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Many sports medicine physicians are currently considering introducing regenerative medicine into their practice. Regenerative medicine and the subclassification of orthobiologics are a complicated topic and have produced widely varying opinions. Although there is concern by government regulators, clinicians, scientists, patient advocacy organizations, and the media regarding the use of regenerative medicine products, there is also excitement about the potential benefits with growing evidence that certain regenerative medicine products are safe and potentially efficacious in treating musculoskeletal conditions. Sports medicine physicians would benefit from decision-making guidance about whether to introduce orthobiologics into their practice and how to do it responsibly. The purpose of this position statement is to provide sports medicine physicians with information regarding regenerative medicine terminology, a brief review of basic science and clinical studies within the subclassification of orthobiologics, regulatory considerations, and best practices for introducing regenerative medicine into clinical practice. This information will help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine and orthobiologics in their practice.

Despite recent advances in microsurgical techniques, functional recovery following peripheral nerve injury remains slow and inadequate. Poor peripheral nerve regeneration not only leaves patients with significant impairments, but also commonly leads to the development of debilitating neuropathic pain. Recent research has demonstrated the potential therapeutic benefits of adipose-derived stem cells, to enhance nerve regeneration. However, clinical translation remains limited due to the current regulatory burdens of the US FDA. A reliable and immediately translatable alternative is autologous fat grafting, where native adipose-derived stem cells present in the transferred tissue can potentially act upon regenerating axons. This review presents the scope of adipose tissue-based therapies to enhance outcomes following peripheral nerve injury, specifically focusing on their role in regeneration and ameliorating neuropathic pain.

Orthobiologic therapies show significant promise to improve outcomes for patients with musculoskeletal pathology. There are considerable research efforts to develop strategies that seek to modulate the biological environment to promote tissue regeneration and healing and/or provide symptomatic relief. However, the regulatory pathways overseeing the clinical translation of these therapies are complex, with considerable worldwide variation. The introduction of novel biologic treatments into clinical practice raises several ethical dilemmas. In this review, we describe the process for seeking approval for biologic therapies in the United States, Europe, and Japan. We highlight a number of ethical issues raised by the clinical translation of these treatments, including the design of clinical trials, monitoring outcomes, biobanking, "off-label" use, engagement with the public, marketing of unproven therapies, and scientific integrity.

Many sports medicine physicians are currently considering introducing regenerative medicine into their practice. Regenerative medicine and the subclassification of orthobiologics are a complicated topic and have produced widely varying opinions. Although there is concern by government regulators, clinicians, scientists, patient advocacy organizations, and the media regarding the use of regenerative medicine products, there is also excitement about the potential benefits with growing evidence that certain regenerative medicine products are safe and potentially efficacious in treating musculoskeletal conditions. Sports medicine physicians would benefit from decision-making guidance about whether to introduce orthobiologics into their practice and how to do it responsibly. The purpose of this position statement is to provide sports medicine physicians with information regarding regenerative medicine terminology, a brief review of basic science and clinical studies within the subclassification of orthobiologics, regulatory considerations, and best practices for introducing regenerative medicine into clinical practice. This information will help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine and orthobiologics in their practice.

Musculoskeletal conditions including osteoarthritis and chronic tendinopathies are leading causes of pain and disability worldwide. The emergence of novel regenerative therapies, referred to as orthobiologics, has led to promising interventions which may reduce pain and improve function. Orthobiologics are biological substances intended to enhance healing and alter the natural course of orthopaedic disease.1 2 Despite growing experience, the field remains under-researched with inconsistent evidence; yet increasing enthusiasm has permitted overexuberant, sometimes inappropriate use with proliferation of misinformation among both providers and patients. An American Medical Society for Sports Medicine (AMSSM) position statement was developed to help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine in their practice.3 The statement contains relevant terminology, review of basic and clinical science, ethics, regulations and best practices for considering regenerative medicine in clinical practice (figure 1). The statement seeks to educate physicians regarding a broad and emerging discipline and is not an endorsement by AMSSM of any specific product or procedure. Figure 1 Responsible use of orthobiologics and other novel regenerative therapies requires multiple considerations before translation into routine clinical practice. Regenerative medicine is rapidly growing with terms and definitions yet to be standardised. While originating with stem cell discovery and translation, regenerative therapies, of which orthobiologics is but one category, are no longer a single platform technology. Rather, they now encompass a heterogeneous collection of biological sources with varying activity that hold the potential to transform human health. Common orthobiologics employed in research and clinical practice are being conflated under the umbrella of ‘stem cell’ therapy in a …

