Publications by authors named "Michael Fredericson"

161 Publications

Comparing Functional Motor Control Exercises With Therapeutic Exercise in Wrestlers With Iliotibial Band Syndrome.

J Sport Rehabil 2022 Jun 25:1-10. Epub 2022 Jun 25.

Division of Physical Medicine and Rehabilitation, Department of Orthopedics, Stanford University, Stanford, CA,USA.

Context: Iliotibial band syndrome (ITBS) is a common overuse injury in runners with parallels to our findings of overuse in Greco Roman wrestlers. Despite research indicating coordination and movement-based factors about the hip, no studies were found using functional motor control (FMC) in runners or wrestlers with ITBS. Thus, we compared FMC exercises and therapeutic exercises (TEs) on pain, function, muscle strength, and range of motion (ROM) in national-level Greco Roman wrestlers with ITBS.

Design: Controlled laboratory study.

Methods: Sixty national-level Greco Roman wrestlers diagnosed with ITBS were randomly assigned to 8 weeks of FMC exercises, TE, and a control group (20 individuals for each group). Pain (visual analog scale), function (triple hop test for distance, single-leg vertical jump test, and agility T test), muscle strength (handheld dynamometer), and ROM (goniometer) were measured at baseline and 8 weeks after intervention as posttest.

Results: Although both interventions significantly reduced pain (P < .001, η2 = .87), improved function (triple hop test P = .004, η2 = .94; single-leg vertical jump P = .002, η2 = .93; and T test P < .001, η2 = .93) and strength (hip abduction (P < .001, η2 = .52), hip external rotation (P = .02, η2 = .95), knee flexion (P ≤ .001, η2 = .94), and knee extension (P < .001, η2 = .91) compared with the control group, FMC showed more significant improvements in comparison with TE. Significant differences (P = .001) were observed between FMC and TE compared with the control group in ROM outcome. However, TE was more effective than FMC in improving ROM hip abduction (P < .001, η2 = .93), hip adduction (P = .000, η2 = .92), hip internal rotation (P < .001, η2 = .92), and hip external rotation (P < .001, η2 = .93).

Conclusion: FMC exercises were superior to TE in terms of pain, function, and muscle strength, whereas TE was more effective for improving ROM. FMC exercise is suggested as an effective intervention for improvement of the outcomes related to ITBS in national-level Greco Roman wrestlers.
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http://dx.doi.org/10.1123/jsr.2020-0541DOI Listing
June 2022

The Impact of Supplements on Sports Performance for the Trained Athlete: A Critical Analysis.

Curr Sports Med Rep 2022 Jul 1;21(7):232-238. Epub 2022 Jul 1.

Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.

Abstract: Elite athletes often use nutritional supplements to improve performance and gain competitive advantage. The prevalence of nutrient supplementation ranges from 40% to 100% among trained athletes, yet few athletes have a trusted source of information for their supplement decisions and expected results. This critical analysis review evaluates systematic reviews, meta-analyses, randomized control trials, and crossover trials investigating commonly used supplements in sport: caffeine, creatine, beta-alanine (β-alanine), branched chain amino acids (BCAAs), and dietary nitrates. By reviewing these supplements' mechanisms, evidence relating directly to improving sports performance, and ideal dosing strategies, we provide a reference for athletes and medical staff to personalize supplementation strategies. Caffeine and creatine impact power and high-intensity athletes, β-alanine, and BCAA mitigate fatigue, and dietary nitrates improve endurance. With each athlete having different demands, goals to maximize their performance, athletes and medical staff should collaborate to personalize supplementation strategies based on scientific backing to set expectations and potentiate results.
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http://dx.doi.org/10.1249/JSR.0000000000000972DOI Listing
July 2022

Artificial Intelligence System for Automatic Quantitative Analysis and Radiology Reporting of Leg Length Radiographs.

J Digit Imaging 2022 Jul 6. Epub 2022 Jul 6.

Department of Radiology, Palo Alto VA Medical Center, 3801 Miranda Ave, Palo Alto, CA, 94304, USA.

Leg length discrepancies are common orthopedic problems with the potential for poor functional outcomes. These are frequently assessed using bilateral leg length radiographs. The objective was to determine whether an artificial intelligence (AI)-based image analysis system can accurately interpret long leg length radiographic images. We built an end-to-end system to analyze leg length radiographs and generate reports like radiologists, which involves measurement of lengths (femur, tibia, entire leg) and angles (mechanical axis and pelvic tilt), describes presence and location of orthopedic hardware, and reports laterality discrepancies. After IRB approval, a dataset of 1,726 extremities (863 images) from consecutive examinations at a tertiary referral center was retrospectively acquired and partitioned into train/validation and test sets. The training set was annotated and used to train a fasterRCNN-ResNet101 object detection convolutional neural network. A second-stage classifier using a EfficientNet-D0 model was trained to recognize the presence or absence of hardware within extracted joint image patches. The system was deployed in a custom web application that generated a preliminary radiology report. Performance of the system was evaluated using a holdout 220 image test set, annotated by 3 musculoskeletal fellowship trained radiologists. At the object detection level, the system demonstrated a recall of 0.98 and precision of 0.96 in detecting anatomic landmarks. Correlation coefficients between radiologist and AI-generated measurements for femur, tibia, and whole-leg lengths were > 0.99, with mean error of < 1%. Correlation coefficients for mechanical axis angle and pelvic tilt were 0.98 and 0.86, respectively, with mean absolute error of < 1°. AI hardware detection demonstrated an accuracy of 99.8%. Automatic quantitative and qualitative analysis of leg length radiographs using deep learning is feasible and holds potential in improving radiologist workflow.
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http://dx.doi.org/10.1007/s10278-022-00671-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9261153PMC
July 2022

Medical and Biomechanical Risk Factors for Incident Bone Stress Injury in Collegiate Runners: Can Plantar Pressure Predict Injury?

Orthop J Sports Med 2022 Jun 15;10(6):23259671221104793. Epub 2022 Jun 15.

Stanford Medical Center, Redwood City, California, USA.

Background: Bone stress injury (BSI) is a common reason for missed practices and competitions in elite track and field runners.

