ISSN 2378-7910 (print)

ISSN 2376-3825 (online)

Review Journal
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INAUGURAL
EXPERT EDITION
Volume 1 Number 1
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Sport Rev J. 2015; 1(1)

Editors-In-Chief
Gerard Malanga, Atlantic Sports Health, NJ
Ken Mautner, Emory University
James Ross, BocaCare Orthopedics, FL

Executive Administrative Editor

Ricardo Vasquez-Duarte, University of Miami, FL

Editorial Board Jeffrey Nepple, Washington University, St. Louis

Alberto Panero, University of California, Davis Jacob Sellon, Mayo Clinic
Alexander Creighton, University of North Carolina Jason Zaremski, University of Florida
Andrew Gregory, Vanderbilt University Joanne Borg-Stein, Harvard University
Arthur Deluigi, Georgetown University Jose Ramirez Del Toro, University of Pittsburgh
Brandee Waite, University of California, Davis Joseph DeAngelis, Harvard University
Bryson Lesniak, University of Pittsburgh Joseph Herrera, Mount Sinai, NY
Brian Leo, Cleveland Clinic of Florida Joshua Sole, South Dakota School of Mines & Technology
Carolyn Marquardt, Swedish Medical Center, Seattle Matthew Matava, Washington University, St. Louis
Cassandra Lee, University of California, Davis Michael Baraga, University of Miami
Charlie Cox, Vanderbilt University Michael Fredericson, Stanford University
Chi Tang, Washington University, St. Louis Omar Bhatti, University of Washington
Clifton Page, University of Miami Pierre d’Hemecourt, Harvard University
David Berkoff, University of North Carolina Ricardo Colberg, Andrews Institute, AL
Ellie Jelsing, Mayo Clinic Scott Faucett, George Washington University
Evan Peck, Cleveland Clinic of Florida Tracy Ray, Duke University
Ivette Guttman, University of Miami William Dexter, Maine Medical Center

Published Reviews
James Alex, MD & William Dexter, MD David Siebert, MD & Ashwin Rao, MD
James Presley, MD & Jonathon Finnoff, DO Elizabeth Joy, MD, MPH
Walter Sussman, DO & Ken Mautner, MD Ruben Tresgallo & Ricardo Colberg, MD

Founder & Publisher
Joshua Rothenberg
Sports Review Journal, NFP
2805 E Oakland Park Blvd # 155
Ft. Lauderale, FL
33306
Editorial Contact & Manuscript Submission
Peter Navarro, Submissions Manager
Email: Submission@sportsreviewjournal.com
Sports Review Journal , NFP is produced and edited by Fellowship Trained Sports Medicine Physicians.
The reviews and summaries included in the publication are intended solely for the education of medical
professionals as assistance in reviewing the large volume of literature that exists in the sports medicine
field. The summaries are not to be used as the basis of clinical diagnosis, management, side effects, or
complications, and are not a substitute for analyzing the original research. Reviews may include subjective
components, and are not entirely objective, thus, it remains noteworthy to refer to the original research
in the journal cited. All journal reviews and summaries include citation to the journal with the original
research. Publication and funding is provided by the publisher himself. No profits or money are collected.
Due to the overwhelming presence of cancer in the community, I would like to raise awareness
each issue for a different cancer. As the yellow ribbon represents ‘Sarcoma’ Awareness’, this will be
our inaugural edition ribbon in support of our Editor-in-Chief, Gerard Malanga.

2 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.

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Sport Rev J. 2015; 1(1)

In This Issue
William Dexter Biography 4

Ashwin Rao Biography 5

Jonathon Finnoff Biography 6

Ricardo Colberg Biography 7

Ken Mautner Biography 8

Elizabeth Joy Biography 9

Does foot strike pattern significantly alter anterior knee forces in runners? 10
James Alex, MD and William Dexter, MD reviewing Vannatta CN et al. Patellofemoral Joint Stress during Running with
Alterations in Foot Strike Pattern. Medicine & Science in Sports & Exercise. 2015 May; 47(5): 1001-1008.

You Found Wolff-Parkinson-White in an Athlete: Now What? 12

David Siebert, MD and Ashwin Rao, MD reviewing Rao AL et al. Evaluation and Management of Wolff-Parkinson-White in
Athletes. Sports Health. 2014 Jul;6(4)326-32.

The Contribution of Medial Elbow Structures to Joint Stability Determined by Stress Ultrasound and Surgical Sectioning
in Cadavers 14
James Presley, MD and Jonathan Finnoff, DO reviewing Ciccotti et al. Stress Ultrasound Evaluation of Medial Elbow
Instability in a Cadaveric Model. Am J Sports Med. 2014 Oct; 42 (10): 2463-9.

Major League Baseball Pitchers That Underwent Revision Ulnar Collateral Ligament Reconstruction: A Look at Post-Revi-
sion Pitching Performance and Longevity.  16
Ruben Tresgallo, BS and Ricardo E. Colberg, MD reviewing Marshall et al. Pitching Performance and Longevity After
Revision Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers. Am J Sports Med; 43 (1051).

Platelet-rich plasma, saline or glucocorticoid injection for chronic lateral epicondylitis. 18

Walter Sussman, DO and Ken Mautner, MD reviewing Krogh TP et al. Treatment of lateral epicondylitis with platelet-rich
plasma, glucocorticoid, or saline: A randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41:625-635.

If We Want Kids to be Physically Active, Make it Fun! 20

Elizabeth Joy, MD, MPH reviewing Visek AJ, et al. The fun integration theory: toward sustaining children and adolescents
sport participation. J Phys Act Health. 2015 Mar;12(3):424-33.

© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.

33
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Expert Author

William Dexter, MD
Dr. Dexter, a recipient of the Maine Governors Council on Physical Activity Lifetime Achievement Award, is a past
President of the American College of Sports Medicine (2013-14). He is the Director of the Sports Medicine Program for
Maine Medical Center, Professor of Family Medicine at Tufts University School of Medicine and adjunct faculty at the
University of Southern Maine, where he also serves as Head Team Physician and Medical Director for the Athletic Training
program. He is the school and team physician for Cheverus HS and a team physician for the Portland Pirates (AHL), Medical
Director of the Maine Marathon and sports medicine consultant for a number of community sports organizations. Graduating
from Dartmouth College and the Medical College of Virginia, he completed his Family Medicine residency at Maine Med-
ical Center and his Sports Medicine fellowship at Hennepin County Medical Center in Minneapolis. Dr. Dexter is active in
sports medicine research and education. He has given over 160 invited presentations nationally and internationally; he serves
on numerous scientific, non-profit and review and editorial boards and in addition to co-editing a textbook on musculoskeletal
ultrasound, has published over 70 book chapters, articles and abstracts. A charter member of the American Medical Society
for Sports Medicine, he chairs the Faculty Development committee and is very involved in “teaching the teachers”. Married to
Cindy, aka “Born to be Wild Rose” (Maine Roller Derby) and a father of three active 20-somethings, he is an avid skier (goal
not yet achieved: 50 days per year!), recreational rower, a hack golfer (24 handicap) and a life-long rugby enthusiast – a former
national team trialist, U-19 coach and referee he continues his involvement in the sport on the USARFU Medical Board.

4 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.

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Sport Rev J. 2015; 1(1)

Expert Author

Ashwin Rao, MD
Dr. Ashwin Rao is board certified in family medicine and sports medicine. He completed his undergraduate studies at
Swarthmore College and his medical degree at Case Western Reserve University. Dr. Rao completed his residency training in
family medicine and his sports medicine fellowship at the University of Washington. He currently assumes the role of associate
professor in UW’s Department of Family Medicine. He is the program director of the University of Washington’s Sports
Medicine Fellowship. Dr. Rao sees patients at the UW Sports Medicine Clinic at Husky Stadium and the UWNC Northgate
Clinic.
Dr. Rao serves as a team physician for University of Washington Husky Athletics and the Seattle Seahawks. He works in both
primary care and sports medicine settings. He is a member of the American Medical Society of Sports Medicine (AMSSM),
the American College of Sports Medicine (ACSM), and the American Academy of Family Physicians (AAFP). He serves
as the chair of the University of Washington ’s Sports Medicine Grand Rounds. He also serves on the Research Committee,
Fellowship Committee, and Program Planning Committee of AMSSM.
Dr. Rao has been honored as a “Top Doctor” by Seattle Met magazine and has served as a team physician for the Super Bowl
XLVIII champion Seattle Seahawks and the five-time defending national champion University of Washington’s crew team, as
well as for UW baseball and UW women’s crew teams.He has won numerous patient satisfaction awards, including the UW
Cares and PRAISE awards. His academic interests include primary and secondary prevention of sudden cardiac death in ath-
letes, mental well-being in athletes, and medical student and resident education and mentorship. His clinical interests include
ultrasound guided procedures, platelet rich plasma (PRP), selective peripheral nerve hydrodissection, management of chronic
tendinopathy and arthritis, concussion evaluation and management, and comprehensive wellness care for the professional and
recreational athlete.

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Expert Author

Jonathon Finnoff, DO
Jonathan Finnoff, DO, FACSM obtained his medical degree from the University of New England. He then completed a resi-
dency in PM&R at the University of Utah, and a Sports Medicine fellowship at the Mayo Clinic. Dr. Finnoff is board certified
in PM&R and Sports Medicine. He is currently the medical director of the Mayo Clinic Sports Medicine Center in
Minneapolis, MN.
Dr. Finnoff has published over 70 articles in peer reviewed journals, and has authored multiple book chapters. He co-edited a
book with Mark Harrast, MD, titled “Sports Medicine: Study Guide and Review for Boards”. Dr. Finnoff has been the key-
note speaker at numerous national and international conferences, and is frequently invited to speak as a guest faculty member at
Universities and hospitals around the country.
Dr. Finnoff is a member of the AAPM&R Board of Governors and was previously the chair of the AAPM&R Musculoskel-
etal Council. He has served as the course director for multiple AAPM&R Musculoskeletal Ultrasound courses and was the
chair of the AAPM&R’s Musculoskeletal Ultrasound Task Force for several years. He is also on the Board of Directors for
the AMSSM, is the Sports Ultrasound Committee Chair, and the program chair for the AMSSM Sports Ultrasound Courses.
Dr. Finnoff is the co-chair of the Comprehensive Sports Medicine Update and Board Review Course co-sponsored by Mayo
Clinic, AAPM&R, ACSM, and AMSSM.
Dr. Finnoff has been a team physician for the United States Ski Team for more than a decade, and has provided medical cover-
age for the team at the Winter Olympics as well as multiple world cup and world championship competitions. He is currently
the head team physician for the United States Nordic Combined team. He was in charge of the Athlete’s Clinic at the Soldier
Hollow venue during the 2002 Olympic Games in Salt Lake City, UT, and was the director of all athlete and spectator medical
care at the Soldier Hollow venue during the 2002 Paralympic Games. He is currently a team physician for the Timberwolves
NBA basketball team, and Lynx WNBA basketball team. Dr. Finnoff has also served as the head team physician for a division
1 university, and has also taken care of multiple high school and club sports teams. Dr. Finnoff has been the medical director
for multiple mass participation sports events including marathons and iron man length triathlons.

