return to sport was 6 months (range, 1 - 36 months). Competitive athletes appeared to return to the same level of competition and this difference was not statistically significant (p = 0.32). The quality of the evidence was very low due to study design (evidence level IV), study limitations and inconsistency. Conclusion: Most athletes with glenohumeral instability returned to sport, however the level maintained after shoulder stabilization with the Latarjet procedure varied substantially. The average time to return to sports was 6 months and results were equally favorable in competitive and recreational athletes.

Athletic injuries to the hip flexors and iliopsoas have been described in populations across all levels of competitive sports. Overall estimates of hip flexor pathology have ranged from 5% to 28% of injuries among high-risk sport specific groups. Although most of these injuries are successfully treated with conservative management, and high rates of return to play are observed, significant rehabilitation time can be involved. As the understanding of hip pathology with imaging modalities such as MRI has advanced, greater importance has been placed on accurately diagnosing hip flexor injuries and initiating rehabilitation protocols early to minimize time loss from sport.

Purpose: To identify the time to return to play (RTP) and evaluate the performance level in wide receivers in the National Football League following anterior cruciate ligament (ACL) reconstruction. Methods: A total of 29 wide receivers in the National Football League who underwent ACL reconstruction between 2013 and 2017 who met inclusion criteria were retrospectively identified and reviewed. For each player, a matched control with similar demographics was identified to compare various in-game performance measurements and seasons played. Results: Of the wide receivers that met the inclusion criteria, 9 of 29 (31%) did not RTP in a regular season game following ACL reconstruction. For players who did RTP, 20 of 29 (69%), the average time was 10.9 months (331.4 ± 41.6 days). When we compared the tear group with the matched control cohort, players with ACL tears ended their careers on an average of 1.9 seasons earlier (2.2 vs 4.1 seasons, P < .001) and also played less than half the number of games (25.5 vs 56.6 games, P = .001), respectively. Those that RTP also saw decreased performance statistics in targets (353.6 vs 125.2 P < .001), receptions (208.0 vs 74.4, P = .001), receiving yards (2691.0 vs 987.9, P = .001), and touchdowns (17.4 vs 6.2, P = .002). Conclusions: Sixty-nine percent of wide receivers who underwent ACL reconstruction were able to RTP at an average of 10.9 months, or 331.4 days. Despite the majority of players being able to RTP, there was a significant decrease in both statistical performance and career duration. Level of Evidence: Level III, case-control study.

Background: Ulnar collateral ligament (UCL) reconstruction and UCL repair of the elbow are commonly performed procedures, resulting in high return-to-play rates. Whether the incidence rate of UCL reconstruction vs UCL repair has changed over time is not currently known. Purpose/Questions: We sought to assess temporal trends in the incidence rates of UCL repair and UCL reconstruction and to identify factors associated with UCL reconstruction. We hypothesized that UCL repair would demonstrate an increased incidence overall in recent years with an associated decline in UCL reconstruction rates. Methods: Using the PearlDiver Research Program to query the Humana administrative claims database, we identified patients who had undergone UCL repair and/or reconstruction from 2007 to 2016. Patients were stratified by age (15–19; 20–29; 30–49 years), sex, and year (2007–2011 vs 2012–2016). Poisson regression analysis (continuous variables) was used to calculate the incidence risk ratio (IRR); chi-square tests were performed for categorical variables, and odds ratios were calculated with 95% confidence intervals (CI). Results: The incidence rate of UCL repair was greater in 2012–2016 than in 2007–2011 (IRR: 1.86, 95% CI: 1.16–2.96). The incidence rate of UCL reconstruction vs UCL repair was greater for patients aged 15 to 19 years (IRR: 3.37, 95% CI: 1.97–5.77) but not patients aged 20 to 29 years (IRR: 0.89, 95% CI: 0.49–1.59) as compared with patients aged 30 to 49. Males aged 19 years were more likely than females to undergo UCL reconstruction (IRR: 10.09, 95% CI: 1.37–3.45). Conclusion: While UCL procedures are becoming more popular, our retrospective analysis showed that young males are preferentially treated with UCL reconstruction, warranting further investigation into these trends.

Objectives: Thoracic outlet syndrome (TOS) can be a career threatening injury for baseball pitchers. The purpose of this study is to determine the efficacy of surgical management for TOS as a function of return to play and quantitative pitching metrics. Methods: Twenty-seven major league baseball pitchers underwent surgical treatment for TOS between January 2001 and December 2017. Analysis of pre and postoperative pitching metrics were used to assess the effect of surgery on 20 pitchers who returned to pitch in Major League Baseball (MLB). All pitching metrics were compared via assessing performance two years prior to surgery and two years after surgery. For 20 pitchers who returned to pitch, MLB pitching metrics of earned run average (ERA), walks plus hits per innings pitched (WHIP), wins above replacement (WAR), strikeouts per nine innings (K/9), average fastball velocity, and strike percentage, were used to assess a pitcher’s ability to return to preoperative performance level. Results: Of the 27 pitchers, 20 pitchers were diagnosed with neurogenic thoracic outlet syndrome (NTOS) and seven with venous thoracic outlet syndrome (VTOS). The average age of onset of TOS was 28.6 years. There was no significant difference between the age of onset between the NTOS and VTOS populations (p=0.272). Of the 27 pitchers, 20 (74.1%) were able to return to MLB play at a mean of 297 days (range, 105-638 days) after surgery. Pitching metrics demonstrated that pitcher ERA remained inferior postoperatively compared to baseline preoperative performance (3.66 vs 4.50, p=0.03). Fastball velocity (p=0.94), strike percentage (p=0.50), and K/9 (p=0.878) were equivalent to pre-injury performance. There was no difference in preoperative pitching metrics between pitchers who were able to return and pitchers who were unable to return to the MLB. Conclusions: About 3/4 of professional pitchers who undergo surgical intervention for TOS are able to return to play at the MLB level. With regards to performance, the majority of metrics were unchanged from prior to surgery, indicating return at a similar functional level.

