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AAOS Now

Published 10/1/2019
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Kaitlyn D’Onofrio

Sports Course Instructors Talk Trends, Biologics, and More

The 21st Annual Sports Medicine Course, presented by AAOS, the American Orthopaedic Society for Sports Medicine (AOSSM), and the Arthroscopy Association of North America (AANA), will take place Feb. 23–27, 2020, in Park City, Utah. Expert faculty will discuss upper- and lower-extremity sports-related injuries and describe injury-specific treatment and rehabilitation guidelines for all patients. Each day is structured so that attendees will have time to enjoy the slopes and beauty of Park City.

Jeff Dugas, MD, recently led a roundtable discussion with the course codirectors, Brian J. Cole, MD, MBA; CAPT (Ret.) Matthew T. Provencher, MD, MC USNR; and Kevin E. Wilk, DPT, PT, FAPTA, to discuss current and developing practices to make return-to-play decisions and reduce reinjury.

Dr. Dugas: What are some of the biggest issues going on in sports medicine?

Dr. Provencher: We are integrating ways to get patients with injuries back to play in a safer, more efficient way. From a surgical standpoint, the improvements in fixation constructs, recognition of injury, and understanding of both anatomy and how to optimally restore function are all helping us treat our patients better.

Dr. Cole: I think the most prevailing issues pertain to single specialization in sports, the absence of real rest, and proper cross-training that’s not directly related to single-sport activities. A lot of that is driven by opportunities for our young people and adolescents today to have access to a single sport almost 12 months a year.

Dr. Wilk: We continue to struggle with determining the best test to utilize for return to play and in the area of training—in particular, things such as conditioning for the baseball player, like weighted ball throwing and long toss programs. We see a lot of injuries as a result of improper use of the weighted ball throwing program.

We’re starting to see information on how the body functions as a whole with sports-related injuries. We’re learning about the role that the core, hips, back, and scapula play in these injuries and the integrative approach to rehabilitation and getting these people back to play through a more whole-body assessment. Can you discuss any of the more recent research findings with regard to return-to-play after injury?

Dr. Provencher: The newest randomized studies have helped us fine-tune bracing and sling use after injury or surgery. We need to be thoughtful about when it is necessary to use braces, crutches, and slings but not overutilize them. With really good post-surgery imaging data that are helping us formulate better return-to-play algorithms, we know more about what happens to bone, labrum, and other healing after injuries to the knee, shoulder, and hip.

Dr. Cole: From a high level, the discussion starts with protecting basic biology and understanding what it takes to heal. Although we place a special emphasis on promoting healing, essentially through biologic adjuncts, we still struggle from the insult of the injury and surgery. I think we’re rarely limited by the quality of the repair; we’re often more limited by the quality of the rehabilitation that is required to get an athlete safely back to play. We often use timeframes, but I think what is more important is the quality of the exercise and reinjury-prevention strategies that are executed during that time, and then having some ability to know that whatever known risk factors existed prior to injury are not still present after treatment and during the recovery phase.

We know that when there are deficits in adjacent joints, we are essentially setting someone up for reinjury. I think we all have to understand that biologic principles are really important in the early phases after treatment. But having some objective measure along the way that demonstrates that high-quality exercise and activity are restoring an athlete back to optimal function remains critical to safe return-to-play decisions.

Dr. Provencher: This is why I think the course is important. Our physical therapists will provide an excellent, up-to-date, and scientifically based overview of when it is “safest” to return to play. This varies based on the patient, demographics, sport, and injury, but there are some evolving guidelines that we know—for example, the minimum time needed after knee or shoulder surgery to be able to return to play as safely as possible.

What do you see as the role of biologics?

Dr. Cole: I think the public’s perception is that we have this ability to regenerate. We have done well with the use of orthobiologics as surgical adjuncts to improve the healing process when it could otherwise be compromised because of very taxing biology. We have also done well using orthobiologics as symptom-modifying treatments in the office. But to date, there is very little use of biologics to provide true “regenerative” therapies. I think the public has to understand what we’re typically using these biologics for—and to also have realistic expectations. We struggle, unfortunately, with misrepresentation and misperception. This is something that we’re going to discuss in great length at this course.