6 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.

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Sport Rev J. 2015; 1(1)

Expert Author

Ricardo Colberg, MD
Ricardo E. Colberg, M.D., is a non-surgical sports medicine and orthopedic physician at the Andrews Sports Medicine and
Orthopaedics Center in Birmingham, AL. He is a Diplomate of the ABPM&R and has a CAQ in Sports Medicine. Dr. Col-
berg has a strong commitment to providing evidenced-based medical care through a patient-centered and holistic approach.
Dr. Colberg grew up in Puerto Rico playing tennis and enjoying water sports such as surfing and sailing. He completed his
undergraduate degree at the University of Pennsylvania. He then moved back to Puerto Rico where he graduated from the
University of Puerto Rico Medical School with an M.D. degree and a Certification in Clinical Research. Dr. Colberg com-
pleted a residency in PM&R at Emory University and a fellowship in Primary Care Sports Medicine at the American Sports
Medicine Institute.
Dr. Colberg has a special interest in treating acute and chronic musculoskeletal injuries, including bone, joint, ligament, muscle
and tendon injuries. He performs various treatment modalities in the clinic that assist the patient in their recovery from the
injury, among them diagnostic musculoskeletal sonography, ultrasound-guided injections, and platelet-rich plasma therapy. His
areas of expertise also include non-surgical management of fractures and dislocations, peripheral nerve injuries (e.g. carpal tun-
nel syndrome), sport-related spine injuries, pediatric sports injuries, biomechanical evaluation of the injured athlete, implement-
ing sports injury prevention protocols, management of osteoarthritis and screening for potential cases that may have a better
outcome by undergoing a surgical procedure.
Dr. Colberg is head team physician for Minor High School, Lawson State Community College, and Alabama Soccer Associ-
ation’s Olympic Development Program (ODP). He has also worked as team physician for the U.S.A. Paralympic Team at the
Lakeshore Foundation, the Chicago White Sox’s AA affiliate team - the Birmingham Barons, the Alabama Ballet, the Univer-
sity of Alabama at Tuscaloosa, University of West Alabama and other local high schools and colleges. He has earned the certi-
fication of Elite Professional from the United States Professional Tennis Association and is currently working with developing
injury prevention protocols for tennis athletes through the American Sports Medicine Institute. In addition, he has extensive
clinical research experience, including a national multi-center study on a regenerative medicine procedure called platelet-rich
plasma injection.

© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.

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Expert Author

Ken Mautner, MD
Dr. Mautner is assistant professor in the department of PM&R and the department of Orthopedics at Emory University in
Atlanta, GA. He is the director of Primary Care Sports Medicine at Emory Sports Medicine Center. He is also the Program
Director of Emory’s Primary Care Sports Medicine Fellowship.
Dr. Mautner came to Emory in 2004, after completing a Fellowship in Primary Care Sports Medicine at the American Sports
Medicine Institute in Birmingham, Alabama. He is board certified in PM&R with a subspecialty certification in Sports Medi-
cine. Dr. Mautner currently serves as head team physician for Agnes Scott College and Pace Academy and a team physician for
Emory University and a consulting physician for Georgia Tech Athletics.
Dr. Mautner is an expert in diagnostic and interventional musculoskeletal ultrasound and teaches and directs courses across the
country on how to perform office-based ultrasound. He regularly performs Platelet Rich Plasma (PRP) and Stem Cell injec-
tions for patients with chronic tendon and joint related problems and is recognized as an expert and thought leader in this area.
In addition, he is the co-editor of the Atlas of Interventional Musculoskeletal Ultrasound.
Dr. Mautner’s other areas of clinical interest include sports concussions, where he is regarded as a local and regional expert in
the field. He was recently co-chairman of the Georgia Concussion Coalition, a group of diverse stakeholders whose aim is to
increase concussion awareness, education, and legislation in Georgia and was instrumental in passing the Georgia Return to
Play Act for concussion.

8 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.

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Sport Rev J. 2015; 1(1)

Expert Author

Elizabeth Joy, MD, MPH

Elizabeth Joy, MD, MPH obtained her medical degree from the University of Minnesota. She then completed a Family
Medicine residency and Sports Medicine fellowship at Hennepin County Medical Center in Minneapolis, MN. Dr. Joy is
board certified in Family Medicine and Sports Medicine, and currently serves the sports medicine community in Salt Lake
City, Utah.
Dr. Joy has published many articles in peer reviewed journals, and has authored multiple book chapters. Her research interests
lie in the areas of physical activity assessment and promotion, practice-based research in primary care, the Female Athlete Triad,
and sports injury prevention.
Dr. Joy currently serves as the President Elect for the American College of Sports Medicine (ACSM) and has held two terms
of office on the Board of Trustees for the American Medical Society for Sports Medicine (AMSSM). She is also on the
Editorial Board for The Clinical Journal of Sports Medicine, and is an Associate Editor for Current Sports Medicine Reports.
She also serves on the Exercise Is Medicine Task Force for the ACSM.
When not seeing patients, she loves to hike, ski and ride her bike with friends and family. Her husband Jim is also a sports
medicine physician, and they have two kids and a chocolate lab.

© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.

