Directors of long-running course preview their January presentation

The 20th Annual Sports Medicine Course, presented by AAOS, the American Orthopaedic Society for Sports Medicine, and the Arthroscopy Association of North America, will take place in Park City, Utah, Jan. 30 to Feb. 3, 2019. This popular educational event, led by course director Brian J. Cole, MD, MBA, and codirectors CAPT (Ret.) Matthew T. Provencher, MD, MC USNR, and Kevin E. Wilk, DPT, PT, FAPTA, once again promises to provide an abundance of useful information on the top-trending topics in sports medicine, as well as valuable insights on emerging and leading-edge technology, orthobiologics, and innovative surgical techniques.

In a roundtable discussion convened for AAOS Now, the three instructors exchanged their views and perspectives and provided a preview of some of the material that will be covered during the course.

AAOS Now: What are some of the top-of-mind issues in sports medicine?

Dr. Cole: In the area of articular cartilage restoration or dealing with young people with meniscal problems—such as meniscal deficiency—in the past, the primary indications involved treating those with problems performing activities of day-to-day living and low-level activities. We are now learning through prospective studies that some of these very same techniques can safely and sometimes predictably get very high-level athletes back to sports. The same techniques that we previously reserved for those who are the most symptomatic with the lowest levels of activity can now, on occasion, be performed and get athletes back at a very high level. We wouldn’t have known this unless we paid attention to our outcomes, so it’s all about tracking the things that we do. Publications from various centers have suggested that meniscus transplant or osteochondral allograft, for example, could get athletes who could not otherwise participate in their high-level, physically demanding sports back to play. This is useful because these are people who sometimes have no other option to make a living or, because of an athletic scholarship, to attend school.

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Dr. Provencher: Something we continue to work on is early sports specialization (ESS). We know that ESS can be detrimental in young athletes, especially those younger than 14 or 15 years old who play a year-round solo sport. There are a few sports such as figure skating, gymnastics, and possibly ice hockey in which peak performance is optimized at a younger age; however, there is still a potential cost to specializing too early. We see this all the time in many other sports, including soccer, lacrosse, field hockey, and volleyball. We are seeing not only injuries to the joints due to overtraining, but also psychological aspects and burnout. For example, the athlete who, due to psychological exhaustion, says, “I was recruited for college but don’t have the desire to perform.”

Dr. Wilk: The hip is very much an emerging area in orthopaedics and sports medicine, much like what some people say the shoulder was maybe five or 10 years ago. In the past, superior labral tears in throwers, anything that showed up as a blip on the MRI, might have been treated surgically, especially if the athlete had shoulder pain. The surgeon might say, “You have something wrong with you; we’re going to operate.” Similar things are now happening with the hip, where MRIs are performed and people have labral tears and femoroacetabular impingement. Conditions are now being delineated with a differential diagnosis—we tell the patient that the labral tear might not be the source of their pain and that not everything is operated on. Some of the thought leaders in this area have come out with papers saying we need to be more critical and treat the patient individually. We have pitchers with those tears, and they are throwing. You have people with beat-up labrums, and they are playing elite soccer and hockey. It’s the correlation of symptoms, clinical examination, MRI, and the ability to function that should guide the diagnosis or how the treatment plan is organized.

AAOS Now: What are some of the trends in sports medicine?

Dr. Cole: I suggest that, as clinicians, we really need to know what can be safely neglected. There are very few things we do that will change the natural history of the joint. We should be focusing on the here and now and not on anatomic abnormalities. Something that happens historically in orthopaedics is that, for better or worse, new technology techniques create an environment where we can fix everything, and sometimes we lose sight of the basics—that not everything needs to be fixed. Frankly, I think many things can be ignored as long as an individual at any level can have acceptable levels of discomfort and performance. If that’s an issue, then they need treatment, but not all treatment is surgical treatment. Technology is a cyclical phenomenon that is associated with clinical adoption and new techniques.

Dr. Wilk: This less-is-more concept—the skillful neglect if you will—is the ability to identify what does well without surgery and what doesn’t do well and requires urgent surgical intervention. We also have that middle ground where you might roll the dice—maybe this patient has a good chance of doing well without surgery and with rehabilitation. We have learned, for the most part, that there are certain things that most of these people are going to do well if you give them time and have them do some rehabilitation exercises.

