What’s New in Sports Medicine

Advances within the field of sports medicine continue to refine approaches to injury management in athletic and active patients. This review synthesizes research findings within the last year, highlighting key developments in the latest evidence across a range of treatment modalities and patient profiles, with a focus on surgical techniques and outcomes, injury prevention, physical therapy, and nonoperative treatment modalities. Through a structured analysis of 40 studies, the aim of this review is to serve as a guide with insights to enhance and implement evidence-based practice regarding the knee, shoulder, hip, and elbow. Knee Anterior Cruciate Ligament (ACL) Reconstruction ACL injury continues to be a main topic of research, with current literature focusing on optimizing techniques, graft choice, and therapy and their effects on return to sport and rate of failure. Lateral augmentation in ACL reconstruction (ACLR) has become a prominent focus in sports medicine research, with various techniques proposed to address persistent rotatory laxity. The addition of lateral extra-articular tenodesis (LET) to ACLR has been shown to add rotational stability and reduce graft rupture. In a multicenter randomized controlled trial (RCT) studying the highest-risk patient profile, the STABILITY Study Group compared hamstring tendon ACLR in isolation and hamstring tendon ACLR with LET in 618 patients with pivot shift grade 2 or higher and generalized ligamentous laxity who participated in high-risk or pivoting sports. At 24 months postoperatively, there were similar rates of return to sport between groups; patients who had undergone ACLR with LET had a lower rerupture rate (11.2% compared with 4.1%; p = 0.004)1. Similarly, a systematic review and meta-analysis of 14 clinical trials with 1,830 patients compared ACLR in isolation and ACLR combined with either LET or anterolateral ligament reconstruction (ALLR). Lateral augmentation was superior to isolated ACLR in terms of improved pivot shift, graft failure, and patient-reported outcome measures (PROMs). Patients who underwent ACLR with LET or ALLR had a lower graft failure rate (range, 3% to 5%) compared with patients who underwent ACLR alone (range, 9% to 12%), with a pooled risk ratio (RR) of 0.42 (95% confidence interval [CI], 0.28 to 0.62; p < 0.001), indicating a 58% lower risk of graft failure. The Lysholm Score (p < 0.05), Tegner Activity Scale score (p < 0.05), and International Knee Documentation Committee (IKDC) Subjective Score (p = 0.03) were all significantly improved with ACLR with LET or ALLR2. For revision cases, a systematic review and meta-analysis compared revision ACLR in isolation and revision ACLR with lateral augmentation. In 8 clinical trials, 334 patients were treated with isolated revision ACLR and 342 patients were treated with combined revision ACLR with LET or ALLR. Revision ACLR with LET or ALLR had a lower failure rate (5.6%) than revision ACLR in isolation (11.7%), with a relative risk reduction of 54% (p = 0.004). Additionally, revision ACLR with LET or ALLR had a lower residual positive pivot shift rate (20.1% compared with 39.2%; RR, 0.50; p = 0.0001) and a lower high-grade (grades 2 to 3) pivot shift rate (3.3% compared with 11.1%; RR, 0.32; p = 0.003) when compared with revision ACLR in isolation3. Both systematic reviews and meta-analyses found no significant differences among the different lateral extra-articular procedures. A topic that is often at the forefront of research related to ACLR is graft choice. Compared with hamstring and patellar tendon autografts, quadriceps tendon autograft is a newer option, with literature now showing equivalent outcomes with no difference in failure rates between quadriceps tendon and patellar tendon autografts at up to 4 years. However, less is known about the long-term sequelae of the quadriceps tendon autograft, such as anterior knee pain and weakness. In a cross-sectional study, 104 patients who had received quadriceps tendon autografts were matched to 104 patients with hamstring autografts and 104 patients with patellar tendon autografts to assess differences in quadriceps strength. At a mean of 7 months postoperatively, patients with quadriceps tendon autografts had the most impaired strength as measured by the limb symmetry index, ranging between 67.5% and 75.1%, compared with patellar tendon autografts (74.4% to 81.5%) and hamstring tendon autografts (84.0% to 89.0%)4. An RCT of 57 patients receiving quadriceps tendon autografts compared with 55 patients receiving hamstring tendon autografts found significantly better ACL RTS (Return to Sport) after Injury (ACL-RSI) scores in the hamstring tendon autograft group at 3 months (p = 0.008), 6 months (p = 0.010), and 12 months (p = 0.014). The hamstring tendon autograft group had better quadriceps strength at 6 and 12 