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Does foot strike pattern significantly alter
anterior knee forces in runners?
James Alexa,c, William Dextera,b
Level of Evidence: 2 (Crossover Study)
Introduction: Patellofemoral pain (PFP) is one of
the most common forms of pain reported by runners.
Patellofemoral joint stress (PFJS) has been implicated
as a primary factor in the formation of PFP, which is
more common among females. Increasing step rate
seems to lead to a more anterior foot strike pattern
and decreased PF force but it is not clear if step rate,
stride length or foot strike pattern is responsible
for decreased PFJS. Vannatta and Kernozek
implemented a crossover study of female runners to
determine if changes to foot strike pattern affect levels
of PFJS among multiple secondary variables. They
hypothesized that transition from habitual rearfoot
strike to forefoot strike pattern would yield decreased
PFJS.
Methods: Seventeen female subjects were included,
having met the following inclusion criteria: >10
miles weekly running, Tegner activity score > 5,
self-reported rearfoot strike pattern, and age 18-
a was unchanged.
James Alex, MD and William Dexter, MD reviewing Vannatta CN
et al. Patellofemoral Joint Stress during Running with Alterations in
Foot Strike Pattern. Medicine & Science in Sports & Exercise. 2015
May; 47(5): 1001-1008.
b
Sports Medicine, Maine Medical Center
c
Corresponding Author: James Alex
Email: JAlex@MMC.org
10
10 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
35. Exclusion criteria included pregnancy, activity-
limiting knee symptoms or lower extremity surgery
within 12 months, knee trauma within 6 months, and
any pathologic cardiovascular medical history. The
Human Body Model system was used to capture and
analyze participant motion in 3 dimensions. Each
subject randomly completed 10 repetitions each of
rearfoot and forefoot running (after brief instruction
in forefoot running technique) down a 20-meter
runway embedded with force plates. The accuracy of
each strike pattern was verified using Novel pressure
sensors within standardized footwear provided for the
study.
Results: Sixteen of 17 participants’ data were
included for analysis with a single set of data
excluded due to inconsistent rearfoot strike pattern.
In accordance with stated hypotheses, statistically
significant reductions in PFJS (average 27% decrease,
P<0.001) and peak quadriceps force were observed
with transition to forefoot strike running with no
change in step length. Contrary to the authors’
hypotheses, peak vertical ground reaction force was
increased with forefoot strike and peak knee flexion
Strengths: The primary strength of this study is the
crossover design comparing forces within individual
subjects changing their foot-strike pattern. This
served to remove much of the variability encountered
in prior studies comparing forces between matched
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groups of runners. The study was also appropriately
powered with an analyzed sample size (16) greater
than the minimum of 14 calculated with beta=0.2 and
alpha=0.05.
Weaknesses: While this study intended to
characterize changes in biomechanical forces
among healthy subjects, it specifically excludes a
key demographic target of its findings: those with
patellofemoral pain limiting their activity within
the last 12 months. Further research is required to
validate the results within clinically significant patient
populations. In addition, the study does not account
for potential biomechanical adaptations which may
occur with transition to habitual forefoot running.
Lastly, the use of a standardized joint model in
this study introduces error between the actual joint
geometry of subjects and that of the standardized
model.
Conclusion: Despite the aforementioned weaknesses,
this study provides convincing evidence that changing
© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
from rearfoot to forefoot strike running significantly
reduces PFJS. The statistical analyses appear well
applied and the methods used for data collection are
well-established. Despite a high internal validity,
care should be taken in extrapolating the results
to demographics outside of the inclusion/exclusion
criteria.
Practice Pearl: This study suggests forefoot running
may be a low-risk therapeutic option for habitual
rearfoot runners who experience patellofemoral pain
in the absence of pathology within the kinetic chain
of foot plantarflexion. A gradual transition to forefoot
running would ideally be used to reduce the rate of
injury seen among fast-transitioning runners.
References:
(1) Vannatta CN, Kernozek TW. Patellofemoral Joint
Stress during Running with Alterations in Foot Strike
Pattern. Medicine & Science in Sports & Exercise.
2015 May; 47(5): 1001-1008.
11
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Sport Rev J. 2015; 1(1)
You Found Wolff-Parkinson-White in an
Athlete: Now What?
David Sieberta,c, Ashwin Raoa,b
Level of Evidence: 1 (systematic review)
Introduction: Wolff-Parkinson-White syndrome
(WPW) is characterized by ventricular preexcitation
by one or more accessory conduction pathways within
the heart, and it may predispose athletes to sudden
cardiac death (SCD). Ashwin L. Rao, MD and
colleagues conducted a systematic review of WPW,
combining epidemiological, pathophysiological, and
treatment-based evidence into a strategy for WPW
evaluation, risk stratification, and management in
athletes.
Methods: Rao and colleagues reviewed and
incorporated conclusions or evidence from a total
of 50 publications. The authors identified relevant
manuscripts by searching Medline and PubMed
databases with the key words or phrases “WPW,”
“Wolff-Parkinson-White,” “pre-excitation,” “sudden
cardiac death,” “risk stratification,” and “athletes.”
Results: The diagnosis of WPW is made by
identifying the classic delta wave with accompanying
a of delta waves during exercise signifies ongoing
David Siebert, MD and Ashwin Rao, MD reviewing Rao AL et al.
Evaluation and Management of Wolff-Parkinson-White in Athletes.
Sports Health. 2014 Jul;6(4)326-32.
b
Sports Medicine, University of Washington
c
Corresponding Author: David Siebert
Email: siebert@uw.edu
12
12 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