Dr. Provencher: The biggest changes in my practice and my approach deal with the scapula and overall core kinetic chain. We have started to look at pathologies, such as a tight pectoralis minor, where you have a pectoralis minor that is overactive due to a variety of conditions. We might pay too much attention to the front musculature, meaning the interior musculature of your body versus the posterior musculature of your body. That dynamic imbalance of anterior versus posterior musculature in the upper chest and the pectoralis versus the scapula can lead to significant dyskinesia problems and other abnormalities. When you end up with a tight pectoralis minor, it can’t be what we call pathologically tight, causing an almost pseudo-impingement pain and continuous problems in a vicious cycle that contracts further. This is a key postural and kinetic chain issue in that we are focusing on the potential imbalance in an athlete of any age of the anterior versus posterior musculature. We help correct that first with physical therapy, pectoralis minor stretching, scapular stabilization, strengthening of the serratus anterior and the low trapezius, and correcting overall postural abnormalities.

AAOS Now: Where does the orthopaedic community stand with biologics?

Dr. Provencher: Biologics continue to evolve. Currently, there is confusion in terms of what biologics mean, both to patients in the Google medicine community and in the scientific literature.

First and foremost, we need to improve, as a community, our definition of biologics and what platelet-rich plasma (PRP), bone marrow aspirate, and a stem cell truly mean. Patients believe that they are getting stem cells, when they are actually receiving PRP or bone marrow aspirate injection. Stem cells constitute less than 1 percent of the overall injection. This is a problem, but we believe these injections can work and provide improvement, especially for patients with inflammatory conditions.

In respect to exploring the potential for treatment of early arthritis of the knee, Dr. Cole and his colleagues conducted a Level I study that compared hyaluronic acid (HA) versus PRP treatments. They found that patients receiving PRP had better pain and function scores at six months. The conundrum, though, is not the stem cell component helping with this, it is likely the other factors such as interleukin, tumor necrosis factor, and other factors from an anti-inflammatory cascade and the synovial lining target of the PRP, which is likely providing a higher benefit than HA.

Although we have come a long way, we still need to determine which patients can best benefit from a biologic injection, what type of injection is best, what is the frequency of administration, and what components of each injection are important.

Dr. Cole: The most important thing about biologics is that, at least as we currently utilize them in orthopaedics, we probably would be better served by calling them orthobiologics rather than regenerative therapies. We rarely associate much of what we do today with regeneration, which is not the same as saying orthobiologics cannot be helpful.

Again, from studies, I think we are getting our arms around the roles and the benefits of, for example, PRP. My personal belief is that the literature would support PRP as a dominant treatment strategy that should be included in the continuum of managing patients with osteoarthritis. The dose and frequency are, however, yet to be firmly established.

We must be very careful because of the tremendous disconnect between what patients believe these therapies can offer and what we know they can offer. The barrier to entry is very low, and the demand is very high on the patient side. We are in a very tenuous time right now where it’s a little unclear who is driving the bus, in terms of the provider versus patient demand.

So, we all must remain highly ethical and pay attention to what we know, what we don’t know, and what we think we know. We have an obligation to educate our patients in this regard, especially as these therapies are often uncovered benefits from a surgical perspective.

Dr. Wilk: Patient enthusiasm for these agents is very high. Patients are looking for guidance, and sometimes they are just looking for hope. Someone gets a PRP injection and then comes out the next day and feels better already. The belief in the cure is stronger than the cure itself sometimes. I have to be a cheerleader at times, and at others, I have to be a cold slap of reality: Just because they injected your ligament, you’re not better in a day. You have to give it some time; there’s a good chance it might work; you have to do your rehab; it’s one part of the treatment. It may set the environment up for potential healing or maybe a cascade of events that decrease or increase inflammation—like in a tendon—but it’s one piece of the puzzle, so to speak.

Dr. Cole: I think if you were to interview patients, you’d find that most believe there are therapies that can be injected into a joint that will cause the regeneration of cartilage and eliminate the need for a joint replacement. There are patients who truly believe that if they have a rotator cuff tear, you can just inject something and that tear will heal without surgery.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.