Hypothesis: It was hypothesized that, after accounting for medical risk factors, higher plantar loading during running, walking, and athletic movements would predict the risk of future BSI in elite collegiate runners.

Study Design: Cohort study; Level of evidence, 2.

Methods: A total of 39 elite collegiate runners (24 male, 15 female) were evaluated during the 2014-2015 academic year to determine the degree to which plantar pressure data and medical history (including Female and Male Athlete Triad risk factors) could predict subsequent BSI. Runners completed athletic movements while plantar pressures and contact areas in 7 key areas of the foot were recorded, and the measurements were reported overall and by specific foot area. Regression models were constructed to determine factors related to incident BSI.

Results: Twenty-one runners (12 male, 9 female) sustained ≥1 incident BSI during the study period. Four regression models incorporating both plantar pressure measurements and medical risk factors were able to predict the subsequent occurrence of (A) BSIs in female runners, (B) BSIs in male runners, (C) multiple BSIs in either male or female runners, and (D) foot BSIs in female runners. Model A used maximum mean pressure (MMP) under the first metatarsal during a jump takeoff and only misclassified 1 female with no BSI. Model B used increased impulses under the hindfoot and second through fifth distal metatarsals while walking, and under the lesser toes during a cutting task, correctly categorizing 83.3% of male runners. Model C used higher medial midfoot peak pressure during a shuttle run and triad cumulative risk scores and correctly categorized 93.3% of runners who did not incur multiple BSIs and 66.7% of those who did. Model D included lower hindfoot impulses in the shuttle run and higher first metatarsal MMP during treadmill walking to correctly predict the subsequent occurrence of a foot BSI for 75% of women and 100% without.

Conclusion: The models collectively suggested that higher plantar pressure may contribute to risk for BSI.
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http://dx.doi.org/10.1177/23259671221104793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9208063PMC
June 2022

Comparison of Ultrasonography to MRI in the Diagnosis of Lower Extremity Bone Stress Injuries: A Prospective Cohort Study.

J Ultrasound Med 2022 Mar 22. Epub 2022 Mar 22.

Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, CA, USA.

Objective: To determine the sensitivity and specificity of ultrasound imaging (USI) compared to the reference-standard of MRI in the diagnosis of bone stress injury (BSI).

Methods: A prospective blinded cohort study was conducted. Thirty seven patients who presented to an academic sports medicine clinic from 2016 to 2020 with suspected lower-extremity BSI on clinical exam underwent both magnetic resonance imaging (MRI) and USI. Participant characteristics were collected including age, gender and sport. Exclusion criteria included contraindication for dedicated MRI, traumatic fracture, or severe tendon or ligamentous injury. The primary outcome measure was BSI diagnosis by USI. An 8-point assessment system was utilized on USI for diagnosis of BSI, and the Fredericson and Nattiv criteria were applied to classify MRI findings.

Results: Thirty seven participants who met study criteria were consented to participate. All participants completed baseline measures. Using MRI, there were 30 (81%) athletes with a positive and seven participants with a negative BSI diagnosis. The most common BSIs in the study were in the metatarsal (54%) and tibia (32%). Compared to MRI, USI demonstrated 0.80 sensitivity (95% confidence interval [CI], 0.61-0.92) and 0.71 specificity (95% CI, 0.29-0.96) in detecting BSI, with a positive predictive value of 0.92 (95% CI, 0.75-0.99) and negative predictive value of 0.45 (95% CI, 0.17-0.77).

Conclusions: USI is a potentially useful point-of-care tool for practicing sports medicine providers to combine with their clinical evaluation in the diagnosis of BSIs. Further research is ongoing to determine the role of USI in follow-up care and return-to-play protocols.
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http://dx.doi.org/10.1002/jum.15977DOI Listing
March 2022

Treatment of Sciatica and Lumbar Radiculopathy with an Intervertebral Foramen Opening Protocol: Pilot Study in a Hospital Emergency and In-patient Setting.

Physiother Theory Pract 2022 Mar 6:1-11. Epub 2022 Mar 6.

Department of Physical and Rehabilitation Medicine, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland.

Aims: Perform a pilot study of a static nerve root foramen opening protocol for lumbar radiculopathy from disc hernia in an emergency hospital setting to establish if patients could execute the protocol, consistency would occur across outcomes, superior outcomes would occur in the experimental group, and if the protocol would be safe.

Methods: Patients with sciatica arrived of their own volition at the local emergency hospital department, were admitted for care and were randomized into two groups: 1) control (n = 10): forward bending, walking, and medication; and 2) experimental (n = 10) as control subjects, plus a static lumbar foramen opening protocol using flexion and contralateral lateral flexion (side-lying). Outcomes were back and leg pain (i.e. visual analog scale), disability (i.e. EuroQol5D5L and Oswestry) and straight leg raise.

Results: At admission, the baseline outcome variables between groups were not significantly different. All patients had moderate or large disc hernias on MRI and 75% had neurological deficits in electrophysiology. At discharge, patients in the experimental group were significantly better (p ≤ .05) than controls in all outcomes. Statistical analysis of the outcomes produced greater significance, effect sizes and minimal clinically important differences in the experimental group. Patients in the experimental group consumed less medication than control patients (21% versus 79%), including less than half the opioids (tramadol). No adverse responses occurred.

Conclusions: Patients could perform the protocol and superior outcomes occurred, with no adverse effects. The data support more detailed study of therapeutic efficacy, days in hospital, costs, conversion to surgery, and medication consumption, including opioids.
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http://dx.doi.org/10.1080/09593985.2022.2037797DOI Listing
March 2022

Lessons learned from the Tokyo games isolation hotel experience.

Br J Sports Med 2022 06 11;56(11):597-598. Epub 2022 Feb 11.

Department of Pediatrics, Haukeland Universitetssjukehus, Bergen, Norway.

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http://dx.doi.org/10.1136/bjsports-2021-105116DOI Listing
June 2022

Iron deficiency in athletes: A narrative review.

PM R 2022 05 17;14(5):620-642. Epub 2022 Mar 17.

Department of Physical Medicine and Rehabilitation, Stanford University Medical Center, Palo Alto, California, USA.