months, whereas the quadriceps tendon autograft group had better hamstring strength at 6, 12, and 24 months5. One side effect of obtaining a hamstring tendon autograft is pain from harvesting both the semitendinosus and gracilis tendons and resultant knee flexion deficits. In the tendon-sparing, all-inside technique, a quadrupled semitendinosus graft is used. An RCT of 98 patients, with 89 patients completing 2-year follow-up (45 all-inside and 44 traditional), showed no significant difference in mean IKDC scores (80.5 ± 14.4 for the all-inside group and 79.2 ± 15.6 for the traditional group; p = 0.51), but the all-inside group had a higher number of revision surgeries (5 compared with 2) and more patients with 1+ and 2+ pivot shift values than the traditional group6. Blood flow restriction rehabilitation is thought to improve recovery and prevent atrophy. A systematic review of 5 studies comparing blood flow restriction training and standard rehabilitation methods for ACL injuries showed mixed results. Two studies showed greater strength gains and greater muscle size with blood flow restriction training, whereas 2 other studies favored standard rehabilitation. The fifth study was the only study that measured PROMs, which showed a significant improvement in the blood flow restriction group, related to physical function7. Meniscus Several studies with regard to the cost-effectiveness of different meniscal tear treatment strategies were published recently. A multicenter RCT from the STARR study group evaluated the cost-effectiveness of arthroscopic partial meniscectomy (APM) compared with physical therapy plus optional delayed surgery. Across 100 patients, higher cost was associated with APM when compared with physical therapy with optional delayed surgery, as measured by health-care costs (€3,645 compared with €2,881) and societal costs (€6,037 compared with €5,778), with no significant difference in quality of life, suggesting that physical therapy should be prioritized as a first-line treatment8. Another multicenter RCT from the FIDELITY Trial compared APM with placebo surgery (diagnostic arthroscopy with simulated partial meniscectomy) in 146 adults with degenerative meniscal tears and no osteoarthritis. The investigators found that APM had increased costs (€7,441 compared with €6,780), in an analysis in which the cost of surgery was standardized, due to productivity loss, medication, and additional health-care visits and associated travel. Additionally, there was no difference in quality of life, leading Kalske et al. to recommend against APM in this population9. A systematic review on the management of meniscal root tears evaluated differences among repair, APM, and nonoperative treatment, with PROMs, radiographic measures, and the rate of conversion to total knee arthroplasty (TKA) as outcome measures. Across 56 studies and 3,191 patients, meniscal root repair had lower rates of conversion to TKA (event rate, 0.00 to 0.22) compared with nonoperative treatment (0.27 to 0.35) and meniscectomy (0.35 to 0.60). Root repair also showed a smaller decrease in joint space width (−0.9 to −0.1 mm) compared with meniscectomy (−2.4 to −0.6 mm) and less medial meniscal extrusion (−0.6 to 6.5 mm) compared with meniscectomy (0.2 to 4.2 mm)10. Anterior Knee Patellofemoral pain is one of the most common symptoms in the adolescent patient and, despite physical therapy, can often be refractory. To assess whether psychological therapy in addition to physical therapy could improve function, a double-blinded RCT assigned 68 adolescent patients with patellofemoral pain to watch videos either on fear-avoidance beliefs, kinesiophobia, and pain catastrophizing or on knee anatomy, biomechanics, and exercise (control). The authors found that the psychologically informed group had significantly greater improvements in the mean Anterior Knee Pain Scale scores at 6 weeks (mean difference, 8.0; p = 0.01) and 3 months (mean difference, 6.2; p = 0.01) and 76% of the psychologically informed group achieved clinically meaningful improvements compared with 52% in the control group (p = 0.03)11. Other common anterior knee pathologies are patellar instability and dislocation. Postoperative rehabilitation protocols for medial patellofemoral ligament reconstruction with tibial tubercle osteotomy have varied widely over the years. An RCT of 50 patients with recurrent patellar instability who underwent medial patellofemoral ligament reconstruction with tibial tubercle osteotomy sought to compare short-term, postoperative outcomes of early rapid rehabilitation versus standard rehabilitation protocols. The early rapid rehabilitation group started weight-bearing at 3 weeks instead of 6 weeks, progressed to 120° range of motion by 6 weeks instead of 9 weeks, and started strength and proprioception training earlier. The rapid rehabilitation group demonstrated higher