Background: Anterior cruciate ligament (ACL) tears are common knee injuries. Despite undergoing extensive rehabilitation after ACL reconstruction (ACLR), many patients have persistent quadriceps muscle weakness that limits their successful return to play and are also at an increased risk of developing knee osteoarthritis (OA). Human growth hormone (HGH) has been shown to prevent muscle atrophy and weakness in various models of disuse and disease but has not been evaluated in patients undergoing ACLR. Hypothesis: Compared with placebo treatment, a 6-week perioperative treatment course of HGH would protect against muscle atrophy and weakness in patients undergoing ACLR. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 19 male patients (aged 18-35 years) scheduled to undergo ACLR were randomly assigned to the placebo (n = 9) or HGH (n = 10) group. Patients began placebo or HGH treatment twice daily 1 week before surgery and continued through 5 weeks after surgery. Knee muscle strength and volume, patient-reported outcome scores, and circulating biomarkers were measured at several time points through 6 months after surgery. Mixed-effects models were used to evaluate differences between treatment groups and time points, and as this was a pilot study, significance was set at P < .10. The Cohen d was calculated to determine the effect size. Results: HGH was well-tolerated, and no differences in adverse events between the groups were observed. The HGH group had a 2.1-fold increase in circulating insulin-like growth factor 1 over the course of the treatment period ( P < .05; d = 2.93). The primary outcome measure was knee extension strength, and HGH treatment increased normalized peak isokinetic knee extension torque by 29% compared with the placebo group ( P = .05; d = 0.80). Matrix metalloproteinase–3 (MMP3), which was used as an indirect biomarker of cartilage degradation, was 36% lower in the HGH group ( P = .05; d = –1.34). HGH did not appear to be associated with changes in muscle volume or patient-reported outcome scores. Conclusion: HGH improved quadriceps strength and reduced MMP3 levels in patients undergoing ACLR. On the basis of this pilot study, further trials to more comprehensively evaluate the ability of HGH to improve muscle function and potentially protect against OA in patients undergoing ACLR are warranted. Registration: NCT02420353 ( ClinicalTrials.gov identifier)

Ultrasound-guided carpal tunnel release was performed on 14 patients (18 wrists) using dynamic expansion of the transverse safe zone. Our patient population included able-bodied patients and those with impairments. The first 8 cases (12 wrists) underwent the procedure in an operating room, the remainder in an outpatient setting. No complications occurred, and all patients were able to immediately resume use of their hands without therapy. Improvements in the Quick Form of the Disabilities of the Arm, Shoulder, and Hand Index and Boston Carpal Tunnel Questionnaire at 3 months were comparable to results reported with mini-open and endoscopic release. Our results show that ultrasound-guided carpal tunnel release can be safely and effectively performed in an outpatient setting.

Objective Tendinopathy is a major clinical problem in sports medicine and is often difficult to treat. Traditional therapeutic approaches have focused on reducing inflammation, yet research suggests that little to no inflammation is present in the tendons that fail to heal. The purpose of this review was to evaluate the effectiveness of the available treatment options for tendinopathy and to inform best clinical practices. Design A narrative review. Methods A comprehensive search of electronic databases (PubMed, Google Scholar and Web of Science) was conducted to identify relevant studies through June 2016. Studies were deemed relevant if they were published in English and contained original research on the management of tendinopathy in humans. Results Studies varied in methodological quality and were often limited by small sample size and lack of sufficient control groups. Critical evaluation of the literature suggests that physical therapy with or without eccentric exercise should be considered a first-line treatment. Corticosteroids and nonsteroidal anti-inflammatory drugs provide short-term symptomatic relief, but long-term efficacy has not been demonstrated. Inconsistent results do not support the routine use of prolotherapy, platelet-rich plasma injections and topical nitric oxide patches. Operative intervention should be reserved until conservative measures fail or an obvious operative lesion is present. Conclusions While numerous therapeutic modalities exist for tendinopathy in the athlete, the ideal treatment protocol has not been clearly defined. The development of new targeted therapies for tendinopathy is likely to follow a greater understanding of the cellular and molecular mechanisms that underlie its pathogenesis.

Eccentric-contraction-induced skeletal muscle injuries, included in what is clinically referred to as muscle strains, are among the most common injuries treated in the sports medicine setting. Although patients with mild injuries often fully recover to their preinjury levels, patients who suffer moderate or severe injuries can have a persistent weakness and loss of function that is refractory to rehabilitation exercises and currently available therapeutic interventions. The objectives of this review were to describe the fundamental biophysics of force transmission in muscle and the mechanism of muscle-strain injuries, as well as the cellular and molecular processes that underlie the repair and regeneration of injured muscle tissue. The review also summarizes how commonly used therapeutic modalities affect muscle regeneration and opportunities to further improve our treatment of skeletal muscle strain injuries.

Cryotherapy has gained popularity among athletes across many sports. The main goals of cryotherapy, and specifically whole-body cryotherapy, are for injury prevention and counteracting negative inflammatory symptoms following athletic performance in hopes of improving recovery.