Iron deficiency is a concern for athletes due to potential for performance impairments attributed to lower iron status with, or without, accompanying anemia. Despite the high interest in the topic for endurance athletes and medical providers who care for this population, the evaluation and management of athletes with iron deficiency is still evolving, particularly in relation to iron deficiency non-anemia (IDNA). This narrative review presents causes of iron deficiency in the athlete, clinical presentation, differential diagnoses, diagnostic evaluation, and proposed strategies for treatment.
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http://dx.doi.org/10.1002/pmrj.12779DOI Listing
May 2022

Sun Protective Behaviors and Attitudes of Runners.

Sports (Basel) 2021 Dec 21;10(1). Epub 2021 Dec 21.

Division of Epidemiology, Department of Health Research and Policy, Stanford University, Redwood City, CA 94305, USA.

Sun exposure is a risk factor for skin cancer. Knowledge and behaviors around sun exposure protective measures are poorly described in athletes including runners. Our primary objective was to describe sun exposure behaviors and knowledge in a population of runners. A cross-sectional online survey was administered to 697 runners to measure the frequency of seven sun protective behaviors: sunscreen use on the face or body; wearing a hat, sunglasses, or long sleeves; running in shade; and avoidance of midday running. Between 54% and 84% of runners reported that they engaged in these behaviors at least sometimes, but only 7% to 45% reported frequent use. Of 525 runners who gave a primary reason for not using sunscreen regularly, 49.0% cited forgetfulness; 17.3% cited discomfort; and only a small percentage cited maintaining a tan (6.1%) or optimizing vitamin D (5.1%). Of 689 runners who responded to a question about what factor most influences their overall sun exposure habits, 39.2% cited fear of skin cancer, 28.7% cited comfort level, and 15.8% cited fear of skin aging. In addition to the seven individual behaviors, we also asked runners how frequently they took precautions to protect against the sun overall. We explored associations between participant characteristics and the overall use of sun protection using ordinal logistic regression. Overall, sun protection was used more frequently in runners who were female, older, or had a history of skin cancer. Runners appear to recognize the importance of sun protection and the potential consequences of not using it, but report forgetfulness and discomfort as the biggest barriers to consistent use. Interventions using habit-formation strategies and self-regulation training may prove to be most useful in closing this gap between knowledge and practice.
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http://dx.doi.org/10.3390/sports10010001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8822891PMC
December 2021

Physical Examination and Patellofemoral Pain Syndrome: an Updated Review.

Curr Rev Musculoskelet Med 2021 Dec 29;14(6):406-412. Epub 2021 Oct 29.

Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Purpose Of Review: Patellofemoral pain syndrome (PFPS) accounts for 25 to 40% of all knee disorders. Diagnosis of PFPS is primarily based on history and physical examination, but the findings on physical examination are often subtle and do not consistently correlate with symptoms described. Yoon and Fredericson published a review article in 2006 detailing the physical examination maneuvers most frequently used to assist clinicians in the accurate diagnosis and treatment of PFPS, and our aim in this review is to provide an update on this previous article focusing on the literature published over the past 15 years regarding the topic.

Recent Findings: Since publication of Fredericson's original review article, there have been studies building on the literature specifically surrounding Q angle, patellar tilt, crepitus, strength and functional testing, and physical examination maneuver clustering. Additionally, multiple studies have been conducted on the use of musculoskeletal ultrasound (US) as a diagnostic tool for PFPS. Recent literature has further supported Q angle (when measured utilizing a standardized protocol), crepitus, weakness of hip abductors and extensors, and weakness detected in functional testing as predictors of PFPS while finding inconsistent evidence behind lateral patellar tilt as a predictor of PFPS. The reliability of most physical examination tests alone remain low, but clustering physical examination findings may provide better sensitivities and specificities in diagnosing PFPS. Musculoskeletal US is rapidly gaining popularity, and decreased vastus medialis obliquus (VMO) volume, asymmetry in gluteus medius thickness, intra-articular effusions, and quadriceps and patellar tendon thicknesses have shown value in diagnosing those with PFPS. Additionally, US has the advantage of providing dynamic examination as well as evaluation of the patellofemoral joint in newborns and infants as a predictor of future patellofemoral instability. Further studies are needed to establish the gold standard for diagnosing PFPS and what US findings are truly predictive of PFPS.
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http://dx.doi.org/10.1007/s12178-021-09730-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8733121PMC
December 2021

The Impacts of COVID-19 on Mental Health and Training in US Professional Endurance Athletes.

Clin J Sport Med 2022 05 27;32(3):290-296. Epub 2021 Oct 27.

Division of Physical Medicine & Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, California.

Objective: We examined how professional athletes are affected by COVID-19. Our primary aim was to assess changes in mental health that occurred after COVID-19 restrictions, and our secondary aim was to assess changes in exercise volume and intensity.

Design: Cross-sectional study.

Setting: United States.

Participants: Strava professional endurance athletes.

Assessment Of Risk Factors: Participants completed a survey, and a subset of participants consented to have their activity data analyzed. The survey included questions on COVID-19 symptoms, exercise, and mental health, as measured by a modified Patient Health Questionnaire.

Main Outcome Measures: Participants were asked about 2 periods in 2020: before COVID-19 (January 1-March 14) and during COVID-19 (March 15-August 25), and activity data from both periods were downloaded. Activity data consisted of Global Positioning System and self-reported uploads.

Results: One hundred thirty-one male and female Strava athletes were enrolled, and a subset of athletes (n = 114) consented to have their activity data analyzed. During COVID-19 restrictions, 22.2% of participants reported feeling down or depressed and 27.4% of participants reported feeling nervous or anxious at least half the days in a week compared with 3.8% and 4.6% before COVID-19 restrictions, respectively (P < 0.0001). Activity data revealed a significant increase (P < 0.0001) in exercise minutes per day during COVID-19 (mean = 103.00, SD = 42.1) compared with before COVID-19 restrictions (mean = 92.4, SD = 41.3), with no significant changes in intensity.

Conclusions: Athletes reported significant increases in feeling down or depressed and nervous or anxious despite an increase in exercise duration during COVID-19. Future research should assess how to support athletes with mental health resources.
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http://dx.doi.org/10.1097/JSM.0000000000000983DOI Listing
May 2022

Low-Energy Availability and the Electronic Preparticipation Examination in College Athletes: Is There a Better Way to Screen?