Tegner scores at 6 weeks and 3 months, higher Lysholm scores at 3 and 6 months, and higher IKDC scores at 6 weeks, 3 months, and 12 months (p < 0.05 for all)12. Shoulder Rotator Cuff Several recent studies have investigated tranexamic acid (TXA) as an adjunct to improve visualization during arthroscopy. In a systematic review and meta-analysis evaluating the use of TXA in arthroscopic rotator cuff repair, 7 studies including 537 patients showed improved surgeon-reported visual clarity (mean difference, +9.10%; p = 0.0004), decreased operative time (mean difference, −11.24 minutes; p = 0.01), and no reported adverse events with TXA use13. A double-blinded RCT of 128 patients involving 5 upper-extremity fellowship-trained surgeons compared placebo saline solution irrigation fluid, epinephrine (0.33 mL of 1:1,000/L) mixed in irrigation fluid (EPI), 1 g intravenous TXA, and TXA and EPI combined. The mean visual clarity (and standard deviation) was 2.0 ± 0.6 for the placebo group, 2.0 ± 0.6 for the TXA group, 2.6 ± 0.5 for the EPI group, and 2.7 ± 0.5 for the TXA and EPI combined group (p < 0.001), suggesting that epinephrine is the most effective adjunct for visualization, with TXA providing no additional benefit14. The retear rates in rotator cuff repair remain high, prompting new research into strategies such as patch augmentation, platelet-rich plasma, and bone marrow stimulation to improve outcomes. In a systematic review evaluating the utilization of patch augmentation in rotator cuff repair, 6 studies with 381 patients were identified, with follow-up ranging from 14.0 to 68.4 months. Four studies indicated retear rates, which were significantly reduced in patients who underwent rotator cuff repair with patch augmentation in 3 studies, ranging from 9% to 53%, compared with patients who underwent rotator cuff repair alone, ranging from 34% to 65%15. To assess biologic adjuvants, a double-blinded RCT aimed to assess whether the retear rate in rotator cuff repair could be reduced by leukocyte-poor platelet-rich plasma. In 96 patients randomized into 2 groups, the retear rate was significantly lower in the leukocyte-poor platelet-rich plasma group (15.2%) when compared with the control group (34.1%), with a mean follow-up of 12 months. There were no significant functional differences between groups at 6 and 12 months. However, in a systematic review and meta-analysis evaluating the use of platelet-rich plasma in rotator cuff repair, 9 studies with 537 patients with follow-up ranging between 6 and 60 months showed a nonsignificantly lower retear rate for rotator cuff repair with platelet-rich plasma compared with rotator cuff repair controls (relative risk, 0.63; p = 0.08). Furthermore, there were no significant differences in visual analog scale (VAS) pain scores, functional improvement, or complications, suggesting that the use of platelet-rich plasma remains controversial16. Bone marrow stimulation is a similar adjunctive therapy that was recently assessed via a meta-analysis of 7 RCTs that included 576 patients with follow-up ranging from 6 to 24 months, which also found no significant difference in retear rates between the bone marrow stimulation group (18.8%) and the control group (21.0%), with an RR of 0.88 (95% CI, 0.55 to 1.42; p = 0.61)17. Shoulder Instability The management of first-time anterior shoulder dislocations is trending toward surgical management. A meta-analysis of 34 studies with 2,220 patients and a mean follow-up of 59.4 months found that arthroscopic stabilization, compared with immobilization, significantly reduced redislocation rates (6.8% compared with 48.6%; odds ratio [OR], 0.09; p < 0.001), cumulative instability (11.2% compared with 67.7%; OR, 0.05; p < 0.001), and subsequent stabilization surgery (6.3% compared with 33.7%; OR, 0.08; p < 0.001). Arthroscopic stabilization also improved return-to-sport rates (OR, 3.87; p < 0.001) and Rowe scores (p = 0.03), favoring early surgical intervention over nonoperative management18. Arthroscopic Bankart repair with remplissage has superior outcomes over Bankart repair alone in the treatment of anterior shoulder instability. A medium-term follow-up of a multicenter RCT comparing these techniques in patients with and bone found significantly lower rates of recurrent instability compared with p = and treatment failure compared with p = in the remplissage group at a mean follow-up of 4 years. patients and sport also significantly from with lower rates of treatment failure and revision This is also by a systematic review and meta-analysis of 12 studies with patients, which found that remplissage significantly reduced postoperative instability (OR, p < 0.001) and revision (OR, p = The rates of return to sport were also higher with with a higher Rowe score p = 0.01) and Shoulder and score p = the improvements in were clinically evidence from systematic review