shortened PR interval on electrocardiography (ECG),
findings that imply ventricular preexcitation via an
accessory pathway. WPW leads to SCD via the
propagation of atrial fibrillation (AF) across the
pathway, thereby bypassing the rate-controlling
atrioventricular node. Such propagation can lead to
malignant ventricular arrhythmias and death. This
mechanism is responsible for at least 1% of cases of
SCD in athletes, carrying a cumulative risk of 0.1%-
0.45% per year.
Intermittent ventricular preexcitation, characterized
by intermittent loss of the delta wave on ECG, is
low-risk for precipitating malignant arrhythmias
and can be followed with periodic ECG monitoring
and symptom counseling, whereas persistent delta
waves merit further investigation. In addition to
echocardiography to rule out structural abnormalities
associated with WPW, Holter monitoring or
exercise stress testing should be employed to assess
for loss of delta waves with exercise. Athletes who
participate in low-intensity sports and demonstrate
loss of delta waves during exercise can be followed
conservatively as above. However, the persistence
ventricular preexcitation and a high-risk accessory
pathway. Electrophysiology (EP) studies should be
pursued in these athletes. EP studies should also be
offered to symptomatic athletes or those participating
in moderate- or high-intensity sports regardless of the
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loss or persistence of delta waves during exercise.
EP studies carry procedural risks, up to and including
death. The decision to pursue testing should involve
a pre-procedural, patient-centered discussion with an
experienced specialist. Intra-procedural identification
of a “shortest pre-excited R-R interval” (SPERRI)
of <250 milliseconds during induced AF implies a
high-risk pathway, and ablation should be considered.
Inducible supraventricular tachycardia should
also prompt consideration of ablation, as should
symptomatic athletes. Athletes not meeting any of
these three criteria can be followed conservatively.
Strengths: This review identifies and interprets the
best-available evidence on WPW. It cites manuscripts
that represent the cornerstones of the syndrome’s
diagnosis and treatment, and it synthesizes them
into an evaluation and management strategy that
is tailored specifically to athletes. It also offers an
easy-to-follow algorithm to guide clinician decision-
making while appropriately accounting for the risks of
EP studies themselves.
Weaknesses: Expert consensus statements, which
represent a lower level of evidence, account for a
© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
notable portion of the conclusions the review cites.
The review does not distinguish low- from moderate-
and high-intensity sports, which could offer further
guidance to physicians less familiar with athletics.
Conclusions: Despite unavoidable limitations
stemming from the level of evidence of some of the
manuscripts from which it draws its conclusions, this
review offers up-to-date recommendations for the safe
management of any athlete diagnosed with WPW.
Practice Pearl: Athletes with WPW and persistent
preexcitation on baseline ECG should be assessed
for the resolution of preexcitation during exercise.
EP studies are indicated in athletes who demonstrate
continued preexcitation during exercise or participate
in moderate- to high-intensity sports. Ablation should
be considered for symptomatic athletes or those who
demonstrate EP evidence of a high-risk accessory
pathway.
References:
(1) Rao AL, Salerno JC, Asif IM, Drezner JA.
Evaluation and Management of Wolff-Parkinson-
White in Athletes. Sports Health. 2014 Jul;6(4)326-
32.
13
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The Contribution of Medial Elbow Structures to Joint
Stability Determined by Stress Ultrasound and Surgical
Sectioning in Cadavers
James Presleya,c, Jonathan Finnoffa,b
Level of Evidence: 2
Introduction: This is a descriptive laboratory study
designed to determine the relative contribution of
medial elbow structures to joint stability under valgus
stress. Ultrasound imaging was used to measure
ulnohumeral joint gapping in cadaveric specimens
as various medial elbow stabilizing structures
were sequentially surgically released. The authors
hypothesized that release of the anterior bundle of the
ulnar collateral ligament (UCL) would result in the
greatest ulnohumeral joint gapping.
Methods: Twelve fresh-frozen cadaveric elbow
specimens were used. The specimens were divided
into two groups and dissection of medial elbow
structures was performed by an orthopedic surgeon in
reverse order in each group. The following structures
were sectioned: transverse, posterior, and anterior
UCL bundles; remaining posterior band of the
anterior bundle, and the flexor-pronator mass. After
each structure was cut, an experienced radiologist
a medial elbow stabilizer against valgus stress and that
James Presley, MD and Jonathan Finnoff, DO reviewing Ciccotti
et al. Stress Ultrasound Evaluation of Medial Elbow Instability in a
Cadaveric Model. Am J Sports Med. 2014 Oct; 42 (10): 2463-9.
b
Sports Medicine, Mayo Clinic
c
Corresponding Author: James Presley
Email: Presley.James@mayo.edu
14
14 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
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measured the ulnohumeral joint gapping (distance
in millimeters between the trochlea of the humerus
and the sublime tubercle of the ulna) sonographically
under a 15-daN valgus stress applied by Telos SE
2000. The mean change in joint gapping after
each dissection was recorded to determine relative
contribution of individual structures to joint stability.
Sectioning of the two groups in reverse sequence was
performed to better analyze an individual structure’s
contribution to joint stability and to minimize the
effect of accumulated tissue disruption leading to joint
instability.
Results: Each medial elbow component released
resulted in a statistically significant increase in
ulnohumeral joint gapping measured with stress
ultrasound. The greatest change in joint gapping
was found to occur after sectioning the entire
anterior bundle of the UCL (anterior plus posterior
bands), resulting in a mean change of 3.4 mm
of joint gapping. All other individual structures