Curr Sports Med Rep 2021 Sep;20(9):489-493

Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, Stanford University, Palo Alto, CA.

Abstract: The electronic preparticipation physical examination (ePPE) is commonly used to identify health conditions that would affect participation in sports for athletes, including disordered eating and/or low energy availability (EA). A secondary analysis was performed using a cohort study of female college athletes attending a Division 1 university between 2008 and 2014. Descriptive statistics and logistic regression analyses were used to explore the association between responses to questions on the ePPE related to eating behaviors and Female Athlete Triad (Triad). Risk categories (low, moderate, or high) were assigned to 239 athletes participating in 16 sports. The majority of responses on the ePPE did not identify athletes associated with moderate-/high-risk categories. Our findings suggest that ePPE may not sufficiently identify athletes at elevated risk for health concerns of the Triad. Our findings suggest that future ePPE may consider validated screening tools for disordered eating to help identify athletes at risk of low EA.
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http://dx.doi.org/10.1249/JSR.0000000000000880DOI Listing
September 2021

Prevalence of Female and Male Athlete Triad Risk Factors in Ultramarathon Runners.

Clin J Sport Med 2022 07 5;32(4):375-381. Epub 2021 Jul 5.

Stanford Department of Orthopaedic Surgery, Stanford University, Palo Alto, California; and.

Objective: To identify the prevalence of male and female athlete triad risk factors in ultramarathon runners and explore associations between sex hormones and bone mineral density (BMD).

Design: Multiyear cross-sectional study.

Setting: One hundred-mile ultramarathon.

Participants: Competing runners were recruited in 2018 and 2019.

Assessment Of Risk Factors: Participants completed a survey assessing eating behaviors, menstrual history, and injury history; dual-energy x-ray absorptiometry for BMD; and laboratory evaluation of sex hormones, vitamin D, and ferritin (2019 cohort only).

Main Outcome Measure: A Triad Cumulative Risk Assessment Score was calculated for each participant.

Results: One hundred twenty-three runners participated (83 males and 40 females, mean age 46.2 and 41.8 years, respectively). 44.5% of men and 62.5% of women had elevated risk for disordered eating. 37.5% of women reported a history of bone stress injury (BSI) and 16.7% had BMD Z scores <-1.0. 20.5% of men had a history of BSI and 30.1% had Z-scores <-1.0. Low body mass index (BMI) (<18.5 kg/m 2 ) was seen in 15% of women and no men. The Triad Cumulative Risk Assessment classified 61.1% of women and 29.2% of men as moderate risk and 5.6% of both men and women as high risk.

Conclusions: Our study is the first to measure BMD in both male and female ultramarathon runners. Our male population had a higher prevalence of low BMD than the general population; females were more likely to report history of BSI. Risk of disordered eating was elevated among our participants but was not associated with either low BMD or low BMI.
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http://dx.doi.org/10.1097/JSM.0000000000000956DOI Listing
July 2022

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play.

Clin J Sport Med 2021 Jul;31(4):349-366

Department of Family Medicine, University of California, Los Angeles, Los Angeles, California.

Abstract: The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.
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http://dx.doi.org/10.1097/JSM.0000000000000948DOI Listing
July 2021

Evidence-Based Medicine Training in United States-Based Physiatry Residency Programs.

Am J Phys Med Rehabil 2022 07 8;101(7 Suppl 1):S40-S44. Epub 2021 Apr 8.

From the PM&R Service, VA North Texas Health Care System, Dallas, Texas (TMA); Department of PM&R, UT Southwestern Medical Center, Dallas, Texas (TMA); Departments of Rehabilitation Medicine and Neurology, New York University Langone Health, New York City, New York (J-RR); Association of Academic Physiatrists, Owings Mills, Maryland (AS); VA RR&D Center for Limb Loss and Mobility (CLiMB), VA Puget Sound Health Care System, Seattle, Washington (DCM); Department of Rehabilitation Medicine, University of Washington, Seattle, Washington (DCM, PS); Department of Rehabilitation Medicine, University of Malaya, Kuala Lumpur, Malaysia (JPE); Department of Physical and Rehabilitation Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria (EI); Departments of Neurology, PM&R, Neuroscience, and Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio (WDA); Department of PM&R, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (MLB, ACB, BED); Department of Physical Medicine & Rehabilitation, University of Missouri, Columbia, Missouri (CM Cirstea); Division of PM&R, Stanford University School of Medicine, Stanford, California (MF); Shirley Ryan AbilityLab, Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, Illinois (PJ); Johns Hopkins School of Medicine, Baltimore, Maryland (PR); Department of PM&R, University of Kentucky, Lexington, Kentucky (LS); Seattle Epidemiologic Research and Information Center and Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington (PS); Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington (PS); Departments of Physical Medicine & Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Kennedy Krieger Institute, Baltimore, Maryland (SJS); Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts (QMW, SP); Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York (MH); Creighton University, Omaha, Nebraska (CM Case); Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania (JW); and Healey & AMG Center for ALS and Neurological Clinical Research Institute, Massachusetts General Hospital, Boston, Massachusetts (SP).

Abstract: Although the physiatric community increasingly embraces evidence-based medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purposes of this article are to report the results of the Association of Academic Physiatrists' surveys of physiatry residency programs in the United States, to discuss the implications of their findings, and to better delineate the "baseline" upon which sound and clear recommendations for systematic EBM training can be made. The two Association of Academic Physiatrists surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, although most respondents reported using traditional pedagogic methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core competencies and the evaluation of their impact.
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http://dx.doi.org/10.1097/PHM.0000000000001752DOI Listing
July 2022

Narrative Review - Knee Pain in the Pediatric Athlete.

Curr Rev Musculoskelet Med 2021 Jun 5;14(3):239-245. Epub 2021 Apr 5.

Department of Physical Medicine and Rehabilitation, Stanford University, 500 Jefferson Avenue #823, Redwood City, CA, 94063, USA.

Purpose Of Review: This review article seeks to highlight common youth athlete knee conditions due to overuse or trauma and elucidate differences from the adult populations.

