Jelsing, Elena J.

Syndesmotic injuries are complex and often require a longer return to play as compared with lateral ankle sprains. As common as they are, they can be difficult to diagnose owing to the complex biomechanics of the ankle joint as well as their varying degrees of stability. A careful physical examination and dedicated imaging can assist with the diagnosis. Weightbearing ankle X-rays should be obtained to assess for fractures or gross instability with anteroposterior, lateral, and mortise views. If these are inconclusive but there is high clinical suspicion, stress views can be added. Advanced imaging also plays a role. Classification systems attempt to distinguish a stable, dynamically unstable, and unstable injury, as this guides management. Stable injuries can be treated conservatively and unstable injuries warrant surgical intervention. It is the diagnosis and treatment of unstable injuries that can be particularly challenging.

Objectives While extracorporeal shockwave therapy (ESWT) may be an efficacious adjunctive treatment option for musculoskeletal injuries, current research is limited by significant heterogeneity within treatment protocols. This study aims to establish international expert consensus recommendations on ESWT terminology, parameters, procedural considerations, contraindications and side effects in the application of ESWT to sports injuries. Methods A systematic literature search was performed on the use of ESWT for musculoskeletal and sports medicine injuries to identify potential panellists, followed by the development of a steering committee-led questionnaire. A three-stage, modified Delphi questionnaire was provided to a panel of 41 international clinical and research experts across 13 countries. Panellists had the opportunity to suggest edits to existing statements or recommend additional statements in Round 1. Consensus was defined as≥75% agreement. Results All 41 panellists completed Rounds 1, 2 and 3. Consensus was reached on 69/118 statements (58.5%), including recommendations on terminology and fundamental concepts, indications for use, procedural aspects for tendinopathy and bone pathologies, treatment correlations with imaging, periprocedural and postprocedural considerations, absolute and relative contraindications and potential side effects. Of the 49 statements that did not reach consensus, 17/49 (34.7%) were related to procedural aspects of bone pathology. Conclusion This international panel presents recommendations on ESWT terminology, indications and treatment considerations to guide ESWT use and decision-making by sports medicine clinicians. While our panel supported the use of ESWT in the treatment of bone pathologies, certain procedural aspects of ESWT specific to these injuries did not reach consensus and require further investigation.

Context Musculoskeletal (MSK) diagnostic ultrasound (US) is increasingly being utilized by physicians to evaluate athletes in outpatient clinics, on the sidelines, and in athletic training facilities. Having a thorough understanding of MSK US will help athletic trainers (ATs) better assist physicians who perform MSK US. Objective To determine if a longitudinal 6-month MSK anatomy and US course would increase ATs’ ability to acquire, label, and optimize US images of normal structures and improve their overall confidence in assisting with performing US and to determine if demographic factors, work-related factors, or higher self-reported confidence was associated with better performance. Design Prospective cohort study. Setting Academic institution. Other Participants Seventeen ATs working with sports medicine physicians at 3 institutions. Interventions Longitudinal 6-month MSK anatomy and US course. Main Outcome Measures Ultrasound image scores (normal structures scored on a 5-point scale) were assessed precourse, during the course, and postcourse. Scores were compared across time points for the assessed body regions (knee, ankle/foot, shoulder, elbow/wrist/hand, and hip). Associations with demographic factors, US experience, and AT self-reported confidence were explored. Results Seventeen ATs completed the course. There was a significant difference among the average overall precourse (average: 1.34/5, range: 0/5 to 4.23/5), during-course (average = 3.53/5; range, 2.6/5 to 4.37/5), and postcourse (average = 3.83/5; range, 2.33/5 to 4.67/5) image scores [χ2(2) = 24.47, P < .001]. There was a significant positive correlation between the numbers of days (rs[17] = 0.62, P = .01) and hours (rs[17] = 0.55, P = .02) per week that the AT spent observing or performing US scanning and the postcourse overall image scores. The ATs’ confidence in identifying structures when they scan and postcourse overall image scores were marginally correlated but not significant (rs[17] = 0.47, P = .06). Conclusions A comprehensive longitudinal MSK diagnostic US course may have resulted in significant improvements in an AT’s ability to acquire, label, and optimize US images of normal MSK structures that are commonly injured by active persons.