Dr. Provencher: There is very little published about biologics in youth sports, but it is gaining interest. There are multiple injuries that could benefit from a magnification of your own healing potential. We have to be careful that this is done thoughtfully, especially in our younger athletes.

Jeff Dugas, MD
Brian J. Cole, MD, MBA
CAPT (Ret.) Matthew T. Provencher, MD, MC USNR
Kevin E. Wilk, DPT, PT, FAPTA

From a rehabilitation perspective, we have seen some good results happening with blood-flow restriction. Can you discuss that as a biologic adjunct to healing and regaining the ability to return to play?

Dr. Wilk: We will also be discussing this during the course. If a physician uses platelet-rich plasma or stem cells, it’s important to do some type of rehabilitation afterward and have a specific protocol, so the patient doesn’t just rely on the procedure but rather is treated for the deficiency that may have led to the tendon failure, tendinopathy, cartilage problem, or arthritis. I think the post-injection rehabilitation is also very critical in restoring strength, normal biomechanics, and flexibility. In addition, we will be discussing blood-flow restriction—this is a specific form of training and has been very useful in the rehabilitation and conditioning area.

Are there any specific considerations for youth athletes or younger patients versus an adult patient population?

Dr. Cole: There are certain conditions in youth athletes that occur as a secondary problem to incomplete rehabilitation or strength, conditioning, or poor biomechanics. We know rotator cuff tears in our younger patients are very different than rotator cuff tears in our older patients. But it’s less common that rotator cuff tears occur at such a young age because patients simply are too young to experience the demise of tissue. There are other factors based on the way they use their extremities that lead to these problems.

Our younger athletes tend to have conditions that are overuse- or trauma-related—not necessarily related to poor-quality tissue. There may be an opportunity for prevention in that population that we might not have in our older population.

Can you give us a preview of what types of things will be discussed during the course?

Dr. Provencher: The course will be delivered in a case-based format with expert panels and extensive audience participation, presenting common practice scenarios. We encourage lively discussion to determine which would be the “best” ways to treat injury—from shoulder dislocation to knee ligament injury, and also hip and other problems. We will also emphasize how to efficiently work up the patient with an injury and come up with a clear treatment plan and review the actual surgery with case-relevant videos.

Dr. Cole: The course will cover injury prevention, the role of preoperative treatment, the importance of recovery, objectivity during recovery, and thoughts on return to sport. Sports medicine courses generally discuss the injury and how-to-fix-it strategies; however, this course also includes perioperative considerations largely related to prevention, early rehabilitation, and safe return-to-sport considerations.

Dr. Wilk: I think the unique aspect of this course is the team approach to treatment. It’s the physician and physical therapist and a combined and interactive model of assessing, treating, and preventing further injury for the athlete. Numerous case studies will be presented, and a multidisciplinary approach will be discussed in those cases. We’ll have rehabilitation breakouts in the evening where we’ll discuss what’s new in anterior cruciate ligament rehabilitation, return-to-play criteria, and the best test based on the type of patient you’re dealing with. We’ll talk about the healing athlete, strategies to prevent injury, and returning the person back to play after injury or surgery—the new and innovative approaches for treating these particular injuries and lesions.

This is the 21st annual course—I think that shows that this is an evolving science. Any final thoughts on these topics?

Dr. Cole: We have handpicked the faculty who really would be considered experts in this field. The course provides an environment that allows people to engage—along with the appropriate mix of education and recreation. There will be plenty of one-on-one time with faculty, and participants will be able to talk with faculty who are really engaged in research in this area, in addition to having the clinical experiences to share.

Dr. Provencher: We are really excited about the course, and we have found that this truly appeals to everyone in the audience, as the cases that are presented are those that we all see. By using the best evidence in 2020, we encourage a lively interaction. We hope that you can join us.

Registration is now open for the 21st Annual AAOS/AOSSM/AANA Sports Medicine Course. To register, visit www.aaos.org/3038A or call 800-626-6726.

Kaitlyn D’Onofrio is the associate editor for AAOS Now. She can be reached at kdonofrio@aaos.org.