Recent Findings: Overuse conditions presented include apophysitis, osteochondritis dissecans plica syndrome, and discoid meniscus. Traumatic conditions presented include patellar instability, patellar sleeve fracture, and patellofemoral osteochondral fractures. Knee injuries affect a significant proportion of youth athletes. These injuries place athletes at higher risk of chronic pain and potentially osteoarthritis. We have reviewed common overuse and traumatic knee injuries and differentiating factors between the adult population to improve and expedite the diagnosis, treatment, and prognosis for youth athletes with knee injuries.
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http://dx.doi.org/10.1007/s12178-021-09708-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137791PMC
June 2021

Narrative: Review of Anterior Knee Pain Differential Diagnosis (Other than Patellofemoral Pain).

Curr Rev Musculoskelet Med 2021 Jun 5;14(3):232-238. Epub 2021 Apr 5.

Department of Physical Medicine and Rehabilitation, Stanford University, 655 Bradford Street #842, Redwood City, CA, 94063, USA.

Purpose Of Review: This review presents a framework for constructing a differential diagnosis for chronic anterior knee pain associated with overuse other than patellofemoral pain. Traumatic, systemic, and pediatric injuries will not be covered.

Recent Findings: From superficial to deep, the anterior knee can be conceptually organized into four layers: (1) soft tissue, (2) extensor mechanism, (3) intracapsular/extrasynovial, and (4) intra-articular. From superficial to deep, diagnoses to consider include bursitis, patellar and quadriceps tendinosis, fat pad impingement, and plica syndromes.
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http://dx.doi.org/10.1007/s12178-021-09704-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137785PMC
June 2021

Markers of Low-Iron Status Are Associated with Female Athlete Triad Risk Factors.

Med Sci Sports Exerc 2021 09;53(9):1969-1974

Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA.

Purpose: The Female Athlete Triad (Triad) is common in female athletes. The Triad is caused by low-energy availability (EA), which is often difficult to measure and has been postulated to be associated with low-iron status. Here, we explore whether markers of low-iron status may be associated with indicators of low EA including Triad risk factors.

Methods: A total of 239 female National Collegiate Athletic Association Division I athletes completed preparticipation examinations that included Triad risk factors, medication/supplement use, diagnosis of anemia, and elected to complete dual-energy x-ray absorptiometry scan to measure bone mineral density. The association of markers of low iron (defined as self-report of iron supplementation and/or history of anemia) with each component of the Triad risk assessment score was assessed by stratifying low-iron status across different levels of Triad risk category. Differences across iron status groups were assessed using Fisher exact testing.

Results: Every component of the Triad risk assessment score excluding delayed menarche was associated with low-iron status. The proportion of women who reported low iron was 11.5% in the low-risk EA group compared with 50% in the moderate-risk and 66.7% in the high-risk EA groups (P = 0.02); respectively. These numbers were 11.6%, 25.0%, and 66.7% (P = 0.02) for body mass index; 9.7%, 16.7%, and 25.0% (P < 0.05) for oligomenorrhea; 10.3%, 45.5%, and 50.0% (P < 0.01) for bone mineral density; and 10.4%, 20.8%, and 30.8% (P = 0.03) for history of stress reaction or fracture. Lean/endurance athletes were more likely to have low-iron status than other athletes (15.5% vs 3.4%, P = 0.02).

Conclusions: Markers for low-iron status were associated with Triad risk factors. Our study suggests that female athletes with a history of anemia or iron supplementation may require further screening for low EA.
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http://dx.doi.org/10.1249/MSS.0000000000002660DOI Listing
September 2021

Topical diclofenac vs placebo for the treatment of chronic Achilles tendinopathy: A randomized controlled clinical trial.

PLoS One 2021 4;16(3):e0247663. Epub 2021 Mar 4.

Department of Physical Therapy, University of British Columbia, Vancouver, Canada.

Introduction: The application of topical diclofenac has been suggested as a possible treatment for Achilles tendinopathy. Our aim was to answer the question, is topical diclofenac more effective than placebo for the treatment of Achilles tendinopathy?.

Methods: 67 participants with persistent midportion or insertional Achilles tendinopathy were randomly assigned to receive a 4 week course of 10% topical diclofenac (n = 32) or placebo (n = 35). The a priori primary outcome measure was change in severity of Achilles tendinopathy (VISA-A score) at 4 and 12 weeks. Secondary outcome measures included numeric pain rating, and patient-reported change in symptoms using a 7 point scale, from substantially worse to substantially better. Pressure pain threshold (N) and transverse tendon stiffness (N/m) were measured over the site of maximum Achilles tendon pathology at baseline and 4 weeks.

Results: There were no statistically or clinically significant differences between the diclofenac and placebo groups in any of the primary or secondary outcome measures at any timepoint. Average VISA-A score improved in both groups (p<0.0001), but the improvements were marginal: at 4 weeks, the improvements in VISA-A were 9 (SD 11) in the diclofenac group and 8 (SD 12) in the placebo group, and at 12 weeks the improvements were 9 (SD 16) and 11 (SD13) respectively-these average changes are smaller than the minimum clinically important difference of the VISA-A.

Conclusion: The regular application of topical diclofenac for Achilles tendinopathy over a 4 week period was not associated with superior clinical outcomes to that achieved with placebo.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247663PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932128PMC
September 2021

Palpitations in an Elite Running Athlete: When to Run Through the Beat? A Case Report.

Curr Sports Med Rep 2021 Feb;20(2):84-86

Physical Medicine and Rehabilitation Residency Program, Department of Orthopedic Surgery, Stanford University Hospital, Palo Alto, CA.

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http://dx.doi.org/10.1249/JSR.0000000000000806DOI Listing
February 2021

The Physiatry Workforce in 2019 and Beyond, Part 1: Results From a Cross-sectional Survey.