Background: Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population. Purpose: To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures. Study Design: Meta-analysis. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures. Results: Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%). Conclusion: The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.

Cervical spinal injuries are a rare, but potentially devastating occurrence in sports. Although many of these injuries occur in unsupervised sports, they are also seen in organized sports - most commonly in football, wrestling, and ice hockey. Additionally, although each sport is associated with its own unique injury patterns, axial loading remains a common theme seen in cervical injuries associated with significant neurologic impairment. Regardless of the mechanism, a cautious and conservative approach should be taken with regards to evaluation, management, and return to play.

Background: Medial ulnar collateral ligament (UCL) injuries are common among baseball players. There is sparse literature on long-term results after nonoperative treatment of UCL injuries in professional baseball players. Purpose: The primary purpose was to assess long-term follow-up on reinjury rates, performance metrics, rate of return to the same level of play or higher (RTP), and ability to advance to the next level of play in professional baseball players after nonoperative treatment of incomplete UCL injuries. The secondary aim was to perform a matched-pair comparison between pitchers treated nonoperatively and a control group without a history of UCL injuries. Study Design: Cohort study; Level of evidence, 3. Methods: Twenty-eight professional baseball players (18 pitchers, 10 position players) treated nonoperatively were identified from a previous retrospective review of a single professional baseball organization between 2006 and 2011. UCL reinjury rates and player performance metrics were evaluated at long-term (minimum, 9 years) follow-up. Rates of RTP were calculated. A matched-pair comparison was made between the pitchers treated nonoperatively and pitchers without a history of UCL injuries. Results: Overall, 27 players (17 pitchers, 10 position players) were available for long-term follow-up at a mean follow-up of 12 years (SD, 2 years). The overall rate of RTP was 85% (23/27), with the rate of RTP being 82% (14/17) in pitchers and 90% (9/10) in position players. Of the 23 players who did RTP, 18 (78%) reached a higher level of play and 5 (21.7%) stayed at the same level. Of the 9 position players who did RTP, the median number of seasons played after injury was 4.5 (interquartile range, 3.3). Of the 14 pitchers who did RTP, the mean number of seasons played after injury was 5.8 (SD, 3.8). In the matched-pair analysis, no significant differences were observed in any performance metrics (P > .05). The overall reinjury rate was 11.1% (3/27), with no players requiring UCL reconstruction. Conclusion: There was a high rate of RTP for professional baseball players treated nonoperatively for incomplete UCL injuries. Compared with a matched cohort with no history of UCL injury, professional baseball pitchers treated nonoperatively had similar performance metrics. Reinjury rates were low, and no player had reinjury requiring UCL reconstruction. Nonoperative treatment of incomplete UCL injuries in professional baseball players, specifically pitchers, is a viable treatment option in the long term.

Category: Ankle; Arthroscopy Introduction/Purpose: Bone marrow stimulation procedures, specifically microfracture, have become a common treatment technique for osteochondral lesions of the talus (OLT). Such procedures have been shown to be effective among a variety of patient populations at postoperative time points up to about 5 years (references?). While microfracture has been shown to be effective in short- to medium-term follow-up, there is a paucity of literature demonstrating the long-term efficacy of this procedure. Recently, the development of additional treatment techniques has been explored, with deterioration of the resultant fibrocartilage being a particular concern with microfracture. The purpose of this study is to determine the long-term effectiveness of microfracture bone marrow stimulation for treatment of OLTs in patients at least 10 years removed from surgery. Methods: A retrospective review of patients undergoing microfracture of an OLT with a single fellowship-trained orthopaedic foot and ankle surgeon at least 10 years prior was performed. Patients meeting the inclusion criteria were contacted to complete the Foot & Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales, visual analog scale (VAS) for pain, as well as surveyed regarding their satisfaction with the outcome of the procedure using a 5-point Likert scale. In addition to medical chart review, patients were asked directly over the phone about any subsequent foot and ankle procedures needed, any injections necessary, and whether they wore an ankle brace/orthotic in the time following the procedure. Patient demographics including sex, age at time of surgery, laterality of surgery, and surgical history following their index procedure were reviewed. Descriptive statistics were calculated for patient demographics and survey responses to assess functional outcomes. Results: Forty-two patients were contacted and completed postoperative surveys. Average patient age at the time of the procedure was 38.6 years, and 24 patients (57%) were male. On average, FAAM-ADL score was 86.57 (+-20.85), Sports score was 72.31 (+-30.48), and VAS pain score was 19.52 (scale of 0-100). Patients reported being satisfied with the outcome of the procedure in 35 of 42 cases (83.3%). Five patients (11.9%) had other foot/ankle procedures since their microfracture, with 3 directly addressing the talus in some fashion. Three patients (7.1%) received injection(s) in their ankle in the follow-up period, and 9 patients (21.4%) reported wearing a brace since the time of surgery with 6 patients (14.3%) reporting it as a direct relation to their OLT and surgery. Conclusion: This study demonstrates that microfracture is an effective functional treatment for OLT in the long term, and addresses the valid questions posed about the ability for the procedure to produce durable fibrocartilage. Patients report average functional and pain assessment scores at the 10-year postoperative mark consistent with a generally successful and effective treatment.

Background Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI. Objective To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions. Methods A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted. Results Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033). Conclusion RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.