Objectives: There has been a rise in elbow ulnar collateral ligament (UCL) injuries in youth pitchers over recent years. With forearm flexor-pronator mass fatigue, the dynamic stability provided could be diminished placing greater stress on the UCL. Pitch count limits have been instituted in an attempt to help curtail this rise in throwing injuries, especially in youth athletes. In order to provide more objective data regarding current pitch count limits for youth pitchers, the purpose of this pilot study was to evaluate for potential fatigue of the flexor-pronator mass by assessing changes in medial elbow laxity, noninvasively characterizing changes in muscle glycogen storage within the forearm flexor-pronator mass, and evaluating changes in subjective fatigue, strength, range of motion (ROM), pitching velocity, and accuracy with increasing number of pitches thrown by 10-year-old pitchers up to their recommended 75 pitch count limit. Methods: After appropriate power analysis, male pitchers 10 years of age were recruited for the study (n=22). Pitchers threw a total of 75 pitches divided into sets of 25 pitches, with standardized periods of rest in between throws and sets to best simulate a game. Bilateral medial elbow laxity was measured by applying 10 decanewtons of valgus force with a standardized stress device and utilizing ultrasound imaging (Figures 1A-B) prior to pitching and after each pitching set. The change in medial ulnohumeral joint distance (Figure 1C) after stress was applied was calculated from baseline without stress. Relative changes in muscle glycogen storage, detected as changes in echogenicity, within the flexor carpi radialis (FCR) and the flexor digitorum superficialis (FDS)/flexor carpi ulnaris (FCU) muscles were measured non-invasively with ultrasound-based software (Figures 1D-E) and recorded as fuel percentile. Repeated measures analysis of variance and post-hoc testing were used to determine statistical significance (alpha=0.05). Results: There were no significant differences in medial elbow laxity between arms or time points. There was a trend for similar decline in FCR fuel percentile values between each arm, indicating relative decreases in glycogen storage bilaterally. However, only the throwing arm demonstrated a statistically significant decline in fuel percentile from baseline to after 75 pitches (p=0.05). There were no statistically significant differences across time points for FDS/FCU fuel percentile values. Fatigue measurements for both arms were significantly higher at all time points compared to baseline (p≤0.03). Grip strength of the dominant arm after 75 pitches was significantly decreased compared to after 25 pitches (p=0.02). There were no statistically significant changes in other strength measurements, ROM, velocity, or accuracy between all time points. Conclusions: By the recommended 75 pitch count limit in 10-year-olds, subjective fatigue and a decrease in grip strength had occurred. Furthermore, relative glycogen storage of the flexor-pronator mass of the throwing arm decreased between pitching 50 to 75 pitches, but without an increase in medial elbow gapping. This study provides a foundation and raises questions for further objective testing of physiologic changes that occur throughout increasing pitching to better guide pitch count limits and ensure the safety of young athletes

Responsivity—or individualised adaptation of treatment within correctional settings—is a particularly important aspect of the therapeutic process and has been identified in recent analyses as a significant predictor of lower levels of recidivism among people with convictions for sexual offences. Religious faith is conceptualised as a key aspect of some people’s identities and has been argued to play a potentially important protective role in the treatment of people with sexual convictions. This chapter outlines how embedding religious philosophies into strategies for treating this population can act as a novel source of responsivity. Insights from Quaker, Buddhist, and Islamic traditions are discussed.

The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 22 panel members and 1 patient from 9 countries and 5 different specialties participated in a 1-day consensus meeting on 29 June 2016. Prior to the meeting, 6 questions were agreed on, and recent relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on the topics of the agreed questions atSports Hip 2016, an open meeting held in the UK on 27–29 June. Presentations were followed by open discussion. At the 1-day consensus meeting, panel members developed statements in response to each question through open discussion; members then scored their level of agreement with each response on a scale of 0–10. Substantial agreement (range 9.5–10) was reached for each of the 6 consensus questions, and the associated terminology was agreed on. The term ‘femoroacetabular impingement syndrome’ was introduced to reflect the central role of patients' symptoms in the disorder. To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings. Suitable treatments are conservative care, rehabilitation, and arthroscopic or open surgery. Current understanding of prognosis and topics for future research were discussed. The 2016 Warwick Agreement on FAI syndrome is an international multidisciplinary agreement on the diagnosis, treatment principles and key terminology relating to FAI syndrome.The Warwick Agreement on femoroacetabular impingement syndrome has been endorsed by the following 25 clinical societies: American Medical Society for Sports Medicine (AMSSM), Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), Australasian College of Sports and Exercise Physicians (ACSEP), Austian Sports Physiotherapists, British Association of Sports and Exercise Medicine (BASEM), British Association of Sport Rehabilitators and Trainers (BASRaT), Canadian Academy of Sport and Exercise Medicine (CASEM), Danish Society of Sports Physical Therapy (DSSF), European College of Sports and Exercise Physicians (ECOSEP), European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), Finnish Sports Physiotherapist Association (SUFT), German-Austrian-Swiss Society for Orthopaedic Traumatologic Sports Medicine (GOTS), International Federation of Sports Physical Therapy (IFSPT), International Society for Hip Arthroscopy (ISHA), Groupo di Interesse Specialistico dell’A.I.F.I., Norwegian Association of Sports Medicine and Physical Activity (NIMF), Norwegian Sports Physiotherapy Association (FFI), Society of Sports Therapists (SST), South African Sports Medicine Association (SASMA), Sports Medicine Australia (SMA), Sports Doctors Australia (SDrA), Sports Physiotherapy New Zealand (SPNZ), Swedish Society of Exercise and Sports Medicine (SFAIM), Swiss Society of Sports Medicine (SGMS/SGSM), Swiss Sports Physiotherapy Association (SSPA).