Am J Phys Med Rehabil 2021 09;100(9):866-876

From the Center for Health Workforce Studies, School of Public Health, University at Albany SUNY, Rensselaer, New York (GJF, ML, SW); IHS Markit, Washington, DC (TMD, RLR, RC); Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania (JW); Department of Rehabilitation Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (NSA); VA North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas (TMA); Stanford University School of Medicine, Stanford, California (MF); Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, Texas (NBJ); Departments of Physical Medicine & Rehabilitation and Anesthesiology & Perioperative Care and Neurological Surgery, University of California, Irvine, California (DPK); Department of Rehabilitation Medicine, University of Washington, Seattle, Washington (DCM); VA Puget Sound Health Care System Center for Limb Loss and Mobility (CLiMB), Seattle, Washington (DCM); Spaulding Rehabilitation Hospital, Boston, Massachusetts (CS); Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts (CS); and Georgetown University School of Medicine, Washington, DC (EW).

Objective: The aim of the study was to describe the current physiatrist workforce in the United States.

Design: An online, cross-sectional survey of board-certified physiatrists in 2019 (N = 616 completed, 30.1% response) collected information about demographic and practice characteristics, including age, sex, practice area, practice setting, hours worked, patient characteristics, staffing, and work responsibilities. Physiatrists were stratified by substantive practice patterns using a cluster analysis approach. Survey responses were arrayed across the practice patterns and differences noted.

Results: The practice patterns identified included musculoskeletal/pain medicine, general/neurological rehabilitation, academic practice, pediatric rehabilitation, orthopedic/complex conditions rehabilitation, and disability/occupational rehabilitation. Many differences were observed across these practice patterns. Notably, primary practice setting and the extent and ways in which other healthcare staff are used in physiatry practices differed across practice patterns. Physiatrists working in musculoskeletal/pain medicine and disability/occupational rehabilitation were least likely to work with nurse practitioners and physician assistants. Physiatrists working in academic practice, general/neurological rehabilitation, and pediatric rehabilitation were most likely to have primary practice settings in hospitals.

Conclusions: Physiatry is an evolving medical specialty affected by many of the same trends as other medical specialties. The results of this survey can inform policy discussions and further research on the effects of these trends on physiatrists and physiatry practice in the future.
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http://dx.doi.org/10.1097/PHM.0000000000001692DOI Listing
September 2021

Assessing Diagnostic and Severity Grading Accuracy of Ultrasound Measurements for Carpal Tunnel Syndrome Compared to Electrodiagnostics.

PM R 2021 08 23;13(8):852-861. Epub 2021 Jan 23.

Division of Physical Medicine & Rehabilitation, Department of Orthopaedics, Stanford University, Stanford, CA, USA.

Background: The combined sensory index (CSI) is the most sensitive electrodiagnostic criteria for carpal tunnel syndrome (CTS), and the CSI and Bland criteria have been shown to predict surgical treatment outcomes. The proposed ultrasound measurements have not been assessed against the CSI for diagnostic accuracy and grading of CTS severity.

Objective: To investigate the use of ultrasound evaluations for both diagnosis and assessment of severity grading of CTS in comparison to electrodiagnostic assessment.

Design: All patients underwent an electrodiagnostic evaluation using the CSI and Bland severity grading. Each patient underwent an ultrasound evaluation including cross-sectional area (CSA), the change in CSA from the forearm to the tunnel (∆CSA), and the wrist-forearm ratio (WFR). These measurements were assessed for diagnostic and severity grading accuracy using the CSI as the gold standard.

Setting: Tertiary academic center.

Participants: All patients referred for electrodiagnostic evaluation for CTS were eligible for the study. Only those with idiopathic CTS were included and those with prior CTS treatment were also excluded. Ninety-five patients were included in the study.

Interventions: Not applicable.

Main Outcome Measures: The primary study outcome measure was concordance between CSI diagnosis and severity categories and the ultrasound measurements. Both outcomes were also assessed using Bland criteria.

Results: Optimal cut-points for diagnosis of CTS were found to be CSA ≥12 mm , ∆CSA ≥4 mm , WFR ≥1.4. Using these cut-points, C-statistics comparing diagnosis of CTS using ultrasound measurements versus using the CSI ranged from 0.893-0.966. When looking at CSI severity grading compared to ∆CSA, however, the C-statistics were 0.640-0.661 with substantial overlap between severity groups.

Conclusions: Although ultrasound measurements had high diagnostic accuracy for CTS based on the CSI criteria, ultrasound measurements were unable to adequately distinguish between CSI severity groups among patients with CTS.
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http://dx.doi.org/10.1002/pmrj.12533DOI Listing
August 2021

Dietary Supplement Use According to Sex and Triad Risk Factors in Collegiate Endurance Runners.

J Strength Cond Res 2021 Feb;35(2):404-410

Departments of Family Medicine and Orthopedic Surgery, University of California, Los Angeles, Santa Monica, California.

Abstract: Barrack, MT, Fredericson, M, Dizon, F, Tenforde, AS, Kim, BY, Kraus, E, Kussman, A, Singh, S, and Nattiv, A. Dietary supplement use according to sex and Triad risk factors in collegiate endurance runners. J Strength Cond Res 35(2): 404-410, 2021-This cross-sectional study evaluated the prevalence in the use of dietary supplements among elite collegiate runners among 2 NCAA Division I cross-country teams. At the start of each season from 2015 to 2017, male and female endurance runners were recruited to complete baseline study measures; the final sample included 135 (male n = 65, female n = 70) runners. Runners completed a health survey, web-based nutrition survey, and Triad risk assessment. The prevalence of dietary supplement use and Triad risk factors, including disordered eating, low bone mass, amenorrhea (in women), low body mass index, and stress fracture history, was assessed. A total of 78.5% (n = 106) runners reported taking 1 or more supplements on ≥4 days per week over the past month, 48% (n = 65) reported use of ≥3 supplements. Products used with highest frequency included multivitamin/minerals 46.7% (n = 63), iron 46.7% (n = 63), vitamin D 34.1% (n = 46), and calcium 33.3% (n = 45). More women, compared with men, used iron (61.4 vs. 30.8%, p < 0.001) and calcium (41.4 vs. 24.6%, p = 0.04); men exhibited higher use of amino acids and beta-alanine (6.2 vs. 0%, p = 0.04). Runners with bone stress injury (BSI) history, vs. no previous BSI, reported more frequent use of ≥3 supplements (61.5 vs. 32.8%, p = 0.001), vitamin D (49.2 vs. 19.4%, p < 0.001), and calcium (47.7 vs. 19.4%, p = 0.001). Low bone mineral density was also associated with higher use of vitamin D and calcium. Most runners reported regular use of 1 or more supplements, with patterns of use varying based on sex, history of BSI, and bone mass.
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http://dx.doi.org/10.1519/JSC.0000000000003848DOI Listing
February 2021

The Physiatry Workforce in 2019 and Beyond, Part 2: Modeling Results.