released resulted in a mean change of less than 0.8
mm of joint gapping. The authors concluded that
the anterior bundle of the UCL was the primary
stress ultrasound imaging allowed for observation of
discrete changes with sectioning of each of the medial
elbow stabilizers in a cadaveric model.
Strengths: The strengths of this study are that a
single experienced orthopedic surgeon and radiologist
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performed vital components to the study for accuracy
and consistency and a standardized device was used
for supplying valgus joint load. The study represents
the only cadaveric study using high resolution
ultrasound to evaluate ulnohumeral joint laxity after
sectioning of individual medial elbow stabilizing
structures.
Weaknesses: Weaknesses of this study include use of
a cadaveric model, a lack of blinding of the radiologist
to which structures had been sacrificed prior to
measuring joint gapping, only testing the stabilizing
effects of each structure in 30 degrees of elbow
flexion, and small number of cadaveric specimens
necessitating sequential sectioning of structures rather
than sectioning in isolation which may be a more
accurate predictor of contribution of an individual
© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
structure to joint stability.
Conclusion: This was a well-designed study that
demonstrated the ability of ultrasound to reliably
detect ulnohumeral joint gapping with valgus elbow
stress, and that the primary restraint to valgus elbow
stability at 30 degrees of elbow flexion is the anterior
bundle of the UCL.
Practice Pearl: This study suggests that ultrasound
can be used to evaluate medial elbow instability, and
that significant laxity of the medial elbow with valgus
stress at 30 degrees of flexion is due to an injury of the
anterior bundle of the UCL.
References:
(1) Ciccotti, MC et al. Stress Ultrasound Evaluation
of Medial Elbow Instability in a Cadaveric Model.
Am J Sports Med 2014 Oct; 42(10): 2463-9.
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Major League Baseball Pitchers That Underwent
Revision Ulnar Collateral Ligament Reconstruction: A Look
at Post-Revision Pitching Performance and Longevity.
Ruben Tresgalloa, Ricardo E. Colberga,b,c
Level of Evidence: 3 (Cohort Study)
Introduction: Ulnar Collateral Ligament (UCL)
tears are one of the most prevalent injuries in
baseball pitchers. Marshall et al. designed a level
3 retrospective, case controlled study to evaluate
statistical performance, return to play and career
longevity in Major League Baseball (MLB) pitchers
after Revision UCL Reconstruction Surgery.
Methods: Pitchers with Revision UCL
Reconstruction (rUCL-R) were selected out of a
cohort of 43 professional baseball players who had
originally undergone primary UCL reconstruction
and then subsequently required revision
reconstruction between 1996 and 2012. Out of the
43 players initially selected, 10 were excluded because
they did not meet the inclusion criteria. Team and
personal websites as well as press releases were used
to identify the rUCL-R group. In order to establish
a reliable trend in performance, pitching statistics
from 3 years before and after revision surgery were
a
Ruben Tresgallo, BS and Ricardo E. Colberg, MD reviewing
Marshall et al. Pitching Performance and Longevity After Revision
Ulnar Collateral Ligament Reconstruction in Major League Baseball
Pitchers. Am J Sports Med; 43 (1051)
b
Sports Medicine, American Sports Medicine Institute, AL
c
Corresponding Author: Ricardo E. Colberg
Email: rcolberg@gmail.com
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16 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
recorded. Only MLB statistics were evaluated.
The rUCL-R group was compared to a Control
Group. The Control Group was age- and position-
matched. Players who had a known history of UCL
Reconstruction were excluded from the control group.
Results: The study reported various statistically
relevant results when comparing the rUCL-R group
to the Control group, including Years in the MLB
post revision surgery (P<0.01), innings pitched per
year/ workload (P<0.01), wins (P<0.01), and Base on
Balls per 9 innings (P<0.01). The author suggested
that rUCL-R pitchers who returned to the MLB after
revision surgery had significantly shorter careers than
the Control Group. On the other hand, the author
concluded that the performance of UCL-R pitchers
that returned to the MLB level after surgery was not
statistically different when compared to the Control
group performances.
Strengths: Marshall et al. conducted the largest
cohort to date of MLB pitchers who have undergone
revision reconstruction. Moreover, the authors went
away from archaic pitching performance statistics
and used more modern data collection in order to
adequately compare the rUCL-R and the Control
Groups for performance. Data from multiple
years before and multiple years after surgery was
collected and analyzed, which allowed the authors to
accurately determine performance in a sport that is so
statistically accurate.
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Weaknesses: This study had a relatively small
sample size (N: 33). In addition, they only looked
at statistics. In order to adequately measure pitching
performance, the statistics should be accompanied
by a biomechanical analysis of the pitchers’ throwing
motion. There may be nothing physiologically or
mechanically wrong with the post UCL revision
pitcher’s throwing motion, but still have performance
deficits related to other confounding factors such as
loss of their confidence. Comparing velocities from
individual pitchers pre and post surgery would have
given more validity to the performance results. The
authors did not separate pitchers into roles. When
numerical comparisons of ERA, Wins, Losses,
etc. are being used to determine performance, it
is important to separate pitchers into relievers and
starters because there are fluctuations in these types of
numbers even when comparing two elite and healthy
pitchers.
© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
Conclusion: Although there are some evident
weaknesses to this study, the authors accurately
demonstrated that the rUCL-R pitchers have
significantly shorter careers when compared to the
Control group. In contrast, rUCL-R pitchers do not