and meta-analysis of 7 studies demonstrated that remplissage in a reduction in the of instability in patients with compared with patients who had undergone isolated Bankart repair (OR, p < 0.001). The addition of remplissage improved flexion (mean difference, p < 0.001) in (mean difference, p = with no clinically on range of and were between these findings remplissage as an effective addition to Bankart repair for shoulder stability in patients with anterior shoulder with or high-risk profiles, and range of There has been evidence with regard to the of the as a revision surgery than a surgery for shoulder instability. A systematic review and meta-analysis of studies found no significant differences between and revision in pain scores, Rowe scores, return to or range of rates were also with no significant differences in complications, recurrent or However, revision were associated with a higher rate compared with p = and a toward increased of instability compared with p = and There remains the for arthroscopy and subsequent In a RCT of in patients who were 14 to 60 of and had or no differences in the in the International score or the sports and in physical and of the and Score were between the group and the group at a follow-up of 2 years. The of patients reported or compared with p = postoperatively, and an score the patient was achieved in of in both groups (p = There was no significant difference in rates compared with p = in the group 1 compared with the group arthroscopy for generalized joint has been shown to functional and clinical outcomes, and evidence has that repair instability and in this group of patients with a A systematic review including studies evaluated PROMs, return to and clinical in patients over of with generalized joint arthroscopy. of the included studies rates of repair and or in patients with generalized joint (5 studies had a In the 8 studies showing PROMs, the from to and the pain score from to effective repair and no significant differences in or clinically difference or were found between patients with and generalized joint in 5 Ligament repair with augmentation has become a to A systematic review of 8 and 9 clinical studies compared repair and reconstruction with or augmentation. The studies with augmentation compared with that repair demonstrated equivalent or superior and at treatment failure, with significantly less and of 7 studies found no significant difference in terms of failure whereas 2 studies demonstrated lower failure in the repair no clinical studies comparing repair with reconstruction were identified, the systematic review showed rates of return to the of for both repair with augmentation across time to to and augmentation across time to to 6 There has been a toward pain management strategies to reduce and associated and adverse A double-blinded RCT of 50 patients arthroscopy found that intravenous in addition to a pain reduced postoperative by compared with placebo compared with p = reported Patients in the group had lower pain scores on postoperative 2 and significantly lower rates of postoperative and Postoperative is also by the by A RCT of patients ACLR compared postoperative use and patient-reported outcomes in 3 groups of patients randomized to or of in addition to a There were no significant differences in pain IKDC scores, or patient across groups, with of within the 3 Patients were more to that thought that the was This that smaller can pain management The has been reported to be an to the standard pain control the risk of in arthroscopic shoulder surgery. In a a was found to have compared with an superior with higher postoperative and in the However, significantly reduced the risk of a for patients at higher risk for Another RCT demonstrated that a combined with and improved postoperative pain and pain scores at 2 weeks compared with alone, there was no difference at 24 Postoperative and were between The management of among remains a topic of traditional and newer techniques such as and A systematic review of studies found rates of return to sport across all with to sport at and to their or The mean return-to-sport time was weeks, across with rates of to sport at for and complications, such as and were with techniques showing a higher rate compared with methods in of cases, with no significant differences between The of a number of recently published studies related to the that received a higher of In addition to in this other to sports medicine surgery are to this review after the standard with a about to guide in an evidence-based in this to of patients a patient after repair of tendon a systematic The repair of tendon tears outcomes with and revision rates in both and A systematic review including studies with showed significant improvements in There was in techniques across all studies, with or repair for tears and or repair in rates were in studies, and