Am J Phys Med Rehabil 2021 09;100(9):877-884

From the IHS Markit, Washington, DC (TMD, RLR, RC); Center for Health Workforce Studies, School of Public Health, University at Albany SUNY, Rensselaer, New York (GJF, ML, SW); Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania (JW); Department of Rehabilitation Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (NSA); VA North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas (TMA); Stanford University School of Medicine, Stanford, California (MF); Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, Texas (NBJ); Departments of Physical Medicine & Rehabilitation and Anesthesiology & Perioperative Care and Neurological Surgery, University of California, Irvine, California (DPK); Department of Rehabilitation Medicine, University of Washington, Seattle, Washington (DCM); VA Puget Sound Health Care System Center for Limb Loss and Mobility (CLiMB), Seattle, Washington (DCM); Spaulding Rehabilitation Hospital, Boston, Massachusetts (CS); Harvard Medical School Department of Physical Medicine and Rehabilitation, Boston, Massachusetts (CS); and Georgetown University School of Medicine, Washington, DC (EW).

Objective: The aim of this study was to assess the current and future adequacy of physiatrist supply in the United States.

Design: A 2019 online survey of board-certified physiatrists (n = 616 completed, 30.1% response) collected information about demographics, practice characteristics, hours worked, and retirement intentions. Microsimulation models projected future physiatrist supply and demand using data from the American Board of Physical Medicine and Rehabilitation, national and state population projections, American Community Survey, Behavioral Risk Factor Surveillance System, Medical Expenditure Panel Survey, and other sources.

Results: Approximately 37% of 8853 active physiatrists indicate that their workload exceeds capacity, 59% indicate that workload is at capacity, and 4% indicate under capacity. These findings suggest a national shortfall of 940 (10.6%) physiatrists in 2017, with substantial geographic variation in supply adequacy. Projected growth in physiatrist supply from 2017 to 2030 approximately equals demand growth (2250 vs. 2390), suggesting that without changes in care delivery, the shortfall of physiatrists will persist, with a 1080 (9.7%) physiatrist shortfall in 2030.

Conclusion: Without an increase in physiatry residency positions, the current national shortfall of physiatrists is projected to persist. Although a projected increase in physiatrists' use of advanced practice providers may help preserve access to comprehensive physiatry care, it is not expected to eliminate the shortfall.
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http://dx.doi.org/10.1097/PHM.0000000000001659DOI Listing
September 2021

Youth running consensus statement: minimising risk of injury and illness in youth runners.

Br J Sports Med 2021 Mar 29;55(6):305-318. Epub 2020 Oct 29.

Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA.

Despite the worldwide popularity of running as a sport for children, relatively little is known about its impact on injury and illness. Available studies have focused on adolescent athletes, but these findings may not be applicable to preadolescent and pubescent athletes. To date, there are no evidence or consensus-based guidelines identifying risk factors for injury and illness in youth runners, and current recommendations regarding suitable running distances for youth runners at different ages are opinion based. The International Committee Consensus Work Group convened to evaluate the current science, identify knowledge gaps, categorise risk factors for injury/illness and provide recommendations regarding training, nutrition and participation for youth runners.
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http://dx.doi.org/10.1136/bjsports-2020-102518DOI Listing
March 2021

Lower Trabecular Bone Score and Spine Bone Mineral Density Are Associated With Bone Stress Injuries and Triad Risk Factors in Collegiate Athletes.

PM R 2021 09 7;13(9):945-953. Epub 2020 Dec 7.

Boswell Human Performance Laboratory, Department of Orthopaedic Surgery, Stanford, CA.

Introduction: Determinants of bone health and injury are important to identify in athletes. Bone mineral density (BMD) is commonly measured in athletes with Female Athlete Triad (Triad) risk factors; the trabecular bone score (TBS) has been proposed to predict fracture risk independent of BMD. Evaluation of TBS and spine BMD in relation bone stress injury (BSI) risk has not been studied in female collegiate athletes.

Objective: We hypothesized that spine BMD and TBS would each independently predict BSI and that the combined measures would improve injury prediction in female collegiate athletes. We also hypothesized that each measure would be correlated with Triad risk factors.

Design: Retrospective cohort.

Setting: Academic Institution.

Methods: Dual energy x-ray absorptiometry (DXA) of the lumbar spine was used to calculate BMD and TBS values. Chart review was used to identify BSI that occurred after the DXA measurement and to obtain Triad risk factors. We used logistic regression to examine the ability of TBS and BMD alone or in combination to predict prospective BSI.

Results: Within 321 athletes, 29 (9.0%) sustained a BSI after DXA. BMD and TBS were highly correlated (Pearson correlation r = 0.62, P < .0001). Spine BMD and TBS had similar ability to predict BSI; the C-statistic and 95% confidence intervals were 0.69 (0.58 to 0.81) for spine BMD versus 0.68 (0.57 to 0.79) for TBS. No improvement in discrimination was observed with combined BMD + TBS (C-statistic 0.70, 0.59 to 0.81). Both TBS and BMD predicted trabecular-rich BSI (defined as pelvis, femoral neck, and calcaneus) better than cortical-rich BSI. Both measures had similar correlations with Triad risk factors.

Conclusion: Lower BMD and TBS values are associated with elevated risk for BSI and similar correlation to Triad risk factors. TBS does not improve prediction of BSI. Collectively, our findings suggest that BMD may be a sufficient measure of skeletal integrity from DXA in female collegiate athletes.
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http://dx.doi.org/10.1002/pmrj.12510DOI Listing
September 2021

A Genome-wide Association Study for Concussion Risk.

Med Sci Sports Exerc 2021 04;53(4):704-711

Department Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA.

Purpose: This study aimed to screen the entire genome for genetic markers associated with risk for concussion.