have a significant decrease in performance when
compared to the Control group.
Practice Pearl: The information in this study can
be used as a proof of concept. This study shows
that pitchers who have underwent Revision Ulnar
Collateral Ligament Reconstruction Surgery have
shorter careers but do not have any performance
deficits after rehabilitation.
References:
(1) Nathan E. Marshall et al. Pitching Performance
and Longevity After Revision Ulnar Collateral
Ligament Reconstruction in Major League Baseball
Pitchers. Am J Sports Med 2015; 43(1051) published
online on April 10, 2015
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Platelet-rich plasma, saline or glucocorticoid
injection for chronic lateral epicondylitis.
Walter Sussmana,c, Ken Mautnera,b,d
Level of Evidence: Level 1 (RCT)
Introduction: Lateral epicondylitis (LE) can be
challenging to treat and there is no clear consensus
on a superior therapeutic approach. Promising results
have been demonstrated with platelet-rich plasma
(PRP) injections, however, earlier studies have
lacked a placebo control. In Krogh et al., the authors
presented a double-blind, randomized controlled trial
assessing the efficacy of an ultrasound (US) guided
injection of either PRP, glucocorticoid or isotonic
saline (placebo) for chronic LE.
Methods: Sixty patients with chronic LE as defined
by symptoms persisting for greater than 3-months and
definitive US evidence of tendinopathy were recruited.
Exclusion criteria included: age <18 years, prior
glucocorticoid injection within 3-months, history
of tennis elbow surgery, or another potential cause
for the lateral elbow pain (history of inflammatory
disease, chronic widespread pain syndrome, or either
neck or shoulder pain). Subjects were randomly
a
Walter Sussman, DO and Ken Mautner, MD reviewing Krogh TP
et al. Treatment of lateral epicondylitis with platelet-rich plasma,
glucocorticoid, or saline: A randomized, double-blind, placebo-
controlled trial. Am J Sports Med. 2013;41:625-635.
b Weaknesses: As
Sports Medicine, Emory University
c
Corresponding Author: Walter Sussman
Email: walter.sussman@emory.edu
d
Editor-in-Chief, Sports Review Journal, NFP
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18 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
assigned to the three treatment arms, and assessed
at 4-weeks and 3, 6 and 12-months. The primary
end-point was a change in pain at 3-months on the
Patient-Rated Tennis Elbow Evaluation (PRTEE)
questionnaire, which assesses the average pain
and function of the arm over the preceding week.
Secondary outcomes included: (1) functional changes
on the PRTEE; (2) US changes in color Doppler
activity; and (3) US changes in tendon thickness.
Results: At 3-months, there was no statistically
significant change in PRTEE pain or functional
scores between the three groups. On ultrasound
evaluation, the glucocorticoid group was superior to
PRP and saline in reducing color Doppler activity
with 90% of subjects having no Doppler activity at
follow-up. The thickness of common tendon decreased
in the glucocorticoid group, while both the PRP and
saline groups demonstrated an increase in tendon
thickness. Due to the high dropout rate, the 6 and
12-month data lacked statistical power and were not
included in the analysis, and the authors concluded
that neither injection of PRP nor glucocorticoid was
superior to saline for pain in chronic LE at 3-months.
Strengths: Thestudy is the first study to compare the
efficacy of PRP to placebo for chronic LE.
acknowledged by the authors, the
major weakness in this study is the large number of
patients lost to follow up. Only 16 of the 60 patients
completed the 12-month trial, which led the authors
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to use the 3-month data as the primary end-point
instead of the 12-month data post hoc. This is a major
limitation, as the maximum benefit from a PRP
injection may not be realized until 6 months after
the injection (3). Another limitation is that the saline
injection technique was not an inactive placebo, and
involved performing 7 tendon perforations at the
origin of the common tendon. In fact, percutaneous
needle tenotomy alone has been shown to be an
effective treatment in itself for LE in numerous
studies (2). Finally, while research is limited there
are studies suggesting that the method used by Krogh
et al. could have inhibited the efficacy of the PRP. In
Krogh et al. lidocaine was injected in the paratendon,
and lidocaine has been shown to significantly decrease
tenocyte proliferation when used with PRP in an in
vitro study of human tendon cells (1).
Conclusion: In the abbreviated 3-month follow up,
there was no significant difference between PRP,
glucocorticoid or saline (plus needle tenotomy) on
subjective pain scores.
Practice Pearl: There remains no consensus on
managing chronic LE, and while PRP has shown
promise for the treatment of chronic LE in earlier
articles, this study did not find PRP superior to
© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
glucocorticoid or saline injections at 3-months. The
abbreviated follow up used by Krogh et al. limits the
conclusions that can be drawn from this study as the
maximum benefit from PRP may not be realized at
3-month follow-up.
References:
(1) Carofino B, Chowaniec DM, McCarthy MB,
et al. Corticosteroids and local anesthetics decrease
positive effects of platelet-rich plasma: an in
vitro study on human tendon cells. Arthroscopy.
2012;28(5):711-719.
(2) Housner JA, Jacobson JA, Misko R.
Sonographically guided percutaneous needle tenotomy
for the treatment of chronic tendinosis. J Ultrasound
Med. 2009 Sep;28(9):1187-1192.
(3) Peerbooms JC, Sluimer J, Bruijn DJ, et al. Positive
effect of an autologous platelet concentrate in lateral
epicondylitis in a doubleblind randomized controlled
trial: platelet-rich plasma versus corticosteroid
injection with a 1-year follow-up. Am J Sports Med.
2010;38(2):255-262.
(4) Krogh TP et al. Treatment of lateral epicondylitis
with platelet-rich plasma, glucocorticoid, or saline: A
randomized, double-blind, placebo-controlled trial.
Am J Sports Med. 2013;41:625-635.
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Sport Rev J. 2015; 1(1)
If We Want Kids to be Physically Active,
Make it Fun!