retear rates were in studies, with the retear rates ranging from to The rates of the to and to were and indicated that all patients clinically meaningful difference in most reported outcome measures for versus autograft for a systematic review of compared with autograft has been a topic of in ligament reconstruction and repair, with different The outcomes are similar for either A systematic review evaluating a total of patients in studies of and autograft for reconstruction or augmentation found no significant differences in between groups across all 3 included studies, were higher in patients who received The rates of revision to compared with to were higher in the autograft group, only 1 study showed significant differences in revision There were no significant differences in the rates of conversion to total arthroplasty to compared with to across all Postoperative radiographic outcomes in and a systematic A systematic review to the radiographic outcomes and rates by and after included studies with The mean follow-up was (range, to The pooled graft rate was to with rates lower than radiographic The most reported postoperative radiographic after were graft a and bone The range of rates was to for and graft and to for a This study that radiographic after and greater in postoperative radiographic is evidence for anterior ligament reconstruction a systematic review of clinical outcomes at to ACLR has been in clinical practice and is a topic for A systematic review on ACLR with and augmentation included 5 studies with patients underwent ACLR with and underwent ACLR with the mean follow-up ranging from 24 to months. The graft failure rate for ACLR with from to which was significantly different from that for ACLR alone, which was to 1 study showed significantly lower graft failure rates in the group that underwent ACLR with (p = There were no significant differences in return to of or tendon and as an adjunct to physical therapy in patients with lateral a multicenter randomized clinical A multicenter RCT the addition of and to a physical therapy for lateral found significantly greater improvements in and compared with physical therapy At 3 months, patients in the group showed effect for in pain Pain CI, to and CI, to as as improvements in CI, to of the group reported improvement on the of compared with in the control group (p < 0.001). The addition of and to physical therapy pain to patients with lateral of for arthroscopic rotator cuff a randomized controlled An RCT the of a as an adjunct during arthroscopic rotator cuff repair in patients with or tendon tears was recently patients the study in the group and in the control at 12 months postoperatively, at which time the retear rate was significantly lower in the group compared with p = There were no significant differences between groups in The addition of an patch augmentation to rotator cuff repair significantly the rotator cuff retear Postoperative treatment with acid rotator cuff but improve outcomes in patients with a randomized To the effects of a RCT evaluated who were of had and were rotator cuff At 2 the acid group had significantly higher tendon rates than the control group (p = but no significant differences in A and of surgical techniques for anterior shoulder a Shoulder A meta-analysis was to surgical techniques for anterior shoulder instability. studies were involving patients with a mean follow-up of months, evaluating an arthroscopic Bankart repair, arthroscopic Bankart repair, and arthroscopic Bankart repair with among The analysis found that the had the rates OR, such as arthroscopic Bankart repair showed higher rates but lower compared with and and varied of a blood flow restriction therapy on early quadriceps strength and patient-reported outcomes after anterior ligament A RCT compared blood flow restriction therapy with standard therapy in patients with patients randomized into 2 groups in the blood flow restriction group and 24 in the control Blood flow restriction therapy significantly increased quadriceps strength at 6 weeks ± compared with the control group ± (p = but showed no long-term at 3 or 6 months. tendon autograft a for anterior ligament a systematic A less ACLR tendon autograft is the tendon A systematic review evaluated the utilization of ACLR with tendon autograft compared with traditional studies were included and 6 with tendon autograft and hamstring tendon or patellar tendon There were no significant differences in treatment failure rates or return to sport across studies (p The tendon autograft clinical outcomes with traditional and was and or more effective for pain control in anterior shoulder A randomized controlled An RCT of patients with anterior shoulder dislocations randomized to or found no significant differences in pain of or rates between the 2 Both techniques reduced pain and achieved patient suggesting that are a and in