Methods: A genome-wide association analyses was performed using data from the Kaiser Permanente Research Bank and the UK Biobank. Concussion cases were identified based on electronic health records from the Kaiser Permanente Research Bank and the UK Biobank from individuals of European ancestry. Genome-wide association analyses from both cohorts were tested for concussion using a logistic regression model adjusting for sex, height, weight, and race/ethnicity using allele counts for single nucleotide polymorphisms. Previously identified genes within the literature were also tested for association with concussion.

Results: There were a total of 4064 cases of concussion and 291,472 controls within the databases, with two single nucleotide polymorphisms demonstrating a genome-wide significant association with concussion. The first polymorphism, rs144663795 (P = 9.7 × 10-11; OR = 2.91 per allele copy), is located within the intron of SPATA5. Strong, deleterious mutations in SPATA5 cause intellectual disability, hearing loss, and vision loss. The second polymorphism, rs117985931 (P = 3.97 × 10-9; OR = 3.59 per allele copy), is located within PLXNA4. PLXNA4 plays a key role is axon outgrowth during neural development, and DNA variants in PLXNA4 are associated with risk for Alzheimer's disease. Previous investigations have identified five candidate genes that may be associated with concussion, but none showed a significant association in the current model (P < 0.05).

Conclusion: Two genetic markers were identified as potential risk factors for concussion and deserve further validation and investigation of molecular mechanisms.
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http://dx.doi.org/10.1249/MSS.0000000000002529DOI Listing
April 2021

The effect of patellofemoral pain syndrome on patellofemoral joint kinematics under upright weight-bearing conditions.

PLoS One 2020 30;15(9):e0239907. Epub 2020 Sep 30.

Division of Mechanical and Biomedical Engineering, College of Engineering, Ewha Womans University, Seoul, Korea.

Patellofemoral pain (PFP) is commonly caused by abnormal pressure on the knee due to excessive load while standing, squatting, or going up or down stairs. To better understand the pathophysiology of PFP, we conducted a noninvasive patellar tracking study using a C-arm computed tomography (CT) scanner to assess the non-weight-bearing condition at 0° knee flexion (NWB0°) in supine, weight-bearing at 0° (WB0°) when upright, and at 30° (WB30°) in a squat. Three-dimensional (3D) CT images were obtained from patients with PFP (12 women, 6 men; mean age, 31 ± 9 years; mean weight, 68 ± 9 kg) and control subjects (8 women, 10 men; mean age, 39 ± 15 years; mean weight, 71 ± 13 kg). Six 3D-landmarks on the patella and femur were used to establish a joint coordinate system (JCS) and kinematic degrees of freedom (DoF) values on the JCS were obtained: patellar tilt (PT, °), patellar flexion (PF, °), patellar rotation (PR, °), patellar lateral-medial shift (PTx, mm), patellar proximal-distal shift (PTy, mm), and patellar anterior-posterior shift (PTz, mm). Tests for statistical significance (p < 0.05) showed that the PF during WB30°, the PTy during NWB0°, and the PTz during NWB0°, WB0°, and WB30° showed clear differences between the patients with PFP and healthy controls. In particular, the PF during WB30° (17.62°, extension) and the PTz during WB0° (72.5‬0 mm, posterior) had the largest rotational and translational differences (JCS Δ = patients with PFP-controls), respectively. The JCS coordinates with statistically significant difference can serve as key biomarkers of patellar motion when evaluating a patient suspected of having PFP. The proposed method could reveal diagnostic biomarkers for accurately identifying PFP patients and be an effective addition to clinical diagnosis before surgery and to help plan rehabilitation strategies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239907PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526904PMC
December 2020

Vitamin D for Improved Bone Health and Prevention of Stress Fractures: A Review of the Literature.

Curr Sports Med Rep 2020 Jun;19(6):202-208

Standford Sports Medicine Clinic, Redwood City, CA.

Vitamin D is a vital nutrient and hormone needed for many essential functions in overall health. There is growing literature examining the role of vitamin D not only in the general population but also in athletes. The most predominantly studied area of vitamin D pertains to bone health. Recently, there has been increased investigation into the relationship of vitamin D and stress fractures, including genetic polymorphisms, levels of 25-hydroxyvitamin D, and bioavailable vitamin D. This review will address the most recent developments of vitamin D research and its important role in bone health in athletes.
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http://dx.doi.org/10.1249/JSR.0000000000000718DOI Listing
June 2020

Taping, Bracing, and Injection Treatment for Patellofemoral Pain and Patellar Tendinopathy.

Curr Rev Musculoskelet Med 2020 Aug;13(4):537-544

Department of Orthopedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, Stanford, CA, USA.

Purpose Of Review: This article will focus on additional treatment options for the two most common causes of anterior knee pain, patellofemoral pain syndrome, and patellar tendinopathy. Conservative management is the first-line treatment for these conditions. For clinicians to maximize the efficacy of conservative treatment options for their patients, they must understand the most up-to-date literature evaluating the potential benefit of taping, bracing, and injections as adjunctive treatments for maximizing treatment success.

Recent Findings: Recent studies of bracing and taping have found them to be helpful for patients in the short-term management of pain and improving function. However, less is known about their exact mechanism but studies are encouraging that they have a subtle role in changing patellofemoral biomechanics. Injections remain a commonly used treatment for musculoskeletal conditions; however, the evidence for their use in patellofemoral pain and patellar tendinopathy is limited. The use of platelet-rich plasma (PRP), sclerosing, high volume, or stem cell injections is an exciting new area in the treatment of patellar tendinopathy. However, evidence at this time to recommend these treatments is lacking, and more well-designed studies are needed. The treatment of patellofemoral pain and patellar tendinopathy consists of a multi-faceted approach of physiotherapy and physical modalities. There is evidence for short-term use of taping and bracing for these conditions. The evidence for injections at this time is limited and remains under investigation. Future well-designed randomized controlled studies will provide insight into the efficacy of several different types of injections in the treatment of patellar tendinopathy. Physicians should feel comfortable integrating taping and bracing into their anterior knee pain treatment paradigm while making cautious use of invasive injections as adjunctive therapy.
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http://dx.doi.org/10.1007/s12178-020-09646-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340692PMC
August 2020
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