Elizabeth Joya,b,c
Introduction: It is widely understood that rates
of child and adolescent obesity have risen over the
past several decades. According to the most recent
results of the Youth Risk Behavior Surveillance Study
(YRBSS), 16.2% of boys, and 9.9% of girls were
classified as obese (1). Forty percent of boys reported
getting 60 minutes or more of physical activity (PA)
in the past 7 days, but only 19.7% of girls, more than
a two-fold difference. Investigators went on to find
that not meeting PA recommendations was associated
with up to a 4-fold increase in the odds of obesity for
both boys and girls. The study concludes that meeting
the PA recommendation may have a protective effect
against obesity (1).
This news is not terribly surprising, and
intuitively makes sense – more movement leads to
healthier energy balance and lower likelihood of
obesity. The challenge is of course to get kids moving
and keep them moving.
School-age children and adolescents spend
a coaches and 57 parents to participate in a qualitative
Elizabeth Joy, MD, MPH reviewing Visek AJ, et al. The fun
integration theory: toward sustaining children and adolescents sport
participation. J Phys Act Health. 2015 Mar;12(3):424-33.
b
Community Health & Sports Medicine, Intermountain Healthcare,
Salt Lake City, UT
c
Corresponding Author: Elizabeth Joy
Email: liz.joy@imail.org
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20 © The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
the majority of their waking hours in school.
Activities before, during and after school offer the
greatest opportunity to increase physical activity.
Activities that “count” toward the accumulation of
60 minutes per day of moderate to vigorous physical
activity include walking to and from school, physical
education classes, recess activities, recreational
activities in and around the school day, and finally,
sports participation. It may surprise you to learn that
a majority (65%) of youth under the age of 17 will
participate in at least one organized sport (2). There
is an extensive body of literature on the benefits of
organized sport participation ranging from health
benefits to improvements in academic performance.
Yet despite these benefits, dropout from sport is high,
with as many as 70% dropping out in their teen years
(2). Why do kids drop out? The primary reason is a
“lack of positive experiences” associated with sport
participation, aka, “it’s not fun anymore.”
Methods: The article, “The Fun Integration Theory:
Toward Sustaining Children and Adolescents Sport
Participation,” published in the Journal of Physical
Activity in Health (2), recruited 142 soccer players, 37
study aimed at identifying all of the things that
make playing sports fun for players. From their data
they created FUN MAPS that provide an evidence-
based blueprint for the Fun Integration Theory –
described as a multitheoretical, multidimensional, and
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stakeholder derived framework that can be used to
maximize fun for children and adolescents, as well as
promote and sustain physical activity.
Results: This mapping process first identified 81
fun determinants through a brainstorming process,
sorted them into 11 themes, and then quantified how
important each was to a player’s perception of fun.
When it was all said and done, the 3 most important
dimensions of fun were “positive team dynamics”,
“trying hard”, and “positive coaching”. Determinants
within “positive team dynamics” include playing well
together as a team, being supported by teammates,
and showing good sportsmanship. “Trying Hard”
includes trying your best, exercising and being active,
along with being strong and confident. Twelve
determinants make up “positive coaching”, which
includes when a coach treats a player with respect,
encourages the team, and serves as a positive role
model.
Strengths: A strength of this study is its mixed
method design, along with a significant sample size
including 236 athletes, coaches and parents providing
investigators with a breadth of data on the various
determinants that contribute to sustained sport
participation.
Weaknesses: The athletes in this study were only
soccer players, and results may not generalize to
athletes in other sports, or to athletes in individual (vs.
team) sports. The vast majority of study participants
were Caucasian. Future studies should intentionally
include athletes, parents and coaches with greater
racial/ethnic and sport diversity.
Conclusion: Having identified key determinants to
sports participation, followed by a process that seeks
© The Authors © 2014 Joshua Rothenberg. All Rights Reserved.
Review Journal
to identify those with greatest influence on sustained
participation, the Fun Integration Theory can provide
coaches, teachers, parents, even physicians, with
information that can be used to encourage regular
physical activity and sustained sport participation
for youth. It can also be used to determine why a
child or adolescent seems to have lost interest in
physical activity and sport, and could be used as a
tool to identify those determinants that resonate the
loudest with an individual and help them find their
way back into sport. For coaches and physical activity
educators the key dimensions and their determinants
should ALWAYS be a part of sport and activity
programming.
Practice Pearl: Physical activity begun during childhood
and sustained in adolescence sets the stage for an active
lifestyle throughout life. It’s intuitively obvious that
“fun” is an important determinant for activity and sports
participation. Understanding the determinants that
create and support that “fun” sporting environment is
important for all of us who promote activity in children
and adolescents.
References:
(1) Laurson KR1, Lee JA, Eisenmann JC. The
cumulative impact of physical activity, sleep duration,
and television time on adolescent obesity: 2011
youth risk behavior survey. J Phys Act Health. 2015
Mar;12(3):355-60.
(2) Visek AJ, Achrati SM, Mannix H, McDonnell
K, Harris BS, DiPietro L. The fun integration
theory: toward sustaining children and adolescents
sport participation. J Phys Act Health. 2015
Mar;12(3):424-33.
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© 2014 Joshua Rothenberg. All Rights Reserved.