Abstract Thumb metacarpophalangeal joint ulnar collateral ligament injuries are common in athletes and range from mild sprains to complete retracted tears. The typical injury mechanism of a valgus force directed onto an abducted or extended thumb is frequently seen in certain sporting activities, such as skiing, football, and baseball. Ultrasound and magnetic resonance imaging are excellent imaging supplements to the clinical evaluation for diagnosis confirmation. Positive treatment outcomes have been demonstrated when these injuries are appropriately managed both nonoperatively and surgically. When deciding on a treatment plan, it is paramount to take the athlete's injury severity and sport-specific factors into account. The aim of this review is to summarize the sport epidemiology, diagnosis, treatment options, and return to play considerations for athletes who sustain an acute thumb metacarpophalangeal joint ulnar collateral ligament injury.

Introduction: Medical education is trending towards an outcome-based curriculum that prepares medical graduates to excel in a rapidly evolving, team-centred healthcare delivery system. The Mayo Medical School (MMS) has recently redesigned its curriculum to introduce early clinical relevance, optimise course integration, provide flexibility and promote active learning. This study aims to evaluate the role that curricular flexibility plays in students’ perceived learning, satisfaction and performance. Materials and Methods: First-year students completed a 5-point Likert scale survey regarding satisfaction with and perceived learning from various components of the flexible curriculum during 2 different academic blocks. Students’ academic performance was assessed by a National Board of Medical Examiners (NBME) Subject Examination after each block. Results: In comparing student-rated satisfaction and perceived learning from didactics versus other curricular components for Block 3 (Pathology and Immunology) and Block 5 (Gross Anatomy and Radiology), students rated didactics higher in all cases in which there was a statistically significant difference in the ratings. There was a statistically significant positive correlation between the amount learned and satisfaction for all curricular components with the exception of Block 5 independent study. During Block 3, only interest in the subject matter correlated positively with the NBME score, while during Block 5, only time spent in class correlated negatively with the NBME score. Conclusions: Although various components of the flexible curriculum do not appear to affect satisfaction and perceived learning, their potential influence on graduate outcomes, in terms of delivering healthcare providers who are patient-centred, creative thinkers and compassionate leaders should not be discounted. Key words: Curriculum reform, Medical curriculum, Outcomes-based education, Student satisfaction

Abstract: A 53-year-old right-handed female weightlifter presented to our clinic for evaluation of left elbow pain and intermittent numbness in her first 3 digits. She reported an elbow injury while weight lifting and carrying heavy planters 6 months earlier. A magnetic resonance imaging obtained previously was interpreted as bicipital-radial bursitis, and she had previously undergone a comprehensive nonoperative management program for her pain and numbness. A diagnostic ultrasound performed in clinic revealed distal biceps tendinopathy, bicipital-radial bursitis, and “pseudotumor,” which was dynamically compressed between the biceps tendon and radius with pronation and also caused a mass effect on the median nerve at the level of the pronator teres. Surgical excision of the mass resulted in near-complete resolution of her symptoms, and histology was consistent with scar tissue. This is the first case to the best of our knowledge to describe point-of-care ultrasound diagnosis of a biceps tendon “pseudotumor,” as well as demonstrating dynamic impingement of this pseudotumor causing mass effect on the median nerve.

Abstract Treatment of musculoskeletal conditions in athletes with extracorporeal shockwave therapy (ESWT) is gaining popularity as greater evidence supports its use. ESWT protocols (describing energy flux density, number of impulses, type of shockwave (focused or radial), number/frequency/duration of treatment session, area of application, and postprocedural therapy protocols) can be adjusted in the clinical setting. Protocols vary across studies, and optimal protocols for most indications are yet to be determined. ESWT can safely be used to treat various musculoskeletal conditions in athletes, including rotator cuff tendinopathy, lateral elbow epicondlyopathy, greater trochanteric pain syndrome, hamstring tendinopathy, patellar tendinopathy, Achilles tendinopathy, other tendinopathies, plantar fasciopathy, bone stress injuries, and medial tibial stress syndrome. ESWT can be used to treat in-season athletes, as it often requires no/minimal time away from sport and may result in rapid benefits. ESWT should be used in conjunction with physical therapy to facilitate longer-term gains in function and to optimize healing.